Birth control resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

Contraception or birth control is the prevention of unwanted pregnancy intentionally by using one of many different methods including devices, sexual practices, chemicals, drugs or surgical procedures. Contraception methods can also be used for other purposes such as prevention of sexual transmitted infection, treatment of different conditions as acne, polycystic ovary syndrome, endometriosis, amenorrhea, dysmenorrhea, premenstrual syndrome, primary ovarian insufficiency, and heavy menstrual periods.

Birth Control Options

Female birth control options

Long acting reversible contraception (LARC): are 99% effective, high rate of satisfaction, long-term use, quick return to fertility when discontinued and include the following:

• Intrauterine device (IUDs) (> 99% effective)
  • Copper IUD: Effective for up to 10 years, used for patients with light menstrual periods, patients who desire long-term contraception without using hormonal contraception
  • Progestin-releasing IUD: Effective for up to 5 years, used for patients with heavy menstrual bleeding and dysmenorrhea
• Subdermal implant (> 99% effective): Effective for up to 3 years

Injectable contraception

• Depot Medroxyprogesterone: (94% effective), IM injection is given every 3 months

Combined hormonal contraceptives

• Oral contraceptive (estrogen/progestin pills) (OCPs) (91% effective)
• Birth Control Patch (91% effective)
• Vaginal Ring (91% effective)

Barrier and chemical Methods

• Female Condom
• Diaphragm
• Cervical Cap
• Sponge
• Spermicide (80% failure rate if used alone). Should be used with cervical cap or diaphragm, may damage the genital epithelium and increase risk of acquiring SDIs

Traditional options/Natural contraception

• Fertility awareness
• Lactational Amenorrhea Method (LAM) (Breastfeeding can help with child spacing)
• Abstinence
• Rhythm Method

Surgical options

• Permanent Sterilization (Tubectomy/tubal ligation)

Emergency contraception

• Copper IUD
• Emergency contraceptive pills

Male birth control options

Barrier contraception

• Condoms (80% effective), the only type of contraception that prevent sexual transmitted infections

Male Sterilization

• Vasectomy

Coitus Interruptus or Withdrawal (75% effective)

Hormonal Contraception

• Testosterone in combination with other hormones under research and development

Note:

• You can use IUD in a nulliparous female
• Progestin subdermal implant is more effective that IUD (failure rate .2-.8%) and female fertilization (.5% failure rate)

Indications

• Prevention of unwanted pregnancy
• Treatment of different conditions such as:
  • Acne
  • Amenorrhea
  • Dysmenorrhea
  • Endometriosis
  • Heavy Menstrual Periods
  • Premenstrual Syndrome (PMS)
  • Primary Ovarian Insufficiency (POI)
  • Polycystic Ovary Syndrome (PCOS): OCPs are used for menstrual regulation

Contraindications

Combined hormonal contraceptives

Absolute contraindications

• Pregnancy
• Less than 6 wks postpartum
• Smoking (age ≥ 35, and ≥15 cigarettes per day)
• Hypertension (systolic ≥ 160mmHg or diastolic ≥100mmHg)
• Venous thromboembolism (VTE) (current of past history)
• Prior history of throboembolic event or stroke
• Thrombophilia (factor V Leiden, APLS)
• Ischemic heart disease
• Cerebrovascular accident history
• Complicated valvular heart disease (pulmonary hypertension, atrial fibrillation, history of subacute bacterial endocarditis)
• Migraine headache with aura or focal neurological symptoms
• Breast cancer (Active)
• History of an estrogen-dependent tumor
• Diabetes with retinopathy/nephropathy/neuropathy
• Severe cirrhosis (active or severe decompensated liver disease) (impair steroid metabolism)
• Liver tumor (adenoma or hepatoma)
• Hypertriglyceredemia

Relative contraindication

• Age ≥ 35 and smoking < 15 cigarettes per day
• Adequately controlled mild hypertension
• Hypertension (systolic 140 - 159mmHg or diastolic 90 - 99mmHg)
• Migrain headache over the age of 35
• Currently symptomatic gallbladder disease
• Mild cirrhosis
• History of combined OCP-related cholestasis
• Medications that interfere with OCPs: Lamotrigine, Rifampine
• Inhirited thrombophilia carrier and family member with thrmbophilia plus thromboembolism

IUDs

• Uterine anomalies or severe distortion
• Active pelvic infection
• Wilson disease
• Complicated organ transplant failure

Subdermal implant

• Progesterone receptor-positive breast cancer

Emergency contraception

Contracetion option	Hours after intercourse	Efficacy
Copper containing IUD	0 to 120 hour/5 days	>99%
Ulipristal	0 to 120 hour/5 days	98-99%
Levonorgestril	0 to 72 hour/3 days	59-94%
Oral contraceptive pills	0 to 72 hour/3 days	47-89%

Side effects

Contraceptive method	Side effects
Combined hormonal contraceptives (OCPs, patch, ring)	Breakthrough menstrual bleeding Breast Tenderness Nausea Weight gain Rare side effects: Cardiovascular events (heavy smoker, over age 35 years) Deep venous thrombosis Ischemic stroke Myocardial infarction Hypertension (patients with a history of hypertension in pregnancy or with a family history of hypertension)
Subdermal implant	Unscheduled bleeding, Weight gain Headache Ovulation and fertility occur within one month after removal
DMPA	Amenorrheah Initial irregular bleeding Reversible bone loss, delayed return to fertility, +/- weight gain
Progestin IUD	Amenorrhea Irregular bleeding
Copper IUD	Heavy menses Dysmenorrhea
Spermicide	May damage the genital epithelium and increase risk of acquiring SDIs

Do's

• Increase the levothyroxine dose in patients with hypothyroidism who started taking OCPs. OCPs (estrogen) increases the liver synthesis of thyroxin-binding globulin (TBG)
• OCPs also decrease the effect of Warfarin, so consider increasing the dose
• Oral contraceptives (estrogen) alter the transport and tissue delivery of thyroid hormone by increasing the synthesis of throxine-binding globulin , relative hypothyroid state in patients with hypothyroidism. Increase the dose of levothyroxine when starting OCPs.
• Give two forms of contraceptives and take monthly pregnancy tests for sexually active women who use Isotretinoin for acne
• Give non-oral form of contraception (IUD, implant) for one year to patients who underwent bariatric surgery to achieve weight loss goals and stabilize nutritional status

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References

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