Contraception

Chapter 26 Contraception



Adriana C. Linares, Ann I. Schutt-Ainé



Chapter contents


Use of Contraception 468
History 468

Prevalence 468

Impediments to Access 468

Counseling 468

Contraception Methods 469
Failure Rates 469

Medical Eligibility Criteria 469

Barrier Contraceptives and Spermicides 470

Fertility Awareness Methods 472

Coitus Interruptus/Withdrawal 473

Combined Hormonal Contraceptives 473

Progestin-Only Contraceptives 474

Intrauterine Contraceptives 475

Sterilization 476
Mechanism of Action 476

Tubal Ligation 476

Vasectomy 476

Emergency Contraception 477
Emergency Contraceptive Pills 477

Copper-T380A Intrauterine Device 477

Conclusion 477

Among U.S. women, the prevalence of ever using a contraceptive method is almost 98% (Chandra et al., 2005). By addressing issues related to contraception at each visit, an informed family physician can help prevent complications stemming from interactions with prescribed and over-the-counter medications, as well as from the use of the contraceptive method itself.



Use of Contraception



History


Humans have tried to control fertility since ancient times. Egyptian papyruses describe methods to avoid pregnancy (Benagiano et al., 2006). The ancient Greeks sought to control the birth of animals using herbs, barrier methods, and other remedies (Riddle, 1999), and evidence of use of barrier methods to prevent pregnancy is found among prostitutes in France (Head, 1961). The approval of the oral contraceptive pill in the second half of the 20th century marked a great revolution in the development and widespread use of contraception methods (Winter, 1970).



Prevalence


The National Survey of Family Growth found the most frequent contraception method used during the first sexual intercourse for men and women was the male condom, which is openly available in pharmacies, supermarkets, and medical offices (Chandra et al., 2005). When asked about use of current contraceptive methods, 62% of women report using a method, and in never-married cohabiting women, the most common method is the oral contraceptive pill (49%).



Impediments to Access


Lack of access is an important impediment to the use of contraception. With the exception of emergency contraception, all hormonal methods in the United States are available by prescription only. More than 47 million Americans (2010) do not have health insurance and have problems accessing primary care, and even with health insurance, access to contraception may be hampered by lack of coverage. For example, in a Washington state study comparing the 91 top-selling insurance plans, almost half did not cover any contraceptive method; 37% of women had no access to sterilization; and 53% had no access to pregnancy termination (Kurth et al., 2001). Another important impediment to the use of contraception can be physician difficulty in being reimbursed for contraception services. Therefore, Table 26-1 lists common International Classification of Diseases (ICD-9) codes for contraception counseling, prescriptions, and follow-up.


Table 26-1 ICD-9 Codes Used for Contraception Reimbursement



































































































Code Description
V25.0 General counseling and advice on contraceptive management
V25.01 Oral contraceptive initiation or counseling
V25.02 Initiation of other contraceptive method (diaphragm fitting, foam, etc)
V25.03 Encounter for emergency contraceptive counseling and prescription
V25.04 Counseling and instruction on natural family planning to avoid pregnancy
V25.09 Other family planning advice
V25.1 IUD, insertion
V25.2 Sterilization
V25.3 Menstrual extraction/regulation
V25.4 Surveillance of previously prescribed contraceptive methods
V25.40 Contraceptive surveillance, unspecified
V25.41 Repeat prescription/surveillance of OCPs
V25.42 IUD check, re-insertion or removal
V25.43 Surveillance of implantable subdermal contraceptive
V25.49 Surveillance of other prescribed contraceptive method
V25.5 Insertion of implantable subdermal contraceptive
V25.8 Post-vasectomy sperm count
V25.9 Unspecified contraceptive management
V26.4 General and counseling and advice on procreative management
V26.41 Procreative counseling and advice using natural family planning
V26.42 Other procreative management and advice
V26.5 Sterilization status
V26.51 Tubal ligation status
V26.52 Vasectomy status
V26.9 Unspecified procreative management
57170 Diaphragm/cervical cap fitting
58300 IUD insertion
58301 IUD removal
99070 Supply, diaphragm, IUD
J7300 IUD, copper (supply)
J7302 IUD, levonorgestrel (supply)

IUD, Intrauterine device; OCPs, oral contraceptive pills.


From World Health Organization (WHO). International Classification of Diseases (ICD-9).



Counseling


When counseling patients about the use of contraception, nonjudgmental, impartial communication is best. Patients often bring experience, opinions, and some knowledge about contraception that are easily elicited by open-ended questions. From this information, counseling can be customized to fit their specific needs. Use of their own words, frequent questions and answers, and feedback from patients play an important role in future compliance with medical advice.


An important consideration in contraceptive counseling is age because fertility among women varies with age. Barrier methods and some hormonal contraceptives can have low compliance in adolescents (ACOG, 2009). Older women can have more complications during pregnancy, making contraception an important component of health maintenance. Older women who are obese, smoke, or have comorbidities (e.g., hypertension, diabetes, migraines) are not good candidates to take combined hormonal contraceptives; progestin-only methods, intrauterine devices (IUDs) and sterilization may be good alternatives (Kaunitz, 2008). Women who use combined hormonal contraceptives after age 40 can be encouraged to stop in their early to mid-50s, when the likelihood of ovulation is low (ACOG, 2006).


Smoking is another important variable to consider when counseling patients. All patients should be encouraged to avoid smoking or to quit if they are smoking. The use of combined hormonal contraceptives in women over age 35 who smoked more than 15 cigarettes per day is contraindicated due to the increased risk of serious cardiovascular effects (Kroon, 2007). All women should be encouraged to use condoms consistently to reduce risk of sexually transmitted infections (STIs), especially in younger women with an increased risk of STI exposure.



Contraception Methods


Contraception is defined as the intentional prevention of conception or impregnation through the use of various devices, agents, drugs, sexual practices, or surgical procedures. The many methods available vary in efficacy, contraindications, and ease of use. Table 26-2 lists preferred contraceptive methods by patient type.


Table 26-2 Preferred Contraceptive Options for Select Patient Groups



















































































Patient type Preferred options Comments
Adolescent DMPA, implant, COC, or IUC plus condoms IUCs are excellent option currently underused in adolescents.
Potentially noncompliant DMPA, implant, patch, ring, IUC —
HIV and STD risk Condom plus any other form of contraception —
Postpartum and lactating DMPA, implant, POP, IUC, LAM up to 6 months if specific criteria met COCs can decrease quality and quantity of breast milk, but only if started before establishment of lactation.
Smoker >35 years old DMPA, implant, POP, IUC, barrier methods ECs contraindicated.
Diabetic DMPA, implant, IUC, barrier methods ECs appropriate in young normotensive well-controlled diabetic women.
Hypertensive DMPA, implant, POP, IUC barrier methods ECs appropriate in young well-controlled nonsmoking hypertensive women.
History of stroke/TIA IUC, barrier methods ECs contraindicated; may consider progestin-only methods.
History of thromboembolism IUC, barrier methods ECs contraindicated; may consider progestin-only methods.
Coronary artery disease IUC, implant, barrier methods ECs contraindicated, may consider progestin-only methods.
Mitral valve prolapse DMPA, implant, IUC. COC; patch or ring if asymptomatic —
Polycystic ovarian syndrome COC, ring, patch, levonorgestrel IUC COCs best shown to suppress androgen excess; levonorgestrel IUC provides excellent endometrial protection.
Sickle cell disease DMPA, barrier methods DMPA shown to decrease frequency of crises.
Gallbladder disease DMPA, implant, IUC COCs may accelerate progression.
Taking anticonvulsants or other hepatic inducers DMPA, IUC Efficacy of COCs, POPs, and implants may be reduced.
Desires long-term reversible contraception DMPA, implants, IUC —
Desires short-term reversible contraception COC, POP, patch, ring, barrier methods —
Desires convenience DMPA, implant, IUC —
Desires permanent contraception; no interest in future fertility Vasectomy or tubal ligation —

COC, Combined (combination) oral contraceptive; DMPA, depot medroxyprogesterone acetate; IUC, intrauterine contraceptive; POP, progestin-only pill; LAM, lactational amenorrhea method; ECs, estrogen-containing contraceptives.


STD, Sexually transmitted disease; HIV, human immunodeficiency virus; TIA, transient ischemic attack.


Data from World Health Organization. Medical eligibility criteria for contraceptive use 2004, and 2008 Update of the Guide (WHO website).



Failure Rates


Failure rates are typically described as percentage of women experiencing an unintended pregnancy within the first year of use (Zeiman et al., 2007). Two failure rates are measured, as follows (Table 26-3):


Perfect-use failure rate refers to the percentage of women who become pregnant during the first year of use when the method is used correctly and consistently according to instructions.

Typical-use failure rate refers to the percentage of women who become pregnant during the first year of use, which includes both those who use the method correctly and consistently and those who do not.

Table 26-3 Failure Rates for Contraceptive Methods: Percentage of Women who Become Pregnant during First Year of Use






























































































































Contraceptive method Women pregnant in first year
  Perfect Use (%) Typical Use (%)
No method 85 85
Barrier contraceptives and spermicides
Male condom 2 15
Female condom 5 21
Cervical cap, nulliparous 9 16
Cervical cap, parous 26 32
Diaphragm 6 16
Contraceptive sponge, nulliparous 9 16
Contraceptive sponge, parous 20 32
Nonoxynol-9 18 29
Fertility awareness methods
Standard Days 4.75 12
TwoDay 3.5 14
Symptomothermal 2  
Postovulation 1  
Lactational amenorrhea 0.45 2.45
Coitus interruptus/withdrawal 4 27
Combined hormonal contraceptives
Combined oral contraceptives (OCs) 0.3 8
Contraceptive patch 0.3 8
Vaginal contraceptive ring 0.3 8
Progestin-Only contraceptives
Progestin-only pills (POPs) 0.3 8
Depot medroxyprogesterone acetate 0.3 3
Contraceptive Implant 0 0.1
Intrauterine contraceptives
Copper-T380A 0.6 0.8
Levonorgestrel intrauterine system 0.1 0.1
Sterilization
Tubal ligation 0.5 0.5
Essure 0 <1
Vasectomy 0.10 0.15

Data from Arevelo et al., 2002, 2004; Harrison-Woolrych and Hill, 2005; Palmer and Greenberg, 2009; Perez et al., 1992; Trussel, 2004; and van der Wijden et al., 2003.



Medical Eligibility Criteria


The World Health Organization (WHO) periodically convenes an Expert Working Group to make evidence-based recommendations for who can safely use a contraceptive method. These criteria can be found on the WHO website.



Barrier Contraceptives and Spermicides



Key Points


• Barrier contraceptives and spermicides create a physical barrier to fertilization.

• Many of these methods are available over the counter, increasing access.

• Some barriers can provide protection against cervical infections; condoms also offer protection against HIV.


Mechanism of Action


Barrier contraceptives provide a physical barrier that prevents sperm from accessing the upper reproductive tract. They are often used in conjunction with spermicides, which act to destroy sperm and prevent fertilization.



Male Condom



Materials


Male condoms have been used since ancient times, with early condoms made from animal intestine. Mass production began in the 1840s with the advent of vulcanized rubber. Modern condoms are most often made of latex or polyurethane, but those made from animal intestine do still exist. Polyurethane condoms provide increased sensitivity for male partners, but the breakage and slippage rates are significantly higher (relative risk, 6.6 for breakage and 6.0 for slippage) compared with latex condoms (Frezieres et al., 1998) (Level of evidence: A). This suggests that latex condoms should be encouraged except for those with latex allergy/sensitivity.



Advantages


Male condoms can decrease the transmission of STIs, including human immunodeficiency virus (HIV), when used correctly and consistently.



Disadvantages


To obtain maximum protection from pregnancy and STIs, condoms must be used correctly with every act of intercourse. Those individuals with an allergy or sensitivity to latex should avoid these condoms. Some men report decreased sensitivity with condom use. A new condom must be used for each act of intercourse.



Female Condom


The female condom is a thin polyurethane sheath with a ring on each end. It can be inserted into the vagina up to 8 hours before intercourse. It should not be used simultaneously with a male condom because of possible breakage or slippage of either device.



Advantages


Female condoms can decrease the transmission of STIs, including HIV, when used correctly and consistently. Many women prefer having direct control over a barrier device. The female condom can be placed in advance of intercourse, increasing spontaneity.



Disadvantages


To obtain maximum protection from pregnancy and STIs, condoms must be used correctly with every act of intercourse. Some women may experience vaginal irritation. A new condom must be used for each act of intercourse.



Cervical Cap and Diaphragm


Diaphragms are dome-shaped devices made from silicone or latex. Diaphragms come in a range of sizes and require a fitting and prescription from a health care provider. Diaphragms are used in conjunction with spermicide, can be placed in the vagina up to 6 hours before intercourse, and should be left in place for at least 6 hours after the last act of intercourse, but no longer than 24 hours. Subsequent acts of intercourse require insertion of additional spermicide without device removal.


A silicone cervical cap (FemCap) was approved by the U.S. Food and Drug Administration (FDA) in 2003. It is reusable, and the design includes a domed cap that completely covers the cervix and a brim that forms a seal against the vaginal wall, funneling the ejaculate into a groove between the dome and the brim that faces the vaginal opening, storing the spermicide and trapping sperm. It comes in three sizes: for nulliparas, for women who have been pregnant but did not deliver vaginally, and for women who have delivered a full-term infant vaginally. It requires a fitting and prescription from a health care provider. The cervical cap is used in conjunction with spermicide and should be left in place for at least 6 hours after the last act of intercourse, but no longer than 48 hours. Subsequent acts of intercourse require insertion of additional spermicide without device removal.



Advantages


Many women prefer having direct control over a barrier device. Diaphragms and cervical caps can be placed in advance of intercourse, increasing spontaneity. These methods may offer some protection against cervical infections and pelvic inflammatory disease (PID) but offer no protection against HIV.

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Oct 3, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Contraception

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