Contraception Versus Sterilization

THAMPU KUMARASAMY, MD , FRCS, FRCOG, MRCP

Associate Professor, Department of Obstetrics and Gynecology, Medical College of Virginia, Health Sciences Division of Virginia Commonwealth University, Richmond, Virginia

The World Health Organization reported 4 Inexpensive that 40% of the pregnancies in the world in 5. Removed from the act of intercourse 1977 were unplanned and 20% were un­ 6. Completely reversible wanted; in the United States in 1978 there were 7. Easily available 1,300,000 teenage pregnancies, of which one There are two types of effectiveness­ million ended in abortions To prevent these un­ theoretical effectiveness and use effectiveness. wanted pregnancies and also to abolish the Use effectiveness is invariably found to be lower cost in terms of money, time and lives, concep­ than theoretical effectiveness. tion control is very important Contraception is The varieties of contraceptive methods as old as the human race. In ancient times Chi­ available are nese women swallowed live tadpoles three days 1. Chance atter their menses for this purpose. North Afri­ 2. Douching can women mixed gunpowder solution and 3. The rhythm method loam from a camel's mouth and drank the re­ 4. Use of spermicides sulting potion. Egyptian women inserted pes­ 5. Condoms saries made of crocodile dung to achieve con­ 6. Diaphrams traception. Greek women in the second century 7. Condoms and spermicides or dia­ made a vaginal plug that contained oil, honey, phram and spermicides cedar gum and fig pulp; others ate the uterus of 8. Oral contraceptives, which can be a female mules. As recently as the 17th century, combined oral contraceptive or pro­ European brides were instructed to sit on their gestin-only (minipill) lingers while riding in coaches or to place 9. Injectable contraceptives roasted walnuts in their bosoms, one for every 10. Intrauterine contraceptives barren year desired. Obviously, an unwanted 11 . Male sterilization child was of as much concern to the ancients as 1 2. Female sterilization it is to modern women. Of these, chance and douching have the These are the characteristics of an ideal lowest rate of effectiveness, and the rhythm contraceptive: method, or the so called "sale period," sup­ 1 . 1 00% effective posedly one week before and one week after 2. Sale with no side effects the first day of menses, should not be consid­ 3. Simple to use ered as particularly sale.

The following is an edited transcript of remarks by Dr. Condoms Kumarasamy at the 51 st Annual McGuire Lecture Series, Condoms have been in use since the 1 7th October 19, 1979. at the Medical College of Virginia, Rich­ century both to prevent venereal disease and to mond, Virginia. Correspcndence and reprint requests to Dr. Thampu avoid impregnating women. Today, in the Kumarasamy, Box 34. Medical College of Virginia, Rich­ United States, 700 to 800 million condoms are mond, VA 23298. produced annually. Condoms may be a prob-

KUMARASAMY CONTRACEPTION VS STERILIZATION / 27 lem for men with borderline impotence or those 5. Depression and changes in libido who cannot maintain an erection for some time. 6. Fatigue The earlier objections to the use of condoms, 7. Moniliasis such as decrease in thermal and/or tactile sen­ 8. Early spotting and breakthrough sitivity have been overcome by the manufacture bleeding of condoms made of very thin but strong mate­ 9. Oily scalp and loss of hair rial. In Japan, the most commonly used con­ Side effects of oral contraceptives are: traceptive agent is the condom. Recently, the 1 . Nausea and vomiting International Planned Parenthood Federation 2. Weight gain has reported that condoms and spermicides 3. Spotting and breakthrough bleeding used in con1unction by motivated people are as 4. Headache effective as oral contraceptives. Those con­ 5. Nervousness and irritability cerned about the use of oral contraceptives and 6. Depression their complications or the complications of intra­ 7. Loss of libido uterine devices, can use condoms and spermi­ 8. Breast discomfort cides. And condoms have the distinct advan­ 9. Acne tage of preventing the spread of venereal 10. Melasma disease. 11 Amenorrhea 1 2. Thromboembolic effects Oral Contraceptives There is some concern that oral con­ The types of oral contraceptives are 1 ) the traceptives may be responsible for genetic combination pill, 2) the progestin-only (minipill), changes and some forms of cancer. So far: and 3) the morning after pill. The mechanism of there is no definite evidence to support the idea action of the combination pill is supposed to be of genetic changes, and no association, ad­ a combination of the following: verse or beneficial, between the use of oral con­ 1 . Prevention of ovulation traceptives and the development of cancer of 2. Some alteration of tubal transport the breasts, endometrium, or cervix, according 3. Changes in the endometrium to current data. Long-term combined oral con­ 4. Alteration of the cervical mucus traceptive use appears to be related to the de-' Symptoms attributed to estrogens in the velopment of benign liver neop\asia. There is combination pill are: also evidence that oral contraceptives may have 1 . Nausea and bloating an adverse influence on the resolution of hyda­ 2. Cyclic weight gain and/or edema tidiform mole. 3. Nervousness, irritability and/or pre- menstrual tension ABSOLUTE CONTRAINOICA TIONS TO THE USE OF THE 4. Venous or capillary engorgement PILL 5. Headache Thrombophlebitis, thromboembolic 6. Breast tenderness or cystic changes disorders, cerebrovascular disease, or 7. Mucorrhea, cervical erosion or polypo­ a past history of these conditions sis 2. Markedly impaired liver function 8. Hypermenorrhea 3. Known or suspected carcinoma of the 9. Dysmenorrhea breast 10. Fibroid growth 4. Known or suspected estrogen-depen­ 1 1 . Changes in carbohydrate metabolism dent neoplasia 1 2. Hypertension 5. Undiagnosed abdominal genital bleed- 13. Thrombophlebitis ing 1 4. Suppression of lactation 6. Known or suspected pregnancy Symptoms related to progestins are: 7 Congenital hyperlipidemia 1 . Amenorrhea or oligomenorrhea 8. Gestational diabetes 2. Acne 9. Progressive heart disease 3. Hirsutism 10 Progressive high blood pressure 4 Increased appetite and steady weight Some relative but not absolute con­ gain traindications are:

28 / KUMARASAMY CONTRACEPTION VS STERILIZATION 1. Obesity arations because of excessive side effects such 2. Headache as nausea, weight gain and mastalgia. 3. Fibroids The progestin-dominant pill is suitable for Intrauterine Contraceptive Devices a woman if she should have: Stoning the camel was a practice that 1 . Excessive outpouring of leukorrhea dates back to ancient Egyptians who introduced 2. A generalized sense of bloating or a small oval stone into the uterine cavity of fe­ nausea while taking a contraceptive male camels to prevent them from becoming with high estrogen component pregnant if they were to be used for long jour­ 3. A tendency toward fluid retention and neys across the desert. premenstrual weight gain Very much later, Pust, a German gynecol­ 4. A degree of emotional instability and .:>gist, designed a number of cervical stem pes­ irritability prior to the menses saries made of glass, a combination of metals 5. Excessive menstrual flow and a silkworm, and used them to treat dys­ 6. More than the average amount of fi­ menorrhea when associated with an acutely brocystic disease and a tendency to­ antiflexed uterus. It was observed that these wards swollen, tender breasts and nip­ pessaries acted as contraceptives. Another ples German gynecologist, Ernst Grafenberg, elimi­ Women experiencing the following are not nated the part of the appliance that lay in the good candidates for progestin-dominant con­ cervical canal and produced his now well­ traceptives: known ring made of coiled silver wire. 1 . Hirsutism and acne The Japanese were the first to make and 2. Underdevelopment of breasts use plastic devices, and today the following de­ 3. Very scanty menstrual flow or a fore­ vices are available for clinical use: shortened cycle 1. Saf-T-Coil 4. Increasing appetite and steady weight 2. Lippes loop gain 3. Copper-? 5. Varying degrees of depression in the 4. Copper-T or Tatum-T menstrual cycle 5. Progestasert 6. Excess weight gain during previous The mechanism of action of intrauterine pregnancy contraceptive devices is not very clear. The the­ 7. Intermittent depression or loss of libido ory that increased tubal and uterine motility 8. Breakthrough bleeding causes the fertilized egg to reach the endome­ trium before the conditions are favorable for im­ plantation has not been substa,ntiated. It is also THE MINIPILL believed that the inflammatory and immune re­ This is a progestin-only preparation which, action within the endometrium may cause prob­ when taken as directed, is an effective oral con­ lems of implantation of the blastocyst. traceptive-, although it is less effective than an The action of copper in copper-impreg­ estrogen-progestin combination. The prepara­ nated intrauterine devices is believed to be due tions available are Micronor, Nor-0.D., and Ov­ to its interference with the migration of sperma­ rette. The anticonception effect is due to a com­ tazoa as well as with implantation, probably by bination of poor endocervical mucus preventing disrupting the sulphydryl groups in the endome­ sperm penetration in addition to the endometrial trium and in the spermatazoa. changes that are out of sequence for proper im­ plantation of the blastocyst. There is also an ef­ fect on tubal motility and the enzymes in the HISTOLOGICAL CHANGES endosalpinges. Presently, the majority of The effects of intrauterine contraceptive women using the minipill continue to ovulate. devices on the endometrium have been well These pills are administered on a continuous studied in human beings. The most obvious daily basis, starting on the first day of men­ changes are 1 ) an increase in the number and struation. The minipill seems to be perfect for size of vascular channels, 2) a diffuse or patchy women who cannot tolerate the combined prep- subsurface stromal hemorrhage, and 3)

KUMARASAMY: CONTRACEPTION VS STERILIZATION / 29 changes in the amount and distribution of fluid as an interval procedure. The routes by whic� in the endometrial stroma this procedure can be performed are via the ab­ dominal wall, via the posterior lornix of the Vi3- ADVANTAGES OF THE INTRAUTERINE DEVICE gina, or by the use of a laparoscope or hys­ 1 . The greatest advantage is that once teroscope. Though the use of the laparoscope the device is in place, no further moti­ for tubal sterilization procedures has gained vation, effort or treatment is required wide acceptance and popularity, the mini­ for continued contraception laparotomy is as safe and quick and effective iri 2. It is especially useful for those who selected females and has the additional advan­ have trouble following directions or re­ tage of low cost. membering to use any other method Damage to the tubes caused by coagu­ 3. There is a lack of systemic effects lation or cauterization via the laparoscope not 4. It may be most suitable for older only damages extensive areas of the tube ana women the broad ligament, but also may cause some ovarian dysfunction leading to post-sterilizatiori DISADVANTAGES OF THE INTRAUTERINE DEVICE problems of pain and bleeding On the other· 1 Pain and difficulty associated with in­ hand, use of mechanical devices to occlude the sertion fallopian tube such as the use of silicone rubber 2. Side effects of cramps and bleeding bands or plastic clips has been shown to mini­ and vasovagal reaction mize the above-mentioned postoperative symp-· 3. Failure (2% to 5% pregnancy rate) tomatology. Because the mechanical devices produce minimal damage to the fallopian tubes COMPLICATIONS OF THE INTRAUTERIN DEVICE this method is most suitable for a young woman 1 Bleeding who may request tubal reanastomosis at a later 2. Pregnancy stage. 3. Expulsion To date, we do not have a single revers­ 4. Pain ible method of sterilization. Any surgical steril­ 5. Perforation ization method is designed to be permanent 6. Infection and tubal occlusion procedures are accepted 7 Fracture of the device or loss of the as the preferred procedure for those women string attached to the intrauterine de­ who have definitely completed their child­ vice bearing and who desire sterilization. Should any uterine pathology and/or symptomatology of CONTRAINDICATIONS significance be found. then hysterectomy is ac­ 1 . Severe dysmenorrhea ceptable and fully justified as a sterilization pro­ 2. Menorrhagia cedure. 3. Pelvic infection, recent or chronic Overall. from my experience. I would ad­ 4. Perimenopausal menstrual abnormal­ vise the following as the best forms of con­ ity traception for the various categories of women: 5. Congenital anomalies of the uterus Unmarried teenagers 6. Some women with fibroids 1. Abstinence through education and self-control Surgical Sterilization 2. Condoms and spermicides 3. Diaphram and spermicides The use of sterilizing procedures is in­ 4. Oral contraceptives creasing world wide. In the male, vasectomy is simple, sale and effective, but has the mild dis­ Married women advantage of not being immediately effective. 1 . Condoms and spermicides On the other hand, in the female, the tubal liga­ 2. Diaphrams and spermicides tion involves no measurable risk to life, can be 3. Oral contraceptives done as an outpatient procedure, and is imme­ 4 Intrauterine contraceptive devices diately effective. Tubal sterilization in the female 5. Tubal occlusion by a method that can be performed in the postpartum period or would result in minimal damage to the

30 / KUMARASAMY CONTRACEPTION VS STERILIZATION tubes. Example: clips, bipolar cautery 2. Saline abonion followed by tubal oc­ or Falope rings clusion 6. Hysterectomy only if uterine pathology 3. Abortion-hysterectomy if, in addition, of significance exists any uterine pathology is found

Women over 35 Postabortal women who desire furtherfertility 1 _ Diaphram and spermicides or con- 1 Barrier methods doms and spermicides 2 _ Oral contraception 2 _ Intrauterine contraceptive devices 3 Intrauterine devices 3. Tubal occlusion 4. Hysterectomy if uterine pathology or symptomatology of significance exists Postpartum women 1 Use of condoms and spermicides Preabortal women 2. Oral contraceptives 1 _ Suction dilatation and curettage fol­ 3 _ Intrauterine devices lowed by tubal occlusion 4 Tubal occlusion

KUMARASAMY CONTRACEPTION VS STERILIZATION / 31