Contraception - Chemical Methods / Hormonal Contraception / Emergency / Morning After Pill

Artificial Non-Barrier Methods of Birth Control (Hormonal / IUD)

By Hans E. Geisler, MD, FACOG, FACS

Definitions

Contraceptive – An agent for the prevention of conception[i]

Contraception – Prevention of conception or impregnation[i]

Impregnation – Act of making pregnant[i]

Pregnancy – The condition of the female from conception to birth[i]

Abortifacient – An agent that produces abortion[i]

Abortion – Giving birth to an embryo or fetus prior to 20 weeks gestation.  May be spontaneous or induced[i].

Life – The state of existence characterized by active metabolism[i].

Prenatal life – That interval of life between conception and birth; in humans, usually divided into embryonic and fetal periods[i]

Metabolism – The sum of the chemical changes occurring in tissue[i]

[NOTE: the term "conception", which used to be synonymous with "fertilization" was redefined by the abortion and contraceptive industries in the 1960s to mean "implantation of the embryo in the uterus".]

Mechanism of Action

Intrauterine device ("Three independent mechanisms have been suggested for the contraceptive action of IUDs, although none has been conclusively established."[ii])

1.    Inhibition of sperm capacitation and survival[ii]. "The data supporting a predominantly spermicidal effect of IUDs are surprisingly weak."[iv]
2.    Inhibition of implantation[iii],[iv],[v],[vi]. Absence of elevated bhCG only proves lack of implantation not lack of conception[iv].

3.    Interference with sperm transport from the cervix to the fallopian tube[ii].

 

Birth control pill

1.    Prevents ovulation by inhibiting gonadotropin secretion via an effect on both pituitary and hypothalamic centers[vii]
2.    Production of an endometrium which is not receptive to conceptus implantation[v],[vii]

3.    Production of cervical mucous which is thick and impervious to sperm transport[vii]

4.    Possible decrease in secretion and peristalsis of fallopian tube[vii]

 

Long-Acting methods of contraception (Norplant, Depo-Provera)

1.    Suppresses luteinizing hormone (LH) surge necessary for ovulation[viii]. One third of cycles of users are ovulatory[viii],[ix],[x]
2.    Thickens and decreases cervical mucous[viii]

3.    Prevention of implantation should fertilization occur[viii]

Emergency contraception (combined estrogen and progestin, estrogen alone, progestin alone)

1.    Blocks implantation of fertilized ovum[iv],[v],[vii],[xi]

2.    Inhibition of ovulation (only proven with mifepristone)[xi]

3.    Regression of corpus luteum causing loss of pregnancy (especially with mifepristone)[ix]

4.    Loss of pregnancy after implantation (especially with mifepristone)[xi],[xii]

 

RU 486 (antiprogestins (mifepristone (RU-486)))

1.  Regression of corpus luteum causing loss of pregnancy (especially with mifepristone)[ix]

2.  Loss of pregnancy after implantation (especially with mifepristone)[xi],[xii]

 

Failure rates

Intrauterine device

1.    Pregnancy rate 0.2 – 3% / year[iii],[xiii].  "Some of the most compelling evidence for a postfertilization action of IUDs lies in the pregnancies that occur during use."[iv]

Birth control pill

1.    Combined pill – pregnancy rate 0.1 – 3% / year[xiii]

2.    Progestin only pill – pregnancy rate  0.5 – 3% / year[xiii]

Long-Acting methods of contraception

1.    Pregnancy rate 0.2% / year[xiii]

2.    Mean level of levonorgestrel in the levonorgestrel implanted device (Norplant) declines steadily. In a clinical study, 20% of women had 1 or more level below 200 pg/ml (210 pg/ml is mean level associated with pregnancy in same study)[xiv]

 

Emergency contraception

1.    Estrogen with progestin – Efficacy rate 74%[xi]

2.    Mifepristone 80% effective even after implantation[xi]

Benefits and risks of birth control methods

 

IUDs

Advantages and benefits

1.    One-time insertion[vi]

< span style="font-size: 10pt; font-family: verdana,geneva">2.    Approved for 10 years (Paragard)[vi]

Disadvantages and complications

1.    Increased risk of septic abortion, septicemia, septic shock and death in patients becoming pregnant with IUD in place[vi]

2.    Risk of pelvic inflammatory disease (highest within 20 days of insertion) which can lead to hysterectomy, tubo-ovarian abscesses, tubal damage and loss of future fertility[ii],[vi]

3.    Risk of uterine or cervical perforation causing abdominal adhesions, intestinal penetration, intestinal obstruction, abscess formation, or erosion of adjacent viscera[vi]

4.    Precipitation of Wilson's disease in a patient bearing a copper IUD (a form of hepatic degeneration secondary to excess copper)[vi]

5.    A pregnancy occurring in a women with an IUD in place is more likely to be an ectopic pregnancy[ii],[vi]

6.    A baby conceived with an IUD in place is at increased risk of premature delivery and birth defects[vi]

7.    Abnormal uterine bleeding[vi]

8.    Anemia (especially with copper IUD)[vi]

9.    Vascular erosions in endometrium[xv]

 

Birth control pills

Advantages and benefits

1.    More regular menstrual cycles[xvi]

2.    Possibly decreased blood loss during periods. Anemia is therefore less likely.[xvi]

3.    Decreased dysmenorrhea (pain with periods)[xvi]

4.    Less frequent ectopic pregnancies[xvi]

5.    Decreased benign breast cysts[xvi]

6.    Decreased acute pelvic inflammatory disease (upper tract disease)[xvi]

7.    Decreased risk for endometrial carcinoma[xvi]

8.    Decreased risk for ovarian carcinoma[xvi]

9.    Decreased risk of benign ovarian cysts[xvii]

Disadvantages and complications

1.    Increased risk of cervical dysplasia including carcinoma in situ[xviii],[xix],[xxiii],[xxiii],[xxii],[xxiii]

2.    Increased risk of cervical carcinoma (both squamous and adenocarcinoma)18,19,20,21,22,23

3.    Increased risk of breast cancer[xxiv],[xxv],[xxvi],[xxvii]

4.    Increased risk of thromboembolic disease (blood clots)[xvi]

5.    Increased risk of heart disease (heart attack and angina pectoris)[xvi]

6.    Increased risk of cerebral vascular accidents (strokes)[xvi]

7.    Increased risk of gallbladder disease[xvi]

8.    Increased risk of benign liver tumors[xvi]

9.    Increased risk of cervicitis (especially Chlamydia trachomatis)[xxviii]

Long-Acting methods

Advantages and benefits

1.    Long-acting[xv]

2.    Some patients may become amenorrheic (decreased anemia)[xv]

3.    Little motivation required[viii]

4.    No effect on breastfeeding[viii]

Disadvantages and risks

1.    Ovulation is not suppressed in all users[xv]

2.    Some women will have irregular periods[xv]

3.    May have delayed return to fertility (Depo-Provera)[xxix]

4.    Surgical procedure required for implantation and removal of Norplant[viii]

5.    No protection against sexually transmitted diseases[viii]

6.    Increased depression, mood changes, and anxiety[viii]

7.    Weight gain[viii]

8.    Bilateral mastalgia[viii]

9.    Galactorrhea[viii]

10.  Acne[viii]

11.  Loss of bone density (Depo-Provera)[viii]

Emergency contraception

Advantages and benefits

1.    No planning ahead needed[xv]

Disadvantages and risks

1.    Potent potential teratogen[xv]

2.    Nausea / vomiting[vii]

3.    Breast tenderness[vii]

4.    Headache[vii]

5.    Dizziness[vii]

6.    Any other potential risks of oral contraceptives (see above)

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REFERENCES

[i]      Stedman's Medical Dictionary, 25th Edition. Williams & Wilkins, Baltimore, 1990.

[ii]      The intrauterine device. ACOG Tech Bull 1992; 164: 1-4.

[iii]      The intrauterine device (IUD). In Clinical Gynecologic Endocrinology and Infertility, 5 ed. (eds. Speroff L, Glass RH, Kase NG). Williams & Wilkins, Baltimore. 1994, 777-794.

[iv]      Spinnato JA. Mechanism of action of intrauterine contraceptive devices and its relationship to informed consent. Am J Obstet Gynecol 1997; 176: 503-6.

[v]      Birth Control. ACOG Patient Education. 1995.

[vi]      ParaGard T380A intrauterine copper contraceptive (package insert, prescribing information) Ortho Pharmaceutical Corporation. 1997.

[vii]      Oral contraception. in Clinical Gynecologic Endocrinology and Infertility, 5 ed. (eds. Speroff L, Glass RH, Kase NG). Williams & Wilkins, Baltimore. 1994, 715-764.

[viii]      Long-acting methods of contraception. In Clinical Gynecologic Endocrinology and Infertility, 5 ed. (eds. Speroff L, Glass RH, Kase NG). Williams & Wilkins, Baltimore. 1994, 765-776.

[ix]      Brache V, Alvarez-Sanchez F, Faundes A, Tejada AS, Cochon L. Ovarian endocrine function through five years of continuous treatment with Norplant subdermal contraceptive implants. Contraception 1990; 41: 169.

[x]      Alvarez F, Brache V, Tejada AS, Faundes A. Abnormal endocrine profile among women with confirmed or presumed ovulation during long-term Norplant use. Contraception 1986; 33: 111.

[xi]     Glasier A. N Engl J Med 1997; 337: 1058-64.

[xii]      Couzinet B, Le Strat N, Silvestre L, Schaison G. Late luteal administration of the antiprogesterone RU486 in normal women: effects on the menstrual cycle events and fertility control in a long-term study. Fertil Steril 1990; 54: 1039-44.

[xiii]     Use of contraception, sterilization and abortion. in Clinical Gynecologic Endocrinology and Infertility, 5 ed. (eds. Speroff L, Glass RH, Kase NG). Williams & Wilkins, Baltimore. 1994, 687-714.

[xiv]      NORPLANT ® System Information. http://www.norplantinfo.com. Wyeth-Ayerst Laboratories, 2000

[xv]      Family planning: contraception and complications. Obstetrics and Gynecology. 4th ed. (ed. Beck WW). Williams & Wilkins, Baltimore. 1997, 241-52.

[xvi]      Mircette (detailed patient package insert). Organon Incorporated. 1998.

[xvii]      Fertility control. In Precis V: an update in obstetrics and gynecology (ed., Droegemueller W.) American College of Obstetricians and Gynecologists, Washington, D.C. 1994: 56-63.

[xviii]      Ory H, Naib Z, Conger SB, Hatcher RA, Tyler CW. Contraceptive choice and prevalence of cervical dysplasia and carcinoma in situ. Am J Obstet Gynecol 1976; 124: 573-7.

[xix]      Vessey MP, Lawless M, McPherson K, Yeates D. Neoplasia of the cervix uteri and contraception: a possible adverse effect of the pill. Lancet 1983; 2: 930-.

[xx]      Brinton LA, Huggin GR, Lehman HF, Malli K, Savitz DA, Trapido E, Rosenthal J, Hoover R. Long term risk of oral contraceptives and risk of invasive cervical cancer. Int J Cancer 1986; 38: 339-44.

[xxi]      WHO collaborative study of neoplasia and steroid contraceptives: invasive cervical cancer and combined oral contraceptives. Br Med J 1985; 290: 961-5.

[xxii]      Brinton LA. Oral contraceptives and cervical neoplasia. Contraception 1991; 43: 581-95.

[xxiii]      Invasive cervical cancer. In Clinical Gynecologic Oncology (eds. DiSaia PJ, Creasman WT.). Mosby, St. Louis. 1997: 51-106.

[xxiv]      Grabrick DM. Hartmann LC. Cerhan JR. Vierkant RA. Therneau TM. Vachon CM. Olson JE. Couch FJ. Anderson KE. Pankratz VS. Sellers TA. Risk of breast cancer with oral contraceptive use in women with a family history of breast cancer. JAMA 2000; 284: 1791-8.

[xxv]      Van Hoften C. Burger H. Peeters PH. Grobbee DE. Van Noord PA. Leufkens HG. Long-term oral contraceptive use increases breast cancer risk in women over 55 years of age: the DOM cohort. Int J Cancer 2000; 87: 591-4.

[xxvi]      Reeves GK. Patterson J. Vessey MP. Yeates D. Jones L. Hormonal and other factors in relation to survival among breast cancer patients. Int J Cancer 2000; 89: 293-9.

[xxvii]      Ursin G. Ross RK. Sullivan-Halley J. Hanisch R. Henderson B. Bernstein L. Use of oral contraceptives and risk of breast cancer in young women. Breast Cancer Res Treat 1998; 50: 175-84.

[xxviii]     Sexually transmitted diseases. In Precis V: an update in obstetrics and gynecology (ed., Droegemueller W.) American College of Obstetricians and Gynecologists, Washington, D.C. 1994: 82-93.

[xxix]      Contraception: the choice is yours. A guide to choosing a method that’s right for you. Ortho Pharmaceutical Corporation. 1996.

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Hans E. Geisler MD, FACOG, FACS, is Director of Gynecologic Oncology at SV Hospitals and Health Services in Indianapolis, Indiana.  He is also a member of the Culture of Life Foundation Board of Directors.

Source: Culture of Life Foundation http://www.christianity.com/partner/Article_Display_Page/0,,PTID4211|CHID102755|CIID487518,00.html