1. Methods of Contraception
Presented by Sarah McCormick, MSIII Kansas City University of Medicine

2. Top Questions to Ask your Patient
What are your contraceptive goals? Do you and when do you plan to get
pregnant?
Are you currently sexually active?
Which methods have you tried already, if any?
What did you like/dislike about each method?
Would you be able to swallow a pill and take it every day at the same time?
If pertaining- how often do you forget to use the method you currently use?
Are there any methods you have heard about and would like to try?
Is protection from STI important to you?
Remember to consider cost and health insurance coverage.

3. Menstrual Cycle
• Follicular Phase (proliferative)
• Estrogen- Causes uterine lining to
proliferate
Day 1-7- Menses, sloughing of
endometrium
Day 14- LH peak secondary to elevated
Estradiol surge activates ovulation, one )
or more) egg(s) is released from the
ovary.. The egg has 24 hrs to be fertilized
after release. It takes 3-4 days for the egg
to reach the uterus
• Luteal Phase (secretory)
• Progesterone- maintains endometrial
lining in preparation for fertilized ovum
Corpus Luteum releases Progesterone
Day 28- CL has diminished, less
progesterone is present causing the lining
of the uterus to slough off.
• http://www.uptodate.com/patients/content/images/endo_
pix/Menstrual_cycle.jpg

4. OCP’s
• The MOA-estrogen induced inhibition of GNRH at mid
cycle preventing ovulation, as well as inhibition of
follicle development. Progestin inhibits tubal peristalsis
and produces environment unfavorable to sperm.
• Efficacy- 99.7% perfect use, 92% typical use
• The Hormones
– Combined Estrogen (Ethinyl Estradiol )+ Progestin
(Norethindrone/Levonorgestrel)- unopposed estrogen in a
female with a uterus increases the risk of endometrial
cancer
– Progestin only- for women who can’t tolerate extra
Estrogen
• More break through bleeding
• Slightly higher failure rate

5. OCP’s• Monophasic/biphasic/triphasic
Monophasic
- all pills contain same amount of hormones.
Bi- and Tri- Phasic
- pills contain 2 or 3 phases of dosages.
-patient receives less hormones over time with same pharmaceutical
effect.
• Initiation
– First day start- start on first day of menses
• most reliable prevents follicle development the best
• No need for back up contraception during first week
– Sunday start- start first Sunday after period begins
– Quick start-start the day given prescription
• Regimen
– Cyclic- 21, 23 or 24 active pills, and 7,5 or 4 inactive respectively
• Reducing the amount of inactive days 7 to 4 decreases the risk of ovulation
(inhibits follicle development) esp. for low estrogen pills (20 mcg).
– Extended- 84 active, 7 inactive pills, or active without any inactive.
(Seasonale/Seasonique)

6. OCP’s
• Side Effects
– Increased risk for venous thromboembolism (3-4x increase, highest during
first year use)
– Slight increase risk breast cancer
– Increase in TG’s and HDL
– HTN
– Increased clotting factors in relation to Estrogen dose
– Progestin only pills-increased risk ectopic pregnancy (1/20) (Rate for all
women is 1/50)
– Cholestasis/cholestatic jaundice
– Increased migraines
• Advantages
– effective and reversible
– Not associated with weight gain
– Increased regulation of cycle and decreased flow
– Lower risk iron deficiency anemia
– Lower risk ovarian and endometrial cancer
– Lower risk ectopic pregnancy with combo pills
– Increased bone density

7. OCP’s
Absolute Contraindictions
- Previous TE
- Hx E dependent tumor
-Liver Disease – OCP’s metabolized in liver
-Pregnancy
-undiagnosed abnormal uterine bleed
-CVA, CAD, valvular heart disease
- >35 yo smoker (>15 cigarettes a day)
-Hypertriglyceridemia

8. OCP’s
• Drugs that reduce OCP efficacy
– Rifampicin
– Phenytoin
– Carbamazepine
– Barbituates
– Primidone
– Topiramate
– Oxcarbazepine
– Griseofulvin
– Antiretrovirals

9. Injectable Contraceptives
• DMPA (Depo-Provera)
– IM injection 150 mg every three months
– 99.7% actual and theoretical efficacy
– 2wk post initial injection altn. Contraceptive
needed
– Progestin only
– Decreased risk of endometrial cancer
– http://pro.corbis.com/images/42-17593835.jpg?size=572&uid={C97D0650-FC67-4FC8-86E9-3CC7C07BB3C6}

10. Contraceptive Implants
• Implanon
– 1 rod implant 68 mg Progestin Etongestrel for 3
yrs
• First year, Initially 60-70mcg/day decreasing to 35-
45mcg/day
• Second year- 30-40 mcg/day
• Third year 25-30 mcg/day
– Pearl Index .38 pregnancies (100 women in 1 year)
http://www.rxlist.com/implanon-drug.htm

11. The Patch
• Ortho Evra
– 20mcg ethinyl estradiol/ 150 mcg norelgestromin
– 99.7% efficacy perfect use, 92% typical use
– Continuous release- avoids peak/trough hormone
levels
– Applied weekly, one patch free week
– Same risks/benefits as
combo ocp’s
• Exception- increased risk TE
• (estrogen)
• Increased risk of failure >90kg
(198 lbs)

12. The Ring
• NuvaRing
– 15 mcg ethinyl estradiol/ 120mcg etonogestrel daily
– Efficacy 99.7% correct use, 92% typical use
– Intravaginal 3 weeks in, one week out
– Remove precoitus but insert 3 hrs postcoitus
– Side Effects
• same as ocp’s
• Local discomfort
• Increased vaginal discharge
• Increased vaginitis
• Headaches
– Benefits
• rapid return to ovulation after cessation of use
• Lower dose of hormones
• Convenient
• Less systemic exposure to ethinyl estradiol (half)

13. Male Condom• Efficacy 98% correct use, 85% typical use (without
spermacide)
– The Condom Rules:
• Use at every coital act
• Place before any contact of penis w/vagina
• w/draw with penis erect
• Hold base of condom during w/drawal
• Condom + spermacide is as effective as hormonal
contraceptives
• Water based lubricants are best (Petroleum based
lubricants can degrade condoms)
• Latex Condoms are most effective in preventing HIV
transmission

14. Female Condom
• Efficacy 95% correct use, 79% typical use
• Polyurethane, prelubricated

15. Diaphragm
-Efficacy- 94% correct
use, 86% typical use
-fit by clinician
-spermacide
-left in vagina 6-8 hrs.
postcoitus, must take
out after this time
-increased risk UTI’s
- Possible increased risk
TSS
- No STI prevention

16. Cervical Cap
• Efficacy is decreased with
parity
– Fit by clinician
– Nulliparous-91% correct
use, 84% typical
– Parous- 74% correct use,
68% typical
– Latex or silicone rubber
– Spermacide
– Can be left in for 48 hours
– Must keep in place 6-8 hrs
postcoitus
– No STI prevention

17. Spermacide
• Nonoxynol-9
• OTC- gel, film, cream, suppository
• Efficacy poor without barrier method 82%
correct use, 71% typical use (gel had worst
efficacy 6% higher risk of pregnancy)
• Must have coitus <1hr after application
• Must place high in vagina near cervix
• Local irritation- increased risk HIV
transmission
• (Microbicide/spermacides under research)

18. The Sponge
• Efficacy depends on parity
– Nulliparous -91% correct use, 84% typical use
– Parous- 80% correct use, 68% typical
– 2”x3/4” disc containing nonoxynol-9 spermacide
– OTC
– can leave in place 24 hrs
– Possible increased
risk TSS

19. IUD
• Efficacy <1% failure rate
• MOA
– Foreign Body activates inflammatory response and
release of cytokines toxic to sperm, ova, and
decreases implantation.2
• Benefits
– same efficacy as sterilization2
– Lower tubal pregnancy rate than those not using
contraceptives, but higher rate of ectopic if
pregnancy occurs2
– No estrogen exposure
– Decreased risk cervical and endometrial cancer2
www.uptodate.com

20. IUD
• Copper IUD (Paragard)
– Copper oxidized and enhances inflammatory reaction in uterus.2
– effective 10 years
– 1/16 Ectopic pregnancy rate
– Increased Risk PID if exposed to STI as compared to Mirena.
– Risk-menorrhagia, dysmenorrhea (50% women), blood loss
anemia2,
Perforation uterus
• Progestin IUD (Levonorgestrel)- (Mirena)
– Progestin-thickens cervical mucous and causes endometrial
decidualization and atrophy of glands, preventing fertilization.2
– 5 years effective
– 20mcg Levonorgestrel/day, declining to 14mcg/day by 5 years2
– Benefits: oligomenorrhea, decreased dysmenorrhea, tx endometrial
hyperplasia, protects uterus from Tamoxifen associated endometrial
proliferation, decreased risk of PID (thickened cervical mucous),
effective tx endometriosis related pain.2
– Risk- highest ectopic pregnancy rate ½, Perforation uterus
-www.uptodate.com

21. IUD
Contraindications:
-Severe Uterine Anatomical Distortion2
-Active Pelvic Infection- foreign body will impede healing2
-pregnancy
-
Wilson’s disease/Copper allergy
-Undx Uterine Bleed
-Current Breast Cancer (Mirena only not to use)
-Previous ectopic/high risk ectopic
Advisory:
-Active Gonorrhea/Chlam. Infection –wait 3 weeks, pelvic
exam r/o PID-insert if negative tests.
- Motrin 1 hr. prior to insertion to reduce cramping

22. Withdrawal Method
• Efficacy 72-80%
• Male withdraws from vagina prior to
ejaculation
• Pre-ejaculate fluid may contain sperm
• Failure do to late withdrawal

23. Fertility Awareness Method
• Fertile 5 days prior to and 24 hours after
ovulation (6 days total every cycle) (study- 8-
19 pregnancy)
• Ovulation day 14 on 28 day cycle, 15 on 30
day cycle
• Estradiol (follicle)-cervical secretions support
sperm transport and nutrition
• Progesterone (CL)-secretions inhibit sperm

24. Fertility Awareness Method
• Methods
– Standard Days Method-
• no unprotected intercourse days 8-19
• Efficacy- 95% correct, 88% typical
– Failure to use barrier or abstain from intercourse
– Irregular cycle, <26 days or >32 days
– Ovulation Method-
• Monitor vaginal secretions to calculate fertility (clear secretions around
ovulation time)
• No unprotected intercourse on wet clear secretion day, during menses, and
up to four days after wet clear secretions.
• Efficacy-97% correct, 77% typical (lowest of all methods)
– Complexity of method
– Failure to use barrier on fertile days or abstain from intercourse
– Better for complex/irregular cycles

25. Fertility Awareness Method
• Methods
– TwoDay Method-
• Avoid intercourse on day of and 1 day after ANY secretions ( approx.
13 days a cycle)
• Efficacy- Correct 96.5%, typical 86%
– Less complicated
– Less days available for intercourse
– Abstain from intercourse/ use barrier on fertile days
– Symptothermal Method
• Eval. secretions several times a day
• Take temperature every morning
• Abstain from intercourse all days of secretions, on all preovulatory
days, after 3 days high temp followed by 6 days low temp, or 4 days
post wet clear secretions
• Efficacy- correct 98% (highest of all methods), typical 80-87%
– Complexity of method
– Ability to abstain or use protection

26. Lactation and Fertility
• Efficacy 98% only if
– Up to 6 months post partum (15-55% > 6months)
– Breast feeding only nutrition for infant
– Not menstruating
• Prolactin released at time of breast feeding
inhibits GnRH from Hypothalamus no FSH,
no LH no ovulation, possible no follicle
development

27. Emergency Contraception
• OTC- 18 yrs or older
• Rx- 17yrs or younger
• Efficacy- 97%-99.8%, must take 72 hrs postcoitus
but linear decline in efficacy over time.
• MOA
– Interferes with tubal transport
– Inhibits implantation
– Causes Corpus Luteum regression
– Do not prevent pregnancy if implantation has
occurred

28. Emergency Contraceptive
• Levonorgestrel “Plan B” recommended more
effective, less side effects
• 2x0.75mg q12h or q24 hr (more effective if more
intercourse during time after pill was taken) or
1.5 mg single dose (recommended)6
• Mifepristone (RU-486)- Rx only, most effective,
delays ovulation and inhibits implantation6
• Copper IUD- most effective >120 hrs postcoitus6

29. Emergency Contraceptives
• Side effects6
– N/V- less with Plan B (no E)
– Dizziness
– Fatigue
– HA
– Intermenstual bleeding
– Breast tenderness bleeding
– Lower abdominal pain
No Contraindications
Advise home supply/giving in advance of need6

30. Sterilization
• Permanent and irreversible
• Reversal attempt only 50% successful
• <30 yo 20% regret/>30 yo 6% regret
• Methods
– Ligation/resection
– Rings/clips placement
– Electrocoagulation-3 or more sites coagulated, best
results
– Intratubal chemical/intratubal device (Essure)
– Male sterilization
– 20 min/local anesthesia

31. Sterilization
• Why Failures?
• Surgical errors (30-50%)
• Fistula formation (electrocoag)
• Faulty clip placement
• Reanastomosis tube
• Pregnant prior to surgery

32. References
1. Zieman MD., Mimi. “Overview of Contraception.” UpToDate. 1
Oct., 2008.
2. Dean MD., Gillian, Alisa B. Goldberg, MD, MPH. “Approach to
Intrauterine Contraception.” UpToDate. 1 Oct., 2008
3. Jennings, PhD, Victoria. “Fertility Awareness-based methods of
pregnancy Prevention.” UpToDate. 23 June, 2008.
4. John O. Schorge, Joseph I. Schaffer, Lisa M. Halvorson, Barbara L.
Hoffman, Karen D. Bradshaw, F. Gary Cunningham. Williams
Gynecology. Accessed 9
Jan.,2009<http://www.accessmedicine.com/resourceTOC.aspx?
resourceID=514>
5. Callanhan, Tamara, Aaron B. Caughey, Linda J. Heffner. Blueprints
Obstetrics and Gynecology. Third Edition, 2004.
6. Zieman, MD., Mimi. “Emergency Contraception.” UpToDate. 12
Mar. 2008.

33. Thank- You!