GYNECOLOGY
Contraception for women and couples is an essential choice in order to be able to experience sexuality in a conscious and responsible way.
It is important to bear in mind, however, that the choice of the type of contraceptive depends on various social, health, economic and religious factors of the couple.
I always recommend to my patients visiting gynecologists in Milan and Florence to ask themselves specific questions, in order to be able to choose the most suitable contraceptive for each one’s needs. Let us see some of them:
How effective is a particular contraceptive?
The effectiveness of a contraceptive is indicated as the number of unwanted pregnancies in 100 women who use a given method for one year (Pearl Index ). Values < 1 represent a good Pearl index, as happens for the pill and for the condom used correctly.
What am I protected from other than pregnancy?
Not all contraceptive methods also offer protection against sexually transmitted diseases: in this sense, the best efficacy is offered by the condom, while the pill and the IUD offer no health protection.
What are the side effects of different types of contraception?
Some contraceptives (for example estrogen-progestogen contraceptives or IUDs) are burdened by side effects, sometimes even serious ones, and have certain contraindications in subjects at risk. Barrier methods, such as condoms, may have an allergic reaction as the only side effect, while intrauterine devices (IUDs) lead to a minimal increase in the risk of infection, ectopic pregnancy and pelvic pain. After all, there are small spirals of the latest generation which limit or cancel a good part of these side effects, acting on the one hand as an intrauterine device and on the other as a hormonal contraceptive, because they directly release small quantities of a hormone locally.
How does it affect the relationship?
The method must be well tolerated by the couple and interfere as little as possible with the spontaneity of sexual intercourse. The pill and the IUD do not interfere with the spontaneity of intercourse, unlike condoms and natural methods.
What are the other benefits of birth control pills?
Some methods can have beneficial effects on women’s health, for example oral contraceptives, which reduce the risk of ovarian and endometrial cancer, if taken for a certain time.
How much does it cost?
Some methods are very cheap, if not free (see natural methods), the pill has a cost that varies from about 14 to 20 euros per month and the condom costs just under 0.5 euros each, on average. People registered with the National Health Service (SSN), resident or domiciled in Tuscany, including STP code holders (Temporarily Present Foreigners) who have the following characteristics, are entitled to free contraceptives:
- young people between the ages of 14 and 25
- adults between 26 and 45 with exemption codes
- women between 26 and 45 years of age, within 12 months of delivery or within 24 months of termination of pregnancy.
- female students up to the age of 25, enrolled in the three Tuscan universities of Florence, Pisa, Siena
What are the free contraceptives available by contacting the consultants?
In Tuscany the free contraceptives available are:
- Estroprogestogen and progestogen pill
- Transdermal patch
- Vaginal ring
- Intrauterine devices with and without hormones (coils)
- Subcutaneous device
- Condoms
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Contraceptive methods are divided into:
- natural methods
- barrier methods
- hormonal methods
Natural contraceptive methods:
The natural regulation of fertility is based on the abstention from genital intercourse during the fertile period of the female cycle which is identified with specific systems. These methods consist of:
- rhythm or calendar method
- basal temperature measurement
- assessment of cervical mucus
- symptothermal method
- hormone dosage method using home kits
The rhythm method (also known as Ogino Knauss ) is based on the calculation of fertile days and establishes the probable ovulation on the 14th day before the future menstruation, which is assumed by means of an average of the previous 6 cycles. This method has a high failure rate (10%) especially in subjects who have hormonal cycles longer than 32 days or less than 26.
Basal temperature measurement should be performed with a special thermometer every morning before getting out of bed and reported in a special grid. About halfway through the cycle there is a rise in temperature of about one degree due to ovulation. Considering that the average survival of the spermatozoa in the female genital tract is 5 days and that the survival of the egg is about 24 hours, the non-fertile days are considered to be those following the temperature rise, i.e. following ovulation.
The Billings or cervical mucus method involves observing the characteristics of the cervical mucus, which becomes more abundant and fluid around ovulation. The fertile period is the one that includes the first day from the appearance of this characteristic up to the 4 days following the end of the same.
Domestic kits have been developed to identify fertile days using different variables: the rovumeter it is a small device capable of aspirating the vaginal mucus at the level of the posterior fornix and evaluating its volume. The volume of cervical-vaginal secretions, in fact, varies significantly during the fertile phase reaching the maximum level 48-24 hours before ovulation. Another “CUE” device proposed by Freundel is an instrument capable of measuring the electrical resistances of saliva and vaginal secretions and their variations during the menstrual cycle, thus signaling the fertile periods. A device called Persona® has recently been proposed that measures urinary levels of LH and estrose-3-glucuronide, a metabolite of estradiol. The detection lasts a few seconds and is performed using a stick that is held in the stream of the first urine of the morning and then subjected to the reading of the device, which is capable of memorizing the recorded hormonal values and the length of each cycle and the first day of the fertile period. A red or green light communicates the result of data processing (red = fertile, green = infertile). The Pearl Index of this method is approximately 2.
The symptom-thermal method combines the Ogino Knauss method with that of basal temperature and cervical mucus, reaching a failure rate of 2% (if performed correctly).
Natural contraceptive methods have many advantages as they are not burdened by side effects, they educate adolescents to a correct interpretation of the value of sexuality, they are openly supported by the Catholic Church and they are cheap. On the other hand, however, they are burdened by a variable and markedly lower efficacy than the other methods, and above all they depend on a constant commitment from both partners and periods of abstinence can cause psychological stress. Furthermore, they require a period of training and have no protective effect against sexually transmitted diseases.
Barrier methods of contraception:
- male condom
- IUD (Intrauterine Device)
- female condom – Femidom
The male condom (condom) is the most common and safest means of contraception for the prevention of sexually transmitted diseases, with a failure rate mainly due to breakage associated with incorrect use. Some important precautions can prevent this complication, such as: use within the expiration date, appropriate conservation, i.e. away from heat sources, correct positioning according to the instructions. It should also be noted that the use of both therapeutic and lubricating vaginal creams can damage the surface of the condom and increase the risk of breakage. In case of latex allergy there are specific condoms free of this substance. The condom has the advantage of being easy to use, does not require a prescription, has a low cost for single use, but high when used for a long time and is the best protection for sexually transmitted diseases. On the other hand, it has the disadvantage of possible rupture, of being opposed by the Catholic Church, of entrusting control of contraception to the male partner and of interfering with the spontaneity of sexual intercourse.
The intrauterine device (coil) is placed by the gynecologist at the level of the uterine fundus. It is usually used in women who have already given birth. It determines a situation of local sterile inflammation which hinders the functionality of the spermatozoa.
There is also a type of IUD medicated with Levonorgestrel a progesterone derivative which enhances this effect. Among the advantages of the IUD are the independence from sexual intercourse, the low cost since it can be kept in place for up to 3-5 years. It is one of the safest methods of contraception with a Pearl index of 0.8% for the non-medicated IUD and 0.1% for the medicated IUD. The most frequent side effects are abdominal colic and menorrhagia limited to the first months of use, while rarer effects consist of an increased risk of ectopic pregnancy, pelvic inflammation and infection (endometritis or salpingitis) and, in extreme cases, uterine perforation.
Hormonal contraceptive methods:
Hormonal contraceptive methods involve taking estrogen and progesterone or progesterone alone with different routes of administration and timing. The mechanism of action depends on the blocking of ovulation by inhibiting the secretion of gonadotropins, the modification of the endometrium making it unfavorable for implantation, the influence on the cervical mucus making it thicker and therefore an obstacle to the passage of spermatozoa.
Oral contraceptives come in packs containing 21 or 28 pills. In preparations of 21 pills the woman takes one pill a day for 21 days starting from the first day of the cycle (first day of menstruation) followed by a 7-day break during which menstruation appears. The 28-pill packs consist of 21 effective pills and 7 pills without any active ingredients to allow continuous intake without a break. The composition of the pills can be the same in all and we speak of monobasic contraceptive or the percentage of estrogen and progesterone can vary and we speak of biphasic or triphasic contraceptive.
The advantages of hormonal contraceptives:
The advantages of oral contraceptives consist in excellent efficacy with a Pearl index < 0.3 in the case of correct use, in the non-correlation with the sexual act and in the rapid reversibility of fertility. They have further beneficial effects on women’s health: it has in fact been demonstrated that some estrogen-progestogen associations reduce the risk of ovarian and endometrial cancer and that this reduction persists years after their use; reduce the risk of benign pathologies such as ovarian cysts, pelvic inflammatory disease and endometriosis, improve the clinical pictures of acne, hirsutism, endometriosis, dysmenorrhea and premenstrual syndrome, fibroid menorrhagia, and polycystic ovary syndrome.
Side effects of hormonal contraceptives:
However, the use of oral contraceptives must be under medical supervision, due to possible side effects and are contraindicated in some subjects with certain risk factors.
The most frequent and mild side effects consist of nausea, headache, breast tenderness, weight gain and changes in mood and libido. In rarer cases and in subjects at risk they can cause deep vein thrombosis, cerebral ischemia, the appearance of hepatic adenomas and very rarely hepatocellular carcinomas. It is the doctor’s duty to carry out an adequate family and personal anamnesis in order to identify certain risk factors for which the administration of oral contraceptives may be contraindicated.
Contraindications to taking hormonal contraceptives:
In detail, the use of hormonal contraceptives is contraindicated in subjects with:
- Hypertension, headache and smokers (>15 mg/day)
- Personal history of previous cerebral ischemia, pulmonary embolism, venous thrombosis.
- Active hepatitis or benign or malignant liver tumors and gallbladder disease.
- Inflammatory bowel disease (the use of contraceptives causes the disease to get worse)
- Breast cancer
- Positive family history for thromboembolic episodes (in this case it may be useful to investigate the clinical picture with specific blood tests)
- There are also special conditions such as epilepsy, obesity, etc. for which a consultation of several specialists is necessary in order to obtain the best result for the patient.
An oral contraceptive containing only progestogen can also be prescribed, the action of which is aimed solely at the cervical mucus, favoring its thickening and creating an environment that is not very favorable for implantation on the surface of the endometrium. Due to the absence of estrogen, this pill is indicated for those patients who have contraindications for combined contraceptives.
Other types of hormonal contraceptives:
In addition to the oral one, there are other methods of administering hormonal contraceptives:
- Progestin -based injectable contraceptives that can be administered quarterly on a monthly basis.
- Subcutaneous implants that release a pre-set amount of hormones daily.
- Transdermal delivery devices that are applied starting on the first day of flow and replaced every week for 3 weeks followed by a week off.
- Transvaginal release devices that are inserted into the vagina by the fifth day of the cycle and left in place for three weeks at the end of which they are removed with the onset of menstrual flow.
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As an obstetric gynecologist I receive my patients every week in the offices of Milan and Florence.