The University of Texas Prevention Research Center Summer Course 2009: Adolescent Sexual Health The University of Texas Prevention Research Center Summer

The University of Texas Prevention Research CenterSummer Course 2009: Adolescent Sexual HealthThe University of Texas Prevention Research CenterSummer Course 2009: Adolescent Sexual Health

Birth Control MethodsPlanned Parenthood of Houston

and Southeast Texas, Inc.

www.pphouston.org

The University of Texas Prevention Research CenterSummer Course 2009: Adolescent Sexual Health

Key Dates in History


Key Dates in History• 1564: Fallopius, Italian doctor, describes the use

of linen CONDOMS to protect against syphilis.• 1840: First patented Diaphragm available in the

United States.• 1873: COMSTOCK LAW: restrict birth control by

forbidding mailing and transportation of contraceptives and in some state their sale and use.


Key Dates in History• 1937: America Medical Association ends the 25

year opposition to contraception; recognized that birth control needs to be taught in medical school.

• 1960: BIRTH CONTROL PILL becomes available in the in the U.S.

• 1966: Griswold Decision: Supreme Court declares laws prohibiting sale and use of contraceptive are unconstitutional.


Oral Contraceptive Pills “OCP’s”Available in many shapes, sizes, strengths, colors, and combinations.

Pills per pack may vary: 21-day, 28-day, and new Seasonale, which is 3-months


Oral Contraceptives: the Pill

Description:• Estrogen and Progestin• 1 pill is taken daily• Time sensitive, the pill is to be taken at

the same time every day


Effectiveness:• Perfect Use Failure Rate in First Year:

0.1% (of every 1,000 women who take pills for one year 1 will become pregnant in the first year)

• Typical Use Failure Rate in First Year: 5 % (of every 1,000 women who take pills for one year 5 will become pregnant in the first year)



Mechanism:• Suppresses ovulation • Thickens cervical mucus• Thins endometrium• Slows tubal motility



ADVANTAGES Regulates menses Decreases blood loss/

menstrual cramps No disruption at time of

intercourse Decrease risk of

ovarian/endometrial cancer

Treatment for acne

DISADVANTAGES Mood Changes,

depression, anxiety Daily pill taking may be

stressful No Protection against STI

(Sexually Transmitted Infections), including HIV

Nausea, breast tenderness, especially in the first few cycles

Weight gain



Special Considerations: Adolescents

• Failure rates are high in teens, due the regimented pill schedule

• At risk for STI, encourage condom use • Most common reason for sick days at

work/school, due to uncomfortable menstrual symptoms (under 25)

• Treats acne



Ortho Evra: The Patch

Description:• Estrogen and Progestin• 1 Patch a week, for 3 weeks• 4th week patch free, Menstruation• Usually worn lower abdomen or buttocks


Effectiveness:• Perfect Use Failure Rate in First Year:

1 women of every 1,000 women will become pregnant in the first year

• Overall Failure Rate: ?



Mechanism:• Prevents pregnancy in the same way

that oral contraceptives do (Ovulation, cervical mucus, endometrium, tubal motility)



Ortho Evra: The PatchAdvantages: Menstrual (Similar to the

Pills) Nothing to do on a daily

basis No disruption at time of

intercourse

Disadvantages: Mood Changes,

depression, anxiety No Protection against STI

(Sexually Transmitted Infections), including HIV

Nausea, breast tenderness, especially in the first few cycles

Weight gain Cannot use if

breastfeeding


Special Considerations:• Avoid placing the patch on exactly the same site two

consecutive weeks• NEVER PLACE PATCH ON THE BREAST!!!• Location of patch should not be altered mid-week• No band aide, tattoos or decals on top of patch as it may

alter absorption of hormones• It is unknown if tanning beds interfere

with efficacy• Avoid placing lotion/creams/powders

on site



Nuva Ring: the RingDescription:• Combined estrogen and progestin• Thin flexible transparent ring• Left in place in the vagina for three

weeks and removed for a week to allow a menstrual period the fourth week.

• Maintains a steady low release rate while in place.


Nuva Ring: the RingEffectiveness:

• Overall pregnancy rate: 1.2 per 100 women


Nuva Ring: the RingMechanism:

• Suppresses ovulation• Similar to combined pills


Advantages: Only TWO TASKS:

Insertion/Removal 1x month

Steady even hormonal levels in blood are achieved

Privacy/No visible patch or pill packages

95% of women say they cannot feel device

Disadvantages: Some women dislike

placing/removing objects into/out of their vagina

Adverse side effects similar to the pill

Possible devise expulsion

Nuva Ring: the Ring


Special Considerations:

• Excellent option for adolescents: Require less discipline than taking pills

• Women wanting regular menstrual periods

Nuva Ring: the Ring


Depo Provera “The Shot”• Private• Don’t have to

remember to take a pill

• Four times a year


Description:• Injected intra-muscularly into the deltoid or

gluteus-maximums every 11 to 13 weeks.• Progestin only

Depo Provera “The Shot”


Effectiveness:• Perfect use failure rate in first year:

0.3% • Typical use failure rate in first year: 3%

Depo Provera


Mechanism:* Suppresses Ovulation* Thickens cervical mucus* Slows tubal and endometrial mobility

Depo Provera


Depo ProveraAdvantages: Less menstrual blood

loss and anemia After one year 50% of

users will develop amenorrhea

80% will develop amenorrhea in 5 years

Only need to remember 1x every three months

Disadvantages: Irregular menses during first

several months Unpredictable spotting and

bleeding Possible weight gain:

Progressive-Significant (5.4 1st year, after 5 years 16.5)

Patient fear of pregnancy or build up of menses in uterus if not explained well

Decreased libido Fear of needles Return to fertility is long

average 10 months from last injection


Special Considerations: Adolescent women: Extremely effective with

long carry over if patient returns late for reinjection

All women, including teens, should be encouraged to take calcium tabs and exercise regularly

Depo Provera


Intrauterine Device “IUD”

• This is not your Mother’s IUD….

• Most popular method in the world, although it is not very popular in the United States.


Intrauterine Contraception: ParaGard/Mirena

Description:• T-shaped device with two flexible arms that bend

down for insertion but open into the uterus.• Two straw-colored strings protrude through the

cervix into the vaginal canal


ParaGard/MirenaEffectiveness:

ParaGard• 99.2%-99.4%

Effectiveness: Mirena

• 99.9%


Mechanism: Paragard• Works by preventing

fertilization• Works primarily as a

spermicide,Copper ions inhibit sperm motility so they rarely reach the tube

Mechanism: Mirena• Progestin Only• Causes cervical mucus to

become thicker then by preventing sperm from moving up the reproductive track

• Prevents implantation

Intrauterine Contraception: ParaGard/Mirena


ParaGardAdvantages: Effective long term (10 years)

contraception from a single decision.

Requires no action at time of intercourse

Cost effective Rapid return to fertility Good option for women who

cannot use hormones 95% user satisfaction, the

highest of any other contraceptive currently begin used by women.

Disadvantages: Blood loss during menstruation

increased by 35% and increase cramping

Must check strings monthly after menstruation

Requires office procedure for insertion and removal, can be uncomfortable

• Increase risk of infection PID• Uterine perforation• May be expelled


MirenaAdvantages: After 3-4 months it decreases

menstrual blood loss more than 70%

Amenorrhea: 20% by 1 year, 60% by 5 years

Reduced risk PID, ectopic pregnancy by 60%

As effective, or more effective than female sterilization

Long lasting method, up to 5 years

Immediate return to fertility

Disadvantages: Possible expulsion Acne, Headaches,

discomfort after insertion or removal

Risk of PID increased Ovarian cysts, most regress

spontaneously


ParaGard/Mirena

Special Considerations: Women at risk for STI’s may be discouraged from

usage. (Paragard/Mirena) Some clinicians require chlamydia and gonorrhea

testing prior to insertion. (Paragard/Mirena)


ImplanonDescription:• Progestin only• Thin, flexible, plastic implant about the

size of a matchstick. • Inserted under the skin by the bicep

muscle.• Implanted in the arm for

3 years.


Effectiveness:• Perfect Use Failure Rate in

First Year: 0.3% • Typical Use Failure Rate in

First Year: 3%

Implanon


Mechanism:• Constantly releases progestin into the

bloodstream• Suppresses ovulation• Thickens the cervical mucus

Implanon


ImplanonAdvantages:• Insertion only takes a few

minutes• Protection against pregnancy

is immediate if you get the implant during the 1st five days of your period

• Ability to get pregnant is immediate after removal

• Gives continuous long-lasting birth control without sterilization

• No medicine to take every day

Disadvantages:• Irregular bleeding is the

most common side effect• Periods become lighter and

may stop altogether or periods may become heavier and last longer

• Some women will have longer heavier periods

• Acne, change in appetite, or sex drive

• Pain at the site of insertion


Cervical Cap

• Inserted into vagina to cover cervix.

• Was once a very popular method. Used with spermicidal jelly or sometimes foam.

• Must be fitted by a clinician.


Diaphragm• Inserted into vagina to

cover cervix.• Was once a very

popular method. Used with spermicidal jelly or sometimes foam.

• Like the Cervical Cap, it must be fitted by a clinician.

• 84%-94% Effective


Emergency Hormonal Contraception: Plan B

Description: Progestin Only (More effective less side effects than

combine EC) ASAP, but can be used up to 120 hours, sooner is

better Pills must be taken 12 hours apart Over-the-counter for women ages 18 and over FDA recently passed a ruling allowing EC to be OTC for

women beginning at 17 yearsof age, but it has not gone effect as of yet



Effectiveness:• Pregnancies/100 women:

< 12 hours: 0.4% 1-3 days: 2.7%Average: 1.1%



Mechanism:• Prevents pregnancy and never by

disrupting an implanted pregnancy• Inhibits ovulation• Thicken cervical mucus• May effect tubal transport of sperm or ova



Advantages Opportunity to prevent

pregnancy after, rape, mistake or method failure

Reduces anxiety Process attaining EC

may initiate women to use ongoing contraception

Disadvantages Time limitation Next menses may be

early Notable changes in

flow for next menses Not as effective as

other forms of birth control

Can be more expensive

23% experience nausea few experience vomiting



Special Considerations:• There is no limit to the number times in a

year a woman can use EC, but it is not to be used in place of birth control (it is also expensive).


Non-Prescription Methods


Non-Prescription Methods

• Female Condom• Male Condom• Spermicidal Foam• Spermicidal Film• Natural Family Planning• Abstinence


FEMALE CONDOMS

•Popular in developing nations because of its durability - in fact, women have been known to wash and reuse it. This is NOT recommended.•NOT REUSABLE •Purchase at a drug store


Female Condom

Description:• Inserted into vagina with the moveable ring

inside the vagina creating an internal sheath. The large ring externally covers the labia.

• Disposable single use sheath made of polyurethane

• Shelf life: 3-5 years• More expensive than male condom


Female Condom

Effectiveness:• Perfect use failure rate in first year of

use: 5%• Typical use failure rate in first year: 21%

• 79% - 95% Effective


Female Condom

Advantages: Can be inserted up to 8 hours

before sex to allow more spontaneity

Woman can make sure she is somewhat protected against STIs

No medical visit required, available over the counter

Can be safely used with individuals who have latex allergies

Disadvantages: Requires careful sexual

practices during intercourse

Noise made during intercourse can be distracting, if occurs add more lubricant

In one study, 88% of females disliked using the female condom

Somewhat difficult for new users

Possible increase risk of UTI

Possible difficulty inserting and removing devise


Female Condom

Special Considerations:• Need to have time to practice inserting prior

to engaging in intercourse• Never use a male and female condom at the

same time. This will increase the risk of breakage of one or both condoms


Male Condoms• The condom is

the oldest method around.

• Worldwide use to protect again HIV


Male CondomDescription:• Made of latex, polyurethane or natural

membranes• Available in at least 2 different sizes and a variety

of textures and thickness• May come with or without spermicidal coating• Reduces risk of pregnancy and contracting

sexually transmitted infections• Natural Skin condoms do not protect against HIV

transmission


Male CondomEffectiveness:Perfect use failure rate in the first year:

3%Typical use failure rate in the first year:

14%

Overall: 85% - 98% Effective


Male CondomAdvantages: Some men maintain erections

longer with condoms If the partner puts the condom

on it can increase the pleasure Makes sex less messy by

catching the ejaculate Intercourse may be more

pleasurable because of the fear of pregnancy and STI’s may be decreased

Cost effective Opportunity of couples to

improve communication and negotiating skills

Disadvantages: Use may be perceived as

interrupting love making Requires discipline to

resist impulse to progress to sexual act after erection

May cause loss of erection.

Decrease the sensation


Male CondomSpecial Considerations:• Users must avoid oil based lubricants (latex

condoms)– Water-based lubricants instead

• Use of N-9 (chemical) coated condoms may be associated with an increased risk of contracting HIV

• Embarrassed about purchasing condoms due to the stigma.


Spermicidal Foam• Available over the

counter.• Can be messy.• Protects against

pregnancy (but not STD’s).

• Suppository or foam applicator.

• Best used with a condom for STD protection. • Only 71%-82% effective if

used alone


Sponge• Non-reusable piece of soft foam filled

with spermicide• Must be inserted into vagina before

intercourse & six hours after intercourse

• 84-94% effective at preventing pregnancy

• No protection against STDs/STIs


Vaginal Film• Available over the

counter.• Small film containing

spermicide that melt inside vagina to offer protection against pregnancy.

• Use with a condom for STD protection.


Abstinence

“Periodic Abstinence” has high pregnancy rate.

“Continuous Abstinence” is effective when sustained over a long period of time.

SEX


Withdrawal

Mechanism:• The man pulls his penis out of the vagina

before he ejaculates• Thought to prevent pregnancy if the sperm

is kept out of the vagina


Effectiveness:• Perfect Use Failure Rate: 96%• Typical Use Failure Rate: 73%• Semen can pick up enough sperm left in the

urethra from a previous ejaculation• Offers no protection against sexually

transmitted infections.

Withdrawal


Advantages:• Can be used when no

other method is available• No medical or hormonal

side effects• No prescription necessary

Disadvantages:• Not for men who don’t

know when to pull out or ejaculate prematurely

• Not recommended for teens and sexually inexperienced men

• Requires great self-control, experience, and trust

Withdrawal


SURGICAL PROCEDURES


Vasectomy - Males• Permanent method of birth control– Occasionally this method can be

reversed (expensive)

• Closes the vas deferens that carry sperm

• 99.9% effective at preventing pregancy

• No protection against STDs/STIs


Tubal Ligation - Females• Permanent method of birth control to

sterilize women– Occasionally this method can be

reversed (expensive)

• Fallopian tubes are cut to prevent the egg and sperm from meeting


NATURAL FAMILY PLANNING/FERTILITY AWARENESS


Natural Family Planning/Fertility Awareness• Keeping track of which days a pregnancy

is most likely to happen – Daily record must be kept of body

temperature & changes in secretions from cervix

– A woman must also keep track of periods

• No STI/STD protection• 75%-96.25% effective at preventing

pregancy

Documents

The University of Texas Prevention Research Center Summer Course 2009: Adolescent Sexual Health The University of Texas Prevention Research Center Summer