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A transdermal contraceptive patch containing 150 mcg norelgestromin and 20 mcg ethinyl estradiol and measuring 20 cm2 is available The patch is applied to the lower abdomen, upper torso, or buttock once a week for 3 consecutive weeks, followed by 1 week without the patch It appears that the average steady-state concentration of ethinyl estradiol with the patch is approximately 60% higher than with a 35 mcg pill However, there is currently no evidence for an increased incidence of estrogen-related side effects The mechanism of action, side effects, and efficacy are similar to those associated with oral contraceptives, although compliance may be better A contraceptive vaginal ring that measures 54 mm in diameter and releases 120 mcg of etonogestrel and 15 mcg of ethinyl estradiol daily is available The ring is soft and flexible and is placed in the upper vagina for 3 weeks, removed, and replaced 1 week later The efficacy, mechanism of action, and systemic side effects are similar to those associated with oral contraceptives In addition, users may experience an increased incidence of vaginal discharge
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4 Intrauterine Devices
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IUDs available in the United States include the Mirena (which releases levonorgestrel) and the copper-bearing TCu380A The mechanism of action of IUDs is thought to involve either spermicidal or inhibitory effects on sperm capacitation and transport IUDs are not abortifacients The Mirena is effective for 5 years, and the TCu380A for 10 years The hormone-containing IUDs have the advantage of reducing cramping and menstrual flow The IUD is an excellent contraceptive method for most women The devices are highly effective, with failure rates similar to those achieved with surgical sterilization Nulliparity is not a contraindication to IUD use Women who are not in mutually monogamous relationships should use condoms for protection from sexually transmitted diseases The Table 17 5 Contraindications to IUD use
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Absolute contraindications Pregnancy Acute or subacute pelvic inflammatory disease or purulent cervicitis Significant anatomic abnormality of uterus Unexplained uterine bleeding Active liver disease (Mirena only) Relative contraindications History of pelvic inflammatory disease since the last pregnancy Lack of available follow-up care Menorrhagia or severe dysmenorrhea (copper IUD) Cervical or uterine neoplasia IUD, intrauterine device
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as well as pregnancy The disadvantages are that it must be inserted near the time of coitus and that pressure from the rim predisposes some women to cystitis after intercourse The cervical cap (with contraceptive jelly) is similar to the diaphragm but fits snugly over the cervix only (the diaphragm stretches from behind the cervix to behind the pubic symphysis) The cervical cap is more difficult to insert and remove than the diaphragm The main advantages are that it can be used by women who cannot be fitted for a diaphragm because of a relaxed anterior vaginal wall or by women who have discomfort or develop repeated bladder infections with the diaphragm However, failure rates are 9% (perfect use) and 16% (typical use) in nulliparous women and 26% (perfect use) and 32% (typical use) in parous women Because of the small risk of toxic shock syndrome, a cervical cap or diaphragm should not be left in the vagina for over 12 18 hours, nor should these devices be used during the menstrual period
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subsequent risk of pelvic infection appears to be primarily related to the risk of acquiring sexually transmitted infections Infertility rates do not appear to be increased among women who have previously used the currently available IUDs At the time of insertion, women with an increased risk of sexually transmitted diseases should be screened for gonorrhea and Chlamydia Women with a history of recent or recurrent pelvic infection are not good candidates for IUD use 3 Menorrhagia or severe dysmenorrhea The copper IUD can cause heavier menstrual periods, bleeding between periods, and more cramping, so it is generally not suitable for women who already suffer from these problems However, hormone-releasing IUDs can be tried in these cases, as they often cause decreased bleeding and cramping with menses NSAIDs are also helpful in decreasing bleeding and pain in IUD users 4 Complete or partial expulsion Spontaneous expulsion of the IUD occurs in 10 20% of cases during the first year of use Any IUD should be removed if the body of the device can be seen or felt in the cervical os 5 Missing IUD strings If the transcervical tail cannot be seen, this may signify unnoticed expulsion, perforation of the uterus with abdominal migration of the IUD, or simply retraction of the string into the cervical canal or uterus owing to movement of the IUD or uterine growth with pregnancy Once pregnancy is ruled out, one should probe for the IUD with a sterile sound or forceps designed for IUD removal, after administering a paracervical block If the IUD cannot be detected, pelvic ultrasound will demonstrate the IUD if it is in the uterus Alternatively, obtain anteroposterior and lateral x-rays of the pelvis with another IUD or a sound in the uterus as a marker, to confirm an extrauterine IUD If the IUD is in the abdominal cavity, it should generally be removed by laparoscopy or laparotomy Open-looped all-plastic IUDs such as the Lippes Loop can be left in the pelvis without danger, but ring-shaped IUDs may strangulate a loop of bowel and copper-bearing IUDs may cause tissue reaction and adhesions Perforations of the uterus are less likely if insertion is performed slowly, with meticulous care taken to follow directions applicable to each type of IUD
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ACOG Committee on Practice Bulletins-Gynecology: ACOG practice bulletin Clinical Management Guidelines for ObstetricianGynecologists Number 59, January 2005 Intrauterine device Obstet Gynecol 2005 Jan;105(1):223 32 [PMID: 15625179]
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