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Contraceptive Toolbag. Diana Koster, M.D. Planned Parenthood of New Mexico April 14, 2010. Goals. Provide: Contextual information about U.S. teen pregnancy rates Updated medical information reproductive healthcare needs contraception LARC (long-acting reversible contraception)

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Contraceptive toolbag l.jpg

ContraceptiveToolbag

Diana Koster, M.D.

Planned Parenthood of New Mexico

April 14, 2010


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Goals

Provide:

  • Contextual information about U.S. teen pregnancy rates

  • Updated medical information

    • reproductive healthcare needs

    • contraception

      • LARC (long-acting reversible contraception)

      • Emergency contraception

  • Comfort in role as educators and counselors of teens



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U.S. Compared to Europe

  • Sexual debut is equivalent.

  • Pregnancy and STIs are more frequent among US teens than among (most) European teens. (New Mexico #1 in teen pregnancy.)

  • US teens have more partners.

  • Use of birth control is less in U.S. than in other developed nations.

  • US teens less likely to use medical (i.e., most effective) contraceptives.





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MissedPills


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Obstaclesto Healthy Sexuality

  • Ignorance

  • Parental discomfort

  • Teacher/counselor discomfort

  • Lack of clarity about how best to deliver messages

  • Lack of access to confidential services

  • Incomplete brain maturation

  • Abstinence-only education (as opposed to abstinence-based education)


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Abstinence-based

Abstinence as preferred for teens

Accurate contraceptive information for future

Proven successful

Abstinence-only

Abstinence until marriage

No contraceptive education

Inaccurate

Unsuccessful

Refusal skills

Abstinence Education


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Myth # 1

Abstinence and contraception cannot both be taught successfully.

Teaching our youth about contraception will make them become sexually active.


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American Academy of Pediatrics

“Reduction of unintended pregnancy is best achieved by strategies that include…effective programs to delay and reduce sexual activity….Strategies to reduce unplanned pregnancies should include improving the knowledge, accessibility, and availability of contraception services, including emergency contraception.”

Policy Statement in Pediatrics, Vol. 116 No. 4 Oct 2005


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Support for Comprehensive Sexuality Education

  • National Institutes of Health

  • Institute of Medicine

  • Centers for Disease Control

  • American Medical Association

  • American College of Obstetrics and Gynecology

  • Society for Adolescent Medicine


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Goals of Sexuality Education

  • Promote good decision-making

    • feelings of comfort

    • appropriate outcomes

  • Pregnancy prevention/delay

  • Prevention of STDs/STIs


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Myth # 2

Minors must have parental consent/permission to obtain birth control.


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New Mexico Law (condensed)

  • Minors of any age may get reproductive healthcare without parental permission.

  • Such care includes birth control as well as testing and treatment for sexually transmitted infections.

  • Sexual activity under age 13 must be reported to CYFD.


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Myth # 3

There are 100% effective birth control methods. Anyone who gets pregnant using birth control “screwed up.”


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Contraceptive Effectiveness(expressed as failures per 100 women years of use)



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Myth #4

Birth control is dangerous.


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Safety of Contraception

Use of a properly selected contraceptive method is always safer for a woman than pregnancy.


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Myth #5

Making emergency contraception (easily) available will increase irresponsible behavior.


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Emergency Contraception(“morning-after-pill”)

  • Provides chance to prevent unplanned pregnancy and to start regular contraceptive care

  • Is not the “abortion pill” – (ovulation disrupted or delayed)

  • Is medically safe for all

  • Can be used in addition to “regular” method

  • Is available “behind-the-counter” for > 17, by prescription for < 16 (not science-based)

  • Does not increase risk-taking

  • Forms include

    • Plan B/Plan B 1-Step

    • Next Choice

    • Birth control pills in special doses


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Emergency Contraception

  • “The sooner, the better”

  • Advance provision ideal – cf. fire extinguisher

  • Available at:

    • Planned Parenthood

    • Public Health Department

    • School-based health centers (?)

    • Pharmacies

    • www.not-2-late.com


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Myth #6

To use (hormonal) birth control safely, a woman must first have a complete physical exam and lab testing including a Pap smear and STD testing.


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Complete history

Testing – Pap, STDs

Complete exam

Pelvic

Breast check

Thyroid exam

Heart and lungs

Blood pressure, weight

Targeted history

Testing – variable, age-specific

Exam – variable, age-specific, usually,none needed for teen

beginning birth control

“Annual Exam”Then Now


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Advantages to New Approach

  • Provides opportunity to educate patients/students concerning individual healthcare needs

  • Avoids fear of pelvic as barrier to initiation of contraception

  • Makes contraception more affordable

  • Allows contraception to be started quickly

  • Spends healthcare dollars more appropriately

    :


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Starting the Pill(and other hormonal contraception)

It is good medical practice to make decisions concerning prescription of birth control pills to women based solely on a careful health history and a blood pressure measurement.

- World Health Organization


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Myth #7

A birth control method can only be started when a woman is having her period.


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Beginning Birth Control

Any contraceptive method may be started at anytime in a woman’s cycle as long as it is reasonably certain that she is not pregnant.


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Myths #7-9

Teens cannot use IUDs.

Women who have not had babies cannot use IUDs.

Unmarried women cannot use IUDs.


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Ideal Contraceptive

  • Easy – little/no attention needed

  • Highly effective

  • Few/no side effects

  • No medical risks

  • Effective for years

  • Rapidly reversible

  • STD/STI prevention

  • Private

  • ONE WITH WHICH USER IS COMFORTABLE!!


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LARC (long-acting reversible contraceptive)

  • Intrauterine contraception

    • IUD – Paragard

    • IUS – Mirena

  • Implant – Implanon


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Tiers of Contraceptive Effectiveness

  • IUDs, implant, sterilization

  • DMPA (“shot”)

  • Pills, patches, rings

  • Everything else

    - David Grimes (modified)


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IUC/IUD/IUS (Intrauterine Contraceptive/Device/System)

  • Effective for 5 or 10 years

  • Private

  • Convenient

  • Cost effective

    • Paragard: ~$500 for 10 years or ~$50 per year

    • Mirena: ~$600 for 5 years or ~$120 per year

  • Generally considered inappropriate for teens. Why?

    • Old data from previous devices


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IUD/IUS/IUC

  • As effective as sterilization

  • Minimal user effort

  • Makes sperm unable to fertilize egg (Paragard), thickens mucus and suppresses ovulation (Mirena)

  • Appropriate method for teens

  • Five (Mirena) or ten-twelve (Paragard) years of protection

  • No STD/STI protection but does not cause PID(pelvic inflammatory disease)


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Implanon

  • As effective as sterilization

  • Minimal user effort

  • Progestin-only implant similar to Norplant

  • Thickens mucus and suppresses ovulation

  • Continuous low levels of hormone

  • Three years of protection


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Other Hormonal Contraception

  • Pills – multiple brands with varying doses

    • Combined = estrogen + progestin

    • Mini-pill = progestin only

  • Patch = OrthoEvra

  • Ring = NuvaRing

  • Shot = DepoProvera (DMPA)

    * * * * * *

  • Emergency contraception (Plan B/Next Choice)


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    Oral Contraceptive Discontinuation

    • 28% discontinue by 6 months

    • 33-50% discontinue by 1 year

    • Reasons for discontinuation range from break-up with partner to fear of medical risks to uncomfortable side effects and include inability to afford birth control


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    HormonalContraception

    • SAME (or very similar):

      • mechanisms of action

      • risks (no estrogen risks with minipill and DMPA)

      • benefits

      • effectiveness

    • DIFFERENT:

      • delivery system

      • real world effectiveness (?)


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    Noncontraceptive Benefitsof hormonal contraceptives

    • Reduces:

      • pain with periods

      • Irregularity of periods

      • amount of blood loss and therefore anemia

    • Decreased risk of cancer of

      • uterus

      • ovary

    • Lessens risk of

      • benign breast disease

      • rheumatoid arthritis


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    Oral Contraceptive“The Pill”

    • Estrogen and progestin taken in low doses daily for three weeks with one hormone-free week each cycle

    • Suppresses ovulation and thickens cervical mucus

    • Modern low doses - fewer side effects, theoretical efficacy = 99+%

    • Increased failure with late or missed

      pills


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    Myths # 10-16

    The Pill causes:

    • acne

    • weight gain

    • cancer

    • sterility

    • heart disease

    • birth defects

    • stunted growth in a teen


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    Myths # 17-19

    A woman should go off contraception periodically to “give her body a rest.”

    There is a limit to how long it is safe for a woman to use contraception.

    A woman should not be on a contraceptive unless she is sexually active.


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    Fears about Hormonal Contraception

    • Inappropriate, based on old data or observations.

    • Estrogen use in smoking woman > 35 year old is the true danger for hormonal contraception

    • Hormonal contraception is extremely safe for most healthy women

      • 20 times safer than pregnancy and childbirth

      • 33 times safer that driving an automobile

  • Decreases the risk of several serious diseases and the severity of several others


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    Ortho Evra(Contraceptive Patch)

    • Skin patch with the same type of hormones as in the birth control pill

    • Requires weekly, not daily attention

    • May have higher “real world” effectiveness because easier to use than pills

    • Less nausea than pill, rare skin irritation


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    Myth # 20

    Ortho Evra is a dangerous birth control method; it causes strokes in many women.


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    NuvaRing

    • Vaginal ring containing same type of hormones as birth control pills

    • Lowerlevels of systemic hormones

    • Requires monthly, not daily or weekly attention

    • May have higher “real world” effectiveness because easier to use than pills


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    Myths #21 & 22

    Not having a period every month is unhealthy: the blood needs to “come down.”

    DepoProvera (DMPA) causes significant weight gain and osteoporosis


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    DepoProvera

    • Failure rate = 3/1000

    • Private

    • Progestin-only - no estrogen side effects

    • Easier adherence: every twelve week injection

    • Absence of periods probable

    • Bone changes reversible

    • Weight change generally not significant


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    Barrier Contraceptives

    • Film, foam, jelly, sponge, condom, diaphragm*, cervical cap*,

    • Must be used before every intercourse

    • Primarily non-prescriptive

    • High failure if solo

    • Highly effective if paired (e.g., film + condoms) and used always

      *require medical professional to fit



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    Myth #22

    There are large holes in condoms that allow free passage of bacteria, viruses and sperm.


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    Condoms

    • STD/STI prevention

    • Only (reversible) male method

    • Use as second method of birth control

      • with other barriers, about equal to pill effectiveness

      • with highly effective methods, approach 100%

    • Female condom


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    STDs/STIs

    • Most people with infections have no symptoms.

    • Prevention messages shouldemphasize:

      • Limiting the number of lifetime partners;

      • Consistent condom use until testing has occurred and relationship is known to be exclusive;

      • Periodic testing.

    • Prevention messages should not include scary pictures.


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    Other Methods

    • Withdrawal

    • Anal intercourse

    • Menstrual cycle timing (periodic abstinence)

    • Saran wrap

    • Coke douches

    • Special positions – e.g., standing up


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    CONTRACEPTIVE ACCESS

    • Medicaid, Family Planning Medicaid

    • Public Health Offices (Teen Clinics) may offer free contraceptive care

    • Planned Parenthood of New Mexico (PPNM): reduced cost contraception

    • Easy access programs at PPNM:

      • HOPE

      • Pills Now, Pay Later (includes patch and ring)

      • Contraception by mail

      • Multipack discount


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    Teen Pregnancy Prevention

    • Professionals need to recognize the realities of life and make contraception easy to access and use.

    • Eliminating gaps in contraception is key to decreasing unintended pregnancy in teens.

    • A teen must feel comfortable with her (his) chosen contraceptive method.

    • Wide-spread use of LARC is essential to reducing teen pregnancy.


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    Sources of Information

    • Contraceptive Technology, ed. Hatcher

    • Planned Parenthood of New Mexico (265-5976)

      Diana Koster, ext.317 or Johnny Wilson, ext.306

    • Websites

      • ppnewmex.org - Planned Parenthood New Mexico

      • ppfa.org – PP Federation of America

      • arhp.org - Association of Reproductive Health Professionals

      • agi.org – Alan Guttmacher Institute

      • Who.org