Contraception and New Millennium
Women's Health & Education Center Contribution
Readers are encouraged to visit the Reproductive Health Home Page of WHO for additional useful and helpful information.
The new millennium has brought optimism to the field of family planning. Recent research and modification to existing contraceptive products have generated confidence, among both healthcare professionals and the public, in the safety, efficacy, and importance of contraceptives. Maybe this is the time to achieve the goal set by the Institute of Medicine (1995); "All pregnancies should be intended.... consciously and clearly desired at the time of conception." Unwanted pregnancies are not only one of the major causes of maternal mortality and morbidity, but are also a great social and financial burden on societies and countries. According to WHO's statistics there are an estimated 200 million pregnancies around the world each year, and one third of these, or 75 million, are unwanted. These pregnancies contribute to women's health problems in two ways. First, unwanted pregnancy can threaten women's health or well being because she may have existing health problems or lack of support and resources, which she needs to have a healthy pregnancy and raise a healthy child. Second, where women do not have access to safe abortion services, many resort to unsafe procedures that can lead to a woman's death or disability. It is estimated nearly 80,000 maternal deaths and hundreds and thousands of disabilities occur around the world because of unsafe abortions. This is a very sensitive issue and let me touch it very delicately, because it is most easily preventable and the role of contraception is vital. Availability, accessibility, and perspectives towards contraception are complex social, political, and economical issues.
Some of our oldest written records describe contraceptive methods. The Kahun Papyrus (Egypt, 1850 B.C.) describes the use of vaginal pessaries made from crocodile dung, and the Ebers Papyrus, (1550 B.C.) details tampons made from lint and soaked in fermented acacia juice. A number of more reasonable and effective means for contraception have been known for a long time: the condom since the 16th century, cervical cap since the 1820s, the diaphragm and vaginal spermicidal since the late 19th century, and intrauterine contraceptive devices (IUCDs or IUDs) since early in the 20th century.
Contraceptive choices in the New Millennium:
Proper use of the contraceptive method is critical and is also strongly influenced by personal factors, such as age, race, education, socioeconomic status, and religion, and by experience with a particular contraceptive method. The alternatives to sexual abstinence are contraception and pregnancy. Estimates of the risk in using a contraceptive method, therefore, must include two components: (1) the health risk from complications of the contraceptive, and (2) the health risk from pregnancy should the method fail. Both risks vary with the method but also with the user. Age is a most important factor. Specific methods of contraception, their mechanism of action, advantage, disadvantage, and use in clinical practice are discussed next. By making judicious choices at different ages, the patient can obtain maximal benefit for least risk. Many couples would be best advised to use two contraceptive methods: hormonal contraception for excellent protection against pregnancy, and barrier contraception for protection from STDs and their consequences.
- Coitus Interruptus:
The Bible and the Koran refer to coitus interruptus, and it was widely advocated in England and the United States in the 18th century. It is thought, along with induced abortion and late marriage, to have accounted for most of the decline in fertility of preindustrial Europe. The most rapid decline in fertility in Europe occurred before the widespread availability of modern contraceptive methods. Coitus interruptus remains a very important means of fertility control in the Third World, yet has received virtually no serious attention from healthcare providers or scholars.
The method has two obvious advantages: immediate availability and no cost. In coitus interruptus, the penis is withdrawn from the vagina just prior to ejaculation. The Oxford Study reported a failure rate of 6.7 per 100 woman-years with this method, a surprisingly low rate. There are some potential problems with coitus interruptus. Neither the woman nor the man knows for sure that he will be able to withdraw in time. Another concern is that the pre-ejaculatory excretion of urethral fluids may contain live sperms.
- Natural Family Planning:
The rhythm method: Pregnancy prevention by avoiding intercourse during the fertile period, has been renamed "natural family planning" (NFP) in recent years. Three versions of NFP are presently taught:
- The Calendar rhythm method,
- The Cervical mucus method,
- The Symtothermal method.
With the Calendar method, the first day of the fertile period is estimated by subtracting 18 from the length of the shortest cycle noted during 6 to 12 months of observation. The last day of the fertile period is estimated by subtracting 11 days from the length of longest cycle observed. Failure rate quoted is 40 per 100 woman-years.
With the Cervical mucus method, also known as Ovulation method or Billing method, the woman attempts to predict fertile period by observing the cervical mucus by feeling at the vaginal opening with her fingers. Many women can note the production of clear, watery mucus in the days immediately before ovulation. Intercourse may be allowed during the "dry days" immediately after menses until mucus is detected. Therefore, the couple must abstain until the 4th day after the "peak day".
In the Symptothermal method, the first day of abstinence is predicted either from the calendar, by subtracting 21 from the length of the shortest menstrual cycle in the preceding 6 months, or from the first day mucus is detected, whichever comes first. The end of the fertile period is predicted by use of basal body temperature (BBT). The woman takes her temperature every morning and resumes intercourse 3 days after the thermal shift, the rise in body temperature that signals that the corpus luteum is producing progesterone and hence that ovulation has occurred. Devices that combine an electronic thermometer with small computers are being explored in an effort to improve the accuracy of BBT as a predictor of the fertile phase.
- Male Condoms:
The development of the condom is attributed to the 16th century Italian anatomist, Fallopius. The name is attributed to a Dr. Condom, a courtier of Charles II (1661-1685) who may have been the royal procurer but of whom no contemporary record exists. Present-day condoms are usually made of latex rubber. The perception that condoms reduce sensation is an excuse or reason commonly given for not using them. A wall thickness of 0.065 to 0.085 mm is standard. Thinner condoms have been used in Japan for many years, and condoms as thin as 0.020 mm are now available in the United States. The risk of condom breakage has been studied. There is estimated to be one break in 115 to 477 acts of intercourse, and breaking usually occurred before ejaculation, and seemed to be related to friction. Condoms and other barriers reduce risk for STDs and provide some protection from cervical neoplasia. The failure rate has been reported to be 10 to 14%.
- Female Condoms:
There is one female condom currently available. These provide a sheath that is attached to a ring of latex that covers the entire vulva as well as vagina. A new one must be used every time person has sex. The female condom can be inserted up to 8 hours before sex. It is about 95% effective and may protect against STD exposure, if it is not torn and does not slip out. Their effect on sensation and acceptability remain to be determined. Your health care provider can help you to explain about its insertion and usage.
- Vaginal Spermicides:
The American physician, Knowlton, proposed in his 1833 pamphlet, that inserting a solution of zinc sulphate to the vagina after intercourse could reduce the pregnancy rate. Suppositories made of quinine in cocoa butter were made and sold in England in the 19th century and continued in use until recently. The active ingredients of modern preparations are non-oxynol-9 or octoxynol, surface-active chemicals that immobilize sperm. Vaginal spermicides combine a spermicidal chemical with a base of cream, jelly, aerosol foam, foaming tablet, film, or suppository. In widespread use in the United States, spermicides alone appear considerably less effective than condoms and barrier methods. Failure rate in the first 12 months ranges from 19 to 26%.
The diaphragm consists of a circular metal spring covered with fine latex rubber. There are several types, as determined by the spring rim: coil, flat, or arcing. Diameter ranges in size from 50 to 90mm, with 5 mm increments available. Most women can be fitted with one in the midrange, from 65 to 75 mm. Too large a diaphragm can produce discomfort and even vaginal ulceration. Healthcare providers must fit the diaphragm for the patient and also must instruct her in its insertion and verify by examination that she can insert it correctly to cover the cervix and upper vagina. In present times the diaphragm is always used in combination with a spermicide; however the contribution of the spermicide to pregnancy prevention has not been definitively determined. The diaphragm can be inserted several hours prior to intercourse. If intercourse is repeated, additional spermicidal jelly should be inserted into the vagina without removal of the diaphragm. The diaphragm is left in place at least 6 hours after intercourse to allow for immobilization of sperm. It is then removed, washed with soap and water, allowed to dry, and stored away from heat. It should not be dusted with talc, which contains contaminating asbestos fibers; genital dusting with talc has been linked to ovarian cancer. The diaphragm failure rate has been estimated as 5.5 per 100 woman years.
Hazards of the Diaphragm: It increases the risk for bladder infections, probably because the diaphragm rests under the urethra and may hinder clearing bacteriuria and may produce cystitis. Toxic shock has been linked to diaphragm use.
- Cervical Cap:
The cap is much smaller than the diaphragm, contains no metal spring in the rim, and covers only the cervix. It is harder to fit the cap and instruction in its use takes more time. However, the advantage of the cap over the diaphragm is that it can be left in place for several days and hence is more convenient. The pregnancy rate is 8 per 100 woman years. The Prentiff cavity rim cervical cap is approved and available in the United States. Sizes 22, 25, 28, and 31 are manufactured. The size is the internal diameter of the rim in millimeters. Most nulliparous women require a No.22 and parous women generally are fitted with a No. 25. The cap is inserted by compressing it between finger and thumb and placing it through the introitus, dome outward. It is then pushed gently up to sit over the cervix. The dome should remain compressed for several seconds, indicating a gentle fit. The cap can be left in place up to 72 hours. The patient is instructed to check for dislodgment of the cap after intercourse.
Hazards of Cervical Cap: The risk for toxic shock is theoretically the same as for the diaphragm. The risk of cystitis is much less. Progression of initially negative cervical cytology to dysplasia occurred in 4% of cap wearers and on less than 2% of diaphragm wearer in a NIH-funded comparative trial.
- Intrauterine Devices:
The German physician Richter described intrauterine insertion of silkworm gut to prevent pregnancy in the early 1900s. Graefenberg (1931) developed an intrauterine device by tying silver wire around strands of silkworm gut. Much of what we know of IUCD in clinical use came from a large multicenter study carried out by Tiertze and Lewit (1970). Larger versions of Lippes loop (C or D) were associated with lower pregnancy rates and lower rates of expulsion but had more incidences of pain and bleeding. The observation that smaller devices are tolerated better led to the development of the small IUCD wrapped with copper wire, the Copper T 200 and Copper 7. Another approach to improving the efficacy of a small IUCD was development of the progesterone releasing T, the Progestasert. These second generation IUCDs were associated with lower pregnancy rates and less discomfort. Further evolution in IUCDs technology produced a third generation of devices. The Copper T 380A (Paragard) is an improved T device with copper wire around the stem and a copper band around the arms. It is associated with a large surface area of copper and it has a remarkably low pregnancy rate, less than 1 per 100 woman years in the first year of use. FDA has approved it for up to 6 years of continuous use. New Paragard IUCDs are used for 10 years.
Mechanism of Action: IUCDs provoke a low grade inflammatory response from the endometrium, resulting in formation of "biologic foam" that contains strands of fibrin, phagocytic cells and proteolytic enzymes released from these cells into the uterine cavity. The altered intrauterine environment interferes with implantation of fertilized ova, but it is now appreciated that the main effect of IUCDs is interference with sperm passage through the uterus and prevention of fertilization.
Insertion: Patient should initially visit for a medical history, physical examination, cervical culture for gonorrhea and chlamydia, along with detailed counseling as to risks and alternatives. Patient should avoid intercourse until returning for insertion on the second visit; some prefer to insert during menses. Premedication with ibuprofen is advised to reduce discomfort and use paracervical block. Insertion is preceded by pelvic examination to determine the size and position of the uterus. The uterine cavity is measured with uterine sound. Depth of the cavity should measure at least 6 cm from external os. Use of tenaculum with insertion is useful to prevent perforation. The cervix is then exposed with a speculum grasped with tenaculum and gently pulled downward to straighten the angle between cervical canal and uterine cavity. The IUCD previously loaded into its inserter is gently introduced through the cervical canal. The string is cut to project about 2 cm from the external os.
Complications: Pelvic Inflammatory Diseases, (PID) Ectopic Pregnancy, lost devices, expulsion, heavy menstruation, irregular bleeding, and pelvic pain are the common side effects.
Hormonal contraceptives contain female sex steroids, either (1) a combination of a synthetic estrogen and synthetic progesterone (progestin) or (2) a progestin only. The most widely used hormonal contraceptive is the combination OC (Oral Contraception). Other forms of hormonal contraception include injected progestins and subdermal implants that release progestins. Vaginal rings and The Patch that release sex hormones are also available.
- Injectable Hormones for Contraception:
An important method of contraception, the most commonly used is Depot Medroxyprogesterone acetate (DMPA), 150 mg given by deep intramuscular injection every 3 months. It is highly effective, safe, low cost, easy to keep confidential, and easy to use. The acceptance of DMPA by young women has been demonstrated by its popularity in younger age groups: 15% of women aged 15 to 17 years who were using contraception chose the injectable method. Side effects primarily are irregular bleeding; some conflicting data suggest loss of bone density, weight gain, loss of hair, and mood changes.
Another injectable hormone, norethdrone enanthate, is shorter acting and must be given as 200mg every 2 months to achieve efficacy comparable to DMPA.
- Subdermal Implants:
The first of the subdermal implant systems (Norplant) became available in the United States in 1991. It is a major advance in hormonal contraception because the constant slow release of the steroid across the wall of the Silastic rubber capsule results in constant low blood levels, in contrast to fluctuation of blood levels of contraceptive steroids taken by the oral route or by injection. The most effective method of birth control, and one of the most cost effective, the levonorgestrel subdermal implant system has limited popularity; it is used by only 1.3% of American women. It has no negative effects on bone mineral density, even though it gives irregular bleeding or amenorrhea. Insertion and removal can be difficult. 6 Silastic capsules are inserted and they are effective for 5 years. One or two Silastic capsules are under study and hopefully will make the insertion and removal easy.
- Emergency Contraception:
Though their use was first published over 40 years ago, emergency contraceptive pills (ECP) have only been widely publicized and marketed in the United States within the past several years. Taken within 72 hours of unprotected intercourse, it is a combination OCS to provide 0.1 mg ethinyl estradiol plus 0.5mg levonorgestrel, taken twice, 12 hours apart. The US Food and Drug Administration (FDA) recently approved 2 dedicated pill products for emergency contraception. In 1997, Preven kits became the first emergency contraceptive product to receive approval. The kits include 4 pills to be taken in pairs. The FDA approved a levonorgestrel only regimen in July 1999. The two pills containing 0.75 mg of levonogestrel taken 12 hour apart were found to be effective. These two plans reduce the pregnancy rates by 75% and 85%. The Emergency Contraceptive Pills do not disrupt an established pregnancy and thus are not abortifacients.
- The Pill:
Oral Contraceptives (OCs), used by 4 out of 5 US women at some point in their lives, remain the most popular form of reversible contraception. While OCs were initially hampered by a negative reputation due to early studies conducted with high dose estrogen pills and lack of controls for smoking, recent studies have alleviated concerns about safety issues and have highlighted the health benefits of OCs. Contraceptive effect of OCs is well-known to the healthcare providers and the communities. Other benefits are reduction of ovarian and endometrial cancer, association with high bone density, regulation of menstrual cycle and help with dysmenorrhea, and perimenopausal symptoms. Acne can be managed with OCs. Modification to OCs has provided women with more choices from which to select a product that best suits their needs.
Efficacy: If used correctly, combination OCs offer near-perfect efficacy. Women aged 25 to 34 taking .05mg estrogen combination OCs had a pregnancy rate of 0.25 per 100 woman years in the first 1 or 2 years of use, that is 2.5 pregnancies if 1000 women were followed for 1 year. The pregnancy rate increases slightly with lower estrogen OCs.
Side effects: Thromboembolic incidence, which is high in the smokers taking OCs, and stroke are still the most worrisome side effects. Weight gain, break through bleeding, increase in blood pressure and adverse effects of Diabetes are also seen with OCs. Older, higher dose OCs may have significant adverse effects on lipids. All OC groups in a multicenter study showed small but statistically significant increases from baseline in plasma triglycerides, very low-density lipoprotein (VLDL) cholesterol, and plasma apolipoprotein B (the protein Component of LDL) and decreased concentrations of HDL.
To determine which birth control pill is right for you, please consult your health care provider.
- The Patch:
There is only one contraceptive patch, applied once a week for 3 weeks. During week 4, no patch is used. There is no interruption with this method. Once stopped it may take a few cycles before you can become pregnant. It is 99% effective. Patch can be applied anywhere on the body except the breasts. It is gaining popularity with teen-age population in USA.
- Vaginal Ring:
There is only one vaginal ring. Each month, the vaginal ring is inserted into the vagina and left in place for 3 weeks and then removed. During week 4, vaginal ring is not worn. Patients need to learn how to insert the ring in the vagina. It is about 98% effective. Once stopped, it may take a few cycles before pregnancy is achieved. It does not protect from STDs (Sexually Transmitted Diseases).
These procedures are permanent and most of the time irreversible and are performed by healthcare professionals.
- Female Sterilization:
Four procedures are common today;
- Tubal sterilization at the time of laparotomy for a cesarean section or other abdominal operation,
- Postpartum Minilaparotomy soon after vaginal delivery,
- Laparoscopic tubal ligation.
With the development of laparoscopy, vaginal tubal sterilization, which was associated with occasional pelvic abscess, has virtually disappeared from USA.
Risks of tubal sterilization: It has become remarkably safe and in large series the failure rates is shown to be 0.14%. The failure rate has been reported slightly higher when tubal ligation is done with cesarean section or post partum.
Reversal of tubal sterilization: It is more successful after mechanical occlusion than after electrocoagulation and with modern microsurgical techniques the success rate can be 75%.
- Male Sterilization:
Vasectomy excision of a portion of the vas deferens provides permanent sterilization for men much more easily than any of the female sterilization techniques. Vasectomy is easily accomplished with local anesthesia in an office setting. Though men frequently worry that vasectomy will decrease their sexual performance, this concern is been proved to be groundless. Failure rates are very low and the no-scalpel vasectomy, which represents 29% of all vasectomies performed in the USA, offers a technique with fewer complications, less pain, and a quicker healing time.
With an expanding armamentarium of contraceptive methods, women today can safely reduce their risk of pregnancy and prevent the socioeconomic impact of unplanned parenthood. Selecting a contraceptive best suited for a woman is a process of balancing the risks and benefits of each method with the individual needs. Creating an environment with improved access to all methods should allow women to control their reproductive health by choice, not chance.
We encourage you to visit reproductive health home page of WHO Department of Reproductive Health and Research web link:
Dedicated to Women's and Children's Well-being and Health Care Worldwide