The majority of women in their reproductive age need contraception. Physicians in primary care and Ob/Gyn should routinely provide contraceptive counselling and services to all women of reproductive age except for those who want to become pregnant, or are pregnant, or have had tubal ligation or hysterectomy. Only by practicing contraception we can hopfully prevent un-wanted pregnancy or abortion.

The following is an update of various contraceptive methods:

Oral contraceptives remain to be the most popular and safe method for contra-ception. Many problems associated with oral contraceptives have been markedly reduced with the decrease of dosage of estrogen and progestin in recent years. The most common type of oral contraceptives currently being prescribed is the triphasic combination pill which contains the lowest dosage of estrogen and progestin. Two major areas of concern are (1) cardiovascular and cerebrovascular complications and (2) risk of cancer.

The risk of cardiovascular disease and stroke is not increased with the current low dose oral contraceptive. However, the non-fatal venous thromboembolic disease (VTE) is increased slightly especially with the new third generation progestin, such as Deso-gestrel and Gestodene. These new third generation progestins are thought to be better than the first generation progestins (Norethindrone, Ethynordiol Diacetate) for th lack of estrogenic activity, better than the second generation progestins (Norgestrel, levonorgestrel) for the lack of androgenic activity and adverse effect on lipoprotein. Britain has banned the use of these third generation progestin products. The recom-mendation of the Advisory Panel of the FDA is not to ban its use, but to use with caution. It should not be used in women with in-creased risk of VTE.

Current studies continue to confirm the early findings of decreased incidences to half to one third of endometrial and ovarian can-ers in long-term oral contraceptive users. The benefit of decreasing ovarian cancer persists even after the oral contraceptive had been stopped for many years. There seems to be an increase of cervical cancer in oral contrceptive users. However, the data is difficult to interpret because of other factors involved such as sexual histroy and HPV exposures. According to a recent report of the Collaborative Group on Hormonal Fac-tors in Breast Cancer, the overall rate of breast cancer in oral-contraceptive ever-users is not increased. However, a slight increase was noted in current users and recent users (last use within 5 yrs). In past users (last use more than 5 yrs ago), the risk is not increased. The risk is also increased in long-time users who started in their teens.

The first available subdermal implant is Norplant. It consists of six capsules of each containing 36 mg of levonorgestrel. the capsules are implanted subdermally and are effective for five years. the major side effect is abnormal bleeding. The use of Norplant in the U.S. is not popular due to the adverse report by the media with regards to the removal of the capsules. Currently, there is a class action law suit from women who en-countered difficulty during capsule removal. The second generation of the subdermal implants, Levonorgestrel 2-Rod System, has been under study for the past 5 years in the United States and other countries. It is equally effective as Norplant and is easier to insert and remove. The Levonorgestrel 2-Rod System was recently approved by the FDA, and hopefully this new system can be used by more women who need a long-term effective contraceptive method.

Depo-Provera is a long acting medroxy-progesterone which has been available for more than 20 years. However, it was not approved by FRA for use until 1991. It is a very effective and carefree contraceptive method. Depo-Provera, 150 mg intramuscular injection, is given every 3 months. Abnormal bleeding often occurs in the first three months and then amenorrhea increases.

Steroids can be imbedded in a silastic vaginal ring to give a continuous release of estrogen plus progestin or progestin alone which is absorbed through vaginal mucosa to provide adequate blood level for contra-ception. This is a new delivery method of the steroids. Women can insert the ring by themselves and remove periodically for cleaning. Each ring can be used for up to 3 months.

High doses of estrogen or estro-gen/progestin could be used within 72 hours after isolated unprotected coitus to prevent conception. This is commonly referred to as the morning-after pills. Current practice is to use Ethinyl Estradiol 100 µg and Norgestrel 1 mg (2 tablets of Ovral) as soon as pos-sible within 72 hours of exposure and repeat another dose in 12 hours. Recent study showed that a single dose of RU-486 was equally effective and had less side effects such as nausea and vomiting.

The use of IUD was very popular in the 70's and 80's. Its use has been declining since one of the IUDs caused an increased rate of pelvic infections. Several maternal deaths were reported in women who became pregnant while using the Dalkon Shield. In the 1980's, several reports implicated that the IUD increased pelvic infection which caused infertility. New studies did not find this correlation; rather, it was found that the pelvic infection was directly correlated with sexual transmittable diseases such as gonorrhea and

chlamydia. The new generation of IUD, the Copper T-380A (Paragard), is very effective and convenient to use. The pregnancy rate is less than 1 per 100 wo-men-year which makes it more effective than the older generation of IUDs. such as Lippes Loop. The IUD is not recommended for nulliparous women or anyone who has an increased risk of contracting STDs. Another concern is whether the IUD increases the risk of ectopic pregnancy. New meta-analysis of existing data from 1977 to 1994 showed that ectopic pregnance was not increased in IUD users. However, the analysis did indicate that the ectopic rate is slightly higher in past IUD users.

1. Diaphragm: the diaphragm remains to be one of the most effective contraceptive methods. However, it requires correct fitting, learning how to use it and use everytime during intercourse. The diaphragm should be used together with a contraceptive cream or jelly. for normal wear and tear, a diaphragm can be used for 2 years. Therefore, it is the most economic contraceptive method. A new diaphragm is being tested under the name of Lea’s Shield which is smaller than the regular diaphragm with one size fits all. Further information is needed to confirm its effectiveness.

2. Condom: The use of condoms has been increased in recent years due to the prevention of sexual transmittable diseases including HIV infection. Condoms, if used togther with vaginal foam, cream or jelly, is a very effective contraceptive method and the only one that also prevents STDs. Plastic condoms made from polyurethane are now available on the market. It is good for those people who are allergic to latax condoms. According to current studies, it is equally effective and acceptable to the users.

3. Female Condom (Plastic vaginalpouch): this is a plastic pouch with an inner ring to be inserted like a diaphragm and an outer ring which stays outside the vaginal introitus and covers the entire valvar-perineal region. It is equally effective as the male condom for both contraception and prevention of sexual tramsmittable diseases.

4. Chemical vaginal contraceptive preparation: At the present time, there is only one spermicidal preparation available on the market. That is Nonoxynol-9 which also has anto-microbial activity including anti-viral activity. Research in this area is very active in hope of finding other antimi-crobias which also has contraceptive activity. The products in research include Gramicidin, Aryl 4-guanidinobenzoate and C31 G (a mixture of alkyl amine and alkyl betaine).