4 questions | Applied Sciences homework help

1. Cosmetic phalloplasty. Medical Letter 46:44, 2004. 82. Growth industry: How a risky surgery became a profit center

for some L.A. doctors. The Wall Street Journal, June 6, 1996. 83. Penile augmentation. American Urological Association position statement, Oct 2008. Chapter Nineteen Sexual and RepRoductive HealtH For more than 50 years, since the successful synthesis of estrogens and progestins, safe and effective pregnancy prevention has been possible. Nonetheless, in the United States an estimated 3.5 million unwanted preg- nancies occur annually, one third of which involve teenagers. iris f. litt, m.d.1 A good diet and a regular exercise program are a more dependable path to better sex than are goats’ eyes, deer sperm, and frogs’ legs. tamar NordeNberg2 Think of your bones as a retirement account: They’re where you stash cal- cium when you’re young, so you’ll have enough to last through old age. CoNsumer reports3 © glasbergen “Let’s play doctor. I’ll give you my list of ailments and you blame it all on my hormones.” Part Five Other Products and Services402 This chapter discusses many of the products, ser- vices, and self-care concerns related to sexual and reproductive function and activities. It includes more for women than for men, but most of it is relevant to both. The topics include menstrual products and prob- lems, feminine hygiene, vaginitis, “jock itch,” sexually transmitted diseases, contraception, induced abortion, pregnancy testing, infertility services, prenatal care, birthing, delivery options, hormone-replacement therapy, osteoporosis, erectile dysfunction, and dubious sex aids. MenStRual pRoductS Menstruation takes place approximately once a month as the uterus sheds the vascular lining it has prepared in response to the woman’s hormones. The debris exits through the vagina over several days. Most women use tampons or pads to dispose of the menstrual fluids. Menstrual cups are another option. An effective tampon is absorbent enough to protect against leaks, but not so absorbent that it dries out the delicate vaginal tissues. It should also be easy to insert, comfortable to wear, and easy to remove. It may help to use a more absorbent one when menstrual flow is heavy and a less absorbent one when flow is light. Using a highly absorbent tampon when flow is light may result in excess absorption of natural vaginal lubrication. Excessive drying of the vaginal tissue can increase the risk of vaginal infection and susceptibility to toxic shock syndrome (TSS), a rare but potentially fatal infec- tion caused by Staphylococcus bacteria. TSS is charac- terized by high fever, vomiting, diarrhea, sunburnlike rash, liver or kidney failure, and a rapid blood pressure drop that can cause shock. In 1989 the FDA ordered manufacturers to standardize tampon labeling so that “junior,” “regular,” “super,” and “super plus” means the same thing regardless of a manufacturer’s brand.

• People who wish to use contraception should consider effectiveness, convenience, safety, protection against sexually transmitted diseases (STDs), and personal and partner preferences.
• Prenatal care that includes abstaining from alcohol and tobacco, sensible eating, regular exercise, close cooperation with a trusted physician, and other childbirth education activities can greatly benefit both mother and child.
• The risk of osteoporosis, a serious condition, can be greatly reduced by minimizing risk factors throughout life.
• Hormone replacement therapy is effective in managing menopause symptoms and preventing osteoporosis but entails risks that, in many women, may outweigh the benefits.
• Treatments are available for infertility and erectile dysfunction, but effective treatments tend to be costly and bogus treatments are widely promoted.

Keep tHeSe pointS in Mind aS You StudY tHiS cHapteR Key Concepts Packages must explain the basis for the rating and advise on choosing the lowest appropriate absorbency.4 A 1994 study by Consumer Reports found that most tampons absorbed amounts within their labeled range.5 Menstrual cups6 are placed in the vagina to capture the menstrual fluid and hold it until the woman removes and empties the cup. The most common type is bell- shaped and can be reused for many years. The other type, which resembles a contraceptive diaphragm, is intended for one-time use. Neither type is effective as a contraceptive device. Tips to Prevent Toxic Shock Syndrome • Wash hands with soap and water before and after inserting or removing a tampon. Use care to avoid carrying bacteria from the skin or rectum into the vagina.

• Choose the lowest absorbency product that is effective.
• Do not use a plastic applicator that may be more likely to scratch the vagina. Cardboard applicators tend to be gentler. On days when secretions in the vagina are scanty, use a water-soluble lubricating jelly on the tampon applicator to avoid nicking the vaginal surface.
• Change tampons often—at least as frequently as every 6 to 8 hours.
• Alternate tampon use with pads during a given menstrual period. Do not use a tampon on days when bleeding is light.
• If symptoms of high fever (102.7°F or higher), vomiting, diarrhea, or sunburnlike rash occur, discontinue tampon use and immediately consult a physician.

√ Consumer Tip Chapter Nineteen Sexual and Reproductive Health 403 MenStRual pRobleMS Many women who menstruate experience significant symptoms before or during their monthly periods. Symp- toms fall into three general categories: dysmenorrhea (painful menstruation), premenstrual syndrome (PMS), and menstrual irregularities. Dysmenorrhea Dysmenorrhea is typically experienced as cramplike lower abdominal discomfort that may come and go in waves. There may also be dull lower backache and, in some women, nausea and vomiting. These symptoms begin shortly before the onset of menstrual flow and usually last 2 or 3 days. A small percentage of women have symptoms severe enough to interfere with their usual activities. Dysmenorrhea may be primary or secondary. Primary dysmenorrhea, by far the more common type, begins during the first year or two after the onset of menstruation, usually lasts only a few years, and is dramatically relieved after childbirth. Self-treatment with a nonprescription pain reliever may be effective when started the day before a menstrual period. (See Chapter 17 for dosage information.) Primary dysmenorrhea does not usually require consultation with a physician unless symptoms are severe and do not respond to self-treatment. The most commonly prescribed drugs are NSAIDs (nonsteroidal antiinflammatory drugs) and oral contraceptives (par- ticularly for women who also want contraceptive protec- tion). Secondary dysmenorrhea refers to menstrual pain that develops in women who previously had little or no cramping with their periods. It is usually associ- ated with an abnormality of the reproductive organs such as a benign uterine tumor (polyp or fibroid), a pelvic infection, or endometriosis. It can also be caused by an intrauterine device (IUD) used for contraception. A physician should be consulted in all cases of secondary dysmenorrhea to determine the presence of any underlying disease that requires treatment. In most cases, medical treatment will be more effective than self-treatment. Premenstrual Syndrome Premenstrual syndrome (PMS; also called premenstrual tension) is a combination of physical and/or emotional symptoms that occur a week or two before menstrua- tion and disappear or become minimal during periods. PMS is said to be very common, but estimates of its incidence are clouded by lack of a precise definition. The symptoms vary from person to person but are usu- ally consistent for each individual; they include tension, depression, irritability, fatigue, difficulty concentrating, crying spells, aggression, headaches, abdominal bloat- ing, swelling of the hands and feet, breast tenderness, constipation, acne, abnormal thirst, and cravings for sweets and/or salty foods. Usually relief occurs when the menstrual period begins. In contrast to dysmenorrhea, PMS usually starts during the late 20s or 30s and worsens with age and after childbearing. When symptoms include depression and are severe enough to interfere with oc- cupational and social functioning, the condition is called premenstrual dysphoric disorder (PMDD). Most women with PMS do not need treatment by a physician. Only symptoms that disrupt their life need medical intervention. Understanding what occurs in the body when symptoms are present often provides signifi- cant relief. The following suggestions may also help:

• For premenstrual water retention (abdominal bloating and swelling of the hands and feet), refrain from adding salt to meals and restrict sodium-containing foods from a few days before the time of the menstrual cycle when the symptoms typically occur until the time they go away. Diuretic drugs may be helpful.
• Cut down on alcohol, coffee, tea, cocoa, cola, and other foods and medications that contain caffeine or related compounds. Although this may not help, it is harmless and relatively easy to do.
• Try to identify and deal with psychosocial stresses. • If eating sweets appears to produce symptoms, try to satisfy

cravings with complex carbohydrates rather than simple sugars that tend to produce greater variability of blood sugar levels.

• Beginning a program of regular exercise often reduces the severity of symptoms.

Over-the-counter (OTC) products for premenstrual discomfort contain one or more of up to four main ingre- dients: a pain reliever, a diuretic, an antihistamine, and caffeine. OTC diuretic ingredients are weak compared to those available by prescription, but they may relieve the symptoms of PMS by helping the body shed water. Some doctors recommend pyridoxine (vitamin B6) for PMS. Many years ago an FDA advisory panel con- cluded that pyridoxine had not been proven effective. Subsequent reports of nervous system toxicity indicate that pyridoxine supplementation is unsafe (see Chapter 11). Other supplementary vitamins were summarily disapproved by the expert panel. Anything that interrupts the hormonal ups-and- downs of the menstrual cycle can dramatically relieve PMS/PMDD symptoms. Most commonly, birth control pills are used. These can also be taken on an “extended cycle” basis to reduce the frequency of periods. One birth control pill, Seasonale, has been specifically approved by the FDA to be taken this way. Part Five Other Products and Services404 A Cochrane review has concluded that selective serotonin reuptake inhibitors (SSRIs) are highly ef- fective against PMS and PMDD.7 These products are prescription drugs that raise the level of serotonin in the brain. Serotonin is an organic compound involved in the transmission of impulses between nerve cells and in the regulation of cyclic body processes. The most commonly used SSRI is fluoxetine, which is marketed as Prozac and a generic version for depression and as Sarafem for PMDD. Menstrual Irregularities During the first few years of menstruation, irregularity is common and is thought to be related to immaturity of the pituitary-ovarian system. The treatment of abnormal uterine bleeding depends on the cause, the woman’s age, and her plans regarding pregnancy. Persistent menstrual irregularity at any age or excessive bleeding after age 35 are reasons to consult a physician. Bleeding for longer than 7 days is considered excessive and warrants evalu- ation by a physician, as does bleeding between periods or after intercourse. Bleeding that occurs 1 year or more after menstrual periods cease (postmenopausal bleed- ing) should be evaluated promptly, because it may be a sign of cancer. Both medical and surgical treatments are available for heavy bleeding due to other causes.8 Women normally lose 1 to 4 tablespoons of blood during a menstrual period, with a daily iron loss of up to 1.4 mg. This amount of iron can be replenished by sensible eating. Individuals with a heavy blood flow (which may result in clots) should be sure that their iron intake is adequate. This can be accomplished by eating iron-rich foods (e.g., liver, veal, other meats, fish, soy- beans), cooking in an iron pot, or using iron supplements. However, self-medication with supplementary iron is unwise unless a deficiency is medically diagnosed with a blood test (see Chapter 17). Even if an individual is iron-deficient, the cause should be established before treatment is begun. To avoid iron overload, women who have stopped menstruating because of contraceptive use or a surgical procedure should not take iron-containing supplements—including some labeled “especially for women.” vaginal HYgiene Under normal circumstances the healthy vagina cleans itself. Like the eyes, nose, and mouth, it is lined with epithelial cells that produce secretions that flush surface debris toward the outside. At the same time, bacteria normally present maintain the normal acidity of the vagina, which discourages the growth of other micro- organisms. Douching Douching consists of forcing water or other fluids into the vagina for “cleansing” purposes. Except for douches prescribed for treating medical problems, douching is unnecessary and may be harmful. Many preparations cause drying of the vaginal tissues and disturb the nor- mal bacteria that help to keep the vagina healthy. Some products contain local anesthetics (e.g., phenol, menthol) that can mask symptoms of infection. Reusable douching materials carry added dangers. Douching within 3 days before a pelvic examination or Pap smear can interfere with the accuracy of these procedures. Douching should never be done during pregnancy or within 6 weeks after giving birth or having a miscarriage. The FDA, which classifies douches as cosmetics, requires that they be labeled: “For cleansing purposes only. Do not use more than twice weekly unless directed by a physician,” or “For cleansing purposes only, after menstruation and after marital relations.” However, it should be noted that postcoital douching is not an ef- fective contraceptive. External Hygiene Vaginal secretions and perspiration can collect on the ex- ternal surfaces of the vaginal folds, where they can break down and become odorous if allowed to accumulate. This is more likely to happen with the use of pantyhose and nylon panties, which increase the accumulation of perspiration. These garments should be washed after each use in mild, nonperfumed soaps. If pantyhose are used, those with a cotton crotch are less apt to allow the buildup of heat and moisture. Washing the skin of the vulva is all that is needed for adequate hygiene. Care should be taken to avoid getting soap on the delicate tissue at the entrance of the vagina and the urethra (where the urine exits the blad- der). So-called feminine deodorant sprays are unneces- sary and can cause trouble not only for product users but also for their sexual partners. Some women who have used these products have experienced infections, irritations, burns, and rashes. Women who decide to use a spray despite these facts should follow the manufac- turer’s directions carefully. The FDA requires a label warning that includes: Do not apply to broken, irritated, or itching skin. Persistent unusual odor or discharge may indicate conditions for which a physician should be consulted. Discontinue use immediately if rash, irritation, or discomfort develops. Chapter Nineteen Sexual and Reproductive Health 405 vaginitiS Vaginitis means inflammation of the vagina. It is often accompanied by vulvitis, an inflammation of the outer tissues of a woman’s genital area, in which case the problem is called vulvovaginitis. Most women have vaginitis at some time during their life. The symptoms are vaginal discharge with or without itching, burning, odor, or burning with urination. The most common causes of vaginitis and vulvitis are chronic irritation by bacteria or yeast (Candida albi- cans and sometimes other species). These microorgan- isms are normally present in small numbers but are kept in check by certain strains of lactobacilli, the bacteria that dominate the vagina and produce lactic acid and other substances that maintain a low (acidic) pH in the vagina. Anything that disturbs these bacteria or reduces their numbers can provide the opportunity for yeast overgrowth. This includes douching, sprays, heat and moisture buildup from clothing, irritants in spermicides and some condoms, soaps, tissues, swimming pool water, antibiotics, “lost” tampons, and even high fevers from other illnesses. Women with diabetes are more vulner- able to vaginitis, especially vaginal yeast infections. The introduction of fecal bacteria into the vulvar and vaginal areas by sexual practices or poor hygiene can cause infections. Vaginitis and vulvitis are also caused by sexually transmitted organisms such as Trichomonas vaginalis and the herpes virus. Rarely, overgrowth of the normal lactobacilli causes similar symptoms. Some of the aforementioned agents can also irritate the vaginal tissues without causing an infection. The treatment of vaginitis and vulvitis depends on the cause. Nonprescription products that are effective against yeast contain an antifungal drug (clotrimazole, miconazole, butoconazole, or tioconazole). Those that contain benzocaine (a local anesthetic) may temporarily relieve symptoms of burning and itching until a physician can be consulted. Homeopathic products, which contain no actual antifungal agent, are worthless for treating yeast infections, yet some pharmacies display them adjacent to approved OTC products. Trichomoniasis is usually curable with a single dose of a prescription drug but both sexual partners should be treated so the causative organism (a parasite) is eliminated.9 There is no scientific evidence that dietary factors play any role in the cause or treatment of vaginitis. Theoretically, treatment with the right strains of lacto- bacilli could be helpful, especially for preventing yeast infections. However, the research carried out so far on acidophilus and other probiotic preparations has been inconclusive.10 Because vaginitis and vulvitis have many causes, some of which are serious, a doctor should be consulted unless a woman is certain that she has a recurrence of a previously medically diagnosed problem that is suitable for self-treatment. In some cases, treatment of a woman’s sexual partner(s) is also necessary. “JocK itcH” “Jock itch” is a rash in the groin caused by a fungal infection. It is more common in men than in women. Its symptoms include itching, burning, and stinging of the skin. Several organisms can cause it, but the most common is the same one that causes athlete’s foot. In its early stages, the problem may be relieved by keeping the area dry, exposing it to air as much as possible, and avoiding tight clothes. Nonprescription creams, oint- ments, liquids, powders, and sprays are available for treatment. Most cases can be self-treated, but sometimes prescribed medication is needed. SexuallY tRanSMitted diSeaSeS Sexually transmitted diseases (STDs), also known as sexually transmissible infections (STIs), are diseases that spread from one person to another through sexual contact. The incurable STDs, such as HIV/AIDS, hepati- tis B, genital herpes (HSV-2), and human papillomavirus (HPV) infection, are caused by viruses. Although they cannot be cured, it is possible to prevent, relieve, or reduce their symptoms. Gonorrhea, chlamydia, syphilis, trichomonas infection, lymphogranuloma venereum, chancroid, granuloma inguinale, pubic lice infesta- tions, and scabies are curable, but some have serious consequences if not diagnosed and treated in time. The U.S. Centers for Disease Control and Prevention has published excellent fact sheets about STDs. About 15 million Americans are newly infected each year. The common symptoms include abnormal discharge from the vagina or penis; pain or burning with urination; itching or irritation of the genitals; sores, blis- ters, or bumps on the genitals; rashes, including rashes on the palms of hands and soles of feet; and pelvic pain. However, other infections or conditions can cause these symptoms and some people who acquire an STD experi- ence no symptoms. For example, only 10% to 25% of HSV-2 carriers have symptoms of genital herpes and most new infections are transmitted by such people.11 Women are more likely than men to suffer long- term consequences, which include pelvic inflammatory disease, infertility, chronic pelvic pain, and cancer of Part Five Other Products and Services406 *Numbers in the middle columns are rates of accidental pregnancy during one year of use. Typical use means used incorrectly or not used with every act of intercourse. Ideal use means consistent and correct use. †Clinics offer some of these services at lower cost. Sources: Pregnancy rates obtained from Choices.16 Costs obtained from Planned Parenthood Web site (www.plannedparenthood.org), October 2011. Method Surgical Male sterilization Female sterilization Hormonal Depo-Provera Implanon implant Pill Ortho Evra patch Vaginal ring Barrier Cervical cap Have given birth Never given birth Diaphragm with spermicide Condom (female) Condom (male) Vaginal sponge Have given birth Never given birth Vaginal foam, film, cream, jelly, or suppository Intrauterine device Mirena ParaGard Other/None Fertility awareness Post-ovulation Symptothermal Ovulation Calendar Coitus interruptus (withdrawal) No method used contRaceptive effectiveneSS and coStS* Table 19-1 Yearly Pregnancy Rate/100 Women Typical Ideal 0.15 0.1 0.5 0.5 3 0.3 0.01 0.01 8 0.3 8 0.3 8 0.3 32 26 16 9

11.5 6

21 5 15 2 24 20 12 9 13–29 6–15 28 18 0.1 0.1 0.8 0.6 25 1 25 2 25 3 25 9 27 4 85 85 Typical Cost† $350–$1000 $1500–$6000 Doctor’s charges plus $30-$75 per shot every 3 months $400–$800 (lasts 3 years) Doctor’s charges plus $20–$50/month for the pills Doctor’s charges plus $15–$70/month for the patches Doctor’s charges plus $15–$70/month for the rings Doctor’s charges plus $60–$75 for cap; additional cost for spermicide Doctor’s visit plus $15–$75 for diaphragm $4 each 65¢–$3 each $3–$5 each plus cost of spermicide 20¢–40¢ per use $500–$1000 for device, exam, inser- tion, and follow-up Charts and kits are inexpensive No cost No cost the cervix. Women are also less likely to seek treatment because they have no early symptoms. In addition, they are more likely to become infected through a single encounter. The major preventive strategies include reducing the number of sexual partners, delaying the onset of sexual activity, and practicing safer sex. Using a con- dom correctly and every time greatly reduces the risk of transmission. However, breakage and/or slippage can occur, and some STDs (most notably herpes) can enter the skin outside of the area covered by the condom. The FDA12 has warned that several companies are marketing products that are fraudulently claimed to prevent STDs. Most cases of HPV can be prevented by vaccina- tion. The FDA has approved two products for use from age 9 through age 26: Gardasil and Cervarix. Gardasil is for males and females. Cervarix is just for females. The optimal age for administration is 11 or 12.13 Highly active antiretroviral treatment (HAART) has transformed HIV/AIDS into a chronic, manageable disease, but recipients may still be able to infect others. Thus proper condom use remains an important strategy against HIV transmission. contRaception Contraceptives are drugs or devices used to prevent pregnancy. Five major types are used today in the United States: fertility awareness (rhythm) methods, barrier methods, intrauterine devices (IUDs), hormonal methods, and surgical sterilization. Planned Parenthood Federation of America14 sug- gests these considerations when selecting a contraceptive method:

• Personal preference: Choose a method with which you are physically and emotionally comfortable and can use consistently.
• Safety: Be aware of any health risks involved, including the risk of sexually transmitted diseases. (The only products that can protect against STDs are condoms made of latex or polyurethane.)
• Effectiveness: Choose a method that provides the amount of protection you need to feel secure. For maximum effective- ness, the method must be understood and used carefully and consistently.
• Convenience: This includes availability and affordability. • Partner preference .

The most recent major survey (2006) found that 49% of pregnancies in the United States were unintended, and about half of these occurred after contraception had failed or been used improperly.15 Table 19-1 compares the failure rates and cost of the various methods. More Chapter Nineteen Sexual and Reproductive Health 407 detailed information is available on the Web sites of Planned Parenthood (www.plannedparenthood.org) and Bridging the Gap Communications (www.managingcon- traception.com). The Planned Parenthood site also has an interactive tool to help identify suitable methods. Fertility Awareness Methods Fertility awareness (rhythm) methods depend on abstain- ing from intercourse or using other forms of contracep- tion during the fertile days of the menstrual cycle. The fertile days are the few days leading up to and including the day of ovulation. Ovulation can be determined by noting (a) changes in body temperature taken each morn- ing, (b) changes in the character of cervical mucus, (c) the position of the cervix, or (d) a combination of these methods. These methods are economical, free of side effects, and practiced successfully by many women, but they are among the least effective even when followed perfectly. They work best in women whose menstrual cycles are regular. Several approaches exist. The symptothermal method takes temperature, mucus characteristics, and cervical position into account. Merely checking mucus (ovulation method) or counting days for several months (calendar method) is not as reliable. The post-ovulation method requires abstention or use of a barrier method from the beginning of each period until the morning of the fourth day after predicted ovulation. Test kits that attempt to predict ovulation are avail- able for home use. They can be useful for helping to achieve pregnancy, but they are not reliable for contra- ceptive purposes. Because sperm can live in the female reproductive tract for a few days, pregnancy can result from having unprotected intercourse a few days before the test shows that ovulation has occurred. Barrier Methods Barrier methods work in one of two ways: the sperm are either immobilized by a chemical (cream, jelly, foam, film, or suppository) or mechanically blocked (diaphragm, cervical cap, or condom) from entering the uterus. Contraceptive effectiveness depends on how conscientiously the method is used. Combinations of a mechanical and a chemical method are far more effec- tive than either type used alone. Barrier products include the following: Male condom: The male condom is a sheath of thin synthetic material (latex or polyurethane) or animal tissue that fits over the penis. All offer good protection against pregnancy, but only the synthetics offer good protection against STDs. Consumer Reports17 has noted that skin condoms (made from part of the intestine of a Personal Glimpse Sample Script for Safer Sex18 If your partner says: What’s that? You can say: A condom, baby. If your partner says: What for? You can say: To use when we’re making love. If your partner says: Rubbers are gross. You can say: Being pregnant when I don’t want to be is more gross. So is getting AIDS. If your partner says: Rubbers aren’t romantic. You can say: Making love and protecting each other’s health sounds romantic to me. If your partner says: Let’s face it. Making love with a rubber on is like taking a shower with a raincoat on. You can say: Well, doing it without a rubber is like playing Russian roulette. If your partner says: But I love you. You can say: Then you’ll help me protect myself. If your partner says: I guess you really don’t love me. You can say: I’m not going to “prove my love” by risking my life. If your partner says: I’m not using a rubber no matter what. You can say: Well then, I guess we’re not having sex. lamb) are less likely to break than latex condoms but do not prevent transmission of the viruses that cause AIDS, genital herpes, or hepatitis. People who are sensitive to latex can use polythylene condoms. Female condom (“vaginal pouch”): The female condom is a soft, loose-fitting polyurethane sheath and two diaphragm-like, flexible polyurethane rings. One ring, which lies inside the sheath, fits internally like a diaphragm and anchors the sheath inside the vagina. The other ring forms the outer edge of the sheath and remains outside the vagina. The female condom is easy to use and does not require fitting by a health professional. It is thicker and covers more of the genital area than the male condom, which means it may offer more protection against sexually transmitted infections. Diaphragm: The diaphragm is a flexible rubber bar- rier that covers the cervix and provides protection for 6 hours. It must be fitted by a doctor, but some women’s anatomy will not permit a diaphragm to stay in place. Learning to use a diaphragm may take time and patience. It should be used with contraceptive jelly or cream and left in place for at least 6 hours after intercourse. Wearing Part Five Other Products and Services408 a diaphragm more than 24 hours is not recommended because of the possible risk of TSS. Cervical cap: The cervical cap is a flexible cup-like device about 11/2 inches in diameter that fits snugly over the cervix. It can be inserted many hours before sexual activity and left in place for up to 48 hours. A pelvic examination by a physician is needed to determine the correct size. The cap is recommended only for women with a normal Pap smear, and another Pap smear should be obtained after 3 months of use to be sure that abnormal changes have not occurred in the cervical tissue. (They occur in about 4% of users.) It is also recommended that users apply spermicide with each use and leave the device in for 6 to 8 hours after intercourse. Petroleum jelly (Vaseline) and other oil-based sub- stances should not be used as vaginal lubricants because they can damage condoms, diaphragms, and caps and irritate the vagina. When lubrication is needed, a water- based product such as K-Y Jelly should be used. Spermicidal foam, cream, jelly, film, suppositories: These products contain nonoxynol-9, a chemical that kills sperm on contact. To be effective, the product must cover the cervix. Combining them with a con- dom, diaphragm, or cervical cap greatly enhances their contraceptive effectiveness. Used alone, aerosol foams are the most effective of these products. Contraceptive suppositories tend to lose their effectiveness within 30 minutes after insertion. Nonoxynol-9 may cause vaginal irritation that can increase the risk of HIV transmission. Vaginal contraceptive sponge: The vaginal sponge is a soft, round sponge, approximately 2 inches in di- ameter, made of polyurethane, and impregnated with nonoxynol-9 that is activated by moistening the sponge with water. When properly inserted, it covers the cervix. The sponge is considered effective for 24 hours after insertion and should be left in place for at least 6 hours after intercourse but removed within 48 hours of inser- tion. A polyester loop attached across the bottom of the sponge permits easy removal. Intrauterine Devices (IUDs) IUDs involve the insertion by a doctor of a small piece of plastic. When the IUD is in place, an attached string hangs through the opening of the cervix so the position of the IUD can be checked. IUDs offer convenience and a high rate of effectiveness as long as they stay in place. In some women they can have major side effects, such as bleeding and increased menstrual cramping. If a sexually transmitted infection occurs after an IUD is inserted, its presence can make the infection more serious. Two types of IUDs are available in the United States.The ParaGard, which is effective for at least 12 years, has fine copper wire coiled around the plastic part and releases copper to prevent sperm from reaching the uterus and prevent implantation of a fertilized egg. The Mirena, which is approved for up to 5 years and is probably effective for 8 or more years, has an insert that releases progestin, which thickens cervical mucus to pre- vent sperm from entering the uterus and thins the uterine wall to block implantation. The Mirena also decreases menstrual cramping, greatly decreases menstrual blood flow, and has about a 20% chance of stopping menstrual bleeding after a year of use. IUDs are not recommended for women with multiple partners or those who have had a recent or recurrent pelvic infection, tubal pregnancy, very heavy periods, or previous trouble with an IUD. Hormonal Methods In addition to the Mirena, several types of contracep- tives prevent pregnancy through the effects of female hormones. These hormones suppress ovulation, thicken the cervical mucus, interfere with the transport of sperm through the tubes, and make the tissue that lines the uterus less receptive to implantation of a pre-embryo. Oral contraceptives (OCs), available only by pre- scription, contain one or two hormones similar to those that naturally regulate menstruation. Combination pills contain estrogen and progestin (a synthetic progester- one), whereas minipills contain only progestin. OCs provide excellent reversible protection, but only if taken properly with no missed doses. Most women also experience lighter and less painful periods, a reduction in breast tenderness and lumps, and, with some OCs, reduced acne. OCs are used to treat some medical condi- tions even when contraception is not needed. Extensive studies have not established that long-term use of OCs increases the risk of developing breast cancer. Those containing both estrogen and progestin greatly decrease the risk of ovarian and uterine (endometrial) cancer. Both kinds of pills reduce the risk of developing benign breast masses and serious infections of the uterus and tubes. Cervical cancer is more common among OC users, but this appears to be due to sexual factors (mul- tiple partners) rather than the pill itself. The list of possible side effects is long, but serious problems are rare. Mild side effects, such as nausea, weight gain, fluid retention, spotting between periods, and breast tenderness, usually subside within a few months. Moderately troublesome side effects include headaches and depression. The incidence of side effects is less with the minipill, but its effectiveness is a bit lower. For this reason, use with a spermicide or condom is advantageous. Most women who take either type of pill Chapter Nineteen Sexual and Reproductive Health 409 have no side effects or complications. Package inserts for oral contraceptive products carry an FDA-approved statement that, except for women older than 35 who smoke, the incidence of death associated with all meth- ods of birth control is low and less than that associated with pregnancy and childbirth. Estrogen-containing OCs pose a significant risk for smokers and for women with a history of blood clots in the legs or elsewhere. The smoking-related risk increases with age. Smokers and women older than 35 should not take them because they increase the risk of heart attacks and strokes. OCs are also unsuitable for women who have active liver disease, cancer of the breast or internal sexual organs, or abnormal vaginal bleeding. Depot medroxyprogesterone acetate (DMPA) is a synthetic drug that is nearly 100% effective when injected every 12 weeks. Marketed as Depo-Provera, it takes effect within 24 hours and halts ovulation for at least 14 weeks, which provides a 2-week grace period before the next injection. The most common side effects are menstrual changes: irregular bleeding and spotting, particularly in the first few months. After 1 year about half of the users do not get their periods, a situation that poses no medical risk. However, DMPA can cause loss of calcium from the bones, so use for more than 2 years is recommended only if other birth control methods are considered inadequate. The Ortho Evra patch, which releases estrogen and progestin that is absorbed into the body, is worn each week for 3 consecutive weeks, usually on the lower abdomen or buttocks. The fourth week is patch-free to permit menstrual flow. The NuvaRing is a flexible 2-inch-diameter ring that is placed in the vagina for 3 weeks and then removed for 7 days to permit bleeding. Like OCs, it delivers both estrogen and progestin and has similar effects. This method is often tolerated by women who are not pleased with or who have trouble remembering to take OCs. In the past, the higher doses of estrogen in OCs tended to cause water retention and weight gain. Current low-dose OCs and the other methods rarely have this ef- fect, but all contain progestins which, because they tend to increase metabolism, can increase appetite. Weight gain can be avoided by eating and exercising sensibly. Emergency Contraception Emergency contraception pills (ECPs) contain the hormone progestin and are sold under the names Plan B, Plan B One-Step, and Next Choice. They work by preventing ovulation or, if that has already occurred, by blocking implantation of a fertilized egg in the uterus. Anyone 17 or older can purchase these products from pharmacies without a prescription. Women 16 and younger must have a doctor’s prescription, which can be obtained through an office visit or by telephone. ECPs are commonly referred to as “the morning- after pill” even though they involve more than one pill and do not need to be taken on the “morning after.” They can be taken up to 120 hours after unprotected sex, but the earlier they are used, the more effective they are. If taken within 12 hours, the pregnancy rate is 0.4%. If taken within 1 to 3 days, the rate is 2.7%. About 25% of users experience nausea.16 The most effective form of emergency contracep- tion (about 1 pregnancy per 1000 users) is the Paragard IUD, which works if inserted within 5 to 8 days after unprotected sex and can remain for ongoing protection. Surgical Sterilization Close to half the married couples who intend to avoid pregnancy include one partner who has been sterilized. Sterilization has the advantage of being permanent. Reversal surgery can be attempted, but it may not work, so the decision to undergo sterilization should be made carefully and only when it is certain that no more preg- nancies are desired. Sterilization in women (tubal ligation) destroys a portion of the fallopian tubes by placing clips or bands, burning them with an electric current, and/or cutting them directly. These procedures are usually done by laparoscopy through one or two small incisions. Most are performed as outpatient operations in the hospital or a surgery center. After tubal ligation, sperm can no longer reach the eggs released by the ovaries. The eggs then die and are resorbed just as they are during any other cycle in which pregnancy does not occur. Tubal ligation also reduces the risk of ovarian cancer, probably by preventing viruses and other substances from reaching the ovaries in the same way that sperm do. Male sterilization (vasectomy) is accomplished by cutting and sealing off the tube (vas deferens) from each testicle through which sperm travel before they are stored for ejaculation. In the traditional method, a local anesthetic is injected into the area, an incision is made on each side of the scrotum, and the tubes are located and blocked. Minor complications (swelling, tender- ness, blood clots, infections, and sperm leakage under the skin) occur in a small percentage of cases. With the no-scal

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