Clinical:Case Study: Appropriate Birth Control

Original materials created in November 2000 by Stephanie Braemer, M.D.

History

JK is a 29 year old single Caucasian woman, Gravida 2 Para 2 presenting to our clinic for her annual well woman exam. She has used oral contraceptives in the past, and has had a good experience with it, but is interested in considering other options.

She is a nonsmoker who has regular menses and no personal or family history of DVT, DM, CA or CAD of note. She considers herself a healthy person and stays up to date with her medical exams (pap smears, etc.). All pap smears to date have been normal. She has never had a mammogram. She and her husband are monogamous and have a healthy sexual relationship. Neither have any history of STDs. They have no plans for more children at this time but would like to keep their options open.

Her husband is very supportive of any type of birth control she may choose, although he himself would prefer not to have a vasectomy. As a family, they travel frequently and a form of birth control that is not a daily chore would be preferable.

I asked what she had heard about other types of birth control so as to dispel any myths and address specific questions. Indeed she had heard that the IUD may cause pelvic infection and that Depo Provera injections cause irregular menses, making pregnancy hard to diagnose.

Exam

BP 129/71 Vitals otherwise stable.

JK is a well nourished woman with a relaxed affect. Chloasma is noted on her face.

Heart and lung exam are normal. Thyroid exam is unremarkable. Her abdomen is soft, without masses and nontender with palpation. Pelvic exam reveals normal female external genitalia with benign appearing white discharge. Parous cervix without lesions and uterus and adnexa nontender to palpation. Uterus is a normal size and aneverted.

Discussion

Success rates as well as side effects of various birth control methods must be reviewed with the patient. Assuming perfect use, oral contraceptives have an efficacy of 99.4-99.9% (with typical use 94 -97.5%). Injectable Depo-provera has an efficacy of 99.7% and IUD ranges from 98.5 – 99.4%. As a point of reference, efficacy with typical use of male condoms is 88%.

Depo provera is a 3-month progestin-only injectable. It is convenient, safe, reversible, and private. After being developed in the 1960s, it was FDA approved in 1992. Microcrystals of medroxyprogesterone acetate with low solubility persist for 3-4 months inhibiting ovulation. Initiation should be within 5 days of onset of menses (can also be given immediately post-partum) and if an injection is missed by more than 2 weeks a pregnancy test should be checked.

Depo-provera frequently causes amenorrhea and educating patients results in higher satisfaction and understanding. Other side effects include weight gain, headaches, breast and abdominal bloating, decreased libido and mood changes.

Studies to date show no increased risk of breast, endometrial, ovarian or cervical Cancer compared with use of oral contraceptives. It may in fact increase prevention of endometrial cancer. There has been a reversible loss of bone mineral density shown although the long term impact is yet unknown. A study initiated in 1994 is due to conclude in 2003 and should assist in clarifying this.

Depo provera is an appropriate contraceptive choice for patients whose medical status precludes them from using estrogen. This includes women over age 35 who smoke, women with cardiovascular/liver disease, complex migraines, and those with increased risk of DVT.

IUD

The intrauterine device is a highly efective, reversible, medium to long term method of birth control. Misinformation as well as health concerns held by many American women has inhibited somewhat the usage of this method here. (There are around 72 million users in China, by comparison). Prototypes available in the USA include the progesterone containing IUD (Progestasert) which must be changed yearly and has afilure rate of 2.9% and the copper T which lasts 10 years and carries a failure rate of less than 1%.

Higher rates of pelvic infection (PID) with with STDs can occur and therefore an appropriate population would be one of monogamous women at low risk for STDs.

The mechanism of action of the IUD is now acknowledged to be prefertilization. It thickens cervical mucus and makes the endometrium thin and inactive. Copper is deleterious to sperm and their motility. Failure of implantation may occur but not at an increased frequency.

A side effect of the IUD is heavier periods and periods with increased cramping. This can be frequently circumvented by starting ibuprofen at the onset of menses each month. With time, the severity usually lessens. Another side effect can be penile abrasions – just another reason to practice safe sex and to know one’s partner well.

Barrier methods

The female condom has been available since 1993 and is covered by Medicaid/ Medi-Cal although it is unknown to many women. It consists of a sheath of polyurethane plastic, sturdier than male latex condoms. The disadvantages are the cost (about $2.50 each) and the failure rate with typical use is 21-26% (5% with perfect use).

The cervical cap/diaphragm need to be fitted in and office and ordered or dispensed. They carry a “typical use” failure rate of 17.4% and a perfect use failure rate of 6%.

Natural Family Planning including withdrawal, periodic abstinence, and complete abstinence are other options and may be acceptable for couples who prefer methods congruous with faith/beliefs. The typical use failure rates for these methods averages 20%.

Lastly, a bilateral tubal ligation is an option for (usually) irreversible birth control. This is an outpatient procedure with high efficacy.

On the horizon is a one-month injectable contraceptive for women which may suit some personal schedules more flexibly. Also under study are transdermal patches and a new IUD.

In JK’s case I counseled her to use either the Depo injection or an IUD. As tubal ligation is not a consideration for her yet, reversible long-term birth control could be attractive. A Copper T IUD would provide her with 10 years of worry-free contraception.

She agreed and 3 days after her following menses she returned to my office where I easily placed her IUD (Her recent pap and infections screens were normal/negative).

At a follow-up visit, she noted her satisfaction with her IUD. She could not feel anything and even better, neither could her husband. She had since been through 3 menstrual cycles with increased but bearable cramping. She noted how pleased she was not to be worried about remembering her pill every night, especially while travelling.

References

Contraceptive Technology, 16th Edition, Hatcher RA et al, 1994, pp. 347-378.

The Contraception Report, Vol. 10 No. 6, February, 2000.