This book is designed primarily as a guide to pregnancy, together with its associated aspects and problems. Family planning, or the control of conception, is an essential part of the subject of reproduction since ideally a child should be born because it is wanted, not because it cannot be prevented. This ideal is made possible by the intelligent understanding of conception and the use of modern contraceptive methods whereby conception can be controlled satisfactorily and safely. The majority of marriages are more satisfactory when there is a good sexual relationship, and this can be achieved more easily by the confident use of conception control than when there is a constant fear of unwanted pregnancy.
That contraception is entirely for the prevention of conception is a rather out-dated idea which must be replaced by the more modern view of the control of conception: that a couple may produce the number of children they desire at a spacing they consider to be expedient, according to their social and economic circumstances. The natural desire to exercise this voluntary control is rapidly increasing with the result that more frequent demands are made for advice and discussion on the available methods of contraception. For various economic and social reasons, the limitation of family size and the optimal spacing of children is a necessity for most married couples.
The National Health Service in Great Britain is in the process of accepting responsibility for the provision of a comprehensive service to advise on the control of conception, mainly because of popular demand and public pressure. Meanwhile, the Family Planning Association, who have more than one thousand clinics throughout the United Kingdom, provide an excellent service. This association is entirely voluntary and its ability to cater for the entire population is, therefore, somewhat restricted. Most local authorities now provide a rather limited family planning service, and the number of family planning clinics in hospitals is gradually increasing, although the majority only provide this service for their own postnatal or other patients.
From a medical point of view certain conditions may provide a temporary or permanent threat to the health of a woman should she become pregnant. These are surprisingly few and far between but pregnancy must be satisfactorily controlled. Pregnancy may be permanently advised against in the presence of a few rare conditions such as advanced heart disease, advanced renal disease, previously treated and cured malignant disease, and some other rare illnesses seldom seen in the United Kingdom. Limiting the number of pregnancies may be necessary in a woman suffering from severe Rhesus incompatability, although this is becoming an increasingly rare condition. Temporary postponement of pregnancy is advisable after an operation or debilitating disease, or after severe preeclampsia in a previous pregnancy, or as a result of recent ‘mental breakdown’, or for social reasons such as caring for elderly relatives or children who are unwell.
From a purely scientific point of view, the medical reasons for limiting or spacing pregnancies must have a very elastic interpretation. Fear of an unwanted pregnancy may have very serious effects on the mental and physical health of a woman. It can limit or stop her desire for sexual intercourse, so that her relationship with her husband may become strained or even break down, and this has far-reaching effects on the health and welfare of the whole family.
Any reliable method used for the control of conception depends for its efficiency on its correct and proper application. Most couples practice some form of conception control without ever having any knowledge, consideration or discussion of all the techniques available to them. It is strange how the most enlightened woman, or even doctor, becomes biased in an opinion of one or more contraceptive methods. The reliability of the different methods must always be considered before a decision is reached and it must be remembered that published figures are often prejudiced by vested interests or by personal enthusiasm.
The choice of contraceptive method depends upon the particular requirements of the couple concerned. It is of paramount importance that if a woman is going to use a contraceptive it must be acceptable to herself as well as to her partner. Her sex life is her own affair and it should not be influenced by elderly relations, neighbours or girl friends. If the method chosen is not acceptable to her mentally, psychologically or aesthetically, then it is bound to have a deleterious effect upon her normal and harmonious sex life. She can only reach a satisfactory decision as a result of enlightened and frank discussion after all the facts have been placed at her disposal.
The methods available are:
Abstinence during the fertile phase
2. Female contraception
Spermicidal substances in the vagina
Intrauterine contraceptive devices
Suppression of ovulation
Altering cervical mucus
3. Male contraception
Withdrawal (coitus interruptus)
Condom or sheath
Total abstinence is the only absolute and certain method of preventing conception. It must be remembered, however, that sperms deposited at the vulva or at the entrance to the vagina can migrate up the vagina and may therefore result in conception. This can happen in a woman who still has an unruptured hymen and has never had complete sexual intercourse. Sperms can also be transferred after ejaculation by a finger inserted into the vagina.
Abstinence during the Fertile Phase
This is known as the ‘rhythm method’, involving the use of the ‘safe period’ which depends on avoiding sexual intercourse during the days when conception is likely to occur. It is a method of control of conception accepted by the Roman Catholic Church. The use of the safe period depends on certain basic principles which must be properly understood if it is to be used as an efficient method of conception control.
The normal menstrual cycle lasts for approximately 28 days, but the duration of the menstrual cycle varies from woman to woman and a regular 28-day cycle is by no means an absolute rule. The importance of this point is that ovulation occurs 14 days before the next menstrual period and not 14 days after the previous period. At ovulation the egg is shed from the ovary and unless it is fertilized within 18 hours it dies. It necessarily follows, therefore, that fertilization must occur within 18 hours of the time of ovulation. Counting the first day of the period as day 1 of the menstrual cycle, ovulation occurs on the 14th day of a 28-day cycle, but since it also occurs 14 days before the next period, it will be on the 15 th day of a 29-day cycle, the 13th day of a 27-day cycle, the 20th day of a 34-day cycle, or the 21st day of a 35-day menstrual cycle.
The exact timing of ovulation may vary even in a person who has a very regular menstrual cycle, although not usually for more than 24 hours on either side of the 14th day before the next period. It may occasionally vary by as much as 3 days, especially as a result of stress, strain or shock. Thus, although ovulation usually occurs 14 days before the next menstrual period it may frequently occur anywhere between the 13th and 15th day of a regular 28-day cycle, and can, on rare occasions, take place anywhere between the 11th and the 17th day (or between the 18th and 24th day of a 3 5-day cycle).
Newly ejaculated sperms are contained within the semi-gelatinous seminal fluid which is slightly alkaline. The vagina is acid and the cervix alkaline. Unless sperms can gain access to the cervix within 15 or 20 minutes following ejaculation they are killed by the acid medium of the vagina. Those that gain access to the alkaline environment of the canal of the cervix rapidly swim up the uterus and along the Fallopian tubes. This journey takes approximately 45 minutes. These sperms survive and remain capable of fertilization for approximately 2 days, but may occasionally live for as long as 3.
By adding together the extremes of sperm survival on the one hand and the range of ovulation on the other, it can be seen that in a normal 28-day menstrual cycle it is possible for conception to occur if intercourse takes place at any time between the 9th and the 17th day inclusive. This is the ‘dangerous period’. The safe period is divided into two parts: the first 8 days of the menstrual cycle, counting from the onset of menstruation and from day 18 to day 28 inclusive, providing the woman has a 28-day cycle. If the menstrual cycle is regular and these rules have been carefully applied conception is unlikely to occur, but a warning must be given that there are plenty of instances of women becoming pregnant following intercourse even as early as the second or third day of a regular 28-day menstrual cycle. This conception results either because sperms have survived for a particularly long time, or, more likely, because of so called ‘spurious ovulation’ at an unusually early day in the cycle. Such a pregnancy is quite normal. Ovulation in the human female, unlike some animals, is not dependent on either sexual intercourse or orgasm but spurious ovulation is a rare phenomenon which may be provoked by sexual stimulation.
The safe period must be very carefully calculated if the visual cycle is not a 28-day cycle. For instance, in a 35-day regular menstrual cycle the dangerous time is from day 15 to day 25 inclusive, so that under these circumstances the safe period is from the first to the 15th day and from the 25th to the 35th day. When the menstrual cycle is irregular, then the time of ovulation is correspondingly irregular and it is difficult to calculate the expected safe period.
A previously regular menstrual cycle may become irregular in the immediate postnatal months, or as a result of travel, strain or illness, and also in the late thirties or early forties, and it is during these times that the safe period is unreliable.
Spermicidal Substances in the Vagina
Chemical spermicides are available as soluble pessaries, creams, jellies or foaming tablets which are inserted into the vagina before intercourse. Spermicidal substances used alone are not recommended because they are not completely reliable and should be used with some form of occlusive device or diaphragm. Spermicidal substances themselves contain chemicals which kill sperms very rapidly, but if ejaculation occurs directly into the canal of the cervix there is no opportunity to kill the sperms before they gain access to the cervical canal. It is for this reason that spermicides only constitute a reliable contraceptive when used with some form of occlusive device. A list of efficient chemical spermicidal preparations which have been tested may be obtained from the Family Planning Association or any of their clinics.
Sponges or tampons soaked in a spermicidal chemical and placed in the upper vagina prior to intercourse are designed to prevent direct ejaculation into the cervical canal. These are relatively inefficient, however, since they are frequently displaced during inter-course and are now little used.
Douching the vagina with a spermicidal or antiseptic solution immediately after coitus in order to wash away the sperms that have been implanted in the upper vagina is a fairly common method of attempting to achieve contraception. It can only be effective if done immediately after sexual intercourse and before any spermatozoa have managed to reach the alkaline medium of the cervical canal, whence they cannot be dislodged. This method has very obvious aesthetic disadvantages as well as being highly inefficient and occasionally dangerous.
An occlusive diaphragm is a rubber or plastic diaphragm which is placed in the vagina, either over the cervix alone or over both the cervix and the anterior vaginal wall, and forms a barrier to the direct passage of sperms into the cervical canal. Sperms can, theoretically, pass round the edge of such a diaphragm and it is therefore only completely effective when used with a chemical spermicidal agent. Sufficient time must be allowed for complete destruction of the sperms before the diaphragm is removed. In actual practice the diaphragm is liberally covered with spermicidal cream or jelly and inserted at any convenient time before intercourse. It should remain in position for a minimum of 6 hours after intercourse. A properly fitted diaphragm causes no discomfort and neither the owner nor her partner should be aware of its presence. Because an occlusive diaphragm is always used with a spermicical cream, douching is unnecessary either after intercourse or after the diaphragm has been removed.
Since it is essential that a diaphragm should fit properly your doctor or the local Family Planning Clinic should be consulted if this method of contraception is contemplated. The technique of inserting an occlusive diaphragm is very simple and although its removal may sound complicated, it is also extremely simple, and the proper use of a diaphragm can be mastered very quickly and efficiently by most women. When a diaphragm is first fitted complete instructions are given for its use. A second visit after a few days shows the doctor whether the diaphragm is being inserted correctly and placed in the proper position.
The size of the diaphragm should be checked regularly since the size and shape of the vagina may change, especially if there is a marked change in weight, or as a result of illness or the formation of vaginal prolapse, or following pelvic operations. In any event, every woman should have a routine vaginal examination, together with a cervical smear and discussion of her contraceptive technique every one or two years. A diaphragm always needs refitting after childbirth and this is usually done at the postnatal clinic.
There are three main types of occlusive diaphragm: the Dutch cap, the cervical cap and the Vimule.
The Dutch cap, or vaginal diaphragm, is a dome-shaped diaphragm made of thin rubber with a rubber covered metal rim containing a spring. The sizes vary from 60 to 95 mm. in diameter. The diaphragm, fits on the anterior vaginal wall stretching from the posterior fornix of the vagina, just behind the cervix, downwards to rest just behind the symphysis pubis. It thus Covers the cervix, and during intercourse the penis is introduced into the vagina between the diaphragm and the posterior vaginal wall, so that ejaculation occurs in a position where the sperms cannot gain direct access to the cervix. The diaphragm itself is held in position by the tension of the gentle spring in the rim. It is unsatisfactory when the vaginal tone is lax, or when a considerable degree of prolapse is present, since it cannot then be retained easily, and it may also be unsatisfactory after repair operations on the vaginal wall.
The correct size of diaphragm is extremely important because a properly fitting diaphragm is both efficient and completely comfortable so that the woman is not conscious of its presence. A diaphragm may be inserted either by compressing it between the fingers or by introducing it into the vagina on a special applicator. When a diaphragm is fitted, instructions are given about the type of spermicidal cream or jelly that should be used and the amount that should be placed upon each surface.
The majority of women who use a diaphragm find it is satisfactory, especially if it is inserted every night as a matter of routine. Most women remove it the following morning about 8 hours after intercourse although at least 6 hours is generally stated to be sufficient. The main reasons for pregnancy occurring when this method is used are that the woman has been careless or has a retroverted uterus. If the uterus is tilted backwards it is very easy to insert the diaphragm so that its upper margin lies in the anterior vaginal fornix thus leaving the cervix exposed. If a woman has a retroverted uterus then special care must be taken in fitting the diaphragm and in its subsequent use.
The cervical cap is a rubber device shaped rather like a thimble with a solid rolled rubber rim. It is available in five sizes and fits snugly to the column of the cervix where it is held by suction. Since it is only reliable if the cervix has parallel sides, is healthy and not lacerated by previous deliveries, the cervical cap is not as popular as the vaginal diaphragm. However, when the uterus is retroverted, the cervix points downwards and forwards into the vagina and the cap is then more easily manipulated onto and off the cervix. Some women prefer a cervical cap to a diaphragm, despite the fact that it is more difficult to manipulate, mainly because it is smaller, covers less of the vaginal wall and may allow more satisfaction during intercourse. Contrary to general belief it is seldom dislodged during intercourse. Very accurate initial fitting as well as careful instruction in its use are essential. It should always be used with a spermicidal cream or jelly and removed about 8 hours after intercourse.
The Vimule is a cross between a diaphragm and a cervical cap and, like these, has to be accurately fitted and careful instruction given to the woman before its use. It remains in place by suction and must be used with a spermicidal cream or jelly.
Intrauterine Contraceptive Devices
Intrauterine contraceptive dcvices arc made of metal or plastic and placed within the cavity of the uterus. They became popular in the 1930s when Grafenberg developed a silver coiled wire ring which was inserted into the cavity of the uterus and left there undisturbed for approximately one year before being removed or changed. Its major disadvantage was that it required an anaesthetic for both insertion and removal. Before this, various types of intrauterine and intracervical contraceptive devices had been used though the majority had, for various reasons, been found unsatisfactory.
The Grafenberg ring earned an undeservedly bad reputation, not only because it was said to be inefficient and ineffective, but also because it was supposed to cause infection in the uterus and the pelvic organs and predispose the woman to cancer of the uterus. In fact from about 1930 to 1950 it was one of the most efficient forms of contraception available. It certainly never caused infection, or the likelihood of cancer of the uterus, but if a woman using a Grafenberg ring developed pelvic infection the symptoms were aggravated by its presence in the uterus.
It must always be remembered that the whole problem of contraception or the control of conception is bedevilled by bigotry and prejudice, and many doctors and scientists have condemned the Grafenberg ring and other intrauterine contraceptive devices because of supposed complications that never existed in reality. After the second world war the pressing need for population control on a scale not previously envisaged resulted in a more critical examination of these methods, as a result of which plastic devices were introduced. They varied in shape and size, as well as in the type of plastic used and eventually replaced other materials such as tantalum, steel, stainless steel and nylon, partly because of their reliability and flexibility, but also because of the ease and cheapness with which they could be produced. The Lippes Loop, Margulies Spiral, Birnberg Bow, Saf-T-Coil and Dalkon Shield became very popular. More recently devices incorporating copper elements which increase their efficacy by a local effect have been introduced and have gained widespread acceptance. The development of safe intrauterine devices has led to their acceptance in most communities.
These devices are flexible so that they can be straightened and fitted into introducers which are then passed gently into the canal of the cervix, after which the device itself is released within the cavity of the uterus to take up its previous shape. The majority have fine nylon threads that hang down through the cervix into the upper vagina, and can be felt by the woman herself or by an examining doctor to make sure that the device is in a satisfactory position.
The threads are so fine that they do not interfere with normal intercourse and neither partner is aware of them. The technique of insertion of a plastic device is simple in any woman who has had a baby or even a miscarriage, and is also painless, or associated with only mild discomfort. It is possible to insert one without any pain or discomfort into some women who have never been pregnant, but the majority, as well as all unduly nervous women, do require an anaesthetic. The removal of the device by pulling gently on the threads is simple, easy and painless.
Intrauterine devices (including the more recently introduced metal and plastic ones) are now previously sterilized by a special irradiation technique which makes their insertion even more simple than before. Some women experience minor degrees of uterine cramp, rather like period pains, immediately after insertion but this is generally relieved by codeine or a similar drug. The device should be inserted cither during or immediately after the period to ensure that the woman is not pregnant. Slight continuous or intermittent bleeding may occur for a few days and the first few periods may be unduly heavy or prolonged. Not all women can tolerate these devices and approximately 20 per cent have to be removed within 3 months because of discomfort, actual pain, continuous and heavy bleeding or vaginal discharge.
The exact mechanism whereby an intrauterine contraceptive device works is not known. The following suggestions have been put forward:
1. The presence of a device alters the chemical composition of the fluid within the uterus and the mucus within the canal of the cervix so that the sperms cannot penetrate through either the cervix or the uterus.
2. The presence of the device within the uterus makes the migration of sperms more difficult.
3. The device provokes increased contractions of both the uterus and the Fallopian tubes, so that the fertilized ovum is propelled towards the uterus far more rapidly than is normal and reaches the uterine cavity before its chorionic villi have developed, or before the lining of the uterus is ready to receive it. This is the most probable factor.
4. The normal preparation of the endometrium is prevented by the presence of the device.
5. The device increases the contractions of the uterus, so that it expels the newly fertilized ovum.
It must always be remembered that the majority of people have very definite views about contraception, particularly about the method of contraception which they themselves should adopt, and despite what anyone may say they will use the contraceptive of their choice. If they are forced to use a contraceptive they do not like or in which they have no confidence, it can quite easily exert a deleterious effect upon their sex lives. One of the strongest indications, therefore, for the use of an intrauterine device is for those people who request it because they do not wish to take hormones nor do they wish to use any mechanical form of contraception, or to practise coitus interruptus or the safe period. It is undoubtedly a relatively efficient and acceptable contraceptive for those women who can tolerate it, although a woman who is happy using a simple mechanical contraceptive correctly, or safely taking an oral contraceptive, gains nothing by using an intrauterine device. Their ideal use and their main value are in the population control of a whole community but there is no reason why they should not be used by particular individuals who so desire.
The contra-indications for intrauterine contraceptive devices are:
1. If a woman has pain with her periods (especially if she has never been pregnant) then an intrauterine device is likely to make it more severe. A small amount of pain may not matter, but fairly severe menstrual pain should be discussed with a doctor or at the clinic before the device is inserted.
2. If the periods are unduly heavy or prolonged then very careful thought must be given before a device is inserted, because they always have a tendency to increase both the amount and the duration of bleeding. This does not matter if the period is short or the amount of bleeding very little, but if the periods are prolonged or the bleeding profuse then a device should not be inserted until these symptoms have been eliminated.
3. An intrauterine device should not be inserted if there is pelvic infection but can usually be inserted with complete safety after this has been cured.
4 Intrauterine devices used not to be inserted unless a woman had been pregnant as it was technically difficult and rather painful unless performed under anaesthetic. With the introduction of the newer and smaller devices this is no longer true and the patient who has never been pregnant can usually have a device fitted with minimal discomfort. This possibility may be ascertained by a simple examination.
5. Intrauterine devices are not usually inserted until several weeks after delivery and during this time some alternative method such as a diaphragm or sheath should be used.
Suppression of Ovulation
If ovulation, or the production of ova, is stopped the woman cannot become pregnant.
Oral Contraceptive Pill
The two main hormones produced by the ovary are oestrogen and progesterone. The administration of both of these hormones in the correct dose will suppress ovulation, but if either progesterone or oestrogen are given alone it requires a relatively high dose to prevent ovulation. A combination of the two hormones is therefore used in the majority of oral contraceptive tablets. The amount of oestrogen which each tablet may contain is limited in Great Britain to 50 microgrammes per day, because higher doses than this have been shown to increase the incidence of clotting disorders in the blood.
Small doses of some progesterone preparations will also act as quite efficient contraceptive agents by altering the constituents of the mucus in the cervical canal as well as the contractions and secretions of the Fallopian tubes, but the contraceptive pills in general use in Great Britain are limited to those which suppress ovulation, although they may also have some of these effects. A great deal of money is being spent on research into the causes of side effects of the contraceptive pill and undoubtedly improved pills and completely new contraceptive agents will be available in the foreseeable future.
Oral contraception by the suppression of ovulation is the most efficient of all contraceptive methods yet available. Approximately one million women in Britain take an oral contraceptive. The tablets are taken for 20 or 21 days in each menstrual cycle, starting on the 5th day after the onset of the period. (Some brands are marketed in packets of 28, containing the 21 tablets with active ingredients followed by 7 tablets containing sugar, or a similar substance, so that one tablet is taken every day.)
The exact mode of action of oral contraceptives is still in doubt. Although their efficiency is accepted and has been widely exploited in their favour, the exact reason for this efficiency is not precisely known. The administration of a small quantity of a mixture of oestrogen and progesterone certainly exerts an influence upon the delicate mechanism of ovulation and seems to hoodwink the body (especially the pituitary gland) into believing that ovulation is not necessary and, therefore, the production of an ovum is suppressed. The mechanism is very similar to that which causes the suppression of ovulation during pregnancy.
The enormous controversy that exists concerning the administration of the contraceptive pill for contraceptive purposes is clouded by many irrelevant issues. It has both good and bad aspects and its advantages and disadvantages are an individual matter for every woman.
The hormones, progesterone and oestrogen, used in contraceptive pills are accepted in much larger doses by doctors and scientists as being satisfactory for the treatment of gynaecological disorders and threatened abortion in early pregnancy. Any drug carries certain dangers, however slight, just as there are dangers in crossing a busy street. From a purely medical point of view, the controversy over the use of oral contraceptives is whether it is justified to administer drugs for contraceptive purposes when there is no medical reason to prevent a pregnancy. An injection of morphine may be given to a man who has just broken his leg in a car accident, but no one would give this to a man if he was not in pain. While some people believe that oral contraception is justified by virtue of its very high rate of efficiency, others, who accept the principle of the control of conception, are incapable of objective evaluation of the methods available. Oral contraceptive agents may contain hidden and as yet unknown dangers, but at the present stage of our knowledge it is surprising how many intelligent and well-meaning people have a genuine opinion against their use. Some doctors feel very strongly about these views, especially if they are asked to perform abortions on patients whose ‘boy friend did not like the idea of the pill’ or whose mother ‘could never agree to it anyway’.
Oral contraception is by far the most efficient contraceptive available. The pregnancy rate is virtually nil amongst those who take the tablets conscientiously and regularly. It is easy, simple and aesthetically acceptable. It does not interfere with sexual intercourse and there are no mechanical devices involved. It controls the menstrual cycle to a regular 28 days and reduces the amount of menstrual loss, as well as controlling or eliminating pain with the periods. There are many other minor advantages.
The modern contraceptive pill contains approximately 10 per cent of the dose of hormone administered in oral contraceptive tablets 20 years ago. The side effects are, therefore, less severe and fewer in number than those previously encountered, but, as the dose of hormone in oral contraceptives has gradually been reduced, the incidence of ‘break-through’ and intermenstrual bleeding has increased. This is related to hormone imbalance and may occur during the first few days of taking a contraceptive pill, or even the first few cycles. This ‘spotting’ between periods varies considerably but affects about 5 to 10 per cent of women who take the pill. The blood loss usually begins on or about the 17th day of the cycle and continues for 1 or 2 days, or, on occasions, lasts until the next period. Rarely is the bleeding sufficiently heavy to be like a period itself. If spotting alone occurs the tablets should be continued for the remainder of the cycle, but if the bleeding is as much as a period the tablets should be discontinued and a fresh course started on the 5th day of the bleeding. Your doctor should be told if this type of bleeding recurs.
Some people are unduly sensitive to specific drugs and this is as true of hormones as it is of antibiotics or aspirin. It is very difficult to assess the other side effects of oral contraceptive agents. Most people, especially women, are either ‘pro-pill’ or ‘anti-pill’ while a few are neutral.
Nausea is usually a transient symptom beginning shortly after the first tablet is taken and lasting for only a few days. It may, however, continue for much longer and become increasingly severe. Actual vomiting is unlikely with modern low-dose contraceptive tablets but does occasionally happen in women who are hypersensitive to hormones.
Fluid retention within the body may produce the rather annoying group of symptoms of which some women complain for a few days before their period: breast enlargement and tenderness, nervousness, irritability, depression, a general sensation of lethargy, headache or even migraine, swelling of the fingers and ankles and a generalized feeling of being waterlogged or bloated. Most women retain fluid for a few days before a period but the severity of the symptoms of premenstrual tension is not always related to the amount of fluid retained. Some women who gain 1.8 or 2.2 kg. in weight have quite severe symptoms while others have no symptoms at all. This applies to women taking oral contraceptives and it is made even more difficult to understand since one of the more successful treatments for premenstrual tension is to give a woman a low-dose oral contraceptive.
Weight gain. Most women undoubtedly gain weight while taking the pill just as some women gain excess weight when they are pregnant. There is a factor in the oral contraceptive agents which causes some fluid retention and may even cause some weight increase but the majority of women gain weight while taking contraceptive pills because they are eating more. Women with a weight problem must be even more careful if they take oral contraceptives. Uncontrolled weight gain is obviously undesirable.
The breasts may increase in size if there is development of breast tissue. This is usually considered an advantage, although the increase is sometimes sufficiently marked to be unwelcome. Breast enlargement may cause discomfort and occasionally pain which is so severe that the pill has to be stopped.
Menstruation itself is normally very much shorter, the loss reduced and the blood darker; actual cessation of periods may occur while taking an oral contraceptive, but this should not give rise to concern, because they will nearly always begin shortly after the pills are discontinued. Only on very rare occasions is a drug, such as Clomiphene, necessary to restore the normal menstrual rhythm after a long course of oral contraception.
Sexual behaviour. The psychological effect exerted by the oral contraceptive pill is virtually impossible to predict. Some women have an increase of libido and others undoubtedly have a suppression of sexual desire, but whether these changes in sexual behaviour are psychological or a result of the hormones themselves is not certain.
The dangers of oral contraception have been very much overstressed but should nevertheless, always be considered with its advantages and the requirements of the woman concerned:
The genital tract. There is no evidence that oral contraceptive tablets predispose to cancer of the uterus or the cervix; in fact it is just the opposite. The mucous secretion from the cervix may be increased causing a certain amount of whitish vaginal discharge. The continuous administration of oral contraceptives undoubtedly predisposes some women to fungus infections of the vagina. An isolated attack can be easily cured by a fungicidal agent and recurrent attacks prevented by treatment on one night each week for an indefinite period. These infections, however, while they are not dangerous, may cause such irritation and annoyance that a woman will change her contraceptive technique.
The breasts. Oral contraceptives do not cause cancer of the breast or even make it more likely to develop, but their use is not advised in any woman who has suffered from malignant disease and this is especially applicable to those women who have suffered from cancer of the breast itself.
The liver. Oral contraceptives may alter the function of the liver but not to a degree that can be recognized clinically. They are not given to a woman suffering from severe liver disease, or to anyone who has been recently jaundiced.
Carbohydrate metabolism. A great deal of publicity has been given to changes which may occur in the carbohydrate (or sugar) metabolism in women taking oral contraceptives. It is thought that they might cause diabetes or other abnormalities of metabolism, and although there is, as yet, no agreement on this it seems certain that any such possible dangers are less than those of pregnancy itself.
Heart disease. Expert advice should certainly be obtained by any woman who suffers from any form of heart disease before embarking on a course of oral contraceptives, although they are not necessarily forbidden.
Varicose veins. A number of women who take oral contraceptives complain that varicose veins in their legs become more prominent, or that actual varices have developed while they have been taking the pill. It is not known if contraceptive pills exert any influence on the formation or increase of varicose veins.
Tbrombo-embolic disease. Both oestrogen and progesterone cause changes in the clotting mechanism of the blood, but the clinical importance of this has been difficult to assess. Undoubtedly, oestrogen causes the greater changes and it is for this reason that the amount of oestrogen has been restricted in oral contraceptives available in Great Britain.
The main problem with regard to alterations of the blood clotting mechanism is that clots which form in blood vessels may then circulate to the lungs and cause what is known as a pulmonary embolus. If the pulmonary embolus is sufficiently large, then sudden and dramatic death may occur. It is estimated that about 1 in every 2,000 women who are taking the pill is admitted to hospital each year for treatment of a venous thrombosis associated with an embolus, whereas in women who are not on oral contraceptives the figure is about 1 in every 20,000. There is also a strong relationship between the use of oral contraceptives and deaths from pulmonary emboli. Deaths occur in approximately 1 in every 100,000 women taking the pill each year. This risk of death is about seven times greater in women who are taking the pill than in women who are not on oral contraception.
The risk of thrombo-embolic disease to a woman on an oral contraceptive is definite although difficult to assess, but it is certainly less than the risk of thrombo-embolic disease during pregnancy. There is no relationship between oral contraception and heart disease or coronary thrombosis.
Pure statistics show that oral contraception is not only the most efficient but is also the safest method of control of conception, since alternative methods, being relatively inefficient, lead more frequently to abortion or pregnancy where the dangers are greater than the intrinsic dangers of the pill itself. There are risks in every form of medication and the risk inherent in taking oral contraceptive pills must be weighed against the known hazards of pregnancy or abortion. Contraceptive pills are not prescribed for any woman who has suffered from malignant disease, liver dysfunction, cardiac disease, renal disease, diabetes, mental depression, epilepsy or who has a history of thrombo-embolic phenomena or thrombophlebitis.
The contraceptive pill can be taken after delivery. Women who are not breast-feeding should start the pill on the 21st day after delivery regardless of the amount of vaginal bleeding still present, so that the first period will begin approximately 6 weeks after confinement. A woman who is fully breast-feeding will not usually ovulate, so she will not menstruate or become pregnant. When weaning begins ovulation recommences and since a woman is unaware of exactly when it occurs, she may conceive. If she is breast-feeding she should start the pill about 21 days before she plans to start weaning her baby. If a period does not come after the first course of tablets she should wait 7 days and start the next course of tablets. A period will arrive after weaning has been completed.
The pill is often prescribed for women who are breast-feeding although lactation is occasionally affected.
The ‘once only’ pill. A particular form of contraceptive pill which has received a great deal of publicity recently, although it does not exist in Great Britain, depends on the theoretical principle that the endometrium, or the lining of the uterus, will be shed if the uterus is given a large amount of hormone in one dose.
This type of contraceptive (or abortion) agent is somewhat unreliable. The later it is given, the less likely is it to be successful. If the tablets are taken after the ovum has embedded on the 21st day of the cycle they are’unlikely to succeed in producing an abortion, but a larger dose of hormone may cause one. If the pregnancy continues despite the administration of these drugs, it is not harmed—similar hormones are frequently used to treat women suffering from threatened abortion. The ‘once only’ pill has obvious advantages for the woman ‘taken unaware’. It is still only in its trial stages and, even if it can be perfected, may not be accepted for a long time.
Long Acting Injections
Loss acting hormone preparations were originally used in underdeveloped countries where the regular use of contraceptives could not be guaranteed. The popularity of such injections is growing in this country and they are particularly useful where combined oestrogen-progestogen pills are contra-indicated or where it is essential that a woman runs no risk of pregnancy, such as in the 3 months after rubella vaccination.
The injection consists of a progesterone derivative which is slowly released from an oily medium over the course of 3 months. Although the injection suits the majority of women who try it, the occurrence of annoying side-effects such as the cessation of irregularity of periods or spotting of blood has prevented its widespread use as a routine contraceptive.
Altering Cervical Mucus
Sperms are deposited at the top of the vagina during ejaculation. The semi-gelatinous seminal fluid protects them from the acid of the vagina for about 15 or 20 minutes, after which they are killed unless they have managed to enter the canal of the cervix. The cervical canal is filled with slightly alkaline mucus which allows them to live. It seems, however, that this mucus is only able to keep the sperms fit and alive when the oestrogen and progesterone which normally circulate through the female body are at a particular level and in a precise balance. These conditions only occur immediately before and during ovulation when the cervical mucus undergoes characteristic changes and there is rapid sperm penetration and easy access to the upper genital tract. It is now believed that sperms are almost completely incapable of penetrating through the barrier of the cervical mucus at any other time during the menstrual cycle.
It should be theoretically possible to alter the hormone balance only very slightly but nevertheless sufficiently to prevent these characteristic changes in the cervical canal at ovulation. The cervical mucus would thus be permanently impenetrable to sperms. Small doses of some progesterone-like substance administered each day will, in fact, have this contraceptive action while being too small to suppress ovulation. Several substances that have been marketed have proved quite effective but have been withdrawn from the British market because of unsatisfactory side effects. It is very likely that drugs acting in a similar manner but without side effects will be available in the not too distant future.
Surgical sterilization of a woman involves blocking the Fallopian tubes which are the passages from the ovaries to the uterus so that neither sperms nor ova can travel along them. Generally speaking, before this is done the written consent of both wife and husband must be obtained. Sterilization of a woman must always be considered as an irreversible procedure, although a few operations to repair Fallopian tubes that have previously been divided or tied have been successful. Reconstruction is impossible if the tubes have been removed.
Sterilization is performed by making a small incision in the lower abdomen and tying, dividing or removing the Fallopian tubes. The operation is today considered less hazardous than the removal of the appendix, but it does require admission to hospital that varies from 3 to 7 days, and a general anaesthetic.
Sterilization by laparoscopy has grown in popularity in recent years. The laparoscope, a very thin telescope, is inserted through the umbilicus and used to visualize the Fallopian tubes. A second small instrument is used to occlude the tubes by diathermy to destroy small segments or by the application of dips or rings to a loop of Fallopian tube. This operation also requires a general anaesthetic but the stay in hospital is reduced to 2 or 3 days.
Sterilization by removal, cutting or diathermy of the Fallopian tubes has no untoward effects after the immediate convalescence from the operation. The periods, the menstrual cycle, menopause, sexual intercourse, sexual satisfaction, and libido are completely unchanged.
It is important that the irreversible nature of the operation of female sterilization is properly understood by any woman and her husband before it is undertaken. A final word of warning is that in very rare instances pregnancy has been known to occur in women who have had their Fallopian tubes either tied or divided.
Coitus interruptus is an extremely common practice to which people usually refer when they say that pregnancy has been avoided by ‘being careful’. Sexual intercourse takes place in a normal manner but the penis is withdrawn immediately before ejaculation. The unreliability of this method is obvious, but it nevertheless has general advantages. It costs nothing and it requires no equipment. It has a high failure rate. The obvious cause of failure is when ejaculation occurs within the vagina, but even if this is avoided the prostatic fluid secreted prior to ejaculation may contain active sperms. Also it is possible for sperms ejaculated at the vulva to migrate up the vagina and enter the uterus.
Coitus interruptus not only imposes a strain upon the man but is also a common reason for the failure of the woman to achieve an orgasm and therefore she does not enjoy intercourse fully. It can thus cause an anxiety state in both partners and the possibility of an unwanted pregnancy adds a further strain. It is not a method that can be recommended but, despite this, is widely used with a high degree of success by a large number of people who make no complaints. It must be repeated, however, that basically the method is unreliable and that people who practise it would probably enjoy their sexual intercourse more frequently and more fully if they used an adequate contraceptive.
Condom or Sheath
In this method the penis is completely covered by a sheath made of very thin rubber (the condom) which is used only once, or a thicker material (washable sheath) which can be used repeatedly. A lubricant is advisable, although the majority of sheaths are already lubricated with a spermicidal jelly or cream. The condom is a fairly reliable method of contraception. Its failure rate depends on the care with which it is used so that the sheath does not break or slip. Some women prefer to use a soluble spermicidal pessary as an additional precaution. It can, however, cause psychological disturbances sufficient to interfere with the potency of some men and many couples object to it because of the impairment of sensation or because of the inevitable interruption when the sheath is put on, since it can only be placed on the penis during an erection.
Several drugs have been developed which either suppress formation of sperms or reduce their speed and energy. These are efficient contraceptive agents because they render fertilization impossible but have, so far, proved either too toxic or have caused impotence. An acceptable male contraceptive pill will undoubtedly be perfected in the near future.
Surgical sterilization of a man is known as vasectomy. Sperms travel along a small duct called the vas deferens from the testicle to the prostate and thence eventually to the penis. The operation, designed to cut and tie the vas as it passes along the inguinal canal in the groin, is a comparatively minor surgical procedure which can be performed under a local anaesthetic in a few minutes. Some surgeons prefer to operate under general anaesthesia, but even then the patient need stay in hospital no longer than a day. The advantage of male sterilization is the ease with which it can be accomplished, and that it is reversible by a further operation in more than 70 per cent of men. (In the woman, operation for reconstruction of the Fallopian tubes is much less satisfactory.) The operation should, nevertheless, be regarded as irreversible.
Following vasectomy, sperms are still present in the seminal fluid for a considerable number of weeks and sexual intercourse need not be avoided but adequate contraception must be used until all sperms are known to have disappeared. This is done by performing seminal analyses. Two consecutive analyses showing a complete absence of sperms must be performed before contraceptive-free inter¬course is allowed, and this may take as long as 3, or even 6 months.
There is no evidence that male sterilization by vasectomy has any deleterious effect upon either the psychology or the sexual activity of the male although it is still believed that this could easily occur, especially in a man who is particularly sensitive.
If sterilization is considered, then a decision as to whether the man or the woman should be sterilized can only be reached after a full discussion between the couple and their doctor.