Sexology
Chapter 7
Contraception and abortion

Both babies and mothers are healthier if pregnancies are spaced three to five years apart.

Hormonal methods

Hormonal methods of contraception are highly effective and come in a number of forms

• The pill
• The patch
• The vaginal ring
• Injections

The combination pill

Combination birth control pills: birth control pills that contain a combination of estrogen and pregestin (progesterone), both at higher than natural levels.
A women takes the pill for 21 days, and then no pill or a placebo for 7 days, after which she repeats the cycle.
Variations have been introduced.

How it works

The pill works mainly by preventing ovulation.
When a women starts taking the birth control pills, estrogen levels are high. This high level of estrogen inhibits FSH production, and the message to ovulate never sends out.
The high level of progesterone inhibits LH production, further preventing ovulation.

The progestin provides additional backup effects

• It keeps the cervical mucus very thick
  Making it difficult for the sperm to get through
• It changes the lining of the uterus in such a way that even if a fertilized egg were to arrive,implantation would be unlikely

When the estrogen and progestin are withdrawn, the lining of the uterus disintegrates, and withdrawal bleeding or menstruation occurs.
The flow is typically reduced because the progestin has inhibited development of endometrium.

Effectiveness

Failure rate: the pregnancy rate occurring using a particular method; the percentage of women who will be pregnant after a year of use of the method.
Effectiveness: 100 minus the failure rate.
Two kinds of failure rate

• Failure rate for perfect users
• Failure rate for typical users

Combination pills are one of the most effective methods of birth control.
The perfect-user failure rate is 0.3 percent.
The typical user failure rate is 9 percent.
Failures occur primarily as a result of forgetting to take a pill for 2 or more days.

If a women forgets the pill for 3 or more days, she should use a condom or abstain from sex until she has taken hormonal pills for 7 days in a row, at which point she will again be well protected.

Side effects

• Slight but significant increases in certain diseases of the circulatory system
  Women who use the pill have a higher chance than non-users of developing blood clots
  • Clots may lead to pain, hospitalization, and (in rare cases) death
  • For some women, the pill can cause high blood pressure
• The pill may aggravate already existing cancer
  • But, the pill protects women from endometrial cancer and ovarian cancer
• For women who have take taken the pill for more than five years, the risk of benign liver tumours increases
  Relatively rare
• Increases the amount of vaginal discharge and the susceptibility to vaginitis (vaginal inflammations such as monilia).
• It may cause some nausea
  This almost always goes away after the first month or two of use
  • Some brands of pills can cause weight gain, by increasing appetite or water retention
• Psychological side effects
  • About 20 percent of women on the pill report increased irritability and depression, which become worse with the length of time they use the pill
    Probably related to the progesterone in the pill
  • Changes in sexual drive

Women of the following groups should not use the pill

• Those with poor blood circulation or blood-clot problems
• Those who have a heart attack or who have coronary artery disease
• Those with liver tumours
• Those with breast cancer
• Those with uncontrolled high blood pressure
• Pregnant women
• Women over 35 who are cigarette smokers should use the pill only with caution

Advantages and disadvantages

The pill as a number of advantages

• It is close to 100 percent effective is used properly
• It does not interfere with intercourse
• It is not messy
• It reduces the amount of menstrual flow and thus reduces cramps
• Can clear up acne

Disadvantages

• Side effects
• The cost
• Place the entire burden of contraception on the woman
  • Taking them correctly is complicated
• For a women who has intercourse only infrequently, it represents contraceptive overkill
• It provides absolutely no protection against sexually transmitted infections

Reversibility

When a women wants to become pregnant, she simply stops taking pills after the end of one cycle.

Drug interactions

If you are taking birth control pills, you are taking a prescription drug that may interact with other prescription drugs you take.

• Some anticonvulsant drugs and intiretroviral drugs decrease the effectiveness of the pill
• The pill may increase the metabolism of some drugs, making them more potent
• Some over-the-counter drugs may also interact with the pill

Other kinds of pills

There are many kinds of combination pills and several kinds of pills other than combination ones.

Combination pills vary from one brand to the net in the dosages of estrogen nad progestin.

• Higher doses of estrogen are more likely to induce blood-clot problems
  • Current pills have considerably lower levels of estrogen than early pills
• High-progestin brands are related to symptoms such as vaginitis and depression

Depending on what side-effect the women wants to avoid, she can choose a brand for its high or low estrogen or progestin level.

Triphasic pills: a birth control pill containing a steady level of estrogen and three phases of progesterone, intended to mimic more closely women’s natural hormonal levels.

Progestin-only pills have been developed.
Sometimes called minipills.
Work by changing the cervical mucus such that sperm cannot get trough, inhibiting implantation, and inhibiting ovulation.
Progestin-only pills have a typical-user failure rate that is higher than that of combination pills.
Their major side effect is that they produce very irregular menstrual cycles.

The patch

The patch contains the same hormones as combination birth control pills but is administered transdermally, through the skinn.
The patch is thin, beige, and about the size of a double band-aid.
It consist of

• An outer, protective layer of polyester
• An adhesive layer that contains the hormones
• A polyester liner that is removed before applying

The patch lasts for seven days, so the woman places a new one once a week for three weeks and then has a patch-free week.
The first time it is used it takes a couple of days for the hormones to reach effective levels, so a backup method should be used for a while.

Advantages

• Women using it do not have to remember to take a pill every day
• The hormones enter the body through the skin rather than going to the stomach and needing to be digested

The patch is new, so we do not have extensive data.
Because the hormones are the same as in the pill, the expectation is that the side effects will be quite similar to those of the pill.
The patch has a slightly higher rate of thromboembolic disorders.
Women also get more estrogen from the patch than with a combination pill.

The vaginal ring

The vaginal ring is a flexible, transparent ring made of plastic and filled with the same hormones as those in the combination pill, at slightly lower doses.
The ring is placed high up in the vagina and remains in place for 21 days.
It is removed and the women goes ring-free for 7 days, then a new ring.

The ring is only recently introduced, so the scientific data are limited.
Because the hormones are the same as in the pill, the side effects should be the same.
It has a higher risk of thromboembolic disorders.
About the same typical-user failure rate as the pill.

It acts mainly by stopping ovulation.

Depo-provera injections

Depo-provera (DMPA) is a progestin administered by injection.
The injections must be replaced every 3 months for maximum effectiveness.

How it works

It inhibits ovulation, thickens the cervical mucus, and inhibits the growth of the endometrium

Effectiveness

Highly-effective, with a typical-user failure rate of 6 percent, making it somewhat more effective than the pill.

Side-effects

No lethal side effects of Depo-Provera have been found.
Long-term studies have not yet been done.

Advantages and disadvantages

Advantages

• Does not interfere with lovemaking
• Requires far less reliance on memory than the pill
• Available for women who cannot use the combination pill

Disadvantages

• Most users experience amenorrhea (no menstrual periods)

Reversibility

The method is reversible by not getting another injection.
Many women are infertile for 6 to 12 months after stopping its use, but then they are able to become pregnant at normal rates.

Emergency contraception

The treatment is most effective if begun within 24 hours and cannot be delayed longer than 120 hours (5 days).
Regular birth control pills containing levonorgestrel (a progestin) are taken at higher doses.

Nausea is a common side effect.

Emergency contraception may work in any of several ways, depending on when in the cycle it is taken

• Stop ovulation
• Inhibit the functioning of sperm
• Prevent fertilization
• Inhibit the development of a nourishing endometrium

Its action is almost always to prevent pregnancy, not to cause abortion.
It is between 75 and 89 percent effective during the most fertile part of the cycle.

An IUD can also be used for emergency contraception for a woman who wants continuing protection.
The failure rate is less than 1 percent if inserted within 5 days of unprotected intercourse.

LARC

LARC: long-acting, reversible, contraceptives; implants and IUDs.
These methods last more than a year, and can be reversed.
These methods are even more effective than the pill.

Implants

Implants are thin rods or tubes containing progestin.
They are inserted under the skin in a woman’s arm and are effective for 3 years.

How it works

It suppresses ovulation, thickens the cervical mucus, and inhibits the growth of the endometrium.

Effectiveness

Implanon is highly effective, with a typical-user failure of 0.05.
It is more effective than the pill.

Side effects

No lethal side effects of implanon have been detected.

Advantages and disadvantages

Advantages

• Requires no reliance on memory for 3 years
• Does not interfere with lovemaking
• Contains no estrogen

Disadvantages

• A lot of women experience changes in their menstrual bleeding patterns
  These changes are unpredictable
  • Unusually long bleeding
  • Frequent bleeding
  • Amenorrhea

Reversibility

If a women wishes to become pregnant, she can have the implant removed.
In most cases, the menstrual cycle returns to normal within 3 months, and the woman can become pregnant.

IUDs

Intrauterine device (IUD): a plastic device sometimes containing metal or a hormone that is inserted into the uterus for contraceptive purposes; also called intrauterine contraceptive (IUC).
It remains in the uterus until the woman wants to have it removed.
One or two plastic strings hang down from the IUD through the cervix, enabling the women to check to see whether it is in place.

How it works

The foreign body in the uterus creates an environment that is toxic to both sperm and eggs.
In the rare event of fertilization, the IUD prevents implantation.

Mirena and Skyla (two IUDs) release progesterone directly into the uterus.
One effect is to reduce the endometrium.
This results in reduced menstrual flow and reduced risk of anemia.
It also disrupts ovulation and thickens cervical mucus.

The small amount of copper that is added to the coper T (and IUD) is thought to have an additional contraceptive effect.
It seems to alter the functioning of the enzymes involved in implantation.

Effectiveness

The IUD is extremely effective.
Most failures occur during the first 3 months of use, either because the IUD is expelled or for other, unknown reasons.
The expulsion rate is about 2 to 10 percent in the first year.

Side effects

• The most common side effects of the copper T are increased menstrual cramps, irregular bleeding, and increased menstrual flow
• Mirena
  Reduces menstrual flow

Advantages and disadvantages

Advantages

• It is cheap
• It is effective
• Once inserted, it is simple to use
• Does not interrupt intercourse in any way
• The women does not have to remember it
• It can be used safely by women after having a baby and while breast-feeding it
• No effects on tampon use or intercourse

Reversibility

When a women who is using an IUD wants to become pregnant, she simply has a health care provided remove the device.
She can become pregnant immediately.

Condoms

The male condom

Male condom: a contraceptive sheath that is placed over the penis

To be effective, condoms must be used properly.
It must be unrolled onto the penis before the penis enters the vagina.
It is best to withdraw the condom soon after ejaculation, while the man still has an erection, in order to minimize the chances of leakage.
A new condom must be used at each act of intercourse.

How it works

The condom catches the semen, preventing it from entering the vagina.
For condoms coated with a spermicide, the spermicide kills sperm and in theory provides extra protection. But they may create allergies to the spermicide for the man or his partner, and the amount of spermicide is probably not sufficient to be effective.

Effectiveness

The perfect-user failure rate is about 2 percent.
The typical-user rate about 18 percent.

Side effects

The condom has no side effect, except that some users are allergic to latex.
For them non-latex condoms are available.

Advantages and disadvantages

Disadvantages

• It must be put on just before intercourse
• Some men complain that the condom reduces their sensation, lessening their pleasure in intercourse

Advantages

• Cheap
• Readily available without prescription
• Fairly easy to use
• They provide protection against many sexually transmitted infections

Reversibility

The man stops using condoms if conception is desired.

The female condom

The female condom resembles a clear balloon.
There are two rings in it

• One is inserted into the vagina
• The other is spread over the vaginal entrance

The penis must be guided into the female condom so that the penis does not slip in between the condom and the vaginal wall.
The condom is removed immediately after intercourse, before the women stands up.

How it works

It prevents the sperm from entering the vagina.

Effectiveness

The typical-user rate is 21 percent.
The perfect-user rate is 5 percent.

Side effects

A few women experience vaginal irritation and a few men experience irritation of the penis as a result of using it.

Advantages and disadvantages

Advantages

• The female condom is made of polyurethane
  This is less susceptible to tearing and does not deteriorate with exposition to oil-based substances
  • It does not create the allergic reactions that some people have to latex
• It is a method that the woman can use herself to reduce her risk if contracting an STI.

Disadvantages

• The spontaneity problem
• It is awkward and makes rustling noises while in use
• More expensive than the male condom

Reversibility

The women stops using the condom when wanting to become pregnant.

Diaphragms, FemCap and the Sponge

The diaphragm

The diaphragm: a cap-shaped rubber contraceptive device that fits inside a woman’s vagina over the cervix.
In order to be used effectively, a contraceptive cream or jelly must be applied tot the diaphragm. The cream is spread on the rim and the inside surface.
It may be inserted up to 6 hours before intercourse, and it must be left in place for at least 6 hours afterwards. It may be left in for as long as 24 hours.
Wearing it longer than that is thought to increase the risk of toxic shock syndrome.

How it works

The diaphragm blocks the entrance to the uterus so that sperm cannot swim up into it.
The contraceptive cream kills any sperm that manage to get past the barrier.
Any sperm remaining in the vagina die after about 6 hours.

Effectiveness

The typical-user failure rate has been estimated to be 12 percent.
Because the proper fit of the diaphragm is essential to its effectiveness, it is important for the women to be individually fitted for one by her health care provider.

Side effects

• Possible irritation of the vagina or the penis
  This irritation is caused by the spermicidal cream or jelly and can be relieved by switching to another brand
• The rare occurrence of toxic shock syndrome.

Advantages and disadvantages

Disadvantages

• Requires some thought on the woman’s part
• The spermicide may leak out after intercourse
• Expensive

Advantages

• Few side effects
• Is very effective
• Provides some protection against sexually transmitted infections because it covers and protects the cervix

Reversibility

If a woman wishes to become pregnant, she stops using the diaphragm.

FemCap

FemCap is a vaginal barrier device similar to the diaphragm.
Made of silicone and comes in three sizes.
It should be used with a spermicide or one of the microbicides.

The sponge

A vaginal barrier method made of polyurethane.
It is small and shaped like a pillow with a concave dimple on one side. The other side has a woven loop to aid in removal.
It contains a spermicide and is inserted much like a diaphragm.
Effective for 24 hours, with multiple acts of intercourse.
Overall, not every effective.
It should not be left in place for more than 24 hours because of a risk of toxic shock syndrome.

Spermicides

Spermicides: a substance that kills sperm.
They come in a tube or can, along with a plastic applicator.
The applicator is filled and inserted into the vagina.
The applicator’s plunger is then used to push the spermicide into the vagina near the cervix.

It must be left in for 6 to 8 hours after intercourse.
One application provides protection for one act of intercourse.

How they work

• The chemicals in term kill the sperm
• The inert base itself mechanically blocks the entrance to the cervix so that sperm cannot swim in.

Effectiveness

Failure rates can be as high 28.
Spermicides are highly effective only when used with a diaphragm or condom.

Side effects

Some people experience an allergic reaction to spermicides.

Advantages and disadvantages

Advantages

• They are readily available, without a prescription

Disadvantages

• The failure rate is really high
• Provide no protection against bacterial STIs.
• They also interrupt the spontaneity of sex
• Some women dislike the sensation of the spermicide leaking out after intercourse, and some are irritated by the chemicals
• They taste terrible

Withdrawal

Withdrawal: a method of birth control in which the man withdraws his penis from his partner’s vagina before he has an orgasm and ejaculates.

Effectiveness

It is not very effective.
The failure rate is around 22 percent.

• The few drops of fluid that come out of the penis during arousal may carry enough sperm for conception to occur
• If ejaculation occurs outside the vagina but near or in on the vulva, sperm may still get into the vagina and continue up into the uterus
• The man sometimes does not withdraw in time

Side effects

It produces no direct physical side effect.

Advantages and disadvantages

Advantage

• The only last-minute method
• Free

Disadvantage

• Not every effective
• Requires exceptional motivation on the part of the man, and may be psychologically stressful to him
• The women may worry about whether the man withdraws in time, and the situation is less than ideal for her to orgasm

Fertility awareness (rhythm) methods

Rhythm (fertility awareness) method: a method of birth control that involves abstaining from intercourse around the time the woman ovulates.

The calendar method: a type of rhythm method of birth control in which the woman determines when she ovulates by keeping a calendar record of the length of her menstrual cycles.

Basal body temperature (BBT) method: a type of rhythm method of birth control in which the woman determines when she ovulates by keeping track of her temperature.
It determines safe days only after ovulation.

Cervical mucus method: a type of rhythm method of birth control in which the woman determines when she ovulates by checking her cervical mucus.

Sympto-thermal method: a type of rhythm method of birth control combining the basal body temperature method and the cervical mucus method.

Effectiveness

The effectiveness of the rhythm method varies considerably depending on a number of factors.
Basically, it is not very effective with typical users.
The typical-user failure rate is around 25 percent for all methods.

Failure rates are lower when the woman’s cycle is very regular and when the couple are highly motivated and have been well instructed in the methods.

Advantages and disadvantages

Advantages

• The Roman Catholic Church considers it an acceptable method of birth control
• No side effects except possible psychological distress
• Cheap
• Easily reversible
• Helps the woman become more aware of her body’s functioning
• Requires cooperation from both partners

Disadvantages

• High failure rate
• Psychological distress
• A certain amount of time is required to collect the date needed to make the method work

Sterilization

Sterilization: a surgical procedure by which and individual is made sterile, incapable for reproducing.

Male sterilization

Vasectomy: a surgical procedure for male sterilization involving serving one the vas deferens.
Typically, the man can return to having intercourse within a few days, but, some of the sperm may still be lurking in his ducts beyond the point of the incision.
Men should not rely on the vasectomy until 3 months after it was performed.
The ejaculate is completely normal, except that is does not contain any sperm.

How it works

The vasectomy makes it impossible for sperm to move beyond the cut in the vas.

Effectiveness

The vasectomy is essentially 100 percent effective.
A failure rate of 0.1 percent.

Side effects

The physical side effect of the vasectomy are minimal.

Some psychological based problems may arise.
The man’s attitude towards having a vasectomy is extremely important.
Only about 5 percent regret having had one.

Reversibility

There are techniques for reversing vasectomies, but men should assume that it is irreversible.
After a vasectomy some men also begin forming antibodies to their own sperm.

Advantages and disadvantages

Advantages

• It is effective
• It has minimal health risks
• Once performed, it require no further thought or planning
• It is very cheap, as a long-term method
• The operation itself is simple, and requires no hospitalization or absence from work
• It is one of the few methods that allow the man to assume contraceptive responsibility

Disadvantages

• It is permanent
• Various psychological problems might result if the man sees sterilization as a threat to his masculinity or virility.

Female sterilization

Several surgical techniques are used to sterilize a woman

• Minilaparotomy
• Laparoscopy
  The doctor blocks the fallopian tubes with clips
• The transcervical approach
  The instruments enter through the cervix and uterus, and a blockage device is placed in each fallopian tube

These techniques differ in terms of the type of procedure used.
They involve the blocking of the fallopian tubes in some way so that sperm and egg cannot meet.

The female sterilization procedures do not interfere with the ovaries and does not bring on premature menopause.

How it works

Female sterilization makes it impossible for the egg to move down the fallopian tube toward the uterus.
It also prevents sperm from reaching the egg.

Effectiveness

These procedures are essentially 100 percent effective.
The failure rate of 0.5 percent is due to an occasional rejoining of the ends of the fallopian tubes, and rare cases in which the women was pregnant before the sterilization procedure was performed.

Side effects

Occasionally there are side effects arising form the surgery

• Infections
• Hemorrhaging
• Problems related to the anesthetic

Generally, only 1 percent of women undergoing the surgery experience complications.

Reversibility

A woman should assume that sterilization is irreversible.

Five years after sterilization, only 7 percent of women regret having had the procedure.

Advantages and disadvantages

Same as for men.

Psychological aspects: attitudes toward contraception

Factors that experts believe are crucial for teens to be consistent users of contraception

• Access to contraceptives and a belief that one has access
• Knowledge about sexual and reproductive health and contraception
• Strong motivation to use contraception

Fantasy may play an important role in contraceptive behaviour.
The media doesn’t quite show contraceptives.

Abortion

Abortion: the termination of pregnancy.

Abortion procedures

Which method of abortion is used depends in part on how far the pregnancy has progressed.

Surgical abortion

Vacuum aspiration method: a method of abortion that is performed during the first trimester and involves suctioning out the contents of the uterus; also called suction curettage.
It is simple and entails little risk.

Dilation and evacuation
Is used especially for second trimester abortions.
Similar to vacuum aspiration.

Medical abortions

Mifepristone (RU-486): the abortion pill.
Can induce a very early abortion.
It has a powerful antiprogesterone effect, causing the endometrium of the uterus to be sloughed off and thus bringing about an abortion.
It is administered as a tablet, followed 2 days later by a small dose of prostaglandin, which increases contractions of the uterus, helping to expel the embryo.
Can be used during the first 7 to 9 weeks of pregnancy.
Effective in 92 percent of cases.
There is little evidence for side effects.

The use of the drug methotrexate, which is toxic to the embryo, with misoprostol, which causes uterine contractions that expel the embryo.

Psychological aspects

Most women do not experience severe negative psychological responses to abortion.
But, some women benefit from talking about their experience, and it is important that postabortion support groups be available.

Men and abortion

Among men who new their partner was having an abortion, 80 percent were supportive of the decision.
Counselling for men who are involved is rarely available.

New advantages in contraception

Male methods

New condoms

Several new models are being tested.

Male hormonal methods

The basic idea underlying the development of male hormonal methods is to suppress the production of LH and FSH by the pituitary, so that sperm would not be produced or would not develop properly.
By, most hormone preparations that have been tried also shut down the user’s sex drive.

RISUG

RISUG: reversible inhibition of sperm under guidance
Involves injection of a porous polymer into the vas through a small injection.
Sperm can pass through the polymer, but the polymer disrupts the membranes of the sperm cells ts they pass through, so that they are not viable.

Immunocontraceptives

A contraceptive vaccine that would increase the individual’s immune system to react in a way that would interrupt one of the steps in the fertility system.

Female methods

Microbicides

Substances that kill microbes and, preferably, sperm.

A better pill

A new pill is being developed that adds an androgen to the combination pill.

Vaginal rings

A ring ring is being developed that would last 12 months.

Reversible, nonsurgical sterilization

Injecting liquid silicone into the fallopian tubes.
The silicone hardens and forms a plug.