Birth Control: is it in you?

At a recent meeting of the Sexual Health Network of Ontario, health care providers came together to examine and extol the virtues of the Intra Uterine Device (IUD).  The IUD is a plastic device wrapped with copper that is inserted into the uterus.  I have always been a proponent of this method of birth control, especially for women looking for an alternative to hormonal methods.

The IUD had to overcome a terrible reputation from the bad old days of the Dalkon Shield.

I remember the Shield well.  I was a very young married woman when I had one inserted.  I complained to my gynecologist that I had ongoing pain on one side which lasted several days a month.  It felt like there was a plumb line attached to my ovary.  It wasn’t until returning from overseas that I had it taken out – or rather dug out – because that’s what it felt like.  The little claws were embedded in my uterus.

It was a deadly device.  The Dalkon Shield’s strings acted like a wick, drawing bacteria into the uterus, causing infections – and in nearly two dozen cases in the US – death.  The deaths in developing countries continued as “developed” countries offloaded their products abroad.

However, in the early 1980s, long after the discredited Shield had tarnished the reputation of all IUDs, new research indicated that the newer copper IUDs were both safe and effective and, in particular, did not cause ectopic pregnancies.  It also became clear that they functioned as a true contraceptive by creating an unfriendly environment in the uterus which repelled sperm.  This opened the door to women who had worried it was an abortifacient.

Copper IUDs

Copper IUDs are 99 – 99.8% effective.  In those rare cases where pregnancy occurs with an IUD in place, the pregnancy can continue as long as it is not ectopic.  Statistically, pregnancy outside the uterus is more likely with an IUD; but given its high effectiveness rate, the risk is very low.  A copper IUD can usually be removed if there is a pregnancy; but that would increase the risk of miscarriage.

A woman with average or no cramps and average bleeding is a good candidate.  She can expect a 10 -20% increase in cramping and bleeding with a copper IUD.  Counselling has changed over the years with regard to multiple partners.  Health care providers were concerned about untreated Sexually Transmitted Infections (STIs) causing Pelvic Inflammatory Disease (PID) with an IUD in place.  However, now STIs can be treated without removing the IUD; although, clearly, a woman with more than one partner is encouraged to use condoms.

Adolescents and women who have not been pregnant can also use the IUD.

Copper IUDs can also be used as emergency contraception up to seven days after unprotected intercourse.

There were a number of questions asked during the presentation; for example, the reason why some IUDs can stay inside the uterus longer than others.  Copper IUDs vary in the number of years they can stay in place: 3, 5 or 10 years.  The main difference between one copper IUD and another is the quantity of copper used.  Although Nova-T is a five year IUD, one practitioner said that they do not use it beyond 30 months because, after that point, they have found an increased risk of pregnancy.  10 year IUDs are larger and more difficult to insert and may cause more cramping on insertion.

The only contraindications to the use of a copper IUD include allergy to copper or other components of the IUD, pregnancy, endometriosis, an abnormally shaped uterus, very heavy bleeding or cramping; or active Pelvic Inflammatory Disease. There are a few risk factors, like perforation of the uterus with insertion, but perforation is rare and the uterus often repairs itself.

Intra Uterine System (IUS)

This progestin-releasing device can assist women with severely heavy bleeding as well as women with endometriosis .  By three to six months, most women who use Mirena (the first IUS on the market) experience dramatically reduced bleeding.  About one third of women will stop having periods after 12 months.

Because it uses the synthetic progestin levonorgestrel, it causes similar effects to Depo Provera which also uses a synthetic progestin; i.e., changes in the cervical mucus and uterine lining, making it harder for sperm to reach the uterus.  And similar to Depo Provera, there may be side effects, including:

  • bleeding and spotting between periods
  • heavier bleeding during the first few weeks after device insertion
  • headache/migraine
  • nausea
  • bloating
  • breast tenderness or pain
  • weight gain
  • changes in hair growth
  • acne
  • depression
  • changes in mood

As always, it is important that health care providers explain fully what a woman may expect.

I learned about some newer IUS devices aside from the more commonly known Mirena: Jaydess, a smaller, low-dose version, good for three years; and Kyleena, which releases the lowest dose of hormones for the longest amount of time.  Mirena has the highest dose of progestin of the three and is approved for five years, although data indicate it is effective up to seven.

The IUS can cause spotting for two to six months.  During the presentation, I had noticed two Orthodox Jewish women and a Muslim woman in attendance.  I made a comment about my birth control counselling at clinic regarding spotting.  Because there may be religious strictures about having intercourse in the presence of blood, I always made sure that women for whom this was an issue were well informed.

Speaking of blood, there was an interesting discussion around using a menstrual cup with the IUD.  Because of the suction on the vaginal walls with a cup, to avoid expulsion it is best to gently break the suction before removing the cup.  Another precaution would be not to use a menstrual cup for two months after an IUD insertion because the risk of expulsion is highest in those first two months.

The copper IUD is an excellent choice for women who want long-term, safe and effective contraception, but prefer not to use hormones.  Make sure that your health care provider has plenty of experience with insertion.

 

 

 

 

 

Birth control – what you need to know

My friend’s Huff Post blog on cervical mucus has garnered 26,000 likes and 3,049 shares. Women have written from all over the world to thank her for this information.  Despite our best efforts as sex educators, although we have been teaching specifics about female fertility for decades, it still seems to remains a mystery – not only to those who want to plan a pregnancy – but also to those who are trying to use their knowledge of fertility as a method of contraception.  With the operative word being “trying”.

Yet, clearly Canadians are using some form of birth control, because the age of first pregnancy is continually rising.  According to a report by Statistics Canada “the switch happened in 2010 and widened in 2011, when there were 52.3 babies born per 1,000 women ages 35 to 39 and 45.7 per 1,000 women ages 20 to 24… birth rates for women in their early 40s now are nearly as high as for teens.”

Young adults are trying to figure out how to succeed at work and somehow “work in” a family to their lives.  The most popular methods used by young people today are male condoms, oral contraceptives and withdrawal.

But what is the best method?

There is no “one size fits all”; but there are some serious considerations – especially for women – before making a choice.

  • age
  • number of partners
  • current health and medical history
  • how effective the method needs to be

The last point may seem odd, but a woman needs to ask herself how she would feel about being pregnant if her birth control method didn’t work.  Some women would accept the pregnancy; others would not.  She needs to examine her feelings about abortion as well as its availability.

What works?

Methods that are 98% –99%+ effective:

  • sterilization
  • intra uterine system (Mirena IUS)
  • combined oral contraceptives (the Pill), the Patch or the vaginal ring
  • Depo Provera (depot medroxyprogesterone acetate)
  • IUD (copper intrauterine device)

Effectiveness is measured in two ways: perfect use and typical use.  For example,

“male condoms are an effective method.  However, a man must use a condom correctly from start to finish.  With perfect use, 2 women out of 100 would get pregnant (98%); but with typical use, 15 would get pregnant (85%)”. 

Withdrawal, the third most common method used by young people must also be used carefully.  An inexperienced man may find that its effectiveness drops as his desire to stay inside increases.

What my friend has written about fertile mucus comes in very handy when using withdrawal or condoms.  If a man does not pull out in time and his partner is at the most fertile time in her cycle, she needs to consider using emergency contraception.  The same advice holds true for a condom that breaks.

What influences the method you choose?

“Ask a woman if she is using birth control and she will likely tell you whether or not she is taking “the pill.” For most women, they are synonymous. Often, she’ll ask her doctor to ‘put’ her on the birth control pill, which conjures the image of a five-minute consultation, prescription pad at the ready. Do the words “informed consent” have any real meaning when it comes to birth control?”

Sadly, pharmaceutical companies skip through the loophole in Canadian laws prohibiting direct to consumer advertising in order to sell hormonal contraceptives, especially the pill.  But safety is an issue.  There is a difference between side effects and risks.  As I point out, some hormonal methods and formulations are riskier than others.

This leaves some people wondering about alternatives.

Unfortunately, there isn’t much that’s new on the contraceptive scene.  A few methods are in clinical trials, but nothing that really changes the birth control landscape.

As for men, how about a remote controlled implant or a “vasectomy switch”, the Bimek SLV?  Unfortunately, there doesn’t seem to be anything on the scene that seems workable.

But perhaps youngish women should not practise contraception too long if they want to have a baby “some day” given the decline in fertility after 35.  As a young friend said to me recently, “Just assume that all my friends who are rapidly approaching 40 are trying.”

 

 

Birth control methods – any real news?

When I first started in this business in 1982, there were few contraceptive methods for men in the West aside from condoms and vasectomy (unless you count withdrawal).  The newer methods for women over the years tended to be hormonal.  Proponents of birth control cheered when they became aware of a Chinese method for men developed in the 1970s – gossypol – derived from cotton seeds.  The downside of this method was explained in 2002.  “The only concern at present appears to be lack of reversibility in over 20% of subjects.  Gossypol should be prescribed preferably to men who… would accept permanent infertility after a few years of use.” (http://www.ncbi.nlm.nih.gov/pubmed/12020773).

In the 1980s, we were excited at the news of another Chinese development, plugs injected into the vas deferens; but again, there were problems: “concern about potential toxicity of a chemical component…”  It also took time to be effective.  The plugs “rupture the vasa deferentia, and it is the slow formation of scar tissue that eventually blocks the flow of sperm.”  (http://malecontraceptives.org/index.php.)

Yikes.

In 2011, this article on birth control innovations hit the popular press: http://www.everydayhealth.com/sexual-health/birth-control-innovations-you-could-see-soon.aspx.  Sadly, in the section on male methods, they said, “it may be decades before male hormonal birth control is available (http://www.everydayhealth.com/sexual-health/male-pill-still-a-ways-off.aspx).

Fast forward to January 2015.  A news story entitled “6 Innovative Ways We’re Reinventing Birth Control” (http://mashable.com/2014/09/10/new-birth-control/?utm_cid=mash-com-Tw-main-link&utm_source=twitter&utm_medium=tweet&utm_content=futurebc&utm_campaign=healthtwitter) came across my Twitter feed.  Again, my hopes rose – and then flagged.  You be the judge.

Microchips – a remote-controlled, implanted microchip that can deliver drugs beneath your skin – including hormonal birth control. It’s designed to last up to 16 years, and can be controlled by wirelessly opening and closing a reservoir that releases the hormone levonorgestrel over a course of 30 days.  They are working to get FDA approval for pre-clinical trials in 2015, with a view to going on the market by 2018.

 The woman shuts off the chip with a remote when she wants to get pregnant.  Seriously?  My esteemed colleague, Abby Lippman wrote, “Everything that can go wrong with remote-controlled devices could happen with this device. There really is no foolproof way to ensure that only ‘registered’ people will have access to control the electric current needed to open the seal on the device to release the daily doses. Nor can there be guarantees that hackers won’t be able to access either the device itself or some interconnected computerized information or devices…” (http://rhrealitycheck.org/article/2014/07/16/im-skeptical-remote-controlled-birth-control-chip/)

For more on levonorgestrel, see below.

Oregami condoms – California-based company, Origami Condoms, redesigned the prophylactic so the wearer feels it even more. It isn’t available commercially yet, but pending regulatory approvals, the Origami Male Condom is expected to reach the market in early 2015.

One question:  What about the other partner?  What sensations do they feel vaginally or anally?

L. Condoms – L. is changing the way condoms are manufactured and marketed. They are made from sustainably tapped, locally sourced, biodegradable latex – without irritating additives often associated with typical latex – and they’re packaged in discreet, 100% recycled boxes.

I’m liking this a lot.  Here’s the icing on the cake:

For every condom sold, one is donated to a developing country battling the HIV/AIDS epidemic. 

RISUG –Reversible inhibition of sperm under guidance (RISUG).  Vasalgel, is a form of male birth control.   One shot of polymer, or gel, is injected into the vas deferens, creating a semi-solid plug that blocks sperm in a 15-minute procedure.  100% effective, low-cost, reversible, and can last between 10 and 15 years.  So far, they are testing the polymer with baboons and plan to start clinical trials in humans in 2015.

Looking good.

Sino implant (II)

Here we go again.  Will they never learn?

The Sino-implant (II) is a subdermal implant made of two thin, flexible rods containing levonorgestrel. Hormonal contraceptive implants were introduced more than 30 years ago – but the Sino-implant (II) is designed for “resource-limited settings.”  (The term they use is “ideal” for those settings, aka poor countries.)  While other implants can cost $20 or more per unit, the Sino-implant (II) is priced at $8 per unit. 

Levonorgestrel is the hormone that was used in Norplant.  Class action lawsuits included complaints of severe headaches, anxiety and panic attacks, depression, acne, weight gain of 60 to 100 pounds, excess growth or loss of hair, ovarian cysts, breast pain, skin discoloration, infection at the implant site or numbness in the arm, as well as a variety of menstrual disorders.  What would follow-up look like in a developing country?

Next.

Caya contoured diaphragm

Lea’s Shield, a silicone rubber diaphragm, was introduced in 2002 but discontinued in 2008.  It was a laudable innovation, but clunky to use.

The Caya-brand contoured diaphragm is a redesigned, single-size diaphragm that ensures increased comfort and ease of use.  It can also aid in the delivery of gels that can prevent HIV and STIs.  The contoured diaphragm was approved by the U.S. Food and Drug Administration in September, 2014.

Like older designs, it has to stay inside the vagina for six hours.  For every act of intercourse you need to reinsert gel with an applicator.  Presumably, one needs access to clean water to use it.  You can use Caya up to two years, which is a bargain in the world of birth control.  The gel (Contragel) can be costly depending on frequency of use.  It does not contain nonoxynol-9 which can irritate mucous membranes.

Health advocates who promote non-hormonal methods will be pleased; but some of the drawbacks are similar to the old diaphragm.  It can slip out.  It takes time to insert.  You have to buy gel and reapply.  You have to wash it after use.

To be honest, the only innovations that get my thumbs twitching upwards are the two male methods, the L. condom and RISUG.  How about you?

Birth control – whose choice? June 3, 2013 –

Ask a woman if she is using birth control and she will likely tell you whether or not she is taking “the pill.” For most women, they are synonymous. Often, she’ll ask her doctor to “put” her on the birth control pill, which conjures the image of a five-minute consultation, prescription pad at the ready. Do the words “informed consent” have any real meaning when it comes to birth control?

Women who need birth control are likely to change methods several times during their reproductive years depending on their age, health status, income, partner(s) and number of children. Knowing those circumstances is key to assisting a woman in finding the method that suits her at that particular time in her life. While health-care providers may have prejudices and biases regarding certain methods, the operative word should always be “choice”: hers.

Oral contraceptives (the pill) are clearly the method of choice for most health practitioners because of the effectiveness when used as prescribed. The copper IUD (intrauterine device) is nearly as effective; but it is only recently that health-care providers changed their prescribing practices due to its updated safety record, resulting in increased use, including for women who have never been pregnant. The cheaper, non hormonal IUD is often overlooked by health-care providers in favour of the Mirena Intra Uterine System (IUS), an IUD that releases a progestin. It was originally designed to help women with very heavy bleeding, but it soon became commonly prescribed, possibly due to aggressive marketing. A woman on social assistance in some provinces, like Ontario, is more likely to use Mirena than the copper IUD, even if she prefers a non-hormonal method, because she has to pay for the copper IUD whereas Mirena is covered by the government. This is illogical and wasteful, as the Mirena actually costs about four times more than the IUD (when obtained in publicly funded clinics); it is usually more expensive when inserted by a family doctor.

A woman who wants to use a combined hormonal method, but does not want to take a daily pill may opt for the patch or vaginal ring. The patch has a higher dose of hormones; the vaginal ring uses a “third generation” progestin (see below). Her remaining hormonal option is Depo Provera, a method that should include comprehensive counselling about potential side effects.

Otherwise, she can use condoms (male or female), withdrawal, Natural Family Planning or a combination. She is unlikely to find a clinic that still carries the diaphragm or the gel that accompanies it.

Teaching a woman the basics of her menstrual cycle—in particular, recognizing fertile mucus with a view to charting her fertile days—is a fundamental strategy in educating women about their bodies. There’s even an app for that. If she wants to use this knowledge to prevent pregnancy, she can use the Standard Days Method.

Understanding fertility can also increase the effectiveness of a method like withdrawal, which has a “perfect use” effectiveness rate of 96 per cent. Granted, with typical use, it drops to 73 per cent. If there’s a slip-up, she can take emergency contraceptive pills (or use a post-coital IUD). Although Plan B does not have a consistently high effectiveness rate, its availability over the counter has increased access.

With regard to hormonal methods, there are safety issues which may not be raised by health-care providers.

Women who were already taking pills often wanted to buy them more cheaply from the sexual health clinic where I worked. Some had been prescribed Diane-35 by their doctor. This medication, which is  only approved for short-term use to treat serious acne and hirsutism, also has contraceptive properties. Pharmaceutical companies highlighted the latter application to doctors. So, although it has never been approved as a contraceptive, it is prescribed “off-label” as birth control. When women asked me about Diane-35, I directed them to the Health Canada website and warning because women using Diane-35 as birth control are likely not aware that its use as a contraceptive is off-label. Diane-35 is no longer prescribed in France because of four thrombosis related deaths, and Health Canada recently reminded prescribers ”that Diane-35 should not be used as an oral contraceptive.”

Third and fourth generation birth control pills contain progestins that are associated with a higher risk of blood clots. The brand name drugs Yasmin and Yaz are currently named in lawsuits because of safety issues with the progestin, drospirenone. The vaginal ring uses a third generation progestin, desogesterel. Is there any discussion of that fact before a woman receives her prescription? Mea culpa: I never mentioned it.

Continuous oral contraceptives were first marketed to women by asking them if they wanted to have fewer periods, presumably with the intention of “liberating” them from this bodily function. Many women did switch to continuous oral contraceptives; however, I am unaware of any research into potential long-term consequences (for example to their breast health) of an increase in estrogen over the long term.

Health-care providers are charged with giving patients clear and up-to-date information so that they can make informed choices. Patients must demand nothing less.