Contraception
Leah Antoniewicz
The use of contraception started since humans were able to associate coitus and pregnancy. Documents from 1850 BCE (the Kahun papyrus) describe several methods to create a hostile environment or a physical barrier for sperm. The Romans during the second century AD developed a spermicidal barrier using wool and an acidic vegetable mix.1
The voluntary control of fertility is of paramount importance to modern society and a central role of health care providers. To ensure suatainable development, countries need to plan population growth. More importantly, empowering women to control their reproductive capacity allows them to reach individual, familial, and societal goals, contributing to personal and collective well-being. Having freedom to decide over their sex life, procreation, and lifestyle is a fundamental right of women and is critical to achieving gender equality and women’s autonomy. Unfortunately, depriving women of their sexual and reproductive rights is the main method used in many societies around the world to keep them from achieving their right place in society.
In the United States, 50% of all pregnancies are unintended, and approximately half of these end in abortion.2 Of these, 50% of unintended pregnancies occurred despite the use of contraception. Although decreasing, adolescents have the highest unintended pregnancy rate. Disappointingly, the rate has increased for low-income and less educated women.3
Regulating fertility improves maternal and neonatal outcomes.4 In developing countries, family planning programs prevent an estimated 187 million unintended pregnancies, including 60 million unplanned births, 105 million abortions, and averts an estimated 2.7 million infant deaths and 215,000 pregnancy-related deaths.4 For a comparison of birth-related and method-related deaths, see Figure 1.1.5
The introduction of birth control methods that are easier to use and more effective provides women the opportunity to choose the one that better fits their personal preferences, health needs, and lifestyles. Contraceptives can be mechanical, hormonal, and behavioral. No method is 100% effective nor does any of them guarantee a perfect fit for every woman’s needs. Each presents its own benefits, risks, and side effects. The decision of which method to use belongs to the patient. The role of the health care provider is to empower the patient by offering suggestions according to her health history, her personal lifestyle, psychological and social factors, the methods’ correct use and side effects, and of course any contraindication that may apply to her case.
OVERVIEW OF CONTRACEPTION
Contraceptives are either hormonal or nonhormonal. Contraceptives can be taken orally, be injected, or be slowly released through direct contact with the body. Hormonal contraceptives use estrogen and/or progesterone and have several mechanisms of action. Estrogen prevents formation of the dominant follicle, potentiates progesterone, and stabilizes the endometrium. Ethynil estradiol (EE) is almost exclusively used as the estrogen component in hormonal contraceptives and is usually the component that is relatively or strongly contraindicated in some patients. Progesterone prevents ovulation, thickens cervical mucus, suppresses endometrial growth, and perhaps alters secretions and peristalsis of the fallopian tubes. The progestational compounds are varied, as are their side effect profiles. In the last two
decades, we have seen a decrease in both side effects and vascular complications of hormonal contraception as a result of lower doses of estrogen and progestins. In general, the estrogen-related contraindications are for those patients with cardiovascular disease, with thromboembolic disease or risks, and with liver disease. The most common contraindication for progestin-only methods is unwillingness or inability to accept irregular bleeding, including amenorrhea. With the exception of the copper-releasing intrauterine device (IUD) and sterilization, nonhormonal methods are far less cost-effective. This chapter begins with considerations of certain medical conditions at certain times of the reproductive spectrum. It continues with a detailed discussion of various reversible methods, starting with the most effective, followed by a discussion of permanent methods.
decades, we have seen a decrease in both side effects and vascular complications of hormonal contraception as a result of lower doses of estrogen and progestins. In general, the estrogen-related contraindications are for those patients with cardiovascular disease, with thromboembolic disease or risks, and with liver disease. The most common contraindication for progestin-only methods is unwillingness or inability to accept irregular bleeding, including amenorrhea. With the exception of the copper-releasing intrauterine device (IUD) and sterilization, nonhormonal methods are far less cost-effective. This chapter begins with considerations of certain medical conditions at certain times of the reproductive spectrum. It continues with a detailed discussion of various reversible methods, starting with the most effective, followed by a discussion of permanent methods.
 FIGURE 1.1 Estimated annual deaths per 100,000 women according to contraceptive use. (From Maguire K, Westhoff C. The state of hormonal contraception today: established and emerging noncontraceptive health benefits. Am J Obstet Gynecol. 2011;205:S4-S8.) |
TABLE 1.1 Percentage of Women With Unintended Pregnancy During First Year of Typical Use and First Year of Perfect Use of Contraception and Percentage Continuing Use at End of First Year, United States | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
TABLE 1.2 Strong Contraindications to Combined Hormonal Contraceptive Use | |
|---|---|
|
Contraception Concerns With Selected Medical Conditions and Special Populations
When considering that the hormone levels in pregnancy are far higher than those produced by combination (estrogen-progestin) hormonal contraceptives (oral contraceptives [OCs], the patch and the ring), there are few absolute contraindications to combination hormone contraceptives (CHCs). Progestin-only methods and nonhormonal methods, such as the copper IUD, are a good option for women with relative or strong contraindications to estrogen. Depending on the patient’s desires, sterilization may be the best option. For a complete list of strong and relative contraindications to CHCs (including the patch and ring), see Tables 1.1 and 1.2. Other disorders that are relative contraindications to the use of progestin-only methods are listed in Tables 1.3, 1.4, and 1.5.
TABLE 1.3 Relative Contraindications to Combined Hormal Contraceptive Use | |
|---|---|
|
TABLE 1.4 Strong Contraindications to Progestin-Only Methods | |
|---|---|
|
Adolescents
Establishing confidentiality is of paramount importance with adolescents. Clinicians need to be familiar with how teens think and feel about sex and birth control, what their beliefs and emotions are, and how individual teens may make choices based on their lifestyles and social and affective circumstances. Oral CHCs and condoms are the most commonly used method by this age group, and concomitant use should be encouraged to protect against both pregnancy and sexually transmitted diseases (STDs). Long-acting reversible contraceptive (LARC) methods (IUDs and implants) are safe and effective and should be considered first line.4
Postpartum
Because of the higher risk of thrombosis after parturition, it is prudent to delay CHCs until 4 weeks postpartum. IUDs can be inserted immediately postpartum or anytime thereafter. The advantages to immediate insertion are obvious but there is evidence regarding increased expulsion
rates for this approach, with the lowest expulsion rates occurring immediately postpartum.5, 6, 7 Progestin-only pills can be given at 3 weeks in nonlactating women. Rarely, depo medroxyprogesterone acetate (DMPA) can cause metrorrhagia if given before 6 weeks postpartum but is otherwise safe to give at anytime in nonlactating women.
rates for this approach, with the lowest expulsion rates occurring immediately postpartum.5, 6, 7 Progestin-only pills can be given at 3 weeks in nonlactating women. Rarely, depo medroxyprogesterone acetate (DMPA) can cause metrorrhagia if given before 6 weeks postpartum but is otherwise safe to give at anytime in nonlactating women.
TABLE 1.5 Relative Contraindications to Progestin-Only Methods | |
|---|---|
|
Lactation
Many authorities recommend nonhormonal or at least delaying hormonal contraceptives until 6 weeks postpartum. Because withdrawal of progesterone with delivery of the placenta is a lactogenic trigger and because estrogen has negative feedback on prolactin, it makes theoretical sense that these hormones could negatively impact lactation. Additionally, there are concerns of hormone transfer to the infant depending on the formulation. A Cochrane review found existing randomized controlled trials are insufficient to establish an effect of hormonal contraception on milk quality and quantity.7 Therefore, if lactational amenorrhea or a nonhormonal option is not possible, a progesterone-containing contraceptive is recommended at 6 weeks postpartum. Earlier administration should be considered for certain situations.
Women Older Than Age 35 Years
Healthy women older than age 35 years who do not smoke and are not obese can safely take CHCs.
Perimenopause
The need for safe and effective contraceptive methods remains great in the perimenopausal period as evidenced by the high unintended pregnancy rate in this age group, often from a misconception that they do not think they are fertile. In fact, the pregnancy termination rate in women 40 to 50 years of age is exceeded only by those women younger than 15 years of age.2
The transition period of changing hormone patterns, or perimenopausal state, begins about 5 to 10 years before the actual menopause. Characteristics of the perimenopause are irregular cycles; changes in both the volume and the duration of bleeding; and for approximately half the women, the onset of variable vasomotor symptoms. The perimenopausal period is characterized by an increased incidence of anovulatory cycles, resulting in an unopposed estrogen state. This predisposes to dysfunctional uterine bleeding, possible endometrial hyperplasia, and a poorly documented, but frequently observed, accelerated growth of uterine myomata. CHC should be the method of choice for nonsmoking, nonobese women to regulate menstrual periods, provide contraception, control vasomotor symptoms, protect bone health, and reduce the risk of endometrial and ovarian cancers. These women often do well on the lowest estrogen dose of 20 mcg. Because there is no good test to confirm menopause, she can continue combined hormonal contraception until the age of 51 to 55 years, unless there is a change in her health status.
Cerebrovascular Disease
CHCs are contraindicated in the presence of cerebrovascular disease. They also increase the risk for stroke in women with other underlying risk factors.8
Migraine and Headache
Patients with a history of migraine headaches should use CHCs cautiously. Some patients will note an improvement, whereas some will notice no change; however, approximately 50% of patients will notice a worsening of their condition, especially during the hormone-free interval. One commonly accepted contraindication to the use of CHCs is a history of classic migraine (migraine with focal neurologic symptoms or aura lasting 5 to 60 minutes) due to an increased potential for stroke. It should be noted that women with a history of migraines have a two- to three-fold increased risk of ischemic stroke, regardless of CHC use.8
Seizure Disorder
CHCs have no impact on the pattern or frequency of seizures. However, some anticonvulsants can decrease serum concentrations of estrogen and thus may increase the likelihood of intermenstrual bleeding.9 An increase in ovulation or accidental pregnancy has never been shown. Although there is no published data to support this, some clinicians start with a 50 mcg EE formulation. Starting with at least 30 to 35 mcg of EE does seem reasonable. If a woman has been started on a 30 mcg EE formulation and develops intermenstrual bleeding, switching to a 50 mcg EE pill may be helpful. Anticonvulsants that do not appear to decrease serum estrogen levels when used concurrently with a CHC include levetiracetam, valproic acid, ethosuximide, and zonisamide.9 Gabapentin, lamotrigine, and tiagabine do not lower estrogen levels either but they have been studied at subclinical doses.8
Cardiovascular Disease
Venous Thromboembolism
Although not a major cause of morbidity and mortality, venous thrombotic disease and pulmonary emboli are
known side effects of CHC use. The dose of EE and type of progesterone influence this risk (desogestrel [DSG] and gestodene [GSD] are associated with a two-fold greater risk). Package labeling for certain progestin-only contraceptives list thromboembolism as a contraindication, but this is no supporting evidence for this claim.13 The transdermal patch, however, did increase venous thromboembolism (VTE) by two-fold in one cohort study.13 Coagulopathy screening is not cost-effective unless there is personal or family history. Unexplained VTE, hypercoagulable states, and VTE associated with pregnancy or exogenous estrogen are contraindications to combination OCs unless the patient is anticoagulated. Other risk factors for VTE should be considered.2
known side effects of CHC use. The dose of EE and type of progesterone influence this risk (desogestrel [DSG] and gestodene [GSD] are associated with a two-fold greater risk). Package labeling for certain progestin-only contraceptives list thromboembolism as a contraindication, but this is no supporting evidence for this claim.13 The transdermal patch, however, did increase venous thromboembolism (VTE) by two-fold in one cohort study.13 Coagulopathy screening is not cost-effective unless there is personal or family history. Unexplained VTE, hypercoagulable states, and VTE associated with pregnancy or exogenous estrogen are contraindications to combination OCs unless the patient is anticoagulated. Other risk factors for VTE should be considered.2
Obesity
Obesity (body mass index [BMI] greater than 30 kg/m2), and even being overweight (BMI greater than 25 kg/m2) are independent risk factors for VTE. In obese women ages 35 years or younger, CHC use is appropriate, although there is some evidence that with overweight or obese patients, the efficacy is less than with women with normal BMI.9 Similarly, women weighing 90 kg or more had significantly higher failure rates with the transdermal patch. Obese women should be counseled regarding this possibility. The levonorgestrel IUD is an excellent choice because it circumvents potential problems related to EE and provides endometrial protection and stabilization.8
Hypertension
If a patient has hypertension, it should be controlled (to less than 140/90 mm Hg) prior to beginning combination OCs because they have the potential to aggravate this condition.12,13
Increases in blood pressure have been reported in women taking OCs, and follow-up evaluation of blood pressure in such patients is advised. If the blood pressure is controlled and no vascular disease is present, CHCs are not contraindicated. A history of pregnancy-induced hypertension does not preclude the use of CHCs as long as the blood pressure returns to normal postpartum.13
Dyslipidemia
Women younger than age 35 years, in the absence of uncontrolled hypertension, diabetes, or other OC contraindications, may consider CHC use. In general, estrogen decreases low-density lipoprotein (LDL), increases high-density lipoprotein (HDL), and increases triglycerides, but does not increase atherosclerosis.13 This effect is seen with the transdermal patch and the vaginal ring. An OC with a less-androgenic progestin increases HDL more and triglycerides less. If a woman’s triglycerides are above 350 mg/dL or in patients with familial hypertriglyceridemia, CHCs should be avoided because they may precipitate pancreatitis and/or adversely affect the patient’s risk for cardiovascular disease.
Mitral Valve Prolapse
In general, CHCs can be safely used by women with mitral valve prolapse (MVP) who are symptom free. Use should be limited to MVP patients with an echocardio-graphic-confirmed diagnosis but without mitral regurgitation. A history of thrombotic complications would require another contraceptive method. Long-acting progestins such as injection or implants are safe to use and may provide increased fibrinolytic activity.
Diabetes
Young diabetic women who are free of retinopathy, nephropathy, hypertension, or other complicating vascular disease(s) are appropriate candidates for low-dose contraceptives. The progestin component of CHCs is believed to increase insulin resistance, although this has not had a verified clinical effect.8 Women with a history of gestational diabetes during their last pregnancy can safely take low-dose CHCs. The incidence of frank diabetes developing within 3 years of pregnancy is no higher in women taking low doses of CHC than in those using nonhormonal contraceptive methods.10
Systemic Lupus Erythematosus
CHCs can be given to women with mild lupus (no vascular disease or nephritis) and no antiphospholipid antibodies.12
Sickle Cell Disease
Internationally, recommendations for women with sickle cell disease and CHC use vary widely. DMPA is an excellent choice, as it reduces painful crises.8 In the United States, many clinicians think that the risks of pregnancy far outweigh the risks associated with CHC use in women with sickle cell disease. Thus, CHC are often prescribed for this population.11,12
Oral Contraceptives and Cancer
Breast Cancer
Fear of developing breast cancer has been a deterrent to the use of both hormonal contraceptives and hormone replacement therapy. The issue has been one of major debate for a number of years, and it is still unresolved.13, 14, 15 Early studies suggested a slight association between OC use and breast cancers in BRCA1/BRCA2 carriers. Results of the Women’s Contraceptive and Reproductive Experiences (CARE)15a study showed no association between CHCs and DMPA and breast cancer in patients with benign breast disease or a family history
of breast cancer, including BRCA1/BRCA2 mutations. Some recent studies have presented nonconclusive results that suggest a slightly increased risk for mutation carriers. Despite the failure to prove any decisive association between CHC use and breast cancer, the hypothesis is biologically plausible. Even a slight but hard to prove risk increase could be highly significant given the high incidence of breast cancer. Therefore, the controversy is likely to continue until larger longitudinal studies show more definitive results.
of breast cancer, including BRCA1/BRCA2 mutations. Some recent studies have presented nonconclusive results that suggest a slightly increased risk for mutation carriers. Despite the failure to prove any decisive association between CHC use and breast cancer, the hypothesis is biologically plausible. Even a slight but hard to prove risk increase could be highly significant given the high incidence of breast cancer. Therefore, the controversy is likely to continue until larger longitudinal studies show more definitive results.
Cervical Cancer
OCs alone do not increase the risk of cervical cancer. However, there is strong evidence that recent use of CHC is associated with increased risk of human papillomavirus (HPV) infection independent of sexual behavior and cervical abnormalities.16 Among HPV-infected women, those who used OCs for 5 to 9 years have approximately three times the incidence of invasive cancer, and those who used them for 10 years or longer have approximately four times the risk.17 On the other hand, such association is not observed with progestin-only contraceptives (i.e., DMPA). The mechanism is probably related to CHC affecting host response, making her less likely to clear HPV infection rather than increasing the risk of HPV acquisition.18
Endometrial Cancer
Numerous studies have shown a decrease in the risk of endometrial cancer of about 50% in combination oral contraceptives (COC) users. The protective effect is greater with longer duration of CHC use and higher progestogen potency and persists for more than 20 years after cessation of the CHC. Because endometrial cancer is thought to be caused by unopposed estrogen stimulation, progestogen-containing contraceptives could protect against endometrial cancer. The reduction of inflammation in the endometrium produced by CHCs may be the cellular mechanism behind the lower incidence of endometrial carcinoma in CHC users.19 Although CHCs can effectively reduce endometrial hyperplasia, it should be used only under certain circumstances in patients with or after endometrial cancer.20
Ovarian Cancer
Use of CHCs is associated with up to a 46% reduced risk of ovarian cancer compared with never use. As with endometrial cancer, protection from ovarian cancer may persist for up to 20 years after discontinuation of COCs.17,19 The blockade of ovulation, follicular rupture, and ovarian production of steroids may explain the lesser incidence of ovarian cancer among CHC users. The degree of protection is directly related to the duration of use, with the most significant reduction seen in women using them for more than 8 years. A 20% reduction is seen for every 5 years of use, but some protection is conferred with as little as 3 to 6 months of use. There does not appear to be any diminution in protection with the use of low-dose combination OCs.20 Furthermore, CHCs appear to reduce ovarian cancer for carriers of BRCA1/BRCA2 mutations.21
Oral Contraceptives and Surgery
Estrogen-containing OCs significantly increase the likelihood of both idiopathic and postoperative venous thrombosis and pulmonary embolism. Although these effects were most marked with early, high estrogen content OCs, there is still risk with present-day preparations containing 30 to 50 mg estrogen. More selective choice of CHC users, reduced estrogen doses, and better surveillance of users appear to have diminished the risk of thromboembolic disease with CHC use. But unfortunately, there are no sure predictors of thromboembolic disease. Because the thrombotic effects of CHCs stop by 4 weeks after termination, it is recommended that CHC use be interrupted one cycle before elective surgery, but the risk of thrombosis should be balanced against the risk of pregnancy. If prolonged immobilization is expected, they should be discontinued. Heparin prophylaxis should be considered if they are continued.22
LONG-ACTING REVERSIBLE CONTRACEPTIVE METHODS
Contributing to the many reasons there is a high unintended pregnancy rate in the United States is the popular use of less effective methods (CHCs and condoms), which have high discontinuation rates. LARC methods (IUDs and implants) could help mitigate these factors, with very few contraindications. Several studies have shown that LARC methods reduced repeat adolescent pregnancy and repeat abortions.3 In fact, expanding access to LARC has been declared a national priority by the Institute of Medicine.23
Although these contraceptive methods may have high cost initially, they have multiple advantages over other methods: They are not user-dependent, are highly cost-effective, have high continuation rates, and satisfaction and effectiveness are higher than other methods. They do not require additional visits for resupply or additional funding; furthermore, they offer a rapid return to fertility once discontinued.
Practitioners can increase LARC use in several ways: First, counseling all patients on these methods, including nulliparous and adolescent women24,25; second, avoiding unnecessary delays, such as screening for gonorrhea, chlamydia, or cervical cancer; third, avoiding waits for a follow-up visit after pregnancy (abortion, miscarriages, or term), especially in patients at risk for not returning.25,26
Intrauterine Devices
IUDs are highly effective with a pregnancy rate of less than 1% after 1 year. All IUDs are spermicidal by interfering with sperm transport and creating a sterile inflammatory environment in the uterus. Prefertilization properties constitute the primary mechanism of action, although the loss of the fertilized ovum may occur before implantation.27 As previously stated, IUDs do not increase the rate of pelvic inflammatory disease or tubal occlusion. Cervical cancer and STI screening can be done just before insertion if indicated. If treatment for infection is necessary, the IUD should not be removed.27 Return to fertility is immediate when removed.
Copper Intrauterine Devices
In addition to the mechanism above, copper is directly toxic to sperm, increasing its effectiveness. The TCu-380A (ParaGard) is currently approved for 10-year placement, but may be effective for 12 years. Because of this, it has the highest efficacy with the lowest cost. It is a good option for women who cannot or do not want to take hormones. It may also be used for emergency contraception. The copper IUD may cause dysmenorrhea and a 30 to 50% increase in menstrual flow, which can be mitigated with nonsteroidal anti-inflammatory drugs (NSAIDs). The discontinuation rates due to these two side effects is 12% so the patient should be asked ahead of time if dysmenorrhea and increase in menstrual flow would be acceptable.28 Over time, copper IUDs are associated with stable ovulatory bleeding patterns, but prolonged bleeding is common in the first few months.29 The 10-year cumulative failure rate is 2.1 to 2.8% (Fig. 1.2).
Levonorgestrel-Releasing Intrauterine Device
The levonorgestrel (LNG)-releasing IUD (Mirena) releases 20 mcg LNG daily. It inhibits sperm transport, thickens cervical mucus, partially inhibits ovulation, and causes reversible atrophy of the lining. These actions reduce menstrual flow by 70% at 6 months and by 90% at 12 months.30 Amenorrhea is seen in 30% of users by 2 years of use.31, 32, 33 The Mirena also improves dysmenorrhea so its use may be preferable in women experiencing heavy or painful periods. The Mirena IUD has been approved for 5 years of use but may be effective for up to 7 years. Two large clinical trials in Finland and Sweden with more than 1600 women and 45,000 cycles of use have demonstrated cumulative 5-year pregnancy rates of less than 0.7 per 100 women.34
Although irregular spotting or bleeding may occur in the first few months, this usually diminishes over time. The majority of women who continue to have cyclical menses with the LNG IUD have ovulatory progesterone levels, but only 58% of these women have normal growth and rupture of ovarian follicles on ultrasound exam. Of the women who do not have cyclical menses, 29% have growth and rupture of follicles.35 It is not surprising then that women using the LNG IUD can develop large (greater than 3 cm) ovarian cysts. In one study, all these cysts spontaneously resolved over a 4-month period, and it is believed the formation of these cysts is of limited significance.36 These findings are similar to what has been seen with the subdermal LNG implants.37 As eluded to earlier, there are a host of noncontraceptive benefits with the LNG IUD. In addition to treatment for menorrhagia and dysmenorrhea, it can be used to protect the endometrium from effects of unopposed estrogen.
 FIGURE 1.2 Copper IUD (ParaGard) readied for placement. |
Complications Associated With IUD Use
The risk of pelvic inflammatory disease (PID) is about 1/1000 and occurs in the first 20 days postinsertion. Women at risk are those with bacterial vaginosis and cervicitis. These infections should be treated with the IUD in place. Uterine perforation is also 1/1000 and is more common with immobile or anteverted or retroverted uteri, lactating women, and inexperienced inserters.
LNG IUD expulsion is more common in younger women, women who have not had children, and when an IUD is inserted immediately after childbirth or abortion. There is a higher risk of expulsion for women who have never given birth.38 LNG IUD expulsion rate is about 3% when used exclusively for contraception and 9 to 14% when used to control bleeding.39,40 IUDs decrease the rate of ectopic pregnancy compared with no contraception. However, if pregnancy occurs, the risk of an ectopic pregnancy is increased and the patient should be evaluated immediately.
When pregnancy is diagnosed in the presence of an IUD, the location of the pregnancy (intra- or extrauterine) should be determined and the device removed as soon as possible in the first trimester. Septic abortion is greatly increased when pregnancy is complicated by IUD. Women who become pregnant with an IUD in place have a 50% increased rate of spontaneous abortion. After removal of the IUD, the spontaneous abortion rate decreases to about 30%. If it cannot be removed or she chooses not to have it removed, she should be counseled that in addition to the increased spontaneous abortion rate, the risk of preterm labor, delivery, and sepsis are increased. She can be reassured that there is no increase in congenital anomalies.
Removal of an IUD in an infected, pregnant uterus should be accomplished only after intravenous antibiotic blood levels have been achieved. The removal of the IUD should be done in a location where emergency measures are available, in case septic shock ensues.
The IUD can be inserted safely at any time after abortion or delivery. There is a higher rate of expulsion for the delayed postpartum insertions, although it can be prevented with high fundal placement. Additionally, the rate of expulsion is lower for immediate postpartum insertions (within 10 minutes of placental delivery) than for delayed insertions (within 48 hours of delivery).22 Insertion of the IUD during the period of lactational amenorrhea has the advantage of significantly decreasing the spotting problem often encountered during the first cycle after insertion. Directions for placement of the copper and progesterone IUDs are found in Appendices 1.A and 1.B.
The patient should check for the IUD string monthly, and the practitioner should check for it at the time of gynecologic examination. If twirling a cytobrush in the cervical canal does not bring the strings into view, an ultrasound should be done to confirm intrauterine location. If the ultrasound does not show it, a flat plate abdominal radiograph can be taken, with an abdominal series to triangulate the location. If the IUD is intra-abdominal/extrauterine, it must be physically retrieved. An intra-abdominal IUD can cause serious problems, including bowel obstruction or perforation. Removal should be done as soon as possible after the diagnosis is made. Copper IUDs, in particular, elicit a strong inflammatory response that may make laparoscopic removal quite difficult. Perforation of the uterus usually occurs at the time of insertion, so it is important to identify the strings a few weeks afterward.
To remove an IUD, the strings are grasped with either a ring forceps or uterine dressing forceps and firm traction is exerted. If the string(s) cannot be seen, a cytobrush in the endocervical canal may help in extracting them. If ultrasound confirms intrauterine location, a paracervical block can be given before using alligator forceps or other instruments in the uterus. Visualization of the IUD with sonography or hysteroscopy may be necessary to facilitate removal.
Implants
Implanon, a single-rod subdermal implant the size of a matchstick, releases 68 mg of etonogestrel (metabolite of DSG) over 3 years. It releases about 40 mcg/day by the end of the first year and 25-30 mcg/day at the end of the third year. It is effective within 24 hours of insertion and prevents pregnancy by immediate thickening of cervical mucus, inhibition of ovulation, and endometrial atrophy. The Pearl index is less than 0.07 pregnancies per 100 woman-years if it is implanted in the first 5 days of the menstrual cycle.38
Implanon is convenient, has a high continuation rate, is rapidly reversible, does not affect bone density, and is easy to remove. Of note, the U.S. Food and Drug Administration (FDA) requires training to place or remove Implanon, and the manufacturer will not fill orders for physicians who are not trained. The procedure is very simple, requiring local anesthesia and a 2- to 3-mm incision between the bicep and tricep of the nondominant arm so that the distal end of the implant is 8- to 10-cm proximal to the medial epicondyle.
Side effects due to atrophy (irregular bleeding) were the most common reasons for discontinuation according to the package insert (11%). Other side effects such as headache and weight gain occurred in more than 5% of users but were not common reasons for discontinuation. Complications related to insertion and removal are much less common than with Norplant.39 Implanon is contraindicated in patients being treated with CYP3A-inducing or CYP3A-inhibiting medications.
Jadelle, a two-rod subdermal implant was approved by the FDA for 5 years of use but is not currently marketed in the United States.
ORAL CONTRACEPTION
The development and widespread use of combination hormone contraceptives (CHC) was a major breakthrough in the 20th century. Many observers regard this development as second in importance only to the development and use of broad-spectrum antibiotics.
In choosing a CHC, the optimal formulation will comprise the lowest effective dose with acceptable bleeding profiles and minimal side effects. Certainly, there is a trend in lower estrogen doses, less androgenic progestins, and fewer total days of menstrual bleeding. CHCs impact protein, lipid, and carbohydrate metabolism, but this may not be clinically important. In the United States, CHCs with less than 50 mcg estrogen use EE as the estrogenic component. Lower doses are as effective and have less thrombotic risk and probably less side effects (nausea, breast tenderness, headache, hypertension). Combined hormonal contraceptives can be taken cyclically, by an extended regimen, or continuously.
Most women start CHCs containing 20 to 35 mcg EE. Some of the newer CHC formulations contain fewer placebo days or days with EE only. Some pills contain iron or folate and are chewable. Among the progestins, there are second-generation CHCs, which contain norethindrone (LNG, norgestimate), and third-generation CHCs, which contain DSG or GSD. Drospirenone and dienogest are the newest. Both DSG and norgestimate are less androgenic. The increase in thromboembolism reported in some studies with DSG and GSD may be due to confounding, as there is no biological evidence of this effect.40 Clinicians can offer several options of CHCs to patients based on their individual characteristics, preference, and tolerance. For example, Yasmin and YAZ are both FDA approved for premenstrual dysphoric disorder (PMDD). These are also a good choice for polycystic ovarian syndrome, hirsuit, or hypertensive patients because drospirenone is antiandrogenic and a diuretic.
Benefits of Oral Contraception
Known benefits of CHC use include the prevention of unwanted and extrauterine pregnancies, reduction in pelvic inflammatory disease, recurrent ovarian cysts, ovulatory pain, premenstrual syndrome, PMDD, and blood loss/iron-deficiency anemia. They also decrease the rate of ovarian, endometrial, and colorectal cancers.41 They may increase the pleasure of intercourse because it can be spontaneous and without worry of pregnancy. The efficacy of CHCs and other methods is depicted in Table 1.1.
Disadvantages of Oral Contraceptives
Unscheduled bleeding and side effects are a major source of patient noncompliance and discontinuation but tend to resolve after 3 months of use. Therefore, watchful waiting and reassurance is a more logical approach to CHC prescribing than continued switching from one formulation to another. The key to success is an informed patient. Breakthrough bleeding (BTB) is more common in women who smoke and with 20 mcg formulations. Make sure she is taking them regularly because this is the most common reason for BTB. If it persists, rule out pregnancy, infections, drugs that interfere with OCs, and cervical cancer. If the bleeding is just before the placebos, she can stop the pack and start again in 4 to 7 days (depending on the number of placebo pills normally in the pack). If it occurs midcycle, give 7 days of estrogen (EE 2 mg or conjugated estrogen 1.25 mg) while she is taking the OCs.40 Alternatively, switch to a higher dose pill. Side effects (nausea, headache, breast tenderness, decreased libido) are markedly reduced with pills containing less than 50 mcg estrogen. When side effects do occur, they will usually decline after the first 3 months of OC use. Patients with refractory nausea may try taking the OC immediately after a meal rather than at night on an empty stomach. Changing to a lower dose pill may also help. Additionally, if side effects occur during the placebo pills, consider an extended or continuous cycle regimen.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
