Contraception

Definition

Contraception is the use of a method, device, or medication to prevent pregnancy by interfering with ovulation, fertilization, and/or implantation. Another term for contraception is birth control.

Purpose

The purpose of contraception is to allow individuals to engage in sexual intercourse without it resulting in pregnancy.

Precautions

There are many methods of contraception. Factors to consider in choosing a method include:

• Safety. What are the risks of using this method? Can its use result in any damage to the female or male reproductive tract? Is its use associated with a higher risk of certain cancers? What are the consequences of its long- term use? Does its use affect future fertility?
• Access. Is a prescription needed to gain access to this method?
• Cost. How expensive is this method?
• Is the cost of this method covered by my health insurance?
• Effectiveness. If this method is used as directed, what is the likelihood that it will fail to prevent a pregnancy?
• Ease of use. Is this method easy or difficult to use correctly?
• Timing. Is this method effective the first time it is used or put in place, or is it necessary to use it for a while before it will be effective?
• Frequency. How frequently will the individual engage in sexual intercourse?
• Temporary versus permanent. Does this method provide temporary birth control, or is it considered a permanent method? If permanent, could it be reversed in the future?
• Ethics. Is this method acceptable within the context of the individual's religious or ethical beliefs?
• Benefits. Other than its ability to provide contraception, does its use have any benefits to the individual's health?
• Postpartum. How soon after pregnancy can this method of birth control be used? Is it safe while breastfeeding? Does fertility return?

Description

During a woman's reproductive years, from its onset at menarche to its termination at menopause, an egg, or ovum, is released each month from one of her two ovaries, and it travels through the adjacent fallopian tube and into the uterus. If the egg is fertilized, it implants into the lining of the uterus and undergoes changes that eventually lead to the development of a fetus. In tandem with the release of the egg, the lining of the uterus, called the endometrium, undergoes changes that will enable it to support a pregnancy should the released egg become fertilized. When the egg is not fertilized, the endometrium that has built up in preparation for the pregnancy is shed. This tissue and the non-fertilized egg leave the uterus through the cervix and exit the body through the vagina in the form of menstrual secretions.

Birth control methods vary in targeting different aspects of this monthly process. The primary methods of birth control are hormonal, barrier, spermicides, intrauterine devices (IUDs), surgical, and periodic abstinence. In choosing a form of birth control it is important to understand how each method works, as well as its associated risks, benefits, and side effects.

• Hormonal. Hormonal methods of birth control include oral birth control pills. Birth control pills, sometimes called the Pill, come in two forms: combination, containing both estrogen and progestin, and progestin only, referred to as the mini-pill. Both forms suppress ovulation
• thicken cervical mucus, and prevent implantation. Both require prescriptions. The hormone doses in the pills are kept as low as possible, while still being effective as a contraceptive. For this reason it is extremely important that they are taken on a daily basis. Skipping doses can put a woman at risk of becoming pregnant and she should supplement the pill with the use of a barrier method. In the first month a woman begins oral contraception, she may not be fully protected, so a barrier method should be used as a back-up. In a survey conducted by Planned Parenthood, only 28% of women take the Pill correctly, and only 42% actually take it on a daily basis. Because of the hormones used, women who suffer from migraines, diabetes, have had breast or uterine cancer, or who smoke, may need to choose another method. Women should always mention their use of birth control pills to their primary health care provider, as some medications prescribed for other conditions may interact with oral contraceptives. Use of the Pill can make other medications less effective, or exaggerate their effectiveness. Serious potential side effects of the combined pill include the formation of blood clots, myocardial infarction, and stroke. Because oral contraceptives suppress ovulation, their use can decrease a woman's risk of getting ovarian cancer. Some women find that their oral contraceptive improves skin problems. Hormonal contraception can be used by breastfeeding mothers, but usually not until the milk supply has been well established. In the case of the mini-pill, it can usually be started earlier, as it does not decrease milk volume. The combination pill can decrease the volume and lower the protein content of the breast milk. Oral contraceptives do not protect against any sexually transmitted diseases, so a condom should be used for that purpose in addition to taking the Pill.
• Depo-Provera and Lunelle are two brands of contraception given by injection. Depo-Provera is the trade name for the contraceptive depot medroxyprogesterone acetate (DMPA). Lunelle is a combination of estrogen and progesterone. They provide protection for about 12 weeks. They may be a good choice for women who have trouble remembering to take the Pill on a daily basis, for those for whom privacy of using a contraceptive is important, and for those engaging frequently in sexual intercourse. They work by suppressing ovulation, fertilization, and implantation. This method may not be a good choice for women who have had breast cancer, blood clots, heart attack or stroke, major depression, high cholesterol or blood pressure, diabetes, migraines, or abnormal results on liver function tests. If given within the first five days of a woman's menstrual cycle, they are considered protective against pregnancy during the first month of use. Side effects include irregular vaginal bleeding, loss of menstruation after one year of use, nausea, breast tenderness, depression, weight gain, vaginal dryness, and increased facial hair. After a woman stops using DMPA, it may take 18 months before a woman is able to become pregnant. They do not provide protection against sexually transmitted disease.
• Barrier methods. Barrier methods work by preventing the sperm from reaching and fertilizing the egg. Male and female condoms, diaphragms, and cervical caps work by creating a membrane through which the sperm cannot travel. Spermicides and the contraceptive sponge contain chemicals that decrease the sperm's ability to travel towards the egg. Condoms, diaphragms and caps should be used in conjunction with spermicides to increase overall effectiveness. Spermicides come in several forms: foam, cream, gel, sponge, and vaginal suppository. Condoms provide the most protection against sexually transmitted diseases. The diaphragm and cervical cap require fitting by a health care practitioner and a prescription. The other barrier methods are available without a prescription. Barrier methods are used at the time of sexual intercourse. They are less effective than hormonal methods of contraception. Individuals who have latex allergies, or who have had an allergic reaction to bananas, avocados or chestnuts, should speak with their health care provider before trying a condom, diaphragm, or cap. The allergic reaction may be mild, with symptoms such as runny nose, itching or a rash, or may be severe, resulting in anaphylaxis in which breathing can be obstructed by swelling. Early signs of anaphylaxis include rash, flushed skin, dizziness, or a tingling sensation. Medical help should be sought right away. A condition called toxic shock syndrome (TSS) has been occasionally reported with diaphragm use. Signs of TSS include high fever, vomiting, diarrhea, flu-like symptoms such as aching joints or sore throat, dizziness, and rash. The diaphragm should be removed right away and the woman should call her practitioner. Diaphragm and cervical caps need to be refitted with weight gain or loss, and after a few years need to be replaced because the rubber begins to tear or decompose, rendering them ineffective.
• Intrauterine devices (IUDs). The IUD is a small, plastic device that is inserted by a health care practitioner into a woman's uterus. While in place it seems to prevent implantation by altering the endometrium. It is also thought that the consistency of the cervical mucus is changed, affecting sperm motility, preventing fertilization. It is easy to have it inserted and can be removed at any time by a practitioner. One brand contains copper and can be left in place for ten years, another contains progestin and needs to be replaced after one year. IUDs have a string attached at one end that hangs into the vagina. This not only assists in its ultimate removal, but also allows a woman to check periodically that it is still in its proper place. If the string appears to be shorter or longer than when inserted, the woman should have its placement checked by her practitioner. The string does not function as a wick, so it does not draw fluid up into the uterus. The IUD is not a good choice for a woman with a sexually transmitted disease or a history of pelvic inflammatory disease (PID). It is usually inserted during a menstrual period by a health care provider. Some practitioners may require the woman to have a negative pregnancy test done just prior to insertion. Some women may experience spotting between periods, or heavier periods with more cramping while using the copper IUD. Because the IUD was inserted through the cervix, a woman may be at a somewhat higher risk of infection, until the cervix closes tightly again (around three weeks). Two rare side effects can occur: the IUD imbedding into the uterus and the migration of the IUD into the abdominal cavity, requiring surgery to remove it. There is also a higher risk of pelvic inflammatory disease and infection of the reproductive organs, which could result in sterility, or require removal of the uterus. IUDs do not protect against sexually transmitted diseases.
• Surgical sterilization. Individuals who have completed their childbearing may choose a permanent form of contraception: surgical sterilization. In the male, this is known as a vasectomy. The vasectomy blocks the sperm from mixing with the seminal fluid. Sperm continue to be produced, but are reabsorbed by the body. Vasectomy does not affect the man's ability to have an erection, to ejaculate, nor does it affect the production of male hormones. It is not effective immediately, as some sperm are still present in the unblocked portion of the tubes. A sperm analysis needs to be done to check for the presence of sperm. Until this process is completed, the man and his partner need to use another form of contraception to prevent a pregnancy. For the woman sterilization is known as tubal ligation, tubal sterilization, or having one's tubes tied. In tubal ligation the fallopian tubes are cut or blocked, preventing the egg from passing through towards the uterus. The ovum will continue to be released each month, but will be reabsorbed by the body after being blocked in the fallopian tube. Menstrual cycles continue as usual, and hormone production is not affected. It is effective immediately. Surgical sterilization is considered permanent and irreversible, although some individuals have been successful at having the process reversed. In a small percentage of cases, the surgery is not successful and the woman becomes pregnant. Both surgeries are done through small incisions, and on an outpatient basis. This form of birth control is not recommended for very young individuals, or those who have not yet had families. Because they involve surgery, complications associated with surgery, such as infection, bleeding, or a reaction to the anesthesia, can occur. Tubal ligation and vasectomy do not provide protection against sexually transmitted diseases. For the individual under- going the sterilization, the surgery must be voluntary.
• Periodic abstinence. Periodic abstinence, or fertility awareness, is a technique of birth control based on abstaining from sexual intercourse on those days when a woman might become pregnant. The same techniques can be used by couples trying to conceive, by identifying the days when a woman is most likely to become pregnant. Using periodic abstinence often requires taking a class to learn the techniques used. The techniques employed are basal body temperature (BBT), cervical mucus identification, and a calendar method. The most effective use is the combination of all three techniques to predict which are the safe and which are the unsafe days for intercourse. Couples may then use this information to abstain from intercourse or use a barrier form of contraception on unsafe days. The calendar method keeps track of a woman's menstrual cycle. The cervical mucus identification method teaches the woman the differences in the vaginal secretions at various times of her cycle, which helps to identify when ovulation is most likely taking place. The BBT method charts the first temperature of the morning. Just prior to ovulation there is a slight dip in the basal temperature, followed by a slight temperature elevation when the woman ovulates. This method requires the use of a special thermometer that is more finely calibrated than one used for checking the presence of a fever. This combination of techniques requires that a woman's menstrual cycles are quite regular, that she has the ability to keep careful records, and that she and her partner(s) can abstain from intercourse or use a barrier method for much of the month. The readings are not accurate when the woman is sick, and may be affected by certain medications.
• Post-coital contraception. No method of contraception is 100% effective. If birth control was not used or if it failed during intercourse, or in the event of rape, the possibility of pregnancy exists. Some reproductive health centers and physicians offer emergency contraception that is used within 72 hours of unprotected sex, failed contraception, or rape. It involves taking oral doses of progestin or an estrogen-progestin combination, similar to that used in oral contraceptives. Some women experience dizziness or nausea and vomiting following the treatment. If a woman has had a positive pregnancy test and wishes to terminate the pregnancy, she may choose between surgical or medical abortion. Medical abortion involves the use of hormonal therapy, referred to in the United States as RU486. Planned Parenthood offers more information about these options through the telephone number listed below in Resources, and on their web site.

Preparation and aftercare

Preparation for the different contraceptive choices varies. Oral contraceptives need to be taken on a daily basis, and require a prescription, a thorough health history, and a visit to a health care provider. Injected hormonal contraception requires periodic visits for the injection. Barrier methods must be used every time there is intercourse, these methods differ in how long they may remain in the vagina, and whether ejaculation can be repeated without the use of a new barrier device. The IUD requires insertion and removal by a practitioner. Surgical sterilization is usually done in an outpatient facility. Patients will be given post-surgical instructions to follow, including which symptoms necessitate contacting their physician. Practitioners will want to be sure that this irreversible decision was made carefully and competently and that the patients are aware that there is a failure rate. Some follow-up care may be necessary. Periodic abstinence requires careful monitoring of a woman's fertility and the ability to abstain from intercourse or use barrier methods on unsafe days.

Complications

Complications of contraception vary according to the method used. Hormonal complications involve a response to the particular hormone and dosage used. Bleeding between periods or difficulty regaining regular menstruation or fertility following their discontinuance may occur. Oral contraceptives can interfere with the effectiveness of other medications. Women over 35 who smoke should not use oral contraceptives, as smoking places them at greater risk of heart attack or stroke. Barrier methods may produce a local reaction to the spermicide use. Spermicide packages should be checked for an expiration date. If used after expiration, they are not reliable. Diaphragm use is associated with the risk of toxic shock syndrome. Individuals unaware of their latex allergy may have a small allergic reaction, or could go into anaphylaxis. IUDs do have a serious but rare risk of puncturing the uterine wall, and also carry a risk of pelvic inflammatory disease with potential complications such as sterility if untreated. IUDs may be expelled from the uterus, so it is important to periodically check for the string that is attached to it. Women who become pregnant while using the IUD are at greater risk of an ectopic preg- nancy. Surgical sterilization involves the risks of surgery, such as bleeding, or infection due to the anesthesia used. Vasectomy is only effective once all stored sperm has been ejaculated. Fertility awareness carries a higher risk of pregnancy, and if hands are not washed prior to checking the cervical mucus, bacteria could be introduced into the vagina and spread.

Results

The end result of effective contraception is prevention of pregnancy. Individuals choosing contraception must weigh the risks of the method against its ease of correct use and its success rate of preventing pregnancy. Hormonal methods are usually at least 95% effective. Barrier methods range from 60–80% effective. The IUD is considered 99% effective. Sterilization is about 99% effective. Fertility awareness is about 85% effective. Of course, effectiveness depends on consistent, careful use.

Health care team roles

Pharmacists are involved in filling the prescriptions of various forms of birth control. Having prescriptions filled at the same pharmacy provides protection against the possibility of interactions between different medications. Nurses provide education to patients on the various forms of birth control the individual is considering. Nurses are also involved in the care of patients seeking surgical contraception, as well as triaging calls from patients when they call their health care providers with questions and concerns about possible side effects. If a patient suspects an IUD has been dislodged, a radiology technician may take an imaging scan to locate the IUD.

KEY TERMS

Anaphylaxis—A serious allergic response that can be fatal if not treated. In anaphylaxis the individual undergoes a hypersensitive reaction to a substance. Initial signs may include itching, wheezing, coughing and shortness of breath. If left untreated, the individual's respiratory passages may begin to swell, blocking the flow of air. Anaphylaxis is a medical emergency, and can result in death.

Ectopic pregnancy—A pregnancy that implants outside of the uterus, most commonly in a fallopian tube. An ectopic pregnancy can cause the fallopian tube to rupture, causing severe internal bleeding and pain. A woman with an ectopic pregnancy must seek medical care right away.

Triage—To organize or sort patients according to the degree or severity of their condition.

Vaginal suppository—Medication that is bullet- shaped, and is inserted into the vagina, where it melts and is absorbed.

BOOKS

Ammer, Christine. The New A to Z of Women's Health, 4th

Edition. New York: Facts on File, Inc., 2000.

Knowles, John and Marcia Ringel. Planned Parenthood. All About Birth Control: The Complete Guide. New York: Three Rivers Press, 1998.

Spencer, Paula. Parenting: Guide to Pregnancy and Childbirth. New York: Ballantine Books, 1998.

PERIODICALS

Croxatto H. B. "Progestin implants."Steroids.

(October/November 2000): 681-685.

Massai, R., S. Diaz, T. Jackaniez, and H. B. Croxatto. "Vaginal rings for contraception in lactating women."Steroids. (October/November 2000): 703-707.

Shulman, L. P. "Contraception 2000: Lunelle, an injectable combination contraceptive option."Journal Womens Health Gender Based Medicine (September 2000): 725-729.

ORGANIZATIONS

Planned Parenthood Federation of America. 810 Seventh Ave.

New York, NY 10019. (212) 541-7800. (800) 230-PLAN(7526). (888) NOT-2-LATE.

Esther Csapo Rastegari, R.N., B.S.N., Ed.M.