1. Current Contraceptive
Choices
James L. Hubbard, DO
Fellow ACOOG
Carolina Ob/Gyn, Rock Hill, SC
Chief of Staff, Piedmont Medical Center
Board of SC Medical Examiners

2. History of Contraception

3. Ancient Egypt Earliest recorded contraception dates back 3,000 years.
Smooth pebbles were inserted into the uteri of camels to prevent them from getting pregnant on long trips across the desert.
Suppositories made from elephant and crocodile dung were inserted prior to intercourse, which has a high concentration of bile salt. Therefore the pH of this dung is the most acidic in the animal kingdom and was both a blocking agent and spermicide.

4. Other Ancient Cultures
The Talmud, an ancient Hebrew text, recommends manually removing the semen and douching with soap and vinegar.
Chinese scrolls recommend dabbing the cervix with a mixture of olive oil and honey, inhibiting both fetal growth and ovulation.
Ancient Greece used mixture of acacia gum, honey, and seed wool which breaks down to lactic acid.
In India, wild carrot seed was used as a post-coital contraceptive. Studies have shown that these seeds are a spermicide.

5. More Recent History
Condoms date back to 1546 made from everything from animal intestine to animal skins to okra pods. The term condom is thought to have originated from a Dr. Condom, a personal physician of King Charles II.
Origins of the pill came about by chance. A researcher discovered certain tribes in Mexico were eating a wild yam which seemed to act as a contraceptive. On analysis he was able to extract progesterone from these yams and formulate the first pill.

6. Barrier Methods

7. Condoms Male and female.
Failure rate if used perfectly is 2% in male, 5% in female.
Typical failure rate is 15% for male, 21% for female.
Protection against STDs.

8. Cervical Caps Failure rate is 29%. Can stay in place up to 48 hours.
Recommend pap 3 months after initial use due to increase chance of dysplasia which drops off after a year.
Does not protect against STDs.
May need to be refitted postpartum.

9. Diaphragms Perfect use failure rate 6%, actual 16%.
Requires fitting, increases UTI.
Recommended use with spermicide.
Some protection against STDs.

10. Spermicide Used independently, failure rate 29%.
Use with condoms no longer recommended.

11. ESTROGEN AND PROGESTREONE CONTRACEPTIVES

12. Combination Pill
Has been available since the 1960’s. Most contain Ethinyl estrogen and at least 7 different progestins.

14. Combination Pill
Mechanism of suppressing ovulation. Perfect use failure rate is 0.3%, actual 6%.
Advantages: shorter, lighter scheduled menses, no ovulation pain, sexual spontaneity.
Generic vs. brand name? FDA allows variability in potency in generics of -20% to +25% in dosing of generics .
Current brand oc available: Loestrin 24 Fe, Lo Loestrin Fe, Beyaz, Natazia, Lybrel, Seasonique.

15. Controversy around Drospirenone
Drospirenone: a derivative of spironolactone found in Yasmin, Yaz, and Beyaz.
Decreasing androgen side effects.
Hyperkalemia (renal insufficiency, hepatic dysfunction, and adrenal insufficiency).
Increased risk of blood clots.

17. Choosing OCs for your patient
New start (Lo loestrin)
Endometriosis (Seasonque, Lybrel)
Menstrual migraines (Seasinque, Lybrel)
Androgen excess/ PCO (Beyaz)
Breastfeeding (Lo loestrin)
Breakthrough bleeding (higher dose oc, Natazia)
Premenopausal (Lo loestrin)

18. NuvaRing® Very low dose
54 mm
4 mm
Very low dose
120 g/day etonogestrel
15 g/day ethinyl estradiol
Flexible transparent ring Outer diameter: 54 mm Cross-sectional diameter: 4 mm
One ring per cycle weeks ring-in week ring-free

19. Ortho Evra Patch
Higher doses of active estrogen in the blood stream than previously thought could increase the chance of DVT.
Less effective in women 190 lbs or above.

20. Lunelle Monthly injectable combination birth control.
No longer available since 2002 due to lack of potency assurance.

21. PROGESTERONE ONLY CONTRACEPTIVES

22. Pills (Mini Pills) Candidates for usage Breast feeding History of DVT
Over 35 years of age
Smokers
History of HTN

23. Depo-Provera injection
Weight gain
DUB
Fertility post-use
Due to decrease in bone mineral density (BMD) in users, the FDA recommends other forms of bc be used after 2 years of consecutive use if other forms of bc available.

24. Implanon Follow-up to Norplant, which was discontinued in 2002.
Single implant 4cm long and 2mm wide.
Placed under the skin of the upper arm.
Used for 3 years.

25. INTRAUTERINE CONTRACEPTION

26. ParaGard (Copper T)
Made from polyethylene with a solid sleeve of copper.
Introduced in 1984.
Primary mechanism of action is as a spermicide (releasing toxic cooper ions, causing phagocytosis, and causing crx mucous thickening).
20% of physicians still believe it has an abortive effect.
Biggest benefits are its long term use (10 years) and its non-use of steroids.
PID, pregnancy, perforation.

27. Mirena 5-year IUD impregnated with progesterone.
Similar mechanism of action as the ParaGard with anovulatory effect.
FDA approved for the treatment of DUB and perhaps premenopausal symptoms.
Use in nulliparous and young patients.

28. TUBAL LIGATION AND OCCLUSION

29. Failure rates of tubal methods
Silicon bands 1.8%
Partial salpingectomy 2.0%
Bipolar cautery 2.5%
S-ring (hulka) clip 3.7%
Filshie clip 0.9%

30. Intrauterine Tubal Occlusion
Essure
Uses a nickel titanium spring coil with polyethylene fibers. These fibers cause chronic inflammation and scarring.
Can be placed hysteroscopically in an outpatient setting with local anesthesia.
May be preferred in obese pts, pts wishing no scars, and pts with hx of adhesions.
Disadvantages are 3 month waiting period followed by histerosalpingogram, difficult to visualize ostia, perforation of tube, or tubal spasms.

31. Intrauterine Tubal Occlusion

32. Intrauterine tubal occlusion
Adiana
Similar to Essure, is placed hysterscopically, but uses a silicone pellet the size of a grain of rice and long with low level radiofrequency energy to create a superficial lesion in the tube.
This technique also needs to have a follow up histersalpingogram 3 months post procedure.

33. Intrauterine Tubal Occlusion

34. THE FUTURE OF CONTRACEPTION

35. Progesterone only vaginal ring Gyenfix Copper IUD
Lasts for a full year.
Gyenfix Copper IUD
6 sleeves of copper on a string embedded in the fundus.
Lasts 3 years and in use in Europe.
Fibroplant
Progestin-releasing fiber fixed to the uterine wall.
Norplant II
Similar to original Norplant but only 2 rods.
Lasts up to 3 years.

36. Quinacrine sterilization
Contraceptive spray
Progesterone delivered to your forearm.
Uses technology similar to EvaMist.
Once a month pill
Uses technology similar to Boniva.
Quinacrine sterilization
Involves insertion of 7 pellets into the uterus with an IUD-type tool.
Repeated 2 to 3 months in a row.
This causes tubular scarring.
Currently used in some third world countries, it remains controversial due to lack of knowing if there are any long-term side effects.

37. The End