Contraceptiv William

INTRAUTERINE DEVICES . . . . . . . . . . . . . . . . . . . . . . . . 696 PROGESTIN IMPLANTS .
. . . . . . . . . . . . . . . . . . . . . . . . 703 PROGESTIN-ONLY CONTRACEPTIVES GROUP. . . . . .

. . . 704 HORMONAL CONTRACEPTIVES . . . . . . . . . . . . . . . . . . . 705 BARRIER
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . 712 FERTILITY AWARENESS-BASED
METHODS . . . . . . . . . . . 713 SPERMICIDES................................ 713 EMERGENCY
CONTRACEPTION . . . . . . . . . . . . . . . . . . . 714 PUERPERAL CONTRACEPTION . . . . .
. . . . . . . . . . . . . . . 715
Half of all pregnancies each year in the United States are unintended (Finer,
2011). These may follow contraceptive method failure or stem from lack of
contraceptive use. Specifically, 10 percent of sexually active American women not
pursuing pregnancy did not use any birth control method (Jones, 2012). And, for
sexually active fertile women not using contraception, pregnancy rates approach
90 percent at 1 year.
For those seeking contraception, various effective contraceptive methods are
available. Preferences of United States women are shown in Table 38-1. With
these methods, wide variations are seen between estimated failure rates of perfect
and typical use during the first year. Similarly, the World Health Organization
(WHO) has grouped methods according to effectiveness tiers that reflect these
failure rates (Table 38-2). Implants and intrauterine devices are found in the top
tier. They are effective in lowering unintended pregnancy rates and are considered
long-acting reversible contraception (LARC) (Winner, 2012).
The American College of Obstetricians and Gynecologists (2013c) recognizes

these efficacy tiers and the high unintended pregnancy rate. Thus, the College
recommends that clinicians provide counseling on all options and encourages
highly effective LARC for all appropriate candidates.
Unfortunately, no contraceptive method is completely without side effects. That

said, an important tenet is that contraception usually poses less risk than
pregnancy. During appropriate method selection, underlying patient health
conditions should be known. Some disorders or the medications used for their
treatment can increase the risk of some contraceptives. The WHO (2010) has
provided evidence-based guidelines, termed Medical Eligibility Criteria, for the
use of all highly effective reversible contraceptive methods by women with
various health conditions. Individual countries have subsequently modified these.
The United States Medical Eligibility Criteria (US MEC) was published in the
United States by the Centers for Disease Control and Prevention (CDC) (2010b),
and its use is encouraged by the American College of Obstetricians and
Gynecologists (2011b). Shown on page 698, the CDC (2011, 2012) has since
added updates to reflect changes for women at high risk for human
immunodeficiency virus (HIV) infection and for women in the puerperium. The
US MEC guidelines and these updates, as well as a free smart-phone application
of the guidelines, are available at the CDC website: http://www.
cdc.gov/reproductivehealth/UnintendedPregnancy/USMEC .htm.
In the US MEC, reversible contraceptive methods are organized into six groups
by their similarity: combination hormonal contraceptives (CHCs), progestin-only
pills (POPs), depot medroxyprogesterone acetate (DMPA), implants, levonorg-
estrel-releasing intrauterine system (LNG-IUS), and copper intrauterine devices
(Cu-IUDs). For a given health condition, each method is categorized 1 through 4.
The score describes a method’s safety profile for a typical woman with that
condition:
696 The Puerperium

TABLE 38-1. Method Use among Women in the United States
TABLE 38-2. Contraceptive Failure Rates During the First Year of Method Use
in Women in
Method
Percentage
the United States
Methoda
Top Tier: Most Effective
Intrauterine devices
Levonorgestrel implants Female sterilization Male sterilization
Second Tier: Very Effective
Combination pill Vaginal ring Patch DMPA Progestin-only pill
Third Tier: Effective
Condom Male
Female Diaphragm with spermicides Fertility-awareness
Ovulation
Fourth Tier: Least Effective
Spermicides Sponge
Parous women
No WHO Category
Withdrawal No contraception
Perfect Use
0.5 0.1
Typical Use
0.5 0.15
Female sterilization
16.5
Male sterilization
6.2
Combination pill
Implants or patch
DMPA
17.1
Progestin-only pill
0.4
Levonorgestrel system
0.9
T 380A copper
0.6 0.8
2.3
0.05 0.05
Vaginal ring
1.3
Intrauterine devices
3.5
Male condom
10.2
Periodic abstinence
Calendar method
Natural family planninga
a
Methods using physiological changes to signal ovulation.
0.6
0.3 9
0.1
Withdrawal
3.2
Other methodsb
0.3
Not using contraceptionc
37.8
0.3 9
b
Includes diaphragm, female condom, cervical cap,
contraceptive sponge, spermicides, and emergency
contraception.
c
Includes those seeking pregnancy, surgically sterilized
for noncontraceptive reasons, sexually inactive, pregnant
or puerperal, and those who are sexually active but not

using contraception. DMPA depot medroxyprogesterone acetate.
Data from Jones, 2012.
0.3 9
Standard days
6 12
24
Two day
Symptothermal
0.4
18 28
(1) no restriction of method use, (2) method advantages outweigh risks, (3)
method risks outweigh advantages, and (4) method poses an unacceptably high
health risk.
Alternatively, depending on the underlying disorder or patient desire, male or

female sterilization may be a preferred or recommended permanent contraceptive
method. These options are fully discussed in Chapter 39 (p. 720).
LONG-ACTING REVERSIBLE CONTRACEPTION:

INTRAUTERINE DEVICES
These are the most commonly used method of reversible contraception
worldwide, and in the United States, nearly 4 percent of women select this method
(d’Arcanques, 2007; Jones, 2012). Fortunately, contraindications to IUD use are
few.
Intrauterine devices (IUDs) that are chemically inert are composed of
nonabsorbable materials. The three IUDs currently approved for use in the
United States are chemically active and have continuous elution of copper or a
progestin. Of these, there are two different levonorgestrel-releasing intrauterine
systems—Mirena and Skyla (Fig. 38-1). Each releases the progestin into the uterus
at a relatively constant rate, which reduces systemic effects. Their T-shaped
radiopaque frames have a stem wrapped with a cylinder reservoir that contains the
levonorgestrel. There are two trailing brown strings attached
0.3 9 0.2 6
218 521
20 24
4 22
Nulliparous women
9 12
85 85
a
Methods organized according to tiers of efficacy by World Health Organization
(WHO), Johns Hopkins Bloomberg School of Public Health, 2007. DMPA
depot medroxyprogesterone acetate. Data from Trussell, 2011a.
to the stem (Bayer Healthcare Pharmaceuticals, 2013a,b). Mirena is currently

approved for 5 years of use following insertion, however, some evidence
supports its efficacy for 7 years (Thonneau, 2008). Skyla is approved for 3 years
of use. It has slightly smaller overall dimensions than its counterpart and was sized
to more appropriately fit a nulliparous uterus (Gemzell- Danielsson, 2012). It can
also be differentiated from Mirena visually and sonographically by a silver ring
near the junction of the device’s stem and arms.
The third device is the T 380A IUD, named ParaGard. It has a polyethylene and
barium sulfate T-shaped frame wound with copper, and two strings extend from
the stem base. Originally
0.2 0.2
SECTION 10
Contraception 697
AB
FIGURE 38-1 Intrauterine devices (IUDs). A. ParaGard T 380A copper IUD. B.
Mirena levonorgestrel-releasing intrauterine system.
blue, the strings are now white. It is currently approved for 10 years of use
following insertion (Teva Women’s Health, 2011). In addition to these three
currently marketed, women may retain discontinued brands of IUD. A Lippes
Loop has two “S” shapes stacked one on the other. The Dalkon Shield has a crab
form, whereas a Copper 7 mirrors that number. Progestasert is an early T-shaped
progestin-releasing IUD. Last, various metal-
eluting ring-shaped devices are common in Asia.
■ Contraceptive Action
All these IUDs are effective. Failure rates are well below 1 percent and similar
overall to those of tubal sterilization (American College of Obstetricians and
Gynecologists, 2013a; Thonneau, 2008; Trussell, 2011b). Their mechanisms have
not been pre- cisely defined, but prevention of fertilization is now favored. Within
the uterus, an intense local endometrial inflammatory response is induced,
especially by copper-containing devices. Cellular and humoral components of this
inflammation are expressed in endometrial tissue and in fluid filling the uterine
cavity and fallopian tubes. These lead to decreased sperm and egg viability (Ortiz,
2007). Also, in the unlikely event that fertilization does occur, the same
inflammatory actions are directed against the blastocyst. The endometrium is
transformed into a hostile site for implantation. With the copper IUD specifi-
cally, copper levels increase in the cervical mucus of users and decrease sperm
motility and viability (Jecht, 1973). With the LNG-IUS, in addition to an
inflammatory reaction, long-term progestin release leads to endometrial atrophy,
which hinders normal implantation. Moreover, progestins create scant viscous
cervical mucus that obstructs sperm motility. The LNG-IUS may also
inconsistently release sufficient progestin to inhibit ovulation, although this is a
lesser effect than its local actions.
■ Method-Specific Adverse Effects

Several method-specific complications may follow IUD insertion and include
uterine perforation, device expulsion, menstrual changes, infection, and
miscarriage if pregnancy occurs. Also, in the past, IUDs were perceived to
increase the risk of ectopic pregnancy. However, this has been clarified.
Specifically, IUDs are so effective as contraceptives that they lower the abso-
lute number of ectopic pregnancies by half compared with the rate in

noncontracepting women (World Health Organization, 1985, 1987). But, the IUD
mechanisms of action are more effective in preventing intrauterine implantation.
Thus, if an IUD fails, a higher proportion of pregnancies are likely to be ectopic
(Backman, 2004; Furlong, 2002).
Perforation
During uterine sounding or IUD insertion, the uterus may be perforated, which is
identified by the tool traveling further than the expected uterine length based on
initial bimanual examination. Rates approximate 1 per 1000 insertions, and risks
include puerperal insertion, lactation, provider inexperience, and extremes of
uterine flexion (Harrison-Woolrych, 2003). Although devices may migrate
spontaneously into and through the uterine wall, most perforations occur, or at
least begin, at the time of insertion.
With the more common fundal perforation, bleeding typically is minimal due to
myometrial contraction around the site. If no brisk or persistent bleeding is noted
from the os following instrument removal, then patient observation alone is
reasonable. Rarely, lateral perforations may lead to uterine artery lac- eration and
brisk bleeding, which may prompt laparoscopy or laparotomy for control.
Following any perforation, although this is not firmly evidence-based, a single
dose of broad- spectrum antibiotic may mitigate infection.
Lost Device
Expulsion of an IUD from the uterus is most common during the first month.
Thus, women should be examined approximately 1 month following IUD
insertion, usually after menses, to identify the tails trailing from the cervix.
Following this, a woman should be instructed to palpate the strings each month
after menses.
If the tail of an IUD cannot be visualized, the device may have been expelled, may
have perforated the uterus, or may be malpositioned. Some have found that IUD
perforation, rotation, or embedding may cause pain or bleeding (Benacerraf, 2009;
Moschos, 2011). Alternatively, the device may be normally positioned with its
tail folded within the endocervical canal or uterine cavity. To investigate, after
excluding pregnancy, a cytological brush can be twirled within the endocervical
canal to entangle the strings and bring them gently into the vagina. If unsuccessful,
the uterine cavity is probed gently with a Randall stone clamp or with a
specialized rod with a terminal hook to retrieve the strings.
It should never be assumed that the device has been expelled unless it was seen.
Thus, if tails are not visible and the device is not felt by gentle probing of the
uterine cavity, transvaginal sonography can be used to ascertain if the device is
within the uterus. Although traditional sonography will document IUD position
adequately in most cases, three-dimensional sonography offers improved
visualization, especially with the levonorgestrel- releasing IUD (Moschos, 2011).
If sonography is inconclusive or if no device is seen, then a plain radiograph of the
abdomi- nopelvis is taken. Computed tomography (CT) scanning or less
commonly, magnetic resonance (MR) imaging is an alternative (Boortz, 2012). It
is safe to perform MR imaging at 1.5 and 3 Tesla (T) with an IUD in place
(Pasquale, 1997; Zieman, 2007).
CHAPTER 38
698 The Puerperium
TABLE 38-3. Contraindications and Cautions with Specific Contraceptive
Methods Condition CHCa
DMP LNG- Cu-

POP Implants
A IUS IUD
Pregnancy Component allergy Postpartum
1 no method restrictions 2 method benefits outweigh risks 3 method

risks outweigh benefits 4 method poses an unacceptably high health risk Blank
space indicates method is category 1 or 2
444 444

21 days 4
21–42 days
Postpregnancy infection Smoking & age Active breast cancer Breast cancer

disease free Multiple cardiovascular risks Well-controlled or mild CHTN 3

35 yr
5 yr
3/4c
33333
3/4d
Systolic BP 160 or Diastolic BP 100 Vascular disease Complicated heart

valve disease Peripartum cardiomyopathy Acute or prior VTE Thrombophilia
Surgery with long immobilization DM DM & end-organ disease Bariatric
surgery & malabsorption Inflammatory bowel disease Cirrhosis (severe,
decompensated) Liver tumorsf
Symptomatic gallbladder disease At risk for GC/CT Distorted uterine

cavity GTD surveillance Ritonavir-boosted PIs Enzyme-inducing
anticonvulsants Lamotrigine
Rifampin/rifabutin
4 4 4 44
434343
3/4d
3/4d
3/4d
20 yr
3/4d
3e 3
2/3d
43333
Condition S/C
Current or history of ISHD Stroke 4 Migraine with aura Migraine, no aura, 

Unexplained vaginal bleeding Cervical cancer before treatment Endometrial

cancer Current PID or cervicitis Rheumatoid arthritis
Acute viral hepatitis AIDS not controlled on ARV Pelvic tuberculosis
444444
2/3b
4 3 3 33
44
33
44
33
44
3333
3
S/C
Start/Continue (S/C)h
S/C
S/C
S/C
S/C
2/3
3/3
2/3
2/3
2/3
3/3
2/3
2/3
2/3
2/3
2/3
35 yr
2/3
35 yr
3/4
4/2
4/2
4/2
4/2
4/2
4/2
2/3j
4/2
4/2
4/2
3/2
3/2
4/3
4/3
SECTION 10
Contraception 699
TABLE 38-3. Continued
Condition
SLE & positive or unknown APAs
S/C
a
Combination hormone contraception (CHC) group includes pills, vaginal ring,
and patch.
S/C
Start/Continue (S/C)h
S/C
S/C
S/C
S/C
SLE & severe thrombocytopenia
3/2
Complicated solid-organ transplantation

4
3/2
3/2
b
Associated risks that increase category score include: age
postpartum hemorrhage, cesarean delivery, smoking, preeclampsia.

c
Smoking
e
Oral agents only. Ring and patch are category 1.

35, transfusion at delivery, BMI

g
These include phenytoin, barbiturates, carbamazepine, oxcarbazepine, primidone,
topiramate.
h
In those methods under Start/Continue columns, the first US MEC number refers to
whether a
method may be initiated in an affected patient. For patients who initially develop the
condition
AIDS acquired immunodeficiency syndrome; APA antiphospholipid

antibodies; ARV antire roviral; BP blood pressure; CHTN chronic
hypertension; Cu-IUD copper intrauterine device
mydial infection; GTD gestational trophoblastic levonorgestrel-releasing

intrauterine system; PI disease; POP progestin-only pills; SLE syste
protease inhibitor; PID lupus erythematosus.

pelvic inflammatory
30,
15 cigarettes/day increases risk category to 4 in this age group. dRisk category

score is modified by associated risk factors and disease severity.
f
Benign hepatic adenoma or hepatocellular cancer.
while using a specific method, the second number refers to risks for continuing
that method. iPrior to evaluation. jThose on chronic corticosteroids and at risk for
bone fracture.
t-
; DM diabetes mellitus; DMPA depot medroxyprogesterone acetate; GC/CT

gonorrhea/chla-
disease; ISHD ischemic heart disease; LNG-IUS 
m Adapted from Centers for Disease Control and Prevention, 2010b, 2011,
2013.
A device may penetrate the muscular uterine wall to vary- ing degrees. Those with
a predominantly intrauterine loca- tion are typically managed by hysteroscopic
IUD removal. In contrast, devices that have nearly or completely perforated
through the uterine wall are more easily removed lapa- roscopically. Chemically
inert devices usually are removed easily from the peritoneal cavity. An
extrauterine copper- bearing device, however, frequently induces an intense local
inflammatory reaction and adhesions. Thus, copper IUDs may be more firmly
adhered. Laparotomy may be necessary, and bowel preparation is considered.
Perforations of large and small bowel and bladder and bowel fistulas have been
reported remote from insertion (Lyon, 2012; Mascarenhas, 2012; Zeino, 2011).
Menstrual Changes
Women who choose the copper IUD should be informed that dysmenorrhea and
menorrhagia may develop. These are often treated with nonsteroidal
antiinflammatory drugs (NSAIDs) (Grimes, 2006). Heavy bleeding may cause
iron deficiency anemia, for which oral iron salts are given (Hassan, 1999).
With the LNG-IUS, women are counseled to expect irregular spotting for up to 6
months after placement, and thereafter to expect monthly menses to be lighter or
even absent (Bayer HealthCare Pharmaceuticals, 2013a). Specifically, the Mirena
device is associated with progressive amenorrhea, which is reported by 30 percent
of women after 2 years and by 60 percent after 12 years (Ronnerdag, 1999). This
is often associated with improved dysmenorrhea.
Infection
The device-related infection risk is increased only during the first 20 days
following insertion (Farley, 1992). Of those who develop an infection during this
time, most usually have an unrecognized coexistent cervical infection.
Accordingly, women at risk for sexually transmitted diseases (STDs) should be
screened either before or at the time of IUD insertion (Centers for Disease Control
and Prevention, 2010a; Sufrin, 2012). That said, device insertion need not be
delayed while awaiting Neisseria gonorrhoeae, Chlamydia trachomatis, or PAP
screen- ing results in asymptomatic women. If these bacteria are found and the
patient is without symptoms, then the IUD may remain and treatment prescribed
as detailed in Chapter 65 (p. 1269). Importantly, routine antimicrobial prophylaxis
before insertion is not recommended (Grimes, 2001; Walsh, 1998). Moreover, the
American Heart Association does not recommend infective endocarditis
prophylaxis with insertion (Wilson, 2007).
After these first 3 weeks, infection risk is not increased in IUD users who would
otherwise be at low risk of STDs. Correspondingly, IUDs appear to cause little, if
any, increase in the risk of infertility in these low-risk patients (Hubacher, 2001).
For these reasons, the American College of Obstetricians and Gynecologists
(2011a, 2012a) recommends that women at low risk for STDs, including
adolescents, are good candidates for IUDs (Table 38-3). The IUD is also safe and
effective in HIV- infected women and may be used in others who are immuno-
suppressed (Centers for Disease Control and Prevention, 2012).
If infection does develop, it may take several forms and typically requires broad-
spectrum antimicrobials. Septic
CHAPTER 38
700 The Puerperium
abortion mandates immediate uterine evacuation in addition to antimicrobials.

Pelvic inflammatory disease (PID) without abscess is treated with systemic
antibiotics. There are theoretical concerns that a coexistent IUD might worsen the
infection or delay resolution. Although a provider may choose to remove an IUD
in this setting, some evidence also supports allow- ing a device to remain during
treatment in those hospitalized with mild or moderate PID (Centers for Disease
Control and Prevention, 2010b; Tepper, 2013). Last, tuboovarian abscess may
develop with PID and is treated aggressively with intrave- nous broad-spectrum
antibiotics and IUD removal.
In addition to these infections, Actinomyces israelii is a gram- positive, slow-

growing, anaerobic indigenous vaginal bacterium that rarely causes infection with
abscess formation (Persson, 1984). Some have found it more frequently in the
vaginal flora or on the Pap smears of IUD users (Curtis, 1981; Fiorino, 1996).
Current recommendations advise that an asymptomatic woman may retain her
IUD and does not require antibiotic treatment (American College of
Obstetricians and Gynecologists, 2013c; Lippes, 1999; Westhoff, 2007a).
However, if signs or symptoms of infection develop in women who harbor
Actinomyces species, then the device should be removed and antimicrobial therapy
instituted. Early findings with infection include fever, weight loss, abdominal
pain, and abnormal vaginal bleeding or discharge. Actinomyces species are
sensitive to antimicrobials with gram-positive coverage, notably the penicillins.
Pregnancy with an IUD

For women who become pregnant while using an IUD, ectopic pregnancy should
be excluded (Chap. 19, p. 379). With intrauterine pregnancy, until approximately
14 weeks’ gestation, the tail may be visible through the cervix, and if seen, it
should be grasped and the IUD removed by gentle outward traction. This action
reduces complications such as subsequent abortion, chorioamnionitis, and preterm
birth (Brahmi, 2012; Kim, 2010). Tatum and coworkers (1976) reported an
abortion rate of 54 percent with the device left in place compared with a rate of 25
percent if it was promptly removed.
If the tail is not visible, attempts to locate and remove the device may result in
abortion. However, some practitioners have successfully used sonography to assist
in device removal in cases without visible strings (Schiesser, 2004). After fetal
viability is reached, it is unclear whether it is better to remove an IUD whose
string is visible and accessible or to leave it in place. There is no evidence that
fetal malformations are increased with a device in place (Tatum, 1976).
Second-trimester miscarriage with an IUD in place is more likely to be infected

(Vessey, 1974). Sepsis may be fulminant and fatal. Pregnant women with a device
in utero who demon- strate any evidence of pelvic infection are treated with
intensive antimicrobial therapy and prompt uterine evacuation. Because of these
risks, a woman should be given the option of early pregnancy termination if the
device cannot be removed early in pregnancy. Last, in women who give birth with
a device in place, appropriate steps should be taken at delivery to identify and
remove the IUD.
■ Insertion Timing
Immediately following miscarriage, surgical abortion, or delivery, an IUD may be
inserted in the absence of infection. Also, Shimoni and colleagues (2011)
describe “immediate” insertion 1 week after medical abortion. The risk of IUD
expulsion is slightly higher if it is placed immediately following any of these
recent pregnancies. That said, the advantages of preventing future unplanned
pregnancies appear to outweigh this (Bednarek, 2011; Chen, 2010; Grimes,
2010a; Steenland, 2011).
Insertion techniques depend on uterine size. After first- trimester evacuation, the
IUD can be placed using the manufacturer’s standard instructions. If the uterine
cavity is larger, the IUD can be placed using ring forceps with sonographic guid-
ance (Stuart, 2012). Immediately following vaginal or cesarean delivery, an IUD
can be placed by hand or with an instrument (Grimes, 2010b). To reduce
expulsion rates and to minimize the perforation risk, some may choose to wait for
complete involution—at least 6 weeks after delivery. Women delivered at
Parkland Hospital are seen 3 weeks postpartum, and IUDs are inserted 6 weeks
postpartum or sooner if involution is complete.
For placement not related to pregnancy, insertion near the end of normal
menstruation, when the cervix is usually softer and somewhat more dilated, may
be easier and at the same time may exclude early pregnancy. But, insertion is not
limited to this time. For the woman who is sure she is not pregnant and does not
want to be pregnant, insertion is done at any time.
Technique
Before insertion, several procedural steps are carried out. Any contraindications
are identified. If there are none, the woman is counseled and written consent
obtained. An oral NSAID, with or without codeine, can be used to allay cramps
(Karabayirli, 2012). Strong evidence does not support an advantage to
supplemental misoprostol, intrauterine or cervical canal instillation of lidocaine,
or paracervical blockade to lessen insertional pain (McNicholas, 2012; Nelson,
2013; Swenson, 2012). Bimanual pelvic examination is performed to identify
uterine position and size. Abnormalities are evaluated, as they may contraindicate
insertion. Mucopurulent cervicitis or significant vaginitis should be appropriately
treated and resolved before IUD insertion.
The cervical surface is cleansed with an antiseptic solution, and sterile instruments
and a sterile IUD should be used. A tenaculum is placed on the cervical lip, and
the canal and uterine cavity are straightened by applying gentle traction. The
uterus is then sounded to identify the direction and depth of the uterine cavity.
Specific steps of ParaGard and Mirena insertion are shown in Figures 38-2 and
38-3 and outlined in their respective package inserts.
Following insertion, only the threads should be visible trailing from the cervix.
These are trimmed to allow 3 to 4 cm to protrude into the vagina, and their length
is recorded. If there is suspicion that the device is not positioned correctly, then
placement should be confirmed, using sonography if necessary.
SECTION 10
AB
Arm
ms
Contraception 701
rel
cervix
eased
Inserte
er tube
IUD
Fla
a
ge 1.5 cm
nge
Flan from
Slider
Handle e
r moved  k to first mark
Slide
back
String
s in cleft
Inserter tube
advan
nced
Aft
ter slider
oved back,
in
serter tube
Flan
ge
rem
abut
moved
s cervix
Sl l
ider
ack
D fro
moved b
Strin ngs
relea ased
m cleft
FIGURE 38-2 Insertion of the Mirena intrauterine system. Initially, threads from behind
the slider are first released to hang freely. The slider found on the handle should be
positioned at the top of the handle nearest the device. The IUD arms are oriented horizon-
tally. A flange on the outside of the inserter tube is positioned from the IUD tip to reflect
the depth found with uterine sounding. A. As both free threads are pulled, the Mirena
IUD is drawn into the inserter tube. The threads are then tightly fixed from below into the
handle’s cleft. In these depictions, the inserter tube has been foreshortened. The inserter
tube is gently inserted into the uterus until the flange lies 1.5 to 2 cm from the external
cervical os to allow the arms to open. B. While holding the inserter steady, the IUD arms
are released by pulling the slider back to reach the raised horizontal mark on the handle,
but no further. C. The inserter is then gently guided into the uterine cavity until its flange
touches the cervix. D. The device is released by holding the inserter firmly in position
and pulling the slider down all the way. The threads will be released automatically from
the cleft. The inserter may then be removed, and IUD strings trimmed.
CHAPTER 38
702 The Puerperium
Base of IUD
Inserter tube
Tip of inserter
Flange
rod
AB
CD
FIGURE 38-3 Insertion of ParaGard T 380A. The uterus is sounded, and the IUD is
loaded into its inserter tube not more than 5 minutes before insertion. A blue plastic
flange on the outside of the inserter tube is positioned from the IUD tip to reflect uterine
depth. The IUD arms should lie in the same plane as the flat portion of the oblong blue
flange. A. The inserter tube, with the IUD loaded, is passed into the endometrial cavity. A
long, solid, white inserter rod abuts the base of the IUD. When the blue flange contacts
the cervix, insertion stops. B. To release the IUD arms, the solid white rod within the
inserter tube is held steady, while the inserter tube is withdrawn no more than 1 cm. C.
The inserter tube, not the inserter rod, is then carefully moved upward toward the top of
the uterus until slight resis- tance is felt. At no time during insertion is the inserter rod
advanced forward. D. First, the solid white rod and then the inserter tube are withdrawn
individually. At completion, only the threads should be visible protruding from the
cervix. These are trimmed to allow 3 to 4 cm to extend into the vagina.
SECTION 10
If the IUD is not positioned completely within the uterus, it is removed and
replaced with a new device. An expelled or par- tially expelled device should not
be reinserted.
LONG-ACTING REVERSIBLE CONTRACEPTION:

PROGESTIN IMPLANTS
■ Etonogestrel Implant
Contraception can be provided by thin, pliable progestin- containing cylinders that
are implanted subdermally and release hormone over many years. One of these,
Implanon is a single-rod implant with 68 mg of etonogestrel covered by an
ethylene vinyl acetate copolymer cover. The implant is placed subdermally on the
medial surface of the upper arm 8 to 10 cm from the elbow in the biceps groove
and is aligned with the long axis of the arm. It may be used as contraception for 3
years and then replaced at the same site or in the opposite arm (Merck, 2012a).
Implanon is not radiopaque, and a misplaced implant may be identified with

sonography using a 10- to 15-MHz linear array transducer (Shulman, 2006). In
some cases, MR imaging may be required if supplemental information is needed
despite sonography (Correia, 2012). To improve radiologic detection, the
manufacturer developed Nexplanon, which is similarly shaped and
pharmacologically identical to Implanon but is radiopaque. Additionally, the
Nexplanon inserter device is designed to assist with subdermal placement and
avert deeper insertions. Both implants are highly effective, and the mechanism of
action for progestin-only products is described on page 704 (Croxatto, 1998;
Mommers, 2012). Although still approved by the Food and Drug Administration
(FDA), Implanon is no longer distributed by the manufacturer.
■ Levonorgestrel Implants
The first progestin implants contained levonorgestrel, and systems are still
available outside the United States. Jadelle, originally named Norplant-2, provides
levonorgestrel and contraception for 5 years through two subdermally implanted
Silastic rods. After this time, rods may be removed and if desired, new rods
inserted at the same site (Bayer Schering Pharma Oy, 2010). Jadelle is approved
by the FDA, however, it is not marketed or distributed in the United States
(Population Council, 2013). Sino-implant II is a two-rod implant with the same
amount (150 mg) of levonorgestrel and same mechanism of action as Jadelle but
provides 4 years of contraception (Shanghai Dahua Pharmaceutical, 2012). Sino-
implant II is manufactured in China and approved for use by several countries in
Asia and Africa.
Both implant systems are highly effective, and the mechanism of action for
progestin-only products is described on page 704. Like the etonogestrel implant,
these systems are placed subdermally on the inner arm approximately 8 cm from
the elbow and have similar removal steps. Implants vary regarding their insertion
technique, and manufacturer instructions should be consulted.
The forerunner of these implants was the Norplant System, which provided
levonorgestrel in six Silastic rods implanted subdermally. The manufacturer
stopped distributing the system in 2002.
■ Method-Specific Adverse Effects

Risks that are specific to implants stem mainly from malposi- tioning. First,
branches of the medial antebrachial cutaneous nerve can be injured if the implant
or insertion needle is placed too deeply or if exploration for a lost implant is
aggressive. Clinically, numbness and paresthesia over the anteromedial aspect of
the forearm are noted (Brown, 2012; Wechselberger, 2006). Second, nonpalpable
devices are not uncommon and may require radiological imaging for localization
as described earlier. If imaging fails to locate an Implanon or Nexplanon implant,
etonogestrel blood level determination can be used to verify that the implant is in
situ.
■ Insertion Timing
For those not currently using hormonal contraception, the etonogestrel implant is
ideally inserted within 5 days of menses onset. If inserted later in the cycle, then
alternative contraception is recommended for 7 days following placement. With
levonorgestrel-releasing implants, contraception is established within 24 hours if
inserted within the first 7 days of the menstrual cycle (Sivin, 1997; Steiner,
2010). For transitioning methods, an implant is placed on the day of the first
placebo COC pill; on the day that the next DMPA injection would be due; or
within 24 hours of taking the last POP (Merck, 2012a). Related to pregnancy, an
implant may be inserted before discharge following delivery, miscarriage, or
abortion.
Nexplanon Insertion Technique

With the patient lying down, her nondominant arm, forearm, and hand are
outstretched on the bed with the inner aspects of each exposed upward, and the
elbow is flexed. The insertion site is marked with a sterile pen 8 to 10 cm
proximal to the medial condyle of the humerus. A second mark is placed 4
centimeters proximally and delineates the final path of the implant. The
Nexplanon is inserted using sterile technique. The area is cleaned aseptically, and
a 1-percent lidocaine anesthetic track is injected beneath the skin along the
planned insertion path. The implant is then placed as shown in Figure 38-4. After
placement, both patient and provider should palpate and identify both ends of the
4-cm implant. To minimize bruising at the site, a pressure bandage is created
around the arm and is removed the following day.
With sterile implant removal, the proximal end of the implant is depressed with a
finger to allow the distal end to bulge toward the skin. After anesthetizing the skin
over this bulge, the skin is incised 2 mm toward the elbow along the long axis of
the arm. The proximal butt of the implant is then pushed toward this incision.
Once visible, the distal implant is grasped with a hemostat and removed. If
present, superficial
Contraception 703
CHAPTER 38
704 The Puerperium
ABCD
FIGURE 38-4 Nexplanon insertion. A sterile pen marks the insertion site, which is 8 to
10 cm proximal to the medial humeral condyle. A second mark is placed 4 cm
proximally along the arm’s long axis. The area is cleaned aseptically, and a 1-percent
lidocaine anesthetic track is injected along the planned insertion path. A. The insertion
device is grasped at its gripper bubbles found on either side, and the needle cap is
removed outward. The device can be seen within the needle bore. The needle bevel then
pierces the skin at a 30-degree angle. B. Once the complete bevel is subcutaneous, the
needle is quickly angled downward to lie horizontally. C. Importantly, the skin is tented
upward by the needle as the needle is slowly advanced horizontally and subdermally. D.
Once the needle is completely inserted, the lever on the top of the device is pulled
backward toward the operator. This retracts the needle and thereby deposits the implant.
The device is then lifted away from the skin. After placement, both patient and operator
should palpate the 4-cm implant.
adhesions surrounding an implant may be dissected away with hemostat tips

placed into the incision.
PROGESTIN-ONLY CONTRACEPTIVE GROUP ■ Actions

and Side Effects
described, pills, and injectables. As their primary contraceptive action, these
progestins suppress luteinizing hormone (LH) and in turn block ovulation. As
other effects, cervical mucus is thickened to retard sperm passage, and atrophy
ren- ders the endometrium unfavorable for implantation. Fertility is restored
rapidly following cessation of progestin-only contraception, with the exception
of DMPA as described on page 711 (Mansour, 2011).
For all progestin-only methods, irregular uterine bleeding is a distinct

disadvantage. It may manifest as metrorrhagia or menorrhagia and is the most
frequently reported adverse event leading to method discontinuation. Often,
counseling and reassurance regarding this effect is sufficient. Particularly
troublesome bleeding may be improved by one to two cycles of COCs, by a 1- to
3-week course of estrogen alone, or by a short course of NSAIDs combined with
the established method. Fortunately, with prolonged use, progestins induce
endometrial atrophy, which leads to sustained amenorrhea. And, for the well-
counseled patient, this is often an advantage.
Most progestin-only contraceptive methods do not sig- nificantly affect lipid

metabolism, glucose levels, hemostatic factors, liver function, thyroid function,
and blood pressure (Dorflinger, 2002). Moreover, these have not been shown to
increase the risk for thromboembolism, stroke, or cardiovascular disease
(Mantha, 2012; World Health Organization, 1998). However, as described on page
711, the increased low-density lipoprotein (LDL) cholesterol and decreased high-
density lipoprotein (HDL) cholesterol levels seen with DMPA may be less
desirable if there are cardiac or vascular risks.
Progestin-only methods do not impair milk production and are an excellent choice
for lactating women. There are no increased risks of genital tract or breast
neoplasia (Wilailak, 2012; World Health Organization, 1991a,b, 1992). Weight
gain and bone mineral density loss are not prominent side effects of this
contraceptive group, except for DMPA, as noted on page 711 (Funk, 2005; Lopez,
2011). Functional ovarian cysts develop with a greater frequency in women
using progestin-only agents, although they do not usually necessi- tate intervention
(Brache, 2002; European Society of Human Reproduction and Embryology,
2001). Last, an association between depression and DMPA or POPs is unclear
(Civic, 2000; Svendal, 2012; Westhoff, 1995). Women with depression may be
prescribed these methods, but surveillance following initiation is reasonable.
■ Contraindications to Progestin-Only Contraceptives

These methods are ideal for most women, but contraindications and cautions are
associated with a few conditions. Current breast cancer and pregnancy are the only
two absolute contraindications. However, conditions for which limited and
cautious use should be considered are listed in Table 38-3.
There are a few instances in which manufacturer restrictions differ from the US
MEC. First, manufacturer prescribing information lists thrombosis or
thromboembolic disorders as contraindications (Merck, 2012a; Pfizer, 2012).
However, for individuals with these disorders, US MEC considers progestin-
containing methods category 2. Second, for many progestin products,
manufacturers note prior ectopic pregnancy as a contraindication. This is
secondary to progesterone’s effect to slow fallopian tube motility and thereby
delay fertilized egg transport to the endometrial cavity. But again, US MEC
considers progestin injectables and implants category 1, and progestin-only pills
are category 2 for those with prior ectopic pregnancy.
SECTION 10
VERY EFFECTIVE CONTRACEPTION: HORMONAL

CONTRACEPTIVES
These currently are available in forms that contain both estrogen and progestin or
contain only progestin. Progestin-only injectables and pills are considered very
effective, yet second- tier agents, due to the need for increased patient compliance.
Similarly, products containing both estrogen and progestin, often termed
combination hormonal contraception (CHC), are considered in this tier. These may
be supplied as pills, transvaginal rings, or transdermal patches.
■ Combination Hormonal Contraceptives Mechanism of

Action
The contraceptive actions of CHCs are multiple, but the most important effect is
suppression of hypothalamic gonadotropin- releasing factors. This in turn blocks
pituitary secretion of follicle-stimulating hormone (FSH) and LH to inhibit ovula-
tion. The progestin component provides ovulation prevention by suppressing LH;
they thicken cervical mucus and thereby retard sperm passage; and they render the
endometrium unfavorable for implantation. Estrogen blocks ovulation by sup-
pressing FSH release. It also stabilizes the endometrium, which prevents
intermenstrual bleeding—also known as breakthrough bleeding. The net effect is
an extremely effective yet highly reversible method (Mansour, 2011).
■ Combination Oral Contraceptive Pills Composition

Combination oral contraceptive pills are the most frequently used birth control
method in the United States. In a 2006 to 2010 survey, 17 percent of US women
were using these (Jones, 2012). COCs are marketed in an almost bewildering
variety (Table 38-4). Most are also available as generics, and the FDA (2013)
confirms the bioequivalence of COC generics. The American College of
Obstetricians and Gynecologists (2013b) supports the use of either branded or
generic preparations.
Pharmacologically, ethinyl estradiol is the most common estrogen present in

COC formulations in the United States. Less frequently, mestranol or estradiol
valerate is used. Unwanted effects most often attributed to the estrogen com-
ponent include breast tenderness, fluid retention, weight gain, nausea, and
headache.
COCs also contain one of several progestins that are structurally related to
progesterone, testosterone, or spironolactone. Thus, these progestins bind variably
to progesterone, androgen, estrogen, glucocorticoid, and mineralocorticoid
receptors. These affinities explain many pill-related side effects and are often used
to compare one progestin with another.
Most progestins used in COCs are related to testosterone and may impart
androgenic side affects such as acne and adverse HDL and LDL levels. To avoid
these effects, progestins more structurally similar to the progestone molecule have
been developed. Medroxyprogesterone acetate is one example, but it is mainly
used in a progestin-only injectable form. Another, nomegestrol acetate, is used in a
COC approved outside the
United States. Despite these pharmacological differences, the true advantage of

one progestin over another is less apparent clinically (Lawrie, 2011; Moreau,
2007).
Another progestin, drospirenone, is structurally similar to spironolactone. The

doses used in currently marketed COCs have effects similar to 25 mg of this
diuretic hormone (Seeger, 2007). Drospirenone displays antiandrogenic activity,
provides an antialdosterone action to minimize water retention, and has
antimineralocorticoid properties that may, in theory, cause potassium retention and
hyperkale- mia (Krattenmacher, 2000). Thus, it is avoided in women with renal or
adrenal insufficiency or with hepatic dysfunc- tion. Moreover, serum potassium
level monitoring is recommended in the first month for patients chronically
treated concomitantly with any drug associated with potassium retention. These
include NSAIDs, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II
antagonists, hepa- rin, aldosterone antagonists, and potassium-sparing diuretics
(Bayer HealthCare Pharmaceuticals, 2012).
Since the development of COCs, their estrogen and progestin content has
dropped remarkably to minimize adverse effects. Currently, the lowest acceptable
dose is limited by the ability to prevent pregnancy and to avoid unacceptable
breakthrough bleeding. Thus, the daily estrogen content var- ies from 10 to 50 g
of ethinyl estradiol, and most contain 35 g or less.
With COCs termed monophasic pills, the progestin dose remains constant
throughout the cycle. In others, the dose frequently is varied, and terms biphasic,
triphasic, or quadriphasic pill are used depending on the number of dose changes
within the cycle. In some formulations, the estrogen dose also var- ies. In general,
phasic pills were developed to reduce the total progestin content per cycle without
sacrificing contraceptive efficacy or cycle control. The theoretical advantage of a
lower total progesterone dose per cycle has not been borne out clinically
(Moreau, 2007). Cycle control also appears to be comparable among mono-
through triphasic pills (van Vliet, 2006, 2011a,b).
Administration
Hormones are taken daily for a specified time (21 to 81 days) and then replaced by
placebo for a specified time (4 to 7 days), which is called the “pill-free interval.”
During these pill-free days, withdrawal bleeding is expected.
With the trend to lower estrogen doses to minimize side effects, there is concern
for follicular development and ovulation. To counter this, the active-pill duration
in some formulations is extended to 24 days. And, these 24/4 regimens do appear
to reduce ovulation and breakthrough bleeding rates (Fels, 2013).
Alternatively, longer durations of active hormone, designed to minimize the

number of withdrawal episodes, have been introduced (Edelman, 2006). These
extended-cycle products produce a 13-week cycle, that is, 12 weeks of hormone
use, followed by a week for withdrawal menses. The product Amethyst provides
continuous active hormone pills for 365 days each year. Such extended or
continuous regimens may be especially suited for women with significant
menstrual symptoms.
Contraception 705
CHAPTER 38
706 The Puerperium
TABLE 38-4. Combination Oral Contraceptives Formulations
Product Name Estrogen mg (days)a Progestin mg (days)
Monophasic Preparations
20–25 m
g estrogen
Yaz, Loryna EE EE
20 (24)
Drospirenone 3.00 (24) Drospirenone
Beyazb
20 (24)
3.00 (24)
Aviane, Falmina, Lessina, Orsythia
Loestrin Fe 1/20c
, Gildess Fe 1/20c
EE 20 Levonorgestrel
0.10
Loestrin 1/20, Junel 1/20, Microgestin 1/20
EE 20 Norethindrone acetate 1.00
, Junel Fe 1/20c,
EE 20 Norethindrone acetate 1.00
Microgestin Fe 1/20c
Loestrin 24 Fec EE
30–35 m
g estrogen
20 (24)
Norethindrone acetate
1.00 (24)
Desogen, Ortho-Cept, Emoquette
EE 30 Desogestrel
EE 30 Drospirenone 3.00 EE 30 Drospirenone 3.00
0.15
Yasmin, Syeda
Safyralb
Kelnor, Zovia 1/35
EE 35 Ethynodiol diacetate
1.00
Nordette, Altavera, Introvale, Kurvelo, Levora, Marlissa, EE 30 Levonorgestrel

0.15 Portia
Lo/Ovral, Cryselle, Low-Ogestrel, Elinest
EE 30 Norgestrel
0.30
Ovcon-35, Balziva, Briellyn, Philith, Gildagia
EE 35 Norethindrone 0.40
Femcon Fec EE 35 Norethindrone 0.40
Brevicon, Modicon, Nortrel 0.5/35, Wera
, Junel Fe 1.5/30c
, Microgestin Fe
Ortho-Novum 1/35, Norinyl
35, Nortrel 1/35,
Norethin 1/35, Cyclafem 1/35, Alyacen 1/35,
Dasetta 1/35
Loestrin 1.5/30, Junel 1.5/30, Microgestin 1.5/30 EE 30 Norethindrone acetate
1.50 Loestrin Fe 1.5/30c EE 30 Norethindrone acetate 1.50
1.5/30c
Gildess Fe 1.5/30c
Ortho-Cyclen, Sprintec, Previfem, Estarylla, Mono-Linyah
EE 35 Norgestimate
0.25
50 m
g estrogen
Ogestrel
EE 50 Norgestrel
0.50
Zovia 1/50
EE 50 Ethynodiol diacetate
g estrogen
1.00
Norinyl
50 Mes 50 Norethindrone 1.00
Ovcon 50 EE 50 Norethindrone 1.00

Multiphasic Preparations
10 m Lo Loestrin Fec EE Norethindrone acetate 1.00 (24)
20 m
g estrogen
10 (24)
10 (2)
Mircette, Kariva, Viorele
25 mg estrogen
EE 20 (21) Desogestrel 0.15
0 (2)
10 (5)
Ortho Tri-Cyclen Lo, Tri Lo Sprintec EE 25 Norgestimate 0.18 (7)
Cyclessa, Velivet EE 25 Desogestrel 0.1 (7)
0.215 (7)
0.25 (7)
30–35 mg estrogen
0.125 (7)
0.15 (7)
Ortho Tri-Cyclen, Tri-Sprintec, Tri-Previfem, Tri-Linyah, EE 35 Norgestimate

0.18 (7)
Tri-Estarylla 0.215 (7)
Trivora, Enpresse, Levonest, Myzilra EE 30 (6) Levonorgestrel 0.05 (6)
40 (5) 0.075 (5)
0.25 (7)
30 (10)
0.125 (10)
1
SECTION 10
Contraception 707
TABLE 38-4. Continued
Product Name
Estrostepc
, Tri-Legestc
Micronor, Nor-QD, Errin, Camila, Heather
Extended-Cycle Preparations
g estrogen
Estrogen
None
mg (days)a
Progestin
mg (days)
EE
20 (5)
30 (7)
Norethindrone acetate
Ortho-Novum 7/7/7, Alyacen 7/7/7, Cyclafem 7/7/7,
Tri-Norinyl, Aranelle
Natazia
Progestin-Only Preparations
EE
EE
EV
35
35
Norethindrone
Dienogest
1.00
35 (9)
0.50 (7)
Dasetta 7/7/7, Nortrel 7/7/7
0.75 (7)
1.0 (7)
Norethindrone
0.50 (7)
1.00 (9)
3
(2
)
2
(5
)
2.00 (5)
2 (17) 1 (2)
3.00 (17)
Norethindrone
0.35 (c)
20 m LoSeasoniqued
30 m
g estrogen
EE
20 (84)
10 (7)
Levonorgestrel 0.10 (84)
Seasonaled, Quasensed
EE
30 (84)
Levonorgestrel
0.15 (84)
Seasoniquee
Continuous Preparation
EE
Amethystf
EE
30 (84)
10 (7)
Levonorgestrel
0.15 (84)
20 (28)
Levonorgestrel
0.09
folate calcium; Mes mestranol.

c
Contains or is available in formulas that contain 75-mg doses of ferrous fumarate
within the placebo pills.
d
12 weeks of active pills, 1 week of inert pills.
e
12 weeks of active pills, 1 week of ethinyl estradiol only. fOne pill every day, 365
days each year.
EE ethinyl estradiol; EV estradiol valerate; LC levome aAdministered for 21

days, variations listed in parentheses.
b
0.451 mg of levomefolate calcium, which is a form of folic acid, is found in each
pill.
Compiled from US Food and Drug Administration, 2013.

0.50 (5) –
For general initiation, women should ideally begin COCs on the first day of a
menstrual cycle. In such cases, a supplementary contraceptive method is
unnecessary. With the more traditional “Sunday start,” women begin pills on the
first Sunday that follows menses onset, and an additional method is needed for 1
week to prevent conception. If menses begin on a Sunday, then pills are begun that
day and no supplementary method is required. Alternatively, with the “Quick
Start” method, COCs are started on any day, commonly the day prescribed,
regardless of cycle timing. An additional method is used during the first week.
This latter approach improves short-term compliance (Westhoff, 2002, 2007b). If
the woman is already pregnant during Quick Start initiation, COCs are not
teratogenic (Lammer, 1986; Rothman, 1978; Savolainen, 1981). Similarly, same-
day initiation can be implemented with the contraceptive vaginal ring or patch
(Murthy, 2005; Schafer, 2006).
For maximum efficiency, pills should be taken at the same time each day. If one
dose is missed, contraception is likely not diminished with higher-dose
monophasic COCs. Doubling the next dose will minimize breakthrough bleeding
and maintain the pill schedule. If several doses are missed or if lower-dose pills
are used, the pill may be stopped, and an effective barrier technique used until
menses. The pill may then be restarted. Alternatively, a new pack can be started
immediately following identification of missed pills, and a barrier method used for
1 week. If there is no withdrawal bleeding, the woman should continue her pills
but seek atten- tion to exclude pregnancy.
With initiation of COCs, spotting or bleeding is common. It does not reflect

contraceptive failure and typically resolves within one to three cycles. If
unscheduled bleeding persists, those with bleeding during the first part of a pill
pack may
CHAPTER 38
708 The Puerperium
benefit from an increase in the pill’s estrogen dose, whereas those with bleeding
during the second part may improve with a higher progestin dose (Nelson, 2011).
■ Method-Specific Effects Altered Drug Efficacy

Combination oral contraceptives interfere with the actions of some drugs. In such
cases, doses can be adjusted as shown in Table 38-5. Conversely, some drugs
decrease the COC effectiveness. Three groups are notable: the antitubercular
drugs rifampin and rifabutin; efavirenz and ritonavir-boosted protease inhibitors,
which are used to treat HIV infection; and enzyme-inducing anticonvulsants,
which include phenytoin (Dilantin), carbamazepine (Tegretol), oxcarbazepine
(Trileptal), barbiturates, primidone (Mysoline), and topiramate (Topamax)
(Gaffield, 2011; Panel on Antiretroviral Guidelines for Adults and Adolescents,
2013). With these, a method other than COCs is preferable. However, if a COC is
selected for concurrent use with an agent from these three groups, then a
preparation containing a minimum of 30 g ethinyl estradiol should be chosen.
In obese women, COCs are highly effective (Lopez, 2010). That said, some but
not all studies point to a potential increased pregnancy risk with COC use due to
lowered hormone bio- availability (Brunner, 2005; Holt, 2002, 2005; Westhoff,
2010). With the transdermal patch method, however, there is stronger evidence
that obesity may alter pharmacokinetics and lower efficacy (p. 701).
Metabolic Changes
Although their effects on carbohydrate metabolism are considered clinically
insignificant, COCs do have notable effects on lipid and protein synthesis. In
general, COCs increase serum levels of triglycerides and total cholesterol.
Estrogen decreases LDL cholesterol concentrations but increases HDL and very-
low density (VLDL) cholesterol levels. Some progestins cause the reverse. Despite
this, the clinical consequences of these perturbations have almost certainly been
overstated. Oral contraceptives are not athero- genic, and their impact on lipids is
inconsequential for most women (Wallach, 2000). But in women with
dyslipidemias, the American College of Obstetricians and Gynecologists
TABLE 38-5. Drugs Whose Effectiveness Is Influenced by Combination Oral
Contraceptives
Interacting Drug Documentation Management
Analgesics
Acetaminophen
Aspirin
Anticoagulants
Imipramine
Tranquilizers
Adequate
Larger doses of analgesic may be required
Probable Larger doses of analgesic may be required
Meperidine
Suspected
Smaller doses of analgesic may be required
Morphine
Probable Larger doses of analgesic may be required
Dicumarol, warfarin Controversial
Anticonvulsant
Lamotrigine monotherapy
Antidepressants
Adequate Avoid
Suspected
Decrease dosage about a third
Diazepam, alprazolam
Suspected
Decrease dose
Temazepam
Possible May need to increase dose
Other benzodiazepines
Suspected
Observe for increased effect
Anti-inflammatories
Corticosteroids Adequate Watch for potentiation of effects, decrease
Aminophylline, caffeine,
dose accordingly
Bronchodilators
Adequate Reduce starting dose by a third
theophylline
Antihypertensives
Cyclopenthiazide
Adequate
Increase dose
Metoprolol
Suspected
May need to lower dose
Antibiotics
Troleandomycin Suspected liver damage Avoid
Cyclosporine Possible May use smaller dose
Modified from Gaffield, 2011; Wallach, 2000.

SECTION 10
(2013e) recommends assessment of lipid levels following COC initiation.
Moreover, for women with LDL cholesterol levels 160 mg/dL or for those with
multiple additional risk factors for cardiovascular disease, alternative
contraceptive methods are recommended.
With COCs, protein metabolism is affected, and estrogens prompt increased

hepatic production of various globulins. First, fibrinogen and many of the clotting
factor levels are increased in direct proportion to estrogen dose and may lead to
thrombosis (Comp, 1996). Angiotensinogen production is also aug- mented by
COCs, and its conversion by renin to angiotensin I may be associated with “pill-
induced hypertension” discussed subsequently. Last, COCs increase sex-hormone
binding glob- ulin (SHBG) levels, which decrease bioavailable testosterone
concentrations and improve androgenic side effects.
Regarding carbohydrate metabolism, there are fortunately limited effects with
current low-dose formulations in women who do not have diabetes (Lopez,
2012a). And, the risk of developing diabetes is not increased (Kim, 2002).
Moreover, COCs may be used in nonsmoking, diabetic women younger than 35
years who have no associated vascular disease (American College of Obstetricians
and Gynecologists, 2013e). Last, studies have not supported a connection between
COCs and weight gain (Gallo, 2011).
Other metabolic changes, often qualitatively similar to those of pregnancy, have

been identified in women taking oral contraceptives. For example, total plasma
thyroxine (T4) and thyroid-binding proteins are elevated. These pregnancy-like
effects should be considered when evaluating laboratory tests in women using
COCs.
Cardiovascular Effects
Despite increased plasma angiotensinogen (renin substrate) levels, most women
using low-dose COCs formulations rarely develop clinically significant
hypertension (Chasan-Taber, 1996). However, it is common practice for patients
to return 8 to 12 weeks after COC initiation for evaluation of blood pressure and
other symptoms.
During initial contraception selection, a history of gestational hypertension does

not preclude subsequent COC use. Also, COCs are permissible in women with
well-controlled uncomplicated hypertension who are nonsmokers, otherwise
healthy, and younger than 35 (American College of Obstetricians and
Gynecologists, 2013e). In contrast, severe forms of hypertension, especially those
with end-organ involvement, usually preclude COC use.
For women with prior stroke, COCs should not be considered due to risks for
repeat events. The risk for a first stroke is substantially increased in women who
have hypertension, who smoke, or who have migraine headaches with visual aura
or other focal neurological changes and use oral contraceptives (MacClellan,
2007). However, for nonsmoking women younger than 35, the risk of ischemic
and hemorrhagic strokes is extremely low, and method benefits considerably
outweigh risks (World Health Organization, 1996, 1998). Moreover, because of
this low risk, the American College of Obstetricians and Gynecologists (2013e)
notes that COCs may be considered for women with migraines that lack focal
neurological signs if they are otherwise healthy, normotensive nonsmokers
younger than 35 years.
For women with prior myocardial infarction, COCs should not be considered.
Also, in women with multiple cardiovascular risk factors, which include
smoking, hypertension, older age, and diabetes, the risk for myocardial infarction
outweighs the benefits of this method. However, for those without these risks,
low-dose oral contraceptives are not associated with an increased risk of
myocardial infarction (Margolis, 2007; World Health Organization, 1997).
It has long been known that the risk of deep-vein thrombosis and pulmonary
embolism is increased in women who use COCs (Stadel, 1981). These clearly are
estrogen-dose related, and rates have substantively decreased with lower-dose
formulations containing 10 to 35 g of ethinyl estradiol. The incidence of
venous thromboembolism (VTE) with COC use is only 3 to 4 per 10,000 woman-
years and is lower than the incidence of 5 to 6 per 10,000 woman-years estimated
for pregnancy (Chap. 52, p. 1028) (Mishell, 2000). The enhanced risk of VTE
appears to decrease rapidly once COCs are stopped. And because these
complications are increased in women smokers older than 35 years, COCs are not
recommended for this population (Craft, 1989).
Those most at risk for VTE include women with thrombo- philias (Comp, 1996).
Other clinical factors that increase the risk of VTE with COC use are
hypertension, obesity, diabetes, smoking, and a sedentary lifestyle (Pomp, 2007,
2008). Moreover, COC use during the month before a major opera- tive procedure
appears to double the risk for postoperative VTE (Robinson, 1991). Thus, the
American College of Obstetricians and Gynecologists (2013d) recommends
balancing the risks of VTE with those of unintended pregnancy during the 4 to 6
weeks required to reverse the thrombogenic effects of COCs before surgery. In the
early puerperium, VTE risks are also increased, and COCs are not recommended
for women within the first 4 weeks after delivery. For all women, an increased
VTE risk with drospirenone-containing COCs has been shown in two studies.
Accordingly, the FDA has encouraged an assessment of benefits and VTE risks
in users of these pills (Food and Drug Administration, 2011; Jick, 2011; Parkin,
2011).
Neoplasia
Fortunately, most studies indicate that overall, COCs are not associated with an
increased risk of cancer (Hannaford, 2007). In fact, a protective effect against
ovarian and endometrial cancer has been shown (Collaborative Group on
Epidemiological Studies of Ovarian Cancer, 2008; Tsilidis, 2011). Protection from
these cancers decreases, however, as time from pill use lengthens (Tworoger,
2007). In contrast, the relative risk of cervical dysplasia and cervical cancer is
increased in current COC users, but this declines after use is discontinued.
Following 10 or more years, risk returns to that of never users (International
Collaboration of Epidemiological Studies of Cervical Cancer, 2007).
Although COC use in the past was linked to development of hepatic focal
nodular hyperplasia and benign hepatic adenoma, large studies do not support this
(Heinemann, 1998). Moreover, there is also no evidence for increased risk of
hepatocellular cancer (Maheshwari, 2007). For women with known tumors, COCs
may be used in those with focal
Contraception 709
CHAPTER 38
710 The Puerperium
nodular hyperplasia, but avoided in those with benign hepatic adenoma and
hepatocellular carcinoma (Kapp, 2009b). Rates of colorectal cancer appear to be
reduced in ever users (Bosetti, 2009; Kabat, 2008).
It is unclear whether COCs contribute to the development of breast cancer, and

major studies show no risk or a small risk among current users, which drops with
time following cessation (Collaborative Group on Hormonal Factors in Breast
Cancer, 1996; Marchbanks, 2002). In women who are carriers of the BRCA1 or
BRCA2 gene mutation, risks for breast cancer are not increased by COC use
(Brohet, 2007; Iodice, 2010). With regard to benign breast disease, COCs appear
to lower rates (Vessey, 2007).
Other Effects
As summarized in Table 38-6, many noncontraceptive benefits are associated with
COC use (American College of Obstetricians and Gynecologists, 2012c). And
indeed, COCs may be used for these effects, even in those without contraceptive
needs.
Low-dose estrogen formulations are not associated with depression or

premenstrual mood changes and may actually improve the latter (Joffe, 2007).
This is especially true with the drospirenone-containing COCs. Several studies
have shown symptom improvement in women with premenstrual dysphoric
disorder (PMDD) who use the drospirenone-containing COC Yaz (Lopez, 2012b;
Pearlstein, 2005; Yonkers, 2005). And, the FDA has approved indications for this
pill to include treatment of PMDD and moderate acne vulgaris for women
requesting oral contraception.
Cholestasis and cholestatic jaundice are uncommon, but they resolve when COCs
are discontinued. For women who have active hepatitis, COCs should not be
initiated, but these may be continued in women who experience a flare of their
liver disease while already taking COCs. Use of progestin-only contraception in
these women is not restricted. Moreover, there is no reason to withhold COCs
from women who have recovered. With cirrhosis, mild compensated disease does
not limit the use of COCs or progestin-only methods. However, in those with
severe decompensated disease, all hormonal methods should be avoided (Kapp,
2009a).
The progestin component of COCs reduces serum free testosterone levels and
inhibits 5-reductase to limit conversion of testosterone to its active metabolite,
dihydrotestosterone. The estrogen component increases SHBG production and
also low- ers circulating androgen levels. The expected results of these actions are
to improve androgenic conditions such as acne and hirsutism.
Hyperpigmentation of the face and forehead—chloasma—is more likely in women

who demonstrated such a change during pregnancy. This is less common with
low-dose estrogen formulations. Cervical mucorrhea, likely due to cervical
ectopy, is common in response to the estrogen component of COCs (Critchlow,
1995). Although previously used for treating functional ovarian cysts, low-dose
COC formulations have no effects related to cyst resolution or prevention
(European Society of Human Reproduction and Embryology, 2001; Grimes,
2011).
■ Transdermal Patch
The Ortho Evra patch is another combination hormonal contraceptive
formulation. It has an inner layer containing an adhesive and hormone matrix, and
a water-resistant outer layer. Thus, women can wear the patch in bathtubs,
showers, swim- ming pools, saunas, and whirlpools without decreased efficacy.
The patch may be applied to buttocks, upper outer arm, lower abdomen, or upper
torso, but the breasts are avoided. Because the hormones are combined with the
adhesive, improper skin adherence will lower hormone absorption and efficacy.
Therefore, if a patch is so poorly adhered that it requires rein- forcement with tape,
it should be replaced.
Initiation of the patch is the same as for COCs, and a new patch is applied weekly
for 3 weeks, followed by a patch-free week to allow withdrawal bleeding.
Although a patch is ideally worn no longer than 7 days, hormone levels remain in
an effective range for up to 9 days. This affords a 2-day window for patch
change delays (Abrams, 2001).
In general, the transdermal patch and vaginal ring produce metabolic changes, side
effects, and efficacy rates comparable to those with COC pills. However, the patch
has been associated with a higher VTE risk in some but not other studies (Cole,
2007; Jick, 2010; Lidegaard, 2012). And despite this lack of convincing
association, the FDA (2008) ordered labeling for the patch to state that users may
be at increased risk for developing VTE. Obesity—90 kg or greater—may be
associated with an increased risk for patch contraceptive failure (Zieman, 2002).
Last, application-site reaction and breast tenderness are more frequent during
initial cycles in patch wearers (Urdl, 2005).
■ Transvaginal Ring
The NuvaRing is yet another form of combination hormonal contraception and is a
flexible intravaginal ring. Constructed of ethinyl vinyl acetate, the ring measures
54 mm in diameter and 4 mm in cross section (Fig. 38-5). During insertion, the
ring is compressed and threaded into the vagina, but no specific final intravaginal
position is required. Its core releases ethinyl estradiol and the progestin
etonogestrel, which are absorbed across the vaginal epithelium. Before being
dispensed, the
TABLE 38-6. Some Benefits of Combined Estrogen Plus Progestin Oral

Contraceptives
Increased bone density
Reduced menstrual blood loss and anemia
Decreased risk of ectopic pregnancy

Improved dysmenorrhea from endometriosis
Fewer premenstrual complaints
Decreased risk of endometrial and ovarian cancer
Reduction in various benign breast diseases
Inhibition of hirsutism progression
Improvement of acne
Prevention of atherogenesis
Decreased incidence and severity of acute salpingitis
Decreased activity of rheumatoid arthritis
SECTION 10
Contraception 711
FIGURE 38-5 NuvaRing: estrogen-progestin—releasing vaginal contraceptive ring.
rings are refrigerated, and once dispensed, their shelf life is 4 months. The ring is
placed within 5 days of menses onset and after 3 weeks of use, is removed for 1
week to allow withdrawal bleeding. Contraception will still be afforded if a ring is
left in place for a fourth week (Merck, 2012b).
Patient satisfaction is high with this method, although vaginitis, ring-related

events, and leukorrhea are more common (Oddsson, 2005). Despite this, no
deleterious affect on vaginal flora or on lower reproductive-tract or endometrial
epithelia has been found (Bulten, 2005; Veres, 2004). Approximately 70 percent
of partners feel the ring during intercourse (Dieben, 2002). If this is bothersome,
the ring may be removed for intercourse but should be replaced within 3 hours to
maintain efficacy.
■ Injectable Progestin Contraceptives

Both intramuscular depot medroxyprogesterone acetate (Depo- Provera), 150 mg
every 3 months, and norethisterone enanthate, 200 mg every 2 months, are
injectable progestin contraceptives that have been effectively used worldwide for
years. Available in the United States, DMPA is injected into the deltoid or gluteus
muscle, but massage is avoided to ensure that the drug is released slowly.
Alternatively, a subcutaneous version, depo-subQ provera 104, is also available
and is injected into the subcutaneous tissue of the anterior thigh or abdomen every
3 months.
DMPA is an effective method, and as with other progestin- only methods,

contraception is provided by ovulation inhibition, increased cervical mucus
viscosity, and creation of an endometrium unfavorable for ovum implantation.
Initial injection is given within the first 5 days following menses onset.
Therapeutic serum levels sufficient to exert a consistent contraceptive effect are
observed by 24 hours. Thus, no additional contraceptive method is required with
initiation within this window. Alternatively, limited data support a “Quick Start”
or initiation of DMPA regardless of cycle day. If so implemented, investigators
recommend an initial negative pregnancy test result before injection, a
supplemental contraceptive method
during the 7 days following injection, and a second pregnancy test after 3 to 6
weeks to identify an early pregnancy (Rickert, 2007; Sneed, 2005). Fortunately,
pregnancies conceived during DMPA use are not associated with an increased
risk of fetal malformation (Katz, 1985). For women who present for intra-
muscular DMPA reinjection more than 13 weeks or subcutaneous DMPA
reinjection more than 14 weeks after the prior dose, the manufacturer recommends
exclusion of pregnancy before reinjection (Pfizer, 2010, 2012).
Actions and Side Effects

Injected progestins offer the convenience of a 3-month dosing schedule,
contraceptive effectiveness comparable with or better than COCs, and minimal to
no lactation impairment. Iron deficiency anemia is less likely in long-term users
because of amenorrhea, which develops in up to 50 percent after 1 year and in 80
percent after 5 years.
Similar to other progestin-only contraceptive, irregular menstrual bleeding is

common, and a fourth of women discontinued DMPA in the first year because of
this (Cromer, 1994). Unique to DMPA, prolonged anovulation can follow
discontinuation, which results in delayed fertility resump- tion. After injections are
stopped, one fourth of patients do not resume regular menses for up to 1 year
(Gardner, 1970). Accordingly, DMPA may not be ideal for women who plan to
use birth control only briefly before attempting conception.
As with other progestins, DMPA has not been associated with cardiovascular
events or stroke in otherwise healthy women. However, in those with severe
hypertension, an increased risk of stroke has been found in DMPA users (World
Health Organization, 1998). Moreover, the US MEC expresses concerns regarding
hypoestrogenic effects and reduced HDL levels from DMPA in women with
vascular disease or multiple risks for cardiovascular disease.
Weight gain is generally attributed to DMPA, and these increases are comparable
between the two depot forms (Bahamondes, 2001; Nault, 2013; Westhoff, 2007c).
In long- term users, loss of bone mineral density is also a potential prob- lem
(Petitti, 2000; Scholes, 1999). In 2004, the FDA added a black box warning to
DMPA labeling, which notes that this concern is probably most relevant for
adolescents, who are building bone mass, and perimenopausal women, who will
soon have increased bone loss during menopause. That said, it is the opinion of the
World Health Organization (1998) and American College of Obstetricians and
Gynecologists (2008) that DMPA should not be restricted in those high-risk
groups. And, it seems prudent to reevaluate overall risks and benefits during
extended use (d’Arcangues, 2006).
It is somewhat reassuring that bone loss appears to be reversible after

discontinuation of therapy but is still not complete after 18 to 24 months (Clark,
2006; Gai, 2011; Scholes, 2002).
■ Progestin-Only Pills
So-called mini-pills are progestin-only contraceptives that are taken daily. These
contraceptives have not achieved widespread popularity and are used by only 0.4
percent of American
CHAPTER 38
712 The Puerperium
women (Hall, 2012). Unlike COCs, they do not reliably inhibit ovulation. Rather,
their effectiveness depends more on cervical mucus thickening and endometrial
atrophy. Because mucus changes are not sustained longer than 24 hours, mini-
pills should be taken at the same time every day to be maxi- mally effective. If a
progestin-only pill is taken even 4 hours late, a supplemental form of
contraception must be used for the next 48 hours. Progestin-only pills are
contraindicated in women with known breast cancer or pregnancy. Other cautions
are listed in Table 38-3.
EFFECTIVE CONTRACEPTION: BARRIER METHODS

■ Male Condom
- phragms, and periodic abstinence have been used for contraception with
variable success (see Table 38-2). The contraceptive efficacy of the male condom
is enhanced appreciably by a reservoir tip and probably by the addition of a
spermicide. Such agents, as well as those used for lubrication, should be water-
based because oil-based products destroy
latex condoms and diaphragms. When used properly, condoms provide

considerable but
not absolute protection against a broad range of STDs. These include gonorrhea,
syphilis, trichomoniasis, and HIV, herpetic, and chlamydial infections.
For individuals sensitive to latex, condoms made from lamb intestines are
effective, but they do not provide infection protection. Fortunately, nonallergenic
condoms have been developed that are made of polyurethane or of synthetic
elastomers. Polyurethane condoms are effective against STDs but have a higher
breakage and slippage rate than latex condoms (Gallo, 2006).
■ Female Condom
The only female condom available is marketed as the FC2 Female Condom. It is a
synthetic nitrile sheath with one flexible polyurethane ring at each end. Its open
ring remains outside the vagina, whereas its closed internal ring is fitted under the
symphysis like a diaphragm (Fig. 38-6). The female condom can be used with
both water-based and oil-based lubricants. Male condoms should not be used
concurrently because simul- taneous use may cause friction that leads to condom
slipping, tearing, and displacement. Following use, the female condom outer ring
should be twisted to seal the condom so that no semen spills. As an added value, in
vitro tests have shown the female condom to be impermeable to HIV and other
STDs.
■ Diaphragm Plus Spermicide

The diaphragm consists of a circular latex dome of various diameters supported by
a circumferential latex-covered metal spring. It is effective when used in
combination with spermicidal jelly or cream. The spermicide is applied into the
dome cup and along the rim. The device is then positioned so that the cup faces
the cervix and so that the cervix, vaginal forni- ces, and anterior vaginal wall are
partitioned effectively from the remainder of the vagina and the penis. In this
fashion, the centrally placed spermicide is held against the cervix. When
appropriately positioned, one rim is lodged deep in the poste- rior vaginal fornix,
and the opposite rim fits behind the inner surface of the symphysis and
immediately below the urethra (Fig. 38-7). If a diaphragm is too small, it will not
remain in place. If it is too large, it is uncomfortable when forced into position. A
coexistent cystocele or uterine prolapse typically leads to instability and expulsion.
Because size and spring flex- ibility must be individualized, the diaphragm is
available only by prescription.
AB
FIGURE 38-6 FC2 Female Condom insertion and positioning. A. The inner ring is
squeezed for insertion. The sheath is inserted similarly to a diaphragm. B. The inner ring
is pushed inward with an index finger.
SECTION 10
FIGURE 38-7 A diaphragm in place creates a physical barrier between the vagina and
cervix.
With use, the diaphragm and spermicide can be inserted hours before intercourse,
but if more than 6 hours elapse, additional spermicide should be placed in the
upper vagina for maximum protection and be reapplied before each coital episode.
The diaphragm should not be removed for at least 6 hours after intercourse.
Because toxic shock syndrome has been described following its use, it may be
worthwhile to remove the diaphragm at 6 hours, or at least the next morning, to
minimize this rare event. Diaphragm use is associated with a slightly increased
rate of urinary infections, presumably from urethral irritation by the ring under the
symphysis.
■ Cervical Cap
FemCap is currently the only available cervical cap in the United States. Made of
silicone rubber, it has a sailor-cap shape with a dome that covers the cervix and a
flared brim, which allows the cap to be held in place by the muscular walls of the
upper vagina. Available in 22-, 26-, and 30-mm sizes, it should be used with a
spermicide applied once at insertion to both sides of the dome cup. For
contraception, it should remain in place for 6 hours following coitus and may
remain for up to 48 hours. Even with proper fitting and correct use, pregnancy
rates with this method are higher that with the diaphragm (Gallo, 2002; Mauck,
1999).
■ Fertility Awareness-Based Methods

All of these family planning methods attempt to identify the fertile days each cycle
and advise sexual abstinence during these days. However, their limited efficacy
is shown in Table 38-2. Common forms of these fertility awareness-based (FAB)
methods include Standard Days, Calendar Rhythm, Temperature Rhythm,
Cervical Mucus, and Symptothermal Methods.
The Standard Days Method counsels women to avoid unprotected intercourse

during cycle days 8 through 19. For
successful use, women must have regular monthly cycles of 26 to 32 days. Those
who use this method can mark a calendar or can use Cycle-Beads, which is a ring
of counting beads, to keep track of their days.
The Calendar Rhythm Method requires counting the number of days in the
shortest and longest menstrual cycle during a 6- to 12-month span. From the
shortest cycle, 18 days are subtracted to calculate the first fertile day. From the
longest cycle, 11 days are subtracted to identify the last fertile day. This is
problematic because ovulation most often occurs 14 days before the onset of the
next menses. Because this is not neces- sarily 14 days after the onset of the last
menses, the calendar rhythm method is not reliable.
The Temperature Rhythm Method relies on slight changes— sustained 0.4∞F

increases—in the basal body temperature that usually occur just before ovulation.
This method is much more likely to be successful if during each menstrual cycle,
intercourse is avoided until well after the ovulatory temperature rise. For this
method to be most effective, the woman must abstain from intercourse from the
first day of menses through the third day after the temperature increase.
The Cervical Mucus Method, also called the Two-Day Method or Billings
Method, relies on awareness of vaginal “dryness” and “wetness.” These reflect
changes in the amount and quality of cervical mucus at different times in the
menstrual cycle. With the Billings Method, abstinence is required from the
beginning of menses until 4 days after slippery mucus is identified. With the Two-
Day method, intercourse is considered safe if a woman did not note mucus on the
day of planned intercourse or the day prior.
The Symptothermal Method combines changes in cervical mucus—onset of fertile

period; changes in basal body temperature—end of fertile period; and calculations
to estimate the time of ovulation. This method is more complex to learn and apply,
but it does not appreciably improve efficacy.
LESS EFFECTIVE CONTRACEPTION: SPERMICIDES

These contraceptives are marketed variously as creams, jellies, suppositories,
films, and aerosol foam. They are especially use- ful for women who need
temporary protection, for example, during the first week after starting COCs. Most
can be pur- chased without a prescription.
Typically, spermicides function by providing a physical barrier to sperm

penetration and a chemical spermicidal action. The active ingredient is nonoxynol-
9 or octoxynol-9. Although these are spermicidal, they do not provide STD
protection. Ideally, spermicides must be deposited high in the vagina in contact
with the cervix shortly before intercourse. Their duration of maximal
effectiveness is usually no more than 1 hour, and thereafter, they must be
reinserted before repeat intercourse. Douching should be avoided for at least 6
hours after coitus.
High pregnancy rates are primarily attributable to inconsis- tent use rather than to
method failure. Even if inserted regularly and correctly, however, they are
considered a less effective method (see Table 38-2). Fortunately, if pregnancy
does occur, they are not considered teratogenic (Briggs, 2011).
Contraception 713
CHAPTER 38
714 The Puerperium
FIGURE 38-8 Today sponges. The sponge is moistened with tap water and gently
squeezed to create light suds. It is then positioned with the dimple directly against the
cervix. The fabric loop trails within the vagina and can be hooked with a finger to later
extract the sponge.
■ Contraceptive Sponge
The Today contraceptive sponge is an over-the-counter, one- size-fits-all device.
The nonoxynol-9–impregnated polyurethane disc is 2.5 cm thick and 5.5 cm
wide and has a dimple on one side and satin loop on the other (Fig. 38-8). The
sponge can be inserted up to 24 hours prior to intercourse, and while in place, it
provides contraception regardless of coital frequency. It should remain in place for
6 hours after intercourse. Pregnancy is prevented primarily by the spermicide
nonoxynol-9 and to a lesser extent, by covering the cervix and absorbing semen.
Although the sponge is possibly more convenient than the diaphragm or condom,
it is less effective than either (Kuyoh,
2003). Most common causes for discontinuance are pregnancy, irritation,

discomfort, or vaginitis (Beckman, 1989). Although toxic shock syndrome (TSS)
has been reported with the contraceptive sponge, it is rare, and evidence suggests
that the sponge may actually limit production of the responsible staphylococcal
exotoxin (Remington, 1987). Still, it is recommended that the sponge not be used
during menses or the puerperium.
EMERGENCY CONTRACEPTION
Many women present for contraceptive care following unprotected sexual
intercourse. In this situation, several emergency contraception (EC) regimens
substantially decrease the likelihood of an unwanted pregnancy when used
correctly. Current methods include COCs, POPs, progesterone antagonists, and
copper-containing IUDs (Table 38-7). Patients can obtain information regarding
emergency contraception by calling 1-888-NOT-2-LATE or accessing The
Emergency Contraception Website: http://not-2-late.com.
■ Hormonal Emergency Contraception

Also known as the Yuzpe method, one EC method provides a minimum of 100 g
of ethinyl estradiol and 0.5 mg of levonorgestrel in each of two doses. As shown
in Table 38-7, a sufficient dose may be achieved by two or more pills. The first
dose is taken ideally within 72 hours of intercourse but may be given up to 120
hours. The initial dose is followed 12 hours later by a second equivalent dose.
With progestin-only regimens, 1.5 mg of levonorgestrel is taken, either as a single,

one-time 1.5-mg dose or as two tablets, each containing 0.75 mg levonorgestrel.
With these regimens, the first dose is ideally taken within 72 hours of unprotected
coitus but may be given up to 120 hours. With the two-pill
TABLE 38-7. Methods Available for Use as Emergency Contraception
Method
Progestin-Only Pill
Plan B One-Step, Next Choice One Dose
Formulation
Pills per Dose
Number of Dosesa
Plan B, Next Choice
0.75 mg levonorgestrel
150 mg levonorgestrel
PRM Pill
Ella
30 mg ulipristal acetate
COC Pillsb,c
Ogestrel
0.05 mg EE

0.5 mg norgestrel
Lo/Ovral, Low-Ogestrel
0.03 mg EE
0.03 mg EE


0.3 mg norgestrel
44
Enpresse (orange), Trivora (pink) Nordette, Seasonale
22
0.03 mg EE
Aviane, LoSeasonique (orange)

0.02 mg EE

Copper-Containing IUD
Paragard T 380A
a
Doses taken 12 hours apart.
b
Other COC brands with formulations identical to those above may also be used
(see Table 38-4).
c
Use of an antiemetic agent before taking the medication will lessen the risk of
nausea, which is a common side effect. COC combination oral contraceptive; EE
ethinyl estradiol; PRM progesterone-receptor modulator.
SECTION 10
regimen, the second dose follows 12 hours later, although a 24-hour interval
between the doses is also effective (Ngai, 2005). One progesterone-receptor
modulator currently available for EC is ulipristal acetate and is marketed as Ella. It
is taken as a single 30-mg tablet up to 120 hours after unprotected inter-
course (Brache, 2010; Watson, 2010). The major mechanism with all hormonal
regimens is inhi-
bition or delay of ovulation. Emergency hormonal contraceptive regimens are

more effective the sooner they are taken and decrease the risk of pregnancy by up
to 94 percent (American College of Obstetricians and Gynecologists, 2012b).
Although highly effective, if EC fails to prevent pregnancy or is mistimed, no
associations with major congenital malformation or pregnancy complications
have been noted with estrogen- or progestin- containing regimens. Data regarding
ulipristal acetate in this setting are limited.
With EC administration, nausea and vomiting can be a significant side effect
(Gemzell-Danielsson, 2013). Accordingly, an oral antiemetic may be prescribed at
least 1 hour before each dose. If a woman vomits within 2 hours of a dose, the
dose must be repeated.
■ Copper-Containing Intrauterine Devices

For women who are candidates, copper IUD insertion is an effective EC method
and provides an effective 10-year method of contraception (Cheng, 2012). If an
IUD is placed up to 5 days after unprotected coitus, the failure rate approximates
only 0.1 percent (Fasoli, 1989; Wu, 2010).
PUERPERAL CONTRACEPTION
For mothers who are nursing exclusively, ovulation during the first 10 weeks after
delivery is unlikely. Nursing, however, is not a reliable method of family planning
for women whose infants are on a daytime-only feeding schedule. Moreover,
waiting for first menses involves a risk of pregnancy, because ovulation usually
antedates menstruation. Certainly, after the first menses, contraception is essential
unless the woman desires pregnancy.
For nursing mothers, progestin-only contraceptives are the preferred choice in

most cases. In addition, IUDs have been recommended for the lactating sexually
active woman. Estrogen- progestin contraceptives may reduce both the rate and
the duration of milk production, although data are limited (Truitt, 2010).
Moreover, very small quantities of the hormones are excreted in breast milk, but
no adverse effects on infants have been reported (World Health Organization,
1988). Thus, in many cases, the benefits from pregnancy prevention by the use of
COCs after the first 4 puerperal weeks would appear to outweigh the risks in
selected patients. Immediate postpartum COC initiation is avoided due to VTE
risks (Centers for Disease Control and Prevention, 2011).

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INTRAUTERINE DEVICES . . . . . . . . . . . . . . . . . . . . . . . . 696 PROGESTIN IMPLANTS .

. . . . . . . . . . . . . . . . . . . . . . . . 703 PROGESTIN-ONLY CONTRACEPTIVES GROUP. . . . . .

The American College of Obstetricians and Gynecologists (2013c) recognizes

Unfortunately, no contraceptive method is completely with- out side effects. That

696 The Puerperium

Top Tier: Most Effective

Levonorgestrel implants Female sterilization Male sterilization

Second Tier: Very Effective

Combination pill Vaginal ring Patch DMPA Progestin-only pill

Third Tier: Effective

Female Diaphragm with spermicides Fertility-awareness

Natural family planninga

Not using contraceptionc

contraceptive sponge, spermicides, and emergency

for noncontraceptive reasons, sexually inactive, pregnant

or puerperal, and those who are sexually active but not

Data from Jones, 2012.

Alternatively, depending on the underlying disorder or patient desire, male or

LONG-ACTING REVERSIBLE CONTRACEPTION:

to the stem (Bayer Healthcare Pharmaceuticals, 2013a,b). Mirena is currently

eluting ring-shaped devices are common in Asia.

■ Method-Specific Adverse Effects

lute number of ectopic pregnancies by half compared with the rate in

DMP LNG- Cu-

1 no method restrictions 2 method benefits outweigh risks 3 method

Postpregnancy infection Smoking & age Active breast cancer Breast cancer

Systolic BP 160 or Diastolic BP 100 Vascular disease Complicated heart

Symptomatic gallbladder disease At risk for GC/CT Distorted uterine

Current or history of ISHD Stroke 4 Migraine with aura Migraine, no aura, 

Unexplained vaginal bleeding Cervical cancer before treatment Endometrial

Acute viral hepatitis AIDS not controlled on ARV Pelvic tuberculosis

TABLE 38-3. Continued

SLE & positive or unknown APAs

SLE & severe thrombocytopenia

Complicated solid-organ transplantation

postpartum hemorrhage, cesarean delivery, smoking, preeclampsia.

35, transfusion at delivery, BMI

AIDS acquired immunodeficiency syndrome; APA antiphospholipid

mydial infection; GTD gestational trophoblastic levonorgestrel-releasing

protease inhibitor; PID lupus erythematosus.

15 cigarettes/day increases risk category to 4 in this age group. dRisk category

; DM diabetes mellitus; DMPA depot medroxyprogesterone acetate; GC/CT

disease; ISHD ischemic heart disease; LNG-IUS 

abortion mandates immediate uterine evacuation in addition to antimicrobials.

In addition to these infections, Actinomyces israelii is a gram- positive, slow-

Pregnancy with an IUD

Second-trimester miscarriage with an IUD in place is more likely to be infected

r moved k to first mark

LONG-ACTING REVERSIBLE CONTRACEPTION:

Implanon is not radiopaque, and a misplaced implant may be identified with

■ Method-Specific Adverse Effects

Nexplanon Insertion Technique

adhesions surrounding an implant may be dissected away with hemostat tips

PROGESTIN-ONLY CONTRACEPTIVE GROUP ■ Actions

For all progestin-only methods, irregular uterine bleeding is a distinct

Most progestin-only contraceptive methods do not sig- nificantly affect lipid

■ Contraindications to Progestin-Only Contraceptives

VERY EFFECTIVE CONTRACEPTION: HORMONAL

■ Combination Hormonal Contraceptives Mechanism of

■ Combination Oral Contraceptive Pills Composition

Pharmacologically, ethinyl estradiol is the most com- mon estrogen present in

United States. Despite these pharmacological differences, the true advantage of

Another progestin, drospirenone, is structurally similar to spironolactone. The

Combination pill Vaginal ring Patch DMPA Progestin-only pill

Female Diaphragm with spermicides Fertility-awareness

1 no method restrictions 2 method benefits outweigh risks 3 method

Postpregnancy infection Smoking & age Active breast cancer Breast cancer

Systolic BP 160 or Diastolic BP 100 Vascular disease Complicated heart

Symptomatic gallbladder disease At risk for GC/CT Distorted uterine

Current or history of ISHD Stroke 4 Migraine with aura Migraine, no aura, 

Acute viral hepatitis AIDS not controlled on ARV Pelvic tuberculosis

r moved  k to first mark

10 m Lo Loestrin Fec EE Norethindrone acetate 1.00 (24)