Contraception

Question 1

contraception for the masses: how to make a pregnancy

Answer 1

*make an egg
*ovulate an egg
*make a sperm
*ejaculate a sperm
*get the 2 together

Question 2

contraception for the masses: how to PREVENT a pregnancy

Answer 2

*don’t make an egg
*don’t ovulate the egg
*don’t make a sperm
*don’t ejaculate a sperm
*block them from getting together

Question 3

egg vs. follicle

Answer 3

*medical word for egg = oocyte, which is the single cell female gamete
*an oocyte never exists alone; it is surrounded by and intimately linked to layers of granulosa cells and layers of theca cells
*the oocyte together with its surrounding granulosa and theca cells = follicle

Question 4

how many follicles does a human ovary have?

Answer 4

*7 million follicles at 20 weeks gestation; 2 million at birth (most are primordial follicles); 400,000 at puberty; only 400 ovulated over the course of reproductive life with atresia of the others that accelerates after approx. age 35-40 until all are depleted at menopause

Question 5

hypothalamic-pituitary-ovary axis

Answer 5

hypothalamus produces GnRH → GnRH stimulates anterior pituitary to produce and release FSH & LH → FSH & LH stimulate the ovary:
1. FSH stimulates GRANULOSA cells to produce ESTRADIOL
2. LH stimulates THECA cells after ovulation to produce PROGESTERONE
estradiol & progesterone act on the uterus (endometrium) to stimulate menstruation/bleeding

Question 6

normal ovulatory cycle - feedback loops

Answer 6

1. estradiol (from the granulosa cell) and all estrogens → negative feedback on FSH levels
2. progesterone (from the theca cell) and all progestins → negative feedback on LH levels

Question 7

underlying mechanism of oral combination estrogen-progesterone contraception: negative feedback loops

Answer 7

*giving estrogen → neg. feedback on FSH → do not recruit/make/mature the follicle

*giving progesterone → neg. feedback on LH (preventing LH surge) → do not OVULATE oocyte from the follicle

Question 8

estrogens - definition

Answer 8

*a class of compounds that bind to the estrogen receptor; agonists
*main estrogens found naturally in humans: estradiol, estrone, estriol
*ethinyl estradiol = the estrogen found in OCPs

Question 9

progestins - definition

Answer 9

*a class of synthetic compounds that bind to the progesterone receptor
*notably, these compounds have various affinity for estrogen, androgen, and mineralocorticoid receptors
*for contraception, your main desire is to use a progestin that is agonistic at the progesterone receptor in the hypothalamus & pituitary so that there is negative feedback on LH and no ovulation

Question 10

estrogen & progesterone in contraception - actions

Answer 10

1. estradiol/estrogen → negative feedback on FSH → FSH levels drop → follicles are not recruited and do not develop
2. progesterone/progestin → negative feedback on LH → LH levels drop (no LH surge) → no ovulation

Question 11

estrogens - effects on the endometrium

Answer 11

*proliferative effect on the endometrium
*great for sperm, work quickly, lose stability very quickly

Question 12

progestins - effects on the endometrium

Answer 12

*stabilizing effect on the endometrium
*induces atrophy
*long term: bad for sperm / prevents sperm from getting through

note - if estrogen & progesterone are given together, PROGESTINS have the dominant effect long-term

Question 13

estrogens - effects on cervical mucus

Answer 13

*estrogen makes cervical mucus thin, watery, stretchy, and a lovely place for sperm to thrive

Question 14

progestins - effects on cervical mucus

Answer 14

*progestins make cervical mucus thick, sticky, and a hostile place for sperm (sperm get stuck and die)

note - if estrogen & progesterone are given together, PROGESTINS have the dominant effect long-term

Question 15

mechanisms of progestins in contraceptives (systemic) - overall

Answer 15

1. negative feedback on LH → prevents ovulation
2. atrophic effect on endometrium, which is hostile to sperm, so the sperm die or become immobile (prevents oocyte & sperm from meeting)
3. thick cervical mucus, which is hostile to sperm, so the sperm die or become immobile (prevents oocyte & sperm from meeting)

Question 16

mechanisms of progestins in contraceptives (IUD) - overall

Answer 16

*the negative feedback on LH does NOT occur because the progestin is not absorbed systemically
*therefore, people with IUD’s still ovulate
*prevention of pregnancy is by the other 2 mechanisms: atrophy or endometrium + thickened cervical mucus

Question 17

do contraceptives affect how many follicles an ovary has?

Answer 17

*NO - you are born with all the follicles you will ever have
*what a contraceptive CAN do is simply change how many you go on to mature or ovulate
*contraceptives also do not alter the rate of follicular atresia

Question 18

contraceptive failure rates

Answer 18

*perfect use effectiveness: rate of effectiveness when the contraceptive method is always used consistently & correctly
*typical use effectiveness: rate of effectiveness in all couples using a method, both consistently and inconsistently
*Pearl Index = number of pregnancies that would occur per 100 women in 1 year

Question 19

methods of contraception: withdrawal

Answer 19

*method of preventing pregnancy; prevent the egg & sperm from getting together
*perfect use 4% failure; typical use 22% failure rate

Question 20

methods of contraception: rhythm method, natural family planning, fertility awareness

Answer 20

*method of preventing pregnancy; prevent the egg and sperm from getting together
*basal body temperature, cervical mucus method, sympothermal method
*requires a great amount of motivation and training
*requires regular menses

Question 21

methods of contraception: Phexxi

Answer 21

*nonhormonal vaginal gel
*mechanism: maintains vaginal acidic pH, which immobilizes sperm
*NOT a spermicide
*must apply before intercourse, lasts for 1 hour
*expensive

Question 22

methods of contraception: spermicides

Answer 22

*foams, creams, suppositories
*active ingredient: Nonoxyl 9, a surfactant that immobilizes sperm on contact by destroying cell membrane
*also a mechanical barrier
*need to be placed in vagina before each act of coitus
*may increase risk of viral transmission (HIV)

Question 23

methods of contraception: contraceptive sponge

Answer 23

*traps & absorbs sperm
*sperm death: continuously releases spermicide to kill sperm
*physical barrier: covers the cervix so that sperm can’t reach the egg
*issues: UTIs, irritation, efficacy, cost

Question 24

methods of contraception: cervical cap & diaphragm

Answer 24

*mechanism: physical barrier to sperm and spermicidal (spermicide use required)
*both diaphragm and cap require fitting an a prescription
*timing issues (insert before, leave in for minimum time post-intercourse)
*issues: UTIs, irritation, need for repeat spermicide, damaging effect of oil based lubricants

Question 25

methods of contraception: male condom

Answer 25

*latex, polyurethane, or animal skin
*good barrier to STD
*failure: 2% with perfect us, 18% with typical use
*correct application important & overlooked
*care taken not to spill ejaculate on withdrawal of condom

Question 26

methods of contraception: female condom

Answer 26

*typical use failure rate estimated to be 21%, 5% with perfect use
*polyurethane: impenetrable by viruses
*less likely to rupture than male condom
*can be left in place longer after ejaculation
*better protection than male condom against STDs, esp. HSV

Question 27

methods of contraception: combination hormonal contraceptives

Answer 27

*combination OCPs, patch, vaginal ring
*contain systemic estrogen & progestin

Question 28

methods of contraception: progestin-only contraceptives

Answer 28

1. progestin-only pills (POPs) - systemic progestin (no estrogen); prevents ovulation; must be taken at exactly same time each day within a 3 hour window
2. shot (depo-provera): systemic progestin

Question 29

non-contraceptive benefits of hormonal contraceptives

Answer 29

*lower rates of endometrial cancer
*less menstrual blood loss
*lower rate functional ovarian cysts
*DMPA: benefits for sickle cell pts and epilepsy
*less pain with periods
*treatment for endometriosis
*reduces PID risk

Question 30

methods of contraception: progestin implant (the rod)

Answer 30

*progestin only mechanism
*left in place for up to 3 years (effective for up to 5)
*return to fertility after removal is within days to weeks

Question 31

methods of contraception: copper IUD

Answer 31

*non-hormonal
*prefertilization: copper is toxic to sperm, so there is inhibition of sperm migration & viability; also makes the endometrium inflammatory due to foreign body effect, which is also hostile to sperm

Question 32

methods of contraception: levonorgestrel IUD

Answer 32

*hormonal
*prefertilization: hostile thick cervical mucus & atrophic hostile endometrium, with inhibition of sperm migration and viability
*does NOT prevent ovulation because the progestin is a local effect in the uterus and not systemic

Question 33

intrauterine devices (IUDs) - benefits

Answer 33

*IUDs are associated with a reduction in uterine cancer risk
*progestin IUD reduces measured blood loss
*note - do NOT cause PID

Question 34

methods of contraception: female surgical sterilization - bilateral tubal ligation (BTL)

Answer 34

*different names depending on when it’s done:
-post partum tubal ligation: done immediately after vaginal delivery
-intraoperative tubal ligation: done during a C-section
-interval tubal ligation: not done in relation to any pregnancy
*mechanism: cut, burn, clip, band, remove a tubal segment; result = occlusion of tubal lumen so you physically block the egg and sperm from getting together

Question 35

pros and cons of bilateral tubal ligation

Answer 35

*pros: permanent, high efficacy, hormone free, no need to take any meds, esp. easy if done at time of c-section
*cons: irreversible (regret), surgical risks, failure rate is slightly higher than IUDs/implants

Question 36

methods of contraception: male surgical sterilization - vasectomy

Answer 36

*must confirm azoospermic semen specimen postoperatively ~3 months post-procedure
*methods: conventional incision, no scalpel method, percutaneous method, local anesthetic in office