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Practitioners’ Corner (continued)
side meant to prevent expulsion but which made insertion and re- moval somewhat painful, and the string on the Dalkon Shield was made of a porous material that also introduced bacteria into the uterus and was associated with the same frequent infections that had plagued the early devices. e Dalkon Shield was removed from production in 1974. Despite availability of other, and much safer mono lament IUD’s such as the Copper T, IUD’s generally remained in disfavor in the U.S. until relatively recently. Currently 6 IUD’s are marketed in the U.S. Five of them ( rst starting with Mirena, approved in 2000) utilize a small dose of levonorgestrel in the uterus and are e ective for up to 5 years.
Two other aspects of contraception deserve mention. All methods discussed so far are reversible and temporary, but per- manent methods of contraception, which are e ective and insti- tuted with relative ease, are currently available. At the beginning of the 20th century, vasectomy began to be used for birth control. Increasing numbers of men volunteered for vasectomies in the 1960s and 1970s because it was less complicated and less expen- sive than sterilization for women, usually done by laparotomy. By the early 1970s, 3/4 of a million American men a year were having vasectomies. Sterilization of women by tubal ligations took place in association with cesarean sections in the mid 20th century as the concept of family planning gained increasing acceptance. By the mid 1970s, tubal sterilization was widely available on an out- patient basis by laparoscopy, making it easier, less expensive, and more acceptable.
Most methods of contraception discussed to this point are planned. Unfortunately, exposure to pregnancy sometimes oc- curs unexpectedly. Either no birth control is used because sex is unanticipated or there is a contraceptive malfunction. In those circumstances, emergency contraception is required. In early his- tory, women would sometimes try to wipe the semen out of their vagina with ngers. Somewhat later, the possibility of removing the sperm with injected uid (douching) became utilized. Cur- rently, emergency contraception is available by use of the birth control pill known as Plan B, no later than 5 days a er unpro- tected intercourse. An IUD inserted within 5 days of intercourse is also e ective by altering cervical mucus and the endometrial implantation site.
Today, a wide variety of contraceptive measures are available which are e ective and safe. Individuals can choose the method most appealing to and appropriate for them a er consultation with their physician. Educating patients about the importance of using “dual contraception”- which includes a barrier method for STD protection is also advocated.
Hormonal contraceptives, which remain the most widely used method of birth control in the U.S., are available in a wide variety of dosages and types, and their principal risk is related to venous thromboembolism and hypertension, though in appropriately chosen candidates, these events are very uncommon. Modern
IUDs, inserted by appropriately trained personnel, are rarely as- sociated with infection and, in those uncommon instances, can usually be easily and adequately treated. Uterine perforation with IUD insertion occurs in less than 1 in 1000 instances.
e newest emphasis in this area is on long acting reversible contraception known as LARC. ese include intrauterine devic- es and subdermal hormonal implants. ey are highly e cacious, and the principal barrier to their use currently is expense, misun- derstanding about their safety, and inadequate counselling. Only 14% of patients currently use LARC versus 28% utilizing steriliza- tion and 32% using contraception. e advantage of LARC is their long-term e cacy and continuation rates compared to the pill that many users stop within one year of use. LARC methods are reversible but are e cacious for periods of 3 to 7 years depending upon the speci c device. e subdermal implants currently uti- lized are easily inserted and removed, as are current intrauterine devices. All LARC devices, interestingly, can be utilized right a er childbirth or abortion, providing immediate contraception and having no impact on the quality of maternal lactation or rst year infant growth. A long-term vaginal hormonal ring and a topical male contraceptive are under investigation. Despite the current availability of good contraception (except perhaps for the poor), the rate of unplanned pregnancy remains higher in the U.S. com- pared to other developed nations.
e proportion of births in America occurring to unmarried women has increased from 3% in 1940 to 41% in 2015. From 1970 to 2010, the median in age for rst marriage among women has increased from 20 years to 28 years of age and the age at rst childbirth has similarly increased. e percentage of women ages 15 to 44 which are married has decreased from 73% in 1950 to 40% in 2010. Pregnancy rates among married women have de- creased from 200 per 1000 women in 1960 to 100 per 1000 wom- en in 2010. e percentage of teenagers who have ever had sex has increased from 25% in 1960 to almost 70% currently.
e average American family, which had 4 children in 1960, now has 1.8 children. With the scienti c advances of medical care, the expected lifespan of the average American has increased from 47 years in 1900, to 68 years in 1950, to 76 years in 2000, and 79 years in 2014. e increasing longevity of Americans, and, in fact, of people in most developed economies, in conjunction with the decreased birth rates seen today, have led some economists to have concern about the ability of young workers in modern society to support this aging population. Articles addressing this within the past six months have been in the New York Times, e Washington Post, and e Economist. It is a new world! Bring on the robots!!!...Or maybe the clones???
A chart comparing the e ectiveness of current contraceptives can be obtained by emailing Dr. Verkauf or Elke at the HCMA (Elu- bin@hcma.net).
HCMA BULLETIN, Vol 64, No. 4 – November/December 2018
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