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Contraception

Vaginal contraceptive film; it’s not all that new but it looks like a little piece of plastic. You fold it over and put it in the uterus like this, in the vagina, in front of the os and it melts. What’s really nice is this is real portable. You can carry it around, you can put it with condoms and it works just as well as any of the other spermicides.

New is the polyurethane condom. It’s for patients with latex allergies. Called Avanti. Female condom, also made out of polyurethane. Had an inner ring and an outer ring and comes with nonoxinol 9, a lubricant.

Let’s talk about combined oral contraceptives. What do they do? They have estrogen and progesterone. They prevent ovulation. I put a lot of other methods of contraception in your handout so you could review it at your leisure. It prevents ovulation, thickens. The estrogen mainly is the part that prevents ovulation. Progesterone thickens cervical mucus. This is the same way that Norplant works, the Depo-Provera works, progestin only - the mini-pill - works. Effectiveness is anywhere from … depends on whether you take it every day or not. Theoretical effectiveness is around 98 - 99% but if you leave it in your medicine cabinet at home and leave for the weekend, it’s not as effective.

There is going to be a shot out soon, that is a shot birth control pill, that has long acting estrogen and progesterone and it has to be given every month.When don’t you use the pill? Well, if they’ve had thrombophlebitis or thromboembolic phenomenon or history thereof. And this is an IV site that has phlebitis. This is … they have a spontaneous clot in a deep vein. If you’ve had a stroke you usually don’t put them back on the pill. Coronary artery, or ischemic heart disease, or history thereof, and if you have breast cancer or have a history of having had breast cancer. Family history of breast cancer, it doesn’t matter. Estrogen-dependent neoplasia, pregnancy. Now there is no evidence that taking the pill while you are pregnant is dangerous. It’s just superfluous. You don’t need it. So if someone is pregnant and has been on the pill, there is no reason to caution to have an abortion or termination. So there is really low risk if you are on the pill and do get pregnant. It’s just that you don't need it. Benign hepatic adenoma - I’ve never seen one - and if you have impaired liver function, like you have real active mono or hepatitis, but once your liver functions are normal, even if you’ve just recently had mono, you can go back on the pill.

How do you group side effects? Well, estrogenic side effects are nausea. Think of pregnancy. Increased breast tissue size, if they are ductal or fatty tissue, it can stimulate a breast neoplasia. This is the warning you give women about cancers and the pill, is that it doesn’t create breast cancer but if there is a cancer there it may speed its development, but the good news is that if a woman is on the pill and a breast cancer is diagnosed it’s usually of a lower grade and not metastasized. Causes you to retain fluid, just like before your period, cyclic weight gain, leukorrhea just means a watery vaginal discharge, you can get cervical erosion. Now the cervical erosion makes you more susceptible to either human papilloma virus or chlamydia. Cervicitis is increased in women on the pill but PID is decreased. The reason PID is decreased is that you have a thickening of the cervical mucus and the germs just can’t get up there. Pulmonary emboli, CVA, adenomas, hepatocellular cancer -extremely, extremely rare. Occasionally increased cholesterol and gall bladder disease. So if a patient has right upper quadrant tenderness, they don’t have cervical motion tenderness, you don’t think they have Fitz-Hugh-Curtis, then think about gall bladder disease if they are on the pill. You can have growth of fibroids and you can have telangiectasias. One other thing, with estrogen you can have the mask of pregnancy. I have a colleague who was going up on a ski lift with his daughter and he noticed this - he’s an OB/GYN - noticed this discoloration on her face and said, "So how long have you been on the pill?" She almost fell off the ski lift. "How do you know?" "Well, you’ve got this rash on your face."

Androgen, male hormone; bad things. Increases appetite and weight gain from increased appetite and eating more, can make you depressed, fatigued and tired. Decreased libido, acne and oily skin. There is kind of a misconception about birth control pills and acne. Practically any pill makes acne better. Ortho-Cyclen, Ortho-Cept, almost any pill - almost any pill - will improve acne. Increased breast size. It alters with LDL and HDL. It makes you more insulin resistant, can cause itching and this is decreased insulin tolerance down there. What the big news about the pill that scared people in Europe was they found that third generation pills, the Ortho-Cyclen, Ortho Tri-Cyclen, Ortho-Cept, ortho without the novum. You know there’s Ortho-Novum, 777 is Ortho-Novum, 135 is an Ortho-Novum. Any ortho other than Ortho-Novum is a third generation low androgen pill. And they found that it increased DVT’s. They don’t know why, and it may actually be a bias in terms of collecting the sample. But you may hear about, "What pill causes increased DVT’s?" and it’s third generation. And you can see pregnant women have a high rate here, about 60 per 100,000. Third generation pills, it’s about 20, second generation pills it’s about 10, and women who aren’t pregnant and not using oral contraceptives, it’s about 5.

Morning after pill; it now comes as a kit that has instructions, a pregnancy test, and two pills to take before and two after. I prefer giving them three sets of pills because if you throw it up, what are you going to do? You don’t have it. I’ve listed all the different pill types that can be used for morning after. This is Ovrette and it is 20 pills but there is no nausea. They will be marketing a 1.75 mg pill of progesterone, which is great, because no nausea. So take one pill and then one pill 12 hours later. Ovrette, you have to take 20, but if women have a lot of nausea with it they are willing to take 20 small pills to avoid throwing up for an hour.