Contraception
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Contraception. Dr Arlene Smalls, MD August 5, 2011 Lankenau Medical Center Department of OB GYN. Objectives of Lecture:. Review of Contraceptive Counseling, Risk Assessment and Method Initiation Discussion of Conceptive methods including Emergency Contraception

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Contraception

Contraception

Dr Arlene Smalls, MD

August 5, 2011

Lankenau Medical Center

Department of OB GYN


Objectives of lecture

Objectives of Lecture:

  • Review of Contraceptive Counseling, Risk Assessment and Method Initiation

  • Discussion of Conceptive methods including Emergency Contraception

  • Discussion of new Guidelines regarding Contraceptive Usage


Contraception needs in us

ContraceptionNeeds in US

  • ~60 million women between ages of 15-44

    • 60% use contraception

    • 33% don’t have a need for contraception

    • 7.3% who are at risk are not using any method

  • 6 million pregnancies yearly in US

    • 50% of pregnancies are unintended

    • 1 million pregnancies occurred on OCP’s

    • 1.4 million abortions performed yearly in US


Counseling

Counseling

  • Efficacy

  • Availability

  • Costs

  • Ease of Use

  • Privacy

  • Reversibility

  • Side Effect and Medical Risks

  • Patient and Partner Desires

  • Informed Decision Making


Contraceptive efficacy

Contraceptive Efficacy

  • Pearl Index:

  • Theoretical Definition of Method Failure Rate based on “Perfect Usage”:

    Number of Failures / 100 Women-years of exposure (x1200 if based on months) (x1300 if based on cycles)

  • “Typical or Usage Failure Rate” based on actual usage activity from Life Table Method


Contraceptive methods

Contraceptive Methods

Combined Hormonal Methods (COC)

  • Oral Contraception

  • Nuva Ring

  • Ortho Evra Patch

    Progestin Only Methods (POP)

  • The Mini Pill

  • Depo-Provera

  • Implanon

    Non Hormonal Contraception - IUD

    Barrier Methods

  • Male / Female Condoms

    Sterilization

    Emergency Contraception


Pre assessment evaluation

Pre-Assessment & Evaluation

  • Discussion of Patient’s Life and Health Plans

    • Reproductive Life Plan

    • Childbearing Goals

    • Birth Spacing

  • Pre-conceptual Health Assessment and Counseling

  • Extensive Personal Medical History and Family History


Pre assessment history

Pre-Assessment History

  • Personal History:

    • Medical History of Hormonal contra-indications:

      (HTN, MI, Cardiac Dz, DM, CVA, DVT, PE, other)

    • Liver Disease

    • Migraine headache with aura or neurologic complaints; Seizure history

    • Tobacco Usage

    • Current Medications

  • Surgical History


Pre assessment history1

Pre-Assessment History

  • Gyn History:

    • Menstrual History including LMP

    • Breast Issues including new or unevaluated masses

    • Uterine fibroids or other anatomic abnormalities

    • STD history, prior and current risk (?)

  • Familial History of Thrombophilia (1st degree relative)


Pre assessment evaluation1

Pre-Assessment & Evaluation

  • Physical Exam not necessary prior to initiation of any birth control method

    • Vital Signs, Weight

    • Breast Exam*, Pelvic Exam (??)

  • Laboratory Testing

    • Factor V Leiden, Anti-phospholipid evaluation, Glucose, and Lipids if there is a concerning personal or family history

  • STD screening prior to IUD placement (?)


Cdc and contraception medical eligibility

CDC and Contraception Medical Eligibility

  • WORLD Health Organization (WHO)established an evidence based guideline for contraceptive usage

  • Global review of the 19 different contraceptive methods for women and men

  • 4th version was revised 2010 (available since 1996)


Coc physiologic effects

COC Physiologic Effects

  • Hormonal Effect

    • Estrogen (ethinyl estradiol) and Progesterone alter FSH/LH secretion via negative feedback

      • Follicle development and Ovulation are suppressed

      • Endometrial thinning

      • Cervical mucous thickening

    • Reduced sperm transport

  • Progestin is the dominant hormone


Coc or ocp s

COC or OCP’s

  • 10.7 million women use OCP (~27% of BC users)

  • Most popular, reversible BCM in the US

  • 21 day cycle, 24 day cycle

  • Extended regimens

  • Monophasic, Biphasic, Triphasic, Quadiphasic (Quailara@)

  • 20mcg, 35 mcg, 50 mcg pill regimens

    (based on Estrogen dosage)


Ocp failure

OCP Failure

  • Failure rate is 0.1%

  • Usage Failure rate is 8/100 woman-years

    • Adherence with OCP – 50% of women miss 1-3 pills a cycle

    • Missing Pills within the 1st week of the pack – breakthrough ovulation

  • Drug Interactions –

    • Anti-seizure medications (G450 activation)

    • Antibiotics – Rifampin, Griseofulvin

    • Anti-viral medications - Norvir


Ocp s concerns

OCP’s concerns

  • Alterations in the Menstrual Cycle

    • Breakthrough bleeding

    • Amenorrhea 0.8% per year

  • Health Risks

    • Headaches and Elevated Blood pressure

    • Weight Gain

    • Breast Cancer risk

  • Risk of Thrombo-embolic events*


Non contraceptive benefits

Non Contraceptive Benefits

  • Acne and Hirsuitism therapy

  • Menstrual Regulation occurs with decreased Menstrual Blood Loss

  • Dysmenorrhea, endometriosis symptoms are improved

  • Rates of Ovarian cysts, ectopic pregnancy, and salpingitis are reduced.

  • Ovarian and Endometrial Cancer rates are reduced with past usage of at least one year


Contra indications to coc usage

Contra-indications to COC usage

  • Medical History

    • Personal H/o Thrombo-embolism (DVT, PE, CVA, MI)

      or

      Familial History of inherited thrombophilia (DVT, PE, CVA, MI)

    • Uncontrolled HTN (>160/100)

    • Hepatic Dysfunction

    • Diabetes

    • Breast Cancer

    • Smokers over the age of 35** (#)

    • Unexplained vaginal bleeding or Pregnancy


Contra indications to coc usage1

Contra-indications to COC usage

  • Postpartum patients* <21 days,

  • Cardiac Disease including h/o ischemic heart disease, valvular heart dz, peripartum cardiomyopathy and multiple risks factors for heart disease*

  • H/o Solid Organ Transplant, complicated

  • H/o Gastric Bypass*

    CDC – Medical Eligibility Criteria, 2010


Pos tpartum contraception

Postpartum Contraception

  • WHO Revised guideline 7/2011

  • PP, 22-84X greater risk of DVT, PE or VTE

  • Ovulation can occur as early at 25 days in non lactating women

  • 21 days pp - No COC or CHC

  • 42 days pp – Non COC or CHC

    • Obesity, Post Cesarean Delivery, Preeclampsia, PP hemorrhage, Transfusion at Delivery, Immobility, Age > 35, Tobacco Users, BMI > 30, Prior h/o VTE, Thrombophilia)

  • POP methods are acceptable immediately


Drug interactions and ocp s

Drug Interactions and OCP’s

  • Anti-Malarial Meds: Rifampicin / Rifabutin

  • Anticonvulsant Medications: Lamotrigine*

    Phenytoin, Carbamazepine, Barbituates, Primidone, Topiramate and Oxcarbazepine

  • Antiretroviral therapy (ARV):

    Ritonavir-boosted protease inhibitors


Ortho evra

Ortho-Evra

  • Weekly Transdermal patch of a hormonal matrix

    • 150 mcg ethinyl estradiol

    • 20 mcg norelgestromin

    • Worn 3 weeks out of 4 weeks per cycle

  • Sites of usage: Back, Upper arm, Abdomen, or Chest

  • Sunday Start or 1st day Start

  • Patch Change Date within 48 hours of scheduled date

  • Failure rate: 1%

  • Not recommended for hormonally naïve patients, smokers*, or patient with h/o skin sensitivity or weights above 198 lbs


Nuvaring

NuvaRing

  • Ethylene vinyl acetate polymer ring

    • 15 mcg of Ethinyl estradiol

    • 120 mcg Etonogestrel

    • Intra-vaginal placement

    • Worn ¾ weeks per cycle with option of one week

  • Menstrual Cycles regulated 98.5% of cycles

  • Failure rate: 0.65-1.18/100 women-years

  • Vaginal Discharge and placement issues


Progesterone only contraception

Progesterone only Contraception

  • Progestin-only pills - POP or “Mini pills” Norethindrone or norgestrel

  • Continuous usage (no pill free interval)

  • Hormone must be taken daily at the same time

    (25% circulating levels of OCP’s / 22hr effect)

    Ovulation seen in 40-50% of POP users

  • Mechanism of action: Cervical Mucous thickening, Thinning of endometrium, reduced sperm transport

  • Failure Rate: 1.1 to 9.6 / 100 women-years

  • Backup method – Barrier Method / Breast feeding


Depo provera @ or dmpa

Depo-Provera@ or DMPA

  • 150milligrams of Medroxyprogesterone acetate

  • IM dose every 11-13 weeks

    • Deltoid or Gluteus Maximus

  • Inhibits LH/FSH surge

    • Ovulation and endometrial proliferation are inhibited

  • New Guidelines regarding missed doses

    • WHO 2009 – Delayed Dosages can be given up to 4 weeks from date originally scheduled

  • Failure Rate: 0.3 – 3%

  • Long lasting but reversible

    • Return to fertility – 50% by 9 months (max – 18 months)


Contraception

DMPA

  • Contra-indications:

    • Breast Cancer

  • Safe if contra-indications to COC’s exist:

    • Tobacco, HTN,

    • SLE, CVA, Thromboembolic events (DVT/PE), Liver Disease (????)

  • Improved Outcomes in Certain Populations:

    • Sickle Anemia / Trait; Seizure Disorder

    • Endometriosis, Dymenorrhea and Pelvic Pain

    • Adolescents, Developmentally Delayed Women


Dmpa risks

DMPA Risks

  • Bone Density alteration due to estrogen deficiency

    • Limited Risk: Bone changes resolve with cessation of DPMA

  • Menstrual Changes

    • 70% have increased bleeding days per month

    • 75% experience amenorrhia after one year of usage

  • Weight Gain

    • More in Women who are Obese at initiation of method

    • 5lbs by year One; 16 lbs by year Five

  • Mood Disorders and Psychiatric Issues


Implanon

Implanon

  • Subdermal, single rod progestin implant

    • Etonogestrel release

    • 3 year duration of use

  • Ovulation suppression and endometrial thinning

  • Failure rate: no failures reported in 4103 women / 70,000 cycles

  • Menstrual pattern alteration – 80%

    • Irregular or prolonged bleeding (3-5 days per cycle)

    • Total Overall Blood loss decreased

    • Treat with NSAIDS, OCP’s or estrogen


Intra uterine device paraguard @ iud

Intra Uterine Device – Paraguard@ IUD

  • Long acting, low maintenance, rapidly reversible contraception

  • Copper T380A - 3.6cm long T shaped device made of polyethylene plastic

  • Length of usage – 10-12 years

  • Prevention of pregnancy via Endometrial inflammatory response and anti sperm activity

  • Failure rate = 0.8% (up to 3% at 10 years)

  • Risk of PID, Expulsion/perforation at insertion and Dysmenorrhea/Menorrhagia


Mirena @ iud

Mirena@ IUD

  • 3.2cm long, T-shaped device with an inner reservoir

    • Levonorgestrel 20 mcg per day

  • Cervical Mucous thickening and Endometrial atrophy

  • Ovulation still occurs in 85% of the cycles

  • Failure rate: 0.14 per 100 women–years 0.71% (5 year failure rate)

  • Menstrual irregularity during the first three months

  • Menorrhagia/Endometrial Cancer treatment


Iud safety

IUD Safety

  • Safe Profile proven with recent studies

    • Safe for Adolescents and Nulliparous Females

    • Limited increased risk of PID/Infection within the first 30 days post placement

      • Screen for STI and BV pre-placement if Risk factors

      • Treat STI and allow 3 months from therapy prior to IUD placement

      • Recommend Condom usage

    • IUD can be left in place if cervicitis or PID diagnosed


Barrier methods

Barrier Methods

  • Male Condoms

    • Latex condoms – STI protection

    • Failure rate – 3% (Actual – 12%)

    • Breakage rates: 1% of heterosexual acts

    • Nonoxynol 9 no longer recommended

    • Polyurethane or Non latex condoms

  • Female Condoms

    • Polyurethane pouch with two rings

    • Can insert up to 8 hours prior to intercourse

    • Female controlled and allows Labia protection


Barrier methods other

Barrier Methods, Other

  • Cervical Cap:

    • Thimble shaped rubber device that fits over the cervix

    • Fitted by gynecologist

    • Can be left in vagina for 48 hours

    • Vaginal Discharge

    • Failure rate: 9% in nulliparous; 20% in parous within 1 year

  • Diaphragm:

    • Dome shaped rubber cups create a barrier over the cervix

    • Use with spermicide

    • May place in vagina up to 6 hours prior to intercourse and remain in place for 8 hours (max 24 hours)

    • Failure rate: 6% / 12%

    • UTI risks


Permanent sterilization female

Permanent Sterilization - Female

  • Female Sterilization is the most common method used in US for married couples

  • 10 million women in US

  • 100 million women worldwide

  • Overall Failure rates: 1.85% over 10 years but differs slightly by method and provider experience

  • Drawbacks: Regret, Failures, Ectopic pregnancy

    (CREST study – NEJM 2001)


Permanent sterilization female1

Permanent Sterilization - Female

  • Laparoscopic Methods: Bipolar Cautery, Sialastic Bands / Falope Ring, Filshie or Hulka Clips,

  • Open Procedure / Minilaparotomy:

    Pomeroy/Modified Pomeroy, Parkland, Irvine, Uchida, Fimbrectomy

  • Hysteroscopic Methods: Essure, Adiana


Male methods sterilization vasectomy

Male MethodsSterilization - Vasectomy

  • Conventional Vasectomy

  • “No Scapel Vasectomy” - In Office Procedure for occlusion of the Vas Deferens

  • Limited Risks:

    • No Missed Work, Minimal Pain

    • Need 2 negative Sperm Analysis

    • Costs: $350 – $1,000

  • Failure Rate: < 1%

  • Reversibility:


Emergency contraception ec

Emergency Contraception – “EC”

Post coital Contraception - Pregnancy prevention

  • Yuzpe method, 1970’s

  • 100mcg estrogen/500mcg Levonegestrel - (2) doses in 12hrs

    • Drawbacks: nausea, vomitting

  • More than 20 brands of OCP can now be used as EC*

  • Reduction in unintended pregnancy rates post EC:

    95% if taken with 12 hours;

    89% if taken with 5 days

  • IUD


Emergency contraception ec1

Emergency Contraception – “EC”

  • Plan B, available since 2000

    • 1.5mg Levonorgestrel

    • Single dose (2 pills) versus 2 One pill dose protocol every 12hrs

    • Available over the counter (Age >17) since 2009

    • Well tolerated

  • Next Choice- progestin only EC, OTC available since 2010


Emergency contraception ec2

Emergency Contraception – “EC”

  • Reduction in unintended pregnancy – 95% if taken with 12 hours;

    75% if taken within 72 hours

    May use EC up to 120 hours after intercourse*

  • If, no menses within 2-4 weeks or persistent irregular bleeding post EC, rule out pregnancy


Contraceptive method initiation

Contraceptive Method Initiation

  • Quick start, Sunday start, Menses Day 1 start

  • LMP to r/o pregnancy needed with Quick start

  • Backup needed for 7 days after initiation – Quick start and Sunday start

  • Altered Menses may be seen with all methods

  • Combination methods – Important

    • Condoms/Barrier methods with hormonal method

    • Emergency Contraception

  • Postpartum


Pos tpartum contraception1

Postpartum Contraception

  • WHO Revised guideline 7/2011

  • PP, 22-84X greater risk of DVT, PE or VTE

  • Ovulation can occur as early at 25 days in non lactating women

  • 21 days pp - No COC or CHC

  • 42 days pp – Non COC or CHC

    • Obesity, Post Cesarean Delivery, Preeclampsia, PP hemorrhage, Transfusion at Delivery, Immobility, Age > 35, Tobacco Users, BMI > 30, Prior h/o VTE, Thrombophilia)

  • POP methods are acceptable immediately


Adolescents

Adolescents

  • Confidentiality Issues

  • Recommend Informed Adult regarding medication

  • Return office appt for contraception

    re-enforcement and assessment


Resources

Resources

  • U.S. Medical Eligibility Criteria for Contraceptive Use, 2010

    www.cdc.gov/mmwr/pdf/rr/rr59e0528.pdf

  • World Health Organization

    http://www.who.int/en/

  • Guttmacher Institute

    www.guttmacher.org/pubs/psrh/full/3809006.pdf


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