CONTRACEPTION

Alicja Halbersztadt: Natural family planning, recognised by most religions, based on knowledge of one’s own body and understanding of the changes taking place within it, can be practised in monogamous relationships, by caring, careful, conscious partners who will be able to identify the moment of ovulation and the days of fertility. The method requires a lot of commitment, the ability to assess the symptoms occurring during each monthly cycle (observation of the cervical mucus, measurement of body temperature, assessment of the regularity of menstrual bleeding). Please note that it is sometimes ineffective in women with an irregular menstrual cycle or under any kind of stress (travel, infection, overwork, etc.).

A specialist gynaecologist should help us choose the proper contraceptive procedure. By promoting a modern, effective contraception, reversible and safe for the patient’s health, taking into account the patient’s acceptance, tolerance and possible additional, non-contraceptive benefits. Explaining the benefits to the patient and presenting the risks associated with the use of a given contraceptive method helps to make an informed decision and ultimately the most beneficial for her health.

Some women expect only protection against unwanted pregnancy, some require additional protection against sexually transmitted diseases such as AIDS, chlamydiosis, human papillomavirus (HPV) infections, genital herpes, gonorrhoea or syphilis. According to the current WHO guidelines, adolescents and young women who are more likely to have intercourse with multiple partners should use double protection in the form of a highly effective method of contraception (for example, a hormonal contraceptive pill or vaginal ring) in combination with a condom to protect against infection at the same time.

Therefore, the best contraceptive method is one that, in consultation with the doctor, will be chosen by the woman, will not affect her lifestyle, bringing the benefit of protection against unwanted pregnancy with minimal risk.

Perhaps the most common method of contraception is barrier methods, and of these, the condom. They work by preventing sperm from getting into the genital tract.

Condoms

Condoms made of latex, less often polyurethane, is a not very expensive method, recommended for rare intercourse, and works well in the case of sexual contact with many partners due to the protection against sexually transmitted diseases. In addition to male condoms, there are also female condoms made of a disc placed outside the vulva and an inner disc that can be placed over the cervix. Most condoms are moistened with silicone, some also contain the so-called spermicides. The main risk with this method is an allergic reaction of the skin of the vulva and vaginal mucosa to latex, moisturisers or spermicides. The main benefit is protection against sexually transmitted diseases and reduction of the risk of acute adnexitis or inflammation of pelvic organs.

Other barrier methods include vaginal membranes and cervical caps.

Vaginal membranes (diaphragm) and cervical caps

The vaginal membrane (diaphragm), which should be inserted just before intercourse or 2-3 hours earlier, provides contraceptive protection for approximately 6 hours after insertion. Before applying the diaphragm, it is recommended to apply spermicide to its edges and neck. The effectiveness of this method depends largely on the appropriate selection of the size and proper positioning of the diaphragm, therefore it is an indicator of the structure of organs and anatomical relations in the smaller pelvis, as well as the muscularity in the lower parts of the birth canal. The skill of proper diaphragm placement is acquired through trial and error. The disadvantages of this method are, first of all, the risk of changing position during intercourse and relatively low effectiveness, amounting to an average of 15-20 pregnancies per 100 women for 1 year of use. Allergic reactions and even toxic shock have been reported due to hypersensitivity to diaphragm components or the spermicide. The advantage is relative protection against sexually transmitted diseases.

The cervical cap can be inserted a few hours before intercourse and remain in the vagina for a minimum of 6 hours, a maximum of 24-48 hours, providing contraceptive protection for approximately 48 hours. Placing it, however, requires more skill than in the case of the vaginal membrane (diaphragm), and the size is selected the gynaecologist. Similarly to the diaphragm, the cap can change its location, which is why this method has a relatively low effectiveness – 15-25 pregnancies per 100 women within 1 year. Some women may be allergic to the material of the cap or the spermicide used. It cannot be used by women with abnormal cytological smears, and it may also contribute to the development of urinary tract and genital tract infections.

Spermicides

Spermicides provide low effectiveness from 15 to 30 pregnancies per 100 women during 1 year of use. Low cost and availability at any pharmacy without a prescription, often also in herbal stores and drugstores, make this method attractive especially for young people. It is worth noting, however, that this method does not protect against sexually transmitted diseases, and users who have several intercourse per day have been reported to be at a higher risk of HIV infection. It can also affect the natural bacterial flora of the vagina, facilitating the development of infections in the reproductive tract including urinary tract infections. Additional to these are the frequently observed hypersensitivities.

Intrauterine device (IUD)

Intrauterine device (IUD) is a highly effective method of contraception with an average risk of failure of 0.6-0.8 pregnancies per 100 women during 1 year of use. This method should not be used by women who have not given birth or by women who have a higher risk of getting sexually transmitted diseases. It is especially recommended for women with children and in a stable relationship, requiring long-term contraception, and for patients with contraindications to hormonal contraception (venous and arterial thrombosis, liver disease, hypertension, smokers over 35 years of age). Once the IUD is in place, there is a slight risk of it falling out or perforation of the uterine wall. Within a few weeks of inserting an IUD, there is a slightly higher risk of an intrauterine infection. Currently available IUDs on the market are: copper-containing IUDs and levonorgestrel-releasing system. The copper IUD works mainly through a spermicidal mechanism and an effect on the endometrium. The suspicion of its early abortive effect has not been proven.  An adverse effect of the copper IUD is an increase in the frequency of menstrual periods, and there may also be increased pain during the first few months after insertion. Abnormal bleeding and uterine contractions are less frequently observed. The most important advantage of the IUD is the fact that it is a long-term, effective contraceptive method, without affecting the hormonal and metabolic state of the woman’s body, without requiring any special involvement of partners.

The levonorgestrel IUD, also known as the levonorgestrel-releasing system, is recommended for women with heavy bleeding because it significantly reduces the course of monthly bleeding, thanks to the topically acting gestagen. Its main mechanism of action is to affect the endometrium, thickening the cervical mucus and altering the functioning of the fallopian tubes to prevent sperm from reaching the egg.

Oral contraceptive pill

Oral contraceptive pill (OCP) – a contraceptive method whose action is based on the change of the sexual cycle, since by affecting the secretion of Gonadotropin-releasing hormone, ovulation is suppressed, the cervical mucus thickened, the properties of the endometrium altered and fallopian tube transport impaired. The method is highly effective – the overall failure rate is 3 to 8 pregnancies per 100 women per 1 year. The main risk with the combined pill, although rare, is venous thrombosis, heart attack, stroke, and a slightly higher risk of developing breast cancer. It is important to note that this type of contraception cannot be used in women with a family history, obesity, certain metabolic disorders and conditions (diabetes, hypertension, heart disease, a history of venous thrombosis, impaired liver function) and those taking chronic medication or smoking tobacco. Modern combined hormonal contraception shows a tendency to continuously reduce the doses of both hormones in preparations and the regimen of use ensuring a reduction in the number of uterine cycles (withdrawal bleeding) in order to improve the safety profile.

Transdermal contraceptive patches (birth control patches)

Transdermal contraceptive patches containing estrogen and gestagen release them into the systemic circulation in a constant amount daily. In a typical cycle using this method, 3 patches are applied at 7-day intervals (i.e. once a week), in the fourth week there is a break and a hormone withdrawal bleeding occurs. The efficacy, contraindications, disadvantages and benefits are similar to those of combined oral contraception, with a slightly higher risk of thrombotic complications.

Vaginal ring

Vaginal ring containing a low dose of the two hormones estrogen and gestagen, works similarly to the combined hormonal contraceptive pill, with the difference that it is inserted into the vagina once every 3 weeks. It is characterized by similar advantages and disadvantages as two-component hormonal contraceptive pill and high effectiveness (0.65 pregnancies per 100 women using the ring for 1 year). In 10-15% of patients using this method, vaginal discomfort is felt, sometimes even causing problems during intercourse.

Hormonal contraception containing gestagens

Hormonal contraception containing gestagens  is an ideal method for women with contraindications to the use of estrogens (epilepsy, sickle cell anaemia, migraine headaches, hypertension, systemic visceral lupus, elderly women, smoking and breastfeeding women.

Depot medroxyprogesterone acetate (DMPA)  is a gestagen administered intramuscularly 1x for 3 months. It works by inhibiting ovulation by influencing the secretion of gonadotrophins, increasing the density of cervical mucus and thinning the endometrium. The success rate is high, with a failure rate of 0.5-3 pregnancies per 100 injecting women per year. Many injecting women stop menstruating and may also experience irregular genital bleeding, usually of minor intensity, for the first 3-6 months or more. The period of menstrual cessation usually does not exceed 6-18 months. This method does not protect against the possibility of infection with sexually transmitted diseases. It lowers the risk of uterine cancer. Side effects include weight gain, fatigue and loss of bone mineral density.

Mini pill

Mini pill– containing only gestagen, it is the most popular preparation among lactating women, although the indications for its use are similar to those of DMPA. The effectiveness of this method is 0.3- to 8 pregnancies per 100 women in the year of use.

Emergency post-coital contraception

Emergency post-coital contraception – a method of contraception to avoid pregnancy after unprotected intercourse or with a known ineffectiveness (for example, condom break) with levonorgestrel oral combination tablets or levonorgestrel alone. This method reduces the risk of an unwanted pregnancy by 75%. Of the side effects, nausea and vomiting are the most common.