Chirurgische Arbeitsgemeinschaft für Adipositastherapie (CA-ADIP) In Zusammenarbeit mit Deutsche Adipositas-Gesellschaft (DAG) Deutsche Gesellschaft für Psychosomatische Medizin und Psychotherapie Deutsche Gesellschaft für Ernährungsmedizin S3-Leitlinie: Chirurgie der Adipositas
Canadian contraception consensusNo. 143 – Part 3 of 3, April 2004
CANADIAN CONTRACEPTION CONSENSUS Amanda Black, MD, FRCSC, Ottawa ON John Collins, MD, FRCSC, Mahone Bay NS Diane Francoeur, MD, FRCSC, Montréal QC Dianne Miller, MD, FRCSC,Vancouver BC Timothy Rowe, MB, FRCSC,Vancouver BC CONTRACEPTION GUIDELINES COMMITTEE
Elke Henneberg, Communications Message & More Inc., Montréal QC Thomas Brown, PharmD,Toronto ON Michèle David, MD, FRCPC, Montréal QC Sheila Dunn, MD, CCFP(EM),Toronto ON William A. Fisher, PhD, London ON Nathalie Fleming, MD, FRCSC, Ottawa ON Claude A. Fortin, MD, FRCSC, Montréal QC Edith Guilbert, MD, MSc, Quebec City QC Louise Hanvey, BN, MHA, Chelsea QC André Lalonde, MD, FRCSC, Ottawa ON Ruth Miller, MEd,Toronto ON Margaret Morris, MD, FRSCS,Winnipeg MB Teresa O'Grady, MD, FRCSC, St. John's NL Helen Pymar, MD, MPH, FRCSC,Toronto ON Thirza Smith, MD, FRCSC, Saskatoon SK Objective: To provide guidelines for health-care providers on
Chapter 8: Barrier Methods
the use of contraceptive methods to prevent pregnancy and 1. Health-care providers should promote the consistent and cor- sexually transmitted diseases.
rect use of latex condoms to protect against pregnancy, Outcomes: Overall efficacy of cited contraceptive methods,
human immunodeficiency virus (HIV) infection, and other STIs.
assessing reduction in pregnancy rate, risk of infection, safety, (Grade A) Men and women should be provided with informa- ease of use, and side effects; the effect of cited contraceptive tion on the male and female condom.
methods on sexual health and general well-being; and the cost 2. Women who use barrier methods of contraception should be and availability of cited contraceptive methods in Canada.
provided with emergency contraception and relevant coun- Evidence: Medline and the Cochrane Database were searched
selling. (Grade B) for articles in English on subjects related to contraception, sex- 3. Health-care providers should educate women and men about uality, and sexual health from January 1988 to March 2003, in the correct use of barrier methods. They should emphasize order to update the Report of the Consensus Committee on the need for dual protection against pregnancy and infections.
Contraception published in May–July 1998. Relevant Canadian Government publications and position papers from appropriate 4. The use of spermicide-coated condoms should no longer be health and family planning organizations were also reviewed.
promoted. Nevertheless, the use of a nonoxynol-9 lubricated Values: The quality of the evidence is rated using the criteria
condom is preferable to the use of no condom at all.
described in the Report of the Canadian Task Force on the Periodic Health Examination. Recommendations for practice 5. Health-care providers should be encouraged to be familiar are ranked according to the method described in this Report.
with the technique of fitting a diaphragm. Diaphragms and cer-vical caps should continue to be available in Canada. (Grade C) 6. Nonoxynol-9 should not be used to reduce the risk of STIs Key Words
and HIV infection. Condoms should always be used to reduce Contraception, statistics, Canada, sexuality, sexual health, hormonal the risk of infections. (Grade A) contraception, emergency contraception, barrier methods of 7. Since frequent use of nonoxynol-9 products may cause epithe- contraception, contraceptive sponge, female condoms, contraceptive lial damage and increase the risk of HIV infection, women diaphragm, cervical cap, spermicide, fertility awareness, abstinence, who have multiple daily acts of intercourse should be advised tubal ligation, vasectomy, sterilization, intrauterine devices to avoid using nonoxynol-9 products. (Grade A) Chapter 9: Natural Family Planning Methods
Contraception in Individuals with Intellectual Disabilities
1. Health-care providers should respect the choice of a natural 1. Health-care providers should include sexual health in the family planning method and be able to provide resources to counselling of women and men with intellectual disabilities, support the correct use of this method. (Grade C) explore potential coercion and abuse and should provide 2. The use of coitus interruptus ("withdrawal") should be rec- counselling to help them avoid coercive and abusive situations.
ognized as a risk-reduction strategy. When couples use coitus interruptus or other natural family planning methods, health-care providers should provide information about emergency J Obstet Gynaecol Can 2004;26(4):347–87.
contraception. (Grade C) 3. Health-care providers should acknowledge and legitimize abstinence as a valid contraceptive choice. (Grade B) CHAPTER 8: BARRIER METHODS
4. Comprehensive sex education should be available to all Canadians. Education programs should provide information on Diane Francoeur, MD, FRCSC,1 Louise Hanvey, BN,
abstinence as well as on contraception and STI prevention.
MHA,2 Ruth Miller, MEd,3 Helen Pymar, MD, MPH,
5. Health-care providers should be able to counsel postpartum women about the contraceptive efficacy and correct use of the lactational amenorrhea method. (Grade A) Chapter 10: Sterilization
1. Couples choosing a sterilization procedure should be in- formed that vasectomy carries fewer risks than tubal ligation.
Barrier methods of contraception use a mechanical or chemi- However, social, cultural, and individual considerations should cal barrier to obstruct the entry of spermatozoa into the upper be taken into account before a choice of procedure is made.
female genital tract. Some of these methods (condoms, sper- 2. Before recommending a transcervical sterilization (cornual micides, sponge) do not require consultation with a health-care occlusion technique), extensive counselling should be offered provider before use, and are widely available. Others and the permanence of the procedure reinforced. (Grade B) (diaphragm, cervical cap) require an initial visit to a health-care 3. Counselling before sterilization should include discussion of provider for fitting. Each method provides variable protection alternative contraceptive methods. Counselling should address against both unplanned pregnancy and sexually transmitted the risks, complications, potential for regret, and failure rates infection (STI).
associated with the procedure. (Grade B) 4. New techniques of female and male sterilization should be available to all Canadians. (Grade C) 1. CONDOMS
Chapter 11: Contraception — Meeting Special Needs
Contraception in Perimenopause
1. Health-care providers should emphasize the need for effective contraception in the perimenopausal woman. Non-contracep- When placed correctly over the penis, the condom acts as a tive benefits of each method should be taken into accountwhen counselling these women. (Grade A) mechanical barrier that prevents contact between semen and the sexual partner. Most condoms are made of latex, although 1. Initiation of combined OC use should be delayed until breast- polyurethane, silicone, and lambskin condoms are available. feeding is established, usually by 6 weeks postpartum. If the The latex condom is the most popular barrier method of woman is not breastfeeding, combined OCs can be started at contraception.1 Latex condoms are 0.3–0.8 mm thick. Sperm 3 to 4 weeks postpartum. (Grade B) cannot penetrate condoms. Latex condoms are offered in a vari- 2. Progestin-only methods should be considered as contraceptive options for postpartum women, regardless of breastfeeding sta- ety of shapes and colours. Novelty condoms, offered in sex toy tus, and may be introduced immediately after delivery. (Grade B) supply stores or catalogues do not offer pregnancy and STI pre- 1. Contraceptive counselling should be offered at the time of A number of polyurethane condoms have recently become abortion, and contraceptive methods should be provided available in Canada. These new condoms may offer better phys- immediately following the procedure. (Grade A) ical properties than latex condoms, and thus may be stronger.
2. Canadian women should have access to safe abortion proce- dures regardless of geographical location. (Grade A) They transmit more body heat, allowing more sensitivity. They Contraception for the Adolescent
can be formulated to feel thinner than they actually are, with a 1. Adolescents should have ready access to contraception and less constricting fit. They are more resistant to deterioration.
methods of STI prevention. (Grade A) Unlike latex condoms, polyurethane condoms are compatible 2. Health-care providers should respect a patient's right to con- with oil-based lubricants. They can be used by those who are fidentiality. (Grade A) sensitive or allergic to latex.2,3 3. The health-care provider should help to ascertain that sexu- ally active adolescents are involved in a consensual relationship Three polyurethane condom brands are currently available that is free of coercion and abuse. (Grade B) in Canada: Avanti, Trojan Supra (lubricated with or without sper- micide), and eZ.on. They cost twice as much as latex condoms.4 STI are inconclusive, but STI rates in populations have been Plastic condoms manufactured from materials other than shown to decline when condoms are used. Condoms lubricat- polyurethane have also been developed. The Tactylon condom, ed with spermicides are no more effective than latex condoms manufactured from a plastic material used in non-allergenic without spermicide.11 Latex condoms decrease the risk of trans- examination gloves, was recently approved by the U.S. Food mission of STI associated with vaginal discharge (chlamydia, and Drug Administration.2,5 gonorrhea, trichomoniasis, and human immunodeficiency Lambskin (also called sheepskin or natural membrane) con- virus).14-16 A lesser level of protection is provided for STI asso- doms are made from a lamb's intestine. While both latex con- ciated with genital ulcer or human papilloma virus (HPV), doms and lambskin condoms prevent pregnancy by blocking because these infections may be transmitted by exposure to areas the passage of sperm through their surfaces, lambskin condoms such as infected skin or mucosal surfaces that are not covered are not recommended for protection against STI. Laboratory by the condom. The ability of condoms to prevent HPV infec- tests have shown the passage of viruses, including hepatitis B, tion is unknown because HPV is often only intermittently herpes simplex virus and HIV through small pores on the sur- detectable. Nevertheless, condom use has been associated with face of lambskin condoms.6 lower incidence rates of cervical cancer, genital warts, and cer-vical dysplasia, all of which are HPV-associated conditions.17-20 Several carefully conducted studies have demonstrated in vivo and in vitro that consistent condom use is a highly effec- tive means of preventing human immunodeficiency virus The efficacy of condoms refers to both pregnancy prevention (HIV) transmission. From incidence estimates, consistent use and prevention of sexually transmitted infection. of condoms can decrease AIDS/HIV transmission by 85%.21-24 Condoms are very effective when used consistently and cor- rectly. The percentage of women experiencing an accidental POLYURETHANE AND OTHER PLASTIC CONDOMS
pregnancy within the first year of perfect use of condoms is esti- Comparisons between Avanti polyurethane condoms and latex mated at 3%, whereas the typical failure rate is approximately condoms showed equivalent levels of contraceptive protection, 14%.7 The highest failure rates are from age 20 to 24, while the but the polyurethane condoms had a higher frequency of break- second-highest failure rate is under the age of 20.8 Non-use age and slippage. These condoms may therefore confer less pro- probably accounts for most of the difference in condom failure tection from STI than do latex condoms.25-27 The eZ.on rates between typical and perfect users. Factors positively asso- polyurethane condom has not been shown to be as effective as ciated with delayed condom use include younger age, primary the latex condom for pregnancy prevention, although the risk partner, lack of partner support, and multiple recent sexual part- of pregnancy in the polyurethane condom group lies in the ners.9 Women identified a low perceived risk of pregnancy or range of other barrier methods. Clinical failures (breakage and infection as the most common reason for not using condoms, slippage) are also higher for eZ.on polyurethane condoms than while men identified the inconvenience or unavailability of the for latex condoms.28,29 condom as the most common reason.10 Polyurethane and other plastic condoms have not been well Condoms used in conjunction with other methods of birth studied for protection against STIs, but they are believed to pro- control will provide additional protection against pregnancy vide protection similar to that of latex condoms. Studies of their and possibly STIs, depending on the method used. Ideal use of effectiveness are in progress. the condom with separate spermicide increases the contracep-tive efficacy close to that of perfect use of combined oral con- traceptives, which is 99.9%.11 The use of intravaginally applied The Tactylon condoms are equivalent to latex condoms in risk spermicide, in contrast to spermicide incorporated in condoms, of slippage, but the breakage rate for the Tactylon condom is guarantees its presence in the vaginal region in the event of con- three to five times higher than the latex condom. Fewer med- dom breakage or leakage.11 ical events (irritation, burning, itching, and genital pain) were In 2000, the U.S. Centers for Disease Control and Preven- reported with Tactylon condoms than with latex condoms.30,31 tion, the U.S. National Institutes of Health, the U.S. Food andDrug Administration, and the United States Agency for Inter- national Development made clear recommendations regarding Lambskin condoms are no longer recommended because of the use of male latex condoms. A summary report was published their lack of protection against STI.6 in July 2001,12 suggesting that correct and consistent use ofmale latex condoms will reduce the risk of sexually transmitted MECHANISM OF ACTION
The data regarding individual use of condoms and risk of The condom acts as a mechanical barrier to prevent exchange of fluid and semen and to decrease contact with genital lesions.
still common: 43% of users applied the condom after penetra- While both latex and lambskin condoms prevent pregnancy by tion, 15% removed it before ejaculation, 40% did not leave blocking the passage of sperm through their surfaces, lambskin space at the tip, 30% placed the condom upside down on the condoms are not recommended for protection against STIs.6 penis and thus rolled it on inside out, and 32% were unable Laboratory tests have shown the passage of viruses, including to maintain erection.37 hepatitis B, herpes simplex, and HIV, through small pores onthe surface of lambskin condoms.6 Some condoms are supplied MYTHS AND MISCONCEPTIONS
pre-lubricated with either a water-based lubricant or a smallamount of spermicide. Condom choices include plain or reser- 1. Everybody knows how to use a condom.
voir-tipped, straight or shaped, smooth or textured, natural or Fact: Women, and especially adolescents seem to expect that brightly coloured, and a variety of sizes. Some condoms tend to all men know how to use the condom correctly to prevent fit better than others; optimal fitting requires trying a variety of breakage or spillage, but this is untrue.
2. I can't get a sexually-transmitted infection if I always use a Fact: Some users believe that condoms prevent all STIs, andthey will have intercourse even in the presence of ulcers or Condoms are indicated for the prevention of pregnancy, STI, genital lesions. Any skin-to-skin contact can lead to trans- and cervical dysplasia. The chief motivation for condom use in mission of STIs.
women is pregnancy prevention rather than STI.32 Ideally, condoms should be used in addition to another pri- mary contraceptive method (dual protection), because condomuse potentially increases the contraceptive and STI protective PROVISION OF CONDOMS
effects of other methods.
Innovative programs have been developed to improve access tocondoms for individuals who find them difficult or embarrass- ing to purchase. Whether condoms should be readily availableto young people through school-based clinics or dispensing The only contraindication to latex condom use is an allergy or machines is a matter for debate. It is of interest that the lowest sensitivity to latex, or lanolin sensitivity in the case of lambskin unwanted pregnancy rates occur in those countries that have condoms. Effective use of condoms requires high motivation more liberated sexual norms, mandated sex education, and pro- and a strong sense of responsibility.
vide easy access to family planning information and servicesthrough school-based clinics.37 PROPER USE AND PRECAUTIONS
Use of a condom increases the contraceptive and STI protec- Packaged condoms that are stored dry and away from light and tive effects of other methods. When the use of a condom is heat can be kept for up to 5 years. The approved lifespan of sper- insisted upon, this may have a positive effect on the nature and micide-containing condoms is 2 years. The expiration date must duration of the relationship.33 be respected. Condoms deteriorate more quickly when exposedto temperatures over 37 degrees Celsius, high humidity, and air SIDE EFFECTS
pollution.38 Unpackaged condoms exposed to ultraviolet lightare weakened by 80% to 90% within 8 to 10 hours.39 The most Side effects with condom use include allergy to latex and irri- common error in using condoms is the additional use of oil- tation. The use of spermicides increases the incidence of E. coli based lubricants, which, unlike water lubricants, have been urinary tract infection because of alteration of the vaginal shown to affect condom integrity by reducing tensile strength, flora.34,35 Some men may complain of decreased sensation or elongation, burst pressure, and burst volume.40 Table 1 lists loss of erection.36 lubricants that are safe or unsafe to use with condoms. Con-doms should not be disposed of in toilets.
In case of condom breakage or leakage, emergency contra- ception should be provided, as well as STI testing if necessary.
Technical problems with condom use (occurrence of an unrec-ognized leak, slippage) are more common when men are not USING A CONDOM
used to the method.37 Condoms are not always available when When this is the only contraceptive method selected, a health- needed. A recent study in college men showed that errors are care provider ideally should instruct both the woman and her partner in the use of condoms, and should provide the woman "USING A CONDOM INTERFERES WITH THE
with a prescription for emergency contraception. (See Table 2.) SPONTANEITY OF SEX."
Condom use may interfere with, or interrupt, foreplay and impair
erection. Encouraging the partner to put the condom on as a partof sex play, eroticizing condom use, and using a condom during The health-care provider should be prepared to deal with com- sex play before intercourse often alleviates this problem.
ments and concerns voiced by the patient regarding condom use.
Here are some suggestions for dealing with common complaints.
"I AM ALLERGIC TO LATEX."
While sensitivity may be related to the spermicide or lubricant,
"I DON'T HAVE THE SAME FEELING WITH A
latex sensitivity is increasing, particularly among workers with repeated exposure to latex medical devices.42 Lambskin con- While condom use may reduce sensitivity, there is no objective doms may be used for contraception, but polyurethane con- evidence for this. Reduced sensitivity may be an advantage for doms should be used for STI prevention.
some men by enhancing erection and preventing prematureejaculation, but others find this frustrating and will stop using "WHAT DO I DO ABOUT CONDOM BREAKAGE AND
a condom. To increase sensation, the male partner may use a textured or ultra-thin condom, or place a water-soluble lubri- Most condoms (92%–98%) will neither break nor come off cant inside the reservoir of the condom.
completely during intercourse.43 The risk of pregnancy has beenestimated at one pregnancy in 23 episodes of condom breakage, "I LOSE MY ERECTION WHEN USING A CONDOM."
and the probability of HIV infection resulting from a single Making the application of the condom by the partner a routine exposure ranges from less than 0.1% to 10%, depending on the part of sex play — during oral sex or masturbation, for example type of transmission (male to male, male to female, or female to — may help overcome this obstacle.
male) and the presence or absence of genital ulcers.44,45 STI test-ing is recommended if there is any fear of infection.
Common reasons for breakage include rough handling of Table 1.41 Lubricants and Products that are Safe or Unsafe to Use
condoms, the use of oil-based lubricants, and incorrect storage with Condoms
or usage after the expiry date. While condoms rarely slip off completely during intercourse, they may slide down the shaft of the penis without falling off. The condom must be held at the base of the penis during withdrawal.43 Excessive lubricant Aqua-Lube Plus (spermicidal) Coconut oil/butter inside the condom will increase the risk of slippage. Emergency Edible oils (e.g., olive, peanut, contraception should be recommended if there is doubt. Contraceptive foams (e.g., Haemorrhoid ointments "I HAVE TROUBLE CONVINCING MY PARTNER THAT
Emko, Delfen, Koromax) Insect repellants WE SHOULD USE CONDOMS."
Contraceptive creams and gels Margarine, dairy butter (e.g., PrePair, Conceptrol, Health-care providers can rehearse specific scenarios with their Petroleum jelly (e.g., Vaseline) Table 2. Using a Condom
ForPlay lubricant • Put a drop or two of water-based lubricant or saliva inside the • Place the rolled condom over the tip of the hard penis (e.g., Monistat, Estrace, Femstat, Vagisil, Premarin, • Leave a half-inch space at the tip to collect semen Rendell's Cone, Pharmatex • If not circumcised, pull back the foreskin before rolling on the Some sexual lubricants (e.g., • Pinch the air out of the tip with one hand (friction against air Elbow Grease, Hot Elbow bubbles causes most condom breaks Grease, and Shaft • Unroll the condom over the penis with the other hand Personal Lubricant • Roll it all the way down to the base of the penis PrePair Lubricant • Smooth out any air bubbles • Lubricate the outside of the condom — pull out before the penis • Don't spill the semen — hold the condom against the base of the penis while you pull out • Throw the condom away • Wash the penis with soap and water before any further contact Table 3. How to Talk About Condoms with a Partner
If the partner says …
You can say …
"I'm on the pill. You don't need a condom." "I want to use it anyway. We will be protected from infections we may not realize we have." "Condoms aren't romantic." "What's more romantic than making love and protecting each other's health at the same time?" "I know I'm clean of disease. I haven't had sex with anyone in ‘X' "As far as I know, I am disease-free too, but I still want to use a condom since a person can't always tell if they have an infection." "I can't feel a thing when I use a condom. It's like wearing a raincoat in "Maybe that way you'll last even longer, and that will make up for it." OR "I think I am woman (man) enough to make you feelsomething." "I don't stay hard when I put on a condom." "I can do something about that." "Putting it on interrupts everything and destroys the romantic "Not if I help put it on." OR "We can make it erotic together." "But I love you." "Then, if you love me, you'll help me protect myself." "I guess you don't really love me." "I do, but I'm not risking my future to prove it." "Just this once." "Once is all it takes." "You carry a condom around with you? You were planning on having "I always carry condoms because I care about myself and I care about "I won't have sex with you if you insist on using a condom." "OK. Let's put it off until we can agree. Let's satisfy each other without "I don't have a condom with me." patients, walk through mentally when and how to purchase J Sex Marital Ther 1999;25(3):217–25.
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12. National Institute of Allergy and Infectious Diseases, National Institutes when there is resistance to condom use. (See Table 3.) of Health, Department of Health and Human Services. Scientific evidenceon condom effectiveness for sexually transmitted disease (STD) preven-tion. Available at <www.niaid.nih.gov/dmid/stds/condomreport.pdf>.Web site updated July 20, 2001. Accessed January 20, 2004.
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MECHANISM OF ACTION
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The female condom is 7.8 cm in diameter and 17 cm long.
34. Handley MA, Reingold AL, Shiboski S, Padian NS. Incidence of acute uri- It has 2 flexible rings, one attached to the sheath and one unat- nary tract infection in young women and use of male condoms withand without nonoxynol-9 spermicides. Epidemiology 2002;13(4):431–6.
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38. Carey RF. Background information, FDA testing of latex condoms. Dis- 8 hours before intercourse.4,7 tributed by KR Foster, Health and Welfare Canada; December 1992.
The polyurethane used in the female condom is less likely 39. Duribon NE.The condom barrier. Am J Nurs 1987;87:1306–10.
to tear or break than the latex in male condoms. In a study of 40. Voeller B, Coulson A, Bernstein GS, Nokamura R. Mineral oil lubricants post-intercourse leakage designed to detect pinholes and tears cause rapid deterioration of latex condoms. Contraception 1989;39:95–101.
after actual condom use, 3.5% of male latex condoms showed 41. Waldron T.Tests show commonly used substances harm latex leakage when tested after use, compared with 0.6% of female condoms. Contraceptive Technology Update 1989;10:20–1.
condoms.8 The female condom does not deteriorate with expo- 42. U.S. Food and Drug Administration. Allergic reactions to latex contain- ing medical devices. March 29, 1991. Publication No.: MDA91-1.
sure to oil-based products, and withstands storage better than 43. Trussell J,Warner DL, Hatcher RA. Condom slippage and breakage latex. It has a longer shelf-life (of up to 5 years) than the male rates. Fam Plann Perspect 1992;24:20–3.
condom. It should be noted that the female condom is not 44. Hatcher RA, Hughes MS.The truth about condoms.The Sexuality Infor- mation and Education Council of the U.S. SIECUS Report 1998;17:1–9.
intended for use with a male condom, because the two con- 45. Liskin L,Wharton C. Blackburn R. Kestelman P. Condoms: now more doms may adhere to one another and slip or become displaced.
than ever. Pop Rep 1990;8, Series H.
2. FEMALE CONDOM
The female condom prevents semen from contacting the vagi- na. A woman who finds spermicides irritating, or does not likethe messiness of other vaginal barrier methods, may prefer to The female condom is a soft, loose-fitting polyurethane sheath use the female condom.
which acts as an intravaginal barrier. (See Figure 1.) The Reality Advantages of the female condom include the following:
• A woman can place it autonomously and has full control Disadvantages of the female condom include of the effectiveness.
• the need to practise insertion and to use the device several • When used correctly, it can provide a high level of pro- times before becoming confident with its use • the inner ring may cause discomfort during coitus9 • It adjusts well to the anatomy of the vagina.9 • cost• noise during coitus16 Promotion of use of the female condom has been met with challenges such as the perceived high cost (approximately $3.00 Some conditions prohibit the use of the female condom.
per condom in Canada). There is also evidence of bias against the method on the part of health-care providers .17 Their atti- • Allergy to polyurethane tudes may improve through more positive and well-designed • Abnormalities in vaginal anatomy that interfere with a training programs.18 satisfactory fit or stable placement • Inability to learn the correct insertion technique.
Women who plan to use female condoms do not require a fit-ting, but they need to: PROTECTION FROM SEXUALLY TRANSMITTED
• understand how to use them correctly • insert them just prior to intercourse or up to 8 hours Polyurethane is impenetrable in vitro to organisms the size of the human immunodeficiency virus (HIV).10 The female condom • use a new condom for each act of intercourse provides protection from sexually transmitted infection (STI) that • remove the female condom immediately after intercourse, is similar to that of the male condom, although specific clinical squeezing and twisting the outer ring to keep semen evidence is limited. The incidence of STI in sex workers given the inside the pouch, before standing up choice of using male or female condoms has been reported lowerthan the incidence in women using male condoms only.11,12 If the female condom slips or breaks, women should be coun- One of the most important features of the female condom is selled to use emergency contraception.
that it is a female-controlled method of contraception and STIprevention.9,13-15 ACCEPTABILITY
Acceptability varies with study groups. For example, female con-
SIDE EFFECTS, RISKS, AND CHALLENGES
doms are well-accepted in sex workers, a group in which asmany as 98% were satisfied with the method.16 The percent- Problems are uncommon with the use of the female condom.
age of satisfaction went down to as little as 65.2% in a survey Slippage has been cited as a problem specific to the use of the of volunteers from hospital staff.19 COST
Like the male condom, the female condom is made for single
use only, so the cost of sustained use can be prohibitive. In
Canada the average cost is $3.00 per condom. Re-using the
female condom has been considered as one approach to make
the female condom more cost-effective; the safety and feasibil-
ity of re-use is currently the subject of research.20,21
1. The World Health Organization. Improving access to quality care in family planning: medical eligibility criteria for contraceptive use. 2nd ed.
2. Bounds W, Guillebaud J, Stewart L, Steele SJ. A female condom (Femshield): a study of its user-acceptability. Br J Fam Plann, 1988;14:83–7.
Figure 1. The Female Condom 3. Farr G, Gabelnick H, Sturgen K, Dorflinger L. Contraceptive efficacy and acceptability of the female condom. Am J Public Health 1994;84(12):1960–4.
4. Gilliam ML, Derman RJ. Barrier methods of contraception. Obstet which is the most common; the arcing spring; and the flat Gynecol Clin North Am 2000;27(4):841–58.
spring. The coil spring diaphragm has a sturdy rim which folds 5. Family Health International.Technical update on the female condom.
Available on-line at <http://www.fhi.org/en/RH/Pubs/booksReports easily for insertion. It remains in a straight line when pinched /fcupdate.htm>.Web site updated December 18, 2001. Accessed at the edges. Women need good pelvic support to feel com- January 26, 2004.
fortable with this type of diaphragm, because it is difficult to 6. Trussell J, Sturgen K, Strickler J, Dominik R. Comparative contraceptive secure the posterior edge into the cul-de-sac over the cervix. It efficacy of the female condom and other barrier methods. Fam PlannPerspect 1994;26(2):66–72.
is often preferred by parous women.
7. Hatcher RA,Trussell J, Stewart F, Cates W, Stewart GK, Guest F, et al, The arcing spring diaphragm slips more easily past the editors. Contraceptive technology. 17th ed. New York, NY: Ardent cervix and is easier to use for most women.1 It is more suitable Media; 1998.
8. Leeper MA, Conrardy M. Preliminary evaluation of Reality, a condom for nulliparous women.
for women to wear. Adv Contracept 1989;5(4):229–35.
A flat spring diaphragm (also called a wideseal diaphragm) 9. Gollub EL.The female condom: tool for women's empowerment. Am J made of silicone is an option for women who are allergic to Public Health 2000;90(9):1377–81.
10. Drew WL, Blair M, Miner RC, Conant M. Evaluation of the virus perme- latex, and is available over the Internet.2 ability of a new condom for women. Sex Transm Dis 1990;17(2):110–2.
Ultimately, the choice of diaphragm will be based on indi- 11. Fontanet AL, Saba J, Chandeying V, Sakhondavat C, Bhiraleus P, Rugpao S.
vidual preferences for comfort and ease of checking for position.
Increased protection against sexually transmitted diseases by granting A diaphragm can be inserted into the vagina with an introduc- sex workers in Thailand the choice of using the male or femalecondom: a randomized controlled trial. AIDS 1998;12:1851–9.
er, but the manual method of insertion is superior because it 12. Welsh MJ, Feldblum PJ, Kuyoh MA, Mwarogo P, Kungu D. Condom use offers the user the opportunity to check for fit. (See Figure 2.) during a community intervention trial in Kenya. Int J STD AIDS2001;12(7):469–74.
13. Musabe E, Morrison CS, Sunkutu MR,Wong EL. Long-term use of the female condom among couples at high risk of human immunodeficiencyvirus infection in Zambia. Sex Transm Dis 1998;25:1–5.
Efficacy rates vary depending on the study and the methodolo- 14. Artz L, Macaluso M, Brill I, Kelaghan J, Austin H, Fleenor M, et al. Effec- tiveness of an intervention promoting the female condom to patients gy used. The WHO failure rate for the diaphragm in the first 12 at sexually transmitted disease clinics. Am J Public Health 2000;90: months of use is 20% with typical use and 6% with perfect use.3 While consistent and correct use of the diaphragm is essen- 15. Latka M, Gollub E, French P, Stein Z. Male and female condom use tial for effectiveness, approximately one-half of method failures among women after counselling in a risk reduction hierarchy for STDprevention. Sex Transm Dis 2000;27(8):431–7.
occur despite diligent use. Therefore, a woman's ability to accept 16. Zachariah R, Harries AD, Buhendwa L, Spielman MP, Chantulo A, an unplanned pregnancy may be a determinant in her suitabil- Bakali E. Acceptability and technical problems of the female condom ity for this barrier method.
amongst commercial sex workers in a rural district of Malawi.TropDoct 2003;33(4):220–4.
A recent study found use of the diaphragm and spermicide 17. Latka M. Female-initiated barrier methods for the prevention of to provide significantly more effective contraception than use STI/HIV: where are we now? where should we go? J Urban Health of the contraceptive sponge.4 18. Mantell JE, Hoffman S,Weiss E, Adeokun L, Delano G, Jagha T, et al.The acceptability of the female condom: perspectives of family planning MECHANISM OF ACTION
providers in New York City, South Africa, and Nigeria. J Urban Health2001;78(4):658–68.
The diaphragm serves as a physical barrier between sperm and 19. Sapire KE.The female condom (Femidom): a study of user acceptability.
S Afr Med J 1995;85(10 Suppl):1081–4.
the cervix and should always be used in conjunction with a sper- 20. International Planned Parenthood Federation. IMAP statement on bar- micide. The spermicidal action of the jelly or cream used rier methods of contraception. IPPF Med Bull 2001;35(4):1.
increases the contraceptive effect. In addition, the use of a 21. World Health Organization.The safety and feasibility of female condom reuse: report of a WHO consultation. Geneva:WHO; 2002.
diaphragm is associated with a reduced incidence of cervicalneoplasia,1,6 dysplasia,6,7 gonorrhea,8 pelvic inflammatory dis-ease,9 and tubal infertility.10 3. DIAPHRAGM
The use of a diaphragm without the addition of a spermi- cidal agent shows variable contraceptive effectiveness.11,12 A recent review found no rigorous studies which were able to dis-tinguish the effectiveness of the device with as opposed to with- The diaphragm is an intravaginal barrier method of contracep- out spermicide.13 Diaphragms should always be used together tion that is used in conjunction with a spermicide (jelly or with a spermicide.14 cream). It consists of a latex dome with an encased flexible steel A diaphragm can be inserted up to 6 hours before inter- ring around its edge. It fits into the vagina to cover the cervix.
course.5 Each repeated act of intercourse requires the application Diaphragms are available in a variety of sizes and types. The of extra spermicide (an applicator is necessary for this repeat three types of diaphragm available in Canada are the coil spring,
A refitting of the diaphragm is required after childbirth, diaphragm's rim on the urethra and the concurrent use of sper- surgery, or if the woman gains or loses at least 10 pounds.
micides.15 Of these, the use of a spermicide may be a moreimportant cause.1 The diaphragm is contraindicated for women or their part- ners who have allergies or sensitivities to latex, rubber, or sper- Diaphragms are well suited for those women who do not wish to use hormonal contraception or for whom hormonal contra- Use of a diaphragm can be associated with toxic shock syndrome ception is contraindicated.1 Diaphragms can also be used by (TSS). Toxic shock syndrome, caused by toxins released by some strains of Staphylococcus aureus, is a rare but serious disorder. Therisk of TSS, although low, is increased in women who use vagi- CONTRAINDICATIONS AND CAUTIONS
nal barrier methods of contraception.
The health-care provider must rule out the presence of a large MYTHS AND MISCONCEPTIONS
cystocele, rectocele, or marked uterine prolapse,10 which wouldreduce the efficacy of the method.
1. All barrier methods protect against HIV infection.
Some women are sensitive to spermicides and to latex.
Fact: Protection from HIV is limited because of the expo- There is also evidence of an increased risk of developing sure of vaginal mucosa.
bacterial vaginosis in diaphragm users.15 Women with 2. Using a diaphragm alone (without spermicide) is equally recurrent urinary tract infections (UTI) may need postcoital prophylaxis with antibiotics, since there is a 2 to 3 fold Fact: Studies suggest a decreased efficacy when used alone.14 increase in UTI risk with the use of spermicides. This isprobably related to changes in the vaginal flora and increased growth of E. coli.16,17 A pelvic examination by a qualified clinician is required for fit- ting diaphragms. (See Table 4.) Fitting rings are produced bydiaphragm manufacturers in various sizes and with different rim The use of a diaphragm offers potential protection from STIs types. Sizes range from 50 to 105 mm in diameter. The fitting and their consequences by decreasing cervical exposure to the rings are most commonly available as flat spring or coil spring causative organisms. Protection from HIV transmission is lim- rim types. It is important to fit the woman with the rim type ited because of the exposure of the vaginal mucosa during the that she will ultimately use, and to have her practise with it use of this method. The use of the diaphragm is also associated under the supervision of the clinician.
with a reduced incidence of cervical neoplasia.6,7 A sample sized diaphragm or fitting ring can then be insert- ed into the correct position in the vagina. The diaphragm RISKS AND SIDE EFFECTS
should fit snugly in the upper half of the vagina, immediatelybehind the pubic bone, with its rim in contact with the lateral The use of a diaphragm may also increase the risk of persistent walls of the vagina and the posterior fornix.1 or recurrent UTI, possibly because of pressure from the Before a woman can successfully use the diaphragm or cer- vical cap, she will require detailed instructions for insertion, theopportunity to practise, and reassurance from the clinician.
Reinforcement of the correct procedures is valuable, as are tipsto becoming more comfortable with one's body. Providinginformation about the menstrual cycle will help women usetheir barrier method more effectively. Providing information Table 4. Fitting for a Diaphragm
The correct diaphragm size can be estimated by• inserting the index and middle fingers into the vagina until the posterior wall is reached (by middle finger); • marking the point at which the index finger touches the pubic bone with the tip of the thumb; and • removing the fingers, then placing rim of diaphragm on tip of the middle finger. The opposite side rim should be lying just in Figure 2. Diaphragm front of the thumb.
about the availability of emergency (post-coital) contraception 4. CERVICAL CAP
will also be essential.
Diaphragm users do not require any special follow-up other than a refitting after a full-term pregnancy, pelvic surgery, orabortion, or if they have a significant change in weight.
The cervical cap is a barrier method of contraception usedintravaginally in conjunction with a spermicide (jelly or cream).
(See Figure 3b.) The only cervical cap approved by HealthCanada is the Ovès contraceptive cap, which is available If a diaphragm user is experiencing recurrent UTIs, a refit or through the Internet.1 change of rim type may help, but the problem may be due tospermicide exposure. Post-coital voiding or prophylactic antibi- otic may help.17 For some women, having recurrent UTIs maybe a contraindication to diaphragm use.
The World Health Organization cites a contraceptive failurerate of 20% with typical use and 9% with perfect use in nulli-parous women. The failure rate for multiparous women in the REFERENCES
first 12 months of use of the cap is 40% with typical use and26% with perfect use.2 1. Speroff L, Darney PD. A clinical guide for contraception. 3rd ed. Phila- delphia: Lippincott Williams & Wilkins; 2001. p. 259–95.
2. Available on-line at <http://www.milexproducts.com/products/other MECHANISM OF ACTION
/diaphrams.asp>. Accessed January 28, 2003.
3. World Health Organization. Improving access to quality care in family planning: medical eligibility criteria for contraceptive use. 2nd ed.
The Ovès cap is made of silicone and places a physical barrier Geneva:WHO; 2001.
between sperm and the cervix; the spermicidal action of the jelly 4. Kuyoh MA,Toroitich-Ruto C, Grimes DA, Schultz KF, Gallo MF. Sponge or cream increases the contraceptive effect. The cap is held in versus diaphragm for contraception: a Cochrane review. Contraception place over the cervix by suction and must therefore be snugly 5. Hatcher RA,Trussell J, Stewart F, Cates W, Stewart GK, Guest F, et al, fitted. It can be left in place for up to 72 hours.
editors. Contraceptive technology. 17th ed. New York, NY: ArdentMedia; 1998. p. 371–404.
6. Wright NH,Vessey MP, Kenward B, Mc Pherson K, Doll R. Neoplasia and dysplasia of the cervix uteri and contraception: a possible protec-tive effect of the diaphragm. Br J Cancer 1978;38(2):273–9.
Women who do not wish to use hormonal contraception, or 7. Becker TM,Wheeler CM, McGough NS, Stidley CA, Parmenter CA, for whom it is contraindicated, may choose to use this barrier Dorin MH, et al. Contraceptive and reproductive risks for cervical dysplasia in southwestern hispanic and non-hispanic white women.
method. It must be used consistently and correctly. A woman's Int J Epidemiol 1994;23(5):913–22.
ability to accept an unplanned pregnancy may be a determinant 8. Keith L, Berger G, Moss W. Prevalence of gonorrhea among women in her suitability for a barrier method such as the cervical cap.
using various methods of contraception. Br J Venereal Dis 1975;51: Cervical caps can be used by lactating women.
9. Keleghan J, Rubin GL, Ory HW, Layde PM. Barrier method contracep- tives and pelvic inflammatory disease. JAMA 1982;248:184–7.
CONTRAINDICATIONS AND CAUTIONS
10. Kost K, Forrest JD, Harlap S. Comparing the health risks and benefits of contraceptives choices. Fam Plann Perspect 1991;23:54–61.
11. Ferreira AE, Araujo MJ, Regina CH, Diniz SG. Effectiveness of the The cervical cap should not be used in women with a current diaphragm, used continuously, without spermicide. Contraception vaginal or cervical infection, current pelvic inflammatory disease, cervical or uterine cancer or dysplasia, or in women with allergy 12. Smith C, Farr G, Feldblum PJ, Spence A. Effectiveness of the non- spermicidal fit free diaphragm. Contraception 1995;51:289–91.
or sensitivity to spermicides. Additionally, it is not recommend- 13. Cook L, Nanda K, Grimes D. Diaphragm versus diaphragm with ed in a woman who has recurrent vaginal, cervical, or urinary tract spermicides for contraception. Cochrane Database Syst Rev 2003;(1) infections, who does not feel comfortable touching her genital area; or who has difficulty applying the cap to the cervix. 14. Craig S, Hepburn S.The effectiveness of barrier methods of contraception with and without spermicide. Contraception The cervical cap cannot be used within 6 weeks of a deliv- ery, after a recent miscarriage or an abortion, or during any vagi- 15. Hooton TM, Finh SD, Johnson C, Roberts PL, Stamm WE. Association nal bleeding including menstruation.
between bacterial vaginosis and acute cystitis in women usingdiaphragms. Arch Intern Med 1989;149(9):1932–6.
16. Hooton TM, Hillier S, Johnson C, Roberts P, Stamm WE. Escherichia coli bacteriuria and contraceptive methods. JAMA 1991;265:64–9.
17. Finh SD, Latham RH., Roberts P, Running K, Stamm WE. Association between diaphragm use and urinary tract infection. JAMA The cervical cap offers potential protection from gonorrheal and chlamydial infections and their consequences.3
RISKS AND SIDE EFFECTS
MYTHS AND MISCONCEPTIONS
Use of the cervical cap may aggravate symptoms in women with 1. Cervical caps increase the risk of cervical dysplasia.
sexually transmitted infections and vaginitis. The risk of toxic Fact: Cervical caps are not associated with an increased risk shock syndrome is increased. Cervical caps may cause more of cervical cancer, although inflammatory changes have been vaginal odour and discharge than diaphragms, and can be dis- lodged during intercourse. Concerns about abnormal cervical 2. It is impossible to obtain a cervical cap in Canada.
cytology associated with cervical cap use have been shown to be Fact: Cervical caps are available in Canada in some family planning clinics and they can also be ordered through theInternet.1 Table 5. Fitting for a Contraceptive Cervical Cap
Most women will use the 28 mm cervical cap. The rim of the cervical cap should be seated in the vaginal fornices around theentire base of the cervix with a snug seal and no laxity.
Table 6. Instructions for Inserting a Cervical Cap
1. Wash your hands carefully before inserting or removing the 2. To make it easier to insert or remove the cap, stand with one leg supported higher than the other (using a chair or the edge Figure 3a. Inserting a cervical cap of the bath) or use a squatting position.
3. Remove the cap from its protective sachet.
4. It is recommended that the cap be used with a spermicidal gel or cream. Place a small amount of the spermiciderecommended by your health-care professional inside thedome.
5. No additional spermicide is required during the 72-hour wearing period.
6. Locate the cervix by inserting a finger inside your vagina.
7. Pinch the cap at its base with the dome facing downwards.
8. Introduce the cap into the vagina and push it toward the 9. When the bottom of the cap comes into contact with the cervix, position the cap so that it covers the cervix correctly.
10. When the cap cannot be pushed any further, you will know that it is placed correctly.
11. Now carefully remove your finger without disturbing the position of the cap.
Table 7. Instructions for Removing a Cervical Cap
1. The cap must not be removed until at least 6 hours after the most recent sexual intercourse.
2. Introduce the index finger into the vagina and find the cervix covered by the cap.
3. Run your finger around the base of the cap until you locate the 4. Hook the loop of the cap with the end of the index finger.
5. Remove the cap using a slow steady movement.
6. Remove the cap, wash it with warm soapy water and store the cap in a dark and cool place.
The cap may stay in place for a minimum of 6 hours after the last intercourse but no longer than 2 days. If an odour developsafter 6 hours, a break and a bath are recommended.
After cleaning and drying the device it can be used again asdescribed.
A woman with a very busy sex life who cannot wait should consider another method.
Figure 3b. Cervical caps The cervical cap can be reused until it is damaged.
pregnated with a combination of spermicidal agents(nonoxynol-9, benzalkonium chloride, and sodium cholate).1 A bimanual pelvic examination must be performed by a qual- The Today Sponge is pillow-shaped and contains nonoxynol-9.
ified clinician to ascertain the position and size of the uterus The concave dimple on one side is designed to fit over the cervix and cervix. Some abnormalities of the cervix, such as a large and to decrease the chance of dislodgement during intercourse.
Nabothian follicle, may interfere with the ability of the cervi- The other side of the sponge incorporates a woven polyester loop cal cap to cover and adhere to the cervix. Three sizes of cervi- to facilitate removal. (See Figure 4.) cal caps are available: these are 26, 28, and 30 mm in diameter.
Women can bring a "fitting pack" containing one of each size EFFICACY
cap to the examination to be sure they are fitted with the cor-rect size. The Protectaid sponge has a theoretical efficacy rate of 90%2 in Before a woman can successfully use the cervical cap, she nulliparous women, but it is much less effective in parous will require detailed instructions for insertion, the opportunity women — 20% of whom conceive unexpectedly within the to practise, and reassurance from the clinician. (See Figure 3a, first year of "perfect" use. The actual failure rates for typical users Tables 6 and 7.) Providing information about the availability of are 18% for nulliparous women and 36% for parous women.3,4 emergency (post-coital) contraception will also be essential. The The Today Sponge has a theoretical efficacy rate of 91% in combination of a female barrier method with a male latex con- nulliparous women, but 20% of parous women conceive unex- dom will provide additional contraception and additional pro- pectedly within the first year of "perfect" use. The actual failure tection from sexually transmitted infection.
rates for typical users are 40% in parous users and 20% innulliparous women.3 As with other female barrier methods, effi- cacy rates can be increased by using the sponge in combinationwith a male condom.3 A recent review of clinical trials found The manufacturer recommends that cervical cap users have a that the sponge was less effective than the diaphragm in pre- health-care provider check the fitting of the cap after a miscar- venting pregnancy, and discontinuation rates were higher.5 riage, term delivery, abortion, or after gaining or losing 3 kg ormore in weight.
MECHANISM OF ACTION
Cervical caps users should be monitored for cervical inflam- mation and abnormal Pap smears, since inflammatory changes The contraceptive action of the sponge is primarily provided by have been reported.3 the action of the impregnated spermicide, augmented by itsability to absorb and trap sperm. The sponge acts as a sustained- release spermicidal reservoir for a period of 12 hours.
1. <www.birthcontrol.com>. Accessed January 27, 2004.
2. World Health Organization. Improving access to quality care in family planning: medical eligibility criteria for contraceptive use. 2nd ed.
The sponge may best meet the needs of women who wish to 3. Kelaghan J, Rubin GL, Ory HW, Layde PM. Barrier method contracep- or must avoid hormonal contraception.3 Some women tives and pelvic inflammatory disease. JAMA 1982;248:184–7.
choose the sponge because of its prolonged 12 hours of pro- 4. Richwald GA, Greenland S, Gerber MM, Potik R, Kersey L, Comas MA.
Effectiveness of the cavity-rim cervical cap: results of a large clinical tection. It is less messy than spermicide used alone or with a study. Obstet Gynecol 1989;74:143–8.
5. Gollub EL, Sivin I.The Prentif cervical cap and Pap smear results: a criti- cal appraisal. Contraception 1989;40:343–9.
5. CONTRACEPTIVE SPONGE
The contraceptive sponge is an intravaginal one-size-fits-all bar-rier method which does not require a visit to a physician or birthcontrol clinic. The sponge is available in pharmacies.
There are 2 forms of the contraceptive sponge available in Canada — both are small, disposable polyurethane foam devices Figure 4. Contraceptive Sponge intended to fit over the cervix. The Protectaid sponge is im- cervical cap or diaphragm. The sponge may be used with Douching after intercourse is not recommended. If sponge other barrier methods such as the male condom to increase users choose to douche, they should wait for at least 6 hours its efficacy.
after intercourse to avoid the removal of spermicide. They canuse male condoms with the sponge for added protection against both pregnancy and sexually transmitted infection.
Before insertion, the Today Sponge should be moistened The sponge should not be used by women who have with about 2 tablespoons of clean water and squeezed once. The • an allergy to spermicide user should insert the dimpled side so that it faces the cervix, • abnormalities in vaginal anatomy that interfere with sat- with the loop away from the cervix. She can use her finger to isfactory or stable placement of the sponge confirm that the sponge covers the cervix.
• an inability to learn correct insertion technique• a history of toxic shock syndrome • repeated urinary tract infections• a need for protection from HIV infection Recurrent vaginal yeast infections or bacterial vaginosis must be • had a full-term delivery within the past 6 weeks, a recent appropriately treated. This may require switching to another spontaneous or induced abortion, or abnormal vaginal method of contraception.3,8 RISKS AND SIDE EFFECTS
1. Courtot AM, Nikas G, Gravanis A, Psychoyos A. Effects of cholic acid and "Protectaid" formulations on human sperm motility and ultra- The risk of toxic shock syndrome (TSS) is increased in women structure. Hum Reprod 1994;9(11):1999–2005.
who use vaginal barrier methods of contraception; they have an 2. Guerrero E.The new Protectaid contraceptive sponge: a scientific annual incidence of 2 to 3 cases per 100 000 women. The over- update. Press Release.Toronto; February 13, 1996.
all health risks attributable to TSS are very low. These cases of 3. Hatcher RA,Trussell J, Stewart F, Cates W, Stewart GK, Guest F, et al, editors. Contraceptive technology. 17th ed. New York, NY: Ardent TSS would result in less than 1 death (0.18) annually for every Media; 1998.
100 000 vaginal barrier users.6 4. Creeatsas G, Guerrero E, Guilbert E, Drouin J, Serfaty D, Lemiex L, et al.
Women using the sponge must be aware of the symptoms A multinational evaluation of the efficacy, safety and acceptability of theProtectaid contraceptive sponge. Eur J Contracept Reprod Health Care and signs of TSS, and must receive instructions consistent with recommended TSS precautions.
5. Kuyoh MA,Toroitich-Ruto C, Grimes DA, Schulz KR, Gallo MG. Sponge versus diaphragm for contraception (Cochrane Review). Contraception2003;67:15–8.
MYTHS AND MISCONCEPTIONS
6. Schwartz B, Gaventa S, Broome CV, Reingold AL, Hightower W, Perlman JA, et al. Nonmenstrual toxic shock syndrome associated with 1. Sponges offer protection against STIs.
barrier contraceptives: report of a case-control study. Rev Infect Dis Fact: The contraceptive sponge may potentially damage vagi- 1989;11 Suppl 1:S43–8.
7. Daly CC, Helling-Giese GE, Mati JK, Hunter DJ. Contraceptive methods nal mucosa and thus may enhance HIV transmission.7 and the transmission of HIV: implications for family planning. GenitourinMed 1994;70:110–7.
8. Mengel MB, Davis AB. Recurrent bacterial vaginosis: association with vaginal sponge use. Fam Pract Res J 1992;12(3): 283–8.
Women using the contraceptive sponge need to know how toinsert and use it correctly. They should • be aware that the sponge provides effective contraceptive protection for 12 hours, regardless of the number of acts of intercourse.
• wash their hands carefully with soap and water before Spermicides are composed of a spermicidal agent in a carrier inserting, checking, or removing the sponge.
that allows dispersion and retention of the agent in the vagina.
• remove and discard the sponge after use; sponges should Nonoxynol-9 (N-9) is the most commonly used spermicidal not be reused.
agent in Canada. Spermicides are easily obtained without a pre- • ensure that the device is in place before the penis enters scription and have no systemic effects. Spermicides are also important contributors to the efficacy of the contraceptive • be familiar with the signs of toxic shock syndrome.
sponge, diaphragm, and cervical caps.
• discuss problems of recurring bladder infections or vagi- The use of a spermicide alone provides less effective con- nal yeast infections with their health-care provider.
traception than using it in combination with a barrier method.1 Spermicides are available as film, jelly, suppository, cream, tablet, contraindication to its use. Spermicides should not be used in and as a foam.
the presence of any condition that prohibits proper placement The Vaginal Contraceptive Film (VCF) is a 2-by-2 in. sheet high in the vagina over the cervix. Such genital tract abnor- of film containing 28% nonoxynol-9. It must be inserted at malities as a vaginal septum or double cervix will make the least 15 minutes before intercourse in order to melt and dis- correct placement of spermicide difficult, and are potential perse. If more than one hour has elapsed before intercourse, contraindications to its use. Women who are uncomfortable another film must be inserted. Inserting the film correctly touching their genital area will likely be uncomfortable using requires practice. Women who are accustomed to douche after spermicides. If there is a personal or medical need for highly intercourse must be advised not to do so for at least 6 hours after effective contraception, spermicides should not be the first contraceptive choice. Spermicides with nonoxynol-9 should Advantage 24 is a bioadhesive jelly that adheres to the cervix also not be recommended to sex workers or to women with and vagina, slowly releasing nonoxynol-9. It can be inserted up an increased risk of human immunodeficiency virus (HIV) to 24 hours before intercourse, but a repeat application is required prior to each additional act of intercourse. Each application comesseparately packaged in inserters that resemble tampon inserters.1 Spermicidal foam is effective immediately and for up to one hour after insertion. This preparation contains 12.5% nonoxynol-9.
The foams, creams, and jellies may be used as lubricants with It is inserted in the vagina using a supplied applicator. A repeat application is required prior to each additional act of intercourse.
Spermicidal jellies (e.g., Orthogynol ll, K-Y Plus, Sure-seal RISKS AND SIDE EFFECTS
Gel) are intended for use with a diaphragm. The Encare suppository, containing nonoxynol-9, must be Genital irritation could lead to easier transmission of HIV.4-7 inserted 10 to 15 minutes prior to intercourse.
The use of spermicides has also been associated with anincreased risk of urinary tract infection.8 MYTHS AND MISCONCEPTIONS
Studies are difficult to compare and vary widely in size,focus, and quality.2 Failure rates in the first year of use vary 1. Use of a spermicide alone provides contraception that is as from 26% with typical use to 6% with perfect use.3 reliable as the use of a barrier method. Fact: Spermicides used alone have a substantially higher fail-ure rate than other contraceptive methods.3,9 MECHANISM OF ACTION
2. Nonoxynol-9 lubricated condoms are more effective than regular condoms. Spermicides are composed of a spermicidal agent in a carri- Fact: Condoms lubricated with or without N-9 are similar- er that allows dispersal and retention of the agent in the va- ly effective in preventing pregnancy.10 gina. Spermicides are surfactants that destroy the sperm cell 3. Spermicides are effective microbicides.
membrane by altering the lipid layer; the spermatozoon thus Fact: Nonoxynol-9 is not an effective microbicide; in fact, becomes permeable and swells, with breakage of plasma and its use may increase the risk of sexually transmitted infec- tion (STI) or infection with HIV.4-7,11 Spermicides appearto have no protective effect against chlamydial and gonor- rheal infections.7 Most of the clinical evidence on the risk of HIV infection The use of spermicides is only recommended as an adjunct with use of N-9 comes from studies conducted among women with other methods of contraception. Spermicide can be who were either sex workers or attending STI clinics. It is not used alone when fertility is naturally reduced. Spermicides known whether these results also apply to situations in which are also used as a backup contraceptive with the use of con- the dosage or frequency of N-9 use is lower.4-6 doms, the diaphragm, and the cervical cap; it is also used as In keeping with the World Health Organization's state- a backup method in lactating women. ments,10 it is recommended that: • nonoxynol-9 not be used for the purpose of preventing STI or HIV infection. Condoms should always be usedto prevent infection.
An allergy to a spermicide or its carrier is the only absolute • although nonoxynol-9 has been shown to increase the risk of HIV infection when used frequently by women at high risk of infection, it remains a contraceptive option forwomen at low risk.
1. Latex condoms, used consistently and correctly, will provide • since high-frequency use of nonoxynol-9 products may protection against pregnancy (Level II-2) and STIs, includ- cause epithelial damage and increase the risk of HIV ing HIV infection (Level II-1). However, no barrier contra- infection, women who have multiple daily acts of inter- ceptive method can provide 100% protection from all STIs. course should be advised to choose another method of 2. Polyurethane and other non-latex condoms have an increased incidence of breakage and slippage compared to • condoms lubricated with nonoxynol-9 are no more effec- latex condoms; hence, the protection they provide against tive in preventing pregnancy or infection than are con- STIs and HIV infection is inferior to that of latex condoms doms lubricated with other products. Since adverse effects (Level I). Polyurethane condoms remain important options due to the addition of nonoxynol-9 to condoms cannot for reducing the risk of STIs in the presence of latex aller- be excluded, such condoms should no longer be pro- gies. Lambskin condoms do not protect against HIV moted. However, it is better to use a nonoxynol-9 lubri- cated condom than no condom at all.
3. The use of spermicide-coated condoms is associated with an • nonoxynol-9 should not be used rectally.
increased incidence of urinary tract infections. (Level II-1) 4. The effectiveness of barrier methods will be complemented by the use of emergency contraception and fertility aware-ness. (Level III) Instructions should be read and followed carefully, especially the 5. Condoms lubricated with nonoxynol-9 are no more effec- length of time from insertion of the spermicide to intercourse, tive in reducing the risk of pregnancy or infection than con- and the duration of effectiveness. (See Table 8.) Fertility aware- doms lubricated with other products. (Level III) ness will increase the likelihood that another barrier method of 6. Spermicides used alone are not a highly effective contracep- contraception will be added to the spermicide at the fertile time tive method, although their efficacy may be enhanced when of the cycle, thus enhancing efficacy. However, use of a spermi- used in combination with another contraceptive method.
cide may interfere with the assessment of cervical mucus. Spermicide users should be counselled about the use of 7. The frequent use of nonoxynol-9 products may cause vagi- emergency contraception in the event that they fail to use the nal epithelial damage and may increase the risk of HIV infec- RECOMMENDATIONS
1. Health-care providers should promote the consistent and
Inserting a spermicide should be practised before coitus takes correct use of latex condoms to protect against pregnancy,
place, in order to increase comfort with use. If genital irrita- human immunodeficiency virus (HIV) infection, and
tion develops, steps must be taken to rule out an STI, vaginal other STIs. Health-care providers should provide men
moniliasis, and bacterial vaginosis. If there is an unpleasant and women with information on the male and female
genital odour, cultures should be taken and any specific condom. (Grade A)
2. Women who use barrier methods of contraception
If "messiness" is a problem, spermicidal film or bioadhesive should be provided with emergency contraception and
jelly should be recommended.
relevant counselling. (Grade B)
If lack of spontaneity is an issue, bioadhesive jelly can be 3. Health-care providers should educate women and men
inserted up to 24 hours before intercourse. about the correct use of barrier methods. They should
emphasize the need for dual protection against preg-
nancy and infections. (Grade B)
Table 8. How to Use Spermicides
4. The use of spermicide-coated condoms should no longer
• Read and follow the package instructions.
be promoted. Nevertheless, the use of a nonoxynol-9
• Insert spermicide high in the vagina to cover the cervix.
lubricated condom is preferable to the use of no condom
• Use the appropriate amount of spermicide.
at all. (Grade C)
• Wait the recommended time between insertion and intercourse.
5. Health-care providers should be encouraged to be
• Insert an additional application of spermicide with every act of familiar with the technique of fitting a diaphragm.
• Do not douche for at least 6 hours after intercourse.
Diaphragms and cervical caps should continue to be
• Always have additional supply of spermicides.
available in Canada. (Grade C)
6. Nonoxynol-9 should not be used to reduce the risk of
coitus in order to reduce or eliminate the potential for con- STIs and HIV infection. Condoms should always be used
ception to occur. This understanding is also used to maximize to reduce the risk of infections. (Grade A)
the potential for conception in couples who wish to conceive.
7. Since frequent use of nonoxynol-9 products may cause
Natural family planning methods include fertility awareness, epithelial damage and increase the risk of HIV infection,
coitus interruptus (withdrawal), and abstinence.
health-care providers should advise women who have
multiple daily acts of intercourse to avoid using
1. FERTILITY AWARENESS
nonoxynol-9 products. (Grade A)
Some natural family planning methods use fertility awareness 1. Hatcher RA,Trussell J, Stewart F, Cates W, Stewart GK, Guest F, et al, as their basis. Fertility awareness methods identify the woman's editors. Contraceptive technology. 17th ed. New York, NY: Ardent fertile period and thereby the days on which intercourse should Media; 1998. p. 216–7.
2. Family Health International. How effective are spermicides? Network be avoided or carefully protected with barrier methods. Cou- 2000:20(2). Available on-line at: <http://www.fhi.org/en/RH/Pubs ples can use this information to guide their efforts to avoid or /Network/v20_2/NWvol20-2spermicids.htm> Web site updated 2003.
achieve pregnancy.1,2 Accessed January 29, 2004.
3. World Health Organization. Improving access to quality care in family The 3 primary fertility signs are changes in cervical mucus, planning: medical eligibility criteria for contraceptive use. 2nd ed.
basal body temperature (BBT), and cervical position. In addi- Geneva:WHO; 2001.
tion to methods that observe biological signs of fertility, some 4. Hoffman T,Taha TE, Martinson F. Adverse health event occurring during an n-9 gel pilot study: Malawi. 13th International AIDS Conference; July methods rely only on calculations using the calendar. 9–14, 2000; Durban, South Africa. Abstract No.TuPpC1171.
5. VanDamme L, Ramjee G, Alary M,Vuylsteke B, Chandeying V, Rees H, et al. Effectiveness of COL-1492, a nonoxynol-9 vaginal gel, on HIV-1transmission in female sex workers: a randomized controlled trial.
The effectiveness of NFP methods is difficult to calculate. Most 6. Wilkinson D, Ramjee G,Tholandi M, Rutherford G. Nonoxynol-9 for published studies are flawed in design and calculate pregnancy preventing vaginal acquisition of sexually transmitted infections by rates incorrectly. Reports of effectiveness do not usually include women from men. (Cochrane Review). Oxford: Update Software.
Cochrane Database Syst Rev 2002;(4): CD003939.
data on methods of teaching, content of teaching, time spent 7. Roddy RE, Zekeng L, Ryan KA,Tamoufem U,Weir SS,Wong EL. A con- teaching, and whether one or both partners were taught.1 The trolled trial of nonoxynol 9 film to reduce male-to-female transmission World Health Organization cites a failure rate of 20% for com- of sexually transmitted diseases. New Engl J Med 1998;339:504–10.
8. Hooton TM, Scholes D, Hughes JP, Winter C, Roberts PL, Stapleton AL, mon use and 1% to 9% for perfect use.3 et al. A prospective study of risk factors for symptomatic urinary tractinfection in young women. New Engl J Med 1996;335:468–74.
MECHANISM OF ACTION
9. Sangi-Haghpeykar H, Poindexter AN III, Levine H. Sperm transport and survival post-application of a new spermicide contraceptive. Advantage24 Study Group. Contraception 1996;53:353–6.
10. World Health Organization.Technical consultation on nonoxynol-9: FERTILITY AWARENESS AND THE SYMPTOTHERMAL
meeting report. Geneva:WHO; October 9–10, 2001. Available on-line at <http://www.who.int/reproductive-health/rtis/N9_meeting_report.pdf>.Web site updated June 25, 2002. Accessed January 29, This method uses all 3 fertility signs.
11. Health Canada. Centre for Infectious Disease Prevention and Control.
Nonoxynol-9 and the risk of HIV transmission. HIV/AIDS Epi Update.
Ottawa: Health Canada; April 2002. Available on-line at <http://www The woman is taught to monitor the volume and changes in quality of cervical mucus before ovulation. The mucus becomes Web site updated May 7, 2003. Accessed January 29, 2004.
clearer and more elastic (described as showing spinnbarkeit) asovulation approaches. After ovulation, the mucus becomes vis- CHAPTER 9: NATURAL FAMILY PLANNING METHODS
cid, opaque, and impenetrable to sperm, and mucus volumereduces abruptly. Three days after "peak" (clearest and most elas- Ruth Miller, MEd,1 Louise Hanvey, BN, MHA2
tic) mucus, the woman enters the less fertile phase. Although there may be a first infertile phase starting with the first day of menses, it varies in length depending on the rapidity of the ovar- Natural family planning (NFP) refers to methods of controlling ian follicular response. If the follicular response is very rapid, fertility that do not involve the use of contraceptive devices or there may be mucus present during menstruation. Although chemicals. It relies on an understanding of the physiology of the the timing of ovulation may be unpredictable, observing cervi- menstrual cycle and on the timing of ovulation to schedule cal mucus changes can alert women to its approach. BASAL BODY TEMPERATURE
16 days before the onset of the next menses, that sperm Body temperature is measured orally or vaginally, using a spe- remain viable for up to 5 days, and that the oocyte survives cial BBT thermometer, after at least 6 hours of sleep. Follow- unfertilized for 24 hours. Based on this method, a couple ing the post-ovulatory elevation of progesterone, basal would avoid intercourse or use another contraceptive method temperature should rise in the luteal phase of the cycle by at during an 8- to 10-day period in each cycle. The woman must least 0.5ºC. Given that this temperature rise follows ovulation, chart a menstrual calendar over several months. Her fertile it indicates that the fertile period has ended. However, for period is determined by subtracting 20 days from the length women who wish to conceive, it may reveal a pattern of ovula- of her shortest cycle (to establish when the fertile period tion for future cycles. To avoid pregnancy, unprotected inter- begins) and subtracting 10 days from the length of her longest course should be delayed until after 3 consecutive days of cycle (to establish when the fertile period ends.) This method temperature elevation. is not recommended as a sole method of contraception.
OVULATION PREDICTOR KITS
Women are taught to detect the changes in the position of the Most research on ovulation prediction and detection devices cervix and in the size of the cervical os. The cervix can be felt has focused on helping women who wish to conceive. Most close to the introitus post-menstrually, and its position rises ovulation-predictor home test kits detect a specific level of appreciably within the vagina during the follicular phase. It luteinizing hormone (LH) in urine or saliva which will be pre- reaches its highest point at ovulation. The consistency of the sent on the day before or the day of ovulation. Women seeking cervix becomes soft and the os more open. During the luteal to conceive can time intercourse to coincide with these days (or phase it descends within the vagina and becomes firm, closed, earlier in the fertile time if she is using a fertility awareness-based and closer to the introitus. This sign is the most difficult to assess method). Two fertility indicator kits available in Canada mon- for most women.
itor saliva patterns which correlate with serum estradiol levelsand ovarian follicular activity. All of these products are market- BILLINGS OVULATION METHOD
ed as aids for women to determine the best time for conception The Billings method relies on cervical mucus changes only, as — not for contraception.7,8 described above. It is used primarily by couples for whom the A new test kit has been developed to help women avoid teachings of the Roman Catholic Church allow no recourse to pregnancy. The test uses a small hand-held electronic monitor barrier methods. In those for whom pregnancy would be unde- and disposable urine test sticks. The monitor measures a sired, reliance on the second infertile phase only (post-ovula- urinary metabolite of estrogen and LH.9,10 An independent tion) is advised.4 prospective study showed a method failure rate of 6.2%,11,12although others consider it to be higher.13 It is available in some countries in Europe.
This is a simple method for identifying the fertile window. Itclassifies a day as "fertile" if the cervical secretions are present LACTATIONAL AMENORRHEA METHOD
on that day or were present on the previous day. This method The lactational amenorrhea method (LAM) of contraception may be useful in populations where other NFP methods are dif- is highly effective as a temporary postpartum method in ficult to implement due to lack of trained NFP teachers or to a variety of cultures, health-care settings, socio-economic the cost and availability of BBT thermometers.5 strata, and in both industrial and developing country locales.14The method is based on the physiological infertility of STANDARD DAY METHOD
breastfeeding women caused by hormonal suppression of This method defines menstrual cycle days 8 to 19 as the fertile window.6 During this time the couple abstains from intercourse.
This method is 98% effective for a breastfeeding woman if This method is only useful for women with cycles ranging from 1. her menses have not returned and 26 to 32 days in length. It requires a long period of abstinence 2. she is fully or nearly fully breastfeeding (i.e., the only addi- but can be combined with a barrier method. It is not as reliable tional intake is infrequent water, juice, or vitamins); and as methods that chart fertility signs, as it does not account for 3. her baby is under 6 months of age. circumstances that would affect the timing of ovulation such as Intervals between breastfeedings should not exceed 4 hours stress or illness.
during the day and 6 hours at night.15 Since the pregnancy rateincreases in women whose infants are receiving supplemen- tary food,16 despite continued lactational amenorrhea, a Women must calculate the onset and duration of their fertile supplementary contraceptive method should be used by these period based on the assumptions that ovulation occurs 12 to women if they wish to avoid conception.
Natural family planning may be a contraceptive option for Instruction in NFP is recommended, although women can learn • couples who wish to avoid using barrier or hormonal this method from a number of reference books — the most com- methods of contraception prehensive of which is Taking Charge of Your Fertility.18 Courses • couples who wish to increase the effectiveness of barrier may be given in the community, although potential users should methods or withdrawal during the fertile phase be aware that some organizations teach natural family planning • couples for whom an accidental pregnancy would be within a religious context and do not condone the use of barrier methods as an adjunct to this method (e.g., the Serena organiza- Please note: One additional indication for LAM is being post- tion). This organization uses a couple-to-couple approach to teach partum which is a contra-indication for the other natural fam- the Symptothermal method of NFP within a religious framework. ily planning methods.
When fertility signs are difficult to assess (such as in the presence of a vaginal discharge), either barrier contraceptives or abstinence should be used. A woman who has intercourse with-in the fertile period could use emergency contraception.
Natural family planning may not be a suitable option for The Billings ovulation method is taught by Billings certi- • couples who are unwilling or unable to be diligent about fied instructors who work within the framework of the Roman observing and charting the signs of fertility, and about Catholic Church.
complying with the rules to prevent pregnancy • women whose menstrual cycles are erratic • women post-partum (except for LAM)• women who have difficulty assessing cervical mucus Couples who chose NFP should be counselled about emergency because of vaginal infection or use of vaginal agents (e.g., lubricants, spermicides) 1. Lamprecht V,Trussell J. Natural family planning effectiveness: evaluating Women who monitor or chart their fertility signs often have published reports. Adv Contracept 1997;13:155–65.
greater awareness of their own gynaecological health and are 2. Stanford JB,White GL, Hatasaka H.Timing intercourse to achieve pregnancy: current evidence. Obstet Gynecol 2002;100:1333–41.
better able to discern the difference between normal and 3. World Health Organization. Improving access to quality care in family abnormal cervical secretions. As well, charting fertility signs planning: medical eligibility criteria for contraceptive use. 2nd ed.
can alert women to factors that may contribute to infertility, Geneva:WHO; 2001.
such as anovulation.4 Incorporating this information into fam- 4. Guillebaud J. Contraception: your questions answered. 3rd ed.
Edinburgh: Churchill Livingstone; 1999. p. 23–37.
ily planning programs generally would greatly benefit 5. Dunson DB, Sinai I, Colombo B.The relationship between cervical secretions and the daily probabilities of pregnancy: effectiveness of thetwo-day algorithm. Hum Reprod 2001;16:2278–82.
6. Aravalo M, Sinai I, Jennings V. A fixed formula to define the fertile win- RISKS AND SIDE EFFECTS
dow of the menstrual cycle as the basis of a simple method of naturalfamily planning. Contraception 1999;60:357–60.
There is a high probability of failure with all fertility aware- 7. Hatcher RA,Trussell J, Stewart F, Cates W, Stewart GK, Guest F, et al., ness methods if they are not used consistently and correctly.
editors. Contraceptive technology. 17th ed. New York: Ardent Media;1998. p. 309–23.
Also, for the protection against STIs condoms need to be used 8. Health Canada. Listing of medical devices licenses. Available on-line at in addition to NFP. <http://www.pigscanfly.ca/ adouglas2/CMBES_Website_pages/daffodil.hc-sc.gc.ca_8080/adouglas/CMBES_healthcanada_page.html>.Web siteupdated September 25, 2003. Accessed February 10, 2004.
MYTHS AND MISCONCEPTIONS
9. May K. Monitoring reproductive hormones to detect the fertile period: development of Persona – the first home-use system. Adv Contracept 1. Most women know when they are fertile.
Fact: Numerous studies have shown that many women are not 10. Pyper CM, Knight J. Fertility awareness methods of family planning: the physiological background, methodology, and effectiveness of fertility well informed about when they are fertile during each month.17 awareness methods. J Fam Plann Reprod Health Care 2001;27:103–9.
2. NFP is unreliable.
11. Bonnar J, Flynn A, Freundl G, Kirkman R, Royston R, Snowden R. Per- Fact: These methods can be quite reliable when used sonal hormone monitoring for contraception. Br J Fam Plann 1999;24:128–34.
correctly. The World Health Organization cites a failure rate 12. Bonnar J, Freundl G, Kirkman R. Personal hormone monitoring for of 20% for common use and 1% to 9% for perfect use.3 contraception. Br J Fam Plann 2000;26:178–9.
13. Trussell J. Contraceptive efficacy of the personal hormone monitoring transmitted infection (STI). system Persona. Br J Fam Plann 1999;24:134–5.
Women who need to avoid pregnancy should not rely on 14. Labbok MH, Hight-Laukaran V, Peterson AE, Fletcher V, von Hertzen H, Van Look PF. Multicenter study of the lactational amenorrhea method this method alone.
(LAM): 1. efficacy, duration and implications for clinical application.
15. Institute for Reproductive Health. Guidelines: breastfeeding, family planning and the lactational amenorrhea method (LAM). Washington,DC: Georgetown University, Department of Obstetrics and Gynecology There are no costs involved. Theoretically, withdrawal re- (2115 Wisconsin Avenue NW, 6th Fl., 20007); 1994. p. 3–5.
duces the risk of male-to-female transfer of human immuno- 16. Kennedy KI,Visness CM. Contraceptive efficacy of lactational amenor- deficiency virus (HIV) because the virus is concentrated in rhoea. Lancet 1992;339:227–30.
17. Seidman M. Requirements for NFP service delivery: an overview.
Adv Contracept 1997;13:241–7.
18. Weschler T. Taking charge of your fertility: the definitive guide to RISKS AND SIDE EFFECTS
natural birth control, pregnancy achievement, and reproductive health.
Revised ed. New York: Quill, Harper Collins; 2002.
Use of withdrawal requires self-control. The man must have the 2. COITUS INTERRUPTUS (WITHDRAWAL)
ability to recognize impending ejaculation and to resist the urgeto pursue coital movement. Theoretically, the pre-ejaculate contains no spermatozoa.
One study has shown the presence of a small number of Coitus interruptus is probably more widely used for contracep- clumped spermatozoa in the pre-ejaculate, presumably from a tion than is acknowledged. Up to 9% of sexually active women in prior ejaculation.5 In HIV-infected men, the pre-ejaculate may Canada report using withdrawal as a method of contraception.1 contain HIV-infected cells.6 Other STIs may also be transferred, Family planning professionals and survey respondents may not if they are transmitted by mucosal or skin contact. regard coitus interruptus as a legitimate contraceptive method, andmay therefore fail either to ask about or to acknowledge its use. It MYTHS AND MISCONCEPTIONS
is widely used in both developed and developing countries.2 1. Withdrawal is not an effective method of contraception. Fact: This method is widely used around the world and canbe effective if followed carefully. It is difficult to accurately assess the effectiveness of this method 2. The pre-ejaculate contains enough sperm to achieve a because data are lacking.3 Failure rates for the first year of using withdrawal have been described as 4% with perfect use and Fact: Although there have been few studies in this area, exist- 19% with typical use, although the estimate of failure with typ- ing research suggests that the pre-ejaculate does not contain ical use is probably high.4 MECHANISM OF ACTION
During coitus the male withdraws the penis from the vagina Health care providers should make people aware that withdrawal prior to ejaculation.
should not be used permanently. Other options of contraceptionshould be offered. The patient should know about all the risks involved since the withdrawal requires considerable self-control.
Withdrawal may be a contraceptive option when • no other contraception is available • the couple prefers to avoid hormonal, barrier, and per- The couple should be counselled about emergency contracep- manent methods of contraception tion, should there be inadvertent contact between the ejaculate • religious considerations preclude the use of other methods and the vagina or external genitalia.
• intercourse is infrequent 1. Fisher W, Boroditsky R, Morris B.The 2002 Canadian contraception study. J Obstet Gynaecol Can. In press 2004.
Since intromission occurs, this method of contraception 2. Gillebaud J. Contraception: your questions answered. 3rd ed. Edinburgh: should not be used if there is a known risk of sexually Churchill Livingstone; 1999. p. 39–43.
3. Rogow D, Horowitz S.Withdrawal: a review of the literature and an deliberately choose to abstain at a number of times throughout agenda for research. Stud Fam Plann 1995;26:140–53.
4. World Health Organization. Improving access to quality care in family planning: medical eligibility criteria for contraceptive use. 2nd ed.
5. Pudney J, Oneta M, Mayer K, Seage G, Anderson D. Pre-ejaculatory fluid as potential vector for sexual transmission of HIV-1. Lancet 1992;340:1470.
Both partners in a relationship should choose this method to 6. Zukerman Z,Weiss DB, Orvieto R. Does pre-ejaculatory penile secre- avoid frustration on the part of one.
tion originating from Cowper's gland contain sperm? J Assist ReprodGenet 2003;20(4):157–9.
Non-contraceptive benefits of abstinence include • freedom from the threat of STI and HIV infection if there is no exchange of body fluids • no physical side effects Abstinence is defined by some as refraining from all sexual • no need to visit a health-care provider. However, health- behaviour, including masturbation; by some as refraining from care providers can offer valuable support, information, sexual behaviour involving genital contact; and by others as and alternative options should individuals wish to con- refraining from penetrative sexual practices.1 sult about this method Giving and receiving sexual pleasure without penetration is • no cost, unless condoms and dams are used an important part of sexual expression for both men andwomen and is effective in decreasing the risk of sexually trans- RISKS AND SIDE EFFECTS
mitted infection (STI) and pregnancy. Risks and side effects include concern that abstinence • may be too restrictive for some couples• does not encourage the use of other methods of contra- If the goal of abstinence is to avoid unwanted pregnancy, this ception, if behaviour patterns change method is very effective and allows people to be involved inother forms of sexual expression without increasing the risk of MYTHS AND MISCONCEPTIONS
pregnancy. However, if the goal is to avoid STIs, then oral-genital sex, anal-genital sex, and other activities that expose the 1. "Just say no," or abstinence-only education, is an effective partner to pre-ejaculatory fluid, semen, cervical-vaginal secre- approach to sex education for young people.
tions, or blood must be avoided.
Fact: No abstinence-only sex education program has been Although very few cases of human immunodeficiency shown to increase the likelihood that young people will delay virus (HIV) transmission have been reported if the only trans- first intercourse for any longer than those who do not receive mission of fluid has been during oral sex,2,3 it is possible to such programs.6 This is in contrast to the results of "absti- transmit gonorrhea, syphilis, hepatitis B, herpes simplex virus, nence-plus" programs that strongly encourage youth to be and chlamydia by mouth-to-penis contact (fellatio).4 Mouth- abstinent but also encourage youth to use condoms and con- to-vulva contact (cunnilingus) can transmit herpes and traceptives if they do have intercourse; these programs have been found to delay first intercourse for an appreciable timeperiod.6 Many studies with very strong research designs have demonstrated that programs with common characteristics,(such as that they clearly focus on reducing specific sexual The use of a dry latex condom during fellatio or a dam during risk-taking behaviours, provide directly relevant informa- cunnilingus can be effective. Spermicidal condoms are not rec- tion, give students the opportunity to develop the motiva- ommended, since they are unlikely to provide better protection, tion and personal insight to use the information, and help and the taste is very often unpleasant.
them develop the necessary behavioural skills), can delay sex-ual intercourse, reduce its frequency, and increase use of con- doms and other contraceptives.7,8 2. Once people have had sexual intercourse, they will not will- Primary abstinence (i.e., abstaining from some or all sexual ingly choose abstinence.
behaviour by a person who has not yet been sexually active) is Fact: Once young men and women have satisfied their initial not uncommon among young people. Indeed, people of all ages curiosity about intercourse, and once they feel socially comfortable with their level of sexual sophistication, they may decide to become abstinent, removing themselves at least tem- 1. Health-care providers should respect the choice of a nat-
porarily from the health risks of intercourse. Health-care ural family planning method and be able to provide
providers can help young people learn that the door between resources to support the correct use of this method.
abstinence and sexual activity opens in both directions.1 (Grade C)
2. The use of coitus interruptus ("withdrawal") should be
recognized as a risk-reduction strategy. When couples use
coitus interruptus or other natural family planning
Asking individuals what they define as abstinence is an impor- methods, health-care providers should provide informa-
tant question with clinical implications. tion about emergency contraception. (Grade C)
Couples and individuals practising abstinence deserve 3. Health-care providers should acknowledge and legitimize
respect, encouragement, and non-judgemental support. They abstinence as a valid contraceptive choice. (Grade B)
should be offered education about other methods of birth con- 4. Comprehensive sex education should be available to all
trol and safer sex to help them if their sexual agenda changes.
Canadians. Education programs should provide infor-
Assisting with communication skills to transmit intentions to mation on abstinence as well as on contraception and
partners can be valuable, especially for young people. Those STI prevention. (Grade B)
who practise abstinence should be informed about emergency 5. Health-care providers should be able to counsel postpar-
contraception and its availability in their community.
tum women about the contraceptive efficacy and correct
use of the lactational amenorrhea method. (Grade A)
Health-care providers should determine with those choosingabstinence why they made this choice, what sexual activities 1. Hatcher RA,Trussell J, Stewart F, Cates W, Stewart GK, Guest F, et al., editors. Contraceptive technology. 17th ed. New York: Ardent Media; they will say "yes" to, and whether they have discussed these 1998. p. 297.
with their partner. It is important to help them avoid high-pres- 2. Bratt GA, Berglund T, Glantzberg BL, Albert J, Sandstrom E.Two cases sure sexual situations and teach them techniques for saying "no." of oral-to-genital HIV-1 transmission. Intl J STD AIDS 1997;8:522–5.
It is also important to suggest that condoms be readily avail- 3. Robinson ED, Evans BG. Oral sex and HIV transmission. AIDS 1999; able in case they change their minds; in addition, they must be 4. Edwards S, Carne C. Oral sex and transmission of non-viral STIs. Sex aware of options for emergency contraception.
Transm Infect 1998;74(2):95–100.
5. Ostergaard L, Agner T, Krarup E, Johansen UB,Weismann K, Gutschik E.
PCR for detection of Chlamydia trachomatis in endocervical, urethral, rectal, and pharyngeal swab samples obtained from patients attendingan STD clinic. Genitourin Med 1997;73(6):493–7.
1. Natural family planning methods may provide effective con- 6. McKay A. Common questions about sexual health education. SIECCAN (Sexuality Information and Education Centre Canada) Newsletter, traception when used diligently and selectively. (Level II-2) Summer 2000;35:1.
These methods may be appropriate methods of contra- 7. Kirby D. Do abstinence-only programs delay the initiation of sex among ception for couples who are willing to accept a potentially young people and reduce teen pregnancy? Washington, DC: National higher rate of contraceptive failure. (Level III) Campaign to Prevent Teen Pregnancy; 2002.
8. Fisher WA, Fisher JD. Understanding and promoting sexual and repro- 2. Fertility awareness may be used in combination with non- ductive health behaviour: theory and method. Annu Rev Sex Res hormonal methods of contraception to enhance the effec- 1998;9: 39–76.
tiveness of these other methods. (Level III) 3. Coitus interruptus ("withdrawal") is preferable to no con- CHAPTER 10: STERILIZATION
traception at all, but failure rates may be high and it does notprovide protection against STIs. (Level II-2) Claude A. Fortin, MD, FRCSC,1 Edith Guilbert, MD, MSc2
4. The lactational amenorrhea method is an effective method of contraception for the first 6 months postpartum in women who are exclusively breastfeeding and have not yetresumed menstrual cycling. (Level II-2) 5. Abstinence is a valid contraceptive choice. Although pro- grams have been introduced to promote abstinence among It is important that individuals who consult for sterilization young people, there is no evidence that abstinence-only pro- want no more children, or want to remain childless, and they grams are successful in delaying first intercourse among ado- need a highly effective contraceptive method. To make an lescents. (Level I) informed decision, these individuals should have an accurate understanding of sterilization and should consider their own laparoscopically are the application of tubal clips or rings, or needs and those of their family. The decision should be made electrocautery of a portion of tube.
without pressure or coercion from anyone else.1 Interval sterilizations may also be performed via a small ("mini") laparotomy incision, or they may be performed at the time of a laparotomy done for an unrelated indication.
With a laparotomy approach, any of the laparoscopic tech- niques for occlusion may be used; more commonly, an inter-vening segment of tube is excised and the ends ligated (the Although in theory tubal ligation will prevent pregnancy Pomeroy method). The vaginal colpotomy approach to inter- absolutely, conceptions do occur. Failure of tubal ligation con- val tubal ligation has now been largely abandoned because of tinues to occur well beyond the first year after surgery, and at increased risks of infection and post-sterilization failure and 10 years post-surgery, the overall figure rises to 1.8%.2 In one Canadian province, the failure rate of tubal ligation at 20 The frequency of concurrent sterilization and abortion is unknown, but effective counselling is mandatory and has to be The 10- and 20-year cumulative probabilities of failure are provided with expertise.8 affected by age at tubal ligation. The probability of failure for Post-partum sterilization must also be performed after care- women sterilized at age 28 or less is greater than for women ster- ful counselling. Post-partum sterilization should be performed ilized beyond age 34, for all methods of sterilization except for either within 7 days of delivery or postponed until at least 4 interval partial salpingectomy.2,3 Tubal ligation performed vagi- weeks after delivery.9 Usually a tubal excision method will be nally may be technically difficult, and may therefore carry a used rather than an occlusive method. Tubal ligation may also higher chance of failure. A New Zealand review4 described a be performed by an excisional technique at the time of Cae- failure rate after vaginal tubal ligation of 4.8%, compared with sarean section. If partial salpingectomy is performed, the a rate of 1.2% after Filshie clip application, 1.4% after applica- superior long-term success appears to be higher.2 tion of Falope rings, and 3.4% after application of Hulka clips.
Two randomized controlled trials comparing use of Hulka and Filshie clips for sterilization showed 24-month cumulative preg-nancy rates of 28.1/1000 women and 9.7/1000 women, respec- As of 2002, a new transcervical approach for tubal occlusion tively — although this difference was not statistically has gained popularity and received acceptance by the Cana- significant.5 The World Health Organization cites a failure rate dian Therapeutic Products Directorate and the U.S. Food and after tubal ligation of 0.5%.6 Drug Administration.10 It is a method of sterilization thatinvolves accessing the tubes through hysteroscopic or blind MECHANISM OF ACTION
placement of a device or occlusive material that blocks thetubes.
Tubal ligation techniques result in the occlusion of the fallopi- The procedure offers numerous potential advantages over an tubes, preventing the ovum and spermatozoa from meeting.
other sterilization methods: no incision is required; it is per- The choice of occlusion method depends upon the sur- formed under local anaesthesia or minimal sedation, in an office geon's training, personal experience, and the technical facilities.
setting with a rapid recovery; and it has been shown to be high- It will also depend on whether the sterilization is performed ly reliable and cost-effective.11 However, health professionals remote from a pregnancy (interval sterilization), or post-abor- need special training to perform this technique, and women tion, or post-partum.
must use another method of birth control for at least 3 months Interval sterilizations are most commonly performed via before the technique is felt to be fully reliable.
laparoscopy. The techniques used for tubal ligation performed The only device available for clinical use in Canada is the Essure System. The device consists of an expandable outer niti- Table 1. 10-Year Failure Rates (Crest Study)2
nol coil, containing polyester fibres and a stainless steel innercoil that dynamically expands into the proximal portion of the fallopian tube. Over a 3 month period, tissue grows over the Bipolar tubal coagulation 2.48 (1.63–3.33) device to occlude the tubes completely. In women in whom Unipolar tubal coagulation 0.75 (0.11–1.39) 1.77 (1.01–2.53) both tubes were accessible and the devices properly placed, no Spring clip (Hulka) 3.65 (2.53–4.77) pregnancies and a low complication rate have been reported.11 Interval partial salpingectomy 2.01 (0.47–3.56) Other transcervical approaches are currently under differ- Postpartum partial salpingectomy 0.75 (0.27–1.23) ent phases of trials or animal studies. These include the Adiana 1.85 (1.51–2.18) system, the Intratubal Ligation Device, and the use of quinacrine pellets or erythromycin tablets for tubal occlusion.12 lihood of expressing regret, requesting information about rever- Effects of the presence of any of these devices on the success of sal of sterilization, and obtaining reversal, increase over the years subsequent in vitro fertilization are unknown.
following sterilization.3,18-21 During a follow-up interview with-in 14 years of tubal sterilization, 20.3% of women who have been sterilized before age 30 expressed regret about undergoingthe procedure, compared to 5.9% of those sterilized after age Assessing the needs of individuals who consult for a steriliza- 30.18 The probability of reversal in one Canadian province, over tion procedure is crucial, because the procedure should be 20 years, was respectively 4.2% and 3.9% for women and men considered permanent. Reversal of sterilization, although fea- who were sterilized before age 30, and 0.4% and 1.0% for those sible, is difficult to obtain, involves riskier surgery than ster- sterilized in their late 30s.3 Other known risk factors for regret ilization itself, is expensive, and often does not succeed in and reversal are having young children; experiencing couple restoring fertility.13,14 There are contraceptive methods other disharmony; and being sterilized at the time of Caesarean sec- than sterilization that are easily available to both men and tion or shortly after delivery, spontaneous or induced abor- women, and the sterilization procedure may have unwanted tion.3,18-24 Common reasons given for requesting reversal are: side effects.
"did not receive enough information," "was pushed into this Health care providers should be aware of the legal require- procedure," sexual side effects from sterilization, the establish- ments for obtaining informed consent for sterilization, includ- ment of a new relationship, improvement in housing or finan- ing an explanation of benefits and risks, options, and cial circumstances, or the loss of a child.22-24 determination of whether the person is competent to under-stand the information.15 When the person has a mental dis- ability, it is even more difficult for the physician to determinetheir capacity to provide informed consent.16 Contraceptive Tubal ligation, although somewhat invasive, provides women sterilization of an incompetent, mentally disabled person is with a very private and cost-effective method of contraception, with no significant long-term side effects, no compliance issues,and no interference with intercourse.
WITH THE TRANSCERVICAL PROCEDURE
Since reversibility of this procedure is virtually impossible, The following are possible short-term side effects from tubal appropriate counselling is extremely important. Women with uterine or tubal disease, who are ambivalent about sterilization, • shoulder tip pain secondary to usage and remaining of or who feel uncomfortable about having a device or materials some gas (CO ) inside the peritoneal cavity inserted into their fallopian tubes should not be offered this • lower abdominal pain or cramps technique. Women who have a contraindication to laparoscopic • bruising, bleeding from incisions sterilization (obese or severe medical conditions), and who are • post-operative nausea and light-headedness over age 30 with no uterine or tubal anomaly, might be eligiblefor transcervical sterilization. Long-term efficacy and potential hidden side effects are not known for this method.
The incidence of complications depends on the procedure per-formed (laparoscopy or laparotomy, mechanical or thermal), The following are considered contraindications to performing the anaesthesia used (local or general), and the experience of the 1. systemic health problems, especially cardiopulmonary con- Potential complications include the following: ditions that may be aggravated by general anaesthesia • anaesthesia-related risks 2. pregnancy (unless the sterilization procedure is done at the • wound infection time of abortion or immediately postpartum) 3. the presence of pelvic infection, or inability to access the fal- • hematoma formation lopian tubes at surgery • urinary complications 4. uncertainty about whether permanent contraception is • mesosalpingeal tears and trans-section of the tube from ring or clip application (may require laparotomy to con- The major concern with sterilization is regret. The cumulative like- • mechanical trauma, including uterine perforation with Fact: A single study found an increased risk of hysterectomy in women who underwent sterilization between the ages of • injury to blood vessels, intestines or other organs (inci- 20 and 29, but not among women sterilized over the age of dence approximately 0.6 per 1000 cases).25 Bowel burns 30.33 No biological basis for these results has been found.33,34 complicating tubal electrocoagulation may result indelayed perforation and peritonitis.
POTENTIAL RISKS WITH USE OF THE
Taking a medical and a contraceptive history is essential. Key elements in the medical history are the patient's age, marital sta- Some risks that are possible with the transcervical procedure tus, spouse's age, type of relationship, number and age of chil- include the following: dren, contraceptive experience, reasons for sterilization, and • perforation or dissection of fallopian tube or uterine cornu systemic health problems. The medical history will emphasize • uterine perforation by the hysteroscope any history of pelvic disease, previous abdominal or pelvic • placement of micro-insert into the myometrium or into surgery, heart or lung disease, bleeding problems, allergies, med- ication, and previous problems with general anaesthesia.
• subsequent procedures such as electrocautery, endome- A complete physical examination must be performed short- trial biopsy, dilatation and curettage, or endometrial abla- ly before sterilization.
tion potentially could dislodge a micro-insert or interrupt Laboratory evaluation may be limited to measurement of its ability to prevent pregnancy11 haemoglobin level. Effective contraception must be used untilthe time of the tubal ligation.
Since post-sterilization regret is common, careful pre-surgery counselling with awareness of risk factors is essential. Informa- tion about the type of operation — including risks and benefits, Ectopic pregnancy should be ruled out whenever a woman the availability of alternative methods of family planning, the shows signs of pregnancy following tubal occlusion. The possibility of failure, and the possibility of reversal — must all CREST study demonstrated a 10-year cumulative probability be discussed so that the individual can provide informed con- of ectopic pregnancy of 7.3 per 1000 women for all methods sent for surgical sterilization. A consent document, readily under- combined.2 A report from Korea of ectopic pregnancies fol- standable in the individual's own language, must be signed. It is lowing sterilization showed an approximately 3-fold greater inci- recommended that the sterilization be performed a few weeks dence of ectopic pregnancies after electro-coagulation than after after the initial interview, to allow more consideration of the the use of silastic rings or clips.26 Ectopic pregnancy was most choice of sterilization. Written information may be useful.
often related to the following: utero-peritoneal fistula afterunipolar electro-coagulation; inadequate coagulation or recanal- ization after bipolar procedures; recanalization or fistula for-mation after Pomeroy, tubal ring, or clip procedures.27 REVERSAL
Reversal of tubal ligation requires major surgery and special sur-
MENSTRUAL PATTERN CHANGES
gical skills. Some women are not appropriate candidates because Abnormal menstrual patterns have been thought to occur fol- of the way the sterilization was performed. Success cannot be lowing sterilization, and a "post-tubal ligation syndrome" has guaranteed and reversal surgery is usually expensive. There are been proposed. There is no supportive evidence.28-31 operative risks due to anaesthesia and the usual risks of major A recent review of the literature comparing sterilized and abdominal surgery. The risk of ectopic pregnancy is about 5% control women found no difference in hormones levels and lit- following reversal surgery and depends on the type of tubal lig- tle difference in menstrual cycle characteristics.32 ation.2 Pre-reversal assessment includes exclusion of male pos-sible infertility factors, female ovulation disorders and laparo- scopic assessment of the tubal segments.
No evidence of psychological problems or detrimental long- Rates of subsequent term delivery vary, but they are high- term effects on sexuality has been demonstrated.
est after reversal of occlusion techniques that damage a smallsegment of the tube (such as with a tubal clip or ring) and low- MYTHS AND MISCONCEPTIONS
est after electrocoagulation. (See Table 2.) The occurrence ofectopic pregnancy after reversal surgery may be due to pre-exist- 1. The risk of having a hysterectomy is increased after tubal ing abnormal tubal function, or to factors arising from the sur- gical technique used. In vitro fertilization (IVF) may be an option for women who are poor candidates for reversal • No-scalpel vasectomy38,47 is done through a tiny punc-
ture opening in the scrotal skin; the rest of the tech-nique is identical to the conventional procedure. No skin IN VITRO FERTILIZATION AND FAILED REVERSAL
sutures are needed. The operating time is reduced to In 37 couples in whom reversal of sterilization either failed or about one-half of the time of the conventional method.38 was not attempted, the probability of pregnancy after IVF relat- Other approaches to male sterilization involve percutaneous ed more to patient age than to previous fertility. Compared to chemical occlusion of the vas,48 or use of silver, silicone rub- a control group of women with tubal pathology, women who ber–silver, or tantalum ring clips — the latter of which is underwent tubal ligation below age 38 produced a similar num- compatible with reversible vasectomy.1,47 ber of oocytes and an identical number of embryos for transfer.26 This method is suitable only for men who seek a permanent method of contraception.
Pregnancy rates following vasectomy vary from 0% to 2.2% with any occlusion method.35,36 No carefully controlled stud-ies have compared the different occlusion methods.36 Contraindications of the vasectomy include the following: Failure rate of vasectomy is also measured through the occur- 1. systemic health problems, such as allergy to local anaesthet- rence of recanalization. Because spermatozoa persist in the sem- ics, immunosuppression, acute infectious diseases, or coagu- inal vesicles, and thus in the ejaculate, for 2 to 3 months or 10 to lation problems that cannot be controlled with vasopressin 30 ejaculations after vasectomy, recanalization cannot be assessed 2. local infection before such time or number of ejaculations have passed.37,38 3. local genital abnormalities impairing adequate localization Recanalization occurs in up to 2.6% of cases within 3 months of the vas deferens, such as hernia, varicocele, hydrocele, or after vasectomy.35-37,39-42 It is important to realise that the main reason for conception post-vasectomy is the failure of couples to 4. uncertainty about permanent contraception use back-up contraception immediately after the procedure.35,36 5. sexual dysfunction Use of an electrocoagulation technique,40,41 fascial inter- position,41,43 removing a larger piece of vas,40 and experience on the part of the physician44 may increase the efficacy of vasec-tomy, although well-controlled trials are yet to be done to con- Vasectomy provides the same advantages as tubal ligation. In firm the importance of these factors. Sterile water irrigation of addition, it is a simple intervention with very few complica- the vas deferens does not seem to increase efficacy or reduce the tions, is easy to perform and to obtain, and does not require possibility of lingering sperm.45,46 MECHANISM OF ACTION
RISKS AND SIDE EFFECTS
There are 2 principal techniques for vasectomy: SIDE EFFECTS
• Conventional vasectomy1 involves making 1 or 2
The side effects of the vasectomy include incisions in the scrotal skin; exposing, isolating, and divid- • local pain and ing the vas; removing a 1.5-cm segment from each side; • scrotal ecchymosis and swelling.
sealing the ends of the vas with non-absorbable suture,cautery-induced burn, or clips; and finally closing the scrotal incision.
The following complications are less common with the no-scalpel vasectomy38 and the use of suturing clips49: Table 2. Probability of Pregnancy Following Reversal of Tubal
• vasovagal reaction: up to 30%50,51 • hematoma: 1% to 10%40,44,49-51 Pregnancy Rate (%)
• infection38,40,44,51: 0.4% to 16% (from mild erythema and stitch abscess to fulminant Fournier's gangrene)52 • granuloma formation from extruded sperm, either at the vas or in the epididymis: 1% to 50%40,42,51; this is Monopolar cautery reduced when the proximal vas is left open.53,54 It pre- disposes to recanalisation51 and may cause significant pain results is likely to be explained by bias, such that the stud- with palpation or during intercourse and ejaculation ies with bias operating will have higher risk estimates than • epididymitis and vasitis: 0.1% to 8%49,51,55 those in which the bias has been adequately controlled.36To date, there is no obvious biological mechanism for a rela- tionship between vasectomy and prostatic cancer,75,78 and, • congestive epididymitis (reduced with open-ended vasec- overall, the weight of evidence suggests that there is no asso- • congestive orchalgia51• vasocutaneous fistula51 • hydrocele49• missed vas deferens or damage to scrotal structures49,51 Taking a medical and a contraceptive history is essential. Key • impotence and depression, which usually respond to psy- elements in the medical history are the patient's age, marital sta- chological treatment51; improved psychosexual adjust- tus, spouse's age, type of relationship, number and age of chil- ment and enjoyment is usually reported following dren, contraceptive experience, reasons for sterilization, systemic health problems, and use of medication that may affect coagu-lation. It is important to inquire about genital anomalies or dis- eases and about sexual dysfunction. Examination of the genitalarea is usually sufficient. Other tests and examinations are done if medically necessary. Measurement of haemoglobin is usually It is now well documented that one-half to two-thirds of vasec- unnecessary for men before vasectomy.
tomized men develop circulating antibodies to sperm after Use of effective contraception is warranted until the time vasectomy,57 and that antibodies may persist for as long as 10 semen analysis shows no spermatozoa. Since post-sterilization years after surgery.58 However, several studies55,57,58 did not regret is common, careful pre-surgery counselling to ensure report any other laboratory abnormalities, nor immunological awareness of risk factors is essential. Information about the type diseases of any kind.57,59,60 of operation — including risks and benefits, the availability ofalternative methods of family planning, the possibility of fail- ure, and the possibility of reversal — must all be discussed so Following the identification of a marked increase of atheroscle- that the individual can provide informed consent for surgical rosis in vasectomized cynomolgus monkeys fed high-cholesterol sterilization. A consent document, readily understandable in diets,61,62 several large studies (more than 4000 men with obser- the individual's own language, must be signed. It is recom- vation over 20 years)59,60,63 explored the possible relationship mended that the sterilization be performed a few weeks after between cardiovascular diseases and vasectomy. None found any the initial interview, to allow more consideration of the choice significant association, and the estimates of relative risk were of sterilization. Written information may be useful.
always near the reference point.59,60,63-68 Stroke is the only vas-cular disease still requiring more long-term studies; at the pre- sent time, there does not seem to be any increased risk of strokein vasectomized men.36,58 No sports or physical strain should be undertaken for 7 dayspost-operatively; sexual intercourse is prohibited for 5 days, and local or systemic analgesia (ice pack, acetaminophen) can be Although a few studies reported an association between vasectomy used if necessary. Post-operative warning signs should be and testicular cancer,69-71 most large studies did not find evidence described, specifically extended scrotal edema, severe pain, or of any risk of testicular cancer in vasectomized men.36,58,59,72,73 fever. The physician should be made aware as quickly as possi-ble if any of these conditions are present.
MYTHS AND MISCONCEPTIONS
Standard practice is to require 2 consecutive azoospermic samples, usually at 3 and 4 months, to confirm success.79 1. Vasectomy increases the risk of prostate cancer.
If the semen analysis shows the presence of motile sperma- Fact: In population-based or hospital-based case-control tozoa in 2 consecutive samples, 3 months or more after vasec- studies, odds ratios for the risk of prostate cancer in vasec- tomy, a repeat procedure is required.44 tomized men ranged from 0.5 to 6.7,36,74-76 while in large If the semen analysis shows the presence of non-motile sper- cohort studies the relative risks varied from 0.8 to 2.1.36,77 matozoa, one year or more after surgery, a cautious assurance The findings concerning the association between vasectomy of sterilization can be given36; annual semen tests may be under- and prostate cancer suggest that the heterogeneity of study taken for additional reassurance.42 choice of procedure is made. (Grade A)
2. Before recommending a transcervical sterilization (cor-
nual occlusion technique), extensive counselling should
Vasectomy reversal may be performed under local, regional, or be offered and the permanence of the procedure rein-
general anaesthesia.14 Various techniques are used (vasovasos- forced. (Grade B)
tomy or vasoepididymostomy, microsurgery or macrosurgery, 3. Counselling before sterilization should include discus-
one-layer or two-layer), and success depends on the patency of sion of alternative contraceptive methods. Counselling
both ends of the vas and on the sperm quality.14,80 The sperm should address the risks, complications, potential for
count rises slowly after vasectomy reversal, and usually reaches regret, and failure rates associated with the procedure.
a plateau by 6 months after surgery. The chance of effective (Grade B)
recanalization and pregnancy declines with increasing time from 4. New techniques of female and male sterilization should
the original procedure14,80 (see Table 3); however, even after pro- be available to all Canadians. (Grade C)
longed obstructive intervals or in men with older female part-ners,81 vasectomy reversal may offer comparable success rates to intracytoplamic sperm injection. Before performing vasec-tomy reversal, counselling should focus on the fertility poten- 1. Liskin L, Benoit E, Blackburn R. New opportunities, population reports: tial of the partner, potential complications, the probability of Series D, No. 5. Baltimore: John Hopkins University, Population Informa-tion Program; March 1992.
success of the reversal, and cost-effectiveness.
2. Peterson HB, Xia Z, Hughes JM,Wilcox LS,Tylor LR,Trussell J.The risk of pregnancy after tubal sterilization: findings from the U.S. Collab- orative Review of Sterilization. Am J Obstet Gynecol 1996;174(4):1161–8.
3. Trussell J, Guilbert E, Hedley A. Sterilization failure, sterilization reversal, 1. Vasectomy is a less invasive and more cost-effective steriliza- and pregnancy after sterilization reversal in Quebec. Obstet Gynecol tion procedure than conventional tubal ligation. (Level II-2) 2. Female sterilization using newer transcervical (cornual occlu- 4. Birdsall MA, Pattison NS,Wilson P. Female sterilisation; National Women's Hospital 1988–9. N Z Med J 1994;107:473–5.
sion) techniques is effective, safe, and less invasive (Level II-2), 5. Dominik R, Gates D, Sokal D, Cordero M, Lasso de la Vega J, but virtually impossible to reverse. (Level III) Remes Ruiz A, et al.Two randomized controlled trials comparing the 3. Although tubal ligation and vasectomy are considered safe Hulka and Filshie clips for tubal sterilization. Contraception 2000;62(4):169–75.
and very effective family planning methods, complications 6. World Health Organization. Improving access to quality care in family may occur and failure is possible, even several years after the planning: medical eligibility criteria for contraceptive use. 2nd ed.
procedure. (Level II-2) Geneva:WHO; 2001.
4. Regret after sterilization is not infrequent, and is likely to be 7. Miesfeld RR, Giarratano RC, Moyers TG.Vaginal tubal ligation: is infec- tion a significant risk? Am J Obstet Gynecol 1980;137(2):183–8.
associated with the following factors (Level II-2): 8. Westhoff C, Davis A.Tubal sterilization: focus on the U.S. experience.
• young age at the time of sterilization Fertil Steril 2000;73:913–22.
• having small children at the time of sterilization 9. Hatcher RA,Trussell J, Stewart F, Cates W, Stewart GK, Guest F, et al, editors. Contraceptive technology. 17th ed. New York, NY: Ardent • sterilization performed soon after delivery, Cesarean sec- Media; 1998.
tion, induced abortion, or the loss of a child 10. Association of Reproductive Health Professionals. ARHP clinical pro- • when there is discord in the relationship ceedings: clinical update on transcervical sterilization, May 2002. Avail-able on-line at <http://www.arhp.org/healthcareproviders/cme/onlinecme/sterilizationcp/index.cfm>.Web site updated February 25, 2003. Accessed February 5, 2004.
1. Couples choosing a sterilization procedure should be
11. Cooper JM, Carignan CS, Cher D, Kerin JF, Selective Tubal Occlusion informed that vasectomy carries fewer risks than tubal
Procedure 2000 Investigators Group. Microinsert nonincisionalhysteroscopic sterilization. Obstet Gynecol 2003;102:59–67.
ligation. However, social, cultural, and individual
12. Lippes J. Quinacrine sterilization: the imperative need for American considerations should be taken into account before a
clinical trials. Fertil Steril 2002;77:1106–9.
13. Neamatalla GS, Harper PB. Family planning counseling and voluntary sterilisation: a guide for managers. New York: Association of VoluntarySurgical Contraception; 1990. p. 70.
Table 3. Probability of Pregnancy Following Vasectomy
14. The American Fertility Society. Guideline for practice: vasectomy rever- sal.The American Fertility Society; August 15, 1992.
Sperm in the
15. Best K. Mental disabilities affect method options. Network Semen (%)
16. Wingfield M, McClure N, Mamers PM,Weigall DT, Paterson PJ, Healy Less than 3 years DL. Endometrial ablation: an option for the management of menstrual problems in the intellectually disabled. Med J Aust 1994;160:533–6.
17. Canadian Medical Association. Committee on Ethics. Statement on More than 14 years Contraceptive Sterilization of the Mentally Retarded. CMAJ 43. Rhodes DB, Mumford SD, Free MJ.Vasectomy: efficacy of placing the cut 18. Hillis SD, Marchbanks PA,Tylor LR, Peterson HB. Poststerilization vas in different fascial planes. Fertil Steril 1980;33(4):433–8.
regret: findings from the United States Collaborative Review of Steril- 44. Philp T, Guillebaud J, Budd D. Complications of vasectomy: review of ization. Obstet Gynecol 1999;93(6):889–95.
16,000 patients. Br J Urol 1984; 56:745–8.
19. Schmidt JE, Hillis SD, Marchbanks PA, Jeng G, Peterson HB. Requesting 45. Mason RG, Dodds L, Swami SK. Sterile water irrigation of the distal vas information about and obtaining reversal after tubal sterilization: find- deferens at vasectomy: does it accelerate clearance of sperm? a ings from the U.S. Collaborative Review of Sterilization. Fertil Steril prospective trial. Urology 2002;59:424–7.
46. Pearce E, Adeyoju A, Bhatt RI, Mokete M, Brown SCW.The effect of 20. Jamieson DJ, Kaufman SC, Costello C, Hillis SD, Marchbanks PA, perioperative distal vassal lavage on subsequent semen analysis after Peterson HB; US Collaborative Review of Sterilization Working Group.
vasectomy: a prospective randomized controlled trial. BJU Int A comparison of women's regret after vasectomy versus tubal steriliza- tion. Obstet Gynecol 2002;99(6):1073–9.
47. Li SQ, Goldstein M, Zhu JB, Huber D.The no-scalpel vasectomy. J Urol 21. Holman CD,Wisniewski ZS, Semmens JB, Rouse IL, Bass AJ. Population- based outcomes after 28,246 in-hospital vasectomies and 1,902 vasova- 48. Lian Y,Wang HX, Li H,Yu R, Lu Y,Wang Z. A 10-year follow-up study of sostomies in Western Australia. BJU Int 2000;86(9):1043–9.
1,086 cases of nonsurgical reversible vas occlusion. Fertil Steril 22. Potts JM, Pasqualotto FF, Nelson D,Thomas AJJR, Agarwal A. Patient characteristics associated with vasectomy reversal. J Urol 49. Leader AJ, Axelrad SD, Frankowski R, Mumford SD. Complications of 2,711 vasectomies. J Urol 1974;111:365–9.
23. Dubuisson JB, Chapron C, Nos C, Morice P, Aubriot FX, Garnier P.
50. Barnes MN, Bland JP, England HR, Gunn G, Howard G, Law B, et al. One Sterilisation reversal: fertility results. Hum Reprod 1995;10(5):1145–51.
thousand vasectomies. BMJ 1973;4:216–21.
24. Ekman Ehn B, Liljestrand J. A long-term follow-up of 108 vasectomised 51. Brownlee HJ,Tibbels KC.Vasectomy. J Fam Pract 1983;16(2):379–84.
men. Scand J Urol Nephrol 1995;29:477–81.
52. Patel, A, Ramsey JW,Whitfield HN. Fournier's gangrene of the scrotum 25. Lam A, Rosen DMB. Laparoscopic bowel and vascular complications: following day case vasectomy. J Roy Soc Med 1991;84:49–50.
should the veress needle and cannula be replaced? J Am Assoc Gynecol 53. Moss W. A comparison of open-end versus close-end vasectomies: a report on 6220 cases. Contraception 1992;46:521–5.
26. Sitko D, Commenges-Ducos M, Roland P, Papaxanthos-Roche A, 54. Denniston GC, Kuehl L. Open-ended vasectomy: approaching the ideal Horovitz J, Dallay D. IVF following impossible or failed surgical reversal technique. J Am Board Fam Pract 1994;7:285–7.
of tubal sterilization. Hum Reprod 2001;16(4):683–5.
55. Gupta AS, Kothari LK, Devpura MS.Vas occlusion by tantalum clips and 27. Adair CD, Benrubi GI, Sanchez-Ramos L, Rhatigan R. Bilateral tubal its comparison with conventional vasectomy in man: liability, reversibili- ectopic pregnancies after partial salpingectomy. J Reprod Med ty, and complications. Fertil Steril 1977;28(10):1086–9.
56. Janke L,Wiest WM. Psychosocial and medical effects of vasectomy in a 28. Geber S, Caetano JP. Doppler colourflow analysis of uterinal and ovari- sample of health plan subscribers. Int J Psychiatry Med 1976–77;7(1): an arteries prior to and after surgery for tubal sterilisation: a prospec- tive study. Hum Reprod 1996;11(6):1195–8.
57. Lepow IH, Crozier, R, editors.Vasectomy: immunologic and pathophy- 29. Taner CE, Hakverdi KU, Erden AC, Satici O. Menstrual disorders and siologic effects in animals and man. New York: Academic Press; pelvic pain after sterilisation. Adv Contracept 1995;11(4):309–15.
30. Ruifang W, Zhenhai W, Lichang L, Fenger Z, Xinglin G. Relationship 58. Ansbacher R. Humoral sperm antibodies: a 10-year follow-up of vas between prostaglandin in peritoneal fluid and pelvic venous congestion ligated men. Fertil Steril 1981;36:222–4.
after sterilization. Prostaglandins 1996;51(2):161–7.
59. Schuman LM, Coulson AH, Mandel JS, Massey FJ Jr, O'Fallon WM.
31. Hakverdi KU,Taner CE, Erden AC, Satici O. Changes in ovarian function Health status of American men: a study of post-vasectomy sequelae.
after tubal sterilisation. Adv Contracept 1994;10(1):51–6.
J Clin Epidemiol 1993;46(8):697–958.
32. Pati S, Cullins V. Female sterilization: evidence. Obstet Gynecol Clin 60. Nienhuis H, Goldacre M, Seagroatt V, Leicester G,Vessey M. Incidence of North Am 2000;27(4):859–99.
disease after vasectomy: a record linkage retrospective cohort study.
33. Stergachis A, Shy KK, Grothaus LC,Wagner EH, Hecht JA, Anderson G, et al.Tubal sterilization and the long-term risk of hysterectomy. JAMA 61. Alexander NH, Clarkson TB.Vasectomy increases the severity of diet- induced atherosclerosis in Macaca fascicularis. Science 1978;201: 34. Santow G, Bracher M. Long term risk of hysterectomy among 80,007 sterilized and comparison women at Kaiser Permanente, 1971–1987.
62. Alexander NH, Clarkson TB. Long-term vasectomy: effect on the Am J Epidemiol 1994;140:661–3.
occurrence and extent of atherosclerosis in rhesus monkeys. J Clin 35. Population Information Program.Vasectomy: safe and simple. Population Reports, Series D, No. 4. Baltimore: Johns Hopkins University; Novem- 63. Petitti DB, Klein R, Kipp H, Friedman GD.Vasectomy and the incidence ber/December 1983.
of hospitalized illness. J Urol 1983;129(4):760–2.
36. Schwingl PJ, Guess HA. Safety and effectiveness of vasectomy. Fertil 64. Walker AM, Jick H, Hunter JR, Dandford A, Rothman KJ. Hospitalization rates in vasectomised men. JAMA 1981;245:2315–7.
37. Richardson DW, Aitken RJ, Loudon NB.The functional competence of 65. Walker AM, Jick H, Hunter JR, McEvoy J.Vasectomy and non-fatal human spermatozoa recovered after vasectomy. J Reprod Fert myocardial infarction. J Urol 1983;130:936–7.
66. Perrin EB,Woods JS, Namekata T,Yagi J, Bruce RA, Hofer V. Long-term 38. Nirapathpongporn A, Huber DH, Krieger JN. No-scalpel vasectomy at effect of vasectomy on coronary disease. Am J Public Health the King's birthday vasectomy festival. Lancet 1990;335:894–5.
39. Alderman PM. General and anomalous sperm disappearance of sperm 67. Wallace RB, Lee J, Gerber WL, Clarke WR, Lauer RM. Vasectomy and after vasectomy. Fertil Steril 1989;51(5):859–62.
coronary disease in men less than 50 years old: absence of an associa- 40. Denniston GC.Vasectomy by electrocautery: outcomes in a series of tion. J Urol 1981;126:182–4.
2,500 vasectomies. J Fam Pract 1985;21(1):35–40.
68. Rosenberg L, Schwingl PJ, Kaufman DW, Helmrich SP, Palmer JR, 41. Esho JO, Cass AS. Recanalization rate following methods of vasectomy Shapiro S.The risk of myocardial infarction 10 or more years after using interposition of fascial sheath of vas deferens. J Urol 1978;120(2): vasectomy in men under 55 years of age. Am J Epidemiol 1986;123(6): 42. Alderman PM.The lurking sperm: a review of failures in 8879 69. Strader CH,Weiss NS, Daling JR.Vasectomy and the incidence of vasectomies performed by one physician. JAMA 1988;259(21):3142–4.
testicular cancer. Am J Epidemiol 1988;128:56–63.
70. Thornhill JA, Conroy RM, Kelly DG,Walsh JJ, Fitzpatrick JM. An evalua- abnormalities, and perinatal and maternal mortality.4 Contra- tion of predisposing factors for testis cancer in Ireland. Eur Urol ception should be recommended until menopause is confirmed 71. Cale AR, Farouk M, Prescott RJ,Wallace IW. Does vasectomy accelerate clinically (usually when amenorrhea has been present for 1 year).1 testicular tumour? Importance of testicular examination before and Most contraceptive options are open to women in peri- after vasectomy. BMJ 1990;300:370.
menopause. This section will discuss some of the considerations 72. Moller H, Knudsen LB, Lynge E. Risk of testicular cancer after vasecto- for perimenopausal women, but the details of the methods are my: cohort study of over 73 000 men. BMJ 1994;309:295–8.
73. Rosenberg L, Palmer JR, Zauber AG,Warshauer ME, Strom BL, Harlap S, located in the respective sections of these guidelines. The choice Shapiro S.The relation of vasectomy to the risk of cancer. Am J Epide- of method will be moderated by the possible desire for non- contraceptive benefits or the desire for permanent contraception.
74. Rosenberg, L, Palmer JR, Zauber AG,Warshauer ME, Stolley, PD, Shapiro S.Vasectomy to the risk of prostate cancer. Am J Epidemiol Women who are not in a steady relationship may choose an inter- mittent method and may need the protection against sexually 75. John EM,Whittemore AS,Wu AH, Kolonel LN, Hislop TG, Howe GR, transmitted infections (STIs) that a barrier method provides. et al.Vasectomy and prostate cancer: results from a multiethnic case-control study. J Natl Cancer Inst 1995;87:662–9.
76. Mettlin C, Natarajan N, Huben R.Vasectomy and prostate cancer risk.
Am J Epidemiol 1990;132:1050–61.
77. Giovannucci E, Ascherio A, Rimm EB, Colditz GA, Stampfer MJ, The use of combined oral contraceptives (OCs) is no longer Willet WC. A prospective cohort study of vasectomy and prostatecancer in US men. JAMA 1993;269:873–7.
contraindicated in non-smoking women over age 35.5,6 Non- 78. Howards SS. Possible biological mechanisms for a relationship between contraceptive benefits may be especially helpful in this age vasectomy and prostatic cancer. Eur J Cancer 1993;29A:1061–4.
group. Low-dose OCs containing 20 to 35 µg of ethinyl estra- 79. Harris NM, Holmes SA. Requests for vasectomy: counselling and diol offer many benefits for the perimenopausal woman. A consent. J R Soc Med 2001;94(10):510–1.
80. Hendry WF. Vasectomy and vasectomy reversal. Br J Urol combined OC containing 20 µg of ethinyl estradiol has been shown to provide effective contraception, reduce menstrual 81. Deck AJ, Berger RE. Should vasectomy reversal be performed in men cycle irregularity, decrease bleeding, and relieve menopausal with older female partners? J Urol 2000;163:105–9.
symptoms.7 Important additional benefits of such treatmentinclude a decrease in the risk of ovarian cancer8 and endome- CHAPTER 11: CONTRACEPTION —
trial cancer,9 reduced dysmenorrhea and menorrhagia,10 and a MEETING SPECIAL NEEDS
lower risk of functional ovarian cysts.11,12 There is a decreasedrisk of hereditary cancers.13 Longer duration of use is associat- Nathalie Fleming, MD, FRCSC,1 Margaret Morris, MD,
ed with decreased risk. The risk of colorectal cancer may also be FRSCS,2 Helen Pymar, MD, MPH, FRCSC,3 Thirza Smith,
reduced with OC use.14,15 MD, FRCSC4
Women taking a combined OC may experience a return of symptoms during the hormone-free interval, although supple- mentation during that time with a low dose of estrogen may be helpful. Alternatively, combined OCs may be taken continu- ously; this may have a number of advantages, including a At different stages of a woman's reproductive life, or in the face decreased incidence of pelvic pain, headaches, bloating/swelling, of disability, contraceptive needs require a unique approach.
and breast tenderness for women who experience these symp- The special needs of these circumstances are considered in the toms during the hormone-free interval.16 following sections.
1. CONTRACEPTION IN PERIMENOPAUSE
The intrauterine device (IUD) is an effective method of con- traception that is well-suited to perimenopause. The copper-bearing IUD has been shown to decrease the risk of endometrial Perimenopause is characterized by fluctuating hormone levels, cancer.17 The levonorgestrel-containing intrauterine system irregular menstrual cycles, and the onset of symptoms such as (LNG-IUS) decreases the amount of blood flow and may lead hot flashes and insomnia that may increase in number and severity as menopause approaches.1,2 While women over the Menorrhagia responds favourably to use of the LNG-IUS.
age of 40 may have difficulty in conceiving, most are still fer- In 2 studies of women scheduled to undergo hysterectomy for tile and do not seek pregnancy.3 menorrhagia, 64% to 80% of women randomized pre-opera- Pregnancy in perimenopause is associated with increased tively to LNG-IUS insertion subsequently cancelled their hys- obstetrical and genetic risks, including miscarriage, fetal terectomy, compared with 9% to 14% of women randomized to receive other medical treatments.19,20 Dysmenorrhea may 2. Prior JC. Perimenopause: the complex endocrinology of the also improve in LNG-IUS users.21 menopausal transition. Endoc Rev 1998;19:398–428.
3. Schmidt-Sarosi C. Infertility in the older woman. Clin Obstet Gynecol PROGESTIN-ONLY METHODS
4. Hosseinzadeh M, Jolly EE. Fertility in the mature woman. J Obstet Gynaecol Can 1997;19:611–8.
5. Inman WH,Vessey MP, Westerholm B, Engelund A.Thrombotic disease The use of depot medroxyprogesterone acetate or the progestin- and the steroidal content of oral contraceptives: a report to the Com- only pill are methods that can be used for contraception in peri- mittee on Safety of Drugs. BMJ 1970;2:203–9.
menopause. These methods may be associated with 6. Rosenberg L, Palmer JR, Rao RS, Shapiro S. Low-dose oral contraceptive use and the risk of myocardial infarction. Arch Int Med 2001;161: amenorrhea22 or irregular vaginal bleeding.23,24 7. Casper RF, Dodin S, Reid RL; Study Investigators.The effect of 20 µg ethinyl estradiol/1 mg norethindrone acetate (Minestrin), a low-doseoral contraceptive, on vaginal bleeding patterns, hot flashes, and qualityof life in symptomatic perimenopausal women. Menopause 1997;4: Barrier methods may be appropriate for use in perimenopausal women. Since an unplanned pregnancy may be more undesir- 8. Schlesselman JJ. Net effect of oral contraceptive use on the risk of can- able in this age group, the relatively lower contraceptive effec- cer in women in the United States. Obstet Gynecol 1995;85:793–801.
9. Jick SS,Walker AM, Jick H. Oral contraceptives and endometrial cancer.
tiveness of barrier methods may be a disadvantage.
Obstet Gynecol 1993;82:931–5.
10. Derzko CM. Perimenopausal dysfunctional uterine bleeding: physiology and management. J Soc Obstet Gynaecol Can 1997;19:589–600.
11. Speroff L. Management of the perimenopausal transition. Contemp Obstet Gynecol 2000;10:14–37.
In the perimenopausal age group, many couples choose male 12. Shaaban MM.The perimenopause and contraception. Maturitas 1996; or female sterilization if they are certain further pregnancy is 13. Narod SA, Risch H, Moslehi R, Dorum A, Neuhausen S, Olsson H, et al.
not desired. Post-sterilization regret is decreased in this age Oral contraceptives and the risk of hereditary ovarian cancer. N Engl J group.25 Menstrual abnormalities are not usually worsened after tubal ligation,26 but the positive effects of combined OCs, the 14. Fernandez E, La Vecchia C, Balducci A, Chatenoud L, Franceschi S, Negri E. Oral contraceptives and colorectal cancer risk: a meta-analysis.
copper IUD, or the LNG-IUS will be lost once their use is dis- Br J Cancer 2001;84:721–7.
15. Troisi R, Schairer C, Chow WH, Schatzkin A, Brinton LA, Fraumeni JF Jr.
Other contraceptive methods are not contraindicated sole- Reproductive factors, oral contraceptive use, and risk of colorectal can-cer. Epidemiology 1997;8:75–9.
ly by age and may also be valuable for some women.
16. Sulak P, Kuehl T, Ortiz M, Shull B. Acceptance of altering the standard 21-day/7-day oral contraceptive regimen to delay menses and reduce hormone withdrawal symptoms. Am J Obstet Gynecol 2002;186:1142–9.
17. Benshushan A, Paltiel O, Rojansky N, Brzezinski A, Laufer N. IUD use 1. In addition to providing effective contraception, low-dose and the risk of endometrial cancer. Eur J Obstet Gynecol combined OCs provide non-contraceptive benefits for healthy, non-smoking perimenopausal women. Non-contraceptive 18. Onyeka BA. Levonorgestrel-releasing (20 mcg/day) intrauterine systems (Mirena) compared with other methods of reversible contraceptives.
benefits include suppression of vasomotor symptoms (Level I), Br J Obstet Gynaecol 2001;98:576–82.
cycle control, decreased incidence of anemia (Level II-1), and 19. Lahteenmaki P, Haukkamaa M, Puolakka J, Riikonen U, Sainio S, decreased incidence of endometrial cancer. (Level II-2) Suvisaari J, et al. Open randomised study of use of levonorgestrelreleasing intrauterine system as alternative to hysterectomy. BMJ 2. The IUD may be a suitable contraceptive method for peri- menopausal women. The levonorgestrel-releasing IUS 20. Hurskainen R,Teperi J, Rissanen P, Aalto AM, Grenman S, Kivela A, et al.
(LNG-IUS) decreases heavy bleeding and may eliminate the Quality of life and cost-effectiveness of levonorgestrel-releasingintrauterine system versus hysterectomy for treatment of menorrhagia: need for hysterectomy. (Level I) a randomised trial. Lancet 2001;357:273–7.
21. Barrington JW, Bowens-Simpkins P.The levonorgestrel intrauterine system in the management of menorrhagia. Br J Obstet Gynaecol 1. Health-care providers should emphasize the need for
22. Betsey EM;Task Force on Long-Acting Systemic Agents for Fertility effective contraception in perimenopausal women. Non-
Regulation. Menstrual bleeding patterns in untreated women and with contraceptive benefits of each method should be taken
long-acting methods of contraception. Adv Contracept 1991;7:257–70.
into account when counselling these women. (Grade A)
23. Sangi-Haghpeykar H, Poindexter AN III, Bateman L, Ditmore JR. Experi- ences of injectable contraceptive users in an urban setting. ObstetGynecol 1996;88:227–33.
24. Broome M, Fotherby K. Clinical experience with the progestogen-only pill. Contraception 1990;42:489–95.
1. North American Menopause Society. Clinical challenge of the 25. Hillis SD, Marchbanks PA,Tylor LR, Peterson HB. Post-sterilization perimenopause: consensus opinion of The North American Menopause regret: findings from the United States Collaborative Review of Steril- Society. Menopause 2000;7:5–13.
ization. Obstet Gynecol 1999;93:889–95.
26. Peterson HB, Jeng G, Folger SG, Hillis SA, Marchbanks PA,Wilcox LS; U.S. Collaborative Review of Sterilization Working Group.The risk ofmenstrual abnormalities after tubal sterilization: findings from the U.S.
Women who are breastfeeding may be good candidates for Collaborative Review of Sterilization. N Eng J Med 2000;343:1681–7.
use of an intrauterine device (IUD). The IUD can be inserted 2. POSTPARTUM CONTRACEPTION
immediately postpartum (within 10–15 minutes after deliveryof the placenta). Women who have an IUD inserted immedi- Barrier methods of contraception and spermicides may be used ately after delivery are at higher risk of expulsion and uterine in breastfeeding and postpartum women when they are ready perforation than women who have an IUD inserted later.14 In to resume sexual activity. If a woman chooses a hormonal most circumstances, it is prudent to wait until the uterus is com- method of contraception, certain restrictions may apply.1 pletely involuted, usually at 4 to 6 weeks postpartum, beforeinserting an IUD. Women should wait until 6 weeks postpar- COMBINED ORAL CONTRACEPTIVES
tum to have the LNG-IUS inserted. In breastfeeding women, use of combined oral contraceptives (OCs) may diminish both the quality and quantity of breastmilk in the postpartum period. It is suggested that combined Some women prefer to avoid all hormonal contraceptive meth- OCs should not be used until after lactation is well established ods while they breastfeed. For these women, it is important to (usually 6 weeks postpartum).2 A significant amount of prog- emphasize that only amenorrheic women who exclusively breast- estational component is present in the breast milk when the feed at regular intervals, even during the night, have this contra- mother is taking combined OCs. Nevertheless, no adverse ceptive effect of lactation during the first 6 months. Supplements effects have thus far been identified. In an 8-year follow-up increase the risk of ovulation even in the absence of menstrua- study of children breastfed by mothers using combined OCs, tion.15 This method is dealt with in more detail in Chapter 9. no effect could be detected on diseases, intelligence, or psycho-logical behavior.3,4 If the woman is not breastfeeding, combined OCs may be introduced 3 to 4 weeks postpartum.2 1. The use of combined OCs decreases breast milk production.
2. Use of progestin-only preparations has not been shown to decrease breast milk production. The small amounts of No adverse effects of contraceptive steroids secreted in breast steroid hormones secreted into breast milk do not have an milk, from use of either combined OCs or the progestin-only adverse effect on the baby. (Level II-2) pill (POP), have been identified in infants.5-8 The POP pro-vides a small increase in milk production and women using them breastfeed a longer time.8 1. Initiation of combined OC use should be delayed until
Progestins administered within the first 72 hours after deliv- breastfeeding is established, usually by 6 weeks postpar-
ery may theoretically interfere with the fall in serum proges- tum. If the woman is not breastfeeding, combined OCs
terone levels that triggers lactogenesis, thereby interfering with can be started at 3 to 4 weeks postpartum. (Grade B)
breast milk production. However, a prospective study did not 2. Progestin-only methods should be considered as contra-
detect any adverse effect on breastfeeding when progestin-only ceptive options for postpartum women, regardless of
contraceptive methods were used within the first 72 hours after breastfeeding status, and may be introduced immediate-
ly after delivery. (Grade B)
Administration of depot medroxyprogesterone acetate (DMPA) 1. Briggs GG, Freeman RK,Yaffe SJ, editors. Drugs in pregnancy and lacta- has been shown to be an effective method of postpartum con- tion: a reference guide to fetal and neonatal risk. 6th ed. Philadelphia: traception with little or no effect on breast milk production or Lippincott Williams & Wilkins; 2001.
2. World Health Organization. Improving access to quality care in family on infant development.9-13 planning: medical eligibility criteria for contraceptive use. 2nd ed.
It may be preferable to wait until breast milk is established Geneva:WHO; 2001.
before giving the first dose of DMPA. If the woman is not 3. Shikary ZK, Betrabet SS, Patel ZM, Patel S, Joshi JV,Toddywala VS, et al.
ICMR (Indian Council of Medical Research) Task Force study on hor- breastfeeding, the first DMPA dose can be given immediately monal contraception: transfer of levonorgestrel (LNG) administered after delivery.
through different drug delivery systems from the maternal circulation into the newborn infant's circulation via breast milk. Contraception termination often require contraceptive counselling at the time of their procedure. Women may ovulate as early as 16 days after 4. Betrabet SS, Shikary ZK,Toddywalla VS,Toddywalla SP, Patel D, Saxena BN.
ICMR Task Force study on hormonal contraception: transfer of nor- the procedure.1 There is a rapid return (within 1 week) of estro- ethisterone (NET) and levonorgestrel (LNG) from a single tablet into gen and progesterone levels to near normal range after abortion.1 the infant's circulation through the mother's milk. Contraception The patient's visit at the clinic to seek an abortion offers a 5. Truitt ST, Frazer AB, Grimes DA, Gallo MF, Schulz KF. Combined good opportunity for the health-care provider to talk about con- hormonal versus nonhormonal versus progestin-only contraception in traceptive options.2,3 Women seeking abortion due to contra- lactation (Cochrane Review). In:The Cochrane Library, Issue 4 2003.
ceptive failure or non-use of contraception should not leave the Oxford: Update Software.
clinic without receiving counselling on how to avoid unwant- 6. World Health Organization Task Force on Oral Contraceptives. Effects of hormonal contraceptives on breast milk composition and infant ed pregnancy in the future. Advance provision of emergency growth. Stud Fam Plann 1988;19(6 Pt 1):361–9.
contraception should be considered for all post-abortion 7. Halderman LD, Nelson AL. Impact of early postpartum administration patients. The following Table 1 lists the recommended timing of progestin-only hormonal contraceptives compared withnonhormonal contraceptives on short-term breast-feeding patterns.
of initiation of contraceptive options after abortion.
Am J Obstet Gynecol 2002;186:1250–8.
8. Tankeyoon M, Dusitsin N, Chalapati S, Koetsawang S, Saibiang S, Sas M, et al. Effects of hormonal contraceptives on milk volume and infantgrowth.WHO Special Programme of Research, Development, andResearch Training in Human Reproduction;Task Force on Oral Contra- 1. Legalized abortion is associated with a lower incidence of ceptives. Contraception 1984;30:505–22.
abortion-related maternal mortality. (Level II-2) 9. Mishell DR Jr. Pharmacokinetics of depot medroxyprogesterone acetate contraception. J Reprod Med 1996;41(5 Suppl):381–90.
10. SOGC Committee Opinion. Injectable medroxyprogesterone acetate for contraception. Policy statement No. 94. J Soc Obstet Gynaecol Can 1. Contraceptive counselling should be offered at the time
2000; August: 14–8.
of abortion, and contraceptive methods should be pro-
11. Pardthaisong T,Yenchit C, Gray R.The long-term growth and develop- ment of children exposed to Depo-Provera during pregnancy or lacta- vided immediately following the procedure. (Grade A)
tion. Contraception 1992;45:313–24.
2. Canadian women should have access to safe abortion pro-
12. Borgatta L, Murthy A, Chuang C, Beardsley L, Burnhill MS. Pregnancies cedures regardless of geographical location. (Grade A)
diagnosed during Depo-Provera use. Contraception 2002;66:169–72.
13. Hatcher RA, Schnare S. Ask the experts: progestin-only contraceptives.
Contracept Technol Update 1993;14:114–5.
14. Grimes D, Schulz K, van Vliet H, Stanwood N. Immediate post-partum insertion of intrauterine devices (Cochrane Methodology Review). In:The Cochrane Library, Issue 4 2003.
1. Lahteenmaki P. Postabortal contraception. Ann Med 1993;25:185–9.
15. Visness CM, Kennedy KI, Gross BA, Parenteau-Carreau S, Flynn AM, 2. Garg M, Singh M, Mansour D. Peri-abortion contraceptive care: can we Brown JB. Fertility of fully breastfeeding women in the early post- reduce the incidence of repeat abortions? J Fam Plann Reprod Health partum period. Obstet Gynecol 1997;89:164–7.
3. Ortayli N, Bulut A, Nalbant H.The effectiveness of preabortion contra- ceptive counseling. Int J Gynecol Obstet 2001;74:281–5.
3. POST-ABORTION CONTRACEPTION
4. Paul M, Lichtenberg E, Borgatta L, Grimes D, Stubblefield P. A clinician's guide to medical and surgical abortion. Philadelphia, PA: Churchill Living-stone; 1999.
Women who have had a miscarriage or elective pregnancy 5. El-Tagy A, Sakr E, Sokal D, Issa A. Safety and acceptability of post-abortal Table 1. Recommended Initiation of Contraceptive Options After Abortion
Initiation (in Relation to Abortion)
Female sterilization Start at time of abortion for first and Consider interval for severe anemia.
early–second trimester; can be done Ensure adequate counselling.
laparoscopically and by minilaparotomy forsecond trimester.
Combination oral contraceptives Start anytime from evening of surgery to 5 days Nausea may be confused with continuingafter surgery.
pregnancy if started right away.
Progestin-only oral contraceptives Start on the day of abortion.
Breakthrough bleeding may cause confusionpost-operatively.
Start immediately after abortion, or up to 5 Ensure plans for next injection are made.
Breakthrough bleeding may cause confusionpost-operatively.
Start at time of abortion in first trimester or No significant increase in bleeding, during/after first menses after abortion.
perforation, pain with immediate vs. delayedinitiation in first trimester.5 Higher rates ofexpulsion if greater than 12 weeks comparedwith shorter gestations.6 IUD insertion and the importance of counseling. Contraception However, to give valid consent for medical treatment, an individual under the legal age of consent must be deemed to be 6. Stanwood N, Grimes D, Schulz K. Insertion of an intrauterine contra- ceptive device after induced or spontaneous abortion: a review of the a "mature minor." Determining whether or not an adolescent evidence. Br J Obstet Gynaecol 2001;108:1168–73.
is a "mature minor" requires an assessment of whether or notthe young person's physical, mental, and emotional develop- 4. CONTRACEPTION FOR THE ADOLESCENT
ment will allow for full appreciation of the nature and conse-quences of a proposed treatment, including the consequences Most contraceptive options are a good choice for adolescents.
of refusal of such treatment.6 Adolescents are commonly involved in serial monogamous rela-tionships in which they are less likely to use a contraceptive method on a regular basis. They are more willing to seek con-traceptive advice in a steady relationship. In all these cases, dou- The following should be considered in determining the opti- ble protection against pregnancy and sexually transmitted mal hormonal contraceptive method for a female adolescent: infections (STIs) should always be recommended. In this spe- • There is no evidence that the estrogen in current low-dose cific age group it is also important to emphasize that the use of combined OCs has any effect on growth.7 barrier methods does not always prevent viral STIs such as her- • In users of low-dose combined OCs, weight gain is min- pes and the human papilloma virus (HPV).1,2 imal and is often related to normal weight gain for age inthe adolescent population. Combined OC users have not been shown to have any significant weight gain on ther-apy.8-12 It is important to note that in Canada • Combined OC use appears to have a favourable effect on • 11% of 15-year-olds, 27% of 16-year-olds, 42% of 17- bone mineral density.13-15 year-olds, and 55% of 18-year-olds have had sexual inter- • In one study, 56% of DMPA users reported an increase in weight (mean gain of 4.1 kg), while 44% either lost • between 85% and 91% (depending on age) used contra- weight or maintained their baseline weight (mean loss of ception at the time of first intercourse.3 1.7 kg).16 Other studies have failed to find an effect of • among coitally experienced adolescents, none were cur- DMPA on weight.17-19 Weight gain associated with rently using spermicidal methods, none were sterilized, DMPA use is thought to be due to appetite stimulation and none were using IUDs. As in other age groups, the and a possible mild anabolic effect.20 dominant methods used by coitally experienced teenagers • Adolescent mothers using DMPA for contraception have aged 15 to 18 were OCs (66%) and condoms (44%); a higher method continuation rate and a lower incidence others included withdrawal (6%) and DMPA (6%); and of repeat pregnancy at 12 months postpartum than those 11% reported no current sexual activity.3 selecting combined OCs during the same period.21 The most important reasons adolescents cite for not using contraceptive methods when they are sexually active are as ADHERENCE TO CONTRACEPTIVE CHOICE
• sexual activity was unexpected and unplanned; The greatest challenges in adolescent users of combined OCs are • a lack of information and knowledge about contracep- incorrect or inconsistent use and high discontinuation rates.22 tives and where to get them; Three months after beginning, 76% of teenage women • fear of medical procedures; remain on oral contraceptives, and 50% continue after 12 • fear of judgmental attitudes and resistance from health- months.23 The most common reason given for discontinuing care providers; and hormonal contraception is side effects,24 especially breakthrough • fear of lack of confidentiality. Many adolescents believe that their risk of getting cancer or blood clots while using hormonal contraception is very high. Itis possible that the adolescent sees unscheduled bleeding or There is no lower age limit for prescribing hormonal contra- other side effects as an indication of a serious consequence such ceptives. The medical and social risks of unplanned pregnancy as cancer. They may also believe that these effects are long-term, exceed the risks of taking hormonal contraceptives; the World lead to sterility, or affect the health of future offspring.24 As a Health Organization states that age alone does not constitute a result, they will feel less confident about the efficacy of the con- medical reason for denying any available contraceptive method traceptive. This can lead to non-compliance and discontinua- tion of the contraceptive.25 STRATEGIES TO IMPROVE ADHERENCE
.cmpa-acpm.ca> Web site updated 2003. Accessed February 16, 2004.
7. Elgan C, Samsioe G, Dykes AK. Influence of smoking and oral contra- ceptives on bone mineral density and bone remodeling in young A supportive, encouraging, and non-judgmental environment, women: a 2-year study. Contraception 2003;67(6):439–47.
where confidentiality is assured, is essential when counselling ado- 8. Endrikat J, Gerlinger C, Cronin M,Wessel J, Ruebig A, Rosenbaum P, lescents. It is also important to counsel them about the value of et al. Body weight change during use of a monophasic oral contracep-tive containing 20 microg ethinylestradiol and 75 microg gestodene dual protection for the prevention of both pregnancy and STI.26,27 with a comparison of the women who completed versus those who The following strategies will increase the probability of an prematurely discontinued intake. Eur J Contracept Reprod Health Care adolescent adhering to a contraceptive plan: 1. Explain how the hormonal method works.
9. Coney P, Washenik K, Langley RG, DiGiovanna JJ, Harrison DD.Weight change and adverse event incidence with a low-dose oral contracep- 2. Dispel myths and misconceptions.
tive: two randomized, placebo-controlled trials. Contraception 3. Demystify the side effects, and reassure the adolescent that the minor side affects are usually short-lived.
10. Gupta S.Weight gain on the combined pill: is it real? Hum Reprod 4. Emphasize the non-contraceptive benefits of the hormonal 11. Vessey MP, Painter R, Powell J. Skin disorders in relation to oral contra- ception and other factors, including age, social class, smoking, and body 5. Schedule frequent follow-ups.
mass index: findings in a large cohort study. Br J Dermatol2000;143(4):815–20.
6. Provide written material that lists myths and misconceptions, 12. Endrikat J, Hite R, Bannemerschult R, Gerlinger C, Schmidt W. Multicen- non-contraceptive benefits, and side effects.
ter, comparative study of cycle control, efficacy, and tolerability of twolow-dose oral contraceptives containing 20 microg ethinylestradiol/100microg levonorgestrel and 20 microg ethinylestradiol/500 microg 13. Kuohung W, Borgatta L, Stubblefield P. Low-dose oral contraceptives 1. Age alone is not a reason to deny any available contraceptive and bone mineral density: an evidence-based analysis. Contraception2000;61(2):77–82.
methods to adolescents. 14. Borgelt-Hansen L. Oral contraceptives: an update on health benefits 2. A health-care provider can supply contraception to a minor and risks. J Am Pharm Assoc 2001;41(6):875–86.
without parental consent as long as informed consent can 15. Jensen JT, Speroff L. Health benefits of oral contraceptives. Obstet be obtained from the individual. Gynecol Clin North Am 2000;27(4):705–21.
16. Polaneczky M, Guarnaccia M. Early experience with the contraceptive 3. A pelvic examination is not a prerequisite for providing con- use of depot medroxyprogesterone acetate in an inner-city clinic traception or emergency contraception. The timing of the population. Fam Plann Perspect 1996;28:174–8.
pelvic examination may be negotiated with the adolescent.
17. Moore LL,Valuck R, McDougall C, Fink W. A comparative study of one- year weight gain among users of medroxyprogesterone acetate, levonorgestrel implants, and oral contraceptives. Contraception1995;52:215–9.
18. Mainwaring R, Hales HA, Stevenson K, Hatasaka HH, Poulson AM, Jones KP, et al. Metabolic parameter, bleeding, and weight changes in 1. Adolescents should have ready access to contraception
U.S. women using progestin-only contraceptives. Contraception and methods of STI prevention. (Grade A)
2. Health-care providers should respect a patient's right to
19. Taneepanichskul S, Reinprayoon D, Jaisamrarn U. Effects of DMPA on weight and blood pressure in long-term acceptors. Contraception confidentiality. (Grade A)
3. The health-care provider should help to ascertain that
20. Rees HD, Bonsall RW, Michael RP. Pre-optic and hypothalamic neurons sexually active adolescents are involved in a consensual
accumulate [3H]medroxyprogesterone acetate in male cynomolgusmonkeys. Life Sci 1986;39:1353–9.
relationship that is free of coercion and abuse. (Grade B)
21. Templeman CL, Cook V, Goldsmith LJ, Powell J, Hertweck SP. Postpar- tum contraceptive use among adolescent mothers. Obstet Gynecol 22. Hewitt G, Cromer B. Update on adolescent contraception. Obstet Gynecol Clin North Am 2000;27(1):143–62.
1. Greydanus DE, Patel DR, Rimsza ME. Contraception in the adolescent: 23. Kalagian W, Delmore T, Loewen I, Herman J, Busca C. Adolescent oral an update. Pediatrics 2001;107(3):562–73.
contraceptive use: factors predicting compliance at 3 and 12 months.
2. Bury JK. Some social aspects of providing contraception for under-16- Can J Hum Sex 1998;7:1–8.
year-olds. Fertil Contraception 1980:4(1):1–6.
24. Clark LR.Will the pill make me sterile? Addressing reproductive health 3. Fisher W, Boroditsky R, Morris B.The 2002 Canadian contraception concerns and strategies to improve adherence to hormonal contracep- study. J Obstet Gynaecol Can. In Press 2004.
tive regimens in adolescent girls. J Ped Adoles Gynecol 4. Rivera R, Cabra de Mello M, Johnson SL, Chandra-Mouli V. Contracep- tion for adolescents: social, clinical, and service-delivery considerations.
25. Sucato G, Gold MA. New options in contraception for adolescents.
Int J Gynecol Obstet 2001;75(2):149–63.
Curr Womens Health Rep 2001;1(2):116–23.
5. World Health Organization. Improving access to quality care in family 26. Cromwell PF, Daley AM. Oral contraceptive pills: considerations for the planning: medical eligibility criteria for contraceptive use. 2nd ed.
adolescent patient. J Ped Health Care 2000;14(5):228–34.
27. Peremans L, Hermann I, Avonts D,Van Royen P, Denekens J. Contracep- 6. Canadian Medical Protective Association. Consent: a guide for Canadian tive knowledge and expectations by adolescents: an explanation by physicians. 3rd ed. Ottawa: CMPA; 1996. Available on-line at <www focus groups. Patient Ed Counsel 2000;40(2):133–41.
5. CONTRACEPTION IN INDIVIDUALS WITH
LEVONORGESTREL INTRAUTERINE SYSTEM
The use of this system in women with mental disabilities has Finding the most appropriate contraceptive method for the not been examined. It provides effective management of men- mentally disabled young woman poses a tremendous challenge strual problems as well as reversible contraception.14 However, to the health-care provider. a general anaesthetic or profound sedation for insertion of the Women with mental disabilities may be at risk for preg- device may be necessary for many disabled women.15 The pos- nancy, sexually transmitted infections, and/or abuse, since sibility that the system may induce amenorrhea or a major decrease in bleeding16 is usually considered a positive aspect by • lack knowledge of sexuality and contraception; the parents or caregivers.
• may be very affectionate and trusting; • struggle to be accepted, and may become compliant to sexual advances.1 The parents of these young women may be concerned Health-care providers should be aware of the legal requirements about their daughters' ability to cope with menses, the risk of for obtaining informed consent for sterilization, including an sexual exploitation,2 and pregnancy.3 explanation of benefits and risks, options, and determination Many will request medication to arrest menses and offer of whether the person is competent to understand the infor- contraception, while others may request permanent steriliza- mation.2 When the person has a mental disability, it is even tion. Reproductive health services should not be coercive; more difficult for the physician to determine their capacity to informed consent is required for all contraceptive methods.4,5 provide informed consent.17 Contraceptive sterilization of an Contraception can prevent pregnancy, but does not replace incompetent, mentally disabled person is illegal.4 Physicians the need for a safe environment for these women.3 In addition, need to be very respectful and provide comprehensive infor- counselling and assertiveness training to help them avoid abu- mation for the parents of these individuals, since they are fre- sive situations are necessary.2,6 quently concerned about their responsibility for any offspring The literature regarding management of menstrual hygiene if their daughter conceives.
and contraception in a woman with a mental disability is sparse.
However, several medical options are available to improve men- strual hygiene and to provide contraception: low-dose com-bined oral contraceptives (OCs), depot medroxyprogesterone 1. The non-therapeutic sterilization of any individual who is acetate (DMPA), levonorgestrel intrauterine system (LNG- not competent to give informed consent is illegal in Canada.
IUS), and sterilization.
LOW-DOSE COMBINED ORAL CONTRACEPTIVES
1. Health-care providers should include sexual health in the
counselling of women and men with intellectual dis-
Oral medications must be well tolerated for combined OCs to abilities, explore potential coercion and abuse and
be a useful option for these women. Oral contraceptives may should provide counselling to help them avoid coercive
be used in a cyclical, tri-cyclic (63 days on, 7 days off), or con- and abusive situations. (Grade B)
tinuous fashion.7-9 The risk of venous thromboembolism may be increased sig- nificantly if the woman is confined to a wheelchair.10 The doseof combined OCs used may need to be adjusted if the woman 1. Price MM. Physically, mentally disabled teens require special contracep- also takes anticonvulsants.11 tive care. Contracept Technol Update 1987;8:154–6.
2. Best K. Mental disabilities affect method options. Network Int Commun Libr Automation 1999;19:19–22.
DEPOT MEDROXYPROGESTERONE ACETATE
3. Grover SR. Menstrual and contraceptive management in women with an intellectual disability. Med J Aust 2002;176:108.
Use of DMPA should be considered if oral medications are not 4. Canadian Medical Association; Committee on Ethics. Statement on well tolerated or are contraindicated. However, the potential for contraceptive sterilization of the mentally retarded. CMAJ1987;136:650.
a reduction in bone mineral density12 and an increase in 5. American Academy of Pediatrics; Committee on Bioethics. Sterilization weight13 with this treatment may not be desirable. If a woman's of minors with developmental disabilities. Pediatrics 1999;104:337–40.
family requests a hysterectomy for hygiene purposes, use of 6. Neufeld JA, Klingbeil F, Nelson-Bryen D, Silverman B,Thomas A. Adoles- cent sexuality and disability. Phys Med Rehabil Clin N Am 2002;13: DMPA provides a good long-term alternative for management when it is well tolerated.
7. Schwartz JL, Creinin MD, Pymar HC.The tri-monthly combination oral contraceptive regimen: is it cost-effective? Contraception 1999;60: NATURAL FAMILY PLANNING
8. Cachrimanidou AC, Hellberg D, Nilsson S,Waldenstrom U, Olsson SE, Natural methods of contraception include abstinence, coitus Sikstrom B. Long-interval treatment regimen with desogestrel-contain-ing oral contraceptive. Contraception 1993;48:205–16.
interruptus, and the application of fertility awareness for the 9. Rutter W, Knight C,Vizzard J, Mira M, Abraham S.Women's attitudes to timing of coitus.
withdrawal bleeding and their knowledge and beliefs about the oral Abstinence as a choice for contraception is unlikely to be a contraceptive pill. Med J Aust 1988;149:417–9.
10. Gaber TA, Kirker SG, Jenner JR. Current practice of prophylactic antico- widely applicable option to reduce the incidence of unplanned agulation in Guillain-Barre syndrome. Clin Rehabil 2002;16(2):190–3.
pregnancy, given that it requires a continuous exertion of will 11. Hatcher RA,Trussell J, Stewart F, Cates W, Stewart GK, Guest F, et al., against instinct. There is considerable political will, particular- editors. Contraceptive technology. 17th ed. New York, NY: ArdentMedia; 1998.
ly in the United States, to validate abstinence as an appropriate 12. Gbolade B, Ellis S, Murby B, Randall S, Kirkman R. Bone density in long- sexual behaviour for young unmarried men and women, and term users of depot medroxyprogesterone acetate. Br J Obstet federal funding has been provided to "market" the idea — although not without concern expressed by human rights 13. Moore LL,Valuck R, McDougall C, Fink W. A comparative study of one- year weight gain among users of medroxyprogesterone acetate, groups.1 Nevertheless, in California, a large randomized study levonorgestrel implants, and oral contraceptives. Contraception of strategies designed to enhance postponement of sexual involvement showed no benefit; paradoxically, they even showed 14. Luukkainen T.The levonorgestrel intrauterine system: therapeutic aspects. Steroids 2000;65:699–702.
potential for encouraging sexual involvement.2 15. Zurawin R, Paransky OI.The role of surgical techniques in the Fertility awareness is based on knowledge of both male and treatment of menstrual problems and as contraception in adolescents female reproduction and on a reliable ability to predict ovula- with disabilities. J Ped Adol Gynecol 2003;16:51–4.
16. Barrington JW, Bowens-Simpkins P. The levonorgestrel intrauterine tion. Traditionally, predicting ovulation has been based on system in the management of menorrhagia. Br J Obstet Gynaecol symptoms, basal body temperature recordings, and the calen- dar. More recently, electronic hand-held devices have recorded 17. Wingfield M, McClure N, Mamers PM,Weigall DT, Paterson PJ, Healy DL.
information about temperature and menstrual cycle character- Endometrial ablation: an option for the management of menstrual prob-lems in the intellectually disabled. Med J Aust 1994;160:533–6.
istics in order to predict the fertile time and alert women to theneed for abstinence or the use of barrier methods of contracep- CHAPTER 12:THE FUTURE OF CONTRACEPTION
tion. There are many kits available for predicting ovulationthrough detection of increased urinary LH excretion, but the Timothy Rowe, MB, FRCSC
range of prediction is only 12–24 hours — insufficient to allow prevention of conception. The Persona kit offers women a homemonitoring system to measure urinary estrone-3-glucuronide as well as LH in order to predict, more remotely, the fertile timeof the cycle.3 Control of fertility is now an assumed fact of life for many peo-ple living in industrialized countries. The current generation of women in the reproductive age group has, for the most part,grown up with the assumption that they can have the families These include condoms, spermicides, diaphragms, and cervical that they want, when they want. There is a trend towards later occlusive devices. The potential for improvement in the design childbearing, with at least 20% of Canadian women having or applicability of the last two categories is limited, although their first child after age 35. Thus, a growing number of women improving these options remains desirable.
spend decades using contraception, much of which is intrusive, Spermicides tend to irritate the vagina, because their sper- messy, or associated with side effects.
micidal action relies on a detergent effect on sperm which also Contraception ideally should be simple, inexpensive, read- affects the vaginal flora. Future spermicides may focus on a ily available, highly effective, entirely safe, free of any symptoms mode of action that interferes instead with the acrosome reac- or adverse effects, immediately reversible, and coitally inde- tion of sperm, and does not affect the vaginal flora. A promis- pendent. In addition, since it is used mostly by healthy young ing candidate with these properties is cellulose sulfate, which women, contraception should confer some health benefit as an has shown less genital irritation than nonoxynol-9 while still incentive for consistent use. Of the currently available approach- providing antifertility and antimicrobial effects.4 Spermicides es in Canada, hormonal contraception for women in one form that coincidentally have antiviral properties are highly desirable or another comes closest to the ideal; but there are many women in the era of the human immunodeficiency virus (HIV); unfor- for whom no ideal contraceptive exists. Refinements of current tunately, a prospective study of a nonoxynol-9 gel (COL-1492) approaches, or new approaches, to the prevention of fertiliza- did not demonstrate protection against HIV transmission in tion or implantation are still needed.
high-risk women.5 The search for suitable agents continues.
Condoms will continue to be a mainstay of contraception several preparations containing new progestins (e.g., dienogest, and strategies to prevent sexually transmitted infections (STIs).
drospirenone, chlormadinone acetate) are available in Europe New condoms made from strong, thin polyurethane and other and may be released in Canada in the future. The newer pro- new polymers should provide better sensitivity and less poten- gestins carry individual potential metabolic advantages over cur- tial for allergic reactions — which is one of the major concerns rently available progestins.14,15 with currently available latex condoms. (See Chapter 8, It is unclear whether or not the dose of estrogen can be fur- "1. Condoms.") These new condoms would also be less prone ther reduced. The use of oral contraceptives by older women to degradation by lubricants. will likely continue to expand, particularly to control peri- Attempts to promote the female condom as a mainstream menopausal symptoms, and expansion of use into the post- contraceptive have been relatively unsuccessful.6 It provides menopausal years has great potential. women with protection against STIs, but it has little aesthetic Most future advances in hormonal contraception for appeal and because of this will require refinement to become females will involve improvements in methods of administra- more popular.
tion. Once-a-month oral contraceptive preparations have beenavailable for some time in China, using a powdered preparation at the time of menstruation to suppress ovulation in the subse-quent cycle.16 Another approach, less successful, has been to The perceived association of intrauterine devices (IUDs) with administer a preparation that causes luteolysis and induction of pelvic inflammatory disease (PID) has led to a steady reduction menses. Mifepristone administered once per month has been in IUD use in North America.7 This perception will be diffi- proposed as an example of this kind of contraceptive; this would cult to reverse, despite the realization that the risk of PID is asso- appeal to women having sporadic intercourse.17 ciated only with insertion of the device.8 (See Chapter 7.) Another approach in attempting to provide estrogen-free Nevertheless, the appeal of the IUD remains: it is highly effec- hormonal contraception has been to administer sequentially an tive, requires no maintenance, and now can be left in place for antiprogestin (mifepristone) followed by a progestin (nom- at least 5 years. The longer duration of placement reduces the egestrol acetate); this treatment combination results in inhibi- risks of insertion (infection and perforation). The risk of expul- tion of ovulation and the development of an irregular secretory sion may be reduced by new frameless and flexible devices endometrium. Use of this combination has reached the stage of which are fixed into the myometrium, and with these devices phase II trials.18 the potential for cramps and excess bleeding is also reduced.9 Routes of hormone administration other than oral have Hormone-releasing devices, particularly those releasing lev- potential for development. The use of depot injections such as onorgestrel (e.g., Mirena), provide reliable contraception with Depo-Provera for contraception in Canada is a recent innova- a dramatic reduction in menstrual bleeding.10 They offer poten- tion by global standards, and its ultimate level of use in Cana- tial for therapeutic applications beyond contraception. Despite da is still unknown. Contraceptive implants releasing either this, liability issues (while not major concerns for modern IUDs) estrogen and progestin or progestin alone are slow to develop, make industry cautious about becoming involved in this area test, and market, and none are currently available in the Cana- of contraception. These concerns discourage companies from dian market. (Sales of Norplant, the only implant to have been revising product labels containing highly conservative warnings marketed in Canada, were discontinued in September 2002.) about IUD use. This conservative product labeling discourages Second-generation implant systems (Implanon and Jadelle) have physicians from recommending use of an IUD.11 been developed to simplify insertion and removal, with use of1 or 2 rods respectively in place of Norplant's 6. (See Chapter 5's section on progestin-only hormonal contraception.)Implanon releases etonogestrel for reliable contraception over a FEMALE HORMONAL CONTRACEPTION
span of 2 years, while Jadelle releases levonorgestrel with reli- Developments in oral contraception have led to a steady reduc- able contraceptive effect over 3 years (and is under FDA review tion in the daily dose of both estrogen and progestin and the as a 5-year contraceptive).19 Another system undergoing trials development of progestins with reduced metabolic impact.
releases a different progestin, nestorone, from silastic implants; Third-generation progestins were introduced with the aim of this may be used safely in lactating mothers, since nestorone is reducing arterial disease in women,12 but the large-scale accep- rapidly metabolized after oral administration and has no appar- tance of preparations containing these progestins has been ent effect if ingested by a baby in breast milk.20 affected by the controversy over whether or not they carry a Progestin implants and depot injections are, however, all higher risk of venous thrombosis than older preparations.13 (See associated with irregular menstrual bleeding and the potential Chapters 4 and 6.) This controversy has to some extent dis- for changes in weight and mood. Bleeding patterns tend to be couraged the release of new oral contraceptive preparations; but more predictable and amenorrhea less common with use of combined estrogen-progestin preparations such as Lunelle,21 production of antibodies to HCG have been under investiga- although the inclusion of estrogen requires the same medical tion for several decades.
considerations as the use of combined oral contraceptives. Fertilization-limiting vaccines under investigation are direct- Future possibilities for administration of contraceptive ed either against sperm surface antigens or against the zona pel- steroids include the use of injectable microspheres containing both lucida. The idea of inducing antibodies in women against sperm estrogen and progestin22 and further development of vaginal is an old one; in 1932, Baskin produced "temporary steriliza- rings and transdermal patches delivering low doses of estrogen tion" in women by injecting them with their husband's sperm.27 and progestin. Each of these would offer better control of vagi- Investigations related to this approach did not continue. How- nal bleeding and theoretically superior compliance.
ever, research to identify specific sperm surface antigens thatcould be the basis for a fertility-regulating vaccine in males or MALE HORMONAL CONTRACEPTION
females has continued, and two of these (FA-1 and YLP(12)) Regrettably, there does not appear to be a bright future for the show particular promise.28 Sperm surface antibodies are able to development of reliable and acceptable means of contraception affect sperm either before they leave the male or when they reach directed at suppression of sperm production. An agent which the female, but only a small proportion of the sperm generated will easily, safely, and reliably suppress sperm production in the male ever reach the site of fertilization in the female. Anti- while leaving libido and erectile function intact has yet to be bodies generated in the female therefore have to deal with sig- nificantly less sperm than do antibodies generated in the male.
Weekly injections of testosterone will induce oligo- or Thus antisperm vaccines appear to have more potential for azospermia after 3 months of treatment, but may be associated effectiveness in females than in males.29 with acne, mood change, adverse lipoprotein changes, and delay The vaccines stimulating antibody production against the in return of fertility.23 The need for weekly injections and the zona pellucida have the undesirable effect of causing oophori- potential for delay in return of fertility limit the appeal of this tis or ovarian failure through depletion of primordial follicles method. The addition of a progestin may allow the use of lower from the ovary.30 Attempts to identify epitopes (specific anti- doses of testosterone, but the approach is not universally effec- genic determinants) that might allow a contraceptive effect of tive. Long-acting testosterone esters, delayed-release pellets of such a vaccine without causing pathological effects within the testosterone and implants of androgen or progestin are being ovary are continuing. explored as possible avenues for acceptable delivery of Research carried out in India under the auspices of the World Health Organization (WHO) in the 1970s resulted in An alternative approach in males is the use of a GnRH ago- the development of a vaccine stimulating the production of nist to suppress testicular function combined with androgen antibodies to the β-subunit of the human chorionic therapy to maintain libido and male habitus and sexual char- gonadotropin (HCG) molecule (and, through linkage of anti- acteristics. This has not proven as successful as hoped,26 and the gens, coincidentally to Clostridium tetani).31 Because of poten- expense of such an approach makes it an impractical option.
tial cross-reactivity with LH, the WHO has sponsored researchusing an antibody to a 37-amino acid section of the β-HCG subunit in order to minimize the risk of autoimmune damageto pituitary cells.29 These antibodies are only effective for a few The idea of using the induction of antibodies to components months and thus require frequent repeat immunizations. How- of the reproductive process for contraception has been pursued ever, there has been no evidence of autoimmune damage to for more than 30 years. While there have been promising pituitary cells, even where antibodies to the entire β-subunit of achievements in animal and some human studies, there is a need HCG are generated; but there has been some evidence of unex- for considerable refinement of the approach before it can pected cross-reactivity against pancreatic and pituitary cells with become a practical option for widespread use. The ideal vaccine antibodies raised against the carboxyl terminal of the β-subunit.
for contraception should be safe and reliable; furthermore, in Long-term studies will be needed to learn whether this finding order to be widely acceptable it should produce a long-lasting is clinically significant.29 effect and should be reversible.
There is political opposition to the development of β-HCG vaccines for contraception, since they could be considered FEMALE IMMUNOLOGICAL APPROACHES
abortifacient.32 The developers maintain that, in human stud- Research in immunocontraception is currently focused upon ies, the length of the menstrual cycle has been unaffected by the two areas of reproduction in the female: fertilization and mater- development of anti-β-HCG antibodies, and that their effect nal recognition of pregnancy. Producing a vaccine that will inter- occurs before the completion of implantation.33 There is simi- fere with fertilization is limited by our understanding of the larity to the concerns that have been expressed by some about molecular mechanisms involved, but vaccines stimulating the mode of action of intrauterine devices.
MALE IMMUNOLOGICAL APPROACHES
cytotrophoblasts at the fetal-maternal interface. These circulat- Developing antibodies against GnRH or FSH to suppress ing antigens have a capacity analogous to that of membrane- sperm production has been shown to be possible.34 However, bound structures to inhibit natural killer (NK) cells.39 the use of suppressive therapy with androgens has been a more Interference with the production or action of the HLA-G anti- practical approach to the induction of reversible oligo- or gens would result in the establishment of an immune response azospermia, since it avoids the possibility of systemic immune to the conceptus, involving NK cells. Raising antibodies to sperm surface proteins should allow sperm production to continue, but the sperm subsequentlywould either be immobilized or rendered incapable of fertiliza- 1. Human Rights Watch.Vol. 14, No. 5 (September 2002). Available on-line at <http://www.hrw.org/reports/2002/usa0902>. Accessed February 5, tion. However, developing antibodies to sperm proteins carries a risk of stimulating testicular inflammation.29 In addition, as 2. Kirby D, Korpi M, Barth RP, Cagampang HH.The impact of the postpon- described above, such antibodies would need to bind to the sur- ing sexual involvement curriculum among youths in California. Fam Plann face of considerably more sperm in the male genital tract than 3. Bonnar J, Flynn A, Freundl G, Kirkman R, Royston R, Snowden R.
at the site of fertilization in the female. Nevertheless, the char- Personal hormone monitoring for contraception. Br J Fam Plann acterization of human sperm surface antigens is in its infancy,35 and it may prove possible to develop vaccines generating 4. Mauck C,Weiner DH, Ballagh S, Creinin M, Archer DF, Schwartz J, et al. Single and multiple exposure tolerance study of cellulose sulfate immune responses in the epididymis or secondary sexual glands gel: a phase I safety and colposcopy study. Contraception 2001;64: that are sufficient to have a contraceptive effect.
5. Van Damme L, Ramjee G, Alary M,Vuylsteke B, Chandeying V, Rees H, et al; COL-1492 Study Group. Effectiveness of COL-1492, a non- NEW APPROACHES TO CONTRACEPTION
oxynol-9 vaginal gel, on HIV-1 transmission in female sex workers: arandomised controlled trial. Lancet 2002;360:971–7.
6. Latka M. Female-initiated barrier methods for the prevention of Lonidamine is an indazole carboxylic acid compound used in STI/HIV: where are we now? where should we go? J Urban Health2001;78:571–80.
cancer treatment. Its development as an antispermatogenic con- 7. Fisher WA, Boroditsky R, Bridges ML.The 1998 Canadian contraception traceptive compound in the early 1980s was abandoned because study. Can J Hum Sex 1999;8:161–216.
of renal damage, but recent derivatives have shown efficacy and 8. Farley TM, Rosenberg MJ, Rowe PJ, Chen JH, Meirik O. Intrauterine devices and pelvic inflammatory disease: an international perspective.
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Nous avons conçu cette brochure en tant que guide pour votre prochaine opération du genou. Cette brochure vous expliquera comment et pourquoi vous serez soigné. Cela vous aidera à bien situer tout ce qui se fera ou devra se faire au cours des semaines à venir. Vous vous sentirez davantage chez vous dans notre service, vous