DR BUVANES CHELLIAH

O & G SPECIALIST

SARAWAK GENERAL HOSPITAL

Cracking the Contraceptive Myths/ Barriers

BATTLE OF MYTH VERSUS FACTBATTLE OF MYTH VERSUS FACT

MYTH : A WIDELY HELD BUT FALSE BELIEF OR IDEAMYTH : A WIDELY HELD BUT FALSE BELIEF OR IDEA

Natural family planning

1.1. Coitus Interruptus effectively prevents pregnancy & STDCoitus Interruptus effectively prevents pregnancy & STD

2.2. Fixed fertile period ( avoidance of SI at day 14 of menses )Fixed fertile period ( avoidance of SI at day 14 of menses )

3.3. Postcoital perineal washing prevent pregnancyPostcoital perineal washing prevent pregnancy

4.4. Breast feeding prevents pregnancyBreast feeding prevents pregnancy

Coitus Interruptus effectively prevents pregnancy & STDCoitus Interruptus effectively prevents pregnancy & STD

It has been suggested that the pre-ejaculate ("Cowper's fluid”) emitted by the penis prior to ejaculation normally contains spermatozoa (sperm cells), which would compromise the effectiveness of the method

Typical failure rate : 18 – 20 %

Avoid during fertile period

DOES NOT PREVENT AGAINST STD

• Only applicable for those with regular menses, cycle length is recorded for the min of 6 cycles,

• Fertile period is not only on day fourteen : ovulation varies each cycle

• Cycle length is recorded for the min of 6 cycles, likely fertile days are then calculated allowing for the survival of sperm and ova

1.1. Fixed fertile period ( avoidance of SI at day 14 of menses )Fixed fertile period ( avoidance of SI at day 14 of menses )

First fertile day : shortest cycle – 20 Last fertile day : longest cycle – 10

Postcoital perineal washing prevent pregnancyPostcoital perineal washing prevent pregnancy

• Semen travels at 28mph

• It takes only 5 minutes for them to travel the 6 inches to the cervix

• Perineal washing does NOT effectively cleanse vagina off the sperm 

Breast feeding prevents pregnancyBreast feeding prevents pregnancy

LACTATIONAL AMENORRHEA METHOD

•Exclusive BF during the first 6 months after last childbirth

•Induced amenorrhea

•2% to get pregnant

PILLS : POP & COCPPILLS : POP & COCP

1.1. Causes hormonal disturbancesCauses hormonal disturbances

2.2. May result in infertility in futureMay result in infertility in future

3.3. May result in weight gainMay result in weight gain

4.4. May cause reduction in sexual driveMay cause reduction in sexual drive

5.5. May result in malignancyMay result in malignancy

Causes hormonal disturbancesCauses hormonal disturbances

• Androgen cause in sebum production and terminal hair growth

• Acne vulgaris – a common skin disorder that involves the sebaceous follicle

• Hirsutism – growth of terminal hair on the body of a woman in similar pattern & sequence as in post pubertal male

• COCPs - serum free testosterone concentration by inhibiting luteinising hormone stimulation of ovarian androgens & increasing sex hormone binding globulin (SHBG) production in the liver

 • COCPs – inhibit 5-alpha reductase activity (required to convert testosterone to

dihydrotestosterone in hair follicles and skin)  

HyperandrogenismHyperandrogenism

• Premenstrual symptom – breast tenderness, bloating, fatique, headaches, mood swings or irritability

• Premenstrual syndrome (PMS) – pre menstrual symptoms severe enough to cause impairment of daily activity. Affect 10-15% of women

• COCPs improve PMS/PMDD by suppressing ovulation

• Drosperinone (a new progestogen derived from spironolactone) containing COCP was shown to be highly effective in PMS/PMDD

• COCPs are better at improving the physical symptoms of PMS/PMDD

• If emotional symptoms are predominant, then selective serotonin reuptake inhibitors (SSRI) are the initial treatment of choice

PREMENSTRUAL SYNDROME

Makes one infertileMakes one infertile

• A woman’s fertility declines with age, genetically determined.

• Fertility is also affected by general and gynaecological health, concurrent illness, weight, exercise levels, cigarette smoking and stress. Weight above and below the recommended range for height can have an impact on fertility

• Systemic review of studies comparing reversible forms of contraception found between 79% and 96% of women were able to get pregnant in the 12 months after they stopped taking the pill.

May result in weight gainMay result in weight gain

Cochrane review identified 49 randomized controlled trials that spanned at least three treatment cycles and compared a combination contraceptive with placebo, no intervention, or another combination contraceptive that differed in drug, dosage, treatment regimen, or study length. Only four of the 49 trials had a control group (placebo or no intervention). None of the four trials found a statistically significant difference in weight change between the combination contraceptive and control groups.

Compared with placebo or no intervention, Compared with placebo or no intervention, the use of combination contraceptives was the use of combination contraceptives was not associated with weight gainnot associated with weight gain

• Some women may experience bloating from water retention before or during periods when COCP.

• Some progestogen ie Drospirenone counteracts the mechanism of water retention thus many women enjoys the freedom from water related weight gain/ discomfort

May cause reduction in sexual driveMay cause reduction in sexual drive

• Findings from studies of the sexual effects of hormonal contraceptives have been inconsistent, and the pharmacologic basis for these effects is unclear

• When women on the Pill were tested, levels of a chemical which wipes out testosterone were found to be seven times higher than in those who had never taken it

May result in malignancyMay result in malignancy

OFFER PROTECTION AGAINST ENDOMETRIAL/OVARIAN AND OFFER PROTECTION AGAINST ENDOMETRIAL/OVARIAN AND COLORECTAL CARCINOMACOLORECTAL CARCINOMA

OVARIAN CARCINOMAOVARIAN CARCINOMA

• OCP (chemoprevention) has highest protective effect against ovarian cancer

• OCP for 5 years reduces the relative risk of developing epithelial ovarian cancer by 50%

• Trials evaluating role of OCP as primary prevention of ovarian cancer particularly hereditary ovarian cancer due to BRCA 1 or BRCA 2 (CASH & SEER)

i. 5 years use of OCP in nulliparous women reduced the risk of ovarian cancer to similar with non user multipara

ii. 10 years use of OCP reduced the risk in women with family history ovarian cancer to lower than those non users and has no family history

Oral contraceptive use and the risk of ovarian cancer: the Centers for Disease Control Cancer and Steroid Hormone Study. Journal of the American Medical Association 249(12):1596-9. 1983 Mar 25. 11 p

ENDOMETRIAL CANCERENDOMETRIAL CANCER

• The use of COCP for 1 year decrease the risk of endometrial cancer by more than 40%

• A meta-analysis has shown that

COLON CANCERCOLON CANCER

• Lesser known benefit of COCPs is protection against colon cancer

• A cohort study – women who used COCP for ≥ 96 months had 20- 40% lower risk of developing colorectal cancer

INTRAUTERINE DEVICE

• Fear of Perforation/ExpulsionFear of Perforation/Expulsion

• Increases the risk of Pelvic Inflammatory DiseaseIncreases the risk of Pelvic Inflammatory Disease

• Causes excessive per vaginal bleedingCauses excessive per vaginal bleeding

• Higher risk of Ectopic PregnancyHigher risk of Ectopic Pregnancy

Fear of Perforation/ ExpulsionFear of Perforation/ Expulsion

• The rate of uterine perforation associated with intrauterine contraceptive use is veryvery lowlow (0–2.3 per 1000 insertions0–2.3 per 1000 insertions).

• Expulsion of intrauterine contraception occurs in approximately 1 in 1 in 20 women and is most common in the first 3 months20 women and is most common in the first 3 months after insertion and often during menstruation

Harrison-Woolrych M, Ashton J, Coulter D. Uterine perforation on intrauterine device insertion: is the incidence higher than previously reported? Contraception 2003; 67: 53–56. 59 World Health Organization (WHO). Mechanism of Action,

Caliskan E, Öztürk N, Dilbaz BÖ, Dilbaz S. Analysis of risk factors associated with uterine perforation by intrauterine devices. Eur J Contracept Reprod Health Care 2003; 8:150–155.

Increases the risk of pelvic inflammatory diseaseIncreases the risk of pelvic inflammatory disease

• Pelvic inflammatory disease (PID) among IUD users is most strongly related to the insertion procedure and to the background risk of STIs.

• A review of 12 randomised trial identified low rates of PID (1.6 per 1000 woman-years).After adjusting for confounding factors, although a six-fold increase in the risk of PID occurs in the 20 days after insertion, the overall risk is low. After this time the risk is low and remains low unless there is exposure to STIs

Women should be advised there may be anincreased risk of pelvic infection in the 20 daysfollowing insertion of intrauterine contraceptionbut the risk is the same as the non-IUD-usingpopulation thereafter (Grade B).

Farley TM, Rosenberg MJ, Rowe PJ, Chen JH, Meirik O.Intrauterine contraceptive devices and pelvic inflammatory disease: an international perspective. Lancet 1992; 339:785–788.

In general, Cu-IUDs do not have any effect on ovulation. Nevertheless, a shorter luteal phase (post-ovulation) with earlier onset of menstruation has been documented. Spotting, light bleeding, heavier or longer periods are common in the first 3 to 6 months following Cu-IUD insertion. These bleeding patterns are not harmful and usually decrease with time.

Causes excessive per vaginal bleedingCauses excessive per vaginal bleeding

World Health Organization. Selected Practice Recommendations for Contraceptive Use (2nd edn). 2005.http://www.who.int/reproductive-health/publications/spr_2/index.html [Accessed 12 October 2007].Faculty of Family Planning and Reproductive Health Care Clinical Effectiveness Unit. UK Selected Practice Recommendations for Contraceptive Use. 2002.http://www.fsrh.org/admin/uploads/Final%20UK%20recommendations1.pdf [Accessed 12 October 2007].

An increase amounting to approximately 20 ml per period without significant variations during the study was recorded. No significant influence upon serum iron and TIBC was found

Higher risk of Ectopic PregnancyHigher risk of Ectopic Pregnancy

• Intrauterine methods are such effective contraceptives that the absolute risk of pregnancy (intrauterine and ectopic) while using these methods is very low.

• A previous ectopic pregnancy is not a contraindication to the use of intrauterine contraception

• Contraceptives that inhibit ovulation will reduce the risk of ectopic pregnancy to a greater degree. A meta-analysis of case-control studies showed no increased risk of ectopic pregnancy with current Cu-IUD use (adjusted odds ratio 1.06; 95% CI0.91–1.24)

Women should be informed that the overall risk of ectopic pregnancy is reduced Women should be informed that the overall risk of ectopic pregnancy is reduced with use of intrauterine contraception when compared to using no contraception with use of intrauterine contraception when compared to using no contraception and no particular device is associated with a lower rate of ectopic pregnancy (Grade and no particular device is associated with a lower rate of ectopic pregnancy (Grade A).A).

FEMALE FEMALE STERILIZATIONSTERILIZATION

• Interferes with sexual intercourseInterferes with sexual intercourse

• Causes early menopauseCauses early menopause

• Causes abnormal uterine bleedingCauses abnormal uterine bleeding

• Is 100% percent effectiveIs 100% percent effective

Interferes with sexual intercourseInterferes with sexual intercourse

Does not interfere with sexual Does not interfere with sexual functionfunction

•Prospective studies have generally reported no change or improvements in sexual function, sexual desire, sexual satisfaction, coital frequency, and self-perceived femininity

• Important to emphasize the “tubal ligation “ does not interfere with tubal ligation “ does not interfere with sexual intercoursesexual intercourse

Causes early menopauseCauses early menopause

Sterilization not proven to cause Sterilization not proven to cause detrimental effect on ovarian detrimental effect on ovarian

functionfunction

Theory of early menopause:

1.interruption and reduction of blood supply to the ovaries. This could cause ovarian dysfunction and alter the ovaries' production and/or release of estrogen and progesterone;

On theoretical grounds alone, such theories arouse suspicion.Two thirds of the ovarian blood supply comes from the uterine artery, through the tubal artery, and one-third is from the ovarian artery.

Given that the anastomotic network between the tubal and ovarian arteries is extensive, it is unlikely that interruption of one of these arteries would result in clinically remarkable reduction in blood flow to the ovaries

Studies of more objective measures of ovarian function do not show any consistent changes in progesterone or estrogen levels ( longest follow up 6.9 years)

Causes abnormal uterine bleedingCauses abnormal uterine bleeding

Postulation that tubal occlusion may cause menstrual changes through 

1.interruption and reduction of blood supply to the ovaries. This could cause ovarian dysfunction and alter the ovaries' production and/or release of estrogen and progesterone; 2. interference with the direct diffusion of estrogen and progesterone from the ovaries to the uterus, leading to endometrial malfunction; 3. interference with the prostaglandin feedback mechanism between the uterus and ovary with deficient prostaglandin production and disturbances in ovarian steroidogenesis; and 4.uterine vascular congestion.

Most cohort studies that controlled for previous menstrual history, previous contraception, or increasing age showed no significant menstrual changes after sterilization

No significant menstrual changes after sterilization

• CREST study reported a 10-year cumulative failure rate of 1.85% for all sterilization methods. (0 .75% for unipolar coagulation and postpartum partial salpingectomy to a high of 3.65% for spring clip application)

• Reasons for sterilization failure include undetected preexisting pregnancy (luteal phase pregnancy), occlusion of the wrong structure, incomplete or inadequate occlusion, slippage of a mechanical device, development of a tuboperitoneal fistula, and spontaneous reanastomosis or recanalization of the previously separated tubal segments.

• When sterilization failure occurs, the pregnancy is more likely to be ectopic

• The overall risk of pregnancy is low among sterilized women. Therefore, the absolute risk of ectopic pregnancy among them is substantially lower than the absolute risk of ectopic pregnancy among women not using contraception

Is 100% percent effectiveIs 100% percent effective

Every contraception may Every contraception may failfail

Koetsawang S, Gates DS, Suwanichati S et al: Long-term follow-up of laparoscopic sterilizations by electrocoagulation, the Hulka clip and the tubal ring. Contraception 41:9, 1990Peterson HB, Xia Z, Hughes JM et al: The risk of pregnancy after tubal sterilization: findings from the US collaborative review of sterilization. Am J Obstet Gynecol 174:1161, 1996

CONTRACEPTION BARRIERS

AwarenessAwareness AvailabilityAvailability

CostCost Social BoundriesSocial Boundries

AwarenessAwareness

Education : both for public and medical staffAvailability of family planning clinics

CostCost

CHEAPEST IS THE BEST ??

A

C

B

D

AvailabilityAvailability

What is available in your clinic?How far is your clinic from patient’s homeRole of mobile clinic ?

SOCIAL BOUNDARIES'SOCIAL BOUNDARIES'

SOCIAL BELIEF

CONSENT ( EXTREMES OF AGE )

CONTRACEPTION FREEDOM

Thank you