Case Study: A healthy couple seeks advice on contraceptive strategies & is wanting to know what the long-term effects of birth control pills is.
Upstream Causes
Downstream Effects
Background
The Reproductive System
Anatomy
Physiology
Structures of reproductive structures
Female
Male
Ducts
Copulatory organ
Penis
Prepuce
Corpus spongiosum
Urethral orifice
Corpus cavernosum
Vas deferens
Urethra
Ejaculatory duct
Epididymis
Accessory glands
Prostate
Bulbo-urethral gland
Seminal vesicle
Scrotum
2 muscles serve to maintain a constant temp
Cremaster muscle
Direct
40 yr old women currently on birth control seeks advice on other contraceptive strategies
Indirect
Thoughts to consider w/this couple compared to another that may be seeking the same information
Happily married
Currently utilizing birth control
Age
Have 2 already almost grown kids
Being that the patient is in her 40's, it seems that she may of had already put much thought into this consideration
This is good information to know b/c it shows that this couple may have a better chance of being more committed to a more permanent option of birth control
Being that she has already been exploring w/this option shows she ready to move forward w/a different method
Being that the couple seems to have prior experience w/kids & these kids are most likely teens
Health
Sounds like the couple has more options to work w/birth control being that they seem to be in good health
Another clue this gives is that the couple may be quite sexually active
Meaning that they may need a birth control that is either more permanent or something that provides a low or no risk of conception
The patient is possibly close to the average menopause age
At this point they most likely want to steer clear of condoms for sure
Therefore, this can mean that she may not want to go through the process of permanent birth control
Being that the patient sounds concerned about the risks associated w/birth control, she may be seeking for more natural alternatives
What this could mean for
Patient
Patient's husband
Being healthy can possibly mean that she is quite fertile
For him, it could mean that his reproductive organs may be in great condition to produce viable sperm capable of inseminating her easily
A sac of skin containing the testes
Designed to regulate temperature of the testes
The location provides for the area to be 3 degrees lower than core body temp
Dartos muscle
Smooth muscle in superficial fascia
Wrinkles the scrotal skin
Bands of skeletal muscle arising from the internal oblique muscle
Serves to elevate the testes
Surrounded by 2 tunics
Tunica vaginalis
Tunica albuginea
Derived from outer pocket of peritoneum
Produces fluid between the visceral & parietal layers so as to prevent friction
This is the "white coat" which is a fibrous capsule of the testis
This houses the septum (inbetween lobules) & the lobule (where seminiferous tubules are contained)
Seminiferous tubules
Where the sperm is produced
These lead straight tubule which -> rete testis
A tubular network on posterior side of the testis
From here, sperm -> efferent ductules & into epididymis
This is where the sperm are matured (learn to swim) & then are stored until ejaculation
Testicular arteries supply the testes
While the testicular veins drain them from the pampiniform venous plexus
This plexus absorbs heat from arterial blood, cooling it before entering testes
Together these along w/vas deferens make up the spermatic cord
Which passes through the inguinal canal
Contains pseudostratified epithelial cells
Sperm are ejaculated from here
Allows for absorption of of excess testicular fluid & pass nutrients -> sperm stored there
Transports sperm during ejaculation
Also contains pseudostratified epithelial cells
In this case, if the couple is exploring permanent birth control options, it may be worth her husband getting a vasectomy
Which may compel the couple to explore more permanent birth control options if they do not object to that
3 Best contraceptive options
1. Vasectomy for the husband (Sterilization)
Process
2) Either the vas deferens are cut through & ligated or the deferens is cauterized
Serves the urinary sys. & the reproductive sys. in males
Transports semen & urine
3 regions
Spongy urethra
Membranous urethra
Prostatic urethra
Portion surrounding the prostate
In the urogenital diaphragm
Runs through penis -> external orifice
A copulatory organ that delivers sperm -> female reproductive tract
Loose skin around the glans that is ordinarily removed at birth
Fills w/blood during excitement -> cause an erection
Extends to form the glans
A sensitive excitable area
This area also fills w/ blood during excitement
The final region urine exits
Accounts for 70% of semen volume
Adds elements -> sperm
Yellow viscous alkaline fluid
Containing
Fructose
Citric acid
Prostaglandins
Sugar & substances to increase sperm motility
To soften uterus
Sperm & seminal fluid mix here & then enter the prostatic urethra
During ejaculation, prostatic smooth muscle squeezes prostatic secretion into prostatic urethra
Such as
Accounting for 1/3 of semen vol.
A milky slightly acidic fluid
That contains citrate & PSA
A thick, clear mucous is released from this gland
Some is released -> spongy urethra to neutralize traces of acidic urine
Mucous also lubricates the glans when excitement is experienced
Uterine tubes
Containing antibiotics
Uterus (womb)
3 regions
Infundibulum
Ampulla
Fallopian tubes (oviducts)
They recieve the ovulated oocyte & is the site where fertilization occurs
Isthmus
Next to infundibulum, this is the fertilization site
This is the opening of the tube into the peritoneal cavity
The margin of it is surrounded by ciliated projections called fimbriae
This empties into the superolateral region of uterus
Bends around ovary during ovulation to capture the oocyte while fimbriae sweep the the ovarian surface
These tubes are covered by peritoneum & supported by the mesosalpinx (a broad ligament)
Wall of uterus
Composed of 3 layers
Myometrium
Perimetrium
A hollow, thick walled muscular organ that receives, retains & nourishes a fertilized ovum
Regions
Body
Fundus
Major portion of uterus
Rounded superior region
Isthmus
Narrowed region between the body & cervix
Cervix
A narrow neck that projects into vagina
Cervical canal
Empties into vaginal canal via external os & connects w/ uterine body via the internal os
The mucosa of this canal contains cervical glands that secrete mucous
Helps to block spread of bacteria while certain mucus blocks sperm entry except at midcycle
Endometrium
The mucosa that lines the uterine cavity
Incomplete outermost layer
Bulky middle layer consisting of smooth muscle
Contracts during childbirth
Consists of simple columnar epithelium & lamina propria
If fertilization occurs, the embryo implants here
Consists of 2 layers
Functional layer
Basal layer
Undergoes cyclic changes in response to blood levels of ovarian hormones
This is the later that sheds during menstruation ~ every 28 days
Stem cells here form the new functional layer after menstruation
Vagina
Copulatory organ
Receives the penis during intercourse along w/semen, provides passageway for delivery of infant & for menstrual flow
A thin walled tube extending from cervix -> body exterior
The wall consists of 3 coats
Mucosa is stratified squamous epithelium
Smooth muscularis
Inner mucosa
Outer fibroelastic adventitia
Containing rugae
To stimulate the penis during intercourse
To stand up to friction
This mucosa has no glands
Rather, it is lubricated by cervical mucous & mucosal fluid -> vaginal walls
Other structures
Hymen
Mucuosa near vaginal orifice broken by sexual intercourse if that penetration has occurred for the first time
Vaginal fornix
Upper end of vaginal canal surrounding cervix
External genitalia
Clitoris
Mons pubis
Vestibule
Labia majora
Bulb of vestibule
Fatty, rounded area overlaying pubic symphysis, hair after puberty is found here
Homologues of scrotum
These 2 elongated hair covered fatty skin folds enclose the labia minora
Consists of
Labia minora
2 thin hair-free skin folds
Homologous to spongy urethra of penis
External openings of urethra & vagina
Greater vestibular glands
Homologous to bulbo urethral glands of male
These glands release mucous into vestibule to keep a lubricated environment
At the posterior end of vestibule, labia minora & vestibule come together forming the fourchette
Composed mainly of erectile tissue
Homologous to penis
Rich w/nerve endings
Making area sensitive
Becomes swollen w/blood during stimulation
Body of clitoris
Has dorsal erectile columns (corpora cavernosa)
Lie along side each of vaginal orifice
Homologous of the single penile bulb & corpus spongiosum
During stimulation, these engorge w/blood
Helps vagina grip penis
Squeezes urethral orifice shut as to prevent semen & bacteria from traveling superiorly into bladder during intercourse
The ovarian cycle
Process
Contraceptive methods
Large follicles are growing in the ovary
As FSH levels rise, so does the follicle
FSH is what allows vesicular follicles to grow & survive
Monthly series of events asscoiated w/maturation of an egg
One of these follicles become more sensitive than the others
As FSH levels drop midline of phase, the follicle outcompetes the others for FSH & this becomes the dominate follicle
This cycle repeats ~ 28 days
10-15% of woman have 28-day cycles
Even though the cycle may vary, the luteal phase remains the constant
The primary oocyte of the dom follicle completes meiosis I to form the secondary oocyte & 1st polar body
Stage is set for ovulation
Uterine phases
I. Follicular phase
The developing follicle
Stages of follicle development
2 phases
I. Gonadotropin-independent preantral phase
II. Antral phase
Follicles are stimulated by FSH & LH
Follicles grow tremendously & the dominate follicle is selected
Development of follicles
1) A primordial follicle is surrounded by squamous cells around it become cuboidal cells
The oocyte enlarges & is now known as a primary follicle. This develops after puberty
2) A Primary follicle becomes a secondary follicle
The zona pellucida develops
Pregranulosa cells proliferate forming stratified cuboidal epithelium
The follicle now is called a secondary oocyte
As the follicle grows, a layer of connective tissue &epithelial cells condense forming thecal cells
Development of follicles #
3) A secondary follicle becomes a vesicular (antral) follicle
A secondary follicle stage ends when a clear liquid accumulates between granulosa cells
When 6-7 layers of granulosa cells are present, the antrum forms
Thecal cells secrete steroid hormones in response to LH
The antrum nearly extends completely around oocyte & the corona radiata extends around that
II. Luteal phase
While the primary oocyte in the dominant follicle resumes meiosis I
Intrafollicular paracrines (cytokines & Gfactors) control oocyte & follicle development
When many vesicluar follicles begin to secrete increasing amounts of estrogens
One of these are selected as the dominate follicle
Ovarian hormone levels #
Ovarian cycle (follicle stage) #
GnRH hormone levels #
This phase lasts from the 1st-14th day
I. Follicular phase
I. Follicular phase
I. Follicular phase
W/ the 14th day being when ovulation occurs
1) One day 1, low hormone levels stimulate hypo. to releases GnRH & this releases FSH & LH (stimulus for ovulation)
2a) FSH stimultes the follicular growth, increasing # of granulosa cells
3) As estrogen rises, the hypo senses the estrogen levels are too high & begins produces less GnRH reducing LH & FSH amounts (reason for dips in chart)
2b) LH makes thecal cells produce androstenedione which cause granulosa cells produce of estrogen
So as the follicle grows, estrogen is jacked up
Granulosa cells are still cranking out the estrogen #
This produces 2 more hormones in higher amounts
Inhibin (A&B)
Progesterone
Role: Inhibit FSH #
As inhibin starts to increase, FSH decreases
But if estrogen reaches a crazy high level (like the peak in the chart), it causes the hypo. to want to release more GnRH! WHAT!!!!!!!!! I thought GnRH was inhibited?!
a) Even though pituitary is releasing FSH, inhibin is already preventing FSH so you wont have much follicle growth
b) So now you just have a HUGE release of LH from pituitary (LUTEAL SURGE)
These two push the follicle to the edge & there goes the oocyte releasing from the follicle. OH my, ovulation just occurred on day 14!
Occurring via negative feedback
Menstrual phase (1-4 days)
Proliferative phase (4-14 days)
Period during which the corpus luteum is active
Secretory phase (14-28 days)
Hormone levels drop dramically
Endometrial lining is shed (functional layer)
Functional layer of endometrium is being rebuilt
Increasing estrogen levels induce a new functional layer
II. Luteal phase (after ovulation)
II. Luteal phase
II. Luteal phase
4) LH is really high still
Together, LH & FSH induce empty follicle to turn into the corpus luteum (yellow body) #
5) Since this corpus luteum is not a follicle any more, estrogen levels decrease (b/c the follicle produces estrogen)
However, the luteum does produce LOTS of progesterone
To prepare uterine lining for gestation (hint the name, progesterone)
Increases blood flow -> endometrium
Progesterone reduces contractility of uterus so embryo doesn't get too disturbed
14 days of prep for implantation
Endometrium thickens
6) Progesterone & little bit of estrogen produced by luteum suppresses FSH & LH production using (-) feedback
Luteum is also producing inhibin, preventing FSH release
7) Luteum needs FSH & LH to survive
Since they are depressed, luteum atrophies
8) When luteum dies off, progesterone & estrogen levels drop
When these stop, the end of luteal phase has occurred
It is AT THIS POINT that MENSTRUATION OCCURS :(
~ 40 mL of blood lost
FSH & LH levels go back up
Nexplanon - Birth control implant
Tubal ligation AKA sterilization
Depo-Provera shot
Barrier methods - Condoms
3 Worst contraceptive options
Sperm will still be produced however, they will not be able to reach the exterior of the body. They deteriorate & are phagocytoced
1) A small incision is made in the scrotum
How it works
This is a shot injected every 3 months
It contains the hormone progestin
Possible side effects
This is NOT progesterone, its a synthetic form of it in which interacts w/receptors on progesterone
It prevents ovulation by mimicking progesterone receptors
My thinking is that the this shot in a way imitates pregnancy ovarian symptoms in that the progestin from the shot mimics progesterone by binding to its receptors
B/c progestins can potentially attach to other receptors in the body, they may attach to estrogens & androgens
The particular response of the individual may vary
If attached to androgens
Acne
Changes in cholesterol
Progestins can also attach to receptors on mineralocorticoids or glucocorticoids
This can cause H2O & salt imbalances
Progestin binding to glucocorticoids can cause bloating
If bound to estrogen from another birth control
This can cause blood clots in the VEINS!!!
This could be a major risk if it travels -> heart, brain, or lungs
In addition, the cervical mucous thickens preventing sperm from going into uterus
Progestin only methods were found to cause irregular bleeding in uterine cycle
Or the absence of bleeding can occur
My thinking on this is that when progestin mimics progesterone, the levels can be unpredictable
94% effective
This would cause the suppression of FSH & LH whereas the progesterone levels would remain higher
This mimics the hormonal state after ovulation
This would make it seem as though ovulation has already occurred
If FSH & LH is suppressed, no egg is released
2. Oral contraceptive pill (OCP)
3) Coitus interruptus (withdrawal of penis before ejaculation)
1. Tubal ligation
Possible side effects
How it works
A rod full of progestin
Inserted under the skin in the upper arm
This lasts 5 yrs
99% effective
Changes in normal menstrual bleeding
Deep vein thrombosis
Cysts developing on ovaries
Weight gain
Weight gain
The progestin works in much the same way that the Depo-provera shot works #
Exept that the progestin is coming from the implant
Headache
85% effective
How it works
Prevents sperm from even reaching the vagina by encasing the penis
Possible side effects
Some may have latex allergies if a latex condom is used
Some condoms may have substances that can cause reactions to the vagina or the penis, more common in the vagina from what I found
Reduced sensation
Some risk with it falling off during intercourse
Possible side effects
Could cause a blood flow problem to each ovary
How it works
99% effective
Fallopian tubes are literally ties off each tube
W/this in place, sperm cannot get to the oocyte to fertilize it
Reason
Part of the blood supply is removed from ovaries
This can be a major issue b/c the ovary may not get the O2 or nutrients it need to function properly
This this affect progesterone levels causing it to lower
Could lead to premenopausal systoms
Migraines
Fatigue
Playing with sex hormones can throw some of the body's homeostatic rhythms out of place
Thyroid hormones run in line w/sex hormones
Hot flashes
This could lead to unbalance between progesterone & estrogen
These two need to work together in order to maintain balance not only for the reproductive organs but the other organs that work in tandem w/the reproductive organs
Once these are not in a rhythmic balance, the body can produce proteins that block cells ability to use thyroid hormone
This could lead to symptoms of hypothyroidism
Such as goiter
If this was an option that was heavily wanted, I would add some natural thyroid & progesterone to the mix so that the hormones can be in balance
Reason
I would say it is safer for the male to get the permanent birth control because they don't have to worry about hormones being in the vas deferens like the women have to worry about the hormones progesterone & estrogen in the ovaries
I deduce that going w/this permanent option is the best choice being that it will not affect the patient's uterine cycle
To add to that, the couple would not have to worry about the effectiveness of the method
2. Following the uterine cycle (Behavioral method)
Process
Reason
3. Progesterone-only products (Hormonal approach)
The patient would need to be precise in calculating her cycle
So starting from day 1 of menstruation
Usually I would be against this b/c there are is a risk still of getting pregnant
However, it could be a very low one if done absolutely correct
This could be an option due to the patient possibly not being to far off from menopause
This way, the patient would not have to worry about anything disrupting her hormones
& Being that the patient is healthy, I would not want to disrupt that if it can be avoided
From there, count -> 28 days, subtract 14
On the 12th -14th day of ovarian cycle, the couple would have to refrain from intercourse to avoid pregnancy
This is what I would deem to be effective, if done right & consistently b/c the oocyte is only viable for 12-24 hours after ejaculated from ovary
The chance of getting pregnant drops to almost zero the next day
Even thought sperm can survive nearly a week, it would still be difficult to get pregnant if you were aware of this
Reason
There can be a high success rate w/this if practiced properly
There is a 24% fail rate w/this so if proper dedication cannot be exercised, a different means of birth control is what I would recommend
Can mess w/many other hormones of the body
Postmenopausal symptoms
Feedback: Many claim to use this method yet come out pregnant
So I would have a physician help w/this process to make certain the patient is on the right track
Also due to the reason the couple have kids & therefore had experience raising them at this point should make it easier for them to decide on a permanent option
Another idea to add to this case is that the couple both are above their 30s so they may be more sure about their choice
Reason
This do not recommend this to be a good option b/c these contain estrogen & progesterone
If estrogen & progesterone are taken together, they trick the HPG axis into making it seem as the the woman is pregnant
This seems to have safer effects than methods containing estrogen & progesterone
These thicken the cervical mucus so as to block sperm from entering the uterus & make it harder for implantation
This method is one of the most effective means of contraceptive
This is a better option than using estrogen along w/it b/c there is less long term effects & symptoms
Both of these together can really disrupt the uterine cycle & other hormones
This can lead to intolerable side effects
Another reason is that these pills can cause adverse cardiovascular effects
Such as hypertension & nausea
Reason
This method is unreliable b/c
Control of ejaculation is not ensured
It can cause stress b/c the couple may always be wondering any semen seeped in