Womens Health

Preventing Pregnancy

Desire to prevent pregnancy

reversible contraception

Background - importance and magnitude of problem
Diagnostic goals - for overall category

    natural family planning
    • withdrawal
    • rhythmn
    • body temperature method
    • the mucus method
    barrier methods
    • condom
    • foam, spermicides
    • sponge
    • diaphragm
    • cervical cap
    • female condom
  • intrauterine devices
    oral agents (pills)
  • intramuscular depo-progestins
  • subcutaneous implants
  • male-medical

Background

There are still no ideal forms of birth control even though it is only in this century that methods have been developed that really work. Some methods are more effective than others but also have more side effects. Some methods can reduce sexual pleasure while others can affect overall mood. Ideally both members of a couple should have a say in choosing a method, however some methods depend entirely on the woman or entirely on the man for implementation.

Internationally, the intrauterine device (IUD) is much more frequently used than birth control pills, injections, implants or even barrier methods. In the United States, IUDs got bad publicity due to one specific IUD (Dalkon Shield) and thus are not commonly used. Oral, injectable and implantable hormones all have side effects such as irregular bleeding, mood changes and occasionally exacerbation of other medical problems. Natural family planning and barrier methods have higher failure rates than some of the other methods.

MethodEstimated pregnancy rate (%)
Oral Contraceptives less than 1-2
Implantable Rod less than 1
Long-acting Injectable less than 1
Intrauterine Device 2-4
Diaphragm 10-20
Condom 5-15
Spermicides 15-35
Rhythm Calendar 15-45
Rhythm Temperature 1-20
Temperature plus intercourse only after ovulation 1-10
Cervical mucus 1-25
Withdrawal 20-25
Post Coital Douche 40
No method 85-90

Goals

The pregnancy or failure rate is a primary consideration for choosing a contraceptive. In some circumstances an unplanned pregnancy is very undesireable while in other circumstances it is inconvenient but not the worst timing. Any medical contraindications should also be a major factor in deciding but most women don't have such contraindications. More often there are reactions or side effects to the most effective contraceptives.

In many instances there is no experience with a given contraceptive so a woman just has to choose and then switch if side effects are a problem. The primary goal is to balance benefits versus side effects or risks in choosing a contraceptive, such as abnormal bleeding while taking oral contraceptives.

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Desire to prevent pregnancy

permanent sterilization

Background - importance and magnitude of problem
Diagnostic goals - for overall category

    Sterilization by tubal ligation side effects, pregnancy rates
    • postpartum
    • interval

    hysterectomy complications
    • vaginal cuff cellulitis/abscess
    • wound infection
    • atelectasis
    • cystitis/urethritis
    • pyleonephritis
    • pelvic vein thrombosis
    • superficial vein thrombosis
    • deep vein thrombosis
    • femoral nerve injury
    • obturator nerve injury
    • peroneal nerve injury
    • ureter injury
    • bladder injury
    • bowel injury

Background

Sterilization is the most common form of contraception used in the United States. Over 18% of women and 8% of men relied on sterilization in 1990. As age goes up, so do the surgical sterilization rates so that at age 40-44, over 50% of women using contraception utilized female sterilizaion.

In many studies there appears to be a protective effect of tubal ligation against ovarian cancer. Risk of cancer of the ovary is less than 50% in women who have had tubal ligation or hysterectomy.

Goals

All of the sterilization methods have a failure rate. A recent 10-year study by the CDC showed a 1.9% overall failure rate with a range from 1-4% depending upon the method of tubal ligation. These rates approach those of contraceptive failures. Younger women have a higher cumulative failure rate than do older women ranging from almost 5% in the 18-27 group undergoing bipolar coagulation to 0.6% overall in the 34-44 age group. About 1-3% of women undergoing sterilization seek to have a reversal of the procedure at a later time. Women who are under 25 years of age and who are having marital difficulties at the time, have the highest regret rates.

Choosing a sterilization method means weighing the failure rates against the complication rates and merging those with the unique situation of each woman. Vasectomy probably has a lower failure rate than female sterilization, but many men are reticent about being sterilized. A high (up to 30%) depression rate among men undergoing vasectomy contributes to the difficulty in making a decision that is best for a specific couple.

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Abortion - desire to terminate pregnancy

Background - importance and magnitude of problem
Diagnostic goals - for overall category

    first trimester to less than 14 weeks
    • morning after pill
    • menstrual extraction
    • suction D&C

    second trimester 14 - 24 weeks
    • dilatation and evacuation
    • intramniotic injection

Background

Before the Roe vs Wade Supreme Court decision in 1973, many abortions were termed "criminal" in that they were performed by non-physicians in situations other than "to preserve the life of the mother." There were high maternal complications and many deaths from those procedures. For over a decade after Roe v Wade, abortions were performed more freely in medical settings with much fewer complications. For awhile it seemed as if abortion was being used as a contraception method. In recent years, abortion is much less used as method to limit family size. It has been determined that in medical professional care, abortion has a low complication rate and low instance of death of the mother due to complications. As a surgical procedure there is a .5/100,000 maternal death rate in the first 13 weeks of pregnancy and a 10/100,00 death rate in the 14-24 weeks of pregnancy. In addition to death of the mother, infection, hemmorrhage and future pregnancy problems can be side effects of the procedure.

Goals

The decision of whether or not to electively terminate an unwanted pregnancy can be a difficult decision. While complication rates for the different types of abortion can be fairly accurately esimated, the mental/psychological effects are extremely difficult to anticipate. Alternatives to abortion such as adoption or carrying the pregnancy and raising the child, must be thoroughly considered.

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