Contraception

Contraception is an inherent part of good health care
for women. Fertility is not a disease, and therefore
contraception is not a purely medical concern but an
area for collaborative care in which the woman and
clinician, as well as frequently her partner(s),
exchange knowledge, values and options in planning
and/or preventing her pregnancies.
Introduction
The “modern” birth control era began in the USA
in 1912 with Margaret Sanger’s efforts. These were
perhaps initiated by her own mother’s experience of
18 pregnancies and 11 live births. Table 7.1 provides
a historical timeline of contraception in the USA.1
The proportion of reproductive age women using
contraception and the percentage of women using
contraception at “first intercourse” continues to
increase. Also, the percentage of sexually active
women not using contraception has declined among
most major US ethnic groups including African-
Americans, Hispanics, and whites.
Despite these successes, 49% of the over six
million pregnancies in the USA each year are “unintended.”
Five percent of US women of reproductive
age report an unintended pregnancy yearly: nearly
half (48%) end in abortion. Unintended pregnancy
rates are substantially higher among younger women
(aged 18–24), unmarried, low-income, those who did
not complete high school and minority women.
While the unintended pregnancy rate rose among
women without a high school diploma, it fell among
college graduates between 1994 and 2001.2,3,4
Women who do not use contraception and have
unintended pregnancies are equally as likely to have
a therapeutic abortion as to continue the pregnancy
and have a live birth. Therefore, effective contraception
for more women would most likely reduce the
number of abortions.5
Family size continues to decline, thereby increasing
the number of years that contraception is necessary
for each woman. The average American family
had 7.0 children in 1800, 3.5 children in 1900 and
2.0 children in 1972. The average woman will need to
practice contraception for more than 20 years, if she
wishes only two children. Most women will use several
different contraceptive methods to meet this need.3
Clinicians should consider making every visit with
a reproductive aged woman a “contraceptive” visit.
They should assess the woman’s need for contraception,
satisfaction with her current method(s) and
desire for change(s). Counseling about unintended
pregnancy is graded as a Level III recommendation
by the Institute for Clinical Systems Improvement
(ICSI), indicating that there is “. . . insufficient evidence
to prove their effectiveness and/or . . . important
harms . . . insufficient evidence does not mean the
service is not effective, but rather that the current
literature is not sufficient to say whether or not the
service is effective.” It should be noted that this is the
same designation ICSI gives advanced directive counseling,
clinical breast exam screening, nutrition and
physical activity counseling, skin cancer screening,
PSA screening and digital rectal exam of the prostate,6
Which are customarily accepted as part of routine
health care. Many facets of effective counseling and
the systems issues beyond individual clinician efforts
which are necessary to enhance efficacy are considered
in the white paper, “Patient Centered Contraceptive
Services: Closing the Counseling Gap.”7
Women and their partner(s) must consider
many factors when selecting a contraceptive method There is no one “perfect” contraceptive
method for a couple at one point in time or throughout
their reproductive lives. The decision is reached
through compromise among various factors. Most
couples desire a highly efficacious, reliable, safe,
accessible and inexpensive method. The “fit” of the
contraceptive method to the individual or couple will
influence the success or failure of the method. Ethnicity
and socioeconomic status may also influence
contraceptive failure and success.8
Contraceptive method effectiveness in terms of
“failure rate” is reported in terms of “perfect” and/or
“typical” use. The difference between perfect use and
typical use is highest (about 7% to 15% variation) for
those methods that must be used at each time of
sexual intercourse. Table 7.3 lists the failure rates for
the currently available contraceptive methods.
Contraceptives are, in general, considered as safe,
and typically result in less morbidity and mortality
than does pregnancy for women younger than age
45 years.9 However, some hormonal contraceptives
may be riskier than a pregnancy for women older
than age 45 years who smoke cigarettes: there are
“safer” contraceptive choices for them.
Women with chronic conditions such as diabetes
mellitus, heart disease, hypertension, and collagen
vascular diseases may have higher morbidity and
mortality from some contraceptive methods than
do women without these conditions. However, these
conditions frequently increase a woman’s risk from
pregnancy and pregnancy-related complications.
Therefore the “risk” of the contraceptive method must be individualized against the risk of pregnancy
for each individual.10
Access to the desired contraceptive method is an
important ingredient in its success. Some methods are
available “over the counter” while others require a
clinician visit. Partners must find the method
“acceptable” and commit to the necessary level of
involvement required for its success. For example,
condoms require participation of both partners,
injectable progesterone or Implanon™ does not.
The ease of use is important for many women. For
some, a one-time decision, such as an intrauterine
device, is easier than a method that requires a “decision”
and a “behavior” with each act of intercourse,
such as with the diaphragm. Some women will find a
“permanent” method desirable. Others prefer methods
with more immediate reversibility.11
Virtually all methods have side effects. The perceived
benefits of the method must outweigh the
adverse effects. Some of these effects are medically
significant, if infrequent, such as uterine perforation
associated with intrauterine device (IUD) insertion.
Others are “nuisance,” such as perceived weight
gain from injectable progesterone. Clinicians, however,
should not disregard “nuisance” symptoms as
“less significant” because they may indeed be highly
significant to the woman and impact the adherence
necessary for the success of the regimen.12
Some side effects constitute desirable benefits.
Many barrier methods combine protection from
sexually transmitted infections and diseases with their
contraceptive effect. The incidence of some cancers
may be reduced with use of some methods. Dysmenorrhea,
iron-deficiency anemia, and acne can be
decreased in users of oral contraceptives.13
Some individuals are concerned with the method’s
mechanism of action, especially methods that may
work by affecting “postfertilization” mechanisms.
This may be extremely important to individuals with
ethical or religious views that would preclude any
interference of embryonic development once fertilization
of the egg by the sperm had occurred.14
Table 7.4 lists the contraceptive choices of women
in 2002. Nine percent of users utilize a combination of
more than one method. Some do this to “improve” the
success of contraception. Others desire enhanced efficacy
with additional benefits. The most common combination
of contraceptives is the condom and the pill.15
Even if the clinician does not actively choose to
incorporate contraceptive planning into a routine
visit, knowledge of contraceptive status is critical even
for the “non-contraception” office visit. For example,
prescribing isotretinoin (Accutane) for a sexually
active woman with acne vulgaris should only occur if
she is known to consistently use a reliable method of
contraception.15 Non ace inhibitor antihypertensives may be a better choice for a woman with high blood
pressure who may become pregnant.
Finally, even if the patient is not interested in
contraception, discussing the nature and frequency
of sexual activity with patients provides an opportunity
to assess the risk of common sexually transmitted
infections. If the woman is “at risk,” counseling can
include safe sex practices such as abstinence. Barrier
methods, such as the male and female condoms, may
be recommended as a strategy to decrease risk while
providing some contraceptive benefit. Screening for
cervical dysplasia and sexually transmitted infections
such as gonorrhea, chlamydia, syphilis, hepatitis B
and HIV may be recommended. Primary prevention
against hepatitis B and HPV can be offered through
vaccination. If, on the other hand, the woman is
interested in becoming pregnant, she may benefit
from preconception assessment and counseling, such
as folic acid supplementation.
Office visits can also provide an opportunity to
discuss the availability of emergency contraception or
“EC” (see below) because even the woman who uses
contraception may experience method “failure.” EC is
now available without prescription for US women
over 18 years of age. Younger women may choose to
keep a prescription for EC “on hand” in much the
same way as women with infrequent asthma may opt
to have a rescue inhaler available.

Posted in: Contraception,Health