CONTRACEPTION...CONTINUED

 METHODS OF CONTRACEPTION

 PAST, PRESENT AND FUTURE

85% of women will get pregnant in one year if they have a normal sex life, and

do not use any contraception. In days gone by they used abstinence.

Withdrawal (coitus interruptus)

This is the oldest form of birth control which is still in practice today. It is also referred to as “The Pull out Method”. The male partner should be experienced enough to know when to pull out before he ejaculates. Even a small drop of semen fallen on the vulva can make this method fail. The other problem is with preejaculate which can sometimes carry sperm. Before your partner starts it is a good idea to pass urine and clean the penis. Make sure as best as you can, that he does not have any STI’s. This is often difficult, as both of you may be intoxicated or drug affected after a party, and withdrawal is the only contraception you can use. If you are young and naive this can be worse. My Idea of sex is for pleasure and relaxation, but if you depend on withdrawal it is risky and takes the pleasure away.

If both of you are focusing on withdrawal   and not relaxing, it creates tension and in my experience of medical practice, I have found that these women suffered anxiety and back aches, maybe from pelvic congestion. I have not come across any documented research on this at this time.

The other very important fact is that this does not protect you from STI’s.

If you are likely to be caught in a situation like this it may be prudent for you to carry a condom. Better to be safe than sorry.

The failure rate of pregnancy after withdrawal varies between 4 to 22 %.If you think you are at a fertile time of the menstrual cycle; “mid cycle” you can seek emergency contraception to prevent pregnancy, which I will discuss in further blogs

In summary the withdrawal method is excellent particularly if practiced by regular monogamous partners. It has no cost, no hormones, no side effects, no change in menstrual cycle, better partner communication, better for some religious groups and it is better than using nothing.

The big disadvantage to this is there is no protection from STI’s. Nervous anxiety about withdrawal takes the pleasure away.

In my view we should educate couples who have no access to other methods on how to improve the performance of the withdrawal method; for example pass urine before starting and wash the penis.

CONTRACEPTION---CONTINUED

 Medical Assessment.

Before you are given contraceptive advice the care givers need to make a detailed medical assessment of your health.

Your age, is particularly important, if you are under 18 or nearing menopause. Other facts we need to know is your menstrual cycle, when did you start , is it regular, how often it comes, is it heavy or scanty(small bleeding), is it painful, does it give you  headaches? These are a lot of questions.  They are all important to choose the best contraceptive for you. You will also need to answer questions about your sexual history, and if you have had any sexually transmitted infections (STI’s or STD’s), or Pelvic inflammatory diseases (PID).  Besides these answers the caregiver will need to know about, high blood pressure, diabetes, kidney disease, liver disease, epilepsy, fibroids, ovarian cyst’s, polycystic ovarian syndrome,  ectopic pregnancy and any gynaecological surgery.  Are   you   on   any medications?  Are   you a smoker? Then there will be questions about your family medical history such as cardiovascular disease (CVD) or thromboembolism (DVT). They will also want to know if you have personally had any of the above   problems. Last but not the least is your Obstetric history. Have you had any pregnancy, miscarriages, abortions or babies? How many babies you have had, when will you likely have your next baby, or is this it? How old is your last child, are you currently lactating?

Do you have any history of taking herbal remedies as this is important, particularly   St John’s Wart. This is often given for   depression, anxiety and many other problems, not properly diagnosed. This   herb interacts with many drugs particularly oral contraceptives and antibiotics. In fact it is banned in France and some others countries are going to put a warning on its packaging. So if you are on any herbal remedies, please let your care giver know.

Examination and tests

The next step before the   contraceptive advice is given is to perform a detailed examination of the client and do the necessary tests. All the examinations and tests I am going to discuss are not done for everyone. The care giver makes a clinical decision, when and on whom to do which tests.

First of all a basic clinical examination   is    essential. This includes general appearance, height and weight (body mass index or (BMI), hearing, vision,   heart, blood pressure, lungs and reflexes. Abdominal examination can tell us if there are any problems with the abdomen. In my working life I have come across many young girls who were already a few months pregnant when I saw them for contraceptive advice.

I saw one, 13 year girl who was almost   full term with her pregnancy when she came to me for contraceptive advice. She had not started her periods as yet, she assured me that she had sex only once and her partner who was a little bit older than her and he had withdrawn his penis .  How   unlucky can you be? There   are   two lessons here. She got pregnant on her first ovulation. Withdrawal method did   not work.  It does not always work. You need a fair bit of experience for this.

The other question arises about pelvic examination. There is some controversy if it should be done for teen age girls. It depends on the history to some extent.

Pelvic Examination is the examination of a woman’s private organs both externally and internally. It is a delicate examination.

The care givers have to be careful performing this on any female particularly if she is a young girl and never had a pelvic examination before. She will be informed of what it involves and why it is being done. She needs to get undressed below the waist and put a gown or to be covered with a sheet. The external parts are inspected for normal appearance or any discharge. Often an internal examination is performed to feel for the Cervix, Uterus or any enlarged Ovaries or pelvic masses. Normal ovaries are not felt on this examination. The next examination is a pap test or Papanicolaou test. This not required if the woman has never had sex. Recently changed recommendations on pap tests do not need to be initiated until 21 years of age. Thus visualizing the cervix with an instrument call the speculum is often not required. It is good to relax if you are having this done otherwise your muscles contract and the examination becomes painful. Tests that are now available on urine and vaginal swabs to look for STI’s and non STI infections also eliminate the need for speculum examination.

Always keep the possibility of current or past sexual abuse in mind

This examination if performed in a sensitive manner without any rush can be a positive experience especially if the teen ager is reassured that all is normal and well.

To summarize pelvic examination before advising contraception to teenagers is required:

 1) Any developmental defect noted on

     external inspection.

 2) Persistent vaginal discharge or urinary    symptoms

 3) Painful periods

 4) Missing periods

 5) Excessive or irregular vaginal bleeding

 6) Contraceptive request for an IUD

      Or diaphragm

7) Need to do a pap test

8) To exclude pregnancy

9) In cases of suspected rape or sexual abuse

Tests

1) Pregnancy test if required

2 ) Blood tests ; for anaemia, general blood test, Hormone tests if the menstrual cycles are abnormal like in cases of Polycystic Ovarian syndrome, or nearing menopause.

3) Pelvic ultrasound this is a most important test. It can be done abdominally or from the vulva ie: from outside our pelvic organs. Both these tests are totally simple and non invasive. Internal ultrasound if explained and done with sensitivity, is also simple and can give a lot more information. it is particularly useful if the patient is older and they do not need a full bladder.

CONTRACEPTION

In one single world you can say failure to conceive or happy sex without the fear of pregnancy. This is also called birth control, or fertility control. Pregnancy is the biggest bondage women have particularly in the developing world in their life time. Not only do they get poor health issues and serious chronic diseases they even die. In recent times nearly 250,000 women die each year, 99% of these die in developing countries.

This also leads to a very unhappy life, poor education for children and domestic violence.

We have made enormous progress in various techniques and drugs for contraception in 100 years.

I will talk about the history of contraception and how it evolved, in the coming paragraphs.

In spite of this there are 222 million women in the developing world who are unable to get access to contraception. It should be our aim to educate them, help them, so their lives can improve, their country will improve as well. STD’S will also be controlled .Birth rate in the western world, has improved. It has dropped from 3.5 births per woman in her lifetime to 2.1. This has not changed so much; but it is changing. WHO (World Health Organisation) is working on it. In some African countries it is still as high as 9 births per woman per lifetime.

Contraception should be considered a human right. It is one of the four pillars to save woman from dying. It has been shown that the use of contraception has decreased the maternal deaths by 1.8 %.

HOW AND WHY DO WOMAN GET PREGNANT

MENSTRUAL CYCLE AND CONCEPTION   

All human females achieve reproductive maturity around the age of 11 to 14 and this lasts for about 40 years. During this period they can get pregnant .The female sex gland called The Ovary starts the maturation of an egg under the influence of female hormones. We are born with a certain number of pre-mature eggs. It takes about 14 days for the egg to mature. When it is mature it is released from the ovary and enters another part of the reproductive system called the fallopian tube I call this the lane way of love. It is here that sperm, swimming through the vagina, the cervix and uterus meets the egg which is then fertilized, and moves back towards the uterus. During the time the egg was maturing the lining of the uterus is prepared to receive the fertilized egg. The egg lives only for 24 hours only after being released from the ovary and during this time it needs to be fertilised by the sperm otherwise it dies and gets absorbed in to the surrounding tissue.  The sperm survives for 5-6 days. If   the   pregnancy does not happen, the uterine lining is shed as a menstrual period.

Soon after a new cycle starts.(  Pl ref to blog a and b for details on female reproductive organs,  hormones and  menstrual cycle).

When all these eggs are used, we stop having menstrual cycles, and therefore the body’s hormones change. This is what we call menopause .                                                       

METHODS OF CONTRACEPTION: PAST, PRESENT AND FUTURE.

Now that we know how conception happens we can prevent it; and that is through contraception. From the dawn of humanity, babies were not always desired. However in the Stone Age nobody new where and how the babies came from. Stone Age people thought it was witchcraft. Abstinence was thought to be the only solution. Then men thought of withdrawal.  Now we call this Coitus Interruptus.  Then they thought of chemicals, women were given terrible thinks to drink and often they died as a result of this. They even used crocodile dung in the vagina. They even used various acidic and alkaline jellies placed into the vagina in an attempt to prevent pregnancy. They may have been spermicidal but harmful and destructive for the vagina. Later on condoms were made from cloth, animal intestines, rubber, and finally Latex (1930). Later on Polyurethane (1997) condoms came on the market they were stronger less sensitive to heat and humidity and tolerant to oil based lubricant. It could be used by latex sensitive people .The latest condom made from polyisoprene was launched in U.K in 2005.These are the best for people sensitive to latex or polyurethane. They are soft and natural to touch.

Similar to male barrier methods. The female barrier method took some time to

reach perfection. They used leaves in the vagina, sponges soaked in chemicals and

half a lemon to cover the cervix called the cervical cap. Proper Spermicidal sponges were also available. Slowly female Diaphragms appeared and they were called uterine veils

The introduction of Female diaphragm (1900) emancipated women in U.K to control their fertility to some extent although contraception was illegal.

Slowly the material and type of female barrier methods improved. Then in 1992 Femidon made of polyurethane became available.

In 2004 first silicone diaphragm reached the market they where two types coil spring and arching spring. They came in several sizes and needed to be fitted by the medical care giver. Not only that they needed re fitting after child birth, weight gain or loss.

Diaphragms offered reusable inexpensive protection on which women had total control. They could use it if and when they required. It has no hormones. It not only protected women from pregnancy but also from some sexually transmitted diseases to some extent. Yet they were not widely recommended either in the developed or developing countries. The diaphragm was ignored once the pill, injectable contraceptives and intrauterine devices (IUD) became available. They captured the market probably because of their ease of use.

Of course women were not totally satisfied. Side effects started to happen.

A group of individuals continued to improve the diaphragm. Finally they have made a diaphragm which is easy to handle and use.  One size fits all .Offers good barrier protection. It is used with a spermicidal gel. This diaphragm is called a SILCS Diaphragm which is made in Germany and was introduced in 2010.

The company is looking to see if this can be used as a method for delivery of microbicide gel it could help to protect women from HIV and STI’s, thus providing dual protection. It will be great. Besides the condom no other contraceptive gives women dual protection. A failure rate of 6% is quoted which is a bit of concern. Once women get experienced in using it, hopefully this will improve.

METHODS OF CONTRACEPTION>

1) Behaviour method .eg: withdrawal

2) Barrior methods. eg: condom

3) Chemicals.eg: Spermicides

4) Intrauterine devices and Intraeturine system.

5) Hormones eg: pills, patches & others

6) Emergency Methods

7) Natural Methods

8) Abortion

9) Permanent Methods eg: Tubal tying , Vasectomy, Essure , Adena .

What method you will choose, will depend on your age your menstrual

and medical history, your need, Medical

Clinic availability and your economic status or what methods are given free.

Hopefully if one of these methods suits you, in that case you can use them happily.

I will discuss all these methods in detail in future blogs

HISTORY OF CONTRACEPTION

Before I discuss various methods of contraception I just want to make you familiar with the history.

When we have unprotected sex it’s the woman who has a lifelong  commitment to this child if she falls pregnant, men often get off easily from this responsibility. Where do you think the idea for contraception came from? As we have mentioned terrible things were used in the name of contraception. So who do you think fought for it, women?  This fight was in its own way the same as The suffragettes fighting for the rights for women to vote. There was an American woman by the name of Margaret Sanger, who opened the first clinic in the USA for contraception and sex education in 1916. She was against abortion therefore she advertised and distributed information on contraception and sex education to the female population in the USA. According to American law, called The Comstock Act, advice on contraception and sex education was considered criminal. Margaret was considered a public nuisance. Her clinic was closed and she was sent to jail for 30 days.

During her fight for her work she was helped by many scientists, social workers and amongst these people was the biologist Gregory Pincus, a gynaecologist John Rock, a Philanthropist Katherine McCormick and prominent British socialist, theosophist Annie Besant. Margaret was a very strong woman. One of eleven children born to a working class Irish family in Corning New York, at age nineteen Margaret watched her mother die of Tuberculosis. Just 50 years old, her mother had wasted away from the strain of eleven childbirths and seven miscarriages. Facing her father over her mother’s coffin Margaret lashed out “You caused this. Mother is dead from having too many children”

In 1938 a judge lifted the ban on birth control and sex education thus ending the Comstock Act.  Margaret and her associates then went full steam ahead with contraceptive services. In 1942  Planned Parenthood Federation of America was established. In the end she won. She really is the mother of modern contraception.