Introduction to Contraception

Introduction to Contraception
Anita Jaynes, CNM, MS University of Nebraska Medical Center Obstetrics & Gynecology

3,000,000 unintended pregnancies occur in the U.S. each year.
50% of U.S. pregnancies are unintended. Despite our modern contraceptives, half of all pregnancies that occur in the U.S. each year are unintended. That translates to about 3 million unintended pregnancies every year!

Women’s Reproductive Life Scan
The reproductive years are defined as ages Of the 39 years spent in the reproductive stages of life, women spend an average of 20 years trying to avoid pregnancy. The reproductive life span is defined as ages (although we know there are exceptions). Of the 39 years spent in the reproductive stages of life, women spend an average of 20 years trying to avoid pregnancy.

Who needs contraception
Who needs contraception? Every reproductive-age woman who is at risk for “sperm exposure” and who does not currently desire pregnancy. Every reproductive age woman who is at risk for “sperm exposure” and who does not currently desire pregnancy should be offered contraception.

Who does not need contraception?
women who self-identify as lesbian celibate women On the other hand, it is important to recognize that every reproductive age woman does not need or desire contraception. Women who self-identify as lesbian --- that is, women who have sex with other women --- are not at risk for “sperm exposure” and therefore do not need contraception. It is a misconception to say that “sexually active” women need contraception, because if they are sexually active only with other women, they do not! Recent studies have shown that 2-4% of adults self-identify as gay or lesbian, although Kinsey’s famous studies from the 1940s reported that as many as 10% of American adults were homosexual. Women who are celibate --- by choice or by circumstances --- do not need contraception. Women who desire pregnancy obviously do not need contraception. And any woman who declines the offer of contraception should not be coerced into accepting a method of birth control. women who do not want contraception − for any reason! women who desire pregnancy

Don’t ASSume anything −
Don’t be an ass! Don’t ASSume anything − ASK! “Do you need contraception?” not “What kind of birth control do you use? Don’t be an ASS by ASSUMING that a woman needs birth control, or that she is using a method. Ask the patient, “Do you need contraception?” NOT “What kind of birth control do you use?”

What is the “best” contraceptive method?
The best contraceptive method for an individual woman is a method that is: medically appropriate effective in preventing pregnancy used consistently and correctly satisfactory to the woman at her stage of life The best contraceptive method for an individual woman is the method that is MEDICALLY APPROPRIATE EFFECTIVE IN PREVENTING PREGNANCY USED CONSISTENTLY AND CORRECTLY and SHE LIKES IT! These criteria will change depending on the individual woman’s stage during her reproductive life.

Life Stage: Menarche to First Intercourse
Fertility goals: postpone pregnancy preserve future fertility Sexual behavior: no intercourse yet possibly experimenting with kissing, petting, etc. Contraceptive need: education The first stage of a woman’s reproductive life is from menarche to first intercourse (or first “sperm exposure”). A young woman’s fertility goals are to postpone pregnancy while preserving future fertility. A young woman in this stage of her reproductive life needs education and preparation for the next stage!

Life Stage: First Intercourse to First Birth
Fertility goals: postpone pregnancy preserve future fertility Sexual behavior: ? multiple partners frequent intercourse spontaneous, unpredictable intercourse Contraceptive needs: efficacy reversibility not coitus-linked STI prevention More than 80% of Americans first have intercourse as adolescents. More than half of women and ¾ of men ages have had sexual intercourse. Surveys conducted in the 1990s found that 70% of adolescents used a contraceptive at the time of their first intercourse. Young women’s fertility goals are to prevent pregnancy now while preserving fertility for the future. In other words, they want a birth control method that is both effective and reversible. Young adults may (or may not) have more than one partner at the same time, or they may engage in “serial monogamy.” They tend to have intercourse frequently, spontaneously, and unpredictably. Therefore, they need contraception that is: highly effective in preventing pregnancy completely reversible (does not adversely effect future fertility) not linked to coitus However, they also need protection from sexually transmitted infections.

Life Stage: First Birth to Last Pregnancy
Fertility goals: space pregnancies preserve future fertility Sexual behavior: one partner (?) moderate to low frequency of intercourse predictable intercourse Contraceptive needs: efficacy reversibility ? OK if coitus-linked ? need for STI prevention After the birth of the first child, a woman’s fertility goals may change. Generally speaking, she wants to space her pregnancies but still preserve future fertility. The woman who has a child or children may have only one partner, less frequent intercourse, and more predictable intercourse . . . BUT DO NOT MAKE THAT ASSUMPTION! ASK!

Life Stage: Last Birth to Menopause
Fertility goals: no further pregnancies no need to preserve fertility Sexual behavior: one partner (?) low to moderate frequency of intercourse predictable intercourse Contraceptive needs: efficacy may be irreversible ? OK if coitus-linked ? need for STI prevention In the last reproductive life stage, when the woman feels that her family is complete, her contraceptive goals change from postponing pregnancy to no further pregnancies. There is no desire to preserve future fertility. Again, this woman might have only one partner and might have infrequent intercourse at predictable times . . . BUT YOU CAN’T ASSUME ANYTHING. ASK!

Contraceptive Options
Estrogen/progestin oral transdermal transvaginal injectable Progestin only implants intrauterine Non-hormonal IUD Barrier methods male condom female condom diaphragm, cervical cap Periodic abstinence or fertility awareness Sterilization tubal ligation transcervical (Essure®) vasectomy What are the contraceptive options? They include: A combination of estrogen and a progestin, which can be delivered: orally (combined OCPs) transdermally (Ortho Evra patch) transvaginally (Nuva Ring) as an injection (Lunelle; currently unavailable in the U.S.) Progestin-only methods: oral (progestin-only or “mini” pills) injectable (Depo Provera) implants (Norplant) intrauterine (Mirena) Non-hormonal IUD: Paragard copper T Barrier methods: male condom female condom diaphragm, cervical cap Periodic abstinence or fertility awareness methods Sterilization female: tubal ligation or Essure transcervical sterilization male: vasectomy Emergency contraception: post-coital contraception • Emergency contraception

Contraceptive Use in the U.S. among reproductive-age women
What are Americans using? 26% of reproductive-age women have undergone sterilization – the most popular contraceptive method 25% of women are taking “The Pill” 19% of couples are using the male condom 10% of reproductive-age men have undergone vasectomy 7.5% of reproductive-age women are using NO CONTRACEPTION 3% are using withdrawal for birth control 3% are using an injectable contraceptive 2.5% are using periodic abstinence 2% are using a diaphragm 1% are using an IUD The rest of the people are using “other” methods such as spermicides, female condoms, the patch, the ring, etc. Hatcher, R.A. et al. Contraceptive Technology. 18th revised edition, 2004.

Contraceptive Considerations
Effectiveness Frequency of intercourse Sexual behavior Desire for future fertility Cost of method Side effects Contraindications Noncontraceptive benefits Patient’s perceptions and misconceptions Patient’s health status and medical conditions These are the clinician’s considerations in helping a woman to choose a contraceptive method: effectiveness frequency of intercourse sexual behavior desire for future fertility whether the method is affordable potential side effects contraindications noncontraceptive health benefits the patient’s perceptions and misconceptions the patient’s general health and any medical conditions

What does a woman want from a contraceptive?
“The great question that has never been answered, and which I have not yet been able to answer, despite my thirty years of research into the feminine soul, is ‘What does a woman want?’” − Sigmund Freud What does a woman want from a contraceptive? • Is it safe? • Does it work? • Will my partner accept it? • Can I afford it? And some women will ask − • Does it cause an abortion? From the patient’s point of view, what most women want to know is: Is it safe? (many misconceptions about safety) Does it work? Will my partner accept it? Can I afford it? Some women will also want to know whether a given method causes an abortion. As the clinician, it is important to be prepared to explain the mechanism of action for each method.

Is it safe? Voluntary risks in perspective
ACTIVITY CHANCE OF DEATH IN A YEAR Motorcycling 1 in 1,000 Automobile driving 1 in 5,900 Playing football 1 in 25,000 Canoeing 1 in 100,000 Age < 35, nonsmoker, OCP use 1 in 200,000 IUD use 1 in 10,000,000 Laparoscopic tubal ligation 1 in 38,500 Vasectomy 1 in 1,000,000 Pregnancy beyond 20 weeks 1 in 10,000 All contraceptives are relatively safe, and safer than pregnancy and childbirth. To put it in perspective, the risk of death during one year from driving a car is 1 in 5,900. The risk of death related to birth control pills in a nonsmoking woman under 35 years of age is 1 in 200,000. The risk of death attributable to use of an IUD is 1 in 10 million. But the risk of death due to pregnancy beyond 20 weeks is 1 in 10,000.

Percentage of women experiencing an unintended pregnancy during the first year of typical use and the first year of perfect use of contraception in the United States METHOD TYPICAL USE PERFECT USE None 85% Spermicides 29% 18% Withdrawal 27% 4% Periodic abstinence 25% Diaphragm 16% 6% This chart shows the percentage of women who will experience an unintended pregnancy during the first year of use of a contraceptive method. Perfect use means that the method is used correctly and consistently, according to directions. Typical use means how many pregnancies will result with imperfect use, that is, with inconsistent or incorrect use. By comparing the rates of typical and perfect use, you can see how “forgiving” a method is of imperfect use. Using no contraception, 85% of women who have “sperm exposure” will become pregnant within one year. Just to look at a couple of examples, you can see that only 4% of women would become pregnant if withdrawal were practiced perfectly. However, due to user errors, the typical pregnancy rate would be 27%

Percentage of women experiencing an unintended pregnancy during the first year of typical use and the first year of perfect use of contraception in the United States METHOD TYPICAL USE PERFECT USE Male condom 15% 2% Pill, patch, ring 8% 0.3% Depo-Provera 3% Paragard IUD 0.8% 0.6% Female sterilization 0.5% Male sterilization 0.15% 0.10% You can see that male condoms are actually a very good method when used perfectly, with only a 2% failure rate. However, when condoms are not used consistently and correctly, 15% of users will become pregnant within one year. Contraceptives containing estrogen and progestin --- the pill, patch, and ring --- have a failure rate of only 0.3% with perfect use but 8% with typical use. Typical use means that the user forgets pills, doesn’t change her patch on time, etc. Even though female sterilization has no “user error,” there is still an unintended pregnancy rate of 0.5%. THE ONLY METHOD THAT IS 100% GUARANTEED IS ABSTINENCE.

Combination Contraceptives (Estrogen & Progestin)
Combination contraceptives contain a combination of estrogen and a progestin. They are available in several forms. All of the most common oral contraceptives are a combination of estrogen and progestin. “Birth control pills” were first introduced in 1960. The Ortho Evra patch came out in 2002 and delivers the same hormones through a transdermal system. Also in 2002, the Nuva Ring was introduced which delivers estrogen and progestin by means of a flexible plastic ring inserted in the vagina. This combination was also available in an injectable form in the U.S. under the brand name Lunelle. Lunelle was introduced into the U.S. market in 2000 and withdrawn by the manufacturer in 2002 because of concerns that some lots of the drug were not sufficiently potent to prevent pregnancy. There is currently no injectable combination contraceptive available in the U.S.

Ingredients: Estrogen (ethinyl estradiol) mcg Progestin (varying forms, doses, potency) Mechanisms of action: Suppression of ovulation Thickening of cervical mucus Thinning of endometrium Slowing of tubal and endometrial motility All of the combination contraceptives contain estrogen as ethinyl estradiol in dosages ranging from 20 to 50 micrograms plus one of seven different progestins. Combination contraceptives work by: (1) suppression of ovulation (90-95% of the time) (2) thickening of the cervical mucus, blocking sperm penetration and entry into the upper reproductive tract (3) thinning of the endometrial lining, thus inhibiting implantation (4) slowing tubal and endometrial motility, thus inhibiting implantation

GENERAL ADVANTAGES • Highly effective in preventing pregnancy when taken correctly • Not related to coitus • Rapid return to fertility after discontinuation • Very safe when prescribed for appropriate users • Can be used throughout the reproductive years When taken correctly and consistently, combination contraceptives are highly effective. With perfect use, the rate of unintended pregnancy is 3 per 1,000 women per year, or less than 1 percent. However, the rate of unintended pregnancy with typical use is 8% because of user error. Combination contraceptives generally improve sexual satisfaction because they do not interfere with love-making. Also, their effectiveness enables women to relax and not worry about becoming pregnant. On average, women who discontinue combination contraception return to ovulation in about 2 weeks. Combination contraceptives are safer for a woman’s health than pregnancy and childbirth. They do not increase a woman’s risk of death unless she is a smoker. For this reason, appropriate client selection is crucial. A 2000 survey showed that 41% of women believed that birth control pills were hazardous to health --- education is important. Combination contraceptives can be used by non-smokers throughout their reproductive years. Age alone is not a contraindication. Women need to know that combination contraceptives will not hasten nor delay the onset of menopause.

HEALTH BENEFITS • Fewer pregnancies = fewer maternal deaths • Reduction in risk of ectopic pregnancy • Decrease in dysmenorrhea • Decrease in menorrhagia • Reduction in PMS symptoms • Elimination of Mittelschmerz • Decreased anovulatory bleeding • Fewer ovarian cyst problems The CDC estimates the current maternal death rate in the U.S. as 11.8 pregnancy-related deaths per 100,000 live births. Since half of pregnancies are unintended, prevention of those pregnancies could decrease the maternal death rate. Use of combination contraceptives reduces the risk of ectopic pregnancy by over 90%. Approximately one in 80 pregnancies in the U.S. is ectopic. Research has shown that combination contraceptives reduce the incidence of all degrees of dysmenorrhea by 60%. Users report fewer absences from school or work and the use of less pain medication. Combination contraceptives reduce the number of days of bleeding and the amount of blood loss. Nearly 50% of women report a reduction in menstrual bleeding. Decreased blood loss helps prevent anemia. PMS symptoms (breast tenderness, bloating, cramping, irritability, increased appetite) are reduced or eliminated. Mittelschmerz (mid-cycle bleeding caused by ovulation) is eliminated. Low-dose oral contraceptive use was associated with an 80% improvement in dysfunctional uterine bleeding caused by anovulatory cycles. Because combination contraceptives suppress ovulation, they reduce the risk of hemorrhagic corpus luteum cysts. Since stimulation of the ovaries by FSH and LH is reduced, the incidence of other functional ovarian cysts is also reduced.

HEALTH BENEFITS • Endometrial and ovarian cancer risk reduction • Decreased risk of benign breast conditions • Suppression of endometriosis • Improvement of androgen-sensitivity or androgen-excess conditions (such as PCOS) • Improvement in hot flashes and hormonal fluctuation symptoms in perimenopausal women When compared with women who have never used oral contraceptives, OC users are 40% less likely to develop epithelial ovarian cancer or endometrial cancer. This protection lasts for at least 20 years after discontinuing the pills! Combination contraceptive users are less likely to develop fibrocystic breast changes, benign cysts, or fibroadenoma. Since combination contraceptives reduce menstrual bleeding, they presumably decrease retrograde menses which is believed to contribute to endometriosis. Combination contraception can be used on an extended basis in women with symptomatic endometriosis to cause temporary atrophy of the endometriotic implants and relief of symptoms. It is important to realize that this is temporary and the endometriotic implants will become active again when hormone therapy is stopped. Combination contraceptives can be used to reduce acne. Only two birth control pills have FDA approval to advertise improvement of acne (Ortho Tri-Cyclen and Estrostep) but other pills with low androgenicity will have the same effect. Women can use combination contraception for symptom relief during perimenopause.

GENERAL DISADVANTAGES • Must be taken consistently and correctly to be effective • Storage, access, lack of privacy • Can interfere with lactation • No protection against STIs • Common side effects include: nausea, vomiting headaches weight gain breast tenderness decreased libido skin hyperpigmentation Combination contraceptives must be used consistently and correctly to be effective. For pill users, this means remembering a pill every day. Women must be able to store their contraceptives in a safe place and have access to them when they need them. For adolescents or women whose partners do not want them to use contraception, this can be a barrier. The patch is visible on the wearer’s body. Estrogen interferes with breast-feeding by reducing the quantity of milk produced. Combination contraceptives do not provide any protection against STIs. Hormones have side effects, which tend to be more bothersome when the method is first initiated.

COMPLICATIONS • Venous thromboembolism • Myocardial infarction and stroke • Hypertension DO NOT Rx TO WOMEN AGE > 35 WHO SMOKE! The risk of venous thromboembolism is increased with the use of estrogen. Estrogen increases liver production of a variety of clot-promoting factors (such as factor VII, factor VIII, factor X, and fibrinogen), decreases the production of clot-lysing factors (such as antithrombin III and protein S), and increases platelet activity. Progestins alone have no impact on the clotting system. When combined with estrogen, they are thought to temper the action of estrogen or have no effect. In most healthy women, estrogen and progestin together have no clinically significant impact on the clotting system. However, women who have clotting disorders such as factor V Leiden mutation or Protein S or Protein C synthesis disorders are at increased risk for VTE with OC use --- and many of these women are undiagnosed. To put the VTE risk in perspective: The rate of VTE is 4-5 for every 100,000 reproductive age women, per 100,000 low-dose oral contraceptive users, and per 100,000 pregnant women. (Smoking does not change the risk of VTE in combination contraceptive users.) Healthy, nonsmoking women who do not have other risk factors for MI or stroke have no increased risk by using combination contraceptives. However, women who smoke have a greatly increased risk. Women who have atherosclerotic coronary vessel damage due to smoking, hypertension, and/or hyperlipidemia are vulnerable to MI because estrogen also causes arterial thrombosis. Estrogen increases circulating levels of angiotensin II, which can cause a rise in both systolic and diastolic blood pressure. Both estrogen and progestin enhance aldosterone activity, which results in fluid retention and can contribute to an increase in blood pressure.

CONTRAINDICATIONS • Personal history of thrombosis; known clotting disorder (factor V Leiden mutation, etc.) • Personal history of stroke or MI • Labile hypertension • Estrogen-sensitive malignancy (such as breast CA) • Active liver disease • Migraines with focal neurologic symptoms

How to Take Birth Control Pills
The 28-day pack contains 21 active pills + 7 placebo pills. Getting started: • “First day” start • Sunday start • “Quick Start” Continuing: one pill per day, every day. Withdrawal bleeding will occur during the placebo week. The birth control pill pack contains 28 pills active pills and 7 placebo pills. There are several ways of starting the pills. The traditional way was to start on the first day of the menstrual cycle. The advantages of this are that it is absolutely certain that the patient is not pregnant and you prevent ovulation during the first cycle. The disadvantages are that she might become pregnant while waiting to start her pills, and she might start her pills on a day that is hard to remember, such as Thursday. The Sunday start means that if the menstrual period starts on Sunday, she takes the first pill that day. If it starts on any other day, she takes the first pill the following Sunday. Since she will then take her last pill of the cycle on Saturday, she may have difficulty obtaining a refill on the weekend in order to start the next pack on time on Sunday. The “Quick Start” method means that the patient takes the first pill right away, in the office. This can be done at any time during the menstrual cycle, as long as you are reasonably sure that the patient is not already pregnant. Research has shown that the Quick Start method is the most effective in getting women started on pills. If they are told to wait for their menses before starting, as many as 25% of young women who are taking pills for the first time will not initiate the method correctly because they forgot the pill-taking instructions, failed to fill the prescription in time, had unanswered questions or concerns about the method, or conceived in the interim. After she has started taking the pills, she must take one pill per day, every day. The last 7 pills are placebo pills. Although it is not necessary to take them, it is recommended as a reminder to stay on schedule. The woman will experience withdrawal bleeding during the placebo week. WITHDRAWAL BLEEDING IS NOT TRULY MENSTRUATION, although the patient will experience it as a “period.” ≈ $35.00 per cycle

Each patch is worn for 7 days.
How to Use “The Patch” Each patch is worn for 7 days. Getting started: apply the first patch to clean, dry skin anywhere except the breast. On the same day of the 2nd week, remove the 1st patch and apply a new one to a different site. On the same day of the 3rd week, replace patch again. On the same day of the 4th week, remove the last patch. Do not apply a patch for 1 week. Withdrawal bleeding will occur. Each patch is worn for 7 days, then removed and replaced. (See directions above.) ≈ $40.00 per cycle Repeat this pattern every 4 weeks.

How to Use “The Ring” Getting started: squeeze the ring between your thumb and index finger. Insert it in the vagina. Leave the ring in place for 21 days (3 weeks). At the end of the 21 days, remove the ring by inserting a finger in the vagina and pulling it out. Discard the ring and wait 7 days. Withdrawal bleeding will occur. Repeat the pattern (3 weeks in, 1 week out) See directions above for Nuva Ring. ≈ $40.00 per cycle

“Extended Use” Regimens
Monthly withdrawal bleeding is NOT necessary! Seasonale provides 84 active pills followed by 7 placebo pills for 4 “periods” a year. Any monophasic pill, the patch, or the ring can be used on an extended basis. The purpose of menstruation in normally cycling women (not on contraception) is to resolve the prior cycle (which did not result in pregnancy) and prepare for the next cycle (which may result in pregnancy). With contraceptive use, pregnancy is not desired. There is NO BIOLOGICAL REASON to have withdrawal bleeding on a monthly basis while on contraception! Seasonale is a monophasic, low-dose combination pill that advertises “4 periods a year.” The patient takes 84 active pills followed by 7 placebo pills, during which withdrawal bleeding occurs. Any monophasic pill, the patch, or the ring can be used on an extended basis, although this is an “off-label” use. “Extended use” means --- temporarily manipulating the cycle for convenience (to avoid having a period while traveling, competing in athletic event, etc.) “bicycling” or “tricycling” --- taking 2 or 3 months’ worth of active pills and then stopping for a withdrawal bleed continuous use --- taking only active pills continuously, without ever stopping or taking placebo pills --- This is safe but most women will have bothersome breakthrough bleeding. ≈ $ per pack

Progestin-Only Contraceptives
Progestin-only methods are available in pill form, as an injectable (Depo Provera), and as an intrauterine device (Mirena). The Norplant contraceptive implant system has been taken off the market in the U.S. but is still available in some other countries. The implants were intended to be used for up to five years. A single-rod implant called Implanon is available in 9 European countries and may be available soon in the US. It will be in place for 3 years.

Mechanisms of action: • Inhibition of ovulation • Prevention of sperm penetration by thickening and decreasing the quantity of cervical mucus • Endometrial atrophy Progestin-only contraceptives work by: Inhibiting ovulation by inhibiting positive feedback of estradiol on LH and FSH (suppressing midcycle peaks of LH and FSH) Thickening cervical mucus to prevent sperm penetration Changing the endometrium so that the atrophic lining is not receptive to the blastocyst

ADVANTAGES OF ALL METHODS • No estrogen • Reversible • Amenorrhea or scanty bleeding • Improvement in dysmenorrhea, menorrhagia, PMS, endometriosis symptoms • Decreased risk of endometrial or ovarian cancer • Decreased risk of PID • Compatible with breast-feeding All of the progestin-only methods have these advantages: Since they contain no estrogen, they do not carry the risks of thrombosis associated with estrogen. Women who do not tolerate estrogen because of migraines, nausea, or hypertension can often use a progestin-only method. Progestin-only methods are reversible. Because of the suppression of ovulation and atrophic endometrium, progestin-only methods decrease heavy bleeding, cramping, PMS symptoms, and pain associated with endometriosis. They also decrease the risk of endometrial or ovarian cancers and PID. Progestin-only methods are compatible with breast-feeding. The best time to initiate the method is controversial. In theory, lactogenesis is triggered in part by the drop in natural progesterone that occurs after delivery. Therefore giving a progestin can interfere with the initiation of lactation. Once breast-feeding is established, there is no effect on milk production and some studies have shown increased milk. Although some clinicians give Depo Provera before postpartum discharge from the hospital, several organizations are recommending waiting until the six-week checkup.

DISADVANTAGES OF ALL METHODS • Menstrual cycle disturbances • Weight gain • Depression • Lack of protection against STIs All progestin-only methods share these disadvantages: Menstrual cycle disturbances – which can include frequent or continuous bleeding Weight gain Progestin-only methods do not seem to cause depression, but they do seem to make it worse in women who are already depressed or prone to depression. Like most other methods, progestin-only methods do not provide protection against STIs.

Progestin-Only Pills Cycle consists of 28 active pills; there is no “placebo week” Vulnerable efficacy! Each pill must be taken on time at 24-hour intervals. Compatible with breast-feeding & recommended in combination with lactational amenorrhea. BRAND NAMES: Micronor Nor-QD Ovrette Progestin-only pills are supplied in 28-day packs. Every pill is an active pill. There is no “placebo week” and no scheduled withdrawal bleeding. Amenorrhea or irregular spotting can occur. Progestin-only pills provide a very low hormone dose. In order to be effective, they MUST be taken every day at 24-hour intervals. A fluctuation of greater than 3 hours increases the user’s risk of unintended pregnancy. For this reason, most providers do not routinely prescribe mini-pills. However, the progestin-only pill is an excellent choice for breast-feeding mothers during the first six months. When combined with lactational menorrhea, the mini-pill provides good contraception and doesn’t interfere with lactation. ≈ $45.00 per cycle

Depo-Provera Advantages: • highly effective Disadvantages:
• discreet & private • use not linked to coitus • requires user to “remember” only 4 times a year Disadvantages: • weight gain • impossible to discontinue immediately • delayed return to fertility • adverse effects on lipids • decreased bone mineral density with long-term use Depo-Provera = depot medroxyprogesterone acetate 150 mg IM q 12 weeks Depo-Provera is highly effective. With perfect use, the rate of unintended pregnancy is 3 per 1,000 woman-years. The “typical use” rate is 3% due to women presenting late for their injections. Depo-Provera is discreet and private since the user does not have to store supplies at home. Adolescents or women whose partners do not want them to use contraception are good candidates for Depo-Provera. Depo-Provera is advantageous because the user does not have to do anything on a daily basis. On the other hand, she does have to make a clinic visit four times a year. Currently a subcutaneous formulation is being developed that would enable women to self-administer Depo at home. The biggest disadvantage of Depo from the patient’s point of view is weight gain. Depo does stimulate the appetite. The average user gains 5-6 pounds in the first year of use and has gained 14 pounds by 4 years of use. Because it is injected, it is impossible to immediately discontinue Depo if it is poorly tolerated. The most common complaints of side effects are headaches, nervousness, depression, acne, and hair loss. The median return to fertility after discontinuing Depo is 10 months. Therefore it is not a good method for women who want to space pregnancies with some precision. Some women who use Depo have increases in total and LDL cholesterol and a decrease in HDL cholesterol. Recently there has been a lot of concern about the effect of Depo on bone mineral density. In one study, Depo was associated with a 3.1% decrease in lumbar bone density compared to a 9.5% increase among control subjects after two years of use by adolescent women. A large study of women aged found that there was a 7.2% decrease in lower spinal bone density in Depo users. The deficit was greatest for women who initiated Depo use before age 21 and those who used it for more than 15 years. At this time, we do not know whether this loss of bone density is reversible. The World Health Organization criteria suggest that the benefits of Depo-Provera in women from menarche to age 18 continue to outweigh the risks. However, some clinicians are limiting Depo use to two years. CALCIUM INTAKE AND EXERCISE NEED TO BE EMPHASIZED IN ALL WOMEN USING DEPO-PROVERA

Progestin Implants Advantages: • highly effective
• eliminate “user error” • long-term • reversible Disadvantages: • high initial cost • insertion & removal require specialized training • cannot be easily discontinued Norplant (off the market) Implanon  FDA-approved & coming soon Norplant was a six-rod system. The rods were implanted in the inner aspect of the upper arm, and could remain in place for up to five years. Insertion was fairly easy but sometimes removal was technically difficult. Lawsuits related to difficult removal and other problems led the manufacturer to take Norplant off the market. You might still see women coming in to have the capsules removed. Implanon is a new single-rod system that has been approved by the FDA and expected to be introduced in the US in It is already available in other countries. Insertion and removal still require special training, but it is supposed to be simpler than Norplant.

Intrauterine Devices (IUDs)
GENERAL ADVANTAGES • highly effective, no “user error” • convenient • long-lasting • reversible • discreet • cost-effective in the long run • low incidence of side effects • independent of coitus Let’s go ahead and talk about intrauterine devices and then I’ll talk about the progestin IUD. There are two types of IUDs currently on the market: the Copper T and the Mirena levonorgestrel system. Both types are: highly effective (unintended pregnancy rate less than 1%) convenient long-lasting (10 years for Copper T, 5 years for levonorgestrel) reversible – both offer rapid return to fertility after removal discreet – they are invisible, no one knows she is using it although initially expensive, they are very cost-effective in the long run they have a low incidence of side effects they do not interfere with sexual activity

GENERAL DISADVANTAGES: • menstrual problems • discomfort with insertion • expulsion of the device • perforation of the uterus • requires office visit with trained professional for insertion & removal • high initial cost • no protection from STIs General disadvantages of IUDs include: menstrual problems (which I will discuss with each individual device) insertion does cause cramping, pain, bleeding The IUD can be spontaneously expelled. This is most likely during the first 3 months of use and during a menstrual period. Perforation of the uterus can occur at the time of insertion. Otherwise, the IUD cannot “migrate” and get out of the uterus (unless it falls out). Insertion of an IUD requires an office visit with a trained health professional both for insertion and removal. IUDs have a high initial cost that can be difficult to afford up front. IUDs offer no protection from STIs.

MYTH: IUDs increase the risk of PID. FACT: IUDs have no effect on the risk of upper genital tract infection. STIs cause PID − IUDs do not. MYTH: IUDs cause abortions. FACT: IUDs prevent fertilization and thus are true contra-ceptives, not abortifacients. MYTH: IUDs increase the risk of ectopic pregnancy. FACT: IUDs reduce the risk of ectopic pregnancy because IUDs prevent all types of pregnancy. MYTH: Only parous women are IUD candidates. FACT: Nulliparous women are more likely to expel the IUD and insertion through the cervical os can be more difficult. The IUD is probably the most misunderstood and feared contraceptive method. Here are a few of the myths and facts. It is a myth that an IUD increases a woman’s risk of PID. IUDs do not cause PID. STIs cause PID. Studies that showed an increased incidence of PID in women with IUDs were flawed. IUDs do not cause abortions. They prevent fertilization, therefore they are true contraceptives. IUDs do not increase the risk of ectopic pregnancy. Because IUDs are highly effective at preventing pregnancy, a woman’s risk of ectopic is reduced by having an IUD. However, if she becomes pregnant with the IUD in place, there is a slightly greater chance that the pregnancy will be ectopic. Any woman is potentially an IUD candidate. However, women who have never been pregnant are more likely to expel the device because of their smaller uterine cavity. Also, it can be more difficult to insert the IUD through the nulliparous cervical os.

Copper T 380A IUD (Paragard)
Contents: polyethylene, copper wire, & barium sulfate for X-ray visibility, white threads Mechanism of action: Causes increase in uterine & tubal fluids containing copper ions, enzymes, prostaglandins, and macrophages that impair sperm function and prevent fertilization The Copper T380A, sold under the trade name Paragard, contains a T-shaped polyethylene frame wrapped in copper wire with barium sulfate for visibility on X-rays. Two white polyethylene strings hang from the cervix. The purposes of the strings are (1) to check that the IUD is still in place, and (2) to remove the IUD. The copper T works by causing an increase in uterine and tubal fluids containing copper ions, enzymes, prostaglandins, and macrophages that impair sperm function and prevent fertilization.

Copper T 380A IUD (Paragard)
ADVANTAGES SPECIFIC TO THE Cu380A: • Can remain in place for up to 10 years • Nonhormonal • Normal menstrual pattern continues DISADVANTAGES SPECIFIC TO THE Cu380A: • Can cause heavier menses with more severe cramping, especially in the first few cycles The copper T is FDA-approved for use for 10 years, although research has shown it may be effective for up to 12 years. It contains no hormones, so it is a good choice for women who prefer to avoid hormones or cannot use them for medical reasons. Because it is nonhormonal, the woman’s normal menstrual pattern will continue. However, many women experience heavier bleeding with more severe cramping, especially in the first few cycles after insertion. This can usually be treated satisfactorily with an NSAID like ibuprofen.

Levonorgestrel Intrauterine System (LNG-IUS) (Mirena)
Contents: polyethylene, levonorgestrel, barium sulfate, dark-colored threads Mechanisms of action: • thickening of cervical mucus • inhibiting sperm capacitation & survival • suppressing the endometrium • suppression of ovulation due to systemic absorption of progestin The levonorgestrel-releasing intrauterine system is marketed under the trade name Mirena. It consists of a T-shaped polyethylene device containing levonorgestrel, barium for visibility on X-rays, and two dark-colored threads. Like other progestin methods, the Mirena works by: thickening cervical mucus inhibiting sperm capacitation and survival suppressing the endometrial lining suppressing ovulation 90% of the Mirena’s progestin activity is localized within the genital tract; only 10% is systemically absorbed.

Levonorgestrel Intrauterine System (LNG-IUS) (Mirena)
ADVANTAGES SPECIFIC TO THE MIRENA: • can remain in place for up to 5 years • protective against endometrial cancer • reduces menstrual bleeding by 90%; 20% of users become amenorrheic • low incidence of progestin side effects (only 10% systemically absorbed) DISADVANTAGES SPECIFIC TO THE MIRENA: • irregular bleeding, especially during the first 6 months The Mirena is FDA-approved for 5 years of use, although in Europe it is being used for 7 years. Because of the endometrial atrophy, it is protective against endometrial cancer. Most users have irregular bleeding --- sometimes daily --- for the first 6 months. After that, menstrual bleeding is reduced by 90% and 20% of users have no bleeding whatsoever. Since only 10% of the progestin is systemically absorbed, the Mirena has a low incidence of other progestin side effects such as weight gain.

Barrier Methods Barrier methods are some of the oldest forms of contraception. They include male and female condoms, diaphragms and cervical caps, and spermicides.

Male Condoms Mechanism of action:
acts as a physical barrier; prevents pregnancy by blocking passage of semen Types available: • latex (natural rubber) • natural membrane (lamb intestine) • polyurethane • spermicidal Male condoms are available in latex, lambskin, and polyurethane. Condoms lubricated with the spermicide Nonoxynol-9 are also available. There is no evidence that they are more effective than nonspermicidal condoms. In fact, there is concern about N-9 causing irritation of the vaginal mucosa than could result in greater susceptibility to HIV. Condoms are one of the cheapest contraceptives available. 50¢-$1.00 each

Male Condoms ADVANTAGES: • male participation • no Rx needed
• very inexpensive • effective in preventing pregnancy when used correctly • minimal side effects • provide STI protection (except for lambskin) DISADVANTAGES: • reduce sensitivity • reduce spontaneity • erection problems • lack of cooperation • embarrassment about purchasing • not very effective with “typical use” • latex allergy Condoms offer some important advantages, including: male participation available without a prescription very cheap effective in preventing pregnancy when used correctly (failure rate with perfect use 2%, with typical use 15%) Condoms have virtually no side effects, except possibly latex allergy. Latex and polyurethane condoms provide protection against STIs, including HIV. The disadvantages of condoms include: a reduction in sensitivity and pleasure for the man they can be perceived to reduce the spontaneity of sexual activity, although this disadvantage can be overcome by incorporating condoms into foreplay some men have difficulty achieving and maintaining an erection when using condoms some men may refuse to use condoms Purchasing condoms in a store can be embarrassing. The Internet is great!

Male Condoms MINIMIZING USER ERROR • Use with every act of intercourse
• Use “from start to finish” • Unroll condom onto penis (do not unroll first; do not test by filling with air or water first) • Hold rim during withdrawal to prevent slippage or leakage • Have several condoms available • Use appropriate lubricants • Store condoms correctly It is easy to assume that everyone knows how to use condoms. However, when you look at the disparity between perfect use and typical use failure rates, obviously something is wrong. So it is not enough to recommend condoms, you need to teach people how to use them also. FAILURE RATES: perfect use 2% typical use 15%

Female Condoms ≈ $3.50 each • No Rx needed • One-time use
• Includes a lubricant • Spermicide not recommended • Can be inserted up to 8 hours prior to intercourse; can remain in place for up to 8 hours • Protects against STIs • Failure rates: perfect use 5% typical use 21% The female condom is marketed under the brand name Reality. It consists of a polyurethane sheath with a flexible ring at each end. The ring at the closed end of the sheath lies inside and anchors the condom. The other ring remains outside the vagina after insertion and provides some protection for the labia and the base of the penis during intercourse. The female condom is coated on the inside with a silicone-based lubricant and comes with additional lubricant for the outside. The lubricant does not contain a spermicide. Each condom is supposed to be used only once. It can be inserted up to 8 hours prior to intercourse and can remain in place for up to 8 hours afterwards. Female and male condoms should not be used together. They can adhere to each other, causing one or both of the condoms to slip or be displaced. Users say that the female condom squeaks during intercourse. It has been called a contraceptive for people with a sense of humor! ≈ $3.50 each

Diaphragms & Cervical Caps
Mechanism of action: • physical barrier to prevent sperm from reaching the cervix • chemical to kill sperm (spermicide) Advantages: • no hormones • virtually no side effects Disadvantages: • require professional fitting • require user skill and commitment • less effective than most other methods Diaphragms and cervical caps are rubber devices that form a physical barrier to prevent sperm from reaching the cervix. Both methods require the use of a spermicide along with the device. The advantages of diaphragms and cervical caps are that they contain no hormones and have virtually no side effects. However, they come in a range of sizes and require fitting by a health care professional. If the woman gains or loses more than 20 pounds, she should be refitted. She should also be refitted after childbirth. In order to use these methods, the woman must be very comfortable inserting her fingers into the vagina. Using them takes practice and can be frustrating and discouraging during the learning process. The diaphragm has a failure rate of 6% with perfect use but 20% with typical use. The cervical cap is more effective in nulliparous women than parous women. With typical use, the failure rate in nulliparous women is 20% but it’s 40% in parous women. Very few women are choosing these methods nowadays. However they can be a good option for the older woman who has intercourse very rarely.

Spermicides Mechanism of action:
Nonoxynol-9 is a surfactant that destroys the sperm cell membrane. Advantages: • available without Rx • easy to use, can use intermittently without advance planning Disadvantages: • no protection against STIs • frequent (> 2x/day) use may cause tissue irritation that could increase susceptibility to HIV FAILURE RATES (when used alone) perfect use 18% typical use 29% The active ingredient in spermicides in the U.S. is Nonoxynol-9. N-9 is a surfactant that destroys the sperm cell membrane. Spermicides are available in any store without a prescription. They come in foams, gels, suppositories, and squares of film. They are easy to use and can be used intermittently without advance planning. The major disadvantages of spermicides when used alone are: a high failure rate (29% with typical use) no protection against STIs concern that frequent use (twice or more daily) causes irritation of the vaginal mucosa that could increase susceptibility to HIV $10-15 per package

Fertility Awareness / Periodic Abstinence
Mechanism of action: users identify the days in each menstrual cycle when intercourse is most likely to result in pregnancy, then abstain from intercourse or use a barrier method during the “fertile window” Fertility awareness methods, also called periodic abstinence or natural family planning, are methods in which the users identify the days in each menstrual cycle when intercourse is most likely to result in pregnancy. They then either abstain from intercourse or use a barrier method during the “fertile window.” These illustrations show a chart for the Billings Ovulation Method, which relies on evaluation of cervical mucus, and a basal body temperature chart. The basal body temperature rises at the time of ovulation.

Methods: • ovulation method (assessment of cervical mucus) • symptothermal methods (basal body temperature + mucus) • calendar rhythm method • standard days method (CycleBeads) • Creighton Model FertilityCare System There are a number of different fertility awareness methods. These include: ovulation method (assessment of cervical mucus) symptothermal method (assessment of basal body temperature, cervical mucus, and other indicators such as the position and consistency of the cervix) calendar rhythm method – consists of counting days on the calendar Standard Days Method – uses a strand of color-coded beads to indicate fertile and infertile days (illustrated) Creighton Model FertilityCare System – a sophisticated cycle-tracking system

Disadvantages: • Methods require varying amounts of training & cost • Detracts from spontaneity, causes friction between partners if not in agreement • Difficult to use if: − recent childbirth − breastfeeding − recent menarche − approaching menopause − recent discontinuation of a hormonal method − irregular cycles − unable to interpret fertility signs Advantages: • No hormones • No side effects • Enables a woman to understand her body’s cycles • Promotes cooperation between partners • Can also be used to achieve pregnancy or to identify infertility problems • The only method approved by the Catholic Church Fertility awareness methods offer these advantages: no hormones no side effects enable a woman and her partner to understand her body’s cycles can be used to achieve pregnancy or to identify infertility problems Natural Family Planning is the only contraceptive method approved by the Catholic Church. Users must abstain from intercourse during the fertile days. Use of a condom is not condoned since this would no longer be “natural.” Fertility awareness methods vary widely in complexity and the cost of training and materials. Periodic abstinence detracts from spontaneous sexual activity. If the partners are not in agreement, it can cause conflict and friction in the relationship. Fertility awareness methods are difficult to use when a woman’s natural hormones are in flux, such as: recent childbirth breastfeeding recent menarche or approaching menopause recent discontinuation of a hormonal method Women who have irregular cycles are not good candidates for fertility awareness methods. Also, a woman who is unable to interpret her fertility signs or to keep records is not a good candidate.

Sterilization Sterilization is chosen by 39% of couples who use contraception in the U.S. 28% of reproductive age women undergo tubal ligation and 10% of men undergo vasectomy. Sterilization is one of the most popular forms of contraception in the U.S. 39% of couples who use contraception choose sterilization at some point. 28% of reproductive age women undergo tubal ligation and 10% of men undergo vasectomy.

Tubal Ligation Mechanism of action: the fallopian tubes are cut or mechanically blocked to prevent the sperm and ovum from uniting Can be performed laparo-scopically or through a suprapubic “mini-laparotomy” incision (or at C-section) Failure rate: 0.5% Tubal ligation can be performed laparoscopically or through a suprapubic mini-laparotomy incision. It can also be performed at the time of C-section. Tubal ligation works by cutting or blocking the fallopian tubes. It has a failure rate of 0.5%. NOTHING IS PERFECT!

Tubal Ligation Advantages: • permanent • highly effective • safe
• quick recovery • lack of significant long-term side effects • cost effective • partner cooperation not required • not coitus-linked Disadvantages: • possibility of patient regret • difficult to reverse • future pregnancy could require assistive reproductive tech-nology (such as IVF) • more expensive than vasectomy Tubal ligation has many advantages, including: permanence highly effective very safe recovery is quick and fairly easy There are no significant long-term side effects. The main short-term side effect is post-op pain which is managed with oral analgesics. In the long run, a tubal ligation is cost-effective. Tubal ligation does not require partner cooperation. A woman does NOT need her husband’s permission to have a tubal. However, we counsel women that they should work to resolve the issue since this can cause a lot of friction in the relationship. Tubal ligation eliminates the need to take any precautions before intercourse. Tubal ligation has disadvantages, including: There is a possibility of patient regret. It is difficult to reverse and future pregnancies could require assistive reproductive technology such as IVF. Tubal ligation is more expensive than vasectomy.

Transcervical Sterilization
Essure™ Mechanism of Action: Using a hysteroscopic approach, one Essure micro-insert is placed in the proximal section of each fallopian tube lumen. The micro-insert expands upon release, acutely anchoring itself in the fallopian tube. The micro-insert subsequently elicits a benign tissue response. Tissue in-growth into the micro-insert anchors the device and occludes the fallopian tube, resulting in sterilization. Essure is a new method of female sterilization using a transcervical approach. A micro-insert that resembles a little spring is inserted into each fallopian tube through a hysteroscope. The micro-insert expands upon release and anchors itself in the tube. Tissue then grows into the micro-insert and occludes the tube, resulting in sterilization. The woman needs to use another method of contraception for 3 months until this process is complete. Essure is a very effective sterilization method, with a failure rate of 0.2% after 3 years. Its main advantage is that it can be performed in the office and does not require an incision or leave a scar. FAILURE RATE: 0.2% after 3 years

Vasectomy Mechanism of action: each vas deferens is cut to prevent the passage of sperm into the ejaculated seminal fluid FAILURE RATE: perfect use 0.10% typical use 0.15% Vasectomy is permanent male sterilization. The vas deferens on each side is severed so that sperm cannot pass into the ejaculated seminal fluid. Vasectomy is highly effective, with a typical use failure rate of only 0.15%. Failures are believed to be due to sperm exposure before all of the sperm have been cleared from the reproductive tract. This takes about 20 ejaculations.

Vasectomy ≈ $500.00 Advantages: • permanent • highly effective • safe
• quick recovery • lack of significant long-term side effects • cost effective; less expensive than tubal ligation • no partner cooperation needed • removal of contraceptive burden from the woman Disadvantages: • reversal is difficult, expensive, often unsuccessful • patient may regret decision • not effective until all sperm cleared from the reproductive tract • no protection from STIs Like tubal ligation, vasectomy is permanent, highly effective, safe, offers a quick recovery, and lacks significant long-term side effects. It is cost-effective in the long run and less expensive than tubal ligation. Coming up with the money up front can be a barrier however. Vasectomy does not require partner cooperation and removes the responsibility for contraception from the woman. Like tubal ligation, vasectomy is difficult and expensive to reverse, with a poor rate of success. Patients can regret their decision to be sterilized. Vasectomy is not immediately effective. All sperm must be cleared from the reproductive tract, which takes about 20 ejaculations. Therefore another method needs to be used in the interim. Vasectomy offers no protection from STIs. ≈ $500.00

Emergency Contraception
Definition: emergency contraceptives are methods a woman can use after intercourse to prevent pregnancy Methods: • Plan B − the only dedicated product marketed specifically for emergency contraception • Off-label use of progestin-only contraceptive pills • Off-label use of combination estrogen-progestin pills • Insertion of a copper-releasing IUD Emergency contraceptives are methods a woman can use after intercourse to prevent pregnancy. Emergency contraceptive pills are sometimes called the “morning after” pill. This is a misnomer since they can be taken for up to 5 days after unprotected intercourse. The only dedicated product marketed specifically as emergency contraception is a progestin-only pill called Plan B. Conventional progestin-only or estrogen-progestin combination pills can be prescribed for this purpose as an off-label use. A copper-releasing IUD can be inserted for emergency contraception. In practice, this is almost never done and will not be discussed here.

Indications for use: • contraceptive failure (condom broke, pills forgotten) • error in withdrawal or periodic abstinence • rape • any unintended “sperm exposure” Contraindications: • pregnancy Indications for the use of emergency contraceptives include: failure of a contraceptive method (condom broke, pills forgotten, late for injection) error in withdrawal or periodic abstinence rape any situation in which unintended “sperm exposure” has occurred The only contraindication to use of emergency contraceptive pills is PREGNANCY. If the woman is already pregnant, the pills will not do any harm but they simply won’t work. It is estimated that use of emergency contraceptives could prevent about half of the unintended pregnancies million pregnancies in the US every year! EC could prevent about ½ of unintended pregnancies − 1.5 million pregnancies in the U.S. every year.

Emergency Contraception: Plan B
Contents: 750 µg levonorgestrel per pill Directions: Take the first tablet as soon as possible within 72 hours after unprotected intercourse. Take the second tablet 12 hours later. The sooner Plan B is taken, the better. It can be taken up to 120 hours after intercourse. If taken within 72 hours as directed, Plan B reduces the risk of pregnancy from a single act of intercourse by 89%. Plan B consists of two tablets, each of which contains 0.75 mg of levonorgestrel. The patient should take the first tablet as soon as possible within 72 hours after unprotected intercourse. She then takes the second tablet 12 hours later. If taken within 72 hours as directed, Plan B reduces the risk of pregnancy from a single act of intercourse by 89%. Research has shown that Plan B can be taken as long as 120 hours (5 days) after unprotected intercourse. However, the longer you wait, the less effective it will be. ≈ $35.00 per pack

Emergency Contraception: Plan B Mechanisms of Action
• Disruption of development and maturation of ovarian follicles • Disruption of egg maturation and ovulation • Interference with corpus luteum function • Alteration of cervical mucus, blocking sperm transport • Disruption of development of the zygote, morula, & blastocyst • Impaired transport in the fallopian tube & uterine cavity • Interference with development of the endometrium to impede implantation Because Plan B is a progestin, it has the same mechanisms of action as the other progestin methods. Its action in a specific case depends on whether it is taken before or after ovulation.

When does pregnancy start???
The American College of Obstetricians and Gynecologists (ACOG), the Food and Drug Administration (FDA), and the National Institutes of Health (NIH) have defined implantation as the beginning of pregnancy. If fertilization has occurred, implantation starts about 7 days after ovulation. When does pregnancy start? According to the American College of Obstetricians and Gynecologists, the Food & Drug Administration, and the National Institutes of Health, pregnancy begins with implantation. If fertilization has occurred, implantation then follows about 7 days after ovulation. Plan B disrupts ovulation and the events leading up to implantation, but does not necessarily prevent fertilization. If fertilization and implantation have already occurred, Plan B will have no effect. Plan B disrupts the events leading up to implantation. After implantation, it has no effect.

Emergency Contraception: Plan B
Is Plan B an “abortion pill?” No. The oral abortifacient is RU-486 (mifepristone, Mifeprex) which is an antiprogestin that blocks the effects of progesterone by binding to its receptors. It is usually given in combination with misoprostol (Cytotec) to medically induce abortion in gestational ages up to 49 days after LMP. If implantation has occurred, Plan B will do nothing. Therefore, Plan B is not an “abortion pill.” Patients may confuse Plan B with RU-486 (mifepristone, Mifeprex). RU-486 is an antiprogestin that blocks the effects of progesterone by binding to its receptors. It is usually given in combination with misoprostol (Cytotec) to medically induce abortion. It is FDA-approved for use in gestational ages up to 49 days after LMP. Evidence has shown that the mifepristone-misoprostol regimen can be used for medical abortion up to 63 days following the LMP.

Alternatives to Plan B: 20 tablets of a progestin-only pill (e.g., Micronor) x 2 doses, 12 hours apart 2 doses of a combined estrogen-progestin pill, 12 hours apart Alesse 5 pink pills (100 µg EE µg levonorgestrel) Triphasil 4 yellow pills (120 µg EE µg levonorgestrel) Ovral 2 white pills (100 µg EE µg levonorgestrel) If you give estrogen, give an antiemetic also! If you don’t have access to Plan B, conventional birth control pills can be used. In order to get an adequate dose of progestin, the patient has to take 20 tablets of a progestin-only pill such as Micronor for each dose. You can also use a combination estrogen-progestin pill. For example, if you use Alesse, you need 5 pink pills for each dose. 5 pink pills supply 100 micrograms of ethinyl estradiol plus 500 micrograms of levonorgestrel. If you use a pill that contains estrogen, be sure to prescribe or recommend an antiemetic. High doses of estrogen almost inevitably cause nausea and vomiting.

Standards of care: • providing information • providing post-coital treatment • providing advance Rx Emergency departments and clinics are now incorporating emergency contraception into their standards of care. All women should be given information on emergency contraception and post-coital treatment upon request. Women should also be offered an advance prescription for Plan B so that they can have either the script or the pills on hand in case of emergency. The American College of Obstetricians and Gynecologists supports making Plan B available over the counter. Two expert panels of the Food and Drug Administration endorsed over-the-counter approval. Nevertheless, the FDA has refused to approve Plan B for sale over the counter. Therefore ACOG has launched a public education campaign called “Every woman, every visit.” They are encouraging OB-GYNs to offer advance prescriptions for Plan B at every GYN visit. “Every woman, every visit.” − ACOG 1-888-NOT-2-LATE

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Introduction to Contraception

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