CONTRACEPTIVES CONTRACEPTIVES against conception • Most people - two needs: • protection from pregnancy • protection from STDs
CONTRACEPTIVES • Contraceptives can fail due to: • method failure (varying %) • user failure • Why? • embarrassment • inhibitions • not spontaneous • memory failure • mood • awkwardness • dulled sensation • alcohol, other drugs
CONTRACEPTIVES • Why? (Cont’d) • fear parents will find out • fear to go to the doctor • heat of the moment • ashamed to buy • expense • takes the danger out of love • embarrassed to ask male partners • lots of guys hate condoms
CONTRACEPTIVES • Before Judeo-Christian era, women used different mixtures quite effectively. • Ex: camel or crocodile dung, herbal preparations • Knowledge gradually disappeared due to religious restrictions. (Patriarchal societies) • Most common contraceptive around the world: • breastfeeding! • Second most common: • tubal ligation • Myths about contraception
CONTRACEPTIVES • Research and education hampered by religious opposition in many countries: • influence on law • jail for contraception providers – Margaret Sanger • Still an issue in some countries, including some states in the USA • In Canada: Pierre Trudeau: the state has no business in the bedrooms of the nation – led to liberalized laws regarding sexual behaviour (1969)
CONTRACEPTIVES • BARRIER METHODS: • Male condom: • latex (best) or intestinal tissue of animals (mostly lambs), lubricated or un • better: polyurethane, thinner, stronger, conduct heat but a bit looser • relatively cheap – depends on frequency of use! • protects against STDs (latex only) • no prescription or fittings • easily available (in urban areas) now internet
CONTRACEPTIVES • BARRIER METHODS (Cont’d): • Male condom (Cont’d): • failure rate 10-12% due to user mistakes • many men dislike it, reduced sensation (?) • spontaneity • damaged by heat (pocket), fingernails • need to be used with other contraceptive methods to prevent STDs
CONTRACEPTIVES • BARRIER METHODS (Cont’d): • Female condom: • polyurethane, lubricated, two rings, one over cervix, one over vulva • polyurethane more resistant to tears and other damage • female control • expensive • high failure rate (preliminary) • spontaneity • awkward
CONTRACEPTIVES • BARRIER METHODS (Cont’d): • Diaphragm: no longer available in NL • rubber with ring • covers cervix loosely but stays in place if properly fitted • used with contraceptive cream/jelly • failure rate in US 18%, due to misuse, lower in Europe and Latin America • can be inserted 6 hrs. before, must be left in 6 hrs. after • can be left in place for repeated sex • need Dr.’s fitting and prescription • does not protect against STDs
CONTRACEPTIVES • BARRIER METHODS (Cont’d): • Diaphragm (Cont’d): • must be with owner when needed • failure due to arousal changes in vagina (ballooning), large changes in weight, birth, etc. need resizing • cream or jelly can be irritating to women or partner • not advisable during menstruation • needs to be washed and dried thoroughly after each use • no harmful side effects • inexpensive
CONTRACEPTIVES • BARRIER METHODS (Cont’d): • Cervical Cap: not available in NL • similar but more difficult to insert • fits more snugly over cervix • doctors in North America not trained to fit it or instruct patient • can be left in longer but risk of TSS and infections • high failure rate in the US • no STD protection
CONTRACEPTIVES • BARRIER METHODS (Cont’d): • Lea’s Shield (now there are different brand names) • is a one-size-fits-all reusable vaginal barrier contraceptive device. Approximately the size of a diaphragm, it is composed entirely of medical grade silicone rubber. The device is washable and reusable. • does not compare with any other mechanical device on the level of form, volume or matter. Unlike other barrier contraceptives, it does not depend on vaginal dimensions or cervical size which vary from woman to woman.
CONTRACEPTIVES • INTRAUTERINE DEVICES • Different shapes, materials. • Inserted inside uterine cavity by physician. • Can work by preventing sperm from swimming up or by preventing implantation. Unknown. • Very old method. • Some brands caused PID (pelvic inflammatory disease) leading to permanent infertility, ectopic pregnancies and hemorrhaging.
CONTRACEPTIVES • INTRAUTERINE DEVICES (Cont’d): • Can perforate uterine wall. • If woman becomes pregnant, high risk of miscarriage. • Periods heavier, cramping, bleeding between periods. • No protection against STDs. • Can be expelled by uterine contractions. • Some women very happy with this method.
CONTRACEPTIVES • CHEMICAL CONTRACEPTIVES: • Spermicides: • Chemical substances that kill sperm. • Ex: nonoxynol-9. Cream, jelly or foam. • Irritation or allergic reaction. • Also added to other contraceptives. • By itself high failure rate • Sponge: • Combination barrier and spermicide. 25% failure rate. • No prescription needed, intercourse can be immediate or within 24 hrs. • Increases rate of TSS and UTIs. • Currently off market.
CONTRACEPTIVES • HORMONAL CONTRACEPTIVES: • Pill: • Estrogen and progestin (synthetic progesterone) • After period estrogen low, prompts FSH. Pill blocks this by elevating estrogen. 95% effective. (ideal users) • Progestin helps by • inhibiting production of LH • thickening cervical mucus (sperm get stuck) • changing the endometrium so implantation is unlikely • Different types of pill, see text. • “Mini pill”: progestin only, less effective
CONTRACEPTIVES • HORMONAL CONTRACEPTIVES: • Norplant: currently not available • Subcutaneous implants of silicone cylinders • Small surgical procedure (upper arm) • Contains progestin • Inhibits ovulation • Thickens vaginal mucus • Prevents thickening of endometrium • Removal is difficult (scar tissue grows around it) same pros and cons as pill except forgetting, so highest effectiveness.
CONTRACEPTIVES • HORMONAL CONTRACEPTIVES (Cont’d): • Depo-Provera: • Injectable progesterone (medroxyprogesterone) prevents ovulation and changes mucus • Breast cancer risk • Osteoporosis • Irregular menstruation • Amenorrhea • Weight gain • Headaches • Anxiety • Stomach pain, cramps • Dizziness • Weakness, fatigue • Loss of libido
CONTRACEPTIVES • HORMONAL CONTRACEPTIVES (Cont’d): • Quarterly shots of estrogen and progestin • Lunelle, Cyclo-provera, Cyclofem • 100% effective • Same pros and cons • Yasmin: ethinylestradiol + drospirenone (type of progesterone) synthetic – recalled – unsafe • Patch: on fleshy body parts
CONTRACEPTIVES • Seasonale • taken continuously for 3 months • low dose estrogen and progestin • only 4 menstrual periods per year • what long-term consequences??? • Plan B • emergency contraception • two progestin pills • within 24 hours of unprotected sex: • 95% effective • the longer the interval, the lower the effectiveness • Plan B is now available prescription-free in most provinces • alternative: two or more pills of any contraceptive pill
CONTRACEPTIVES • Drugs that interact with oral contraceptives (partial list): • acetaminophen: pill lessens pain relief • alcohol: pill enhances alcohol effects • anticoagulants: pill decreases their effect • antidepressants: pill enhances their effect • barbiturates: interfere with pill effectiveness • penicillin: decrease pill effectiveness • tetracycline: ditto • More & more people on prescription drugs: potential for dangerous interactions
CONTRACEPTIVES • Side effects of hormonal contraceptives: • blood clots, can lead to heart attack and stroke • can lodge in lungs (respiratory difficulties) • carcinogens: • mixed data • need more long term studies • increased breast cancer, ovarian & endometrial • decreased cervical cancer • different studies yield different data • increased infertility after long term (over 10 years) but could be due to age
CONTRACEPTIVES • Side effects of hormonal contraceptives: • liver tumors, can lead to death • Difficulty: • so many different formulations, ever changing • controversial, contradictory results • who funded the research? • of most done by pharmaceutical companies (biased) • how is the data obtained? • many based on self-report. Long term vs. short term • increased monilia and trichomona vaginal infections • more susceptible to STDs (vaginal pH altered) • nausea • migraines or severe headaches • drug interactions: either increase or decrease effectiveness
CONTRACEPTIVES • Side effects of hormonal contraceptives (Cont’d): • depression • lower interest in sex • bloating and/or weight gain • interfere with milk production • cost • forgetting • infrequent sex • smokers • break-through bleeding • no STD protection • Environmental effects: the urine of users of hormonal contraceptives gets into the water systems affecting animals and possibly humans.
Remember “ACHES” for the Pill: Symptoms of Possible Serious Problems With the Birth Control Pill
CONTRACEPTIVES • NEW DEVELOPMENTS • The vaginal ring (which may also have estrogen) is a flexible polymer ring, inserted into the vagina for three weeks at a time. Removal at the start of fourth week brings on period • Skin patch: • emits estrogen and progestin • same as pill • applied anywhere, once a week • four week cycle (three on, one off) • Not effective in heavy women (thick fat pad under skin prevents good absorption) • Methotrexate (kills embryo) + misoprostol (a prostaglandin) causes uterine contractions. In Dr.’s office. It’s an abortifacient.
CONTRACEPTIVES • NEW DEVELOPMENTS (Cont’d): • Essure coil: • inserted into Fallopian tubes through the vagina and uterus • tissue grows around coil in 3 months, results in total blockage • sterility ($1,000, not covered) • not 100% effective
CONTRACEPTIVES • NEW DEVELOPMENTS: • Male Contraceptives • Testosterone enanthate: • inhibits sperm production (injection) • Vaccines, FSH stops sperm production • Male reversible contraceptive • IntraVas device • two flexible silicon plugs inserted into vas deferens • new method being tested in India: a polymer injected into the vas, disables sperm
CONTRACEPTIVES • Natural Methods: How good are they? • breastfeeding: only under certain conditions • rhythm or calendar: “Vatican roulette” • withdrawal (coitus interruptus) • avoid ejaculation (coitus reservatus) • sympto-thermal method: basal body temperature + vaginal mucus • abstinence
SYMPTOTHERMAL METHOD +ovulatory mucus observation
CONTRACEPTIVES • PERMANENT (MORE OR LESS) SURGICAL METHODS: • Tubal ligation: • Fallopian tubes cut, several methods, some failures. • Usual surgical risks. • Some evidence of increased incidence of hysterectomy for various problems. • Vasectomy: • Much simpler surgery: vas deferens cut or blocked. • Can be done for reversibility (50-70% success). • Two months wait for sperm already there to die. • Very small % of men experience post-surgery discomfort for a few months, most OK in 48 hrs. • Both methods still require condoms for STDs.
ABORTION: • Widely used for centuries. • Even early Christianity did not condemn it. • Until 20th century: • quickening • Canadian laws not like U.S.
ABORTION (Cont’d): • First trimester: • Very early (2-3 weeks): • RU-486 – methotrexate + misoprostol • D & C (dilatation and curettage) • D & E (dilatation and extraction)
ABORTION (Cont’d): • Second trimester: (10%) • Saline injection: • Fetal death, delivery follows within 24 hrs. • Prostaglandin injection: • Causes labour • D & E: • Under general anesthetic. • Fetal skull may need to be crushed for passage • Hysterotomy: • Like a Cesarean section • Hysterectomy: • Removal of uterus and contents