Sexually Transmitted Diseases - I. I. Mavrov 2005

Contraception
Contraception in Women

Contraception (birth control) has become widely used as a method for birth control, implementing family planning programs, preventing abortions, and the like.

Medical advancements in preventing unplanned Pregnancy have yielded a range of Methods that, when properly chosen and skillfully applied, are optimal for healthy women of reproductive age.

When prescribing a particular contraceptive method, a physician must provide a woman who is not currently planning a pregnancy with reliable medications that have minimal adverse and harmful effects and best suit her individual tolerance. The fundamental principle of contraception should be an individualized approach, as by no means is the entire arsenal of birth control methods applicable to the absolute majority of women.

Agents used to prevent pregnancy are called contraceptives or birth control methods. In medical practice, the following types are used: mechanical contraceptives—devices that prevent sperm from entering the female reproductive tract or prevent the implantation of the fertilized egg; chemical (spermicidal) agents—substances with a lethal effect on sperm; intravaginal chemical agents—for vaginal insertion; intrauterine devices—for insertion into the uterine cavity; hormonal agents—preparations of Female Sex Hormones that suppress ovulation; and combined methods—combinations of mechanical, chemical, or hormonal contraceptives.

Contraceptive methods must meet certain requirements, first and foremost being sufficiently effective. When using contraceptives, it is essential to closely monitor that they do not exert a harmful effect on a woman's health. The contraceptive effect must necessarily be temporary so that the woman's reproductive function can be fully restored at her discretion. In accordance with the old medical rule, contraceptives should not negatively affect the sex Organs, thereby disrupting the physiology of sexual intercourse and causing negative emotions.

Today, several intravaginal chemical contraceptives are used, either independently or as an adjunct to other methods. They provide a relatively reliable contraceptive effect. These include vaginal Sponges (made of foam-like Materials, porous rubber), suppositories, and pastes containing spermicidal substances and the like. Vaginal sponges are prepared as follows: after boiling, the sponge is impregnated with a spermicidal agent—a 2% acetic acid solution or table vinegar solution (one tablespoon per cup of Water); a 2% lactic acid solution or soap solution is also used for this purpose. The need to prepare sponges before sexual intercourse and the fact that the birth control method is not always 100% reliable limit their use for contraception.

When using vaginal douches with solutions of the aforementioned acids, one must consider a negative aspect of this contraceptive method: the need to perform it immediately after intercourse, since within 90 seconds of ejaculation, sperm can already enter the Uterus, rendering douching ineffective.

Currently, intravaginal chemical contraceptives cannot be excluded from the arsenal of birth control agents. Their advantage is the ability for a woman to insert and remove them independently; they are particularly indicated in cases of condom rupture discovered immediately after intercourse. In recent years, Barrier methods of contraception have gained popularity due to the rising incidence of infections. For instance, benzalkonium chloride exhibits both spermicidal and pronounced bactericidal activity. When introduced into the vaginal cavity in the form of tablets, cream, suppositories, or impregnated sponges, benzalkonium chloride immobilizes and ultimately destroys sperm, serving as protection against the most common Sexually Transmitted Infections. It also has antiviral activity, destroying Herpesviruses and HIV. This type of contraception is suitable for women of any age (particularly in the postpartum period).

Intrauterine devices (IUDs) are metal or plastic loops, spirals, rings, etc. In recent years, preference has been given to IUDs containing copper or silver, which significantly enhances their contraceptive effect and provides antiseptic properties. Today, sufficient experience has been accumulated with IUDs that contain and continuously release small amounts of progesterone into the uterus, exerting an additional local effect. These include IUDs made of plastic and polylactamide film containing norgestrel, medroxyprogesterone acetate, and other progesterone preparations, as well as nortestosterone derivatives, notably norethisterone.

Observations show that The Use of IUDs is associated with a relatively high frequency of infectious complications. Currently, two risk factors are considered for pelvic inflammatory disease (PID) in women using IUDs: first, the Introduction of infection during the insertion of the IUD into the uterine cavity, and second, infection associated with the prolonged presence of the IUD in the uterus. The risk of PID associated with IUD insertion is presumably caused by The transfer of Bacteria from the lower genital tract to the upper tract.

The use of IUDs increases the risk of urogenital infections (chlamydial, mycoplasmal, viral, etc.) by 9 times, particularly in young women with a history of reproductive tract infections and multiple sexual partners.

The use of almost all types of IUDs may contribute to The Development of pelvic actinomycosis (see corresponding chapter). Most often, the disease develops after two years of IUD use; furthermore, it can occur even 2–3 months after the insertion of the IUD into the uterine cavity. At the same time, it cannot be ruled out that genital actinomycosis may result from oral-genital contacts.

Bleeding, heavy menstruation, or intermenstrual spotting occurring with IUD use are becoming a serious problem. Increased bleeding in this case may result from local endometrial erosions or ulcerations, capillary fragility, increased prostaglandin production in the endometrium, impaired Blood Coagulation processes, or a local increase in fibrinolytic activity. A change in the Menstrual cycle pattern accompanied by heavy bleeding in patients using IUDs who did not previously experience such symptoms may be the first sign of an emerging infectious process.

There is a correlation between IUD use and lower abdominal pain, vaginal discharge, bleeding, and the presence of microorganisms cultured from samples taken from IUDs after their removal. Our accumulated experience provides grounds to assert that in the absence of a rapid response to Treatment, removing the IUD in these patients is most appropriate.

Hormonal contraceptives are characterized by good tolerability, high reliability, and ease of use. Their efficacy is linked to their inhibitory action on ovulation. Combined progestin-estrogen hormonal preparations (norethynodrel, norethindrone) are used for contraception. A combination of preparations is used as a birth control method: mestranol (the estrogen component) and norethynodrel (the progestin component). Observations show that the combination of estrogens and progestins is most effective and achieves a 100% contraceptive effect. Under METABOLISM/18.html">The Influence of combined preparations, FSH and LH levels in the blood decrease almost equally throughout the entire menstrual cycle, and their mid-cycle surge disappears. As a result, ovulation does not occur. In addition, combined preparations alter the composition of cervical mucus and the state of the endometrium, thereby hindering sperm penetration and the implantation of the fertilized egg into the uterus.

The main criterion for selecting a preparation is the pattern of menstrual bleeding. Patients with heavy and prolonged menstruation tolerate preparations with a predominant progestin or estrogen component better than those with short and scanty periods. A more detailed gynecological and endocrinological examination allows for a more precisely tailored Selection of the preparation. When prescribing various drug combinations, their side effects must be taken into account. Women with pronounced manifestations of androgenization (acne, seborhea, mild hirsutism) should be prescribed contraceptives with anti-androgen activity (Ovosiston, Diane-35, etc.). Women with a marked predominance of estrogens in their phenotype or hypersensitivity to them tolerate hormonal contraceptives with a higher progestin-to-estrogen ratio better, as the latter require an excess of follicle-stimulating hormone.

Hormonal preparations for contraception are usually used in the form of pills, tablets, as well as parenterally administered hormonal agents. A contraceptive effect is also achieved using intravaginal or intrauterine devices containing specific hormonal preparations. Oral hormonal contraceptives (Bisecurin, Rigevidon, Postinor, etc.) vary in composition, the doses of specific hormones, and the timing of administration.

Bisecurin is recommended for women with a balanced hormonal status or a significant predominance of estrogens; it is a dual-component oral contraceptive with mild progestational activity that provides a virtually 100% contraceptive effect. A condition for the drug's successful action is the precise and consistent adherence to cyclic administration According to the instructions. The cyclic administration of Bisecurin (containing low doses of progestin-estrogen components) ensures a monophasic cycle without ovulation, and bleeding occurs following the periodic discontinuation or withdrawal of the drug. Bisecurin is taken 1 tablet daily from the 5th to the 25th day of the menstrual cycle (21 days), followed by a 7-day interval before continuing the 3-week course. A certain amount of time is required for Bisecurin's contraceptive effect to develop; therefore, and due to the possibility of early ovulation at the beginning of continuous courses, reliable absence of ovulation can only be counted on during the second cycle of intake.

Rigevidon is an oral contraceptive with a progestin predominance. The progestogenic action of this preparation is more intensive, and the estrogenic action is less pronounced, than in Bisecurin. The preparation is taken continuously, starting from the 5th day of menstruation until the 25th day of the cycle, at 1 tablet per day. Following the discontinuation of the 3-week course, bleeding occurs within 2–3 days, on the 5th day of which the next 21-day course can be initiated. Bleeding typically appears during the 7-day interval between courses.

Currently, Ovidon is often recommended for women with a pronounced predominance of estrogens (reflected in their constitution); it is an oral contraceptive containing an optimally low amount of active substances (0.25 mg levonorgestrel and 0.05 mg ethinyl estradiol per tablet). The preparation is taken daily, 1 tablet starting from the 5th day of menstruation to the 25th day of the cycle (3 weeks of intake followed by a 1-week break). Ovidon is a reliable contraceptive with good tolerability. Alongside its central and direct effect on the Ovaries, it also affects cervical mucus. Ovidon is recommended for women who do not tolerate other combined preparations.

In cases where there are contraindications to the regular use of oral contraceptives, or for women who do not have regular sexual activity, postcoital oral contraception—used immediately after sexual intercourse—helps prevent pregnancy. The most effective preparation in such cases is Postinor (1 tablet contains 0.75 mg levonorgestrel). Taking a single large dose of levonorgestrel blocks the possibility of conception and the Development of the fertilized egg in the early phase.

The contraceptive effect of Postinor is based on its action on the Hypothalamus-pituitary-ovarian system, resulting in the suppression of ovulation, direct Prevention of implantation, alteration of tubal motility, and a direct effect on the blastocyst. The preparation (1 tablet) is taken immediately after sexual intercourse, but no later than one hour. If sexual intercourse is repeated after 3 hours, a second tablet must be taken. In cases of multiple acts of intercourse, 1 tablet is taken after the first act, and another tablet is taken 3 hours later and the following day. The reliability of the postcoital method is equivalent to that of intrauterine devices.

A progestin-estrogen combination can also be used as a postcoital agent: two doses of 0.1 mg ethinyl estradiol and 0.5 mg levonorgestrel taken 12 hours apart, but no later than 72 hours after intercourse. Estrogens alone are also used for this purpose—5 mg of ethinyl estradiol per day for 5 days, no later than 72 hours after sexual contact.

Depot contraceptives also have a contraceptive effect. Specifically, estrogens (1 pill every 7 days) and progestins (one-, three-, or six-month injections) are used. The preparation Depistone (1.0 mg ethinyl estradiol sulfate) is prescribed once a week for 3 weeks, followed by a short-acting progestin (1.0 mg norgestrel acetate) in the 4th week. Due to the significant predominance of the estrogen component, uterine hyperplasias may develop in women taking it; therefore, the preparation can be recommended for women under 40 years of age and for no more than 2 years. A single progestin injection (e.g., 150 mg medroxyprogesterone) provides a pronounced contraceptive effect for 2 months, but side effects of this contraceptive method can include irregular and prolonged bleeding, and Amenorrhea lasting many months. Depot contraceptives can be recommended for women who are unable to take medications regularly.

Continuous use of low doses of progestins (minipills)—such as Femulen, Conludar, Micronor, Microlut, and others—is recommended. These preparations are prescribed from the first day of the menstrual cycle, 1 tablet daily, particularly for women with varicose Veins, those following breast Cancer surgery, very young women, and those with an unstable menstrual cycle.

In special cases (estrogen intolerance, Lactation period in women, history of thromboembolic disorders), a single-hormone contraceptive agent, continuin (1 tablet containing 0.5 mg of ethynodiol diacetate), is prescribed. Unlike combined hormonal preparations, the contraceptive effect of continuin is primarily based not on the inhibition of ovulation, but on increasing the viscosity of the cervical mucus, which makes it impermeable to spermatozoa. The contraceptive effect of continuin is also ensured by its direct action on the blastocyst, alteration of fallopian tube motility, and prevention of fertilized egg implantation. Dosage: starting from the first day of the menstrual cycle, take 1 tablet daily without interruption, regardless of the timing of the next bleeding. The time interval between taking two tablets must not exceed 24 hours. The application is not always effective; pregnancy, sometimes ectopic, may occur.

Contraception using hormonal preparations or their combinations may cause side effects and adverse reactions. They are divided into subjective (determined by the woman) and objective (established by the physician) side effects. Most subjective side effects are considered relatively harmless in their pathophysiological nature, although they make contraception less acceptable, and in some cases unacceptable, to the woman. However, some of them, as well as certain objective symptoms, signal danger to the patient and necessitate the discontinuation of the drug. Biochemical and metabolic disturbances may appear, which, according to modern concepts, are insignificant.

Women usually complain of headache, nausea, vomiting, mastodynia, symptoms of lower extremity thromboembolism, increased vaginal discharge, and edema. These signs are considered the result of estrogen action. The onset of fatigue, irritability, nervousness, decreased libido, predisposition to depression, increased appetite, and, consequently, weight gain are considered relatively specific effects of androgens.

Hormonal contraceptives can frequently cause menstrual cycle disturbances. In particular, the previous rhythm of the menstrual cycle changes—shorter (20-24-day) or longer (36-45-day) cycles appear; marked or spotting bleeding may occur; and menstruations can be scanty or absent (hidden menstruation, suppression of menstruation).

The resulting Menstrual disorders or bleeding pose a major problem associated with the use of implantable pellets that slowly release progestins. Intermenstrual bleeding may indicate a decrease in contraceptive reliability (failure to adhere to the pill-taking regimen, simultaneous use of other drugs that accelerate steroid metabolism, or impaired absorption of Steroids in the gastrointestinal tract).

In some cases, life-threatening side effects of hormonal contraceptives are observed. A direct correlation has been noted between hormonal contraceptives, on the one hand, and CORONARY Heart DISEASE, Hypertension, thromboembolism, cerebral stroke, Metabolic Disorders, Gallbladder disease, and Liver tumors, on the other. It is believed that in these cases, Hormonal contraception is merely one of the contributing factors to the disease. Therefore, women with the aforementioned cardiovascular disorders and liver diseases, as well as those with risk factors for their development, should refrain from using hormonal contraceptives or be monitored by a physician while taking them. The onset of hypertension in women taking hormonal contraceptives should be a signal for their discontinuation. Hormonal preparations are also discontinued 4-6 weeks prior to planned surgical interventions (which may only be performed after the first spontaneous menstruation).

Following emergency surgeries, thrombosis prophylaxis should always be carried out by administering low doses of heparin. All this indicates The Need for monitoring during hormonal contraception, which consists in the timely detection of side effects of estrogen-progestogen preparations. In this regard, a follow-up examination by a gynecologist is conducted every 6 months of use, including colposcopy, smear Cytology, and breast Palpation. Blood pressure measurements, urine tests for protein and sugar are also indicated. Aspartate (Alanine) transaminase levels are determined, and in the presence of clinical symptoms, a liver ultrasound is performed.

There are guidelines regulating the use of oral contraceptives and indications for their discontinuation. Relative contraindications to hormonal contraception include a history of thrombosis and thromboembolism, liver and gallbladder dysfunction, hypertension, Diabetes Mellitus, Epilepsy, otosclerosis, Ulcerative Colitis, allergies, uterine myoma, and Chronic Kidney Disease. Absolute contraindications include acute thromboembolism, pregnancy, hormone-dependent malignant tumors, congenital defects of liver excretion, progressive liver disease, Sickle Cell anemia, pronounced hyperlipoproteinemia, cerebrovascular disease, a history of myocardial infarction, and coronary heart disease.

Indications for stopping hormonal contraception are: pregnancy, sudden acute visual impairment, acute thromboembolic complications, biliary tract pathology, jaundice and acute liver diseases, persistent increase in blood pressure, prolonged immobilization, severe migraine, planned surgical Procedures, marked weight gain, voice changes, and growth of myoma.

Mechanical contraceptives. These include, for example, vaginal diaphragms made of dense rubber, cup-shaped with an elastic rim. The Diaphragm is inserted into the Vagina so that it rests against the posterior part of the vaginal fornix on one side and the posterior surface of the symphysis on the other. A woman can insert it into the vagina herself. Usually, to enhance the contraceptive effect of the diaphragm, chemical spermicidal agents in the form of pastes, jellies, vaginal suppositories, etc., are additionally introduced into the vagina. After intercourse, douching is recommended to remove semen from the vagina. The diaphragm must remain in the vagina for at least 6 hours. Vaginal diaphragms are recommended during lactation when other contraceptives cannot be used. Contraindications include pelvic floor incompetence, old perineal tears, and uterine retroflexion.

More reliable than diaphragms are cervical caps, which are hemispherical cups made of metal, rubber, or plastic and are placed over the cervix to prevent sperm from entering it. The inconvenience of this method lies in the need to visit a doctor for the insertion of the cap. The cap can be removed by the woman herself after prior douching. Contraindications to prescribing the cap include various inflammatory conditions in the cervix and vagina (erosion, Endocervicitis, colpitis) and cervical deformation, which often occurs after tearing during childbirth.

Coitus interruptus provides fairly reliable pregnancy prevention, but it is unphysiological. Its use is harmful to the health of both men and women. First and foremost, it disrupts the orgasm phase in both sexual partners and causes high emotional stress. Post-coital deviations are also observed. Therefore, the constant use of interrupted intercourse is not recommended for preventing pregnancy, despite its accessibility.

Contraception can be achieved through a physiological method—the "rhythm" method. It is based on abstaining from sexual intercourse during the period when the occurrence of pregnancy is most likely. Observations show that ovulation typically occurs on the 12th–16th day of a 28-day menstrual cycle. Pregnancy is possible with intercourse only during the period from the 10th to the 17th day from THE START OF the previous menstruation. In the post-ovulatory period, once the corpus luteum has developed and until the onset of the next menstruation, pregnancy does not occur, even if contraceptives are not used during this time.

The advantages of the "rhythm" method are its physiological nature, harmlessness, and accessibility. Currently, it has become widespread. Errors occur with irregular menstrual cycles when it is difficult to determine the "unsafe" days. For young married couples, prolonged sexual abstinence (from the 10th to the 17th day of the cycle and during menstruation) can be difficult, and therefore the use of contraceptives is recommended during this period.

Sterilization as a contraceptive method is currently widely used in some countries, particularly in India, the UK, and the USA. In Ukraine, sterilization surgery can be performed (on both men and women) only for medical indications and with the patients' consent. Indications for female sterilization include severe cardiovascular and respiratory disorders, kidney disease, mental illness, significant pelvic narrowing, uterine scars after Cesarean Section, myomectomy, etc. Following tubal ligation, menorrhagia may occur, and irregular menstrual cycles may be observed (in 25-50% of cases). This is explained by ovarian dysfunction associated with altered blood flow and reduced transport of Ovarian Hormones to the uterus. However, there is no consensus in the literature on this issue, which casts doubt on the existence of the post-tubal ligation syndrome.

Women who have undergone sterilization have a lower risk of pelvic inflammatory disease (PID) compared to women who do not use contraceptives. Some authors explain the protective effect of sterilization by the fact that such women belong to a low-risk demographic group for PID (married women and those over 30 years of age), while others attribute it primarily to the limitation of the fallopian tube segment accessible to pathogens, regardless of whether they spread independently or attached to spermatozoa or trichomonads.

At the same time, one should keep in mind the varying degrees of PID risk among sexually inactive women, married women, sexually active women wishing to have children, unmarried sexually active women who do not wish to become pregnant, etc.

Contraception in Young Women

This group includes women aged 14–18 who have had regular menstruations (every 25–32 days) for two years and have no contraindications to the use of contraceptives. As a rule, they are initially prescribed preparations with a reduced estrogen content—trisiston or minisiston. In some cases, postinor can be recommended, which, as is well known, is successfully used in nulliparous women, since the insertion of an IUD in them is contraindicated. This especially applies to young women who have never been pregnant.

When prescribing hormonal contraceptives to young women, one should take into account the increased probability of intermenstrual bleeding (so-called "extra" periods). In this regard, a sequential change of contraceptives is advisable. In cases of scanty regular menstruation or uterine hypoplasia, hormonal contraception should be started with preparations containing predominantly estrogens and deposiston.