Evolution of contraception

Evolution ofEvolution of
Contraception: PotionsContraception: Potions
to Progestinsto Progestins
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BasicsBasics
• 48% pregnancies in the US are unintended
• Age group with second highest rate of
unintended pregnancy is women 40-44
• Half of all unintended pregnancies end in
abortion
• 45% of abortions occur in women 25-30 years
old and 24% occurred >30 years old
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Pregnancy PreventionPregnancy Prevention
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Lactational Amenorrhea (LAM)
•Typical use 95%
• Perfect use 98%
Natural Family Planning
• 78-88%
No method
• 15%

Ancient “Technology”Ancient “Technology”
• Vaginally administered honey
• Drinking the water used to wash the dead
• “Sponges” made from crocodile dung or fermented
dough
• Lemon wedges over the cervix
• Middle Ages women died of lead, arsenic, mercury, or
strychnine poisoning after drinking for theoretical
contraceptive or abortifacient effects
• Earwax of a mule worn as an amulet to ward off
pregnancy
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““Modern” ContraceptionModern” Contraception
• 1930s Austrian physiologist suggested
extracts of ovarian hormones could inhibit
fertility
• Researched hampered by unavailability of
hormones
• 1960s FDA approved first oral contraceptive
• Estimates suggest that by the end of their
reproductive years 80% of US women will
have used OCs for an average of 5 years
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Development of Non-hormonalDevelopment of Non-hormonal
MeansMeans
• First IUD made of silk suture in 1929
reported a 3% pregnancy rate
• 1930s rings wrapped in silver wire 1.6%
pregnancy rate
• 1960s first copper IUDs introduced
• 1980s litigation involving Dalkon Shield led to
decrease in IUD use
• Today IUDs used by 2% US women
• 2 available forms: Progesterone
(Mirena/Progestasert) and copper (Paraguard)
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Barrier MethodsBarrier Methods
• Condoms (male & female)
• Diaphragm (used by <2% of women)
• Cervical cap (no longer available in the US)
• Contraceptive sponge
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Progestin Only OptionsProgestin Only Options
Injection
Depo Provera
Intrauterine Devices
Mirena – good for up to 5 years
Progestasert – inserted yearly
Implants
Implanon – good up to 3 years Brought to you by

Mechanism of ActionMechanism of Action
Progestin Only FormsProgestin Only Forms
• Blocks LH
• Maintains thickness of cervical mucous
• Reduces mobility of fallopian tubes
• Changes uterine lining making it unfavorable
for implantation
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Side Effects Progestin OnlySide Effects Progestin Only
• Headache
• Vaginitis
• Breast pain
• Weight gain
• Acne
Most disappear within a few months of starting
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Depo ProveraDepo Provera
• FDA approval for contraception in 1991
• Given as an IM injection every 11-13 weeks
• Suppresses ovulation
• Depresses ovarian steroidogenesis
• Estradiol can dip into menopausal ranges
leading to increased bone mineral resorption
• Continuous use should not exceed 2 years
(not lifetime)
• Menstrual changes
• 50% amenorrheic by 12 months
• 75% amenorrheic by 24 months
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Depo Provera cont.Depo Provera cont.
• Weight gain more variable than with other
methods
• Return to fertility can be delayed (median 9-
10 months)
• May be used in breast feeding
• May be used in women with contraindications
to estrogen containing products (eg. Smokers
over 35, thrombophilias)
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ImplanonImplanon
•Available in Europe and
Asia for 8 years and used
by 2 million women
•Easier insertion and
removal than its
predecessor Norplant
•99% efficacious (Pearl
index 0.38)
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ImplanonImplanon
• Single 4 cm rod implant
(Etonogestrel)
• Implanted subdermally
in the upper arm
• No meaningful effects
on lipids, carbohydrate
metabolism, liver
function, blood
pressure, thyroid or
adrenal function
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ImplanonImplanon
Advantages
• Dysmenorrhea relief in 88%
of women
• Safe in breast feeding
• High efficacy
• No abortifacient properties
• Long term use
• Does not suppress estradiol
levels
Disadvantages
• Requires minor surgical
procedure
• Lack of protection against
STDs
• Bleeding irregularities
Infrequent bleeding (27%)
Amenorrhea (18%)
Prolonged bleeding (15%)
Frequent bleeding (7%)
• Weight gain
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Progesterone IUDsProgesterone IUDs
• Introduced in the US 2002
• Approved for 5 years of use
• 5 year failure rate 0.7%
• Actions primarily local (thickens
cervical mucous)
• Ovulation not usually impaired
• Rapid return to fertility
• Long term effects on endometrium
• By 12 months bleeding reduced 70-90%
• Majority of women amenorrheic at one year
• Useful in patients with dysmenorrhea
and menorrhagia
Copper
Mirena
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IUD Mechanism of ActionIUD Mechanism of Action
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Mirena & Cycle EffectsMirena & Cycle Effects
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Who Shouldn’t Use the IUDWho Shouldn’t Use the IUD
• History of pelvic inflammatory disease
• Copper allergy (Copper IUDs only)
• Multiple sexual partners
• Uterine abnormalities
• Untreated infections of the cervix or uterus
• History of ectopic pregnancy
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Oral ContraceptivesOral Contraceptives
• Combination of ethinyl estradiol and one of
several progestins or progestin alone
Mechanism of Action
• Inhibit the LH surge needed for ovulation (progestin)
• Modulating GnRH release/FSH production (estrogen)
• Alter cervical mucous
• Induce atrophic changes in the endometrium
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Estrogen PharmacokineticsEstrogen Pharmacokinetics
Naturally occurring
estrogens
• Readily absorbed by GI tract,
skin and mucous membranes
• Also fairly well absorbed when
given IM
• Partially inactivated by P450
system
Synthetic estrogen
analogs
• Well absorbed by GI tract,
skin and mucous membranes
• Fat soluble stored in
adipose tissue
• Prolonged action and higher
potency than natural
estrogens
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ProgesteroneProgesterone
PharmacokineticsPharmacokinetics
• Rapidly absorbed after administration by any
route
• Short half life
• Almost completely metabolized after one
passage through the liver
• Synthetic progestins less rapidly metabolized
Adverse Effects
Edema/depression/Increase LDL:HDL
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Disadvantages of EstrogenDisadvantages of Estrogen
• Even for healthy users slight increase of
blood clots
• For smokers over the age of 35 this risk is
dramatically increased
• Contraindicated in women with history of
certain forms of cancer
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Contraindications to EstrogenContraindications to Estrogen
Containing ContraceptivesContaining Contraceptives
• Migraine with aura
• Smokers over the age of 35
• History of thromboembolic disease
• Coronary artery disease
• Diabetes or hypertension with vascular
disease or older than 35
• Lupus erythematosus
• Hypertriglyceridemia
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OCs – NoncontraceptiveOCs – Noncontraceptive
BenefitsBenefits
• Lower incidence of endometrial and ovarian cancers
• Fewer ovarian cysts
• Decreased risk of ectopic pregnancy
• Minimize acne
• Regulation of menses – lighter flow
• Reduction in dysmenorrhea
• Reduction in symptomatic fibrocystic breast disease
• Decrease upper genital tract infection (PID)
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OCs – DisadvantagesOCs – Disadvantages
• No protection against STDs
• Increase in thromboembolic events
• Compliance issues
• Nausea/weight gain/breast tenderness
• May precipitate migraine headaches
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Oral ContraceptivesOral Contraceptives
• Combination pills
• Progestin only pills
• Post-coital (Emergency)
contraception
Mechanism of Action
Suppression of ovulation by feedback
inhibition of endogenous estrogen
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Combination FormulationsCombination Formulations
• Estrogen prevents
ovulation
• Progestin prevents
implantation and makes
cervical mucus
impenetrable to sperm
• Perfect use efficacy
99%
• Rapid return to fertility
on discontinuation
Ethinyl estradiol*
Estrogen in 99% of all
OCPs
Monophasic
Triphasic
Extended Cycle
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Ortho EvraOrtho Evra
• Introduced in 2002
• Combination estrogen/progestin
• Inhibits ovulation similar to OCPs
• Each worn for 1 week at a time for 3
consecutive weeks
• Fourth week is patch free
• Return to fertility within one month
• Weight > 198 pounds associated with
higher pregnancy rates
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Nuva RingNuva Ring
• Introduced in mid-2002
• Combination therapy
• Half the estrogen dose than traditional oral
contraceptives
• Inserted at the top of the vagina
• Slow, continuous release of hormone over a 3 week period
• Return of fertility within one month
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Progestin Only PillsProgestin Only Pills
• “Mini-pill”
• Safe in breast feeding
• Ovulation not necessarily affected
• Must be taken at the same time every day to
ensure effectiveness
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Improper CounselingImproper Counseling
• 42% women will discontinue method without
consulting health care provider
• Poor compliance
• 47% users miss one or more pills/cycle
• 22% miss two or more
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Emergency ContraceptionEmergency Contraception
• High dose estrogen/progestin administered within 72
hours of unprotected intercourse
• Two doses 12 hours apart
• Single mechanism of action not identified
• Inhibition or delay of ovulation
• Histologic/biochemical changes in the endometrium
• Alterations in tubal transport
• 98% patients will menstruate by 21 days after
treatment
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Emergency ContraceptionEmergency Contraception
Preven Emergency Contraceptive Kit
Plan B
• High incidence of nausea & vomiting
• Effectiveness rate 75%
If 100 women had unprotected intercourse in the middle two weeks
of their cycle 8 would become pregnant. Use of emergency
contraception would reduce this number to 2 (75% reduction)
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Nutrition & HormonalNutrition & Hormonal
ContraceptionContraception

Hormonal Contraception &Hormonal Contraception &
CancerCancer
Ovarian Cancer
• Reduces risk by 30-50%
• Even in women with genetic
predisposition
• Believed to be due to progestin
component
• Protection after 5 years of use
and persists for up to 20 years
Uterine Cancer
• Reduces risk by 40-50%
Cervical Cancer
• Unknown whether increased risk
arises from true oncogenic effect
or discontinued condom use and
risk taking behavior (increased
risk of HPV acquisition)
Breast Cancer
• Studies conflicting
• Risk was higher with older higher
dose pills
• Study in 2002 no association
between Ocs and breast cancer
after 15 years of use

Surgical SterilizationSurgical Sterilization
• One of most common methods of contraception in the
US (25%)
• In every case should be considered permanent
• Patency of fallopian tube disrupted by excision,
ligation, cauterization, or occlusion by rings or clips
• 10 year failure rates range from 0.75% to 3.65%
• Male sterilization involves disruption of vas deferens
• First year failure rate 0.15%
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Essure Tubal OcclusionEssure Tubal Occlusion
• Available in the US since 2002
• Micro-insert composed of stainless steel
inner coil, nitinol elastic outer coil and PET
fibers
• Inserted in the proximal section of each
fallopian tube under hysteroscopic guidance
• Elicits an intended benign occlusive tissue
response
• Clinical trials 2 year failure rate 0%
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EssureEssure
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Essure Follow-upEssure Follow-up
Normal HSG Abnormal HSG
Dye spillage
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Essure AdvantagesEssure Advantages
• Non-incisional
• Non-hormonal
• Can be performed without general anesthesia
• Rapid recovery - discharged 45 minutes after
and 92% returned to work the next day
• Highly effective
• Available to patients with not eligible for
invasive sterilization
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Essure DisadvantagesEssure Disadvantages
• Chance that both micro-inserts can not be
placed (14% in clinical trials) - 83% were
placed on second attempt
• Must rely on back-up contraception for 3
months
• Removal of inserts requires surgery and may
result in hysterectomy
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Natural Family PlanningNatural Family Planning
Fertility Awareness Methods
• Basal body temperature
• Ovulation method
• Symptothermal
Success based on:
• Method’s accuracy in determining fertile days
• Ability to comply with method diligently
• Couple’s ability to avoid intercourse on fertile days
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Ovulation MethodOvulation Method
Billings Method
• Monitoring cervical secretions
• Avoid unprotected intercourse during
preovulatory days until the 4th day after the
“peak” secretions day (last day of watery
discharge)
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SymptothermalSymptothermal
• Observation of cervical secretions as well as
taking basal body temperatures
• Avoidance during peak fertility days
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Standard DaysStandard Days
• Based on physiology of the menstrual
cycle & functional life span of the
sperm and ovum
• Best for women with cycle length
between 26 and 32 days
• Pregnancy only likely on Days 8-19
• Intercourse 5 days prior to ovulation
4% probability
• 2 days preceding ovulation 25-28%
• 24 hours after 8-10%
• Day after 0%
• 5% Failure rate
• 12% Typical use failure rate
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Evolution of contraception

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