Modern contraception – making every child a wanted child.
WORLD Contraceptive Day was celebrated on Wednesday in countries across the globe. The initiative was conceived in 2007 by the European Society of Contraception in an effort to highlight that 85% of teenage pregnancies globally are unplanned, and that each year, millions of people are infected with sexually transmitted diseases due to a lack of contraception awareness.
In Malaysia, contraceptive usage is low, with only 48% of women within the fertile age group of 15 to 49 years using any form of contraception. This is one of the lowest rates compared to neighbouring countries (in Singapore and Thailand, contraceptive usage rates are 71% and 73% respectively). Because of this, a significant number of women end up having unplanned pregnancies.
This is a very unfortunate situation as there are many widely available modern contraceptives that are considered safe and effective. With so much misinformation regarding contraception among Malaysian women, many opt for unreliable contraception (eg withdrawal method) or use contraceptives incorrectly, thus resulting in unplanned pregnancies.
Some of these women opt to have an abortion, while others go through pregnancy and deliver their babies, only to dump or abandon their newborns shortly after birth.
More than half of these abandoned babies do not survive, and the media carries stories of these cases regularly.
Figures from the Malaysian Maternal Mortality review show that 70% of women who die from pregnancy-related causes in Malaysia have never used contraception. The maternal mortality rate (death related to pregnancy-related causes) in grand multiparas (women who have delivered five or more babies) is double that in primigravidas (women in their first pregnancy).
Women should consult their healthcare providers to choose an appropriate contraceptive method that is effective, safe and that would suit their individual lifestyles.
The oral contraceptive pill
The oral contraceptive pill is one of the most effective methods of contraception available, with 99% effectiveness when used correctly. It was first introduced in the early 1960s, and there are now over 100 million women using the pill globally.
The modern-day oral contraceptive pill, when correctly prescribed, is safe and very effective.
The doses of the two hormones within the “combined” pill – oestrogen and progesterone – have been gradually reduced over the years, greatly reducing the incidence of side effects, and increasing safety.
The pill comes in packs of 21 or 28. In the 28-day packs, the last seven pills that coincide with the “period” do not actually contain any active medication. New low-dose pills have recently been introduced (24/4 regimes), where only the last four pills do not contain hormones.
A woman initiating contraception with the pill should start taking the pill on the day her period starts.
The pill acts by preventing ovulation (release of an egg); making the mucous in the cervix thick, so that sperm are less likely to enter the uterus; as well as making the lining of the uterus thin, and therefore, less hospitable for implantation of a fertilised egg.
Women should be aware that certain medications like antibiotics and anti-epileptic drugs, can reduce the efficacy of the pill. The pill will also not protect against sexually transmitted infection.
There are a number of concerns that patients have regarding the oral contraceptive pill. The most common concern is weight gain. I usually explain to my patients that less than 10% of patients experience weight gain while on the pill.
The patients on the pill who do experience weight gain do so because of fluid retention caused by the progesterone component of the pill. Pills are now available that have a very low incidence of fluid retention and weight gain.
Other concerns include risk of the pill causing infertility, as well as breast cancer. The reality is that fertility returns within one to two months of stopping the pill. I have many patients who have been able to become pregnant when they stopped taking the pill.
The latest research indicates that the pill does not increase the risk of getting breast cancer.
The pill is generally a very safe medication, but it does increase the risk of blood clots in the veins (deep venous thrombosis), strokes and heart attacks in some women. Women who are at risk of cardiovascular disease due to multiple risk factors like hypertension, diabetes and high cholesterol, as well as female smokers over 35 , should not use the combined oral contraceptive pill.
Side effects like bleeding, breast tenderness, nausea and headaches, are usually transient, and can occur in a small number of patients. If these side effects persist, medical advice should be sought.
There are many other benefits of the pill. It makes menstrual cycles lighter and regular. The incidence of anaemia is thus decreased in women on the pill. It also decreases period pain in many women, and is effective in decreasing the incidence of acne.
Other conditions like pelvic inflammatory disease (infections of the uterus and fallopian tubes) can be reduced by as much as 50% by taking the oral contraceptive pill. There is a 17% decreased risk of fibroids for every five years of oral contraceptive pill use.
Oral contraceptive pills also decrease the incidence of some breast conditions (fibrocystic disease and fibroadenoma), as well as ovarian cysts.
Excess body hair or hirsutism can affect up to 8% of women, understandably causing distress. The contraceptive pill that contains a particular progesterone (cyproterone acetate) is particularly effective in treating this condition.
In addition, there are pills formulated to treat pre-menstrual syndrome (PMS) and pre-menstrual dystrophic disorder (the most severe form of PMS, where the women’s physical and emotional symptoms become severe enough to impact her daily life), as well as pills that are very effective treatments for women who have heavy periods.
Women close to the menopause (perimenopausal women) sometimes have irregular periods, heavy periods and menopausal symptoms. The pill can help in achieving better menstrual cycle control – reducing heavy periods, as well as reducing menopausal symptoms and mood swings in these women.
The pill also protects against endometrial (womb) and ovarian cancer. Endometrial cancer risk is reduced by 40% with two years of use, and up to 72% with 12 years of use. Ovarian cancer risk is reduced by 50% with five years use of the pill.
Other ‘combined’ hormonal methods
There are other hormonal methods of contraception that use different methods of delivery, namely through the skin (patch) and the vaginal lining (vaginal ring). The action, side effects and contraindications are similar to the oral contraceptive pill.
In this method, the hormones are delivered by a skin patch applied to the skin on the buttocks, stomach, back or upper arms. Each patch is used for seven days, and a patch is used each week for three weeks, followed by a week with no patch being used, during which a period will occur. The patch is less effective in women who are over 90kg in weight.
The vaginal ring is a soft plastic ring (54cm in diameter), which is inserted into the vagina by the woman herself. The ring is held in place by the walls of the vagina, and will neither fall out nor be felt during intercourse.
It can be removed for up to three hours at a time per day and still maintain effectiveness as a contraceptive. The ring is placed in the vagina for three weeks, and then removed for a week when a period will occur.
Side effects are uncommon. In addition to those generally associated with the pill, vaginal irritation, discharge and discomfort can occur in a small number of patients.
Progesterone-only hormonal contraception
The hormone oestrogen is contraindicated in some women – women who smoke, have severe or uncontrolled hypertension, and migraines, those who are obese (body mass index more than 30kg/m²), and women who are breastfeeding.
It is possible to use hormonal contraception in this group of women by prescribing a “progesterone-only pill”.
In addition to pills, it is possible to use progesterone as a contraceptive in other forms, namely progesterone injections (Depo-provera) and progesterone implants. This method of contraception will not protect against sexually transmitted diseases.
Depo-provera is a hormonal method of birth control administered by giving injections in the upper arm or buttock every 12 to 13 weeks. The method works by preventing ovulation (the release of eggs every month).
The benefits are that the woman will only need approximately four injections during the year, and does not need to worry about taking pills. Irregular bleeding is common during the first few months of use.
By one year, about 50% of women will stop having periods. Despite popular belief, it is not harmful to stop periods. In fact, this can even be beneficial for women who have heavy or painful periods.
One of the side effects of this method is a decrease in bone density, which is reversible upon stopping this method of contraception. Weight gain is also seen in some women due to increased appetite.
Although it is a reversible method of contraception, it can take up to nine months after the last injection for regular menstrual cycles to return.
This is a hormonal method similar to the injection. A small rod about the size of a matchstick is inserted in the clinic (after administering a local anaesthetic), using a special applicator, into the upper arm. After insertion, the implant cannot be seen, but it can be felt if the skin over it is pressed.
The implant will last for three years, after which it should be removed (again under local anaesthetic in the clinic), and a new implant inserted, if further contraception is desired.
With the implant, fertility returns soon after removal. The most common side effect is irregular bleeding in the first few months after insertion. Periods can become scanty in many women, and may stop completely.
Other side effects are weight gain, mood changes, headache, acne and depression.
An intrauterine device (IUD) is a small plastic device that is inserted into the uterus in the clinic using an applicator by a healthcare professional.
There are two types ofIUDs, the copper-containing IUD and the progesterone-releasing intra-uterine system (Mirena). IUDs are reversible, and very effective methods of contraception. They can be inserted during the time of the menstrual period, six weeks after delivery, or even after an abortion.
This method is not recommended in women who have not had children, and will also not protect against sexually transmitted diseases.
This method of contraception works by preventing fertilisation of the egg by releasing a small amount of copper within the cavity of the uterus. Depending upon the brand used, they can last for three or five years.
The advantage of this IUD is that once inserted, nothing else is needed to prevent pregnancy. It is not felt by the woman or her partner, and does not interfere with daily activities or sexual intercourse.
Side effects include irregular bleeding, usually confined to the first two to three months after insertion. Sometimes, periods may become heavy or painful.
Pelvic infection, manifesting as pelvic pain, fever or vaginal discharge, can occur infrequently. If this occurs, a healthcare provider should be consulted. Expulsion of the device also rarely occurs. Perforation of the wall of the uterus is a rare complication during insertion (approximately once in 1,000 insertions)
Intra uterine system (Mirena)
The Intrauterine System (IUS) is impregnated with the hormone progesterone instead of copper and lasts for five years, at which time it can be changed. The IUS is a very effective contraceptive, and in addition, it is also an effective method of treating women with heavy periods.
Irregular bleeding, as well as heavier and prolonged bleeding, often occurs in the first three to six months. This usually settles in most women, and the periods will then become very scanty, or even cease completely.
A small number of women may have side effects that are related to the progesterone in the device. These may include headaches, nausea, breast tenderness, and pelvic pain, due to the development of small cysts in the ovaries.
The symptoms usually decrease within the first couple of months, and the cysts usually disappear without treatment within two months.
This is the use of contraception after a woman has had sexual intercourse without birth control, or if the method has failed (eg breakage of condom, missed birth control pills). These methods are not as effective as the methods described earlier, and should not be used as routine contraception.
However, emergency contraception, also called the “morning after pill”, is better than no contraception, and may be useful for up to five days after unprotected intercourse. They act by stopping ovulation or fertilisation of an egg, or by preventing implantation of a fertilised egg.
They can be used at any time during the menstrual cycle, and even more than once in the cycle. A progesterone called levonorgestrel, which is present as a component of some brands of oral contraceptive pills, is used, either as a single dose of 1,500 microgram, or two 750 microgram doses 12 hours apart.
If taken within 24 hours of unprotected intercourse, they can prevent about seven out of eight pregnancies that would have otherwise occurred.
Side effects include menstrual irregularity, transient abdominal pain and nausea.
Another option is to insert a copper-containing IUD within five days of unprotected sex. This method is about 99% effective. It is contraindicated in the presence of pelvic infection or where there is a risk of pelvic infection, and in women who have not had children yet.
The condom is a single-use latex sheath worn over the erect penis before intercourse. It has the very important additional benefit of helping to prevent sexually transmitted diseases. It is widely available “over the counter”.
Correct use is important, and it must be put on before any contact between the penis and female genitals. The condom-covered penis should also not be allowed to become flaccid while still within the vagina, as leakage of semen may occur. With perfect use, it is 98% effective; and with typical use, it is 85% effective.
In addition to the methods described above, there are permanent surgical methods of preventing pregnancy. These include tubal ligation for the female, and vasectomy in the male.
Although reversal is possible, these operations are not always successful; therefore, the couple must be very sure that they do not want any more children.
Reversal of tubal ligation is successful in approximately 70 to 80% of women. Success of reversal of vasectomy is related to the duration between the vasectomy and reversal procedure. About 76% of reversals are successful when performed within three years of the vasectomy, but only 30% are successful when the reversal is carried out more than 15 years after the vasectomy.
Following a vasectomy, it is important that some form of contraception is used until the doctor confirms that the patient is sterile. Semen will be collected 12 weeks after surgery and examined under the microscope to ensure that no sperms remain, before unprotected sexual intercourse is permitted.
The so-called natural methods of contraception, such as the withdrawal method, fertility awareness and rhythm (calendar) method, are considered less medically reliable than the methods of contraception described earlier. Regardless of the method chosen, it is important to discuss the options with your doctor, and discuss any concerns you have until you receive answers to your satisfaction.
Dr Suresh Kumarasamy is a consultant obstetrician & gynaecologist/gynaecological oncologist and president of the Obstetrical & Gynaecological Society of Malaysia.