Nausea is a common side effect during the first few months of combined OCP use. Taking the pill with food or at bedtime will often minimize this symptom. For some women, crushing the pill and taking it mixed with food may be helpful. If nausea occurs in a long-time pill user, pregnancy or other causes must be excluded. Vomiting with combined OCP use is rare. If vomiting does occur a combined OCP with a lower estrogen content may be better tolerated.

The presence of galactorrhea is an indication for an assay of serum prolactin. If prolactin is elevated then an evaluation for possible causes [hypothyroidism, pregnancy, prolactinoma, certain medications, breast or chest wall lesions] is essential. If the prolactin levels are normal on the combined OCP, reassurance is sufficient and no intervention is warranted. If spontaneous leakage becomes a problem then the pill should be discontinued for a few months [with an alternative method in use] and medications such as Bromocriptine or Dostinex could be tried.

Mild mastalgia is common in first few months of combined OCP use and usually resolves spontaneously. This symptom may be troublesome for women with fibrocystic breast disease and for women who have chosen to take combined OCPs continuously to avoid menstrual associated side effects (like headache). For women on continuous combined OCPs a brief break (3-5 days at the end of a pill pack) every two months will usually allow breast symptoms to abate. Severe or persistent mastalgia warrants careful breast examination to rule out local lesions and galactorrhea. A decreased caffeine intake may be helpful when mastalgia is mild. For women with fibrocystic breast disease, where this symptom is distressing, a non-hormonal contraceptive method may be preferable. If mastalgia persists despite discontinuation of the combined OCP the use of low doses of Danazol (50-100 mg daily) will usually provide dramatic relief for the mastalgia.

If chloasma occurs, changing to another pill will not help. Certain individuals show this hypersensitivity to estrogen both when using the combined OCP and in pregnancy. The hyperpigmentation may never completely disappear. Referral to a dermatologist may be appropriate as certain skin care products may offer cosmetic improvement.

If pregnancy does occur in a woman taking combined OCPs, she should stop taking the pill immediately.There is no increased risk of birth defects [above the baseline 3% risk] as a result of inadvertent pill use in early pregnancy.

If three pills are missed in a row, she should throw out the remainder of the pack and start a new pack immediately. She also requires a back-up method of contraception (condoms) for seven days after missing three pills. She may not have a period that month. All clinicians should offer women written instructions about what to do if they miss pills in as simplified a format as possible. Some companies provide tear-off sheets explaining this information in a clear and concise fashion. This information should be made available at the time of the woman’s first prescription. Counselling about emergency contraception and a prescription for emergency contraception are recommended when any contraceptive method is initiated.

If one pill is missed, the woman should be instructed to take the combined OCP as soon as she remembers, even if it means taking two pills in one day. All clinicians should offer women written instructions about what to do if they miss pills in as simplified a format as possible. Some companies provide tear-off sheets explaining this information in a clear and concise fashion. This information should be made available at the time of the woman’s first prescription. Counseling about emergency contraception and a prescription for emergency contraception are recommended when any contraceptive method is initiated.

Reassurance is often the best approach to this common concern, as break through bleeding usually disappears by the third pill cycle. If breakthrough bleeding persists beyond three months the clinician should rule out infection or cervical disease and ensure correct use. If breakthrough bleeding still persists it might be worthwhile to try a combined OCP with another category of progestin or change to a 50ug estrogen combined OCP. Unfortunately, no good evidence supports any of the numerous published recommendations for the management of intermenstrual bleeding. A short course of exogenous estrogen such as conjugated estrogen, 1.25 mg conjugated estrogen or estradiol 1-2 mg can be administered when the bleeding is present no matter where a woman is in her cycle. A woman should continue to adhere to the schedule of pill taking. Doubling up or tripling up on the pill increases the risk of estrogen related side effects without altering the ratio of estrogen to progestin that may be responsible for the endometrial instability -and has not been shown to be effective. Given the gradual decline in bleeding over the first six months, changing formulations before six months of use is not generally warranted.

Yes. When short term vomiting precludes oral ingestion of the pill consider vaginal pill delivery. Vaginal administration of standard combined OCP may not achieve the same levels of contraceptive steroids in circulation as achieved following oral administration so use either a pill containing 50 ug of ethinyl estradiol or two 30-35 ug pills inserted into the vagina. A new contraceptive skin patch (EVRA) will soon be available in Canada, which could be substituted for the oral contraceptive either in such an emergency situation or for continuous use in individuals who do not tolerate oral ingestion.

Absolutely not. The pill, when taken properly, is extremely effective for contraception. Sexual activity in the pill-free week does not increase the risk of pregnancy. The risk of pregnancy does increase if two or more pills are missed in the first or last week of the 21 active pills. The effectiveness of the pill depends on how regularly you take it, not where you are in your cycle. You are protected from pregnancy throughout your cycle with a failure rate less than 1% for perfect use and 6% for typical use. If you miss two or more pills, especially in the first or last week of the three weeks of active pills, your risk for accidental pregnancy increases and you should consider using emergency contraception (Plan B).

Yes, but the more regularly you take the pill, the more reliable it will be in protecting you from pregnancy. The most important days to be on time are in the week after your pill-free or placebo pill week. If the 7 day hormone-free interval is lengthened the risk of failure will be increased. Failure rates with perfect use-implying taking the pill at the same time daily and not missing any pills-are around 0.1%. In contrast, with typical use-accounting for less regular use and missed pills-failure rates are around 3-8%. If a pill is missed and taken late, then take it as soon as you remember, even if that means taking two at the same time. If this occurs during the first week of active pills you should consider using a backup method of birth control, such as condoms, for the next seven days. You may also need to take emergency contraception.

No. There are many different bleeding patterns while on the pill. Some women may only have 2-3 days of bleeding, while others will bleed for 7-8 days. As long as you take one pill a day and start the next pack on time, no additional form of contraception is needed.

your oral contraceptive product should only be taken as directed by your health-care professional. Your health-care professional may have directed you to take your 28 day cycle product off-label, which is sometimes referred to as “stacking” or “semi-continuous use”. When doing so a woman will usually still get her period in the week off the pill. It often takes a few days for a period to start after the last pill has been taken. A small percentage of women will also achieve amenorrhea, or no periods, as a result of thinning of the lining of the uterus such that there is no tissue to shed when the pill is stopped (thus no menstrual bleeding). It is good practice to get a pregnancy test the first time you miss your period when on hormonal contraception since accidental pregnancy can result if pills are missed. There is currently an approved birth control pill available in Canada made specifically for extended use called Seasonale. It is designed for extended use, meaning that an active hormonal pill is taken for 84 days straight, followed by 7 days of sugar pills. This means that a woman will have a period four times a year instead of every 28 days, which can help reduce lifestyle interruptions during important events.

If you have missed one pill (and have had 8 days off instead of 7), you should consider using EC if you have had unprotected intercourse within the last 5 days. Although EC is most effective if taken within 3 days of unprotected intercourse (the sooner the better!), it may still be effective up to 5 days after an act of unprotected intercourse. You can start your new pack of birth control pills the next day. You should also use condoms for the first week of the new pack.

No specific treatment is required (as long as pregnancy is initially ruled out) as the amenorrhoea is usually due to a relative deficiency of estrogen (endometrial stimulator) in comparison to progestin (endometrial suppressor) in the combined OCP. Permanent atrophy does not occur, and resumption of normal ovarian function after the pill is stopped will quickly restore endometrial growth and development. If the woman cannot reconcile herself to the lack of bleeding or if she fears pregnancy each month a brief course of supplemental estrogen will often induce sufficient endometrial regrowth to result in withdrawal bleeding for the next few cycles. Typically conjugated estrogen 1.25 mg, or estradiol 2 mg can be administered daily in addition to the usual oral contraceptive for the first 10 days of the next cycle of combined OCP treatment. This can be repeated as often as desired.

It is very common for irregular bleeding within the first three months of starting a new birth control pill, even if you had been using a different brand of pill before. This generally gets better if you are patient and continue to use the pill. If you have been using a birth control pill for many months or years and suddenly start having unexpected bleeding, here are some things that should be considered:

The most common reason for breakthrough bleeding is missed pills. If you miss more than one pill in each pack, you may have some irregular bleeding. If you have trouble remembering to take the oral contraceptive pill on time, talk to your doctor. You may be better suited for using the birth control patch (which is applied once a week) or the vaginal contraceptive ring (which is inserted once a month).

Women who smoke have more irregular bleeding on the pill.
Consider a visit to your health care provider, because a sexually transmitted infection like chlamydia or gonorrhea can cause bleeding.

Another factor could be a polyp, which is a small growth either from the uterus or the cervix. This can be found during a pelvic examination and/or an ultrasound.

What you are describing is called “breakthrough bleeding” and it is annoying but not harmful. It is very common to have breakthrough bleeding in the first few months of starting on a new pill while your body gets used to the hormones.

If the breakthrough bleeding has occurred after the first few months, it could be because you forgot or were late in taking a pill or two, or if you were sick with diarrhea or vomiting (and may not have absorbed the medication well from your GI tract). Medications like rifampin (an uncommon antibiotic) or anti-seizure medications can interact with the pill. If you have been taking your pills regularly at the same time, and you are not on a medication known to reduce the pill’s effectiveness, rest assured that the pill is still working as a contraceptive.

There can be other reasons for breakthrough bleeding on the pill. Smoking can cause irregular spotting because it interferes with your liver’s metabolism of the estrogen in the pill. Pregnancy should always be ruled out by a urine pregnancy test. Cervical infections such as gonorrhea or chlamydia can also result in bleeding, so see your doctor to get checked for these, as well as to update your Pap smear. When he or she looks at your cervix, there may be an “ectropion” (which is when cells from inside the cervical canal shift to the outside of your cervix under the influence of the hormones in the pill) or a polyp (a benign growth). These are both harmless conditions, but can be treated if they are thought to be the source of the bleeding.

Although one pill is not known to be better than others in terms of breakthrough bleeding, a different pill may have different side effects depending on the individual. Often trying another pill can help, but unfortunately there is no “magic” formula.

As you can see, there are many causes of breakthrough bleeding. If this problem has not continued, there is likely no need to worry. If it persists, you may want to see your doctor to discuss things, or perhaps try a different pill.

It is becoming more common for doctors to prescribe birth control pills in a semi-continuous or continuous fashion. This means that instead of taking active pills for three weeks and then taking a week off (either with inactive pills or by not taking any pills that week), you take active birth control pills every day.

Taking birth control pills this way has many benefits. For women who have painful or heavy periods, menstrual migraines, or who participate in sports, having fewer periods can be a good thing. Taking pills this way is not abnormal or unsafe. The medication in the pills prevents the lining of the uterus from building up as quickly, so there is less tissue to shed. Once you stop taking the pill, the hormone levels drop and that signals your body to have a period.

Most women who start taking the pill continuously will experience some irregular bleeding in the first few months as the medication starts to thin out the uterine lining. If you experience irregular bleeding or spotting when using continuous oral contraceptive pills, and you have been using the pills for at least three weeks, you can stop the pills for 5 to 7 days to allow a regular type period and then restart them in continuous fashion once again. Eventually, most women who use the pill continuously will experience no bleeding at all.

Sometimes, having unexpected bleeding while taking birth control pills (called breakthrough bleeding) is not just a side effect of the medication. Women who have a sexually transmitted infection, like Chlamydia or gonorrhea, can have irregular spotting, and abnormalities of the cervix (which are detectable with a PAP smear) may sometimes be the cause for spotting. If you are concerned about bleeding or other symptoms while taking the pill, please see your doctor.

Any time you miss pills while having vaginal intercourse it is possible to become pregnant. Even with perfect pill use, 1-2 women in 100 will become pregnant each year. If your next period is late, consider a pregnancy test. If you find that you are often forgetting your pills, it’s a good idea to speak to your doctor to try to see if another birth control method would be better for you.

OPTION 1
If the woman misses two pills in a row during the first two weeks of the pack, she should take two pills on the day that she remembers as well as two on the following day. She also requires a back-up method of contraception (condoms) for seven days after missing pills.

OPTION 2
If two pills are missed in a row in the third week of the pack, the user should throw out the remainder of the pack and start a new pack immediately. She may not have a period that month. She also requires a back-up method of contraception (condoms) for seven days after missing two pills.

All clinicians should offer women written instructions about what to do if they miss pills in as simplified a format as possible. Some companies provide tear-off sheets explaining this information in a clear and concise fashion. This information should be made available at the time of the woman’s first prescription. Counselling about emergency contraception and a prescription for emergency contraception are recommended when any contraceptive method is initiated.

If 1 pill is missed, take that pill as soon as you remember, then take the next pill on schedule. This could mean taking 2 pills in one day. You may want to use a backup method such as condoms for the next seven days.

If 2 pills are missed, take two pills on the day you remember and two pills on the following day. Then return to your regular schedule. Use a backup method for the next seven days.

If more than 2 pills are missed, use a backup method for the next 7 days. Throw away your current package of pills and start a new pack of pills on the day you remember.

It is common to have unexpected bleeding in the first 2-3 months on a birth control pill. As long as you have taken a pill every day at about the same time, you are protected from pregnancy. Hang in there and keep going with the pills. You may have more bleeding during the week of sugar pills. After 2-3 months of the pill, this irregular bleeding should settle down. If it does not, see your health-care provider to make sure there is not another reason for having bleeding, such as a sexually transmitted infection. Also, if you smoke, that makes it more likely for you to spot.

Yes. Reduced menstrual flow occurs commonly among combined OCP users because all pills are progestin dominant. Remember that estrogen stimulates endometrial growth while progestins suppress it. Therefore prolonged exposure to a progestin dominant pill leads to gradual thinning of the endometrium to the point where there may be no tissue to shed at the end of the pill cycle when hormonal support of the endometrium is withdrawn. Failure to experience withdrawal bleeding (amenorrhoea) occurs in five to ten percent of combined OCP users. Many women (particularly those whose adherence is not perfect) feel more at ease when they experience a menstrual bleed signaling with few exceptions that they are not pregnant. The addition of conjugated estrogen (1.25 mg for the first ten days of one or two successive pill cycles) may stimulate endometrial growth enough to induce a withdrawal bleed.

No. Some women do report an increase in weight. Studies have shown that weight gain in combined OCP users is not greater than an age matched population using barrier methods of contraception. Some women may experience cyclic pre-menstrual bloating /fluid retention which they perceive as weight gain. There may be increased appetite when the combined OCP is initiated and new users should be cautioned about this.

While it has been suggested that latex condoms have microscopic pores which might leak during use, studies testing condom permeability have suggested that the expected exposure to HIV due to leakage through approved condoms would be no more than a single virus for every 100 condoms used. Infection with HIV requires exposure to large quantities of the virus; hence, condoms provide substantial protection. More importantly, sero-conversion cohort studies among sero-discordant couples found that individuals who consistently used condoms were significantly less likely to sero-convert than were those who did not (less than 2.3% among condom users versus 7 to14% in non users).

Yes, latex condoms have been shown to protect against gonorrhea, ureaplasma, herpes simplex virus and HIV infection. Condoms, therefore, may decrease the likelihood of infertility or cervical intra-epithelial neoplasia by decreasing the risk of sexually transmitted infections responsible for these disorders. Furthermore, the simultaneous use of a condom and a separate spermicide is estimated to be 99.9 percent effective in reducing the risk of STD transmission per act of intercourse.

Remember: Condoms may not afford protection from STIs that are transmitted by skin-to-skin contact in other areas (i.e. genital herpes (condylomata accuminata) etc).

1. Prevent sperm allergy
2. Protection against unplanned pregnancy
3. Protection against many sexually transmitted infections
4. Protection against tubal infertility and cervical cancer
5. Are readily accessible, relatively cheap and are portable
6. Offer improved hygiene (avoiding post-coital discharge of semen)
7. May in certain circumstances where there are disparities in time to orgasm improve sexual relationships by delaying male orgasm
8. Silastic (non-latex) condoms afford protection from STIs that is comparable to latex condoms.
9. Lambskin condoms are effective in preventing pregnancy but they are not recommended for protection against STD’s. Laboratory tests have shown the passage of viruses, including hepatitis B, herpes simplex virus and human immunodeficiency virus (HIV) through small pores on the surface of lambskin condoms.

1. Require high motivation
2. May reduce sensitivity during intercourse
3. May interfere with the maintenance of an erection
4. May interfere with or interrupt foreplay
5. May interfere with either partner’s enjoyment of intercourse
6. May break or slip
7. May have an unpleasant taste if used during oral sex
8. Latex, spermicide and/or lubricant may be irritating or allergenic
9. Requires assertiveness by both partners to ensure that the condom is placed appropriately on the penis and removed correctly
10. Lambskin condoms are effective in preventing pregnancy but they are not recommended for protection against STI’s. Laboratory tests have shown the passage of viruses, including hepatitis B, herpes simplex virus and human immunodeficiency virus (HIV) through small pores on the surface of lambskin condoms.

If in fact the condom does break on one occasion it is unlikely that pregnancy will result. One survey found only one pregnancy reported for every 23 condoms breaks. Although the risk of pregnancy after condom breakage is small all women should be offered emergency contraception. The Yuzpe method and Plan B can reduce the average risk of pregnancy from eight to less than four percent depending on the time between unprotected intercourse and treatment. All women should be educated about emergency contraception when receiving contraceptive counselling. It has been estimated that the probability of HIV infection from a single exposure (post-ejaculatory condom break) ranges from 10 percent to less than 0.1%, depending on the type of transmission (male-to-male, male-to-female, and female-to-male) and the presence of genital ulcers.

If a condom breaks during intercourse a woman should insert additional spermicidal foam or gel into the vagina if available. Common products include Delfen contraceptive foam, Advantage 24 vaginal contraceptive gel, Gynol II contraceptive jelly, KY PLUS spermicidal lubricant, and vaginal contraceptive film. If no spermicidal product is available, immediately wash the penis with soap and water and the vagina with a vaginal douche of dilute soapy water. Emergency contraception should be sought as soon as possible. The Yuzpe method and Plan B can reduce the average risk of pregnancy from eight to less than four percent depending on the time between unprotected intercourse and treatment. All women should be educated about emergency contraception when receiving contraceptive counselling.

Condoms are available in dry or lubricated form, plain or reservoir-tipped, straight or shaped, smooth or textured, natural or brightly coloured, flavored, and in several sizes. Some condoms tend to fit better than others. Optimal fitting may require trying a variety of condoms.

A new condom should be used after every act of intercourse and after every ejaculation. You cannot use it more than once.

NO! Two condoms are not better than one.

There is a myth that putting on more than one condom at a time will increase protection. This is not true. In fact, there is an increase in friction between the two condoms which means that the condoms are more likely to break during intercourse.

The same is true for the female condom - it should not be used in combination (not at the same time) with a male condom.

No. If you are experiencing some irritation you should see if the same problem occurs after using a non-flavoured variety. It is possible that you have a sensitivity to latex, the material that most condoms are made from. If this is possible try using a non-latex condom. Ask your pharmacist for help in selecting one.

It is estimated that the percentage of women experiencing an accidental pregnancy within the first year of perfect condom use is approximately three percent, whereas the typical user failure rate is approximately 12 percent per year. The highest failure rates are in women from ages 20 to 24, while the second-highest failure rate is in those under the age of 20. Non-use or inconsistent use probably accounts for most of the difference in condom failure rates between “typical” and “perfect” users. The Pearl index for the careful user is 3.1-4.8/100 women years (failure rate for 100 women using the method for one year).

There are a couple of non-latex alternatives on the market in Canada. The male condoms are made of polyurethane and, unfortunately, are more likely to break than latex condoms. This obviously leaves the users at higher risk of pregnancy and infection. However, for men (or women) who are unable to use latex due to allergy or sensitivity, non-latex condoms remain a good choice. Reality makes a female condom out of polyurethane. It is placed in the vagina by the woman before intercourse, and has two rings (one at each end) that hold it in place.

Durexs polyurethane brand sells for about $3.00 per condom, Trojans brand sells for about $2.00, and the polyurethane female condom by Reality sells for about $4.00 each. Regular latex condoms are about 70 cents each.

Trojan also makes a condom out of lamb skin. This condom DOES NOT provide protection against infections, but it does prevent pregnancy almost as effectively as other condoms. If you are having intercourse with a new partner or are unsure if they have an infection, you need to use a polyurethane or latex condom.

The condom acts as a mechanical barrier when placed over the penis, preventing transfer of sperm and potential infectious seminal fluid to the female as well as potential infectious vaginal or cervical fluid to the male. It will also prevent contact with genital lesions on the penis or in the vagina. Condoms may not afford protection from sexually transmitted Infections (STIs) that are transmitted by skin-to-skin contact in other areas (i.e. genital herpes and condylomata accuminata). Most condoms available today are manufactured from latex. Because of its elasticity, latex allows ultra thin condoms for improved sensation. Other non-latex condoms are available for those with latex allergies but are expensive and limited in variety. Non-latex condoms manufactured from the intestinal caecum of lambs (“lambskin”) do not afford adequate protection from viral transmission.

A drop or two of water-based lubricant or saliva may be placed inside the condom to facilitate rolling the condom down over the tip of the erect penis. The tip of the condom is not pulled tightly against the penis -but rather a half-inch of space is left as a reservoir to collect semen. If not circumcised, the foreskin should be pulled back to increase sensation in men who are not circumcised before the condom is rolled down the length of the penis. One hand is used to pinch the air out of the tip to avoid friction against air bubbles (which is thought to be responsible for most condom breaks). The other hand is used to roll the condom down to the base of the penis. All air bubbles should be smoothed out of the condom before insertion into the vagina. After intercourse the condom should be held against the base of the penis as the penis is withdrawn to avoid spillage of semen.

Packaged condoms that are stored dry and away from light and heat can be kept for up to five years. Condoms deteriorate more quickly when exposed to temperatures over 37C or high humidity. Unpackaged condoms exposed to ultraviolet light are weakened by 80 to 90 percent in eight to ten hours. Condoms sold in Canada carry an expiry date on each pack. The approved lifespan of spermicide containing condoms is two years and for regular condoms it is five years.

Estimates from mathematical modeling suggest that the contraceptive failure rate in couples with simultaneous “perfect” use of condoms and separately applied vaginal spermicide is reduced to 0.1 percent, the same rate as that associated with perfect use of the combined oral contraceptive. The use of intravaginally applied spermicide, in contrast to spermicide incorporated in condoms, guarantees its presence in the vaginal region in the unlikely case of condom breakage or leakage. Some spermicides incorporate chemicals with additional viricidal properties that may also afford additional protection from viral sexually transmitted Infections (STIs) in the event of condom breakage.

Yes, but only if it is a water-based lubricant. Oil based lubricants have been shown to affect condom integrity by reducing tensile strength, elongation, burst pressure and burst volume. Lubricants that should be avoided include: 1. Baby Oil 2. Petroleum Jelly (Vaseline) 3. Coconut Oil/Butter 4. Edible Oils 5. Margerine/Butter 6. Hemorrhoidal Ointments 7. Mineral Oil 8. Palm Oil 9. Suntan Oil 10. Fish Oil 11. Vaginal Creams (e.g. Monistat) Lubricants that can be used safely include: 1. Aqua-lube 2. Astroglide 3. Aloe-9 4. KY jelly 5. Transi-lube 6. Duragel 7. Condom-mate 8. Egg white 9. H-R Lubricating jelly 10. Marketed contraceptive foams, creams or gels

You are referring to a combination of the “withdrawal method” (or “coitus interruptus”) and the male condom. Strictly speaking, correct use of the male condom requires putting it on before any genital-genital contact. With perfect use (which means using a condom correctly with every act of intercourse) the male condom’s failure rate can be as low as 2% per year. Using a condom as you describe may be one reason for the condom’s higher “typical” or real-world failure rate of up to 15% per year. So, to answer your question, you could start sex without a condom as you have suggested, but this would likely increase your risk of pregnancy by a small but unpredictable amount.

The reason for this is similar to the reasons why the withdrawal method is less reliable than condoms as a birth control method. Withdrawal involves unprotected sexual intercourse until just before ejaculation (male orgasm) when the man pulls out (or “withdraws”) his penis and ejaculates (or “comes”) away from his partner. This method has a failure rate of about 20%, mostly because it is hard for a man to time ejaculation, so often there is some semen spilled inside or near the vagina. There may be sperm in the pre-ejaculatory fluid as well.

You need to consider your own situation, and how devastating an unplanned pregnancy would be. If it would be a bad thing, you’d be better off using a condom from the start, or by using another method. If prevention of STIs is a consideration then a condom should be put on before any contact, as any unprotected contact could increase the risk of infection.

To increase sensation, the male partner may use a textured or ultra-thin condom or place a small amount of water-soluble lubricant inside the reservoir of the condom. Too much lubricant however, inside the condom may increase the risk of slippage.

There is no change – antibiotics do not affect anything.

It will not fall out with regular activity, like walking, running, or even swimming. However, some women have had it fall out during intercourse. When you have intercourse the first few times with the Nuva Ring in, check to be sure that it has not fallen out. If it has (and it has been out for less than 3 hours), rinse it under warm tap water and put it back in.

During intercourse, women do not usually notice the ring. When the men were asked, 8 out of 10 did not feel the ring during sex. Those that did, however, did not mind it or find it uncomfortable.

No. The studies have shown that there is no increase in bacterial or sexually transmitted infections when using Nuva Ring. It does not protect against sexually transmitted infections, so consider using a condom if you might be at risk.

If the ring has been out for less than 3 hours, rinse it off under lukewarm tap water and put it back in the vagina.

If it has been out for more than 3 hours:

During Weeks 1 and 2: Contraceptive effectiveness may be reduced. Re-insert ring as soon as you remember and use a back-up method of birth control, such as male condoms or abstinence, until the ring has been used continuously for seven days.

During Week 3: Throw the ring away and choose one of the following two options:

1. Insert a new ring immediately. Inserting a new ring will start the next three-week use period. You may not experience a period from your previous cycle. However, breakthrough spotting or bleeding may occur. Use a back-up method of contraception for the next 7 days.

2. Wait up to seven days and then put a new ring in. You will probably have a period during the time when you don’t have the ring in. Do not go for more than 7 days without having the ring in. If you do, you will need to use a back-up method of birth control for the first seven days after the ring has been inserted.

If it has been in for more than three weeks, but less than four weeks, take the ring out and take a 7 day break. Re-insert the next ring within 7 days. If the ring has been in longer than four weeks, it is possible that you were not protected against pregnancy. Consider emergency contraception (now available from pharmacies without a prescription) if you have the ring in for more than 4 weeks and you had sexual intercourse. You need to confirm you are not pregnant before inserting the next ring. If you are not pregnant, insert the next ring right away, and use a backup method of contraception for 7 days.

If it has been less than seven days since you took the last ring out, you can go ahead and put in the new ring right away. If has been more than 7 days, insert the new ring right away and use another backup method of birth control (like condoms or abstinence) for 7 days. If you think you might be pregnant, do a pregnancy test and see your health care provider as soon as possible.

It is possible that you might be pregnant. Although Nuva Ring is not harmful if used while pregnant, you should make sure you aren’t pregnant before inserting a new one. If you left the ring out for more than three hours, took more than a 7 day break between rings, or left the ring in for more than four weeks, or have missed two or more periods in a row, you need to do a pregnancy test.

You should avoid smoking while using Nuva Ring. It can increase your chance of events like stroke or heart attack, especially if you are over the age of 35. If you are breastfeeding, you may want to delay using the Nuva Ring as it may interfere with breast milk production. Speak to your health care provider. If you are on any other medications, let your doctor know about them before starting Nuva Ring. Some medications may interfere with the ring, possibly making one or the other less effective.Do not use a diaphragm for contraception with Nuva Ring in place. It will not fit properly.

If it is sitting in the right place, you do not know it is there. If you can feel it, it is probably too close to the outside of the vagina. Gently push it up higher with your finger, and you will likely not feel it any more.

Just remove the ring. Your period should come within the next 2 weeks. The birth control hormone is out of your system in 1-2 days. There is no impact on future fertility after you stop using the Nuva Ring.

Tampons are safe to use with the ring, although you have to be careful not to pull the ring out with the tampon. If the ring does come out with the tampon, simply rinse the ring off under the tap (lukewarm water) and reinsert it.

Although many women are hesitant to try the vaginal contraceptive ring (NuvaRing®) because they don’t like the idea of a foreign object in the vagina, it is rare for the contraceptive to cause women problems related to intercourse. A male partner will not usually notice the ring and if he does, it generally is not bothersome. Only 1-2% of women using the NuvaRing® will stop using it because of problems related to intercourse, such as the ring falling out.

No, it cannot. The vagina is a bit like a sock, with an opening at one end and closed at the other. There is nowhere for the ring to go, so it cannot get lost. At worst, it can fall out, but it cannot go into your abdomen.

No. The ring is designed to release a small amount of hormone every day. However, do not use more than one ring at a time.

Yes, you may safely use vaginal yeast treatments or spermicides with the ring in place and the effectiveness of the treatments and the NuvaRing® will not be compromised.

A cervical cap is a barrier method of birth control that is not used very often these days but may be a good contraceptive option for some women.

Only one cervical cap, the silicone Oves cap, is approved by Health Canada . The latex Prentif cervical cap is more commonly used but is not officially approved by Health Canada . It is, however, approved by the American Food and Drug Administration (FDA) so women can get a prescription from their Canadian doctor and order it on-line.

Cervical caps are designed to fit over the cervix only (as opposed to a diaphragm, which covers some of the vagina as well) and provide a physical barrier preventing sperm from entering the cervix. Spermicidal jelly should be used with the cap at the time of insertion, but more spermicide is not necessary for further acts of intercourse, unlike the diaphragm. The cervical cap can be left in place for 48 to 72 hours (depending on the manufacturers instructions) and provides protection for unlimited sex in that time. It must be fitted by a health care professional.

The cap has a higher failure rate than some of the other methods, especially in women who have had a baby before. For women who have never had a baby, the failure rate with perfect use (meaning correct use with every single act of intercourse) is 9 % per year, while the failure rate with typical use is 16% per year. For women who have had a baby before, the failure rates are 26% with perfect use and 32% with typical use.

The cervical cap is likely to cause problems for women (or their partners) who have allergies or sensitivities to latex, rubber or spermicides. Women with any cervical structural deformity or asymmetry, abnormal cervical cytology, chronic cervicitis and recurrent salpingitis are also poor candidates for the cervical cap. Women with some physical disabilities, or with neurologic impairment which limits their flexibility or fine motor control may also not be well suited to the cervical cap, as this method requires dexterity to properly fit the cervical cap. Women who are not comfortable with insertion or do not have the assertiveness to insist on the timing of insertion and removal may also be poor candidates for the cervical cap.

The diaphragm is poorly suited to women if they or their partners have allergies or sensitivities to latex, rubber or spermicides. Women with anatomic distortion due to large cystoceles, rectoceles or uterine prolapse are also poor candidates for the diaphragm. Women with some physical disabilities, or with neurologic impairment which limits their flexibility or fine motor control may also not be well suited to the diaphragm, as use of this method requires dexterity for proper diaphragm placement. Women who are not comfortable with insertion or do not have the assertiveness to insist on the timing of insertion and removal may also be poor candidates for the diaphragm.

Cervical caps are available in 22, 25 and 31 mm sizes, referring to the internal rim diameter. The restricted number of sizes is a limitation to the use of the cervical cap in the general population.

Cervical cap users do not require any special follow-up other than a refitting after a full-term pregnancy, pelvic surgery or abortion, or if there is a major change in weight. Routine gynecologic exams should be part of the woman’s yearly physical exam. Pap smears may show cervical inflammation secondary to the cervical cap use and therefore should be performed yearly. Cervical cap users also need to understand proper maintenance of their cervical cap including checking the integrity of the cervical cap periodically.

Diaphragm users do not require any special follow-up other than a refitting after a full-term pregnancy, pelvic surgery or abortion, or if there is a major change in weight. Routine gynecologic exams should be part of the woman’s yearly physical exam. Diaphragm users also need to understand the importance of proper maintenance of their diaphragm including checking the integrity of the diaphragm periodically.

After each use the diaphragm should be washed with warm water and a mild soap. It should be patted dry and stored in its case, away from obvious sources of heat and excessive light. The diaphragm should be dusted with powder or cornstarch prior to storage. Disinfectants, carbolic soaps and detergents should be avoided when caring for the diaphragm. Before each use the diaphragm should be checked for small holes or tears by holding it up to a light. The diaphragm does need to be replaced periodically after approximately one or two years or at any time the device appears damaged or bent.

A cervical cap is a small barrier contraceptive device made of rubber. It is held in place over the cervix by suction and must be snugly fitted. Spermicide is placed in the cervical cap with initial insertion.

After each use the cervical cap should be washed with warm water and a mild soap. It should be air dried and stored in its case, away from obvious sources of heat and excessive light. The cervical cap should be dusted with powder or cornstarch prior to storage. Disinfectants, carbolic soaps and detergents should be avoided when caring for the cervical cap. Before each use the cervical cap should be checked for small holes or tears by holding it up to a light. The cervical cap does need to be replaced periodically after approximately one or two years or at any time that the device appears damaged.

Diaphragms may occasionally result in recurrent urinary tract infection because pressure from the rim on the urethra may result in incomplete bladder emptying. If the woman is experiencing recurrent UTIs, a refit or change of rim type may help. There are three types of diaphragms available. The most frequently used diaphragm is the coil spring because of its ease of insertion. Other options include the arcing spring and flat spring. For some women, UTIs may be a reason to switch from or avoid this family planning option.

The diaphragm can be inserted immediately before or up to 6 hours before intercourse and should be removed no sooner than 6 hours after intercourse. It can be left in place for up to 24 hours after intercourse. Additional spermicide is required with subsequent acts of intercourse. If more spermicide is required it should be placed in the vagina and the diaphragm should be left in place.

The cervical cap can be inserted from immediately before up to 6 hours before intercourse and should be removed no sooner than 8 hours after intercourse. It may be left in place for up to 48 hours after intercourse. Additional spermicide is NOT required with subsequent acts of intercourse.

A bimanual, pelvic examination must be performed to ascertain the position and size of the uterus and cervix. Speculum examination allows visualization of the cervix, which is helpful in estimating the internal cap diameter. Two or more cervical cap sizes should be tried to achieve the optimal fit. A cervical cap that fits too tightly can cause trauma to the cervix, and one that fits too loosely will be more likely to become dislodged or to not form a secure seal. When fitted properly, a vacuum is created and the cervical cap cannot turn. It is estimated that six to thirty percent of women may experience difficulty achieving a good fit with the limited size selection of available cervical caps.

If used perfectly the probability of failure during the first year of use for the diaphragm is 4 -8%. While consistent and correct use of these products is essential for effectiveness, approximately one-half of the failures in diaphragm users occur despite diligent use. The Pearl index is 4-20/100 women years (failure rate for 100 women using the method for one year). The lower failure rates occur in older women probably because they have lower natural fertility with advancing age.

A pelvic examination by either a physician or a skilled health care provider is required for fitting diaphragms. Fitting rings are produced by diaphragm manufacturers in various sizes and with different rim types. Sizes range from 50 to 105 mm. They are most commonly available in flat spring or coil spring rim types. Diaphragms between 60 -85 mm in diameter will provide the correct fit for most women. Initially the fitting ring size is estimated by clinical assessment of the vaginal length. Smaller or larger sizes are then inserted until the correct fit is achieved. It is important that each individual is fitted with the type of rim that she will ultimately use as the rim type can affect fit and ease of insertion. It should fit snugly into the upper half of the vagina, immediately behind the pubic bone, making contact with the lateral walls of the vagina and the posterior fornix. The anterior rim (behind the pubic bone) should not cause significant pressure and yet should not allow easy insertion of a finger between the diaphragm and the pubic bone. The user should practice insertion under supervision and placement should be inspected to ensure that the fitting ring is correctly positioned in the vagina. Fitting is best done without an empty bladder so that the user can test to ensure that urination is easily accomplished with the selected fitting ring in place. The diaphragm may require resizing following a full-term pregnancy, pelvic surgery, or abortion, or if there is a major change in weight.

Diaphragms are barrier methods of contraception used by women, in conjunction with a spermicide. These devices place a physical barrier between sperm and the cervix by fitting snugly behind the pubic bone when inserted into the vagina. The spermicide is placed in the diaphragm prior to insertion and repeat applications are recommended with subsequent acts of intercourse. If additional spermicide is required it should be placed directly into the vagina and the diaphragm should be left in place.

Cervical caps are barrier methods of contraception. These devices place a physical barrier between sperm and the cervix by fitting snugly over the cervix. Spermicide is required with the initial application of the cap, however, additional spermicide is not necessary with subsequent acts of intercourse.

If used perfectly the probability of failure during the first year of use for the cervical cap is 10 to 13 percent. The cervical cap has a substantially higher first year failure rate in women who have previously been pregnant because of difficulty in achieving an exact fit (26 to 27% failure in the first year). While consistent and correct use of these products is essential for effectiveness, approximately one-half of the failures of these methods occur despite diligent use. The Pearl index is 11-19/100 women years (failure rate for 100 women using the method for one year).

The correct diaphragm size can be estimated by :

1. inserting the index and middle fingers into the vagina until the posterior wall is reached (by middle finger)
marking the point at which the index finger touches the pubic bone with the tip of the thumb to estimate vaginal length
2. using this estimate of vaginal length to determine diaphragm size by placing one rim of the diaphragm on the tip of the middle finger the opposite side of the diaphragm rim should lie just in front of the thumb when the correct size is selected

As with other female barrier methods, using the diaphragm in combination with a male condom may provide additional contraceptive efficacy and be of benefit to women at risk for sexually transmitted diseases.

As with other female barrier methods, using the cervical cap in combination with a male condom and spermicide may provide additional contraceptive efficacy and be of benefit to women at risk for sexually transmitted diseases.

Cervical caps may cause more vaginal odour and discharge than diaphragms. The user should remove the cervical cap no later than 24 hours after insertion and should clean and dry the cervical cap between uses. If a woman is experiencing persistent vaginal discharge, despite these preventative measures, an alternate contraceptive device should be considered.

Toxic shock syndrome is a very rare complication of the diaphragm, which is usually a consequence of failure to remove the diaphragm within 24 hours. The user should seek medical attention if any symptoms of toxic shock syndrome are displayed (sudden high fever, diarrhea, vomiting, dizziness, weakness, muscle aches or sunburn-like rash).

Toxic shock syndrome is a very rare complication of the cervical cap, which is usually a consequence of failure to remove the cervical cap within 48 hours. The user should seek medical attention if any symptoms of toxic shock syndrome are displayed (sudden high fever, diarrhea, vomiting, dizziness, weakness, muscle aches or sunburn-like rash).

Yes. The diaphragm is suitable for use during lactation although careful fitting is required in the post-partum woman. The diaphragm should be refitted no sooner than six weeks post-partum.

Yes. The cervical cap is suitable for use during lactation although care must be taken to ensure the use of a correctly sized cap and to ensure correct positioning each time. The cervical cap should not be used in the first 6 weeks post- partum or immediately after an abortion or miscarriage as the cervical size may be changing rapidly at this time. The cervical cap has a higher failure rate in women who have previously had a baby because it is more difficult to find an appropriate fit.

The cervical cap cannot be used within six weeks of a full-term delivery, after a recent abortion or miscarriage, or during any vaginal bleeding, including menstruation.

Yes, but oil-based lubricants should be avoided as they can damage both the diaphragm and the cervical cap.

Lubricants that should be avoided include:

Baby Oil
Petroleum Jelly (Vaseline)
Coconut Oil/Butter
Edible Oils
Margerine/Butter
Hemorrhoidal Ointments
Mineral Oil
Palm Oil
Suntan Oil
Vaginal Creams (e.g. Monistat)
Fish Oil

Lubricants that can be used safely include:

Aqua-lube
Astroglide
Aloe-9
KY jelly
Transi-lube
Duragel
H-R Lubricating jelly
Marketed contraceptive foams, creams or gels
Condom-mate
Egg white

In the majority of woman the next period occurs on time or earlier. If menstruation is delayed by more than one week a pregnancy test should be performed.

A defined follow-up visit is ideally set for three to four weeks post treatment. At this visit the results of the emergency contraception can be assessed and the woman can be provided with counselling for regular contraception. This is also a good time to discuss screening for and counselling about sexually transmitted disease (STD) prevention and condom use.

The most common side effects following hormonal contraception are nausea and vomiting. An anti-nauseant given before each dose may reduce this. If vomiting occurs within one hour of the administration of the medication, the dose should be repeated. It is reasonable to provide an additional dose, at the time of dispensing, to be used if vomiting occurs within one hour or in the future. Plan B has been associated with less nausea and vomiting than the Yuzpe method.

Yes if a woman is fearful of the nausea and vomiting that the combined oral contraceptive form of ECP (Ovral) induces in many women -either because of what she has read or heard from friends or because of a bad experience with it in the past a new levonorgestrel (pure progestin) formulation of ECP (Plan B) is available. Plan B has a much lower frequency of nausea and vomiting. This may sufficiently reassure her.

The only proven alternative to oral ECP is placement of a copper intrauterine contraceptive device (IUCD). The IUCD is effective up to seven days after unprotected intercourse and may be the only effective method if ECP is needed in a cycle during which multiple ovulation has occurred (because the elevated estrogen of the stimulated cycle may prevent the constituents of the ECP from sufficiently disrupting the normal implantation process).

If less than 120 hours have passed since sexual intercourse occurred either one of the hormonal methods can be used. After 120 hours there is an increase in failure if the Yuzpe method or Plan B is used. This does not mean that hormonal methods are absolutely contraindicated after 120 hours. If the woman presents later than 120 hours but before seven days, and will not accept the intrauterine contraceptive device (IUCD), one of the hormonal mechanisms can be given provided that the woman is aware of the increased failure rate. After 5 days, however, the IUCD is the less likely to result in failure than the Yuzpe or Plan B method. If the IUCD is to be used the woman should be preferably an otherwise good candidate for the IUCD.(see question on patient selection for the IUCD).

A copper IUCD can be offered to women who are unable to take hormones, who have no contra-indication to IUCD use, and in whom exposure to conception occurred less than seven days previously. This is the only option available to a woman who presents three to seven days following unprotected intercourse

Emergency contraception is not as effective as other methods of birth control that are used regularly. It does not replace the consistent use of a birth control method. Emergency contraception should be used only in emergency situations (unprotected intercourse, condom failure, diaphragm failure, missed birth control pill, sexual assault). Frequent use of emergency contraception is not recommended, although repeated use over time poses no health risks.

A medical exam, although suggested, is not required before getting the morning after pill. There is no need to do a full physical or pelvic exam before using a hormonal form of emergency contraception. Appropriate screening for sexually transmitted infections (STIs) and other contraindications to the methods (hormonal or intrauterine contraceptive device) should be considered when emergency contraception is sought.

Emergency contraception (EC) is available without a prescription in pharmacies across Canada. A from a wide range of health services also carry EC- a doctor, hospital emergency room, walk-in clinics, sexual health clinics, and birth control clinics but there is greater accessibility in pharmacies.

Yes, the emergency contraception will still work. Emergency contraception used to be called the morning-after pill, and it is sold in Canada under the brand name Plan B. It consists of two doses of the progestin levonorgestrel which is also used in some birth control pills. Usually one pill is taken right away (the sooner after unprotected sex the better) and the second one is taken 12 hours later. Taken within 3 days (72 hours) of unprotected sex, it reduces your risk of pregnancy by 85%. Its effectiveness is decreased after that, but it can still be used for up to 5 days after unprotected intercourse.

Studies have shown that emergency contraception has the same effectiveness as long as the second dose is taken within 24 hours of the first. Researchers have also found out that taking both pills at the same time right away (instead of waiting 12 hours to take the second pill) is just as effective as taking them 12 hours apart. This might be a good idea for someone like yourself whose second dose falls in the middle of the night. No need to set your alarm for 3 a.m. just take both pills at the same time!

Multiple mechanisms have been proposed including induction of endometrial asynchrony, altered endometrial receptors, suppression or delay of the LH surge, and ovarian steroid changes through pituitary suppression with subsequent corpus luteum disruption. Most of these mechanisms are felt to either suppress ovulation or prevent fertilization. The mechanism may also be through blocking implantation. Women should be aware of the possible mechanisms of emergency contraception because for some women this may not be an ethically acceptable option.

The female condom is a soft, disposable polyurethane sheath with two flexible rings (one at either end). It is not made of latex, so latex allergy is not a contraindication to use. Its main disadvantage is an aesthetic one as some users report that it noisy during use.

It provides a physical barrier between the penis and vagina /vulva preventing contact of the vagina with both the penis and semen. One ring anchors it inside (like a diaphragm) and the other external ring holding it in place against the perineum.

My doctor wants me to go on the pill because he doesnt believe condoms are effective enough. I have tried several pills in the past and have reacted badly to them. I have also tried the cervical cap, diaphragm, and spermicides with condoms but I got a continuous yeast infection during those times. I have no trouble with spermicidal condoms, but Ive heard they arent more effective than regular condoms. I am reluctant to try an IUD because my Mom did and she had lots of problems. Options?

Your doctor can provide you with information about birth control, but it is no ones choice but your own. What you choose also depends on your personal situation your health and how disastrous an unplanned pregnancy would be for you.

When used perfectly, with every act of intercourse, condoms have a failure rate if about 2% per year. With typical use, (used incorrectly or inconsistently) the failure rate is up to 10 15%. If you are a reliable and experienced condom user (and it sounds like you are), you can get good contraception with condoms. If that is your method of choice, it can be a very effective method of contraception. Condoms also reduce the spread of most sexually transmitted infections.

You may want to consider emergency contraception in case the condom breaks or slips. You can either get a prescription from your doctor or get it from a pharmacy without a prescription soon.

You are right condoms lubricated with spermicide are not more effective than plain condoms. However, using a vaginal spermicide as well (film, foam or gel) helps to improve the effectiveness of condoms because if the condom breaks or slips, the spermicide is still there. Unfortunately, spermicides can cause vaginal irritation in some women and can change the normal vaginal environment (which is probably what you perceived as a yeast infection). They may therefore not be the best option for women having multiple daily acts of intercourse for an extended period of time.

Some women can have side effects with the oral contraceptive pill. Since you had the same reaction with several pills, trying another pill may not help in your case. Generally, women may find that a trying a different pill does help, because another type of pill may not have the same side effects.

Lastly, you should not judge IUDs (intrauterine devices) based on your mothers experience with them. Her situation may have been unique. The IUD has changed a lot since she used it. Modern IUDs are safe and very effective when used in an appropriate candidate. The copper IUD can make periods heavier and crampier, but many users are quite happy with this method. It is relatively inexpensive and contains no hormones. The new levonorgestrel-releasing intrauterine system is an even more effective birth control method and has the added benefit of making periods lighter and less crampy. Browse through the birth control pages of www.sexualityandu.ca for more information and options.

In vitro fertilization (IVF) may be an option for women who are poor candidates for reversal surgery. However IVF is very expensive and is associated with a success of approximately 25% per cycle.

Women who have migraines with an aura (visual changes, nausea, vomiting or numbness/tingling in arms or legs) should not take a combined oral contraceptive pill. In addition, women who have migraines and are over 35 years old, who smoke or have high blood pressure should refrain from using the combined pill.

However, women with simple migraines during their periods, or in the pill-free interval of their birth control pill package may benefit from continuous use of the oral contraceptive or an extended cycle oral contraceptive.

If you cannot use the combined oral contraceptives, these options may be worth considering:

1. Progestin only hormonal contraception such as Depo Provera, or the “mini-pill” (Micronor). It is the estrogen in the birth control pill that should be avoided in migraines with aura. However, progestins can occasionally make headaches worse. The mini-pill may be an option to try before committing to a long acting method.
2. Intrauterine devices (IUDs).
3. Other barrier methods such as the diaphragm and condoms.

Yes the combined oral contraceptive pill (OCP) is an excellent choice of contraceptive for most women with menorrhagia due to a bleeding disorder (although disease specific treatments may still be more effective - i.e. nasal Desmopressin acetate for Von Willebrands disease). Combined OCPs are also effective for alleviating the recurrent ovulatory intraperitoneal bleeding that affects some women with hemorrhagic diastheses. If satisfactory reduction in flow is not achieved through standard cyclic combined administration of the combined OCP then use of a product approved for extended cycle use such as Seasonale can help by reducing the number of periods to only 4 per year, or a continuous combined OCPs can be used to prevent ovulation and avoid withdrawal bleeding all together. Depo-Provera can be administered with caution (to avoid hematomas after intramuscular injection) in women who desire amenorrhea or reduced bleeding for whom OCPs are not appropriate or tolerated.

Norplant was discontinued in the fall of 2002. Currently, no similar product is available in Canada. The Norplant system consists of six silastic rods containing 36mg of Levonorgestrel, which is effective for five years. Though the product was discontinued, some people may still be using the product until 2007.

The progestin implant provides the most effective reversible contraception available. It requires no additional responsibility on the part of the user beyond attendance for insertion and removal. Women who stop menstruating while using the implants may also benefit from the absence of menstrual bleeding and menstrual related symptoms.

Treatment options for menstrual cycle irregularity in Norplant users include:
A short course of a non-steroidal anti-inflammatory medication is often a useful temporizing measure, however this rarely provides a long-term solution
Adding cyclical estrogen for 21 days (if there is no contraindication) with 2 mg ethinyl estradiol, 1.25 mg conjugated estrogen, or the combined oral contraceptive pill (OCP) for a couple months may help to build up a thin (atrophic) endometrium Neither of these treatment options will interfere with the contraceptive efficacy of Norplant.

Functional ovarian cysts have been reported in some users of Norplant. These usually regress spontaneously. This is more likely to occur in women who are not ovulating regularly.

In Norplant users, 86 percent will have a change in their menstrual pattern. The alterations reported include: prolonged bleeding (40%), irregular bleeding (38%), intermenstrual spotting (37%), more frequent bleeding (16%) and amenorrhoea (12%). These changes are usually not associated with major blood loss. Pregnancy must be excluded whenever a woman has a significant change in her menstrual pattern.

A minor decrease in HDL-cholesterol levels from baseline levels has been reported. The clinical significance of this change is unknown.

Medications that affect the hepatic enzyme system should be avoided in women using Norplant because of lower blood levels of Levonorgestrel. These medications include Rifampin , Grisiofulvin and many anti-convulsants (Carbamazepine, Ethosuximide Phenobarbital, Phenytoin and Primidone). Norplant should also be avoided in epileptics because anti-epileptic drugs lower serum progestin levels secondary to increased protein binding altering Norplant’s effectiveness.

It may be. Over five years of use, Norplant users gain an average of 2.5Kg. Some women have gained weight excessively in a short period of time, necessitating removal of the implants. The weight gain is predominantly attributable to increased appetite, so that all users, especially adolescents, should be counseled about the importance of monitoring caloric intake and regular exercise.

Yes. Disturbance of the menstrual cycle is by far the most frequent reason for removal of the implants, and this must be emphasized in pre-therapy counselling. Some alteration of menstrual patterns will occur during the first year of use in approximately 60% of users. Abnormal bleeding may be a consequence of using Norplant but it may also arise from pathological causes such as infection or cervical pathology. Other causes of abnormal uterine bleeding should be ruled out in any woman if symptoms persist for more than 3 months.

Norplant is a highly effective contraceptive, with an overall failure rate of 0.2 pregnancies per 100 women years (failure rate for 100 women using the method for one year). Most pregnancies associated with Norplant use are already present (but unrecognized) at the time of insertion. Accordingly every effort should be made to exclude pregnancy before Norplant insertion.

Levonorgestrel released from the implants causes endometrial suppression and thickening of cervical mucus [rendering the mucus impenetrable to sperm] for its contraceptive effect. Ovulation is inhibited in only 66 percent of women using Norplant and therefore is only one of the mechanisms of pregnancy prevention.

The contraceptive effect lasts for five years. If a woman is overweight (>70 kg) contraceptive efficacy is lower in the fourth and fifth year and the implants should therefore be exchanged earlier.

Progestin-only contraception may be associated with alterations in mood, possibly arising from alterations in serotonin metabolism. Clinical depression is however much less common. When depression is suspected close follow-up is mandatory, antidepressant medication should be given, and removal of Norplant may be necessary if there is not a satisfactory response to anti-depressants.

No. Progestin implants must however, be surgically removed before cycles will resume (and fertility is restored). There is usually no delay in the return of ovulation.

Norplant may have androgenic effects leading to the development of acne. This can usually be controlled with topical measures.

Yes. Norplant can be used even if a woman has a past history of venous thrombo-embolism. Progestins do not appear to increase the risk of thrombosis or thrombophlebitis. Women with a past history of thrombotic event can use progestin-only contraception, including implants whereas many of these individuals would be advised not to consider combined (estrogen/progestin) oral contraceptives. If a venous thrombo-embolic event occurs with an implant in place, the woman can be reassured that the implant will not affect management of the episode.

Yes. Norplant has no adverse effects on lactation or coagulation and can be used in women who are breastfeeding. It is prudent, however, to wait until lactation is well established before insertion.

Headaches occurring in Norplant users may be unrelated to the presence of the implant. If severe headaches develop associated with blurred vision following Norplant insertion, removal of the implants is recommended. A pseudotumour cerebri-like syndrome (benign intracracial hypertension) has been rarely reported in Norplant users and although it is uncertain whether or not the Norplant is causally related the implant should be removed.

Ideal candidates for Depo-Provera include:

1. Women who have side effects with, or a recognized contraindication to, combined oral contraceptive pills (OCP) or estrogen
2. Women who have trouble remembering contraceptive methods that require daily use
3. Women over the age of 35 who smoke
4. Women who have discontinued oral contraceptives while awaiting major surgery
5. Women with migraine headaches, including focal varieties
6. Women with sickle cell disease
7. Women who have experienced failure with other contraceptive methods requiring additional steps
8. Women on anti-convulsants that interfere with the combined OCP
9. Women with developmental challenges who have trouble remembering contraceptive methods that require daily use.

Regardless of whether a woman is or is not breastfeeding, Depo-Provera may be given immediately post-partum. Earlier administration i.e. before six weeks may increase the likelihood of heavier and prolonged post-partum bleeding.

Depo-Provera serum levels decline exponentially over time. After 133 days (19 weeks) the levels of medroxyprogesterone acetate are close to zero.

Depo-Provera should be administered during the first five days of a normal menstrual cycle (in order to avoid inadvertent administration during pregnancy) and/or immediately following pregnancy termination. Contraceptive effectiveness is achieved within 24 hours. Users must return every three months for injections.

Contraceptive effectiveness is achieved within 24 hours of receiving Depo-Provera. Depo-Provera should be administered during the first five days of a normal menstrual cycle (in order to avoid inadvertent administration during pregnancy) and/or immediately following pregnancy termination. Depo-Provera may also be administered at any time, and with no added precautions if the woman is currently on the combined oral contraceptive pill or the progestin only pill and is definitely not pregnant.

A routine history and physical examination is advisable. The first visit is also a good time to discuss screening for and counselling about sexually transmitted disease (STD) prevention and condom use .The importance of annual pap smears as well as the benefits of smoking cessation should be discussed. No routine blood work is required.

Depo-medroxyprogesterone acetate (Depo-Provera) is the only injectable contraceptive currently marketed in Canada. It was approved for contraceptive use in Canada in April 1997.

Depo-Provera’s effect may be markedly depressed with concomitant administration of aminoglutethimide, but these two medications are rarely required in the same individual.

Within the first six months patience and reassurance is the best treatment. After six months one may consider treatment, however, no good evidence supports any of the numerous published recommendations for the management of irregular bleeding. If the woman is unable to tolerate the irregular bleeding one might consider one of the following options:

A short course of a non-steroidal anti-inflammatory medication (such as Ibuprofen 400mg twice daily for ten days) is often a useful temporizing measure, however this rarely provides a long-term solution

Reducing the interval between Depo-Provera injections from twelve weeks to eight to ten weeks until the bleeding is controlled

Adding cyclical estrogen for 25 days per month (if there is no contraindication) with either 2 mg ethinyl estradiol or 0.65-1.25 mg conjugated estrogen or estrogen patches (17 B estradiol) 50-100mg

Increasing the dosage of Depo-Provera to 225-300 mg for two to three injections at the usual interval and then decreasing the dosage to normal (150mg)

Counselling and reassurance before administration of the first dose is essential. In the first year of Depo-Provera use 30-50% will develop amenorrhoea; in the second year amenorrhoea occurs in 70%. If this is a concern for a woman a course of oral estrogen for 14-21 days will often induce regular withdrawal bleeds again.

Each 150 mg injection provides reliable contraception for 13 weeks (90 days). If the injection is delayed 1 week it is advisable to first determine if the woman has been sexually active in the last week. If the woman has not had sexual intercourse a negative pregnancy test should be obtained and the Depo-Provera should be given. If the woman has been sexually active she should be instructed to use an alternative birth control for two weeks. After the two week interval a negative pregnancy test should be obtained and the Depo-Provera should be given as prescribed. There is no need to wait for a woman’s next menstrual cycle to give the repeat injection.

No. Depo-Provera can be used even if a woman has a past history of venous thrombo-embolism. Progestins do not appear to increase the risk of thrombosis or thrombophlebitis. All women with a past history of a thrombotic event can use Depo-Provera, whereas many of these individuals would be advised not to consider combined (estrogen/progestin) oral contraceptives.

No routine laboratory screening is required. Assessing the cholesterol-lipoprotein profile and carbohydrate metabolism should follow standard guidelines. A hemoglobin and platelet level may be warranted if there is a history of menorrhagia. A Von Willebrand factor may be included in the adolescent with severe menorrhagia.

Some, but not all studies, have demonstrated weight increase associated with the use of Depo-Provera. It is believed that this weight gain may in fact be due to increased food intake secondary to appetite stimulation rather than due to Depo-Provera itself. Weight gain should be discussed with your woman prior to prescribing Depo-Provera and good eating habits should be emphasized. Some women may report a weight gain of 2.5 Kg in the first year of use up to 6.3 Kg after the fourth year of use.

Disadvantages of Depo-Provera include:
1. Menstrual cycle disturbance.
2. Weight gain.
3. Decreased bone density
4. Headaches
5. Alterations in mood

There is conflicting evidence regarding the association of bone loss and Depo-Provera. Four cross-sectional studies have reported a significant decrease in the BMD among Depo-Provera users. However, other research studies have failed to show any difference between users and nonusers. It is clear that a randomized controlled trial is needed to ascertain the effects of long term Depo-Provera on BMD. Until further studies are available caution should be taken when prescribing Depo-Provera to women with other risk factors for osteoporosis. Women can also be reassured that the observed bone loss in the studies claiming concern did not fall into the osteoporotic range and the lost bone was recovered when the Depo-Provera was discontinued.

There are no absolute contraindications to Depo-Provera other than known or suspected pregnancy and the presence of undiagnosed vaginal bleeding. The use of anticoagulants necessitates special care to avoid hematoma with intramuscular injection. Past severe arterial disease, severe hepatic disease with markedly abnormal liver function, acute porphyria, recent trophoblastic disease (until hCG is undetectable) and rare hypersensitivities to the constituents of Depo-Provera are also considered contraindications to Depo-Provera use.

No. Depo-Provera has no adverse effects on lactation and can be used in women who are breastfeeding. It may be preferable, however, to wait until lactation is well established before initiating Depo-Provera. In women where adherence may be an issue Depo-Provera can be given prior to discharge from hospital on day two or three post-partum. This earlier administration i.e. before six weeks may increase the likelihood of heavier and prolonged post-partum bleeding.

No. If given during the first 5 days of a normal menstrual cycle or following a termination of pregnancy additional contraceptives are not necessary. Otherwise use an additional contraceptive method for 2 weeks. Commonly Depo-Provera is used by individuals whose lifestyle and risk taking behaviors put them at increased risk for sexually transmitted infections so that condom use should always be encouraged.

A pelvic examination is not mandatory prior to prescribing Depo-Provera, and may be postponed until a follow-up visit. The pap smear should also be discussed at the first visit as an expectation during future follow-up visits.

Normally Depo-Provera® is given every 12 weeks. But if you can get your injection before 14 weeks from your last shot, you should be protected from pregnancy. If it will be 14 weeks or more before you can get your shot, then you will not be protected right away. If you had intercourse in the last 10 days, you should have a pregnancy test before your next shot and then use a backup method of contraception for the first two weeks after your injection. However, you will need another pregnancy test in 2 weeks. If you did not have intercourse in the last 10 days, you don’t need to do another pregnancy test 2 weeks after the first one. Another option is to have your shot early since it can be given as frequently as every 10 weeks, and you can rest assured you’ll be protect from pregnancy without any gaps of fertility.

Half of women will be amenorrheic (have no periods) after one year on Depo-Provera®. Chances are, the spotting will settle in the next 6-7 months. If it does not, there are a few things to try to make it stop. These include increasing the dose or decreasing the time between shots for a few doses. If you are a smoker, stop smoking.

Depo-Provera is a highly effective form of contraception, with a failure rate of not more than 0.3 per 100 women years (failure rate for 100 women using the method for one year).

Depo-Provera has no permanent effect on fertility. However, a delay in return to normal fertility does occur after a decision to discontinue the method as compared to other forms of contraception. Depo-Provera users have been found to have about a nine-month delay to restoration of full fertility after the last injection. Depo-Provera should therefore not be used in women who desire pregnancy within the next year or two.

150 mg of Depo-Provera is given intramuscularly every 13 weeks. The contents should be shaken well and administered intramuscularly into the deltoid or gluteus maximus with a needle 2.5-4.0 cm in length and 21-23 gauge. Depo-Provera is provided in both a 50mg/ml solution and a 150mg/ml solution. The advantage of the 150mg/ml dose is that it is dispensed in a smaller volume than 3 vials of the 50 mg dose making it the better and less painful choice for deltoid injection.

The sustained level of medroxyprogesterone acetate suppresses ovulation in the majority of women. It also renders cervical mucus impenetrable to sperm and induces a thin endometrium (atrophy), which is unsuitable for implantation.

No, you can do anything you want. You may have some cramping 1-2 days which ibuprophen looks after and some spotting which is normal.

A recent study examined the pain associated with the insertion of a copper-T intra-uterine device (IUD) and whether a 400 mg dose of ibuprofen would improve the pain scores.

A total of 2019 women participated, 1011 used ibuprofen 45 minutes before IUD insertion, and 1008 used a placebo (sugar) pill.

Using a visual analog scale (a line labeled from 0 to 10, with 0 being no pain, and 10 being the worst pain imaginable), participants marked an X on the line that measured the amount of pain they felt with the IUD insertion. There was no significant difference in pain scores between the two groups. Forty-eight percent of women marked a pain score of 1 or less, while only 4.4 % marked a score of 7 or higher. Women who were older, had never had a baby, or whose last pregnancy had ended more than six months ago had higher pain scores. The 400 mg dose of ibuprofen did not improve the pain score in any group.

What is reassuring is that the overall pain scores were quite low. Women who are afraid of discomfort associated with an IUD insertion can be reassured that, in general, the pain experienced with this procedure is very low.

The IUCD is especially suited for:

1. Women who seek a reversible, effective, coitally independent method of contraception
2. Women seeking a private form of contraception
3. Women who are concerned that they may not remember to use a daily method
4. Women who are considering sterilization
5. Women who desire contraception immediately after delivery or abortion
6. Women who are breastfeeding
7. Women who cannot use a hormonal method of contraception.
8. Women who have regular periods and minimal dysmenorrhea It is particularly appropriate for family spacing or in 9. women who are considering long-term contraception.

The recognized absolute contraindications to the use of an IUCD are as follows:

1. Pregnancy or possible pregnancy
2. Current pelvic inflammatory disease (PID), cervicitis, or chlamydial or gonococcal genital infection
3. Lifestyle with increased risk of STD
4. Known allergy to any constituent of the device
5. Wilson’s disease (for copper devices only)
6. Conditions leading to increased susceptibility to infection, especially AIDS, leukaemia, IV drug abuse.
7. Undiagnosed irregular genital tract bleeding
8. Immunosuppressed individuals

The recognized relative contraindications to the use of an IUCD are as follows:

1. Valvular heart disease
2. Past history of PID
3. Presence of a prosthesis, which is potentially at risk from any blood-borne bacteremia (or bacterial contamination)
4. Abnormalities of the uterus resulting in a distorted cavity or a cavity that sounds to less than 6.0cm
5. History of ectopic pregnancy.
6. Severe primary dysmenorrhoea.
7. Menorrhagia.
8. Cervical stenosis.
9. Uterine fibroids or congenital uterine anomaly.

1. Uterine perforation
Perforation rarely occurs, partially or completely, at the time the device is inserted. The perforation rates for devices available in Canada are approximately 0.6 incidents per 1,000 insertions. Perforation is more likely to occur when the device is inserted post-partum. Post-partum insertion of an IUCD should be performed cautiously, and preferably by an experienced individual. IUCDs are too large to escape from the uterus through the fallopian tube. All perforations into the abdominal cavity occur through a tract in the muscular wall of the uterus.

2. PID
Pelvic inflammatory disease (PID) related to IUCD use is limited to the first few months of use; IUCD-related PID is rare beyond 20 days after insertion. In the Women’s Health Study the relative risk of PID was 3.8 in the first month after insertion, reaching baseline risk after four months and remaining unchanged thereafter. Bacteriologic studies have shown that the endometrial cavity becomes temporarily contaminated with bacteria at the time of IUCD insertion, but that the cavity soon becomes sterile again in normal individuals.

3. Expulsion
Expulsion may occur following insertion of an IUCD. It is highest in the first year and especially if the IUCD is inserted immediately postpartum. Up to 10% of women will have expulsion of their IUCD. Women should be encouraged to identify the string of the IUCD after each menstrual period since menstruation is the time when expulsion is most likely to occur.

The optimal time to insert an IUCD is during menstruation since a partially open cervix makes the procedure easier to perform. Insertion of an IUCD can also be done at any time in the menstrual cycle and may be inserted up to one week after an episode of unprotected sexual exposure as a means of emergency contraception (Nova-T IUCD only). An IUCD can be safely inserted into the uterus following completion of a therapeutic abortion. The insertion of an IUCD in post-partum women however has been associated with higher rates of expulsion and uterine perforation. As a result IUCDs are most commonly inserted at the four to six week post-partum check.

This combination of symptoms may be a physiological uterine response to the presence of the device. Pre-IUCD use of the combined OCP may also have masked irregular menstrual cycles. The progestin releasing intrauterine system (Mirena) however frequently alters the menstrual bleeding pattern because of the direct action of Levonorgestrel on the endometrium. When these symptoms occur on an isolated occasion the presence of a pregnancy complication (ectopic pregnancy, spontaneous abortion), pelvic infection, or malpositioning of the device( including perforation) should be considered.

Usually the IUCD can be left where it is until after the conclusion of the pregnancy. Laparoscopic removal can often be successfully accomplished however bowel preparation is wise in case the device is found to have partially perforated the bowel.

Most discomfort (menstrual-like cramps) associated with the insertion of an IUCD can be prevented by using local anaesthetic prior to any uterine manipulation and by ingestion of a non-steroidal anti-inflammatory (NSAID) 1 hour before the procedure. Rarely a woman will experience a vagal reaction in which her pulse slows abruptly due to pain and or anxiety associated with the insertion. In such a circumstance the device should be promptly removed and supportive measures taken (including possible intravenous injection of atropine).

The possibility of ectopic pregnancy must be excluded first. After confirming an intrauterine pregnancy most physicians recommend removal of the IUCD if possible because of the increased risk of spontaneous abortion. The 1989 study from the UK Family Planning Research Network indicated that 75 percent of pregnancies aborted if the IUCD remained in situ; this figure was significantly reduced if the IUCD was removed, with 89 percent of those women having a live birth. A pregnant woman who retains an IUCD has a two- to four-fold increase in the risk of delivering prematurely and/or developing a severe infection. If the woman wishes to terminate the pregnancy the IUCD may be left in situ until the termination of pregnancy is performed.

An IUCD, which has partially or completely perforated the uterine wall, must be removed by whatever means necessary. Even partial perforation will reduce the contraceptive effectiveness of the device. An IUCD that escapes into the abdominal cavity may adhere to other structures or may penetrate into bladder or bowel.

If the woman wishes to conceive, she will need to have the device removed. This will usually require hysteroscopy and removal under direct vision either with a local or general anaesthetic. If she has no wish to conceive, and the device is inside the uterus, it can be left in place. If an IUCD has perforated the uterine wall, it must be removed surgically as it can cause injury to other intraperitoneal organs (bowel or bladder).

If the strings are not seen in the cervical os, the device may have been expelled or may have perforated the uterine wall. Alternatively, the strings may have been drawn up into the cervical canal. This can occur spontaneously or be caused by an intrauterine pregnancy. The first step is to rule out pregnancy. If pregnancy is confirmed, management is directed towards this. Once pregnancy is excluded, the cervical canal should be explored (with Q-tip swab, cytobrush, uterine forceps or with an IUCD locating device) to see if the strings can be found. If the strings are not found, a pelvic ultrasound should be done to identify whether the IUCD is inside or outside the uterus. If the device is seen within the uterus, it can be left in situ. If the device is not identified with-in the uterus or in the pelvis, and there is no history to suggest expulsion, a plain X-ray of the abdomen will identify whether or not the device may have perforated the uterine wall and migrated within the abdomen. The devices are radio-opaque and will be seen on x-ray. If an IUCD is not seen one can assume the IUCD has been expelled and another device should be inserted or an alternative contraceptive method initiated.

If pain or abnormal bleeding persists after insertion of an IUCD, it is usually best to remove the device. If the woman wants to leave the device in place, it is important to rule out infection and complications of pregnancy as underlying causes. If these are excluded, the use of a non-steroidal anti-inflammatory (NSAID) (prior to and during menses) will reduce the volume of menstrual bleeding by up to 40 percent and will reduce prostaglandin-induced menstrual cramping.

Pregnancy must be excluded. If the patient is not pregnant, her amenorrhoea should be managed as for a woman without an IUCD. The Mirena intrauterine system will cause amenorrhoea in approximately 25 percent of users. If she is post-menopausal, the device should be removed.

Colonization of an IUCD with a fungus (actinomycosis) is usually detected through cervical cytology (PAP smears). After five years of continuous use of an IUCD, more than 20 percent of cervical smears may show evidence of this organism. Frank actinomycotic infection is potentially life threatening. Demonstration of the organism in the cervical smear of a woman with an IUCD raises the possibility of serious pelvic infection. If the woman is entirely asymptomatic she may be counseled about a slight increase risk of pelvic inflammatory disease and be followed closely. Alternatively she may be treated with ten to fourteen days of penicillin, tetracycline or erythromycin. The most conservative treatment however, is removal of the device and appropriate follow-up.

The woman should be advised to feel for the strings of the IUCD after her next menstrual period to exclude expulsion. A follow-up appointment may also be arranged following the woman’s next period. The woman should be encouraged to use barrier protection until there is confirmation that the IUCD is correctly situated. A follow-up appointment will also allow for the exclusion of infection, an assessment of menstrual symptoms, and overall tolerability. The woman should be advised to seek medical attention thereafter if she has delayed menses (to rule out pregnancy), if she has unusual pelvic pain or bleeding (to rule out infection, ectopic pregnancy or a pregnancy complication), if her partner complains of pain during intercourse or if the device is expelled. If expulsion is suspected this should be confirmed by direct visualization of the device (by the woman) or by an ultrasound examination of the uterus and/or flat plate x-ray of the abdomen(if not pregnant). There is ordinarily no need for her to check for the strings after each period or before intercourse. As for any sexually active woman, an IUCD user should have annual pelvic examinations and Pap smears.

Pain and heavier than normal menstrual flow are the most common side effect associated with the copper intrauterine contraceptive device (IUCD). At one year after insertion, five to 15 percent of IUCD users will have had the device removed because of increased menstrual pain or bleeding. Most often these concerns can be minimized with the use of non steroidal anti-inflammatory agents (NSAIDs).

No there appears to be no increase in the rate of congenital anomalies in the offspring of women who continue through pregnancy with an IUCD in situ. Remember the IUCD is always located outside the gestational sac.

No. Most women who discontinue use of an IUCD in order to conceive achieve pregnancy at the same rate as women who have never used an IUCD.

No. Women using an IUCD have between one-half and one-fifth of the risk of ectopic pregnancy faced by a woman using no contraception. This translates into an incidence in IUCD users of less than 1.5 ectopic pregnancies per 1,000 woman-years of use. Nevertheless, because of the potential seriousness of the diagnosis a woman who conceives with an IUCD in place should have a diagnosis of ectopic pregnancy excluded. However when a pregnancy results from a contraceptive failure, ectopic pregnancy is more likely in IUCD users than in women using other methods of contraception.

Fortunately, perforating the uterus during the insertion of an IUD is uncommon. The muscle typically heals without any problem and there is no effect on fertility. If you become pregnant with an IUD in place, it is very important to let your physician know. In certain circumstances, such as early in pregnancy with visible IUD strings, it is appropriate to remove the IUD. At other times, leaving the IUD in place is the better course of action.

An IUD (such as Nova T, Flexi T 300, or the Mirena® and Jaydess® IUSs) is actually effective immediately, however most health-care professionals recommend waiting a week (use either condoms or abstinence) before relying on it to protect against pregnancy.

If the strings are visible, gentle traction is applied to remove the device. If the strings are not visible, gentle exploration of the cervical canal is performed to locate the IUCD strings. If the IUCD is inaccessible the patient should be informed about the increased risk of spontaneous abortion and premature delivery associated with a retained IUCD during pregnancy. Occasionally a hysterectomy is performed in pregnancy through the IUCD under direct vison.

Most IUD’s currently available consist of a polyethylene T-shaped frame that is attached to two strings. When the IUD is inserted, the strings are cut so that they can be seen coming from the cervix when the doctor performs a speculum exam at your yearly visit.

In order to remove an IUD, your health care provider will usually perform a speculum exam. If he/she is able to see the strings, he/she will grasp the strings with an instrument and gently remove the IUD. This usually takes all of 2 seconds!

If your health care provider cannot see the strings, he/she may gently open up the cervix and use a probe to find the IUD in your uterus and remove it. This may require local anesthetic (freezing).

In very rare cases, the health care provider may not be able to remove the IUD in the office and it may need to be removed in the operating room with the help of a hysteroscope (a telescope that is inserted into the uterus to help him/her locate the IUD).

The IUCD is a highly effective contraceptive method, with a Pearl index of 0.2-2 /100 women years (failure rate for 100 women using the method for one year). Approximately one third of these pregnancies are secondary to unrecognized expulsion of the IUCD in the first year.

A vaginal speculum is inserted and the cervix is visualized. The cervix is cleansed using an aqueous antiseptic solution. Local anaesthetic (e.g. lidocaine 1%) can be injected into the anterior lip of the cervix, prior to application of a tenaculum, and it can also be used to establish a para-cervical block, particularly in nulliparous women. The tenaculum on the anterior lip of the cervix though not mandatory is often extremely helpful in straightening and aligning the cervical canal with the uterine cavity (thus decreasing the risk of perforation). The uterus is usually sounded. The IUCD is then loaded into the barrel of the inserter, using sterile technique and following the manufacturer’s recommended method. The device is loaded only as far as needed to allow insertion. The flange on the outside of the barrel is adjusted to the depth of the uterine cavity (as measured by the sound). The long axis of the flange should be aligned with the arms of the device to help to correctly align the device within the uterine cavity. The tip of the inserter barrel is directed into the cervical canal and passed gently to the fundus of the cavity. The flange should abut the cervix. The device is then expelled from the barrel by pulling back on the barrel while holding the inner plastic rod against the device; it is important to follow the directions on the package insert at this stage. The flange should abut the cervix again and the barrel is then removed, leaving the IUCD in the uterine cavity and allowing the strings to trail through the cervix. The strings are clipped at a distance of approximately 2.5cm from the external os, in order to facilitate removal of the device.

The primary action of all IUCDs is the induction of a foreign-body reaction within the endometrium. This sterile inflammatory process is toxic to gametes, primarily spermatozoa, and effectively prevents viable sperm from passing into the fallopian tubes. The copper bearing device has an independent toxic effect on spermatozoa. The progestin-releasing devices produce changes in endometrial architecture and function that reduce the potential for implantation of a fertilized egg. The progestin effect on the cervical mucus also reduces the penetrability of sperm. There are two IUCDs available in Canada at present. The Nova-T IUCD is a copper IUCD and Mirena is a progestin releasing intrauterine system (IUS).

Yes, there is a transient increase in the risk of pelvic infection. PID related to the IUCD is usually limited to the first 20 days after insertion. Any further PID that occurs is due to exposure to a sexually transmitted disease and not specifically to the use of the IUCD. Use of an IUCD in low-risk women (particularly those in stable, mutually monogamous relationships) carries no added risk of PID.

Women with a copper bearing IUCDs are more likely to experience more blood loss each month than nonusers. The increased blood loss typically occurs because of increased duration and heaviness of menstrual flow, but may also result from intermenstrual bleeding and spotting. In contrast to the copper IUCD, women with a progestin releasing intrauterine system will experience a reduction in the amount of menstrual bleeding as well as the duration after three to six months of use.

IUDs are highly effective and safe for long-term contraceptive use for women at low risk for sexually transmitted infections (STIs).

In the past, many health care providers have been reluctant to provide women with IUDs because of a concern about the potential risk of infection and pelvic inflammatory disease (PID). PID is especially concerning because it can be associated with infertility. This would obviously be of great concern to a woman who has never had a child before.

Fortunately, the increase in risk of infection associated with IUD use appears to be related only to the insertion process. After the first month of use, the risk of infection is not significantly higher than in women without IUDs

Results of a large study confirmed that nulliparous women (women that have never had a baby) could safely use the IUD without affecting their future fertility, provided that they were al low risk for sexually transmitted infections.

In summary, nulliparity is not a contraindication to IUD use. In carefully selected nulliparous women, IUDs may be successfully used.

Hubacher D et al. Use of copper IUDs and the risk of tubal infertility among nulligravid women. The New England Journal of Medicine 2001;345(8): 561-567

Ideally all candidates for IUCD insertion should be screened for sexually transmitted diseases (STD) at an earlier visit so that appropriate treatment may be given before the insertion. If this is not possible, the cervix should be carefully inspected, and the uterus and tubes and ovaries palpated before IUCD insertion. If there is any purulent discharge or pelvic tenderness, insertion should be deferred and appropriate vaginal and cervical samples obtained for STD screening. Bimanual pelvic examination also serves to determine the size, position and shape of the uterus. Sounding the uterus to determine the direction and depth of the endometrial cavity, and to rule out any major distortions within the cavity is important before IUCD insertion.

No, you can do anything you want. You may have some cramping 1-2 days which ibuprophen looks after and some spotting which is normal.

An altered menstrual bleeding pattern is common after Mirena is inserted This change in the menstrual bleeding pattern is due to the direct action of Levonorgestrel on the endometrium. The duration and volume of menstrual bleeding gradually decreases after the first three to six months. With continued use of Mirena bleeding patterns vary from scanty menstruation in some women to, oligomenorrhea or amenorrhea in others. Hormonal side effects are also common particularly in the first three to six months. The most common side effects reported include headache, breast tenderness, acne, weight change and depression. These side effects do subside over time.

A vaginal speculum is inserted and the cervix is visualized. The cervix is cleansed using an aqueous antiseptic solution. Local anaesthetic (e.g. lidocaine 1%) can be injected into the anterior lip of the cervix, prior to application of a tenaculum, and it can also be used to establish a para-cervical block, particularly in nulliparous women. The tenaculum on the anterior lip of the cervix though not mandatory is often extremely helpful in straightening and aligning the cervical canal with the uterine cavity (thus decreasing the risk of perforation). The uterus is usually sounded. The IUS is then loaded into the barrel of the inserter, using sterile technique and following the manufacturer’s recommended method and making sure that the arms are perpendicular to the barrel. The strings are held in place in the groove found at the end of the barrel. The flange on the outside of the barrel is adjusted to the depth of the uterine cavity (as measured by the sound). The tip of the inserter barrel is directed into the cervical canal and passed gently into the uterine cavity. The barrel should be inserted until the flange is approximately 1.5 centimeters away from the cervix. The device is then expelled from the barrel by pulling back on the green button to the marked line. While holding the green button in place the flange is advanced until it abuts the cervix. The green button is then slid to the end of the barrel, leaving the IUCD in the uterine cavity and releasing the strings from the groove. The strings are clipped at a distance of approximately 2.5cm from the external os, in order to facilitate removal of the device. It is important that all users receive instruction on the correct insertion of the IUS.

Although this is not a common side-effect, it has been reported in less than 1% of women who use the Mirena®. Some of the progestin from the device enters your system and can cause the ovary to produce less testosterone. This is likely to lessen after the device has been in place for several months and less progestin is absorbed into your body.

An IUD (such as Nova T, Flexi T 300, or the Mirena® and Jaydess® IUSs) is actually effective immediately, however most health-care professionals recommend waiting a week (use either condoms or abstinence) before relying on it to protect against pregnancy.

Yes, it is. This IUS is made of two components, plastic and levonorgestrel (a progestin hormone). The levonorgestrel is released slowly from the IUS and causes the lining of the uterus to become very thin. When the Mirena is first inserted, before the lining becomes completely thinned out, women may have unpredictable spotting. Eventually, the lining becomes so thin that many women stop having their periods altogether. It should get better over the next few months. If that is not happening, see your health care provider to make sure there is not another cause for the bleeding.

The Lea’s Shield is a vaginal barrier device manufactured from medical grade silicone. It should be used in combination with a spermicidal agent. It is designed with a one-way flutter valve that prevents trapping of air between the device and the cervix, and allows for a snug and unobtrusive fit on the cervix. It is designed to fill the posterior fornix, thus reducing the chance of becoming dislodged. The Shield has an anterior loop to facilitate insertion and removal.

The Lea Contraceptive is a soft, re-usable silicone device that is inserted into the vagina and covers the cervix. It acts as a barrier to prevent sperm from entering the cervix. It has a small one-way valve on it that allows air to escape while it is being placed - this creates a suction to keep the device in place against the cervix. The valve also allows uterine and cervical fluids to escape. It is latex-free.

The Lea contraceptive comes in one size only (“one size fits all”) and so does not need to be fitted by a health care provider. A prescription is not needed to get a Lea contraceptive

The Lea contraceptive must be used with a spermicide. With perfect use, small studies have found that it has a failure rate of 8.7 pregnancies per 100 women. The device must be inserted prior to intercourse and should be left in place for at least 8 hours after an act of intercourse. It may be left in place for up to 48 hours.

The device acts as a true barrier to sperm, with additional spermicide being used to supplement its contraceptive effectiveness. The Lea’s shield does not require individual fitting but a demonstration on insertion and removal of the device should be provided to all women who choose this form of contraception.

The Lea’s shield consists of a cap-shaped appendage and a “control loop” that together form an elliptical device. The shield should be placed behind the pubic bone, as far as it can comfortably go. The loop aids in insertion and removal of the shield and stabilizes the device. When in place the lower tip of the cap is positioned under the cervix (with the cervix resting in the interior of the cap) while the control loop extends towards the posterior aspect of the pubic symphysis. Spermicide should be applied to the rim and the bowl (1/3 full) of the device prior to insertion. Additional spermicide is only required if sex occurs more than eight hours after insertion. If more spermicide is required it should be placed in the vagina without removing the Lea’s shield.

In the limited number of trials completed to date, the effectiveness of Lea’s Shield compares very favorably with other female barrier methods, with a failure rate of 6.4 per 100 women when used with a spermicide and 12.2 per 100 women at six months when used without a spermicide. The Pearl index is 13-24/100 women years (failure rate for 100 women using the method for one year).

The shield can be inserted into vagina at any time before intercourse and should be removed no sooner than 8 hours after the last coital act but no more than 24 hours after insertion. The woman should be instructed to insert the shield behind the pubic bone as far as it can comfortably go. Spermicide should be applied to the rim of the device prior to insertion. Additional spermicide is only required if sex occurs more than eight hours after insertion. The spermicide should be placed in the vagina and the Lea’s shield should be left in place.

Up until January 2003, the device was available in Canada from its distributor, Thermamed Corporation. However, Thermamed decided to discontinue distributing the Lea contraceptive in January 2003. It is however currently still available through Canadian on-line providers. The Lea contraceptive is available in the US (it received FDA approval recently) and a few European countries.

After using the Lea’s sheild, the device should be washed with warm water and soap. The Lea’s sheild should then be rinsed and dried. All water based cleansing agents are safe to use when caring for a Lea’s shield.

Yes it is possible to get pregnant even when ejaculation doesn’t occur in the vagina because sperm may be present in the pre-ejaculation fluid. Withdrawal also does not protect against sexually transmitted infections or HIV thus using a birth control pill and a condom together are strongly recommended.

Failure of these methods may be attributed to improper teaching and understanding of the method, risk-taking during the fertile days and/or natural variability in timing of ovulation resulting in conception during the so-called “safe period” of the cycle.

Avoidance of vaginal intercourse is very effective for preventing unwanted pregnancy and still allows a couple to be involved in other forms of sexual expression. However, if a secondary goal is to avoid sexually transmitted infection, then oral-genital sex and other activities that expose the partner to pre-ejaculatory fluid, semen, cervical-vaginal secretions or blood must be avoided unless the partner is known to be free of any possible infectious agents.

Of the available natural methods, the symptothermal method is the most effective and the calendar method the least effective.

Coitus interruptus or the withdrawal method is a frequently used method of family planning. During coitus, the man attempts to withdraw the penis from the vagina prior to ejaculation. This form of contraception carries significant risks for pregnancy and is used mostly by couples with no other method of contraception available (less commonly by those who prefer to avoid hormonal or barrier methods of contraception)

Any couple that chooses the withdrawal method should know about the significant risks of failure of the method and should be provided with information and a prescription (where needed) for emergency contraception should there be inadvertent contact between ejaculate and vagina or external genitalia. Spermicides may also be used although the effectiveness after ejaculation has not been determined.

Any couple practicing abstinence should be offered education about other methods of birth control and safer sex to help them in the future if their sexual agenda changes. It is also important to suggest that condoms be readily available in case they change their minds. They must also be aware of emergency contraceptive options.

When starting to employ these methods, all couples should use abstinence or another non-hormonal method of contraception until the cycle pattern is established and recognized. The couple should also be carefully instructed about the reproductive cycle, the symptoms to monitor and methods for temperature charting (including the need for a special basal body temperature thermometer). The couple will likely benefit from a repeat visit following a few cycles of charting to review the method and individualize the concept of fertile days.

The couple should be willing to accept the risk of failure. It requires the participation of both partners and is dependent on an understanding of the fertility cycle. There is no protection from sexually transmitted diseases and HIV transmission. If the woman has an unpredictable cycle these methods are unreliable. Furthermore not all ovulatory women have recognizable cyclic mucus changes.

This method requires self-control on the part of the man, who must recognize impending orgasm and resist the urge to pursue coital movement. He must withdraw the penis in time to prevent the ejaculate from coming into contact with the vagina or vulva. The couple is not protected from sexually transmitted diseases including HIV. Examinations of the pre-ejaculate of HIV-infected men have revealed the presence of HIV-infected cells in some cases. There is also a theoretical risk that the pre-ejaculate may contain spermatozoa, therefore making conception possible even if withdrawal is achieved prior to ejaculation.

There are no disadvantages of abstinence if a couple is able to maintain a fulfilling relationship without the need for penetrative sex. When couples choose this approach they are wise to become knowledgeable about contraceptive alternatives and to have barrier methods available in the event that they decide to have penetrative sexual intercourse at some later date.

There is no drug or device related side effects. The method is ideal for the motivated couple when the woman has regular, predictable menstrual cycles.

The advantages of abstinence include

1. Minimal risk of misuse
2. Freedom from the threat of STD and HIV infection, if no exchange of body fluids occurs
3. No physical side effects
4. No need to visit a health care provider
5. No cost, unless condoms and dams are used for oral-genital sex

There are no costs involved and the method is universally available.

Withdrawal (also known as coitus interruptus) is better than nothing. However, the failure rates of this method are high, around 27% with typical use. The idea is to withdraw the penis from the vagina prior to ejaculation. This is very difficult to do consistently because it requires considerable self-control. This method also does not provide protection from sexually transmitted infections.

The LAM is 98 percent effective in preventing pregnancy in the first six months after delivery provided that (1) the woman has not experienced her first postpartum menstrual bleed, (2) the woman is fully breastfeeding with feeds not more than four hours apart, and (3) the infant’s diet is not supplemented. As the pregnancy rate increases in women whose infants are receiving supplementary food, despite continued lactational amenorrhoea, a supplementary contraceptive method should be used to avoid conception in this circumstance.

This method uses a combination of BBT (basal body temperature) change and change in cervical mucus, or other cyclic symptoms. A chart of symptoms and basal body temperature is helpful in identifying the fertile days. Some women are aware of ovulation discomfort (Mittelschmerz), which may also be incorporated into the charting. Pain may occur just prior to, during or just after ovulation. The couple is not protected from sexually transmitted diseases including HIV.

Lactation has been a major form of contraception for centuries, and has played a key role in family spacing in many parts of the developing world. Breastfeeding in the traditional fashion of nearly constant suckling suppresses ovulation. Modifications of the traditional breast-feeding patterns that were incorporated to accommodate western lifestyles however have dramatically reduced the effectiveness of this technique. Accordingly, the time from delivery to resumption of ovulation varies considerably and is affected by a number of factors, including the frequency and intensity of suckling and the use of supplementary feeding. The lactational amenorrhoeic method (LAM) is an effective temporary contraceptive method as long as the woman can recognize reliably when she is again at risk of ovulation or wouldn’t care if it failed. The risk for return of ovulation increases as breast-feeding frequency declines, if milk supplements are used, or if menstrual bleeding resumes. In these circumstances, even if lactational amenorrhoea persists, a supplementary contraception should be used to avoid conception. The couple is also not protected from sexually transmitted diseases including HIV when using this method.

This method relies on the observation of changes in the quality of vaginal mucus around the time of ovulation. One day before, during, and one day after ovulation, the vaginal mucus (arising from the cervix) may change in quality to become opaque, sticky and tacky. The recommendation is to check vaginal secretions before urinating and examine the elasticity, consistency and lubrication. Intercourse can be resumed on the fourth day after peak mucus production. It is less reliable for women who have an insufficient quantity of mucus, or vaginal conditions, for example, vaginal infections, masking cervical mucus changes. The couple is not protected from sexually transmitted diseases including HIV.

This is the most common of the fertility awareness methods. Women will calculate the onset and duration of their fertile period based on several assumptions that:

1. ovulation occurs 12 to 16 days before the onset of the next menses,
2. sperm remain viable for two to three days and
3. the egg survives for 24 hours.

Based on this method, a couple would avoid intercourse or use another contraceptive during an eight- to ten-day period in each cycle. The woman should chart a menstrual calendar over several months. Her fertile period is determined by subtracting 20 days from her shortest cycle (to establish when the fertile period begins) and subtracting 10 days from her longest cycle (to establish when the fertile period ends). Recent studies show that there may be a wider variation in the “fertile time” than traditionally calculated by this method-hence inadvertent pregnancies may result when this technique is used as a means to avoid pregnancy. The couple is not protected from sexually transmitted diseases including HIV.

Home ovulation predictor kits are available to confirm the presence of urinary luteinizing hormone (LH), which precedes ovulation by one to two days. These kits are expensive and usually used by women who wish to conceive, rather than as an adjunct to monthly contraception. By establishing when the LH surge occurs sex can be avoided for the next five days (for contraception) or scheduled around this time when pregnancy is desired. The couple is not protected from sexually transmitted diseases including HIV.

Home ovulation predictor kits are available to confirm the presence of urinary luteinizing hormone (LH), which precedes ovulation by one to two days. These kits are expensive and usually used by women who wish to conceive, rather than as an adjunct to monthly contraception. By establishing when the LH surge occurs sex can be avoided for the next five days (for contraception) or scheduled around this time when pregnancy is desired. The couple is not protected from sexually transmitted diseases including HIV.

The answer is yes. There is some concern that the effectiveness of the patch for birth control is slightly lower in women who weigh more than 90 kg (198 lbs). The typical effectiveness rate for the patch is around 99%, which is similar to the pill. The initial effectiveness research studies looked at 3300 women who used the patch for over 22,000 months in total. There were more patch failures in women who weighed over 198 lbs, although there were only 15 unexpected pregnancies in all. So, if you are overweight, the patch will still work to protect you from an unwanted pregnancy, and will definitely work better than using no contraception at all.

NO! Please do not do this! The patch will NOT work for birth control unless it is worn continuously. The usual way to wear the patch is for three weeks (changing to a new patch each seven days) and then take a week off from the patch. You will usually have a period during this week off. If a patch accidentally becomes detached, it becomes ineffective for birth control if more than 24 hours have passed. Replace the patch as soon as you can, and use a back up method of birth control for one week if the patch has been off for more than 24 hours.

The estrogen present in the patch and the pill stabilize the lining of the uterus, which is shed during menstruation. When estrogen levels decline bleeding can occur. This can happen when the patch is removed late. The patch will still offer effective protection from pregnancy if you change it up to two days late-the so-called two days of forgiveness-but beyond this you should use a backup method for a week. There are no two days of forgiveness if the patch falls off or is removed.

The contraceptive patch is very similar to the oral contraceptive pill in terms of side effects like weight gain. Research comparing the patch and the pill to placebo (an inactive pill that looks the same so people don’t know whether or not they’re taking the real pill) showed that the average weight gain was less than 1 lb per year. In other words, the weight gain had nothing to do with being on the pill or patch. Some women lost weight, some women gained more weight. It all depends on how many calories you take in versus how much energy you burn off with activity. Neither the pill nor patch will make you gain weight.

The birth control pill is very effective if taken properly, with a typical user failure rate of three percent per year. In order for the Pill to be most effective it should be taken at the same time every day. It is also important to remember that the birth control pill will only prevent pregnancies and not protect from sexually transmitted infections. A condom and a birth control pill are the most effective means of preventing unwanted pregnancies and harmful sexually transmitted infections.

It may take a few cycles off the oral contraceptive before returning to regular cycles (ovulating once per month). Thus, for the purposes of calculating how far along a woman is in her pregnancy, it may be beneficial to wait until her cycles return to normal prior to conceiving. The oral contraceptive pill is however not teratogenic; that means that no ill-effects have been found in fetuses inadvertently exposed to the birth control pill, nor to babies conceived shortly after a woman has stopped using the oral contraceptive.

A certain percentage of women who discontinue the combined oral contraceptive pill (OCP) will not get the immediate return of normal menstrual periods. Initially this was thought to be due to some persisting effect of the pill -hence the name “Post Pill Amenorrhoea”. This term has now been abandoned because the real reason for this lack of menstruation has been clarified. Long-term use of any contraceptive method by a group of women who initially have regular periods will be associated with some women gaining or losing weight [the commonest reason for menstrual disruption], developing thyroid dysfunction or a pituitary prolactinoma etc. Pill users who have these conditions do not manifest the lack of menstrual periods because the contraceptive steroids maintain menses until the combined OCP is stopped. Then, when the combined OCP is stopped, the lack of periods becomes apparent. Accordingly the absence of menstruation after the combined OCP is stopped should not be merely ascribed to an effect of the pill but should be investigated like any other situation in which menstruation ceases. An investigation for secondary amenorrhea should be performed when there has been no resumption of cycles within six months following discontinuation of the combined OCP.

Diane-35 is a medication that became available in Canada in 1998 for treatment of mild to moderate acne, hirsutism (abnormal hair growth on the face and body), and oily skin. It contains two hormones: ethinyl estradiol (an estrogen) and cyproterone acetate, a progestin. Estrogen and progestins are present in all combined oral contraceptive pills (COC), but the cyproterone acetate in Diane-35 is better at improving acne than other progestins. Although in Canada it approved only for the treatment of acne and hirsutism, Diane-35 is also a very reliable form of contraception. Its failure rates are similar to other birth control pills on the market in Canada.

There was some concern raised recently about the risk of venous thromboembolism (VTE or blood clots) while taking Diane-35. Like any COC, the risk of VTE is higher when taking Diane-35 than if no medication is taken. The absolute risk of VTE in combined oral contraceptive users is 1-1.5 per 10,000 women years, and is slightly higher in the first year of use (SOGC Contraception Consensus Guidelines 2004). The data are not conclusive as to whether cyproterone acetate has a higher rate of VTE than other progestins, but the general thinking is that the rate is similar to that of other birth control pills (Spitzer, Lidegaard, JOGC 2003).

In Canada, Diane-35 is approved for treatment of acne and hirsutism, but not specifically for contraception. Acne therapy with Diane-35 should be re-evaluated 3-4 months after the acne problem has resolved.

If you have a history of blood clots, you should speak to your health care provider because you may not be a good candidate for Diane-35 or any other COC.

Birth control effectiveness is measured in a Pearl Index. Basically, this index estimates the number of pregnancies that will occur in one year, for every 100 women who are using this birth control method. If the birth control pill is used perfectly, for every 100 women who take the pill, 1-2 women will become pregnant each year. However, since most women do not take the pill perfectly, the actual-use failure rate is about 2-4 women who become pregnant each year.

Yes. It is prudent to recommend that combined OCP users discontinue use at least four weeks before any surgery which is likely to be followed by a sustained period of reduced activity or immobilization, or before surgery for a malignancy. Combined OCP users who undergo major emergency surgery should discontinue use of combined OCPs and receive prophylactic peri-operative anti-coagulant therapy using subcutaneous heparin. At the same time, it is important to substitute a reliable form of contraception (e.g. a progestin-only method) when oral contraception is withdrawn. When the use of a reliable alternative contraceptive method is doubtful in a given situation, the risk of unintended pregnancy may exceed the risk of venus thombo-embolism. In such circumstances continuation of the combined OCP with addition of peri-operative anticoagulation may be more appropriate. Clinical judgment is important with documentation of the rationale for making an exception in an individual woman.

The first signs of puberty in a girl are when she begins to develop breasts, although sometimes underarm and pubic hair starts first. The start of the growth spurt occurs around the same time. The rate of fastest growth happens later, but still before the first menstrual period. A girls first period usually takes place about 2 years, on average, after the beginning of puberty. By the time a girl starts having her period her rate of growth has already started to slow down, and she usually only grows 2 or 3 inches more after that.

Growth in the child and adolescent is complex, and is strongly influenced by a girls general health, her nutrition and her genetic potential. A girl who eats poorly, has short parents, comes from an ethnic background where people are shorter, or who has almost any chronic medical condition will not be as tall as a healthy girl who eats well and whose parents are tall. Hormones such as growth hormone, among others, affect height as well. Estrogen does have an influence on the normal pubertal growth pattern. In early puberty, the low levels of estrogen in a young womans blood are in part responsible for the rapid increase in height. In later puberty, higher levels of estrogen makes the growth plates in the bones fuse which, over months to years, causes growth to stop, reaching her adult height.

Because your daughter has already started to menstruate, she is already close to her adult height regardless of whether or not she takes an oral contraceptive. There is no evidence that the eventual height of a young woman taking a modern low-dose birth control pill is any lower than it would otherwise have been. In fact, one study followed girls from around 12 years of age, and did not find any difference in height at age 21 between those who chose to use the birth control pill, and those who never used them 1.

One possible reason for the common misperception that the pill might reduce a girls height may come from an older practice in the 1960s and 70s of using high doses of estrogen to slow down the growth of girls who are predicted to be very tall. This is not frequently done today. The doses of estrogen used in those cases were very high around five times higher than the average birth control pill today.

When a young woman has heavy bleeding, the potential risks of taking the oral contraceptive pill should be weighed against the physical problems (ranging from iron deficiency to life-threatening hemorrhage) and social inconveniences of troublesome periods. Whether or not a young woman needs birth control must also be considered.

1 Reference: Lloyd T, Lin HM, et al. Oral contraceptive use by teenage women does not affect body composition. Obstetrics and Gynecology 2002; 100(2): 235-9.

No. Choice of oral contraceptive preparation can be strongly affected by the combined OCP in use by peers or siblings, and by the size and color of the OCP package. Low dose (20 ug of ethinyl estradiol) combined OCPs may be better tolerated as they are associated with less breast tenderness, nausea and headache-unwanted estrogen side effects that appear more likely to adversely affect compliance in teens.

The oral contraceptive can be discontinued at any time. In order to decrease possible menstrual disruption, stopping the birth control pill after the last “hormone” pill (ie. day 21) is preferable. Fertility is not impaired from previous oral contraceptive use. A woman can get pregnant at any time after stopping her birth control pills, without side effects to the fetus. Allowing at least one spontaneous period off the birth control pill, before attempting to conceive, can help to time ovulation more accurately.

No. If compliance in a new user is a potential problem backup contraception may be prudent initially. This back-up method is particularly important during the first month of use because first time pill users may take the pill incorrectly. Many first time users also require dual protection for sexually transmitted infections (STIs). In “at risk” individuals condom use should be encouraged in addition to the combined OCP to help prevent the transmission of STIs.

No, taking the pill will not alter the pregnancy test. A pregnancy test looks for a hormone called beta-hCG, which is only produced from the fetus. This hormone is not in the pill, so being on the pill will not change the test. If you miss a period while on the pill, or have unusual (very light or very heavy) bleeding or spotting during the week where you would normally have a period, consider taking a pregnancy test as you may have become pregnant by accidentally missing scheduled pills. There is no harm to the pregnancy if you take birth control pills without knowing you are pregnant.

Starting to have sex at a young age is associated with a higher risk of cervical cancer (and of precancerous changes in the cells of the cervix) because these conditions are associated with the human papillomavirus (HPV), which is sexually transmitted. Young womens cervices may also be more susceptible to HPV.

Although a higher risk of cervical cancer has been observed in pill-users, this association seems to be related to a reduced condom use when a woman starts the pill, rather than an effect of the pill itself. Some other risk factors are multiple sexual partners, smoking, or a deficient immune system. Using condoms can reduce (but not completely prevent) transmission of the papillomavirus by reducing the contact between genital skin and bodily fluids.

The good news is that cervical cancer is almost completely preventable by Pap smear screening. A Pap smear is designed to pick up small precancerous changes in the cervical cells, which can be treated before they have a chance to become cancer (which takes years and years). See the February 2005 e-newsletter for more information about HPV including the exciting new vaccine being created to prevent infection with this virus.

As for your other concern, there is no reason to believe that taking the pill could cause harm to your “developing organs”, which, by the way, are no longer really “developing” at all. By the time you start your period, your internal sexual organs are already completely mature.

The consequences of sexual activity can harm your pelvic organs though. sexually transmitted infections (STIs), especially chlamydia and gonorrhea, can spread up into your uterus and fallopian tubes, potentially causing damage without necessarily causing any symptoms. This is called pelvic inflammatory disease or PID. Scarring from PID can cause infertility, chronic pelvic pain, and tubal pregnancies (dangerous pregnancy in which the fetus develops outside of the uterus, usually in a fallopian tube).

As for pregnancy, this is one of the biggest health risks in the life of an otherwise healthy young woman, not to mention the devastating social consequences of having a baby at age fourteen. So, if you were sexually active, it was a very good idea for you to start the pill to prevent pregnancy. Remember that the pill does not prevent STIs though, so you still need to use condoms.

In the past, oral-contraceptive pills were not prescribed to women in their late 30s and 40s because of the concern of an increased risk of heart attack, blood clots, strokes. However, as the dose of hormones in the pill has been reduced and more experience has been gained with pill use in older women, it appears that many older women may continue to use the oral contraceptive pill

Healthy women who do not smoke, do not have high cholesterol and do not have a strong family history of cardiovascular disease may be able to use the birth control pill safely right up until menopause.

The pill will not interfere with the physiological process of menopause but it will mask the symptoms that usually inform women that the change is taking place. Once menopause is established, contraception is no longer necessary, but a woman may not be able to tell when to stop the pill because the hormones in the pill will prevent hot flashes and provide uterine stimulation that results in a monthly menstrual flow.

The average age of menopause is 51, so when a women on birth control pills approaches that age, she can stop the pill and see if she is having her own spontaneous menstrual cycles. However, since the menopause process waxes and wanes in the transition period, she should continue to use another form of contraception to prevent unintended pregnancy during this time. Once there are no spontaneous cycles for one year she should no longer require contraception.

That is a very good question. Medications that you take by mouth must be absorbed through the lining of your intestines into your blood stream in order to work. Anything that makes things pass through your intestines faster than normal (like the flu, inflammatory bowel disease or other conditions) can reduce the amount of a medication that is absorbed because there is less time for absorption to occur. Having less medication in your blood likely makes it less effective.

If a woman has a temporary condition like a stomach flu, or food poisoning, her pill may not be as effective. In such cases, she should use a condom, or other back-up contraceptive method, until her diarrhea has stopped for at least a week. Alternatively, research has shown that two oral contraceptive pills placed in the vagina (when you are unable to keep medicine down by mouth) will be absorbed in an amount that approximates the amount from one pill taken orally.

In your case, reduced effectiveness of oral medication may be an ongoing problem. You could use a condom in addition to the pill when you have a flare in your condition, or you could switch to another method altogether. You might want to think about changing to the contraceptive patch or vaginal ring because these do not depend on intestinal absorption. Speak to your health care provider.

The pill has an efficacy (theoretical effectiveness) of 99.9 percent, with a typical user failure rate of three percent per year. The difference between efficacy and typical failure rate is attributed to adherence (correct usage), drug interactions, and individual variability. The Pearl index is 0.1-0.2/100 women years (failure rate per 100 women using the method for one year).

The answer to your question is yes and no. So far, the science says there are only two antibiotics proven to change the level of drug in your blood, making your birth control less effective. These drugs are rifampin (used to treat tuberculosis) and griseofulvin (used to treat fungal infections of the skin).

If you take an antibiotic and it gives you diarrhea, it is possible that your birth control may be less effective because it is harder for your digestive tract to absorb the pill. There are also some people who just dont absorb the pill well when they are on an antibiotic. The problem for health care providers is that we dont know who those people are. So, just to be on the safe side, its a good idea to use a second form of birth control like condoms while you take the antibiotics, and continue using them until you get your next period. Once you are done the antibiotics and have started a new package of pills it would be reasonable to stop the back-up method. However, using condoms is ALWAYS recommended to help protect you from getting a sexually transmitted infection

The primary mechanism of action of combined OCPs is the inhibition of ovulation. Additional mechanisms, for example interference with 1) ovum transport, 2) endometrial development and 3) cervical mucus production, account for the formulations’ multiple contraceptive actions.

Many women are concerned about the possibility of birth defects with oral contraceptive use.

Fortunately, studies have found no association between OCPs and birth defects

A 1990 review of the literature (meta-analysis) found no overall increase in birth defects (RR 1.0, (95% CI, 0.8-1.2). Because the progestin hormone in the OCP is so low, there is no risk of causing masculinization of the female fetus.

In summary,the OCP does not cause birth defects. If the OCP is mistakenly taken at the time of conception or in early pregnancy, it will not harm the fetus.

The different colours helps to tell which pills contain hormones (the “active pills”) and which pills do not contain hormones (“sugar pills”).

If you use a pill that varies the amount of hormones that you are taking from week to week (for example, Triphasil®, Triquilar®, Tri-Cyclen®, Tri-Cyclen Lo®), the different colour pills correspond to different amounts of hormone.

If you use a pill that contains the same amount of hormones from week to week (for example MinEstrin®, Alesse®, Marvelon®, Cyclen®, Yasmin®), the one colour of pill represents the pills that contain the active hormones, while the other colour represents the pills that contain no hormones (the placebo pills or “sugar pills”).

Birth control pills come in either a 21-day or a 28-day pack. Packs with 28 pills have 21 pills that contain hormones (active pills) and 7 pills that contain no medication (placebo or sugar pills). Packs with 21 pills only have 21 active pills. When using 21-pill packs, women have to remember to start taking pills again after the 7 days off, and for some this can be difficult. The reason that pills also come in 28 packs is to help women remember to take their pills at the right time. With a 28 pack, you take the 21 active pills, followed by the 7 sugar pills. Once that pack is finished, you start a new pack the next day.

The effectiveness at preventing pregnancies is similar among all combined oral contraceptives. In order to reduce cycle disruption, start the new package of pills after the 7 day “pill-free” interval. If no more than 7 days were passed between the last “active” (hormonal) pill and the start of the new pack, and no pills were missed, the oral contraceptive will be effective in preventing pregnancies.

If the oral contraceptive is started no later than 5 days into your cycle (day 1 being the first day of your menses), it will provide effective contraception. However, if you missed a pill, have irregular periods, or started the pill at a different point in your cycle, backup protection such as condoms is recommended for the first 7 days on your first pack of pills. It is important to remember that the birth control pill does not protect against STIs, so condom use is always recommended.

The different colours helps to tell which pills contain hormones (the “active pills”) and which pills do not contain hormones (“sugar pills”).

If you use a pill that varies the amount of hormones that you are taking from week to week (for example, Triphasil®, Triquilar®, Tri-Cyclen®, Tri-Cyclen Lo®), the different colour pills correspond to different amounts of hormone.

If you use a pill that contains the same amount of hormones from week to week (for example MinEstrin®, Alesse®, Marvelon®, Cyclen®, Yasmin®), the one colour of pill represents the pills that contain the active hormones, while the other colour represents the pills that contain no hormones (the placebo pills or “sugar pills”).

Birth control pills come in either a 21-day or a 28-day pack. Packs with 28 pills have 21 pills that contain hormones (active pills) and 7 pills that contain no medication (placebo or sugar pills). Packs with 21 pills only have 21 active pills. When using 21-pill packs, women have to remember to start taking pills again after the 7 days off, and for some this can be difficult. The reason that pills also come in 28 packs is to help women remember to take their pills at the right time. With a 28 pack, you take the 21 active pills, followed by the 7 sugar pills. Once that pack is finished, you start a new pack the next day.

Smoking increases the risk of many illnesses including heart attacks, strokes, and lung cancer. Smoking as few as four cigarettes a day makes you seven times more likely to develop heart disease. Any birth control pill that contains estrogen has a small increased risk of blood clots (venous thromboembolism).

Young women rarely have heart attacks, so the risk of complications is very small. However, in women over the age of 35 who smoke, the risk of a cardiovascular event (stroke or heart attack) increases significantly if they are also taking the birth control pill, so doctors usually advise smokers over 35 not to take the birth control pill

Smoking is generally detrimental to your health. All smokers are encouraged to quit. In particular, women who are on the birth control pill and who smoke cigarettes are strongly advised to stop.Though the rates are still low, oral contraceptive users who smoke cigarettes have an increased the risk of stroke, heart disease and leg/lung clots. Due to the inherent rise in these risks with age, women 35 years of age and older who smoke cigarettes should not use the birth control pill. Oral contraceptive users who smoke cigarettes also have higher rates of breakthrough bleeding/spotting.

If you smoke, talk to your health care provider about your best birth control options, or better yet talk to your doctor about ways to quit smoking!

No. There is no evidence to support periodic pill breaks. The belief that a “pill holiday” is advisable remains one of the commonest reasons for unplanned pregnancy. Long-term use has not been associated with adverse effects or with a delay in return to fertility after the pill is discontinued. In fact, Health Canada has approved the extended cycle the birth control pill Seasonale. Its formulation of 30 mcg of ethinyl estradiol and 150 mcg of levonorgestrel is similar to Min-Ovral, but it is packaged for a 91day cycle instead of 28 days. This means only 4 periods per year. The 28 day cycle, on the usual oral contraceptive, was designed to mimic a woman’s natural cycle. The monthly withdrawal period would then offer a woman some reassurance that she was not pregnant. However, if the birth control pill is taken for longer periods or in a continuous fashion, no periods are needed. There is a misconception that blood is thus stored in the uterus. Instead the lining of the uterus simply stays thin and does not need to shed. Studies have shown that taking the pill in an extended or continuous fashion is as effective in preventing pregnancies as the 28 day cycle. The advantage is a reduction in days of bloating, menstrual pain, and days requiring protection from bleeding. There is an increased rate of women having no periods at all. The rate of adverse events such as headaches and unexpected bleeding was similar to the 28 day pill cycle. Unpredictable bleeding or spotting can be an issue, as in the 28 day cycle, but has been shown to settle after 6-9 months of use. This new formulation results in a slight increase in exposure to the hormones in the pill (23% more), but this is still less than the previous birth control combinations. Research is underway for extended use of the contraceptive ring and the transdermal (patch) contraceptive. Kwiecien, M. et al., Bleeding patterns and patient acceptability of standard or continuous dosing regimens of a low-dose oral contraceptive: a randomized trial, Contraception 67 (2003) 9-13 Anderson, F.D. et al., A multicentre, randomized study of an extended cycle oral contraceptive, Contraception 68 (2003) 89-96

A pelvic examination is not mandatory prior to the first oral contraceptive prescription, and may be postponed until a follow-up visit. The pelvic exam and pap smear should be discussed at the first visit as an expectation for future follow-up visits.

Starting an oral contraceptive is an important decision, and you are encouraged to involve your parents if possible. However, your health care provider does not need your parents’ permission to prescribe contraception, providing you understand the potential risks and potential benefits of your decision.

Your health care is confidential. Unless there is abuse, or issues related to the criminal code, your interaction with your health care provider is kept private and will not be disclosed to other members of your family.

Information about drug interactions with POPs is less clear than that for combined oral contraceptive pills. As the progestins used in POPs are metabolized through the hepatic cytochrome p450 enzyme system, any medication causing enzyme induction may theoretically increase metabolism and reduce the contraceptive effectiveness of POPs.

Medications that may reduce the contraceptive effectiveness of the POP may include:

1. Griseofulvin
2. Rifampin
3. Carbamazepine
4. Ethosuximide
5. Phenobarbital
6. Phenytoin
7. Primidone

The POP should also be avoided in epileptics because the anti-epileptic drugs lower serum progestin levels secondary to increased protein binding reducing the POPs’ effectiveness.

If even one pill is forgotten or vomited, a back-up method of contraception (condoms) must be used for at least 48 hours and some even recommend up to a week to restore the hostile mucus effect. The woman should continue to take her tablets as prescribed.

Chloasma may occur in the POP user however, it usually develops in women on the combined oral contraceptive pill (OCP). A non-hormonal method of contraception may have to be chosen if this situation arises.

 Yes. Disturbance of the menstrual cycle is by far the commonest side effect from the use of progestin-only pills, and this must be emphasized in pre-therapy counselling. Abnormal bleeding may be a consequence of using POPs, but it may also arise from pathological causes such as infection or cervical pathology. Other causes should be ruled out if abnormal bleeding persists for more than 3 months. Some women will continue to have regular menstrual cycles on the POP. The women with the most acceptable, regular cycles are at greatest risk for pregnancy because they are most likely to be ovulating. If alterations in the menstrual cycle do occur on the POP the bleeding is usually neither heavy nor painful.

Candidates for the progestin only pill include:

1. Women who have side effects with, or a recognized contraindication to, combined oral contraceptive pills or estrogen

2. Women over the age of 35 who smoke

3. Women with migraine headaches, including focal varieties

4. Lactating women

5. Women with sickle cell disease

There are no absolute contraindications to progestin-only pills other than known or suspected pregnancy and the presence of undiagnosed vaginal bleeding. If pregnancy would be devastating to a woman with underlying medical or obstetrical problems the POP may not be as good a choice, because of the diligence required to achieve reliable prevention. If the woman has had a serious side effect with the combined oral contraceptive pill that is not conclusively linked to estrogen such as liver adenomas or steroid associated cholestatic jaundice the POP may be contraindicated. Past severe arterial disease, acute porphyria, recent trophoblastic disease (until hCG is undetectable) and rare hypersensitivities to the constituents of the POP are also considered contraindications to POP use.

No. Progestins can be used even if a woman has a past history of venous thrombo-embolism. Progestins do not appear to increase the risk of thrombosis or thrombophlebitis. All women with a past history of a thrombotic event can use progestin only contraception, whereas many of these individuals would be advised not to consider combined (estrogen/progestin) oral contraceptives.

No, progestin-only pills may be started immediately after delivery as they have no adverse effects on lactation or coagulation. There is also no deleterious effect on the infant from the small amounts of progestin that may be transferred in breast milk.

The major advantages to the POP are that:

1. There are no absolute contraindications- they may be used in women with contraindications to the combined oral contraceptive pill (OCP) such as thromboembolic disease and myocardial disease.

2. They may be used in women over 35 who smoke, during breastfeeding and when the combined pill is discontinued before major surgery.

3. They have no estrogen- related side effects.

The progestin-only pills should be taken from the first or second day of the menstruation cycle, and daily (nonstop) thereafter. Contraceptive reliability requires regular pill taking at the same time each day. It is important to emphasize that unlike the combined oral contraceptive pill (OCP) there is no pill free interval and that all twenty-eight pills in a package contain active medication.

Norethindrone 0.35mg (Micronor 28) is the only progestin-only pill marketed for contraception in Canada.

A routine history and physical examination is advisable. The first visit is also a good time to discuss screening for and counselling about sexually transmitted disease (STD) prevention and condom use .The importance of annual pap smears as well as the benefits of smoking cessation should also be discussed. No routine blood work is required.

No, routine laboratory screening is not required. Assessing the cholesterol-lipoprotein profile and carbohydrate metabolism should follow standard guidelines. A hemoglobin and platelet level may be warranted if there is a history of menorrhagia. A Von Willebrand factor may be included in the adolescent with severe menorrhagia.

No if the POP is started on day one or day two of the menstrual cycle no additional precautions are required. If adherence in a new user is a potential problem backup contraception may be prudent initially. This back-up method is particularly important during the first month of use because first time pill users may take the pill incorrectly or forget to take the pill. Many first time users also require dual protection for sexually transmitted diseases (STD). In “at risk” individuals’ condom use should be encouraged in addition to the POP to help prevent the transmission of STIs.

Progestin-only pills have a theoretic contraceptive effectiveness of 90 to 99 percent. The failure rate is lowest in highly motivated women. The effectiveness drops off dramatically with missed or delayed pill administration. The Pearl index is 0.3-4/100 women years (failure rate for 100 women using the method for one year).The higher Pearl index results when adherence is poor, particularly in very young users. The lower rate applies particularly during lactation.

Pills should be prescribed for one year, with annual physical assessments, but a follow up visit in the first few months after the initial one is recommended to enhance adherence and to reinforce correct usage. This will ensure that early concerns and questions (especially about nuisance side effects) are addressed and will enhance adherence. This is particularly important for first time users and adolescents. Adolescents may require more than one follow-up in the first year to increase adherence.

The pills should always be taken at the same time of day (within three hours) to ensure a reliable effect. It is important to emphasize that unlike the combined oral contraceptive pill (OCP) there is no pill free interval and all twenty-eight pills in a package contain active medication.

Micronor® is a progestin-only birth control pill (“mini-pill”). Its main method of action is to thicken the cervical mucus thus preventing the passage of sperm. Other mechanisms of action include thinning the lining of the uterus (to inhibit implantation), and suppression ovulation (in only 50% of cases).

The hormonal pills must be taken every day (no pill-free interval), within a 3-hour window. The stringent rules for its use results in reported failure rates that range from 0.3% (for perfect use) to 8% (typical use). Using a backup method such as condoms will decrease the risk of unintended pregnancies.

This birth control pill is used more commonly in women with a contraindication to estrogen containing contraceptives (such as complicated migraines, smokers over 35 years of age, or previous leg /lung clots), or breastfeeding mothers.

The progestin-only pill (POP) causes endometrial suppression and thickening of cervical mucus [rendering the mucus impenetrable to sperm] for its contraceptive effect. Ovulation is inhibited in only 60 percent of women taking the POP. Because of its multiple mechanisms of action the POP, when used correctly, provides a reliable means of contraception.

Spermicides contain a chemical called nonoxynol-9. It comes in the form of cream, gel, foam, film, or suppository. By inserting spermicide in the vagina, in front of the cervix, it destroys sperm on contact. By themselves, spermicides are not a very effective method of birth control. For this reason, they should be used with another form of contraception like condoms.  Plus, spermicides do not provide any protection against sexually transmitted infections.

The Today sponge has recently been released in Canada. It is waiting for FDA approval in the United States. It was originally on the market in the States from 1983 to 1995. It was removed from sale secondary to manufacturing costs.

This is a very rare complication of the sponge, which is usually a consequence of failure to remove the sponge within 24 hours. The user should seek medical attention however if any symptoms of toxic shock syndrome are displayed (sudden high fever, diarrhea, vomiting, dizziness, weakness, muscle aches or sunburn-like rash).

There is preliminary evidence suggesting some protection from HIV by the spermicidal agents that are impregnated in the sponge, particularly cholic acid (sodium cholate). To maximize protection from HIV transmission, however, use of the sponge should be combined with use of a (male) latex condom.

 The sponge should be placed as high as possible into the vagina prior to intercourse or prior to any genital contact that may lead to ejaculation of semen

The sponge can be inserted immediately or up to 24 hours before intercourse and should be left in place for at least 6 hours and no longer than 24 hours after intercourse. The maximum wear time is 30 hours. Forgotten sponges carry a risk of toxic shock syndrome and vaginitis.

Some sponge users are plagued with recurrent vaginal yeast infections or recurrences of bacterial vaginosis. Other sponge users may have a presumed infection because of irritation that is actually an allergic or reactive response to the sponge. A physician should evaluate any persisting irritation.

The contraceptive sponge (Protectaid) is a non-prescription, one-size-fits-all barrier method that does not require a visit to a physician or birth control clinic. It is a small, disposable polyurethane foam device intended to fit over the cervix. The sponge is impregnated with a combination of spermicidal agents (nonoxynol-9, benzalkonium chloride and sodium cholate).

It is inserted into the vagina and through expansion it creates a barrier between the penis and the cervix. A small perforation in the sponge allows it to be removed 6 hours or more after intercourse by simply hooking a finger into the opening.

The sponge’s contraceptive action is primarily provided by the spermicide impregnated in the sponge, augmented by the sponge’s ability to absorb and trap sperm.

The Today sponge looks like a circle 2 inches in diameter and 3/4 inch in width, with an attached loop. It is impregnated with the spermicide nonoxynol-9.

It protects from pregnancies for up to 24 hours, regardless of how many times the woman has sex, without the need of more spermicide. It must be left in at least 6 hours after the last act of intercourse, and no more than a total of 30 hours.

The sponge offers less efficacious protection against pregnancy than the diaphragm (approximately 20 women per year would become pregnant using the sponge as opposed to 12 women with the diaphragm)

Allergic reactions such as itching, redness, and irritation of the vagina can occur in about 4 women per year of use.

As frequent use of vaginal spermicide can cause vaginal irritation, it may increase the possibility of acquiring the HIV as well as other STIs. Thus condom use is suggested.

The advantages of the contraceptive sponge include:

1. Can be inserted prior to intercourse.
2. Requires no preparation.
3. Requires no additional spermicide.
4. Is portable and easily accessible
5. Requires no fitting or physician intervention
6. Causes no systemic reactions
7. Provides continuous protection for up to 24 hours,
8. It may provide some STI protection
9. Contains no latex (made from polyurethane)
10. Does not interrupt lovemaking

The disadvantages of the contraceptive sponge include:

1. It must be left in place for at least six hours after intercourse
2. It must be used correctly and consistently to avoid failure
3. It is less effective in women who have previously been pregnant
4. The spermicidal agents used in conjunction with it cause occasional sensitivity reactions
5. It may increase vaginal yeast infections or bacterial vaginosis
6. It may increase the risk of toxic shock syndrome if left in place too long
7. It should not be used during menstruation
8. It may be forgotten and left in place
9. The user must be comfortable with insertion and removal as well as assertive enough to insist on correct timing of this insertion and removal

If genital irritation is a problem, steps should be taken to rule out STDs, vaginal moniliasis and bacterial vaginosis. If it is simply a “messy discharge” that is the concern, the use of spermicidal suppositories, film or bioadhesive jelly can be used. It is important however, to try to distinguish between latex sensitivity, lubricant sensitivity and spermicide sensitivity. Often the spermicide is not the cause for the woman’s genital irritation.

1. Jelly, cream and foam spermicides are effective immediately after application.

2. Spermicidal suppositories need 10 to 15 minutes to dissolve and disperse throughout the vagina before they are effective.

3. The vaginal contraceptive film is a two-by-two inch sheet of film resembling wax paper. It contains 72 mg of nonoxonol-9, and needs five minutes to melt and disperse prior to becoming effective.

4. Advantage 24 is a bioadhesive jelly that adheres to the cervix and vagina, slowly releasing nonoxynol-9. It provides protection for up to 24 hours prior to a single act of intercourse unlike most spermicides, which are good for one hour only. With repeated acts of intercourse additional spermicide is required.

Some advantages:
1. Spermicides are easily obtained without a prescription.
2. Although they have some contraceptive effectiveness when used alone, they are best used in conjunction with other barrier methods.
3. They have no systemic effects although rare sensitivities can result in irritation of the penis and vagina.

Some disadvantages:

1. Spermicide use may result in a temporary irritation of the vulva, vagina or penis
2. Spermicides, especially foams, jellies and creams, can be messy, which can lead to reduced use
3. Spermicide must be applied repeatedly with each act of intercourse
4. Some spermicides have an unpleasant odor or taste

Spermicides can be used:

1. In conjunction with another method of contraception to enhance effectiveness
2. At mid-cycle to augment contraception provided by fertility awareness techniques
3. To help prevent accidental pregnancy after a condom breaks or slips off
4. As an emergency method in the event of missed oral contraceptive tablets or an expelled intrauterine contraceptive device preferably before intercourse.

The creams, jellies, suppositories and films remain effective for no more than one hour, and a repeat application of spermicide is recommended for each act of intercourse. The bioadhesive technology (Advantage 24) provides protection for up to 24 hours prior to a single act of intercourse. However, a repeat application is required prior to each additional act of intercourse even with Advantage 24.

The effectiveness rates of spermicide used alone ranges from 79 to 94 percent. The lowest pregnancy rates are found in motivated women who are knowledgeable about how to properly use and apply the spermicide. Spermicides are also more effective in women whose fertility is naturally reduced, as in women over age 45, those who are breastfeeding, and those with absence of regular menstrual periods. The Pearl index can be as high as 18-28/100 women years (failure rate for 100 women using the method for one year).

The popular spermicide called nonoxynol-9 does not protect people from sexually transmitted infections as previously thought. Contraceptive products that contain this spermicide, such as condoms, vaginal gels, inserts, and contraceptive film, are now required by the Food and Drug Administration (FDA) in the United States to carry a label indicating nonoxynol-9 does not protect against STIs. It may actually increase the risk of getting HIV from an infected person, because of the irritation it can cause to the lining of the vagina or rectum. The SOGC recommends that spermicide only be used by women who are at low risk for STIs and HIV, for example, women in monogamous relationships where STIs have been ruled out. It’s best to use uncoated condoms instead of nonoxynol-9 coated condoms.

Spermicides are composed of a spermicidal agent in a carrier that allows dispersion and retention of the agent in the vagina. Nonoxynol-9 is the most commonly used spermicidal agent, and it is the active component in most of the spermicide preparations available in Canada. Spermicides destroy the sperm cell membrane by altering the lipid layer. The sperm then become permeable to moisture resulting in swelling and break down of vital sperm cell membranes.

The only absolute contraindication to spermicide use is a known allergy to the spermicide or the carrier. This occurs in two to four percent of users, both female and male. Spermicides should not be used in any condition that prohibits proper placement high in the vagina in contact with the cervix. Such genital tract abnormalities as a vaginal septum or double cervices will make the correct placement of spermicide difficult and are potential contra-indications to its use, depending on the motivation of the woman.

Spermicides, chemicals that kill sperm, come in different forms including vaginal contraceptive film (VCF), foam, cream, and gel. They are inserted deep in the vagina shortly before intercourse. Contraceptive foams block the entrance to the uterus with bubbles and contain a spermicide, preventing the sperm from meeting with the egg. Contraceptive creams, gels, and film (VCF) contain spermicide and melt into a thick liquid in the vagina that blocks the entrance to the uterus. Nonoxynol-9 is the active chemical agent in spermicidal products available in Canada and the US. They can all be purchased without a prescription in a drugstore or a supermarket. Used alone they are 72-94% effective at preventing pregnancy so they are often used in addition to another method of birth control, for example the condom or diaphragm, to increase their effectiveness.

Vaginal contraceptive film (VCF) consists of a 2"x2” paper-thin sheet of soluble film filled with spermicide. The film is inserted into the vagina at least 15 minutes (but no more than one hour) prior to intercourse. To insert the film, be sure that your fingers are completely dry. Place one sheet of film on your fingertip and slide it along the back wall of the vagina as far as will go so the film rests on or near the cervix.

For the gels, creams, and foam, the application technique is essentially the same. To insert the foam, first shake the foam container vigourously and then use the nozzle to fill the plastic applicator. To fill the applicator for vaginal gels or creams, simply squeeze the spermicide tube into the applicator. Next, insert the applicator into the vagina as far as it will comfortably go and then push the plunger to release the cream, gel, or foam (similar to inserting a tampon with a tampon applicator!). The spermicide should be deep in the vagina close to the cervix.

Another application of spermicide will be required if:

More than one hour has gone by since the spermicide was first inserted (exception is Advantage contraceptive gel)
with each new act of intercourse

Using spermicides may provide modest protection against bacterial STIs (decreases the risk by up to 25%), however they do not appear to provide any protection against HIV. Condom use is still recommended for STI and HIV protection.

1. Age under 30 years
2. Postpartum sterilization
3. Failing relationship
4. Young children
5. Loss of a child through accident or illness

The incidence of regret is around five percent for both women and men.
Known risk factors for regret include:

1. Having young children
2. Experiencing couple disharmony
3. Being less than 30 years of age at the time of sterilization
4. Being sterilized during Caesarean section or shortly after delivery or therapeutic abortion.

1. Wound infection
2. Bruising
3. Haematoma formation
4. Anaesthesia-related
5. Mesosalpingeal tears which may require laparotomy to control bleeding
6. Injury to blood vessels of the abdominal wall or those of the lower abdomen and pelvic sidewall,
7. Injury to the urinary tract or the bowel
8. Uterine perforation
9. Procedure failure with unexpected pregnancy (higher risk of ectopic pregnancy)

1. Shoulder tip pain
2. Lower abdominal pain or cramps
3. Bruising or bleeding from incisions
4. Postoperative nausea and lightheadedness

Contraindications to tubal ligation include:

1. Systemic health problems, especially cardio-pulmonary, that may be aggravated by general anaesthesia. An anaesthesia consult is recommended if there is any uncertainty about the woman’s surgical status
2. Pregnancy (unless the sterilization procedure is done at the time of pregnancy termination)
3. The presence of pelvic infection/adhesions, or inability to gain access to the fallopian tubes at surgery
4. Uncertainty about permanent contraception

Post-partum sterilization can be performed within hours or days of delivery through a mini infra-umbilical incision. It may also be postponed until four to six weeks after delivery and be performed laparoscopically or through a mini Pfannensteil incision (“bikini”). Usually a tubal excision method will be used rather than an occlusive method if performed immediately post-partum. Tubal ligation may also be performed by an excisional technique at the time of Caesarean section.

Immediately following surgery. Pregnancies that occur immediately following tubal ligation were usually conceived (but unrecognized) before the procedure.

Essure is a form of permanent contraception, like a tubal ligation (i.e., getting your tubes tied). A tubal ligation requires a surgical procedure to enter the abdomen and either tie off the fallopian tubes, burn them, or place a clip across them. Unlike a tubal ligation, Essure does not require a general anaesthetic or incisions in the abdominal wall. Instead, little coils of metal are inserted into the opening of the fallopian tubes where they enter the uterus. This is done using a telescope device (hysteroscope) inserted from below the uterus. This procedure requires that local anaesthetic be placed into the cervix, and that the cervix is gently dilated open so the hysteroscope can be inserted. This gives access to the inside of the uterine cavity. The surgeon can then see the openings to the tubes and the coils are placed.

Sometimes, there may be difficulty seeing the tube openings and placing the coils. If this technique is successful, it is considered impossible to reverse. If a woman were to change her mind about having children after having an Essure procedure, even in vitro fertilization (IVF) may not be an option for her, as the Essure device sticks into the cavity of the uterus.

This procedure is available in Canada. They are inserted by gynecologists or other physicians with the special training. Speak with your primary care physician about a referral.

A certain amount of vaginal discharge is normal. It is a result of the hormones that are produced by your body. Normal vaginal discharge does not have a strong odour and is usually clear, white, or slightly yellow. If you find that the discharge is smelly, has changed color, or is itchy or irritating to your skin, see a healthcare provider.

Tubal ligations may be performed laporoscopically (with bipolar coagulation, clips or silastic rings) or by a small mini Pfannensteil (“bikini”) or infra-umbilical incision (post-partum) or at the time of a laparotomy done for an unrelated indication. Vaginal tubal ligation involves removal of a portion of the fallopian tube through the upper vagina. Although this method avoids an abdominal incision it is associated with slightly higher rates of postoperative complications. The choice of occlusion method depends upon the surgeon’s training, personal experience, and the technical facilities and equipment available. It will also depend on whether the sterilization is performed remote from a pregnancy (interval sterilization), post-abortion, or post-partum.

Tubal ligation although somewhat invasive, provides women with a very private and cost-effective method of contraception, with no important long-term side effects, no adherence issues and no interference with intercourse.

A complete medical and a contraceptive history is essential. The medical history should elicit any history of pelvic disease, previous abdominal or pelvic surgery, heart or lung disease, bleeding problems, allergies, medications, and previous problems with general anaesthesia that might be a contraindication for surgery. A complete physical examination including pelvic examination is also warranted prior to surgery. Particular attention to the uterine position, mobility and the adnexa is important. Use of an alternative effective means of contraception is essential until the time of the tubal ligation. Because post-sterilization regret is common, careful pre-surgery counseling with awareness of risk factors is essential. Information about the type of operation including risks and benefits, the availability of alternate methods of family planning, the possibility of failure and the possibility of reversal should be discussed and documented.

Yes, it is possible, but not all gynecologists and anesthetists are comfortable with doing a tubal ligation without a general anesthetic. During a laparoscopic surgery, the abdominal cavity is filled with carbon dioxide gas. This sensation can be uncomfortable and distressing for some women who have local freezing only.

Alternatives to a general anesthetic include a spinal anesthetic, or local anesthetic with sedation. A spinal is when the anesthetist injects freezing into the space beside the spinal cord, which causes numbness below the level of injection (approximately from the ribs downward). However, a person may still be bothered by the abdominal distention. The technique with local anesthetic involves injecting the freezing only where the skin incisions will be and on the fallopian tubes. Medication to cause drowsiness is also used, but the woman may still be able to feel movements or other sensations that may not be painful but which may still be uncomfortable.

One newer technique involves using a camera called a hysteroscope to look inside the uterus and insert coils into the openings of the tubes, which over time scar into the tubes causing blockage. This device is called Essure, and is not yet widely available across Canada .

Sterilization should be considered permanent. Sterilization reversal, although feasible, is difficult to obtain, involves riskier surgery than sterilization itself, is expensive, and often does not succeed in restoring fertility. Reversal of tubal ligation is successful approximately 70% of the time but reversal of vasectomy is less successful with time (70% Vs. 40% after 8 years). Pregnancy rates after reversals of female sterilization depend not only on the length of tube remaining but also on the fertility of both partners (which declines with age).

No. Women who have chosen a surgical means of contraception however, may be more likely to seek a surgical approach to subsequent bleeding problems than other women in general. There is no good biological explanation why prior tubal ligation should increase subsequent hysterectomy rates.

Yes. Tubal ligations performed vaginally may be more technically difficult and are associated with a higher chance of failure (as high as 4.8 % after ten years). Their only advantage is the lack of an abdominal scar.

Both male and female sterilization should be considered permanent procedures, but even with careful counseling beforehand some men and women will request a reversal if their life circumstances change and they desire more children.

A reversal of sterilization (male or female) may be possible however it requires special surgical skills, is expensive and not usually covered by health plans, and not all patients are appropriate candidates. Sucircleess rates for reversal of female sterilizations vary and are partly dependent on the original method of sterilization and the amount of tubal damage. Sucircleess rates for reversal of vasectomy are also variable and depend on the skill of the surgeon, the time since the vasectomy was performed, and the presence of antisperm antibodies.

Yes. Overall rates of pregnancy are dramatically reduced after tubal ligation but if a pregnancy occurs the tubal distortion resulting from the procedure makes it more likely that the pregnancy will become trapped in the tube. The rate of ectopic pregnancy among sterilized women ranges from four to 73 percent of all pregnancies, depending upon the method of sterilization. There is an approximately three-fold greater incidence of ectopic pregnancy after electrocoagulation than after the use of silastic rings. Ectopic pregnancies may occasionally occur at six or more years after sterilization.

Rates of subsequent term delivery following a tubal reversal vary. The time between sterilization and reversal does not seem to influence success rates for female sterilization reversal (as it does in men). Success after sterilization reversal depends on the residual tubal length, the method of reversal, the skill of the surgeon, and the fertility of both partners. The results are highest after reversal of occlusion techniques that damage a small segment of the tube such as a tubal clip or ring (75-90%) and lowest after electrocoagulation (50%). The occurrence of ectopic pregnancy after reversal surgery is about 5% - 8% and is likely due to scarring at the site of anastomosis affecting tubal transport of the fertilized egg.

Permanent sterilization is most commonly performed in a woman by cauterizing (burning), tying and removing a piece of tube, or by putting a ring or a clip on the tubes. All these methods try to occlude the lumen (opening) of the Fallopian tube such that the egg and sperm cannot meet.

A woman who is considering this method of birth control needs to be sure of her decision not too want any more children, regardless of the changes in her life. This is a permanent method. Though it can be reversed, this requires a second surgery that is not covered by provincial healthcare, and is not always successful.

Tubal ligation can fail on average in one woman in 200. There is an increased risk of ectopic (tubal) pregnancies in women who have undergone this procedure: over 10 years after sterilization, approximately 7 women per 1000 will have had a tubal pregnancy.

An important issue to consider is that women sterilized before the age of 28 have an increased risk of failure over time, when compared to women older than 34 years at the time of the procedure. In addition the risk of tubal pregnancies, if the procedure fails, is higher in younger women.

Though most women do not regret choosing tubal sterilization, the probability of regret is greater in women less than 30 years at the time of sterilization (20% versus 6% in women over age 30), in an unstable relationship, or who had their surgery less than one year from their last childbirth.

For further information, involve your doctor in this discussion, and make sure you are fully informed on other effective reversible forms of birth control.

Peterson, HB, et al., The risk of pregnancy after tubal sterilization: Findings from the U.S. Collaborative Review of Sterilization, Am J of Obstet and Gynecol, 174, April 1996
Peterson, HB, et al., The risk of ectopic pregnancy after tubal sterilization, NEJM, 336, March 13, 1997, 762-67
Hillis, SD, et al., Poststerilization regret: findings from the United States Collaborative Review of Sterilization, Obstet and Gynecol, 93, June 1999, 889-95

The Pearl index is 0.6/100 women years (failure rate for 100 women using the method for one year). Failure of tubal ligation may occur quickly after the procedure in the event that complete tubal occlusion is not achieved or many years after the original procedure due to fistula development between the two occluded tubal remnants. The ten-year cumulative probability of failure is affected by age at the time of tubal sterilization. The probability of failure is greater for women sterilized before age 30 than for women sterilized after that since the natural fertility declines with advancing age.

Sterilization (tubal ligation or vasectomy) results in the occlusion of the ducts (fallopian tube or vas deferens) to prevent the ovum and the spermatozoa from meeting.

Interval sterilizations refer to sterilizations performed some weeks or months after a pregnancy. These are most commonly performed using laparoscopy. Interval sterilizations may also be performed by a small (“mini”) Pfannensteil incision (“bikini”). When performed by a laparotomy approach, any of the laparoscopic devices for occlusion may be used such as a clips, silastic rings or bipolar coagulation. More commonly an intervening segment of tube is excised and the ends ligated (the Pomeroy method) at the time of laparotomy.

Yes. The ten-year failure rates of the commonly performed tubal ligations are as follows:

1. Filshie clip application 1.2 %
2. Bipolar electrosurgical tubal coagulation 2.48 %
3. Unipolar electrosurgical tubal coagulation 0.75 %
4. Silicone/Falope ring 1.77 %
5. Spring clip (Hulka) 3.65 %
6. Interval partial salpingectomy 2.01 %
7. Post-partum partial salpingectomy 0.75 % The overall ten-year failure is 1.85 percent. Many of the late failures result in ectopic pregnancy.

No. There is no convincing evidence to support the development of abnormal menstrual patterns following sterilization. Pre-procedure pregnancy or the use of the combined OCP may have masked irregular menstrual cycles.

No. According to the Supreme Court of Canada 1986 (Re Eve) only women who are able to give informed consent may undergo sterilization. The Canadian Medical Association position supports the procedure only in the event that there is clear benefit to the woman and less permanent methods of contraception have failed or are inappropriate.

Tubal ligation (also called female sterilization) seals the fallopian tubes so that the egg and sperm cannot meet. The procedure may be done either laparoscopically (in which viewing and operating instruments are inserted into the abdomen through small incisions), or by minilaparotomy (where the surgeon uses a small incision to open the abdomen and seal the tubes).

The tubes may be sealed using cautery (burning the tubes), with specially designed clips or rings, or by cutting a portion of the tubes.

This procedure has no effect on the ovaries, which produce the hormones that control menstruation and menopause. Thus, it has no effect on when menopause occurs.

For many years it was believed that tubal ligation may cause menstrual irregularities including increased bleeding, bleeding between periods, and menstrual pain (“post-tubal ligation syndrome”). However evidence does not support the existence of “post-tubal ligation syndrome”.

A large study published in 2000 reported that there was no difference in hormone levels and little difference in menstrual cycle characteristics after a tubal ligation. Women who have had a tubal ligation are no more likely to have menstrual irregularities than those who didn’t have the procedure.

U.S. Collaborative Review of Sterilization Working Group. N Engl J Med 2000; 343(23):1681-1687

1. No sports or physical strain should be undertaken for seven days postoperatively
2. Sexual intercourse is prohibited for five days (contraception continues to be required until vasectomy success has been confirmed by semen analysis)

There are two principal techniques for performing a vasectomy:

Convential
The conventional vasectomy involves making one or two incisions in the scrotal skin under local anaesthesia. The vas deferens is then isolated and divided and a 1.5 cm segment of each vas is removed. The ends of the vas are then sealed with non-absorbable suture, cautery-induced burn or clips and the scrotal incision is closed.

No-scalpel
The no-scalpel vasectomy is done through a tiny puncture opening in the scrotal skin employing local anaesthetic. The rest of the technique is identical to the conventional procedure. No skin sutures are needed. The operating time is reduced to about one-half of the time for the conventional method.

Less common
Other less common approaches to male sterilization involve percutaneous chemical occlusion of the vas, or use of silver or silicone rubber-silver ring clips, the latter being compatible with reversible vasectomy.

Common reasons given for requesting reversal include:

1. “Had not received enough information”
2. “Had been pushed into this procedure”
3. Sexual side effects
4. Long-term scrotal pain (after vasectomy)
5. Establishment of a new relationship
6. Improvement of housing or financial situation
7. Loss of a child.

Contraindications to a vasectomy include:

1. Systemic health problems e.g. allergy to local anaesthetics, immunosuppression, acute infectious diseases, coagulation problems that cannot be controlled with desmopressin acetate (DDAVP).

2. Local genital abnormalities impairing adequate localization of the vas deferens, including hernia, varicocoele, hydrocoele, or tumour.

3. Uncertainity about permanent contraception.
4. Sexual dysfunction.

1. Vasovagal (fainting) reaction (1-30 %)
2. Hematoma (bruising) (1-10 %)
3. Infection (0.4-16%)
4. Granuloma (nodule) formation from extruded sperm, either at the vas or at the epididymis (1 - 50 %)
5. Epididymitis and vasitis (inflammation and pain in the epididymis or vas deferens) (0.1 - 8 %)

1. Transient pain
2. Minor scrotal bruising or swelling

The likelihood of pregnancy decreases with time because of the development of circulating antibodies to sperm. The probability of pregnancy following vasectomy reversal is reported to be as high as 75% after three years and as low as 30% after 14 years, which correlates to a decreasing number of motile sperm in the semen- the result of immobilizing sperm antibodies.

A vasectomy is declared “successful” after confirming that there is no motile sperm in the semen sample. The man must have a sperm sample between 6 weeks and three months following the surgery that demonstrates the absence of motile sperm before engaging in unprotected intercourse.

Vasectomy although somewhat invasive, provides men with a very private and cost-effective method of contraception, with no important long-term side effects, no adherence issues and no interference with intercourse. In addition, it is a simpler and safer to obtain and perform than a tubal ligation and has very few complications. Unlike tubal ligation it rarely requires general anaesthesia.

No. Most studies did not find any evidence of increased risk of testicular cancer in vasectomized men. The studies on prostate cancer have been more inconsistent. The National Institutes of Health and the American Urological Association suggest screening for prostate cancer in the same fashion as men who have not undergone a vasectomy.

No. Recent evidence is reassuring with no significant association between cardiovascular disease and vasectomy observed.

The Pearl index is 0.2/100 women years (failure rate for 100 women using the method for one year). Pregnancy rates following vasectomy vary from zero to 2.2 percent with any occlusion method. No carefully controlled studies have compared the different occlusion methods. Spermatozoa persist in the seminal vesicles and, thus, in the ejaculate, for two to three months or 10 to 30 ejaculations after vasectomy hence a vasectomy is not declared a success until a follow-up semen analysis reveals that no sperm remain in the ejaculate. The main reason for conception post vasectomy is the failure to use back-up contraception in the three months following the procedure and until a semen analysis reveals no residual living sperm. Failures of vasectomy can occur years later due to fistula formation or recanalization of the vas deferens.

Following a vasectomy, you may resume sexual intercourse after 2-3 days if it is comfortable. However, you are not sterile immediately. For many men, sperm will not be cleared from the tubes until after 20 ejaculations (or 3 months). Until then, another method of birth control should be used to prevent pregnancy. Most doctors will recommend performing a semen analysis after 20 ejaculations to verify that no sperm is present in the ejaculate.

Remember, although vasectomy is very effective occasional failures do occur (0.2-2% failure rate). It does not provide protection against sexually transmitted infections (STIs).

Normally viable sperm will continue to be present in the ejaculate for several weeks after occlusion of the vas deferens. Other means of contraception need to be used until a follow up semen analysis reveals that no more sperm are present in the ejaculate. A sperm analysis is performed 6 weeks to three months following the procedure.