Birth Control Insight Report

Background

Contraceptives are devices, drugs, or methods for preventing pregnancy, either by preventing the fertilization of the female egg by the male sperm or by preventing implantation of the fertilized egg.

Contraceptive Options

Choosing the appropriate contraceptive is a personal decision. Contraceptive options include:

• Hormonal contraceptives (oral contraceptives, skin patch, vaginal ring, implant, injection)
• Intrauterine devices (IUDs), which contain either a hormone or copper
• Barrier devices with or without spermicides (diaphragm, cervical cap, sponge, condom)
• Fertility awareness methods (temperature, cervical mucus, calendar, symptothermal)
• Female sterilization (tubal ligation, Essure)
• Vasectomy

The condom is the only birth control method that provides protection against sexually transmitted diseases (STDs).

The pill works in several ways to prevent pregnancy. The pill suppresses ovulation so that an egg is not released from the ovaries, and changes the cervical mucus, causing it to become thicker and making it more difficult for sperm to swim into the womb. The pill also does not allow the lining of the womb to develop enough to receive and nurture a fertilized egg. This method of birth control offers no protection against sexually-transmitted diseases.

Determining Effectiveness

Contraceptive effectiveness is characterized by "typical use" and "perfect use":

• Typical use refers to real-life conditions, in which mistakes (such as forgetting to take a birth control pill at the right time) sometimes happen.
• Perfect use refers to contraceptives that are used correctly each time intercourse occurs.

The most effective standard female contraceptives are surgical sterilization, intrauterine devices (IUDs), and the implant. They all have an estimated failure rate of 1% or less during the first year of normal (typical) use. Vasectomy (male surgical sterilization) is the only male contraceptive that is equally effective. By comparison, the estimated failure rate of the male latex condom is 17% with typical use and 2% with perfect use. To put these rates into perspective, a sexually active woman of reproductive age who does not use contraception faces an 85% likelihood of becoming pregnant in the course of a year.

Oral Contraception and Combination Hormonal Methods

Oral contraceptives (birth control pills) are available only by prescription and come in either a combination of estrogen and progestin or progestin alone. Many brands of each form are available. Although both are equally effective with typical use, the combined pill is more effective with perfect use, and most women choose this form.
Some women, however, experience severe headaches or high blood pressure from the estrogen in the combined pill and must take the progestin-only pill. Not all combined pills or progestin-only pills are alike, and brands differ in the amount of estrogen or progestin they contain. Many oral contraceptive combined brands now use lower estrogen doses and have fewer side effects than earlier oral contraceptives.
For all oral contraceptive users, a check-up at least once a year is essential. It is also important for women to have their blood pressure checked 3 months after beginning the pill. Once woman stop taking oral contraceptives they usually regain fertility within 3 - 6 months, but some women may regain it even sooner.

Hormones Used in Contraceptives

Estrogen (Estradiol)
Estrogen is the major female hormone and is responsible for female characteristics. The estrogen compound used in most oral contraceptives is estradiol , which is always used with a progestin.
Effects on Reproduction. When used throughout a menstrual cycle with progesterone, estrogen suppresses the actions of other reproductive hormones (luteinizing hormone, or LH, and follicle stimulating hormone, or FSH) and prevents ovulation.
Progesterone (Progestin)
When used in contraception, progesterone is referred to by one of several names:

• Progesterone is the name for the natural hormone.
• Progestogen is a synthetic form.
• Progestin is the term for any hormone, natural or synthetic, that causes progesterone effects; it is used as the general term in this report.

Progestins may be used alone or with estrogen in oral contraceptives. In addition, certain specific progestins are used in other kinds of contraceptives, such as etonogestrel in the Implanon implant and depo-medroxyprogesterone acetate in the injectable contraceptive Depo-Provera.
Progesterone can prevent pregnancy by itself in several ways:

• Blocking luteinizing hormone (LH) and preventing ovulation
• Maintaining a powerful barrier against the entry of sperm into the uterus by keeping the cervical mucus thick and sticky

Progestins used in contraceptives are referred to as:

• Second generation (levonorgestrel, norethisterone).
• Third generation (desogestrel, gestodene, norgestimate, drospirenone). The third-generation progestins tend to have fewer side effects. Some studies suggest, however, they may pose a slightly higher risk for blood clots than the older progestins.

Combination Estrogen-Progestin Contraceptive Pills

Oral contraceptives that contain both estrogen and progestin are the more common type of oral contraceptive. At least 10 million American women and 100 million women worldwide use combination oral contraceptives. When they were first marketed in the early 1960s, oral contraceptives contained as much as 5 times the amount of estrogen and up to 10 times the amount of progestin currently used. After reports of severe complications (stroke, heart attack, and pulmonary embolisms) in young women, the hormone amounts were significantly reduced.
The estrogen compound used in most oral contraceptives is ethinyl estradiol (also called estradiol, or EE). Fifty micrograms of estradiol is considered high dose, 30 - 35 micrograms are considered average dose, and 20 micrograms or fewer is low-dose. (The high doses found in current oral contraceptives are still much lower than earlier forms of the pill.) Doctors recommend using the lowest possible progestin and estrogen doses. Estrogen doses should not exceed 50 micrograms, as higher doses increase the risk for complications.
Many different types of progestins are used in combination with estradiol. Some common types of progestin, and popular combination oral contraceptive brands, include:

• Desogestrel is the progestrin used in Mircette. Approved in 1998, Mircette was the first oral contraceptive to offer a low estrogen dose and a new type of dosing regimen. Some studies suggest an increased risk for blood clots with desogesterel.
• Drospirenone is used in Yasmin and Yaz. (Yaz contains a lower dose of estrogen than Yasmin.) Because drospirenone increases blood levels of potassium, women should not use Yasmin or Yaz if they have kidney, liver, or adrenal diseases.
• Levonorgestrel is used in Seasonale and Seasonique, as well as many other oral and non-oral contraceptives.
• Norethindrone is used in Loestrin and Loestrin 24 Fe (which adds iron supplements to the placebo pills).
• Norgestrel is used in various generic and brand contraceptives.

Types of Regimens . Combination pills are sold in 21-day or 28-day packs:

• Each pill in a 21-day pack contains estrogen and progestin. Women take 1 pill a day for 21 days, and then wait 7 days before starting a new 21-day pack.
• 28-day packs typically start with 21 hormone pills and add 7 placebo pills that do not contain hormones. After taking hormone pills for 21 days, a woman takes the inactive pills for 7 days. Some newer brands, like Yaz, use 24 days of active pills and 4 days of inactive pills. Mircette uses 21 days of low-dose progestin and estrogen, followed by 2 placebo days, and then 5 days of very low-dose estrogen. Loestrin 24 Fe uses 24 days of active pills followed by 4 days of iron-containing placebo pills.

Oral contraceptives may be taken in cycles that include pills of the same or different strengths. These are categorized as monophasic (one-phase), biphasic (two-phase), or triphasic (three-phase). Monophasic pills contain the same amount of hormones in each dose. Biphasic and triphasic pills contain different dosages of hormones within the pill packs. Because monophasic pills have a consistent amount of hormones, they tend to cause fewer hormone-fluctuating side effects than biphasic or triphasic pills. Research shows little difference in effectiveness between these three types of oral contraceptives. Monophasic pills are often recommended as the best first-choice for birth control pills.
Taking the Pills. A woman usually takes the first pill either on the Sunday after her period starts or during the first 24 hours of her period. (The first pill can be started at any time during the menstrual cycle without affecting the bleeding patterns. Ovulation can occur that month, however.) The remaining pills are taken once a day, ideally at the same time of day, until the pack is used up. If a woman has a 21-day pack, she waits 7 days before starting a new pack. If she is on the 28-day pack, she takes the 7 inactive pills. Women should use another method of birth control during the first month taking the pill.
If you skip one or more pills, take the following precautions:

• Missing the first pill in a new cycle. Take a tablet as soon as you remember and the next one at the usual time. Two tablets can be taken in one day. Use barrier contraception for 7 days after the missed dose.
• Missing a pill 2 days in a row. Take 2 pills as soon as you remember and then 2 more the following day. Also use back-up barrier contraception until the next pill cycle.
• Missing more than 2 days. Discard the pack, use a back-up birth control method, and begin a new cycle on the following Sunday, even if you have started bleeding.

Continuous-Dosing Oral Contraceptives

Standard oral contraceptives come in a 28-pill pack that contains 21 active pills and 7 inactive pills. Newer "continuous-dosing" (also called "continuous-use") oral contraceptives aim to reduce -- or even eliminate -- monthly periods and thereby prevent the pain and discomfort that may still accompany menstruation in women taking oral contraceptives. Women who have medical conditions, (such as endometriosis), which cause heavy or painful menstrual periods may benefit from continuous-dosing oral contraceptives. These oral contraceptives contain a combination of estradiol and the progesterone levonorgestrel, but use extending dosing of active pills.
Seasonale, the first continuous-dosing contraceptive, contains 81 days of active pills followed by 7 days of inactive pills. Women who take Seasonale have on average a period every 3 months. Seasonique, a follow-up to Seasonale, also produces about 4 periods a year. With Seasonique, a woman takes 84 days of levonorgestrol-estradiol pills followed by 7 days of pills that contain only low-dose estradiol.
Lybrel supplies a daily low dose of levonorgestrol and estradiol with no inactive pills. Because Lybrel contains only active pills, which are taken 365 days a year, it completely eliminates monthly menstrual periods. About 60% of women who take Lybrel completely stop menstrual periods by the end of the first year. Some women, however, experience occasional unscheduled bleeding or spotting during the first 3 - 6 months.

Progestin-Only Oral Contraceptives ("Mini-Pills")

Progestin-only pill brands include:

• Levonorgestrel 
• Norethindrone 
• Norgestrel

Progestin-only pills, which only contain progestins, are always sold in 28-day packs and all the pills are active. An exception is Plan B, which is emergency contraception. [For more information, see Emergency Contraception section in this report.) Progestin-only pills, which are also called “mini-pills,” must be taken at precisely the same time each day to maintain effectiveness. If a woman deviates from her pill schedule by even 3 hours, she should call her doctor about using back-up contraception for the next 2 days.
Progestin-only pill users experience even lighter periods than those taking combination pills. Some may not have periods at all. Because these pills do not contain estrogen, they may be a safer choice for women over age 35, smokers, and those who have other risk factors that contraindicate estrogen use.

Advantages of Oral Contraceptives

Oral contraceptives are the choice of most women who use birth control, making them the most popular reversible contraceptives .Oral contraceptives are among the most effective contraceptives. Failure rates are relatively low (9% with typical use) and are usually due to noncompliance.
Oral contraceptives also have the following advantages, which may vary depending on the type and brand used:

• Reduce menorrhagia (heavy menstrual bleeding) and, therefore, reduce the risk of anemia.
• Reduce dysmenorrhea (severe menstrual pain)
• May help reduce symptoms of premenstrual syndrome. Yaz is specifically approved for treating premenstrual dysphoric disorder (premenstrual depression).
• Improve acne
• Improve symptoms of endometriosis.

Endometriosis is the condition in which the tissue that normally lines the uterus (endometrium) grows on other areas of the body causing pain and irregular bleeding.

• Reduce risks of ovarian cysts
• Possible protection against bone loss with estrogen-containing oral contraceptives
• Reduce risks of ovarian and endometrial (uterine) cancers with long-term use (more than 3 years)

Disadvantages of Oral Contraceptives

Common Side Effects. Many women experience some side effects during the first 2 - 3 months of birth control use. These side effects usually subside. Estrogen and progesterone have different side effects, and women on the combined pill may experience different effects from those on the progestin-only pill.
Common side effects of oral contraceptives include:

• Nausea and vomiting (can often be controlled by taking the pill during a meal or at bedtime)
• Headaches (in women with a history of migraines, they may worsen)
• Dizziness
• Breast tenderness and enlargement
• Irregular bleeding or bleeding between periods
• Weight gain

Newer formulations of combination pills that use low-dose estrogen, and newer progestins, may reduce and even lower the risk of many of these side effects, including weight gain.
Serious Side Effects . Symptoms of serious problems may include severe abdominal pain, chest pain, unusual headaches, visual disturbances, or severe pain or swelling in the legs. If you experience any of these symptoms, you should immediately contact your doctor.
Potential Risks . Combination birth control pills can increase the risk of developing or worsening certain serious medical conditions. The risks depend in part on a woman’s medical history. You should discuss your health history with your doctor to determine if combination oral contraceptives are safe for you. This is especially important for women who are age 35 or older, smoke, or have a history of high blood pressure, high cholesterol or unhealthy blood lipid profile, diabetes, or migraine headaches.
Serious risks of birth control pills may include:

• Heart and Circulation Problems. Combination birth control pills contain estrogen, which can increase the risk for stroke, heart attack, and blood clots in some women. The risk is highest for women who smoke or have a history of heart disease risk factors (such as high blood pressure or unhealthy cholesterol/lipid levels) or cardiac events. Women who have certain metabolic disorders, such as polycystic ovary syndrome (PCOS), are also at higher risk for heart-related complications associated with these pills. Women who have migraines may possibly be at increased risk for stroke and may need to consider progestin-only pills or other contraceptive methods in place of combination oral contraceptives.
• Venous Thromboembolism. All combination estrogen/progestin birth control products carry an increased risk for blood clots in the veins (venous thromboembolism), which can lead to blood clots in the arteries of the leg or lung (pulmonary embolism). The risk is lower for oral contraceptives than for the birth control patch (Ortho Evra) or the ring (NuvaRing), which expose women to higher levels of estrogen than birth control pills. Women who smoke, who are obese, or who have heart disease risk factors may want to consider using alternatives to estrogen-containing contraceptives, such as progestin-only oral contraceptives ("mini-pills"), intrauterine devices, or barrier contraceptive methods.
• Diabetes. Women who have diabetes, and high blood pressure, vascular disease, kidney disease, or other diabetes-related health problems, should not take birth control pills.
• Cancer Risks. Several studies have reported a strong association between increased risk of cervical cancer and long-term use of oral contraception. Women who take oral contraceptives for more than 10 years appear to have a much higher risk of human papilloma virus (HPV) infection than those who do not use oral contraceptives. Women taking oral contraceptives for less than 5 years have no significantly higher risk. Although studies have been conflicting about whether estrogen in oral contraception increases the chances for breast cancer, the most recent research indicates that oral contraceptive use does not significantly increase breast cancer risk. Women who have used oral contraceptives may have slightly more risk for breast cancer than women who have never used them, but this risk declines once a woman stops using birth control pills. Long-term use of birth control pills reduces the risk for ovarian and uterine cancers.
• Liver Problems. In rare cases, oral contraceptives have been associated with liver tumors, gallstones, or jaundice. Women with a history of liver disease, such as hepatitis, should consider other contraceptive options.
• Interactions with Other Medications. Certain types of medications can interact with and decrease the effectiveness of oral contraceptives. These medications include anticonvulsants, antibiotics, antifungals, and antiretrovirals. The herbal remedy St. John’s wort can also interfere with birth control pills’ effectiveness. Make sure your doctor is aware of any drugs, vitamins, or herbal supplements that you take.

Other Methods for Administering Combination Hormones (Patch and Ring)

New methods of administering the combination of progestin and estrogen are now available. Failure rates with perfect use (0.1 - 0.6%) are similar to those of combined oral contraceptives.
Skin Patch. Ortho Evra is a birth control skin patch. It contains a progestin (norelgestromin) and estrogen. The patch is placed on the lower abdomen, buttocks, or upper body (but not on the breasts). Each patch is worn continuously for a week and reapplied on the same day of each week. After three weekly patches, the fourth week is patch-free, which allows menstruation. (The patch remains effective for 9 days, so being slightly late in changing it should not increase the risk for pregnancy.)
The Ortho patch exposes women to higher levels of estrogen than most birth control pills, and therefore increases the risk for blood clots in the veins (venous thromboembolism). Venous thromboembolism can cause blockage in lung arteries and other serious side effects. Older women (over age 40) and women with risk factors for blood clots (such as cigarette smoking) may find other birth control products to be a safer choice. Discuss with your doctor whether the patch is appropriate for you.
Vaginal Ring. NuvaRing is a 2-inch flexible ring that contains both estrogen and progestin (etonogestrel). It is inserted into the vagina. Women can insert the ring by themselves once a month and take it out at the end of the third week to allow menstruation. It works well and may cause less irregular bleeding than oral contraceptives. Some women find it uncomfortable, and a few have reported vaginal irritation and discharge, but such problems rarely cause a woman to discontinue use. As with the patch, NuvaRing may put women who take it at higher risk for blood clots than oral contraceptives.

Implant Contraception

Implant contraception involves inserting a rod under the skin. The rod releases into the bloodstream tiny amounts of the hormone progestin.
The first implant was the Norplant system, which used six rods that contained levonorgestrel. Due in part to serious complications, Norplant was withdrawn from the U.S. market in 2002. The main complication was difficulty inserting and, in particular, removing the rods. (Many women experienced scarring.) In addition, some women who used Norplant experienced heavy irregular bleeding. A two-rod implant called Jadelle is sold in other countries, but not the United States.
In 2006, the Food and Drug Administration approved Implanon, a new implant contraceptive. In contrast to Norplant:

• Implanon uses one rod, not six.
• It is not inserted as deeply into the skin.
• It uses etonogestrel, a different type of progestin than the levonorgestrel used in Norplant.
• Only specially trained health care providers are allowed to insert and remove Implanon.

Implanon insertion takes about a minute and is performed with a local anesthetic in a doctor’s office. The rod remains in place for 3 years, although it can be removed at any time. (The removal procedure takes a few minutes longer than insertion.) After the rod is removed, a new one can be inserted.
Studies indicate that Implanon is safe. Irregular bleeding and headaches are the main side effects. However, some doctors are concerned that Implanon may have some of the same risks as Norplant.

Injected Contraception

Injected contraceptives are given once every 3 months. Most injectables are progestin-only. In the United States, depo-medroxyprogesterone acetate (Depo-Provera) is the only approved injected contraceptive. Depo-Provera (also called Depo, or DMPA) uses a progestin called medroxyprogesterone.
Depo-Provera is very effective in preventing pregnancies. About 3 in 100 women who use it become pregnant. However, Depo also carries the risk for many mild and serious side effects. The most serious side effect is loss of bone density (see "Disadvantages"). Because of this complication, Depo-Provera should not be used for longer than 2 years.
Administering Injections :

• A physical examination is necessary before beginning the injections.
• Depo is injected into a muscle in the patient's arm or buttock. During months between injections, the hormone slowly diffuses out of the muscle into the bloodstream.
• Depo requires an injection by the doctor once every 3 months.
• If more than 2 weeks pass beyond the regular injection schedules, the woman should have a pregnancy test before receiving the next injection.

Candidacy

Because Depo-Provera does not contain estrogen, it is safe for many women who may be riskier candidates for combination oral contraceptive use, such as women over age 35, women with high blood pressure, obese women, and smokers.
Depo-Provera should not be given to women who have a history of:

• Current or past breast cancer
• Stroke or blood clots
• Liver disease
• Epilepsy, migraine, asthma, heart failure, or kidney disease (due to the fact that the drug causes fluid retention)
• Unexplained vaginal bleeding
• Risk for osteoporosis

Because of the long lag time between ending treatments and restoration of fertility, Depo-Provera is not recommended for women who are thinking of becoming pregnant within 2 years.

Advantages of Depo-Provera

• Provides highly effective reversible protection against pregnancy without placing heavy demands on the user's time or memory.
• Does not increase risk for breast, ovarian, or cervical cancer. May protect against endometrial cancer.
• May be useful for women with painful periods, heavy bleeding (including heavy bleeding caused by fibroids), premenstrual syndrome, and endometriosis.

Disadvantages and Complications of Depo-Provera

• Weight gain. Most women gain an average of 5 - 8 pounds.
• Other common side effects include menstrual irregularities (bleeding or cessation of periods), abdominal pain and discomfort, dizziness, headache, fatigue, nervousness.
• Most users of Depo-Provera stop menstruating altogether after a year. Depo can cause persistent infertility for up to 22 months after the last injection, although the average is 10 months.
• Long-term (more than 2 years) use of Depo-Provera can cause loss of bone density. Depo-Provera’s label warns that the decline in bone density increases with duration of use and may not be completely reversible even after the drug is discontinued. The FDA recommends that Depo-Provera should not be used for longer than 2 years unless other birth control methods are inadequate. Some studies indicate that this bone loss may be reversible once Depo-Provera use is discontinued. Some doctors recommend that women take calcium and vitamin D supplements while on Depo-Provera.
• The injections do not provide protection against sexually transmitted diseases.

Intrauterine Devices (IUDs)

The intrauterine device (IUD) is a small plastic T-shaped device that is inserted into the uterus. An IUD's contraceptive action begins as soon as the device is placed in the uterus and stops as soon as it is removed. IUDs have an effectiveness rate of close to 100%. They are also a reversible form of contraception. Once the device is removed, a woman regains her fertility.

The intrauterine device (IUD) shown uses copper as the active contraceptive. Others use progesterone in a plastic device. IUDs are very effective at preventing pregnancy (less than 1% chance per year). IUDs come with increased risk of ectopic pregnancy and perforation of the uterus and do not protect against sexually transmitted disease. IUDs are prescribed and placed by health care providers.

Intrauterine Device Forms

Two types of intrauterine devices (IUDs) are available in the United States:

• Copper-Releasing (ParaGard). This type of IUD can remain in the uterus for up to 10 years. Copper ions released by the IUD are toxic to sperm, thus preventing fertilization.
• Progestin-Releasing (Mirena). This type of IUD can remain in the uterus for up to 5 years. Mirena is also known as a levonorgestrel-releasing intrauterine system, or LNG-IUS. Levonorgestrel impairs sperm motility and viability, thus preventing fertilization. LNG-IUS is long-acting, safe, very effective in preventing heavy bleeding, and helps reduce cramps. In fact, some doctors describe it as a nearly ideal contraceptive. In addition to being a contraceptive, it is approved as a treatment for heavy menstrual bleeding.

Inserting an Intrauterine Device

With some exceptions, an intrauterine device (IUD) can be inserted at any time, except during pregnancy or when an infection is present. It may be inserted immediately postpartum or after elective or spontaneous miscarriage. It is typically inserted in the following manner by a trained health professional:

• A plastic tube containing the IUD (the inserter) is slid through the cervical canal into the uterus.
• A plunger in the tube pushes the IUD into the uterus.
• Attached to the base of the IUD are two thin but strong plastic strings. After the instruments are removed, the health care provider cuts the strings so that about an inch of each dangles outside the cervix within the vagina.

The strings have two purposes:

• They enable the user or health care provider to check that the IUD is properly positioned. (Because the IUD has a higher rate of expulsion during menstruation, the woman should also check for the strings after each period, especially if she has heavy cramps.)
• They are used for pulling the IUD out of the uterus when removal is warranted.

The insertion procedure can be painful and sometimes causes cramps, but for many women it is painless or only slightly uncomfortable. Patients are often advised to take an over-the-counter painkiller ahead of time. They can also ask for a local anesthetic to be applied to the cervix if they are sensitive to pain in that area. Occasionally a woman will feel dizzy or light-headed during insertion. Some women may have cramps and backaches for 1 - 2 days after insertion, and others may suffer cramps and backaches for weeks or months. Over-the-counter painkillers can usually moderate this discomfort.

Candidates for the Intrauterine Device

Intrauterine devices are an excellent choice of contraception for women who are seeking a long-term and effective birth control method, particularly those wishing to avoid risks and side effects of contraceptive hormones. The LNG-IUS may be better suited for women with heavy or regular menstrual flow.
Around the time of insertion and shortly afterwards, women should be considered at low risk for sexually transmitted disease (mutually monogamous relationship, using condoms, or not currently sexually active).
Women with risk factors that preclude hormonal contraceptives should probably avoid progestin-releasing IUDs, although the progestin doses are much lower with LNG-IUS and probably do not pose the same risks.
Women with the following history or conditions may be poor candidates for IUDs:

• Current or recent history of pelvic infection (the risk of pelvic inflammatory disease is higher for all women who have multiple sex partners or who are in non-monogamous relationships--not just those with IUDs)
• Current pregnancy
• Abnormal Pap tests
• Cervical or uterine cancer
• A very large or very small uterus

IUDs have the following advantages:

• The IUD is more effective than oral contraceptives at preventing pregnancy, and it is reversible. Once it is removed, fertility returns. (Studies have found no adverse effects on fertility with the current IUDs.)
• Unlike the pill, there is no daily routine to follow.
• Unlike the barrier methods (spermicides, diaphragm, cervical cap, and the male or female condom), there is no insertion procedure to cope with before or during sex.
• Intercourse can resume at any time, and, as long as the IUD is properly positioned, neither the user nor her partner typically feels the IUD or its strings during sexual activity.
• It is the least expensive form of contraception over the long term.

Additional advantages, depending on the specific IUD, include:

• The progestin-releasing LNG-IUS (Mirena) is now considered to be one of the best options for treating menorrhagia (heavy menstrual bleeding). (However, irregular breakthrough bleeding can occur during the first 6 months.)
• The copper-releasing IUDs do not have hormonal side effects and may help protect against endometrial (uterine) cancer.

Complications of Specific Intrauterine Devices

Menstrual Bleeding. Both intrauterine device (IUD) forms have effects on menstruation, although they differ significantly by type:

• Copper releasing IUDs can cause cramps, longer and heavier menstrual periods, and spotting between periods. Prescription medications are available to control the bleeding and pain, which, in any event, usually subside after a few months.
• Progestin-releasing IUDs produce irregular bleeding and spotting during the first few months. Bleeding may disappear altogether. (This characteristic is a major advantage for women who suffer from heavy menstrual bleeding but may be perceived as a problem for others.)

Ovarian Cysts . The LNG-IUS may increase the risk for benign ovarian cysts, but such cysts usually do not cause symptoms and resolve on their own.
Expulsion. About 2 - 8% of IUDs are expelled from the uterus within the first year. Expulsion is most likely to occur during the first 3 months after insertion. Expulsion rates may be higher than average if the IUD is inserted immediately after delivery of a child. In 1 in 5 cases, the woman fails to notice that the device is gone, and thus faces the risk of unintended pregnancy. The risk for expulsion is highest during menstruation, so women should be sure to check the strings to make sure the IUD is in place.
Pelvic infections . What was thought to be an increased risk of pelvic inflammatory disease has proven not to be true. The risk does not seem to be any greater than the risk in the general population The risk for infection may be increased around the time of insertion of the IUD, but routine screening before insertion is generally not recommended. There is also no evidence that IUD usage increases the risk of HIV infection.
Effects on Pregnancy.

• None of the current IUDs increase the risk for infertility. Women with a history of using an IUD are no more likely to be diagnosed with infertility than those who have not used IUDs. This seems to be true both for women who have never been pregnant or women who have been pregnant previously.
• In the very unlikely event that a woman conceives with an IUD in place, however, there is a higher risk of an ectopic pregnancy or miscarriage. Ectopic pregnancy is when the fertilized egg implants outside of the uterus. Most ectopic pregnancies occur in the fallopian tubes. However, overall, women who use IUDs have a significantly lower rate of ectopic pregnancies than women who do not use any contraception. Even for women who have a history of ectopic pregnancies when not using contraception, the IUD is considered safe and may even lower their risk for another one.

If the IUD is removed right after conception, the risk for miscarriage is close to average (about 20%). There is no evidence that the IUD in a pregnant woman increases the risk for birth defects in the infant.
Perforation. A potentially serious complication of the IUD is the accidental perforation of the uterus during insertion or later perforation if the IUD shifts position. Such an occurrence is very rare, particularly if the doctor is experienced with insertion.

Spermicidal and Barrier Contraception

Barrier contraceptives are devices that provide a physical barrier between the sperm and the egg. Examples of barrier contraceptives include the male condom, female condom, diaphragm, cervical cap, and sponge. The condom is the only contraceptive method that helps prevent sexually transmitted diseases (STDs).

Spermicides

Vaginal spermicides are sperm-killing substances available as foams, creams, gels, films, or suppositories, and are often used in female contraception with barrier and other devices. Spermicides are usually available without a prescription or medical examination.
The active ingredient in U.S.-made spermicides is usually nonoxynol-9, which attacks the surface of the sperm cell. Nonoxynol-9, however, does not provide any protection against sexually-transmitted diseases or HIV (the virus that causes AIDS). Research indicates that frequent use can cause vaginal and rectal irritation and abrasions that may actually increase the risk for HIV transmission in women. In addition, use of a spermicide with a barrier device may increase the risk for a urinary tract infection in women, regardless of whether the device is a condom or diaphragm. (Non-spermicidal lubricated condoms are safe to use.)
In general, spermicides may be an appropriate choice for women who have intercourse only once in a while, or need backup protection against pregnancy (for instance, if they forget to take their birth control pills). Spermicides should not be used alone as the primary method of birth control.

The Male Condom

The condom is still the only reversible form of male contraception currently available.
Pregnancy Protection . The condom should be put on before intercourse when the penis is erect, since the male can discharge sufficient semen to cause pregnancy before ejaculation occurs. With typical use, the average rate of pregnancy for couples that rely only on condoms for protection is high -- about 17%. For those who use a condom correctly each time, the annual risk for pregnancy is 2%.
Prevention of Sexually Transmitted Diseases . Condoms are important in the prevention of sexually transmitted disease including gonorrhea, Chlamydia , syphilis, herpes, trichomoniasis, and HIV.
Most condoms come pre-lubricated. Lubricants can also be purchased and applied separately. Only water-based lubricants (K-Y Jelly, Astroglide, AquaLube, glycerin) should be used with latex condoms. Do not use petroleum jelly or other oil-based lubricant products as these can damage the condom. In general, it's best to use a pre-lubricated condom or to apply a water-based lubricant. Unlubricated condoms may injure vaginal tissue and make it vulnerable to infections.
Condom Materials . Condoms made of latex rubber are the most common types. They are less likely to slip or break than those made of polyurethane, and they are contoured for a better fit that can provide fairly effective protection. Some people are allergic to latex, however, and in some cases the reaction can be very dangerous. The latex smell may also be unpleasant for some people. Condoms made from animal membrane (such as lambskin) can prevent pregnancy, but they are permeable and do not protect against sexually transmitted infections.

Female Condom

The female condom (Reality, Femidom) is a lubricated, loose-fitting pouch that lines the vagina. It is designed to create a physical barrier against sperm and sexually transmitted diseases by surrounding the penis during intercourse. The failure rate for the female condom is about the same as for the diaphragm and cervical cap. It is available without a prescription but may be hard to find. The female condom may be a good option for women at risk for sexually transmitted diseases and who are not certain that their male partner will use a condom.
Use and Insertion of the Female Condom. The female condom is about 3 inches wide and 6 - 7 inches long (larger than a male condom), with a flexible ring at both ends. Current products are made of polyurethane.

• The ring at the closed end is used to insert the device into the vagina and hold it in place over the cervix.
• The ring at the open end remains outside the vagina and partly covers the labia (lips).

The insertion process may seem difficult at first but becomes much easier with practice:

• The female condom is inserted by hand into the vagina up to 8 hours before intercourse. (It should never be used in combination with a male condom.)
• Although the female condom is prelubricated, extra lubricant is sometimes needed while inserting the device or during intercourse. (It is not made of latex, so oil lubricants will not harm it.)
• During intercourse, the woman checks to be sure that the outer ring is lying flat against her labia and then guides her partner's penis into the ring.

The female condom should be removed in the following circumstances:

• If it tears during insertion or use
• If the outer ring is pushed inside
• If it bunches up inside the vagina

Advantages of the Female Condom. The female condom is an effective barrier to viruses, including HIV, and other sexually transmitted organisms, particularly since it covers a large area, including external genitals. However, it does not completely protect against sexually transmitted diseases.

• The standard female condom is made of polyurethane, which is thin and soft but at the same time stronger than the latex male condoms. Polyurethane is not damaged by lubricating oils, as latex is and is also less likely to cause an allergic reaction. It transmits body heat better than latex, providing a more "natural" sensation.
• The man does not have to withdraw his penis immediately after ejaculation, as is the case with the male condom, but can, if he wishes, withdraw after he has lost his erection.

Disadvantages and Complications of the Female Condom. Compliance rates are low for many reasons. About 25% of women have difficulty on the first attempt at self-insertion. Some women are distressed by self-insertion. The inner ring may be uncomfortable for some women (in which case it can be removed). Some couples complain that the female condom is unpleasant to look at and can be noisy during intercourse. Without sufficient lubrication, it can also be pushed out of place by the penis. Using more lubricant can help keep the female condom in place and reduce the noise. Female condoms are also expensive, and some women wash them out and reuse them to save money. (In such cases, they should be disinfected first and then washed carefully.) Repeated washings can increase the risk for damage and holes.

Diaphragm

The diaphragm is a small dome-shaped latex cup with a flexible ring that fits over the cervix. The cup acts as a physical barrier against the entry of sperm into the uterus. A diaphragm is usually used along with a spermicide, although whether spermicide is necessary is an issue of some debate.

The diaphragm is a flexible rubber cup that is filled with spermicide and self-inserted over the cervix prior to intercourse. The device is left in place several hours after intercourse. The diaphragm is a prescribed device fitted by a health care professional and is more expensive than other barrier methods, such as condoms.

Diaphragms come in different sizes and require a fitting by a trained health care provider. Some women will need to be refitted with a different-sized diaphragm after pregnancy, abdominal or pelvic surgery, or weight loss or gain of 10 pounds or more. As a general rule, diaphragms should be replaced every 1 - 2 years.
Although the diaphragm has a relatively high failure rate, even with perfect use, it is considered a good choice for women whose health or lifestyle prevents them from using more effective hormonal contraceptives. Certain conditions of the vagina and uterus, a history of toxic shock syndrome, or a history of recurrent urinary tract infections, may disqualify a woman from using the device. The diaphragm should not be used if either partner is allergic to latex or spermicides.
Using and Inserting the Diaphragm. The diaphragm can be placed in the vagina up to 1 hour before intercourse. The following are general guidelines for insertion:

• Before or after each use, the woman should hold the diaphragm up to the light and fill it with water to check for holes, tears, or leaks.
• A small amount of spermicide (about 1 tablespoon) is usually placed inside the cup, and some is smeared around the lip of the cup.
• The device is then folded in half and inserted into the vagina by hand or with the assistance of a plastic inserter.
• The diaphragm should fit over the cervix, blocking entry to the womb.
• If more than 6 hours pass before repeat intercourse occurs, the diaphragm is left in place and extra spermicide is inserted into the vagina using an applicator.
• The diaphragm must remain in the vagina for 6 - 8 hours after the final act of intercourse, and can safely stay there up to 24 hours after insertion.
• The diaphragm should be washed with soap and warm water after each use and then dried and stored in its original container, which should be kept in a cool dry place.

Advantages of the Diaphragm. The diaphragm can be carried in a purse, can be inserted up to an hour before intercourse begins, and usually (although not always) cannot be felt by either partner. It does not interfere with a woman’s hormones.
Disadvantages and Complications of the Diaphragm. Some disadvantages or complications are as follows:

• Failure rates are high, about 16% with typical use.
• Some women dislike having to insert the device every time intercourse occurs or have trouble mastering the insertion and removal process.
• The diaphragm can be dislodged during sex.
• Frequent urinary tract infections and vaginal infections are a problem for some women. This difficulty can sometimes be resolved by a refitting, by urinating before inserting the device, or by urinating after intercourse.
• Some women may have allergic reactions to the latex or spermicides.
• Although rare, cases of toxic shock syndrome have been reported among diaphragm users. To be safe, the diaphragm should not stay in place for more than 24 hours and should not be used during menstrual periods. (For pregnancy protection, however, the diaphragm should stay in place for 6 - 8 hours after intercourse.)
• The diaphragm does not protect against sexually transmitted diseases.

Cervical Cap

The cervical cap (FemCap) is a thimble-shaped latex cup that fits over the cervix. It is always used with a spermicidal cream or gel. It is similar to a diaphragm, but smaller, and is available in only four sizes. The cap is sold by prescription and requires a pelvic examination, Pap test, and fitting by a health care provider.
Insertion and Use of the Cervical Cap. After a small amount of spermicide is placed in the cap, the device is inserted by hand. As in diaphragm use, instruction and practice is required. The cap must be kept in the vagina for 8 hours after the final act of intercourse. Caps wear out and should be replaced every 1 - 2 years. A refitting may also be needed when a woman experiences certain changes in her health or physical status.
Candidacy for the Cervical Cap. Because of the restricted range of available sizes, about 1 in 5 women will not be able to be fitted for the cap. The cap is not widely used, and some women, particularly those who live in sparsely populated areas, may not have access to health care professionals who are trained in fitting this device. Other conditions that can preclude cap use include:

• An abnormal Pap test
• A history of toxic shock syndrome
• A sexually transmitted or reproductive tract infection
• Inflammation of the cervix
• The cap has little value for women who have had children, because the stretching of the vagina and cervix makes a proper fit more difficult and failure rates are high.

Advantages of the Cervical Cap. Among women who have never given birth, the cap's failure rate is similar to that of the diaphragm. The cap in general is also similar to the diaphragm in terms of cost, ease of use, and also the potential for latex or spermicidal allergies. But unlike the diaphragm, the cap can safely remain in the vagina for up to 48 hours (twice the time limit for a diaphragm), so it can be inserted well in advance of intercourse. The cap is rarely associated with urinary tract infections.
Disadvantages of the Cervical Cap. The following are disadvantages of the cervical cap:

• May be difficult to insert
• May be pushed out of place during sex
• Cannot be used during menstruation
• High failure rates (32% typical use) for women who have given birth

Lea’s Shield . Approved in 2002, Lea’s shield is similar to a cervical cap but contains an air valve that helps it stick to the vaginal walls and allow for the passage of cervical mucus. Unlike cervical caps, it is available in only one size and does not need to be fitted. Lea’s shield is made of silicone, and its cup-shaped bowl completely surrounds the cervix without resting on it. The shield is as effective as the diaphragm and cap when used with spermicide. Its advantages are:

• One size fits all
• Can be left for 48 hours after intercourse
• Reusable for 6 months

The Sponge

The sponge is a disposable form of barrier contraception. It is made of soft polyurethane foam coated with spermicide, is round in shape, and fits over the cervix like a diaphragm, but is smaller and easily portable. The Today sponge is the only brand of contraceptive sponge available in the United States.
The Today sponge originally came on the U.S. market in 1983, but was withdrawn in1994 because of problems at the company's manufacturing facility. In 2009, after several failed attempts, the Today sponge was relaunched and is now available in drugstore chains throughout the United States.
Use and Insertion . To use the sponge, the woman first wets it with water, then inserts it into the vagina with a finger, using a nylon cord loop attachment. It can be inserted up to 6 hours before intercourse and should be left in place for at least 6 hours following intercourse. The sponge provides protection for up to 12 hours. It should not be left in for more than 30 hours from time of insertion.
The sponge should not be used during menstruation, after childbirth, miscarriage, or termination of pregnancy, or by women with a history of toxic shock syndrome.
Advantages and Disadvantages. The sponge is easy to use, is not felt during intercourse, and can be inserted up to 6 hours before intercourse. However, because it contains the spermicide nonoxynol-9, it does not protect against sexually transmitted diseases and may increase the risk for vaginal irritation and transmission of HIV.

Fertility Awareness Methods

Fertility awareness methods, also called natural family planning, do not use drugs, physical devices, or surgery to prevent pregnancy. Instead, these cycle-based methods rely on tracking the changes in the body that signal fertility. A woman is only fertile during part of her menstrual cycle. By monitoring certain changes in her body, a woman can more or less predict the fertile phase and abstain from sexual intercourse during that time. She can also use barrier methods if they are not prohibited by religious beliefs.
Fertility awareness methods include:

• Temperature
• Cervical mucus (ovulation)
• Calendar
• Symptothermal

Temperature Method. To determine the most likely time of ovulation and therefore the time of fertility, a woman is instructed to take her body temperature, called her basal body temperature. This is the body's temperature as it rises and falls in accord with hormonal fluctuations.

• Each morning before rising, the woman takes her temperature with a specialized basal body thermometer and marks the result on a graph-paper chart.
• She also notes the days of menstruation and sexual activity.
• The so-called "fertile window" is 6 days long. It starts 5 days before ovulation and ends the day of ovulation.
• The chances for fertility are considered to be highest between days 10 - 17 in the menstrual cycle (with day 1 being the first day of the period and ovulation occurring about 2 weeks later). However, not all women are fertile within that period of time. Women who have a longer or shorter menstrual cycle may have different time periods of fertility.
• Immediately after ovulation, the body temperature increases sharply in about 80% of cases. (Some women can be ovulating normally yet not show this temperature pattern.)

By studying the temperature patterns over a few months, couples can begin to anticipate ovulation and plan their sexual activity accordingly. To avoid losing spontaneity, couples should try to avoid becoming fixated on the chart in scheduling their sexual activity.
Cervical Mucus Method. The cervical mucus method (also called the ovulation method) requires a woman to take a sample (by hand) of her cervical mucus every day for a least a month and to record its quantity, appearance, feel, and to note other physical signs connected with the reproductive system. Cervical mucus changes in predictable ways over the course of each menstrual cycle:

• Six days before ovulation, mucus is affected by estrogen and becomes clear and elastic. Ovulation is likely to occur the last day that mucus has these properties.
• Right after ovulation, mucus is affected by progesterone and is thick, sticky, and opaque.

Once a woman's individual pattern is understood, analyzing cervical mucus can provide a highly accurate guide to fertility.
Calendar Method . The calendar (rhythm method) is considered the least reliable of fertility awareness methods. Women who have very irregular periods may have even less success with this method. In the calendar method, the woman first keeps a record of her menstrual periods for about 6 - 12 months. She then subtracts 18 days from the shortest and 11 days from the longest of the previous menstrual cycles. For example, if a woman's shortest cycle was 26 days and her longest cycle was 30 days, she must abstain from intercourse from day 8 through day 19 of each cycle.
Symptothermal Method . This method combines the temperature, cervical mucus, and calendar methods and is considered the most effective fertility awareness method. In addition, the woman tracks symptoms that may identify her fertile period. These symptoms include changes in the shape of the cervix, breast tenderness, and cramping pain.

Candidacy for Fertility Awareness Methods

Because of the high risk for pregnancy, fertility awareness methods are recommended only for those whose strong religious beliefs prohibit standard contraceptive methods. Couples who are not guided by religious authority, but who simply want a more natural sexual life, may use a barrier contraceptive during the fertile phase and no contraception during the rest of the cycle. However, they should understand the risk of pregnancy will be higher with this method. To be effective against pregnancy, cycle-based methods require not only training, commitment, discipline, and perseverance, but also the cooperation of the male partner. Cycle-based methods are not recommended for women unless they are in a stable, monogamous relationship, and can count on their partner's willing participation.
Fertility-based awareness methods do not protect against sexually transmitted diseases.

Emergency Contraception

Emergency contraception is a birth control method to prevent pregnancy in women:

• After a sexual assault or rape
• When a condom breaks or a diaphragm slips out of place
• When a woman forgets to take birth control pills
• When you have sex and do not use any birth control

Basics of Emergency Contraception

Emergency contraception most likely works by preventing or delaying the release of an egg from a woman's ovaries. This method prevents pregnancy in the same way as regular birth control pills.
TYPES OF EMERGENCY CONTRACEPTION
Two emergency contraceptive pills may be bought without a prescription:

• Plan B One-Step is a single tablet that contains 1.5 mg of levonorgestrel.
• Next Choice is taken as two doses, which each contain 0.75 mg of levonorgestrel. Both pills can be taken at the same time or as two separate doses 12 hours apart.
• Either may be taken for up to 5 days after unprotected intercourse.

Ulipristal acetate (ella) is a new type of emergency contraception pill that requires a prescription from a health care provider.

• Ulipristal is taken as a single tablet.
• It may be taken up to 5 days after unprotected sex.

Two other methods that may be used to prevent pregnancy after unprotected sex are:

• Birth control pills. Talk to your health care provider about the correct dosage. In general, you must take 2 - 5 birth control pills at the same time to have the same protection.
• A copper-releasing intrauterine device (IUD) may be used as an alternative emergency contraception method. It must be inserted by your health care provider within 5 days of having unprotected sex. Your doctor can remove it after your next period, or you may choose to leave it in place to provide ongoing birth control.

MORE ABOUT EMERGENCY CONTRACEPTIVE PILLS
Women ages 17 and older can buy Plan B One-Step and Next Choice at a pharmacy without a prescription or visit to the doctor. Younger girls need to contact a health care provider to get a prescription for these pills.
Emergency contraception works best when you use it within 24 hours of having sex. However, it may still prevent pregnancy for up to 5 days after you first had sex.
Emergency contraception may cause side effects. Most are mild. They may include:

• Changes in menstrual bleeding
• Fatigue
• Headache
• Nausea and vomiting

After you use emergency contraception, your next menstrual cycle may start earlier or later than usual. Your menstrual flow may be lighter or heavier than usual.

• Most women get their next period within 7 days of the expected date.
• If you do not get your period within 3 weeks after taking emergency contraception, you might be pregnant. Contact your health care provider.

Sometime, emergency contraception does not work. However, research suggests that emergency contraceptives have no long-term effects on the pregnancy or developing baby.
OTHER IMPORTANT FACTS
You should not use emergency contraception if:

• You think you have been pregnant for several days
• You have vaginal bleeding for an unknown reason (talk to your health care provider first)

You may be able to use emergency contraception even if you cannot regularly take birth control pills. Talk to your health care provider about your options.
Emergency contraception should not be used as a routine birth control method. It is less effective at preventing pregnancies than most types of birth control.

Female Sterilization

Female surgical sterilization (also called tubal sterilization, tubal ligation, and tubal occlusion) is a low-risk, highly effective one-time procedure that offers lifelong protection against pregnancy. About 700,000 women undergo this procedure each year in the United States.

Basics of Female Sterilization

Female surgical sterilization procedures block the fallopian tubes and thereby prevent sperm from reaching and fertilizing the eggs. The ovaries continue to function normally, but the eggs they release break up and are harmlessly absorbed by the body. Tubal sterilization is performed in a hospital or outpatient clinic under local or general anesthesia.

The uterus is a hollow muscular organ located in the female pelvis behind the bladder and in front of the rectum. The ovaries produce the eggs that travel through the fallopian tubes. Once the egg has left the ovary it can be fertilized and implant itself in the lining of the uterus. The main function of the uterus is to nourish the developing fetus prior to birth.

Sterilization does not cause menopause. Menstruation continues as before, with usually very little difference in length, regularity, flow, or cramping. Sterilization does not offer protection against sexually transmitted diseases.

Specific Tubal Sterilization Techniques

Laparoscopy. Laparoscopy is the most common surgical approach for tubal sterilization:

• The procedure begins with a tiny incision in the abdomen in or near the navel. The surgeon inserts a narrow viewing scope called a laparoscope through the incision.
• A second small incision is made just above the pubic hairline, and a probe is inserted.
• Once the tubes are found, the surgeon closes them using different methods: clips, tubal rings, or electrocoagulation (using an electric current to cauterize and destroy a portion of the tube).
• Laparoscopy usually takes 20 - 30 minutes and causes minimal scarring. The patient is often able to go home the same day and can resume intercourse as soon as she feels ready.

Minilaparotomy. Minilaparotomy does not use a viewing instrument and requires an abdominal incision, but it is small -- about 2 inches long. The tubes are tied and cut. Generally speaking, minilaparotomy is preferred for women who choose to be sterilized right after childbirth, while laparoscopy is preferred at other times. Minilaparotomy usually takes approximately 30 minutes to perform. Women who undergo minilaparotomy typically need a few days to recover and can resume intercourse after consulting their doctor.
Essure . The Essure method uses a small spiral-like device to block the fallopian tube. Unlike tubal ligation, the Essure procedure does not require incisions or general anesthesia. It can be performed in a doctor’s office and takes about 45 minutes. A specially trained doctor uses a viewing instrument called a hysteroscope to insert the device through the vagina and into the uterus, and then up into the fallopian tube. Once the device is in place, it expands inside the fallopian tubes. During the next 3 months, scar tissue forms around the device and blocks the tubes. This results in permanent sterilization.

Candidacy for Female Sterilization

Before undergoing sterilization, a woman must be sure that she no longer wants to bear children and will not want to bear children in the future, even if the circumstances of her life change drastically. She must also be aware of the many effective contraceptive choices available. Possible reasons for choosing female sterilization procedures over reversible forms of contraception include:

• Not wanting children and being unable to use other methods of contraception
• Health problems that make pregnancy unsafe
• Genetic disorders

If married, both partners should completely agree that they no longer want to have children and should also have ruled out vasectomy for the man. Vasectomy is a simple procedure that has a lower failure rate than female surgical sterilization, carries fewer risks, and is less expensive.
Even if all these factors are present, a woman must consider her options carefully before proceeding. Women at highest risk for regretting sterilization include:

• Women who are younger at the time of sterilization
• Women who had the procedure immediately after a vaginal delivery
• Women who had the procedure within 7 years of having their youngest child
• Women in lower income groups

If a woman changes her mind and wants to become pregnant, a reversal procedure is available, but it is very difficult to perform and requires an experienced surgeon. Subsequent pregnancy rates after reversal depend on the surgeon’s skill, the age of the woman, and, to a lesser degree, her weight and the length of time between the tubal ligation and the reversal procedure. Not all insurance carriers cover the cost of reversal.

Advantages of Female Sterilization

Women who choose sterilization no longer need to worry about pregnancy or cope with the distractions and possible side effects of contraceptives. Sterilization does not impair sexual desire or pleasure, and many people say that it actually enhances sex by removing the fear of unwanted pregnancy.

Disadvantages and Complications of Female Sterilization

• Failure is rare, less than 1%, but can occur. More than half of these pregnancies are ectopic, which require surgical treatment.
• After any of the procedures, a woman may feel tired, dizzy, nauseous, bloated, or gassy, and may have minor abdominal and shoulder pain. Usually these symptoms go away in 1 - 3 days.
• Serious complications from female surgical sterilization are uncommon and are most likely to occur with abdominal procedures. These rare complications include bleeding, infection, or reaction to the anesthetic.

Resources

• www.nichd.nih.gov -- National Institute of Child Health and Human Development
• http://ec.princeton.edu -- Emergency Contraception Website
• www.acog.org -- American College of Obstetricians and Gynecologists
• www.guttmacher.org -- The Alan Guttmacher Institute
• www.arhp.org -- Association of Reproductive Health Professionals

Rhesus Disease

Introduction 

Rhesus disease is a condition where antibodies in a pregnant woman's blood destroy her baby's blood cells. It's also known as haemolytic disease of the foetus and newborn (HDFN).
Rhesus disease doesn't harm the mother, but it can cause the baby to become anaemic and develop a yellow discoloration of the skin and eyes referred to as jaundice.

 

Causes of rhesus disease 

Rhesus disease is caused by a specific mix of blood types between a pregnant mother and her unborn baby.
Rhesus disease can only occur in cases where all of the following happen:

• the mother has a rhesus negative (RhD negative) blood type
• the baby has a rhesus positive (RhD positive) blood type
• the mother has previously been exposed to RhD positive blood and has developed an immune response to it (known as sensitisation)

These are explained in more detail below.

Blood types
There are several different types of human blood, known as blood groups, with the four main ones being A, B, AB and O. Each of these blood groups can either be RhD positive or negative.
Whether someone is RhD positive or RhD negative is determined by the presence of the rhesus D (RhD) antigen. This is a molecule found on the surface of red blood cells.
People who have the RhD antigen are RhD positive, and those without it are RhD negative. In the UK, around 85% of the population are RhD positive.

How blood types are inherited
Your blood type depends on the genes you inherit from your parents. Whether you're RhD positive or negative depends on how many copies of the RhD antigen you've inherited. You can inherit one copy of the RhD antigen from your mother or father, a copy from both of them, or none at all.
You'll only have RhD negative blood if you don't inherit any copies of the RhD antigen from your parents.
A woman with RhD negative blood can have an RhD positive baby if her partner's blood type is RhD positive. If the father has two copies of the RhD antigen, every baby will have RhD positive blood. If the father only has one copy of the RhD antigen, there's a 50% chance of the baby being RhD positive.

Sensitisation
An RhD positive baby will only have rhesus disease if their RhD negative mother has been sensitised to RhD positive blood. Sensitisation occurs when the mother is exposed to RhD positive blood for the first time and develops an immune response to it.
During the immune response, the woman’s body recognises that the RhD positive blood cells are foreign and creates antibodies to destroy them.
In most cases, these antibodies aren't produced quickly enough to harm a baby during the mother's first pregnancy. Instead, any RhD positive babies the mother has in the future are most at risk.

How does sensitisation occur?
During pregnancy, sensitisation can happen if:

• small numbers of foetal blood cells cross into the mother’s blood
• the mother is exposed to her baby's blood during delivery
• there's been bleeding during the pregnancy
• an invasive procedure has been necessary during pregnancy – such as amniocentesis, or chorionic villus sampling (CVS)
• the mother injures her abdomen (tummy)

Sensitisation can also occur after a previous miscarriage or ectopic pregnancy, or if a RhD negative woman has received a transfusion of RhD positive blood by mistake (although this is extremely rare).

How sensitisation leads to rhesus disease
If sensitisation occurs, the next time the woman is exposed to RhD positive blood her body will produce antibodies immediately.
If she's pregnant with an RhD positive baby, the antibodies can lead to rhesus disease when they cross the placenta and start attacking the baby's red blood cells.

Symptoms of rhesus disease 

Rhesus disease only affects the baby, and the mother won't experience any symptoms.
The symptoms of rhesus disease depend on how severe it is. Around 50% of babies diagnosed with rhesus disease have mild symptoms that are easily treatable.

Signs in an unborn baby
 Anaemia because red blood cells are being destroyed faster than usual by the antibodies.
If your baby is anaemic, their blood will be thinner and flow at a faster rate. This doesn't usually cause any noticeable symptoms, but it can be detected with a type of ultrasound scan known as a Doppler ultrasound.
If the anaemia is severe, complications of rhesus disease, such as internal swelling, may be detected during scans.

Signs in a newborn baby
The two main problems caused by rhesus disease in a newborn baby are haemolytic anaemia and jaundice. In some cases, the baby may also have low muscle tone (hypotonia) and they may be lacking in energy.
If a baby has rhesus disease, they won't always have obvious symptoms when they're born. Symptoms can sometimes develop up to three months afterwards.

Haemolytic anaemia
Haemolytic anaemia occurs when red blood cells are destroyed. This happens when the antibodies from the mother’s RhD negative blood cross the placenta into the baby’s blood. The antibodies attack the baby’s RhD positive blood, destroying the red blood cells.
In the newborn baby, this may cause pale skin, increased breathing rate, poor feeding or jaundice (see below).

Jaundice
Jaundice in newborn babies turns their skin and the whites of their eyes yellow. In babies with dark skin, the yellowing will be most obvious in their eyes or on their palms and soles.
Jaundice is caused by a build-up of a chemical called bilirubin in the blood. Bilirubin is a yellow substance that's made naturally in the body when red blood cells are broken down. It's normally removed from the blood by the liver, so it can be passed out of the body in urine.
In babies with rhesus disease, the liver cannot process the high levels of bilirubin that build up as a result of the baby's red blood cells being destroyed

 

 

 

 

Diagnosing rhesus disease 

Rhesus disease is usually diagnosed during the routine screening tests you're offered during pregnancy.

Blood tests
A blood test should be carried out early on in your pregnancy to test for conditions such as anaemia, rubella, HIV and hepatitis B.
Your blood will also be tested to determine which blood group you are, and whether your blood is rhesus (RhD) positive or negative (see causes of rhesus disease for more information).
If you're RhD negative, your blood will be checked for the antibodies (known as anti-D antibodies) that destroy RhD positive red blood cells. You may have become exposed to them during pregnancy if your baby has RhD positive blood.
If no antibodies are found, your blood will be checked again at 28 weeks of pregnancy and you'll be offered an injection of a medication called anti-D immunoglobulin to reduce the risk of your baby developing rhesus disease (see preventing rhesus disease for more information).
If anti-D antibodies are detected in your blood during pregnancy, there's a risk that your unborn baby will be affected by rhesus disease. For this reason, you and your baby will be monitored more frequently than usual during your pregnancy.
In some cases, a blood test to check the father's blood type may be offered if you have RhD negative blood. This is because your baby won't be at risk of rhesus disease if both the mother and father have RhD negative blood.

Checking your baby's blood type
It's possible to determine if an unborn baby is RhD positive or RhD negative by taking a simple blood test during pregnancy.
Genetic information (DNA) from the unborn baby can be found in the mother's blood, which allows the blood group of the unborn baby to be checked without any risk. It's usually possible to get a reliable result from this test after 11-12 weeks of pregnancy, which is long before the baby is at risk from the antibodies.
If your baby is RhD negative, they're not at risk of rhesus disease and no extra monitoring or treatment will be necessary. If they're found to be RhD positive, the pregnancy will be monitored more closely so that any problems that may occur can be treated quickly.
In the future, RhD negative women who haven't developed anti-D antibodies may be offered this test routinely, to see if they're carrying an RhD positive or RhD negative baby, to avoid unnecessary treatment.

 

Monitoring during pregnancy

If your baby is at risk of developing rhesus disease, they'll be monitored by measuring the blood flow in their brain. If your baby is affected, their blood may be thinner and flow more quickly. This can be measured using a type of ultrasound scan called a Doppler ultrasound.
If a Doppler ultrasound shows your baby’s blood is flowing faster than normal, a procedure called fetal blood sampling (FBS) can be used to check whether your baby is anaemic. This procedure involves inserting a needle through your abdomen (tummy) to remove a small sample of blood from your baby. The procedure is performed under local anaesthetic, usually on an outpatient basis, so you can go home on the same day.
There's a small (usually 1-3%) chance that this procedure could cause you to lose your pregnancy, so it should only be carried out if necessary.
If your baby is found to be anaemic, they can be given a transfusion of blood through the same needle. This is known as an intrauterine transfusion (IUT) and it may require an overnight stay in hospital.
FBS and IUT are only carried out in specialist units, so you may need to be referred to a different hospital to the one where you were going to have your baby.

 

Diagnosis in a newborn baby

If you're RhD negative, blood will be taken from your baby’s umbilical cord when they're born. This is to check their blood group and see if the anti-D antibodies have been passed into their blood. This is called a Coombs test.
If you're known to have anti-D antibodies, your baby’s blood will also be tested for anaemia and jaundice.




 

Treating rhesus disease 

Treatment for rhesus disease depends on how severe the condition is. In more severe cases, treatment may need to begin before the baby is born.
Around half of all cases of rhesus disease are mild and don't usually require much treatment. However, your baby will need to be monitored regularly, in case serious problems develop.
In more severe cases, a treatment called phototherapy is usually needed and blood transfusions may help to speed up the removal of bilirubin (a substance created when red blood cells break down) from the body.
In the most serious cases, a blood transfusion may be carried out while your baby is still in the womb and a medication called intravenous immunoglobulin may be used when they're born if phototherapy isn't effective.
If necessary, the baby may be delivered early using medication to start labour (induction) or a caesarean section, so treatment can start as soon as possible. This is usually only done after about 34 weeks of pregnancy.

Phototherapy
Phototherapy is treatment with light. It involves placing the newborn baby under a halogen or fluorescent lamp with their eyes covered.
Alternatively, they may be placed on a blanket containing optical fibres through which light travels and shines onto the baby's back (fibre optic phototherapy).
The light absorbed by the skin during phototherapy lowers the bilirubin levels in the baby’s blood through a process called photo-oxidation. This means that oxygen is added to the bilirubin, which helps it to dissolve in water. This makes it easier for the baby’s liver to break down the bilirubin and remove it from the blood.
During phototherapy, fluids will usually be given into a vein (intravenous hydration) because more water is lost through your baby's skin and more urine is produced as the bilirubin is expelled.
Using phototherapy can sometimes reduce the need for a blood transfusion.

Blood transfusions
In some cases, the levels of bilirubin in the blood may be high enough to require one or more blood transfusions.
During a blood transfusion, some of your baby’s blood is removed and replaced with blood from a suitable matching donor (someone with the same blood group). A blood transfusion normally takes place through a tube inserted into a vein (intravenous cannula).
This process helps to remove some of the bilirubin in the baby’s blood and also removes the antibodies that cause rhesus disease.
It's also possible for the baby to have a transfusion of just red blood cells to top up those they already have.

Blood transfusion to an unborn baby
If your baby develops rhesus disease while still in the womb, they may need to be given a blood transfusion before birth. This is known as intrauterine foetal blood transfusion.
An intrauterine foetal blood transfusion requires specialist training and is not available in all hospitals. You may therefore be referred to a different hospital for the procedure.
A needle is usually inserted through the mother's abdomen (tummy) and into the umbilical cord, so donated blood can be injected into the baby. An ultrasound scanner is used to help guide the needle to the right place.
Local anaesthetic is used to numb the area, but you'll be awake during the procedure. A sedative may be given to keep you relaxed and your baby may also be sedated to help stop them moving during the procedure.
You may need more than one intrauterine foetal blood transfusion. Transfusions can be repeated every two to four weeks until your baby is mature enough to be delivered. They may even reduce the need for phototherapy after birth, but further blood transfusions could still be necessary.
There's a small risk of miscarriage during an intrauterine foetal blood transfusion, so it's usually only used in particularly severe cases.

Intravenous immunoglobulin
In some cases, treatment with intravenous immunoglobulin (IVIG) is used alongside phototherapy if the level of bilirubin in your baby’s blood continues to rise at an hourly rate.
The immunoglobulin is a solution of antibodies (proteins produced by the immune system to fight against disease-carrying organisms) taken from healthy donors. Intravenous means that it's injected into a vein.
Intravenous immunoglobulin helps to prevent red blood cells being destroyed, so the level of bilirubin in your baby’s blood will stop rising. It also reduces the need for a blood transfusion.
However, it does carry some small risks. It's possible that your baby may have an allergic reaction to the immunoglobulin, although it's difficult to calculate how likely this is or how severe the reaction will be.
Concerns over possible side effects, and the limited supply of intravenous immunoglobulin, mean that it's only used when the bilirubin level is rising rapidly, despite phototherapy sessions.
Intravenous immunoglobulin has also been used during pregnancy, in particularly severe cases of rhesus disease, as it can delay the need for treatment with intrauterine foetal blood transfusions.




 

Complications of rhesus disease 

Although rhesus disease is rare and most cases are successfully treated, there are some risks to both unborn and newborn babies.

Unborn babies
If rhesus disease causes severe anaemia in an unborn baby, it can lead to:

• foetal heart failure
• fluid retention and swelling (foetal hydrops)
• stillbirth 

Blood transfusions given to a baby in the womb (intrauterine transfusions [IUT]), can be used to treat anaemia in an unborn baby. However, this treatment also carries some risks of complications. It can lead to an early labour that begins before the 37th week of pregnancy and there's a 2% risk of miscarriage or stillbirth.

Newborn babies
Rhesus disease causes a build up of excessive amounts of a substance called bilirubin. Without prompt treatment, a build-up of bilirubin in the brain can lead to a neurological condition called kernicterus. This can lead to deafness, blindness, brain damage, learning difficulties or even death.
Treatment for rhesus disease is usually effective in reducing bilirubin levels in the blood, so these complications are uncommon.

Blood transfusions
The risk of developing an infection from the blood used in blood transfusions is low, because all the blood is carefully screened. The blood used will also be matched to the baby’s blood type, so the likelihood of your baby having an adverse reaction to the donated blood is also low.
However, there may be a problem with the transfusion itself. For example, the tube (catheter) used to deliver the blood can become dislodged, causing heavy bleeding (haemorrhage) or a blood clot.
Generally, the risks associated with blood transfusions are small and don't outweigh the benefits of treating a baby with anaemia




 

Preventing rhesus disease 

Rhesus disease can largely be prevented by having an injection of a medication called anti-D immunoglobulin.
This can help to avoid a process known as sensitisation, which is when a woman with RhD negative blood is exposed to RhD positive blood and develops an immune response to it.
Blood is known as RhD positive when it has a molecule called the RhD antigen on the surface of the red blood cells.

Anti-D immunoglobulin
The anti-D immunoglobulin neutralises any RhD positive antigens that may have entered the mother’s blood during pregnancy. If the antigens have been neutralised, the mother’s blood won't produce antibodies.
You'll be offered anti-D immunoglobulin if it's thought there's a risk that RhD antigens from your baby have entered your blood – for example, if you experience any bleeding, if you have an invasive procedure (such as amniocentesis) or if you experience any abdominal injury.
Anti-D immunoglobulin is also administered routinely during the third trimester of your pregnancy if your blood type is RhD negative. This is because it's likely that small amounts of blood from your baby will pass into your blood during this time.
This routine administration of anti-D immunoglobulin is called routine antenatal anti-D prophylaxis, or RAADP (prophylaxis means a step taken to prevent something from happening).

Routine antenatal anti-D prophylaxis (RAADP)
There are currently two ways you can receive RAADP:

• a one-dose treatment: where you receive an injection of immunoglobulin at some point during weeks 28 to 30 of your pregnancy
• a two-dose treatment: where you receive two injections; one during the 28th week and the other during the 34th week of your pregnancy

There doesn't seem to be any difference in the effectiveness between the one-dose or two-dose treatments. Your local clinical commissioning group (CCG) may prefer to use a one-dose treatment, because it can be more efficient in terms of resources and time.

When will RAADP be given?
RAADP is recommended for all pregnant RhD negative women who haven't been sensitised to the RhD antigen, even if you previously had an injection of anti-D immunoglobulin.
As RAADP doesn't offer lifelong protection against rhesus disease, it will be offered every time you become pregnant if you meet these criteria.
RAADP won't work if you’ve already been sensitised. In these cases, you'll be closely monitored so treatment can begin as soon as possible if problems develop.

Anti-D immunoglobulin after birth
After giving birth, a sample of your baby's blood will be taken from the umbilical cord. If you're RhD negative and your baby is RhD positive, and you haven't already been sensitised, you'll be offered an injection of anti-D immunoglobulin within 72 hours of giving birth.
The injection will destroy any RhD positive blood cells that may have crossed over into your bloodstream during the delivery. This means your blood won't have a chance to produce antibodies and will significantly decrease the risk of your next baby having rhesus disease.

 

Complications from anti-D immunoglobulin

Some women are known to develop a slight short-term allergic reaction to anti-D immunoglobulin, which can include a rash or flu-like symptoms.
Although the anti-D immunoglobulin, which is made from donor plasma, will be carefully screened, there's a very small risk that an infection could be transferred through the injection.
However, the evidence in support of RAADP shows that the benefits of preventing sensitisation far outweigh these small risks.
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