Comprehensive Gynecology 7Ed (Chap 13)  about 20 μg of levonorgestrel (LNG) from IUD is

released into the endometrial cavity each day with

Family Planning
5 years effectiveness
 most common methods are the oral contraceptive  IUD also reduces menstrual blood loss and has been
pill (16%), female sterilization (15.5%), condoms used therapeutically to treat excessive uterine
(9.4%), long-active reversible contraception (LARC) bleeding
(7.2%), or intrauterine devices (IUDs) and implants Mechanisms of Action
 All contraceptive methods have a typical use  All IUDs induce a sterile local inflammatory reaction
effectiveness and perfect use effectiveness of the endometrium, creating an environment that
 coitus-related methods and more user-dependent is hostile to sperm so that fertilization of the ovum
methods are less effective than “forgettable does not occur
methods” such as LARC  medicated IUDs containing either copper or
TIER 1 METHODS: HIGHLY EFFECTIVE (FEWER THAN 1 levonorgestrel produce additional local effects that
PREGNANCY PER 100 WOMEN IN 1 YEAR) increase their efficacy in preventing pregnancy
LARC METHODS Copper IUD
 top-tier contraceptive methods include all LARC  Copper markedly increases the extent of the
methods inflammatory reaction
 methods require only one act of motivation to  accumulate throughout the uterine lumen and
enable long-term use penetrate the cervix and fallopian tubes
 LARC methods are highly effective and immediately  copper impedes sperm transport and viability in the
reversible cervical mucus
 LARC methods be offered as first-line contraception  Because of these actions of IUDs, very few, if any,
to most women sperm reach the oviducts, and the ovum usually
 LARC methods = single-rod etonogestrel subdermal does not become fertilized
implant (Nexplanon) LNG-IUS (Mirena)
INTRAUTERINE DEVICES  primary effect of the progestin in the LNG-IUS is to
 IUD is the most commonly used reversible method thicken cervical mucus
of contraception worldwide  impedes sperm penetration and access to the upper
 Pregnancy rates are somewhat related to the skill of genital track
the clinician inserting the device  it decreases tubal motility and also produces a thin,
 failure rates associated with IUDs are comparable to inactive endometrium
those achieved with surgical sterilization  low levels of circulating steroid sometimes inhibit
Types of IUDs ovulation
 copper T 380A IUD (Paragard) is the only copper- Insertion
bearing IUD currently marketed in the US  inserted on any day of the cycle provided the
woman is not pregnant, immediately postabortion,
immediately postpartum following either vaginal or
cesarean section delivery
 Immediate postpartum insertion carries a higher
risk of IUD expulsion
 copper IUD can be used as emergency
contraception for up to 5 days following
 copper IUDs require periodic replacement due to unprotected intercourse
constant dissolution used for 10 years and  preparation with misoprostol increases pain
maintains its effectiveness for at least 12 years
 Ibuprofen = cramping that occurs after insertion
 Adding a reservoir of a progestin to the vertical arm
Adverse Effects
also increases the effectiveness of T-shaped devices
 majority of women discontinuing the copper IUD is
due to heavy or prolonged menses or
intermenstrual bleeding
 increased bleeding may be produced by an  implant is inserted superficially into the
increased rate of prostaglandin release (due to subcutaneous tissue of the upper arm using a trocar
foreign “IUD”)  steroid diffuses into the circulation at a relatively
 prostaglandins stimulate uterine contractions, may constant rate
prolong menses, which is about 1 day longer  implant must be removed at the end of its duration
 heavy bleeding rarely leads to anemia of use through a small 2-mm incision
 Excessive bleeding in the first few months following  implant can be inserted on any day during a
IUD insertion should be treated with reassurance woman’s cycle provided she is not pregnant
and supplemental oral iron  most commonly used implant in the United States is
 bleeding usually diminishes with time, as the uterus the Nexplanon used for 3 years
adjusts to the presence of the foreign body  Ovulation inhibition for 30 months is the main
 potentially serious complications associated with mechanism of action of Nexplanon with thickening
IUD use is perforation of the fundus of the uterus of the cervical mucus
 Perforation always begins at the time of insertion  Ovulation resumes rapidly, and 90% of women
 Perforation of the uterus is best prevented by ovulate within 1 month after removal
straightening the uterine axis with a tenaculum  Bleeding irregularities are the most common reason
 clinician should always suspect a perforation if the for discontinuation
user cannot feel the threads and did not observe PERMANENT CONTRACEPTION: STERILIZATION
that the device was expelled  highly effective, permanent methods of
 if the stem of the device is visible at the external contraception
cervical os, the IUD should be removed  prevalent method of contraception used by U.S.
 In the event of an intrauterine pregnancy, the women over the age of 30
device should be removed regardless of whether  Male sterilization, or vasectomy, is a safe and highly
the pregnancy is desired or undesired effective outpatient procedure that takes about 20
 As uterus grows with the pregnancy, the threads minutes and requires only local anesthesia
will eventually be drawn inside the cervix and  vas deferens is isolated and cut, ends are closed
become inaccessible  when IUD is not removed, either by ligation or by fulguration, and then
spontaneous abortion occurs replaced in the scrotal sac
 In case of undesired pregnancy, a manual vacuum  occlusion of the vas prohibits sperm from passing
aspiration can be performed with the IUD in place into the ejaculate
for removal of both the pregnancy and the device  ejaculate is therefore sperm free, but otherwise
 use of the IUD would markedly increase the unchanged
incidence of pelvic inflammatory disease (PID)  Vasectomy offers several important advantages
 suspicion of infectious endocervicitis  (1) purulent over tubal sterilization of women
vaginal discharge, (2) adnexal tenderness, or (3) o it is the most cost-effective of all
cervical motion tenderness contraceptive methods
 IUDs not be inserted into women with any of the  13 to 20 ejaculations must occur after the operation
following six conditions: (1) pregnancy or suspicion before the ejaculate will be sterile
of pregnancy, (2) acute PID, (3) postpartum  vas reanastomosis is difficult & careful procedure
endometritis or infected abortion, (4) known or that has a success rate of approximately 50%
suspected uterine or cervical malignancy, (5) genital  female sterilization may be done at the time of CS
bleeding of unknown origin, and (6) a previously or with an infraumbilical minilaparotomy incision
inserted IUD that has not been removed after vaginal delivery
Subdermal Implants  blocks fertilization by cutting or occluding the
 are among the most effective methods of fallopian tubes and preventing the union of the
contraception available, with an effectiveness equal sperm and egg
or superior to that of sterilization and IUDs  Tubal occlusion can occur at the time of cesarean
 Subdermal implants consist of one or more thin section, immediately postpartum through an
rods containing a progestin hormone
 infraumbilical minilaparotomy while the uterus is  major side effect of DMPA is a change of the
still enlarged  transabdominal approach menstrual cycle
 Laparoscopic approach  increased risk of surgical  first 3 months = 30% amenorrhea and 30%-40%
complications have irregular bleeding and spotting occurring more
 Essure device involves the introduction of than 11 days per month
microinsert device transcervically through  after D/C, about half of women resume a regular
hysteroscope (Figure 13.5) cyclic menstrual pattern within 6 months
o device causes tissue ingrowth and  gain weight usually in the first 6 months of use of
permanent tubal occlusion DMPA
 product labeling lists depression and mood changes
as side effects of DMPA
 headaches is the most frequent medical event
reported by DMPA users and a common reason for
TIER 2 METHODS: VERY EFFECTIVE (6 TO 12 discontinuation of its use
PREGNANCIES PER 100 WOMEN IN 1 YEAR)  DMPA suppresses production of estradiol, bone
 Depo-Provera, or depo-medroxyprogesterone remodeling is increased and may resemble
acetate (DMPA), given in a dose of 150mg IM or menopause
104mg SC every 3 months  reduction in risk of primary dysmenorrhea,
 DMPA, the long-acting injectable formulation of symptoms of endometriosis, ovulation pain, and
MPA, consists of a crystalline suspension of MPA functional ovarian cysts, endometrial cancer in
o inhibition of ovulation by suppressing levels women on DMPA is long lasting and substantial
of FSH and LH and eliminating the LH surge  If given later than 7 days into the menstrual cycle,
o thickening of cervical mucus inhibiting backup contraception should be used for 7 days
 If pregnancy occurs in a woman receiving DMPA,
sperm from reaching the oviduct
the hormone does not adversely impact the
o altering the endometrium, which causes
pregnancy
atrophy
ORAL CONTRACEPTIVES
 Medroxyprogesterone acetate (MPA) is a 17-
 effectiveness and ease of administration of oral
acetoxy-6-methyl derivative of progesterone that
contraceptives  became the most widely used
has increased progestogenic potency; longer acting
method of reversible contraception
 Typical failure rates are around 6%
 with minor side effects such as nausea, breast
 These effectiveness rates apply to women of all
tenderness, and weight gain that frequently led to
body weights
discontinuation of use
 IM is given by injection deep into the gluteal or
 Reduction in ethinyl estradiol (EE) dose has
deltoid muscle, after which the progestin releases
coincided with a lower incidence of severe adverse
slowly into the systemic circulation
cardiovascular effects and minor adverse symptoms
 SC DMPA in 0.65 mL of diluent and is injected into
without increasing the failure rate
the subcutaneous tissue of the anterior thigh or
 major effect of the progestin component is to
abdominal wall
inhibit ovulation, thickening of the cervical mucus
 DMPA can be started at any time EXCEPT WHEN
and thinning of the endometrium
PREGNANT
 major effects of the estrogen are to maintain the
 resumption of ovulation is delayed on average for 6
endometrium and thus prevent unscheduled
months to 1 year after a single injection
bleeding as well as to inhibit follicular development
 median delay to conception is 9 to 10 months after
 3 major types of OC formulations include daily
the last injection
progestin-only pills (POPs), also known as minipills,
 Women who wish to become pregnant after
fixed-dose (monophasic) combination pills, and
discontinuing, might experience a delay in the
multiphasic combination pills
resumption of fertility until the drug has cleared
 different tablet color corresponds to each dose
from their circulation
 Many combination OC formulations provide active  Use of OCs by women older than age 35 who also
pills continuously for 21 days (3 weeks) followed by smoke is contraindicated due to the risk of MI
a 7-day hormone-free interval (HFI)  After discontinuation of low-dose OCs, completely
 withdrawal bleeding usually lasts 3 to 4 days and is normal endocrine function occurs
generally lighter than menses in an ovulatory cycle  no risk of congenital malformations or other
 Extended cycle regimens contain 84 days of active adverse outcomes in pregnancies among women
pills followed by a 7-day HFI that results in who conceive while taking OCs or shortly thereafter
withdrawal bleeding only four times a year  Although OC use increases the risk of breast cancer
 OCs have a 1% failure rate with perfect use and an by 25%, this risk disappears after cessation of use
8% failure rate with typical use  with increasing duration of OC use, risk of cervical
 important that the pill-free interval is not extended Ca
more than 7 days  there is a a strong protective effect between OCs
 be advised that the most important pill to and endometrial cancer
remember to take is the first one of each cycle  OCs reduce the risk of developing ovarian cancer
 When a woman misses two or more pills in a pack,  development of a benign hepatocellular adenoma is
she should take emergency contraception and use an extremely rare occurrence
backup contraception  some of the immediate benefits of OC use include
 Unscheduled (breakthrough) bleeding and absence improvement of menorrhagia and dysmenorrhea
of withdrawal bleeding (amenorrhea) occur as a and decreased acne
result of insufficient estrogen to support the  absolute contraindications = history of vascular
endometrium disease (thromboembolism, thrombophlebitis,
 most frequent symptoms produced by the estrogen atherosclerosis, and stroke) and systemic disease
component include nausea (12%), breast (active lupus erythematosus with vascular
tenderness (9%), and headache (18%)  use involvement or diabetes with retinopathy or
reduced EE nephropathy), pregnancy
 OCs decrease androgen levels, which tends to  relative contraindications = cigarette smoking,
reduce acne due to androgenicity of the progestin >35y/o, uncontrolled hypertension, undiagnosed
component, the extent that endogenous androgens uterine bleeding and elevated triglyceride levels,
circulate freely liver diseases, migraine headaches
 Weight gain represents a common complaint of  OCs are not teratogenic
women using hormonal contraception  OC use may mask the symptoms produced by a
Progestin-Only Pills (POPs) prolactin-secreting adenoma
 minipill formulations consist of tablets containing a o either galactorrhea or amenorrhea should
low dose of progestin and no estrogen  thus, not receive OCs
progestogenic effects become the primary  progestin-only contraceptive formulations have a
mechanism of action lower incidence of risks than do the combination
 taken every day without steroid-free interval formulations
 counsel patient that preparations should be  factors that predispose to thromboembolism =
consistently taken at the same time of day caused by the estrogen component
 women may still ovulate  estradiol and CONTRACEPTIVE PATCH
progesterone produced by the ovary will affect  primary mechanism of action is the inhibition of
endometrial bleeding patterns  experience gonadotropin release and prevention of ovulation
irregular bleeding, spotting, or amenorrhea, same as OC
depending on an individual woman’s response  contraceptive skin patch Ortho Evra contains 75 μg
 Obesity = a modest risk factor for VTE ethinyl estradiol and 6 mg norelgestromin
 extreme obesity (BMI >40) = should be considered a  One patch is applied to the skin each week for 3
relative contraindication to use of a combined consecutive weeks and no patch for the following
hormonal method week of a 4-week cycle to allow withdrawal
bleeding
 patch may be applied to one of four anatomic sites:
buttocks, upper outer arm, lower abdomen, or
upper torso excluding the breasts
 both steroids appear in the circulation rapidly and
reach a plateau within 48 hours
 patch efficacy may be slightly lower in women with
body weight more than 90 kg
 even in the heaviest women the patch was 90%  cervical cap is a cup-shaped silicone or rubber
effective device that fits around the cervix
CONTRACEPTIVE VAGINAL RING  FemCap made of soft, durable, hypoallergenic,
 main mechanism of action is inhibition of silicone rubber, is designed to contact the vaginal
gonadotropins and prevention of ovulation walls as dome of device sits over cervix (Fig. 13.14)
 A flexible ring-shaped device containing 2.7 mg of
ethinyl estradiol and 11.7 mg of etonogestrel
 Steroids pass easily through the vaginal epithelium
directly into the circulation
 contraceptive ring (NuvaRing) is placed in the vagina
for 21 days and then removed for up to 7 days to
allow withdrawal bleeding  then woman inserts a
new ring regardless of whether withdrawal bleeding  diaphragm and cervical cap should be used with a
has occurred spermicide and be left in place for at least 8 hours
 the ring comes in only one size and does not have after the last coital act
to be fitted or placed in a certain location  If repeated intercourse takes place, additional
 each ring delivers sufficient steroids to inhibit spermicide should be used vaginally
ovulation for 6 weeks, contraceptive action can be  Failure rate during the first year of use for the
assumed even if the ring is left in place for 21 days diaphragm ranges from 13% to 17%
 Ring expulsion is uncommon, and both partners  diaphragm and cervical cap may also reduce the risk
typically report high acceptability with use of cervical dysplasia and cancer
TIER 3 METHODS: EFFECTIVE (18 OR MORE ¤ Male and Female Condom
PREGNANCIES PER 100 WOMEN IN 1 YEAR)
 latex and polyurethane male condoms are the only
BARRIER METHODS
method with FDA-approved labeling that supports
¤ Diaphragm and Cervical Cap
use of the product to prevent both pregnancy and
 female-controlled reversible contraceptive method the transmission of STI
 diaphragm is a thin, dome-shaped membrane of  condom should be applied to the erect penis before
latex rubber or silicone with a flexible spring any contract with the vagina or vulva
modeled into the rim
 tip should extend beyond the end of the penis by
 spring allows the device to be collapsed for about half an inch to collect the ejaculate
insertion and then allows for expansion within the
 After ejaculation, the penis must be removed from
vagina to seat the rim against the vaginal wall,
the vagina while still somewhat erect, and the base
creating a mechanical barrier between the vagina
of the condom grasped to ensure the condom is
and the cervix
removed without spillage of the ejaculate
 FDA approved single-size diaphragm that does not
 The typical use failure rate is around 15%
require fitting by a practitioner, intended for use
 female condom consists of a soft, loose-fitting
over the counter (Figure 13.13)
polyurethane sheath with two flexible rings closed
end of the sheath and serves as an insertion
mechanism and internal anchor for the condom
inside the vagina
 outer ring forms the external edge of the device and of elevated basal temperature, or when she is
remains outside the vagina after insertion, thus postovulatory
providing protection to the introitus and the base of  cervical mucus method requires that the woman
the penis during intercourse (Figure 13.15) recognize and interpret the presence and
 female condom is prelubricated and intended for consistency of cervical mucus
one-time use only  Increasing estradiol levels increase the production
 device is available over the counter and does not of cervical mucus
require fitting by a health professional xD  Intercourse can occur after menses ends until the
first day that copious, slippery mucus is observed to
be present and again 4 days after the last day when
the characteristic mucus was present
 calendar, temperature, and cervical mucus
methods can be used separately or in combination
LACTATIONAL AMENORRHEA METHOD (LAM)
with one another, or the symptothermal method
 since prolactin inhibits gonadotropin pulsatility,
 typical failure rates are around 24%
women remain amenorrheic for a variable length of
 Women with irregular cycles should not use
time after giving birth
periodic abstinence methods, over the age of 35, or
 nursing contribute to menstrual suppression and
immediately following a pregnancy
night nursing is highly correlated with anovulation
COITUS-RELATED METHODS
and amenorrhea
 Removal of the penis from the vagina prior to
 criteria for successful use of LAM are continuous
ejaculation to prevent pregnancy is an ancient
amenorrhea and exclusive breast-feeding (no
male-controlled method of contraception without
supplements) for up to 6 months after delivery
contraindications
PERIODIC ABSTINENCE
 Withdrawal can fail because of the small numbers
 Many motivated couples use abstinence from
of sperm present in some preejaculate, the fluid
sexual intercourse OR barrier method during the
produced by the penis during sexual excitement and
days of the menstrual cycle when the ovum can be
before climax
fertilized, or during the 5 days preceding ovulation
 Correct and consistent use with every act of
or the day of ovulation
intercourse should be stressed
 oldest of these is the calendar rhythm method
 major drawback of the method is the lack of any
 period of abstinence is determined by calculating
protection against sexually transmitted infections
the length of the individual woman’s previous
 Failure rates range from 4% with perfect use to 22%
menstrual cycle and makes three assumptions:
with typical use
o human ovum can be fertilized for only
EMERGENCY CONTRACEPTION
about 24 hours after ovulation
 allows women to prevent pregnancy after an act of
o sperm can fertilize for 3 to 5 days after
unprotected intercourse
coitus
 most dedicated EC medications contain the
o ovulation usually occurs 12 to 16 days
progestin levonorgestrel
before the onset of menses
 copper IUD is the most effective form of EC
 woman therefore establishes her fertile period by
subtracting 18 days from the length of her previous
shortest cycle and 11 days from her previous
longest cycle and abstains from coitus during this
time
 Increasing levels of progesterone occurring after
ovulation cause a detectible rise in daily basal body
temperature
 woman must abstain from intercourse from the
cessation of menses until the third consecutive day