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Contraception for the 21st century – The Obsolescence of Abortion? - (8/1/2018)

By Dr. Ron Gasbarro

To abort or not to abort? 
Contraceptives are the name given to medicines and other devices that are used to prevent unwanted pregnancy. The most common reasons women consider contraception are:
An inability to support or care for a child
To prevent an unwanted pregnancy
To prevent the birth of a child with birth defects or severe medical problems
To terminate a pregnancy resulting from rape or incest
Yet, a fraction of these women become pregnant despite contraception. Some of these women consider abortion as a means for ending a pregnancy. The most common reasons women consider abortion are:
Failure of a birth control method
An inability to support or care for a child
The pregnancy is unwanted 
To prevent the birth of a child with birth defects or severe medical problems
Pregnancy resulting from rape or incest
A Roe v. Wade backgrounder
Abortion is legal in the United States following Roe v. Wade. Roe v. Wade, 410 U.S. 113 (1973) is a landmark decision issued in 1973 by the United States Supreme Court on the issue of the constitutionality of laws that criminalized or restricted access to abortions. The Court ruled 7–2 that a right to privacy under the Due Process Clause of the 14th Amendment extended to a woman's decision to have an abortion. However, this right must be balanced against the state's interests in regulating abortions to protect both women's health and the potentiality of human life. Arguing that these state interests became stronger over the course of a pregnancy, the Court resolved this balancing test by tying state regulation of abortion to the third trimester of pregnancy.

In 1992, in Planned Parenthood v. Casey, the Supreme Court rejected Roe's trimester framework while affirming its central holding that a woman has a right to an abortion until fetal viability. The Roe decision defined "viable" as "potentially able to live outside the mother's womb, albeit with artificial aid." Justices in Casey acknowledged that viability might occur at 23 or 24 weeks, or sometimes even earlier, in light of medical advances.
In disallowing many state and federal restrictions on abortion in the US, Roe v. Wade prompted a national debate that continues today about issues including whether, and to what extent, abortion should be legal. Also, who should decide the legality of abortion, what methods should the Supreme Court use in constitutional adjudication, and what roles should religious and moral views play in the political sphere? Roe v. Wade reshaped national politics, dividing much of the US into pro-life and pro-choice camps while activating grassroots movements on both sides.

How frequent are abortions today?
One would surmise that the number of abortions in the US would be on the decline given the availability of many different types of contraception. Yet, contraception can fail. The Centers for Disease Control and Prevention (CDC) reported 652,639 legal induced abortions in 2014, the latest statistics available. The abortion rate for 2014 was 12.1 abortions per 1,000 women aged 15–44 years, and the abortion ratio was 186 abortions per 1,000 live births.

Compared with 2013, the total number and rate of reported abortions for 2014 decreased 2%, and the ratio decreased by 7%. Additionally, from 2005 to 2014, the number, rate, and ratio of reported abortions decreased 21%, 22%, and 22%, respectively. In 2014, all three measures reached their lowest level for the entire period of analysis (2005—2014).

Women in their twenties accounted for the majority of abortions in 2014. That year, the majority of abortions took place early in gestation:  91.5% of abortions were performed at ≤13 weeks’ gestation; a smaller number of abortions (7.2%) were performed at 14–20 weeks’ gestation and even fewer (1.3%) were performed at ≥21 weeks’ gestation. In 2014, 22.6% of all abortions were early medical abortions. The percentage of abortions reported as early medical abortions (versus late-term abortions) increased 110% from 2005 to 2014, with a 1% increase from 2013 to 2014.

The CDC first started posting Abortion Surveillance in 1979. In that year, 1,251,921 legal abortions were reported, an 8.1% increase over the number reported for 1978. In 1980, the total was 1,297,606, an increase of 3.6% over 1979. Over the 2-year period, the national abortion ratio increased by 3.5%, from 347.3/ 1,000 live births in 1978 to 359.4/1,000 in 1980. Over 90% of this increase occurred between 1978 and 1979. Since 1978, the national abortion rate increased from 23 to 25 abortions per 1,000 women aged 15 to 44. Hence, compared with 1979, the number of abortions had been cut in half by 2014. An increase in sex education and the emergence of better birth control methods contribute to much of this decline.  

The following graphic, published by the American College of Obstetricians and Gynecologists, shows the effectiveness of various contraception methods. As noted, the newer contraception methods are more efficient and offer a higher degree of adherence because they do not have to be taken every day or used right before intercourse.  

Permanent methods of contraception 

Because fumbling with condoms or forgetting to take a daily oral contraceptive can increase the chances of getting pregnant, the best contraceptives are those that last a long time. Sterilization is considered a permanent method of contraception. In certain cases, sterilization can be reversed, but the success of this procedure is not guaranteed. For this reason, sterilization is meant for men and women who do not intend to have children in the future. 

A vasectomy is a form of sterilization of a man. A vasectomy ensures that no sperm will exit from his penis when he ejaculates during sexual intercourse.

Tubal ligation
Tubal ligation is also known as "having one's tubes tied," or having a "tubal." Tubal ligation is for women, and like a vasectomy, should be considered a permanent form of birth control.

Hysteroscopic sterilization
Hysteroscopic sterilization is a nonsurgical form of permanent birth control in which a physician inserts a 4-centimeter (1.6 inch) long metal coil into each one of a woman's two Fallopian tubes via a scope passed through the cervix into the uterus (hysteroscope), and from there into the openings of the Fallopian tubes. Over the next few months, tissue grows over the coil to form a plug that prevents fertilized eggs from traveling from the ovaries to the uterus.

A hysterectomy is the surgical removal of a woman's uterus and, depending on her overall health status and the reason for the operation, perhaps her ovaries as well. For practical purposes, no woman who has had a hysterectomy can become pregnant; it is an irreversible method of birth control and absolute sterilization.

New long-lasting, reversible methods

The ring that is good for one year
Annovera™ (segesterone acetate/ethinyl estradiol) is a reusable, nonbiodegradable, flexible vaginal ring placed in the vagina for 3 weeks and then removed for 1 week during which women experience a menstrual period. The schedule is repeated every 4 weeks for 1 year, covering 13 menstrual cycles of 28 days each. It is essentially a reusable version of the NuvaRing, which has been available since 2001.

The efficacy and safety of Annovera were studied in 3 open-label clinical trials with healthy women ranging in age from 18 to 40 years. Based on the results, about two to four women out of 100 may get pregnant during the first year they use Annovera, the FDA said. Annovera carries a boxed warning relating to cigarette smoking and serious cardiovascular events. Women aged over 35 years who smoke should not use Annovera. Cigarette smoking increases the risk for serious cardiovascular events from combination hormonal contraceptive use.

Annovera is contraindicated in women with a high risk of arterial or venous thrombotic diseases; current or history of breast cancer or other estrogen- or progestin-sensitive cancers; liver tumors, acute hepatitis, or decompensated cirrhosis; undiagnosed abnormal uterine bleeding; hypersensitivity to any of the components of Annovera; and use of hepatitis C drug combinations containing ombitasvir/paritaprevir/ritonavir, with or without dasabuvir.

The most common side effects in women using Annovera are similar to those of other combined hormonal contraceptive products and include headache/migraine, nausea/vomiting, yeast infections, abdominal pain, dysmenorrhea, breast tenderness, irregular bleeding, diarrhea, and genital itching.

The FDA will require postmarketing studies to evaluate the risk for venous thromboembolism and the effects of CYP3A modulating drugs and tampon use on the pharmacokinetics of Annovera.

The drawbacks of this system include:
The vaginal system has not been adequately studied in females with a BMI >29 kg/m²
The system could have a compliance problem if not re-inserted after the menstrual period
The prescribing information has not yet been released by the manufacturer, TherapeuticsMD/The Population Council
o Unclear as to how it is stored
o How does misplacing the ring influence insurance issues?

The 1000-day implant

A contraceptive implant is a popular form of long-acting reversible contraception (LARC). Norplant, the first contraceptive implant, became available in 1983 but was later removed from the market owing to patient dissatisfaction with adverse effects that ultimately led to several lawsuits against the manufacturer. It was also difficult to remove. The currently available implant, Nexplanon, is a rod that contains the progestin etonogestrel and is intended for subdermal implantation in the non-dominant arm. It is the second-generation of the device; the first-generation was called Implanon. The currently available device differs from its first-generation counterpart in that the implant itself is radiopaque and its applicator design is improved to prevent placement deeper than the intended subdermal location.

The advantage of an implantable form of contraception is that it provides effective long-term contraception that does not depend on the recipient’s daily compliance. The implant has become a popular choice among adolescents and young women and is appropriate for both nulliparous or parous women.

The most recent generation of implantable devices is the most effective form of birth control available and can usually be inserted by trained practitioners in less than one minute. The pregnancy rate with the implant is 0.05%, which is slightly lower than the levonorgestrel intrauterine device (0.2%) and the copper intrauterine device (0.6%). A release rate of 25-30 µg/day of etonogestrel is required to suppress ovulation. With this device, the initial rate of release is 60-70 µg/day, which slowly decreases over time, to about 30 µg/day. Maximum serum levels are attained the fourth day after insertion, on average.

One advantage that Nexplanon has over Norplant is that the latter involved inserting 6 rods, whereas Nexplanon involves only one rod. 

The drawbacks of this system include:
Overweight women: Nexplanon may become less effective in overweight women over time, especially in the presence of other factors that decrease etonogestrel concentrations, such as concomitant use of hepatic enzyme inducers
Insertion and removal complications: Pain, paresthesias, bleeding, hematoma, scarring or infection may occur
Elevated blood pressure: The Nexplanon implant should be removed if blood pressure rises significantly and becomes uncontrolled
Ectopic pregnancies: Be alert to the possibility of an ectopic pregnancy in women using Nexplanon who become pregnant or complain of lower abdominal pain
Abortion is never a pleasant, unemotional choice. Thus, the way to circumvent most abortions is not to get pregnant following intercourse. The best method of contraception for any woman is the method that she is going to use correctly and consistently. A reversible, long-acting method gives women the ultimate control over family planning. In time, abortion may become obsolete.

Ron Gasbarro, PharmD, is a registered pharmacist, medical writer, and principal at Rx-Press.com. Read more at www.rx-press.com  


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