Posts tagged ‘contraception’

The IUD 4 U! (An intro to the Intrauterine Device)

I think it’s time to introduce you, faithful reader, to the best contraceptive you’ve probably never used.  Yet.    

 An intrauterine device (IUD) is a small, flexible, “T”-shaped piece of plastic which is inserted into a woman’s uterus. Its job there is to prevent pregnancy. IUD’s are a very popular method of birth control throughout the world, but only 2% of women in the United States choose this method from among the many contraceptive choices we enjoy.    

There are two types of IUD approved by the FDA (the US Food and Drug Administration).    

The Mirena IUD is distinguished by its hormonal activity. The plastic in the device releases a small amount of levonorgestrel, which is a type of progesterone similar to those found in birth control pills. The amount of progesterone in the IUD is much much MUCH less than in a birth control pill. It only acts locally, on the uterus and cervix, as opposed to circulating around the body to be absorbed systemically.     

Mirena IUD

  

    

The progesterone in Mirena causes a number of changes in the uterus and cervix. First of all, it makes the cervical mucus thick and inhospitable to sperm. They can knock all they want, but they can’t get in. Sorry guys, you don’t have to go home but you can’t stay here.    

But your Mirena doesn’t stop there. It also affects the fallopian tubes. So, whereas the cells lining the fallopian tubes normally ferry the egg down toward the uterine cavity, these cells slow down under the influence of progesterone. The egg is delayed at the departure gate and never makes the flight to rendezvous with her awaiting sperm (assuming he somehow got past security). Honeymoon cancelled. No pregnancy.    

The lining of the uterus is also affected by progesterone. It thins out and becomes inhospitable to a pregnancy. So even if a fertilized egg were to arrive in the honeymoon suite, it would find a cruddy motel room it wouldn’t want to stay in anyway. This thinning of the uterine lining also has the added benefit of giving you shorter, lighter periods. Yay!    

The other kind of IUD is called Paragard. It does not contain ANY hormones. It has a copper coil around the shaft of the “T”. This coil slowly releases copper ions into the uterine cavity. This makes the womb inhospitable to both sperm and egg. It’s a toxic environment where fertilization is unlikely to occur and pregnancy can’t establish itself. Like your mother-in-law’s house.    

Paragard IUD

  

Both types of IUD have thin strings which pass through the cervix and allow the IUD to be easily checked (to see if it’s in place) or removed. A Mirena IUD lasts up to 5 years before it needs to be replaced. A Paragard lasts up to 10 years. Both can be removed anytime after placement if a woman changes her mind or if side effects (such as light bleeding between periods) are troublesome.     

On a serious note, I’d like to remind you that none of this represents an abortion.  If a fertilized egg never implants, it hasn’t established a pregnancy.  It passes with the next menstrual cycle.  You get a period.  Period.    

 So, why wouldn’t everyone want one of these?  Well, for starters, you can’t just pick one up at your local pharmacy. An IUD needs to be inserted in the uterus by a healthcare professional. This can be done during a woman’s peroid to minimize discomfort. It’s often easy to insert in a woman who has been pregnant in the past. It’s a little more tricky if a woman has never been pregnant, but obstacles can be overcome with a little medicine and proper counseling.    

The other reason an IUD requires careful consideration is that it’s not a great form of contraception in women who are not in a monogamous, trusting relationship. An IUD does not protect against sexually transmitted infections (but it doesn’t CAUSE them either). However, if you get a sexually transmitted infection, like gonorrhea or chlamydia, with an IUD in place, it can turn into a very serious medical condition called pelvic inflammatory disease. This may require hospitalization and DEFINITELY requires removal of your IUD.    

I think it’s also a good idea to address myths about the IUD.  The IUD does not cause ectopic (tubal) pregnancy.  A woman with an IUD in place is LESS likely to have an ectopic preganancy than either woman who is not using contraception or one using condoms.  However, in the unlikely event that a pregnancy occurs in woman who has an IUD in place, she needs prompt medical evaluation.      

A properly placed IUD is also very unlikely to ”slip out of place.”   Whereas an IUD can be lost (i.e. slip out of the uterus and into the vagina, from which it will inevitably fall out), it would be pretty obvious that your IUD isn’t protecting you anymore when it shows up in your panties or toilet.  If the IUD is put in place properly, it CAN NOT migrate up the uterus/tubes and into the abdominal/pelvic cavity.  But that’s why it’s important to have the IUD placed by a trained professional.    

In summary, an IUD is a great way to prevent pregnancy. They may be an especially good idea in women who have been pregnant in the past and are at minimal risk of contracting a sexually transmitted infection. They are placed by a healthcare provider and can stay in place for 5 to 10 years if desired.    

For more information, try this link to the American College of Obstetrics and Gynecology’s patient education materials on the intrauterine device.  Planned Parenthood also has a very informative site.    

And if you still have questions, you know who to ask!

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June 25, 2010 at 11:05 pm 24 comments

Progesterone In Your Pill: If the shoe fits, wear it!

So, what makes one combination oral contraceptive pill (OCP) different from another?  What’s the difference between brand-name and generic versions, if any? 

The answer generally boils down to one word: progesterone.  How do we know this?  Because the chemical composition of the estrogen component of almost every OCP marketed in the U.S. is exactly the same.  It’s ethinyl estradiol.  The only thing that changes from pill-to-pill is the dose (thus the idea of “low dose” pills, “triphasic” pills etc), as described in my previous post

So, although all “low dose” OCP’s may contain 20 micrograms of estrogen, there are dozens of different kinds because each manufacturer uses one of eight different kinds of progesterone in each type of pill. 

Progesterone

The type of progesterone is indicated by the second word in the pill’s generic name.  For example, Loestrin is ethinyl estradiol and NORETHINDRONE.  Other pills have other progesterone components (i.e. Ortho-Tri-Cyclen and Ortho-Tri-Cyclen-Lo contain NORGESTIMATE, Yasmin andYaz contain DROSPERINONE).  You get the idea.

So, why do we need so much variety?  Can’t everyone just use the same pill in different doses?  Like Advil or Tylenol, just use a higher dose if you need more of it?

Well, it’ s not that simple.  The dose isn’t the important thing (it’s usually low, about 1-2 mg).  It’s the differences in the chemical characteristics of the progesterone that make each pill unique and separate it from its similar contraceptive cousins.   

Some progesterones have a higher level of progestational activity.”  This means the degree to which it binds with progesterone receptors in the body.  In addition to preventing pregnancy, stronger progestational agents can lessen menstrual bleeding, reduce acne, lessen excessive hair growth, etc. 

Some progesterones have an effect on blood levels of potassium or cholesterol.   Some can increase a person’s risk of blood clots.   These risks and benefits are an important topic to discuss with your gynecologist (or other prescriber). 

As if things weren’t confusing enough, generic OCP’s have active ingredients (estrogen and progesterones) which are chemically identical to the brand-name version.  They are, however, made by different manufacturers. They may contain different additives or be formulated in a slightly different way.

That’s why some people find that, while the brand name version worked well for them, different symptoms occur when they switch to the generic version(or vice-versa).   This means you may need to pay more (or less) for the version you prefer.  The cost difference can be significant ($50 or more!), so consider the choice carefully. 

It’s often difficult to predict which oral contraceptive (and which progesterone) will work best with a particular person’s chemistry.  While your gynecologist (or other provider) can often guide you toward picking an oral contraceptive which is the most likely to satisfy your partiuclar needs, sometimes, it’s necessary to try out a few different types before you hit on a pill that you like.  

But when you do…  Wow.  It’s like Cinderella fitting perfectly into that glass slipper and living happily ever after.   And not getting pregnant on that pumpkin-carriage ride home.

Happily Ever After

June 21, 2010 at 11:16 pm 4 comments

Why are there so many different types of oral contraceptives? – The Estrogen Equation

Well, if you’ve read my previous post (which I’m sure you did!) you already know that the two main components of combined OCP’s are estrogen and progesterone.  What makes each type of pill distinct is the way in which these two components are dosed and formulated.  In this post, let’s discuss only the estrogen component.  We can talk about the progesterone later.

Combination OCP’s can be described as low-dose, medium-dose or (rarely) high-dose.  This refers to the dose of estrogen in the tablet.  A low-dose pill usually contains 20 micrograms of estrogen.  Medium dose pills contain between 30 and 35 micrograms.  Higher doses can go up to 50 micrograms.   

Why does it matter?  Well, a low-dose pill is great for somebody who needs the pill for pregnancy prevention, but doesn’t require the higher doses needed to suppress other conditions (like endometriosis or excessive menstrual bleeding).  A low dose of estrogen also minimizes the risk of complications from oral contraceptives (such as an increased risk of blood clots and other potentially life-threatening medical conditions). 

So, why wouldn’t everyone choose to take a low-dose pill?  Some women taking low-dose pills may not have bleeding during the week of placebos (inactive pills) because the low dose of estrogen keeps the lining of the uterus (womb) very thin.  Therefore, little tissue is shed (as menstrual flow) when the body withdraws from the estrogen.  Amenorrhea (absence of a period) can be normal and healthy in this situation and is not a cause for concern in the absence of other symptoms. 

In some women, bleeding between periods (metrorrhagia) may occur when the dose of estrogen is too low to stabilize the lining of the uterus between cycles.  If this occurs, it doesn’t mean the pill isn’t protecting you against pregnancy.  It just means you may need to switch to a different pill in order to reduce inconvenient or unpredictable bleeding

Spotting or mid-cycle bleeding can also be more likely to occur on a low-dose pill if doses are missed or are taken late.  Therefore a low-dose pill may be a poor option for women who can’t manage to take their pill on time every day.  Obviously, back-up contraception (a condom, perhaps?) should be used when necessary.

Oral contraceptives with 30 to 35 micrograms of estrogen may be a better choice for women who need to suppress their menstrual cycles because of endometriosis, pelvic pain, excessive menstrual bleeding (menorrhagia), or who have had irregular bleeding on lower dose oral contraceptives. 

If they dose of estrogen is the same in every pill, the type of pill can be called “monophasic.”  Some oral contraceptives have a dose of estrogen which varies from the first to the third week (triphasic).  These pills are meant to mimic the natural variation in hormones that occurs during a normal menstrual cycle.  Whether a monophasic or a triphasic pill is right for you will depend on a number of factors which you may wish to discuss with your gynecologist.

June 9, 2010 at 10:12 pm 1 comment

Oral Contraceptives: The little pill that could (and did!)

Continuing our journey through the world of contraception, I think The Pill deserves special mention.  It has been used in the US since 1960 as a way of preventing pregnancy.  It continues to be one of the most popular methods of birth control.

Running the risk of waxing overly poetic, I’ll tell you that The Pill has a long and storied history which has helped shape the roles of women in society.  It has freed a generation of women from fear of unwanted pregnancy and has helped countless others battle the miseries associated with their monthly gift.  But what is this miracle tablet?  What’s in it?  And  how is it used?  

‘The Pill’ is a common term for what the medical community calls a ‘combined oral contraceptive’ or ‘oral contraceptive pill’ (OCP).  This consists of a combination of estrogen and progesterone which is taken in order to prevent pregnancy. 

It does this in several ways.  The most important of these is that OCP’s prevent ovulation, the release of an egg from a woman’s ovary.  No egg, no baby.  Easy. 

It also causes a thickening of cervical mucus.  While this may sound kinda icky, it actually serves the important purpose of reducing the likelihood sperm will be able to pass through the cervix and up through the uterus and tubes on its way to fertilize an awaiting egg (which isn’t going to be there anyway… see above).  No egg-sperm rendezvous, no baby.

It also causes a thinning of the lining of the uterus, reducing the likelihood that, even if a runaway egg and super-ambitious sperm were to elope successfuly, a resulting embryo would not be able to implant.  No implantation, no pregnancy.  (This, by the way, is NOT an abortion.  An embryo needs to implant in order to establish a pregnancy.  Otherwise, you get a normal period.) 

In order for an OCP to effectively prevent pregnancy, it needs to be taken every day for 21-24 days a month.  In a best-case scenario, it should be taken at the same time every day.  This is what’s called “perfect use.”  Humans are not perfect.  Given an opportunity to screw up, we will most likely take it at some point in our lives.  This is called “typical” use.  Therefore, when we talk about the likelihood somebody will get pregant while taking OCP’s we talk about “perfect” and “typical” use patterns. 

The pregnancy rate among “typical” users of OCP’s varies depending on the population being studied and ranges from 2-8% per year. On the other hand, the rate of pregnancy among “perfect” users of OCP’s is about 0.3% per year.  I don’t know about you, but I think that’s pretty good motivation to stive for “perfection.” 

Some combined oral contraceptives aren’t pills at all, but are administered as a vaginal ring (Nuvaring) or a patch (Ortho-Evra).  These can be good options for some patients who can’t reliably take a pill every day.  (However, the Ortho-Evra patch has been scrutinized for the possibility that it delivers more estrogen than most other combined contraceptives, including the ring, and that it may lead to an increased risk of blood clots in some patients.  See below.)

A caveat:  You want to talk to your gynecologist before starting an OCP.  The pill doesn’t protect you against sexually transmitted diseases (STD’s).  If you are at risk for STD’s, you should be using a condom and getting tested at regular intervals.

The Pill also has some risks.  That’s because combined oral contraceptives (those containing estrogen) can increase a woman’s risk of blood clots, heart attack and stroke.  This risk is minimal if you are young (under 35– ouch!), otherwise healthy, and do not smoke.  You should ask your gynecologist (or other healthcare provider) about your risk factors to help determine whether The Pill is a safe option for you.

If you have certain medical problems (like heart disease, a prior blood clot, or a history of certain types of cancer), are a smoker over 35, or are taking certain other types of mediation, you should not take estrogen-containing combined oral contraceptives. Ever. There are other, potentially safer options out there for women who can’t take OCP’s.  More on that in a future post.

I’m also planning a post to explain WHY OH WHY there need to be SO MANY different pills out there!  Really, I promise there’s a good reason.  See you soon!

June 4, 2010 at 3:55 pm 7 comments

Condoms: A little something for everybody

Condoms are one of the cheapest and most widely available methods of pregnancy prevention. They are a type of barrier protection. This means that they work by forming a physical barrier between sperm and egg. Most condoms are made of either latex or lamb skin and may be lubricated (or not) with spermicide (a chemical intended to kill sperm).

A condom is placed over the penis prior to intercourse. If the condom is put sometime in the middle of intercourse (ie prior to ejaculation), unintended pregnancy is still possible. This is because the penis does emit some pre-ejaculatory fluid which can (and often does) contain sperm.

Female condoms are also availabe. These are placed in the vagina and are held in place by a flexible plastic ring. They are a little more expensive than male condoms and a little trickier to put in place, but they work essentially the same way.

So if you choose to use condoms, the rules are

1. put one on before intercourse

2. leave it on until after intercourse is complete

3. use a new condom with each act of intercourse

4. never “double-wrap” with more than one condom at a time (this causes friction and can lead to breakage)

Condoms come in a variety of shapes and sizes. Some have features like flavor (a plus if you are using one to protect your partner during fellatio [oral sex]), texture (ie “ribbed for her pleasure”), color (to match your partner’s dress and/or eyes?), or glow in the dark (for… I don’t know what– A sudden loss of electrical power?!).  In short, there’s something for everybody.

Condoms are cheap and, when used correctly, over 90% effective in preventing pregnancy.  They are also one of the only methods of birth control that can also help prevent the transmission of a number of sexually transmitted diseases, including gonorrhea, chlamydia, HIV/AIDS, hepatitis, syphillis, HPV (human papilloma virus), herpes and other unpleasant nasties.

So what do you do if the condom breaks, falls off, or never made it out of your partner’s wallet? Plan B is a medication intended to prevent unintended pregnancy if used within 72 hours of unprotected intercourse. It’s more effective the sooner it is taken (ie 24 hourse is better than 48 hours is better than 72 hours). It contains progesterone, a hormone that is one of the 2 main components of conventional birth control pills.

Plan B is not the abortion pill and won’t bring an end to an already-established pregnancy. It is available over the counter at a number of major pharmacy chains nationwide. If you have questions about how to use it properly or how to make sure it was effective, or you need testing for sexually transmitted diseases, you should call your doctor.

May 25, 2010 at 2:31 pm 4 comments

Abstinence: The world’s oldest form of contraception

There’s a lot more buzz about abstinence than there was when I was a teenager. My high school generated a lot of buzz back in the 1995 when it was the first on Long Island to distribute condoms.  (Then again, a lot of the fashion in those days had an unintended contraceptive effect.)  But I think the pendulum has begun to swing the other way in a lot of communities.  So I think it may be time to take another look at abstinence.

Abstinence is the oldest and cheapest form of contraception.  Not having sex with a male partner is a sure way for a woman to avoid pregnancy. 100%.  Pretty simple math.

Historically, abstinence has the method of choice for a lot of people because of expectations set by religious faith and family roles.  You remember: First comes love, then comes marriage, then comes baby in a baby carriage.  Premarital sex and unintended pregnancy don’t rhyme well.  (Neither does Baby Bjorn, so I guess baby carriages are also a more moral option for infant transport).

The downside of abstinence is that it can be an unrealistic expectation, especially for younger people.  Teens in particular may struggle with their natural inclination and interest toward sex.  This is compounded by things like peer pressure and widening social acceptance of premarital sex and sex outside of monogamous relationships.  We won’t even go into what constitutes maintaining one’s “virginity.”  But oral sex doesn’t get you pregnant.

If you choose to abstain from sex, it’s not a bad idea to have a back-up plan (ie condoms, the pill, etc…).  This doesn’t mean you’re not committed to abstinence, it means you’re realistic.  You wouldn’t drive a car without a spare tire, would you?  Does that mean you’re planning on getting a flat?  No.  It means you’re responsible.  What?  You don’t know how to change a flat?  Well, that’s what boyfriends are for.

May 19, 2010 at 1:40 pm 3 comments

When to schedule your first exam with a gynecologist.

Your first gynecololgic visit can be a daunting prospect at any age.  But with a better idea of what to expect, there’s no reason for your visit to be intimidating, uncomfortable, or painful.

It is appropriate to make an appointment to see a gynecologist for the first time, whatever your age, for any of the following reasons:

  1. If you are considering becoming sexually active and need to discuss contraceptives and STD prevention
  2. If you are already sexually active
  3. If you have not been sexually active, but are experiencing symptoms which may be related to your menstrual cycle (such as pain, irregular cycles or excessive bleeding
  4. If you think you may be pregnant
  5. If you think for any other reason you might need gynecologic care.  (Even if you might be wrong.)

Some organizations recommend seeing a gynecologist by age 21 even if none of the above applies to you. 

It is not unusual to bring a parent, a good friend, or your partner to your first visit.  It can help to have someone there to share your concerns, be an additional listening ear, or to calm your nerves.  They don’t have to go into the examining room with you.  Most of the time, they don’t want to anyway. 

There should always be a time during your visit when your doctor gives you the opportunity to discuss things with him or her alone, so that you can discuss private issues in PRIVATE, without alienating the person who accompanied you.  This is especially important to remember if you are under 18 and you are considering bringing a parent.

 

 

A note on timing: The best time to schedule your visit is about a week after your period.  However, it may not be necessary to cancel your visit if you are still bleeding the day of your exam.  If you are unsure, call ahead and ask if your provider recommends that you still keep your appointment.  Most providers don’t charge a cancellation fee if you need to reschedule.

May 7, 2010 at 4:44 pm Leave a comment


Linda M. Nicoll, MD

Welcome to my blog! Here you will find information about minimally invasive gynecologic surgery as well as some more general information about common gynecologic disorders such as endometriosis, ovarian cysts, fibroids, infertility, and pelvic pain.

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