Family Planning
Overview
For a reproductive-age women engaging in regular intercourse, there is an 85% chance she will be pregnant within a year if no contraception is used.
When advising patients, it is important to consider:
Patient compliance
Side effect profile
Comorbidities
For example, the combination transdermal patch is not approved for women >200 lbs.
Progesterone-only methods do not contain estrogen. Examples include
Levonorgestrel IUDs (Mirena, Skyla)
Medroxyprogesterone acetate injection (Depo-provera, "the shot")
Etonogestrel subcutaneous implant (Implanon, Nexplanon) and
Progesterone-only pills (Micronor, "mini-pill")
Estrogen containing methods include various combination oral contraception pills (OCPs), the norelgestromin and ethinyl estradiol combination transdermal patch (Ortho-Evra) and the etonogestrel and ethinyl estradiol combination vaginal ring (Nuvaring). Estrogen-containing contraceptives are absolutely contraindicated in patients with:
Breast cancer
Other estrogen-dependent cancers
Smokers >35 years old
Reversible, non-hormonal options include
behavioral methods (withdrawal, timed intercourse, basal body temperature, etc)
barrier methods (male and female condoms, diaphragm)
spermicides (foam), and
copper IUD (Para-Gard)
Abortion
The most common cause of spontaneous abortion (50%) is an anembryonic gestation (aka "blighted ovum") - there are no identifiable embryonic elements.
The second most common cause (25%) is aneuploidy.
Embryonic miscarriages (as differentiated from anembryonic miscarriages) are usually associated with some sort of anomaly of the zygote, embryo, fetus, or placenta.
Aneuploid abortions typically occur early in gestation (75% occur within the first 8 weeks).
95% of fetal aneuploidies result from maternal gametogenesis errors, only 5% are due to paternal errors.
The single most frequent aneuploidy seen in spontaneous abortion is trisomy 16.
Some maternal factors also increase the risk of spontaneous abortion. These include:
Age >35
Infections
Diabetes
Inflammatory and autoimmune diseases (Celiac, inflammatory bowel disease, lupus)
Morbid obesity
Inherited thrombophilias
Uterine defects
Drug Caused
Methotrexate is an abortifactant medication. It is a folic acid analog and irreversibly binds to dihydrofolate reductase, which synthesizes tetrahydrofolate. Tetrahydrofolate is needed for thymidine (↓ dTMP) and purine synthesis (so methotrexate prevents DNA synthesis).
Toxicities of methotrexate include:
Myelosuppression
Leukopenia
Steatosis
Mucositis
Lung toxicity
Therapeutic Abortion
Therapeutic abortion (TAB) is an elective termination of pregnancy.
In the first trimester, pregnancy can be terminated with abortifactant medication (e.g. mifepristone, methotrexate, misoprostol) or surgically (manual aspiration, dilation and curettage with vacuum aspiration).
In the second trimester, surgical termination, in the form of "dilation and evacuation" is performed.
Mifepristone (RU-486) is a partial progesterone receptor agonist, meaning that in the presence of progesterone (such as in a pregnant woman) mifepristone functions as a competitive progesterone receptor antagonist. (In the absence of progesterone, mifepristone acts as a partial agonist.) Since progesterone is required to maintain pregnancy, the presence of a competitive progesterone receptor antagonist leads to termination of the pregnancy.
Mifepristone also functions as an anti-glucocorticoid and anti-androgen, but since it is normally only used for short periods of time, these effects are not clinically significant.
Clinically, mifepristone with misoprostol (prostaglandin E1) is used to terminate pregnancy. In the setting of a therapeutic abortion, the most common regimen starts with mifepristone then follows with misoprostol 24-72 hours later. Mifepristone with misoprostol is also used as an alternative therapy to complete SABs.
Side effects of mifepristone include:
Heavy vaginal bleeding
Abdominal pain
GI issues (nausea, vomiting, anorexia)
Misoprostol is a PGE1 analogue that softens the cervix and induces uterine contractions.
Indications: Used to induce labor and as an abortifactant.
Adverse effects of misoprostol include:
Diarrhea
Abdominal pain
Headache
Uterine rupture (especially in patients with a history of cesarean section)
Recurrent
Definitions of recurrent pregnancy loss vary, but the most common definition is 3 or more consecutive spontaneous abortions in one patient.
If patient is losing pregnancies early in the first trimester, suspect chromosomal abnormalities and order karyotype of patient and fetus.
Losses occurring later in pregnancy may indicate mother having a hypercoagulable state, such as lupus or protein S deficiency. A panel should be ordered to evaluate.
Uterine anomalies and cervical incompetence should be evaluated using ultrasound imaging.
Septic
Septic abortion occurs when an abortion (spontaneous, indicated, or elective) is complicated by a severe intrauterine infection, usually when there is a long period of time between rupture of membranes and removal of all products of conception from the uterus. It may lead to systemic illness, including sepsis and septic shock.
The symptoms of septic abortion are essentially the same as those of chorioamnionitis and include
Fever
Pelvic pain
Purulent cervical discharge
Septic abortion is treated with
Broad-spectrum antibiotics
Suction D&C to remove any remaining products of conception
IV fluids
Rho(D) immune globulin (RhoGAM) (in rh-negative patients)
Most women respond within 1-2 days of treatment (once the source has been removed by D&C), and are discharged once afebrile without outpatient antibiotics.
Note: As with any infection, if sepsis is suspected, blood cultures should be ordered. Despite the name, patients with a septic abortion do not always have sepsis! Remember: Sepsis = 2 out of 4 SIRS criteria plus a source. We have a source, but the patient doesn't have to have 2 of 4 SIRS criteria to be diagnosed with septic abortion. For more information about SIRS and sepsis, see our topic on sepsis here.
Rarely, in cases of aggressive or untreated septic abortion, infection spreads outside of the uterus or causes extensive tissue necrosis, and laparotomy with hysterectomy and open pelvic debridement may be required. This should be considered if a patient fails to respond to D&C and IV antibiotics after 1-2 days.
Other types
Complete abortion: when the product of conception (POC) has passed and the cervical os is closed. If possible, send tissue to pathology for confirmation. No treatment necessary.
Incomplete abortion: when some POC has passed, but some remains in utero. The cervical os is open. A dilation and curettage may be needed to clean the uterus.
Inevitable abortion: describes a condition in which the cervix has already dilated open, but the fetus has yet to be expelled.
Missed abortion: death of the embryo or fetus (no cardiac activity) <20 weeks of gestation but no tissue has passed. The cervical os is closed. A Dilation and Curettage may be needed to clean the uterus.
Threatened abortion: patient complains of cramping and bleeding, but no tissue has passed and the fetus remains viable (+ fetal cardiac activity). The cervical os is closed.
Patients should be counseled and followed expectantly with weekly pelvic ultrasounds until:
The bleeding stops
Ultrasound detects fetal demise, or
All products of conception have passed
Intrauterine fetal demise: absence of fetal cardiac activity.
Note: The major difference between missed abortion and intrauterine fetal demise is that:
Missed abortion occurs at <20 weeks gestation
Intrauterine fetal demise occurs at >20 weeks gestation
In a suspected SAB, obtain a quantitative BHCG and ultrasound.
Ultrasound can detect a gestation sac at 5 weeks, a fetal pole at 6 weeks, fetal cardiac activity at 6-7 weeks.
If transvaginal ultrasound reveals an irregular gestation sac without a fetal pole or cardiac activity, a spontaneous abortion should be suspected.
Maternal blood type should be checked and Rho(D) immune globulin (RhoGAM) should be given if mom is Rh negative.
Spontaneous abortion (SAB) is defined as a pregnancy loss before 20 weeks gestational age.
60% of chemically-evident pregnancies end in SAB, and 15% of known pregnanciesend in SAB.
Barrier Methods
Barrier methods are the only form of contraception that can reduce the spread of STDs. Remember that this includes the male condom, female condom and dental dams for oral sex.
Condoms are placed over the penis and left in place until withdrawal following ejaculation. They are most commonly made of latex, but other materials can be used for patients with latex sensitivities.
Condoms provide a physical barrier to the passage of sperm.
Advantages:
Effective at preventing STDs
98% effective with ideal use (including placing the condom before any penetration occurs)
Disadvantages:
Only 85% effective with typical use
Risk of breakage
Alternative materials for latex-sensitive patients may be less effective or more prone to breakage
Diaphragms or cervical caps are barriers that are inserted into the vaginal canal before intercourse to block the cervix, then left in place for several hours. They are typically used with spermicide.
Advantages:
Durable, without ongoing expenses
Disadvantages:
Inconvenient
Frequent poor compliance
Increased risk of UTI
Only 88% effective with typical use
Must be fitted by an experienced provider
The contraceptive sponge is a spermicide-impregnated polyurethane sponge that is inserted prior to intercourse and left in place for 24 hours.
Advantages:
Hormone-free
Disadvantages:
Inconvenient
91% effective with ideal use, 80% effective with typical use in women without prior vaginal births. This drops to 80%/60% in women who have delivered vaginally in the past.
Increased risk of toxic shock syndrome
More expensive than condoms ($9-15 for a pack of 3 sponges)
Spermicide may also be used alone (without a barrier method), but this is difficult as it may require multiple applications. This method is 82% effective with ideal use, and 71% effective with typical use.
Behavioral
The withdrawal method consists of withdrawal of the penis from the vagina immediately before ejaculation.
Disadvantages:
73% effective with typical use
Decreased pleasure
Poor compliance
Lactation can be used as a contraceptive method for the first 6 months postpartum, as long as the mother is exclusively breastfeeding and menstruation has not returned. When these conditions are met, lactation is 95% effective at preventing pregnancy in the absence of other birth control methods.
Please note that women who are not breastfeeding exclusively may become pregnant within weeks of delivery if they engage in sexual intercourse. Postpartum contraceptive plans must be discussed during prenatal visits to avoid unintended close-interval pregnancy!
Because return of menstruation is unpredictable, lactating mothers should use a backup birth control method. They may select any method without estrogen, but many providers encourage long-acting methods such as the intrauterine and implantable devices, as new mothers often struggle to remember to take pills consistently.
Several rhythm-based methods of contraception occur. These rely on abstaining from intercourse at certain times of the menstrual cycle as determined by basal body temperature and cervical mucous.
Advantages:
Hormone-free
May provide information that can help to diagnose infertility
>95% effective with ideal use
Disadvantages:
83% effective with typical use
Requires detailed daily tracking and record-keeping
Implants
Contraceptive implants and devices provide long-term, highly reliable and completely reversible birth control.
An intrauterine device (IUD) is a highly effective, reversible form of contraception that may or may not contain hormones. The two types available are the levonorgestrel (Mirena, Skyla) IUDs and the copper (Para-Gard) IUD, both described below.
The levonorgestrel (Mirena, Skyla) IUDs contain progesterone and work by thickening cervical mucus, creating a local inflammatory reaction in the uterus that destroys sperm, and thinning the endometrium. The Skyla device is a smaller version of the Mirena IUD, meant for use in women who have never been pregnant.
The copper (Para-Gard) IUD creates a local inflammatory reaction in the uterus that destroys sperm and prevents implantation.
The copper (Para-Gard) IUD contains no hormones but cannot be used in patients with Wilson’s disease or those with heavy menses (menorrhagia).
Advantages:
99% effective
Placed in the physician's office, then left in place for 3 years (Skyla), 5 years (Mirena) or 10 years (Para-gard)
Nothing to remember every day
Safe for breastfeeding mothers
Copper IUD may be used as emergency contraception
Levonorgestrel IUDs may lead to shorter, lighter periods or amenorrhea
Disadvantages:
Small risk of spontaneous abortion if placed in the second half of the menstrual cycle
Small risk of uterine perforation
Small risk of expulsion
Etonogestrel implant (Nexplanon, formerly Implanon) is a subcutaneous implant that slowly releases progesterone over approximately 3 years.
The mechanism of progestin implants is systemic release of progestin, similar to the progestin-only pill.
Advantages:
Nothing to remember every day
Highly effective (>99%)
Shorter, lighter periods and often amenorrhea
Disadvantages:
Irregular bleeding, especially in the first 6 months
Breast pain
Hormonal
Hormonal contraceptive methods include oral contraceptive pills (OCPs), medroxyprogesterone injection, intravaginal ring, transdermal patch and a progestin-containing IUD.
NuvaRing
An intravaginal estrogen and progestin ring (NuvaRing) can be inserted into the vagina for 3 weeks, then removed to allow withdrawal bleeding. It releases a lower dose of estrogen than most combination oral contraceptive pills.
The intravaginal estrogen ring works in a similar way to combination oral contraceptive pills.
Advantages:
99% effective with ideal use
Nothing to remember every day
Disadvantages:
Only 92% effective with typical use
Device-related discomfort
Headache
Increased risk of DVT (due to estrogen content)
Morning After
Post-coital contraception ("morning-after pill"): Used after unprotected intercourse. There are multiple options for post-coital contraception, including oral estradiol and progestin and a copper IUD.
Note: It used to be thought that high-dose progesterone inhibited implantation, but more recent studies have demonstrated that this is not the case. If fertilization has already occurred, post-coital contraception will not be effective because it does not prevent implantation of the zygote.
The main drug used is the "plan B" pill, or levonorgestrel, which is a high dose progesterone.
The high dose of progesterone delays ovulation with the goal of preventing ovulation until sperm from a single episode of unprotected intercourse are non-viable (about 5 days post-intercourse). The patient may still ovulate later in the same cycle, and must use appropriate contraception.
Another option is to take multiple combination oral contraceptive pills at once, leading to an increased dose of estrogen and progesterone. This must be done within 72 hours of unprotected intercourse.
A copper IUD inserted within 4-5 days of unprotected intercourse interferes with sperm function and prevents implantation.
Advantages:
>90% effective at preventing pregnancy following a single episode of unprotected intercourse
Disadvantages:
Hormonal methods may cause severe headache and nausea
Menstrual bleeding is expected within 1 week of administration
Hormonal methods are effective only if ovulation has not yet occurred.
Copper IUD insertion may lead to inadvertent termination of a very early pregnancy.
Transdermal
The transdermal contraceptive (ortho-evra) patch delivers a combination of estradiol and progestin similar to combination OCPs. It must be changed weekly.
The transdermal contraceptive patch works in the same way as combination OCPs.
Advantages:
Nothing to remember every day
99% effective with ideal use
Disadvantages:
Not approved for women >200 lbs.
Patch may fall off and not be noticed
Nausea, headache, weight gain, irregular bleeding, breast pain (pregnancy symptoms)
Increased risk of DVT (due to estrogen content)
Only 92% effective with typical use
Depo Shot
Medroxyprogesterone acetate (Depo-Provera) injection is a progestin analogue injected in the office every 3 months.
Depot medroxyprogesterone acetate works by suppressing pulsatile release of GnRH, therefore inhibiting ovulation. It also thickens cervical mucus to block sperm entry.
Advantages:
Nothing to remember every day
Highly effective (99% with ideal use, 97% with typical use)
Shorter, lighter periods and often amenorrhea after several months
Disadvantages:
Nausea
Headache
Weight gain (5 lbs. average)
Irregular bleeding, especially in the first 6 months
Must go to the doctor's office every 3 months, within a 2-week window
Unpredictable time to return of fertility following discontinuation
Progesterone pills must be used around the same time of day (generally within 3 hours) to be effective, and therefore there is not much room for error.
Progesterone pills work by causing thickening of the cervical mucus(hostile to sperm migration) and thinning of the endometrium (unprepared for implantation). Progesterone pills also suppress ovulation, though unpredictably and not in all cycles.
Advantages of progesterone pills include:
Safe in breastfeeding moms, do not interfere with lactation
Highly effective (>99% if used properly)
Decreased risk of endometrial and ovarian cancers
Safe for women who cannot use estrogen-containing contraceptives due to thromboembolic risk
Disadvantages of progesterone pills include:
Does not protect against sexually transmitted diseases
Must be taken daily, at exactly the same time
Undesirable side effects (e.g. nausea, depression, hypertension)
Increased breakthrough bleeding
Combination OCP
Combination Oral Contraceptive Pills (OCPs) contain varying levels of estrogen and one of several progestins.
Combination Oral Contraceptive Pills (OCPs) work by:
Inhibiting follicle development and ovulation (estrogen inhibits FSH/LH)
Changing endometrial quality
Increasing cervical mucus viscosity
Essentially, these are like the progesterone-only OCPs, except that the estrogen inhibits ovulation.
Advantages:
Highly effective with ideal use (99%)
Disadvantages:
Only 92% effective with typical use
Must be taken every day
Possible nausea, headache, weight gain
This hormonal state mimics early pregnancy, which is why women do not ovulate
Increased risk of DVT due to estrogen
Contraindicated for heavy smokers, history of DVT, estrogen-related cancers, liver disease, and elevated triglycerides
Yaz and Yazmin contain drospirenone, a progestin with aldosterone-antagonist effects that may help to combat premenstrual bloating.
Permanent
Surgical (i.e. permanent) options include the Essure procedure (hysteroscopic tubal occlusion) and surgical tubal ligation, as well as vasectomy for the male partner.
Advantages:
All three methods are nearly 100% effective
No hormones
One-time expense
Disadvantages
May be difficult to reverse
Increased risk of ectopic pregnancy in case of failure or following reversal
Essure consists of coils placed hysteroscopically in-office into the openings of the fallopian tubes.
Over the course of three months, these tubes "scar in" and the tubes are occluded. The patient uses a backup method (usually medroxyprogesterone injection aka depo-provera) for these three months, then undergoes a hysterosalpingogram to confirm occlusion of the tubes.
Tubal ligation involves surgical clipping of the fallopian tubes, or removal of a portion of the tube. It may be performed through a mini-laparotomy or laparoscopically. Compare this surgical approach to hysteroscopic tubal occlusion (the Essure device).
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