Diaphragm

A flexible ring with a rubber dome that must be fitted by a gynecologist: It forms a barrier from the cervix to the anterior vaginal wall. It must be inserted with spermicide and left in place after intercourse for 6 to 8 hours.

Types

■ Flat or coil spring type (for women with good vaginal tone)

■ Arcing type (for poorer tone or vaginal/uteral irregularities such as cys-toceles or long cervices)

Efficacy rates for spermicides are much higher when combined with other barriers (e.g., condoms, diaphragms).

Efficacy

Complications

■ If left in for too long, may result in Staphylococcus aureus infection (which may lead to toxic shock syndrome)

Cervical Cap

A smaller version of a diaphragm that fits directly over the cervix; more likely to cause irritation or toxic shock syndrome. It is more popular in Europe.

Efficacy

Spermicide

Foams, gels, creams placed in vagina up to 30 minutes before intercourse Types

■ Nonoxynol-9 and octoxynol-3; effective for only about 1 hour

Efficacy

Sponge

A polyurethane sponge containing nonoxynol-9 that is placed over the cervix: It can be inserted up to 24 hours before intercourse.

Efficacy

Risk

■ Toxic shock syndrome

HORMONAL AGENTS

Oral Contraceptives

Efficacy

The following are the various types of oral contraceptives.

Combination Pills

Contain estrogen and progestin; come as fixed dosing and phasic dosing:

■ Fixed dosing—requires the same dose every day of cycle

■ Phasic dosing—gradual increase in amount of progestin as well as some changes in the level of estrogen

Mechanism (there are several)

■ Estrogen suppresses follicle-stimulating hormone (FSH) and therefore prevents follicular emergence.

■ Progesterone suppresses the midcycle gonadotropin-releasing hormone (GnRH) surge, which suppresses luteinizing hormone (LH) and therefore prevents ovulation.

■ Causes thicker cervical mucus

■ Causes decreased motility of fallopian tube

■ Causes endometrial atrophy

Progestin-Only Pills

Contain only progestin: There is LH suppression and therefore no ovulation. The main differences from combination pills are:

■ A mature follicle is formed (but not released).

Progestin-only pills are used in the following circumstances:

■ Lactating women (progestin, unlike estrogen, does not suppress breast milk)

■ Women who cannot take estrogens for other medical reasons (e.g., estrogen-sensitive tumors)

Benefits of Oral Contraceptives

■ Decreases risk of ovarian cancer by 75%

■ Decreases risk of endometrial cancer by 50%

■ Decreases bleeding and dysmenorrhea

■ Regulates menses

■ Protects against pelvic inflammatory disease (PID) (thicker mucus)

■ Protects against fibrocystic change, ovarian cysts, ectopic pregnancy, osteoporosis, acne, and hirsutism

Risks of Oral Contraceptives

■ Increases risk of venous thromboembolism/stroke (3/10,000)

■ Increases risk of myocardial infarction (in smokers over 35 years old)

■ Depression

Contraindications of Oral Contraceptives

■ Thromboembolism

■ Cerebrovascular accident (CVA) or coronary artery disease (CAD)

■ Breast/endometrial cancer

■ Cholestatic jaundice

■ Undiagnosed vaginal bleeding

■ Hepatic disease

■ Known/suspected pregnancy

■ Concomitant anticonvulsant therapy

■ Some antibiotics

■ Relative contraindications: Migraines, hypertension (HTN), lactation

In combination oral contraceptives, at the time of desired/expected menstruation, a placebo, or "sugar-pill," is given to simulate the natural progesterone withdrawal.

Mechanism in a nutshell:

Estrogen inhibits FSH. Progestin inhibits LH.

Estrogen suppresses breast milk, so combination pills are not used for nursing mothers. Progestin-only pills are preferred.

Oral contraceptives' link to an increase in breast cancer is not proven.

Why is estrogen a procoagulant? Estrogen increases factors VII and X and decreases antithrombin o

Women with SLE who want birth control should use injectable progesterone. Also good for people with poor compliance (e.g., retarded or drug addicts)

Side Effects of Oral Contraceptives

■ Breakthrough bleeding

■ Breast tenderness

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