Contraceptives

00:00 Let’s now talk about what is the most effective contraception we have available. This arrow here will help to guide you from the least effective to the most effective. Nothing is 100% effective, only abstinence all the time. Now let’s look at the least effective. Spermicides are bad. They can actually lead to vaginitis and really shouldn’t be used. Fertility awareness methods - not too great. This looks at your cervical mucus to determine whether or not you may be close to ovulation. However, different factors can actually make this method very difficult to use. A diaphragm - we almost never use diaphragms in gynecologic practice in modern day.

00:47 Diaphragms have to be fitted to the size of your cervix. Male and female condoms usually result in inconsistent use but are a good barrier method especially for the young population which is at risk for STIs such as Chlamydia and gonorrhea that can lead to PID. Withdrawal - This is unfortunately a commonly used method by very young people in the US. It essentially means that a man removes his penis before he ejaculates. One problem though, pre-ejaculation contains sperm. The sponge - a sponge is usually soaked in some type of spermicide and it’s thought to be somewhat of a barrier, but it’s not very effective. Then the cervical cap. I’ve actually never seen one. Breastfeeding - women who uniquely breastfeed are suppressed. That means that they don’t ovulate; however, you have to give the baby for it’s every meal breast milk. This is hard to do in the American lifestyle. Women who take Depo-Provera are also very suppressed and it is a decent effective method. The pill is also good at suppressing ovarian function but has to be taken consistently everyday. Missed pills can lead to decreased efficiency. The vaginal ring - The vaginal ring is made of a polymer that contains ethinylestradiol and a progestin. This is released overtime and this is worn for 3 weeks and taken out for 1 week to allow a withdrawal bleed. The patch is a very effective method; however, there are certain weight restrictions that limit its use. The most effective method and the safest method for a woman is for the male to have a vasectomy. However, female sterilization is still a very common method in the US. We do have long-acting reversible contraception in the form of an IUD which often should negate the need to perform sterilization. And don’t forget, an implant is another form of long-acting reversible contraception. There are some risks associated with oral contraceptive pills. We know that there’s a two-fold risk of venous thromboembolism. That means a blood clot forming in your leg and traveling to your lungs. We know that there is no increased risk of breast cancer, while there have been some early reports those have been refuted. There is a risk of cervical cancer in every woman but this is not directly related to OCP use. There is no additional risk of congenital anomalies if conception occurs while taking a birth control pill. Remember, the placenta makes some of the same hormones that we find in the birth control pill. There’s no risk of weight gain. This is a common misconception among the US population. I’ll show you why in just a few slides. There’s also decreased libido and even newer reports of increased depression while taking OCPs. Patients need to be made aware of this phenomenon. There is also the risk Oral contraceptives or OCPs are associated with an increased risk of hepatic adenoma.

04:11 This is still a highly tested subject on the USMLE.

04:15 There is also the risk of increased blood pressure and blood pressure needs to be monitored. In the past, you may have read that hepatic adenomas have been associated with OCP use. This is older data and is not currently accepted as an association with OCPs. Let’s now talk about hormonal contraceptives and weight gain. There was a ___ in review that actually summarized 3 placebo-controlled randomized trials of combined hormonal contraceptives. There was no evidence of a causal association between combined OCPs and weight gain. One randomized trial demonstrate that Depo does not cause short-term weight gain. Remember, you have to eat more to gain weight. Oral contraceptive pills do more than just prevent pregnancy. They actually help regulate the menstrual cycle.

05:12 They help with menorrhagia or AUB. They treat dysmenorrhea or pain with menses. They can induce amenorrhea for the sake of lifestyle considerations. It’s okay not to have a period while taking the birth control pill. If you don’t have a period naturally, that’s pathological. Treatment of premenstrual syndrome is very helpful with the oral contraceptive pill. OCPs also prevent menstrual migraines. There is a decreased risk of endometrial, ovarian, and colorectal cancer in users of the birth control pill. It also treats acne and hirsutism. It improves bone mineral density and can treat bleeding associated with leiomyomas and pain due to endometriosis. There are some distinct benefits for the individual, families, and society in terms of contraception use. The individual will have expanded access to education. For instance, women can delay childbearing to achieve their goals. That leads to increased work and financial security and for individual families, it increases resources and they can focus greater attention and care to each child when they plan their pregnancies. In terms of society, there is higher productivity, increased gender equality, and reduced public spending on unintended pregnancies. In the US, we have a great problem. As you can see, women who are users of birth control do quite well at decreasing the risk of unintended pregnancy. When women don’t use contraception, you can see that 47% of pregnancies are unintended. The small portion of women who do not use contraceptives account for roughly half of all unintended pregnancy. Rates in the US are very high. Their highest among women 15 to 24 years of age. Unmarried women who may lack societal and familial support and women who have children that are unintended are likely to live at 200% below the federal poverty level. This is highest we see in some minority groups including African-Americans and Latino women. Thank you for listening and good luck on your exam.