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Contraception Update

Contraception Update. Pregnancies in the U.S. 25 % Unintended Used Contraception. 52 % Intended. 23 % Unintended No Contraception. Unintended Pregnancy A Major Public Health Issue. The 2002 National Survey of Family Growth reported that

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Contraception Update

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  1. ContraceptionUpdate

  2. Pregnancies in the U.S. 25 % Unintended Used Contraception 52 % Intended 23 % Unintended No Contraception

  3. Unintended PregnancyA Major Public Health Issue The 2002 National Survey of Family Growth reported that • 50% of U.S. women experience at least one unintended pregnancy • The vast majority of women reported using some form of birth control 2002 National Survey of Family Growth

  4. Abortion Rates diverge • In the 70’s, abortion rates of wealthy and poor groups of women were about the same • By 2000, poor women’s abortion rate doubled that of wealthy women • Ethnic/racial differences in rates diminish when income level is controlled • Economic disparities in abortion rate parallel the widening gap between rich and poor in access to basic health care

  5. Mandy • 17 y/o girl with normal sports physical 4 years ago • LMP 3 weeks ago • Here today for pregnancy test • She had unprotected sex 4 days ago. • Her urine pregnancy test is negative.

  6. Emergency Contraception:Levonorgestrel(Plan B) Sig: 2 tabs at once, up to 5 days after unprotected sex

  7. Emergency Contraception (EC)WILL NOT DISRUPT AN IMPLANTED PREGNANCY • Inhibits ovulation • Traps sperm in thickened cervical mucus • Inhibits tubal transport of egg or sperm • Prevents implantation • May interfere with fertilization, early cell division, or transport of embryo

  8. Emergency Contraception (EC) • EC use doubles when provided in advance1 • Easy access to EC does not lead to decreased use of usual contraceptive method2 • Easy access does not increase STIs or unprotected intercourse2 • Direct Pharmacy Access in following states: • Washington, Maine, California, Alaska, New Mexico & Hawaii 1.Bissel et al Soc Sci Med.2003;57:2367-2378 2 Raine et al JAMA.2005;293:54-62

  9. EC treatmentsimplified (progestin only) • OLD : 2 doses of 1 Plan B pill • First dose within 72 hours after intercourse • Second dose 12 hours later • NEW : 1 dose of 2 Plan B pills • As soon as possible – but up to 120 hours after intercourse

  10. “Quick Start”1 • As many as 25% of women do not start prescribed OCPs with Sunday or 1st day start • “Quick Start”1 – first pill on day of visit at any time of the month. Confirm HCG neg. If she needs EC, start contraception w/in 24 hrs of EC. • More women using pill in 3rd cycle • No increased spotting or bleeding2 1. Westhoff et al Contraception 2002 2. Westhoff et al Fertil Steril 2003

  11. Mandy, later • Mandy gets a 4-month supply of birth control pills. • She calls 4 months later requesting a 1-year renewal prescription. • She has never had a Pap smear.

  12. FDA Advisory Committee’s Recommendation on Delay of Pelvic Exam “Physical examination may be deferred until after initiation of oral contraceptives if requested by the woman and judged appropriate by the clinician.” FDA Advisory Committee Recommendation. www.contraceptiononline.org

  13. Does a woman need a pap before getting OCPs? Why tie PAP to birth control? Would you ask a man to have a prostate exam before giving him condoms?

  14. What is Required Before Prescribing Hormonal Methods? Medical History: Required BP: Helpful Breast exam, Pelvic exam, Pap, Hemoglobin, other lab tests, STI testing: NOT REQUIRED! Stewart F, et al. JAMA. 2001;285:2232-2239

  15. Morgan • 24 y/o G0P0 • Does not like hormones, cause nausea • Does not like condoms either • 246 lbs, normal BP, LMP 2 wks ago • Normal Pap/STI tests 1 year ago • Needs birth control before next week’s anniversary celebration

  16. Intrauterine Devices • 2 options today: Copper T 380A (ParaGard) and Levonorgestrel releasing system (Mirena) • United States has lagged behind other countries in adopting the IUD: in 2002, only 2 percent of contraceptive users in the United States chose IUDs. By comparison, IUDs were used by over 50 percent of contracepting women in parts of Asia and 6 to 27 percent of female contraceptive users in Europe • New interest and surge of use in US 1.Hubacher Contraception 2004;69:437-446

  17. IUD Myths • IUDs DO NOT cause Abortion: • IUDs thicken cervical mucus, suppress endometrium; progestin IUD has some anovulatory effect • IUDs DO NOT increase risk of PID: • IUD itself carries no risk of infection. Transient risk w/ insertion .1 Progestin IUD: may protect against PID, 5-year PID associated removal risk 0.8. 2 • IUDs DO NOT increase risk of ectopic pregnancy • In fact IUDs: • DO NOT cause pelvic infection • DO NOT decrease the chance of future pregnancies • CAN be used for women who have not been pregnant 1. Grimes 2.Andersson Contraception 1994;49:56-72

  18. More IUD Myths • May insert at any point in the menstrual cycle • Okay to use in nulliparous women • No need for prophylactic antibiotics • OK to do STI testing at time of insertion (& treat infections w/ IUD in place)

  19. FDA Changes • The copper IUC revised its package label (September 2005) to remove the prior section on "recommended patient profile" that included multiparity, mutually monogamous relationship and history of PID.

  20. Leslie • 34 y/o G3P1 • Having an abortion today in your office • Used condoms in the past • Which contraceptive methods can she start today?

  21. Post-abortion birth control options WHO guidelines suggest the following methods without restriction after an early abortion: • estrogen/progestin pills, patch, ring; • progestin-only injection, implants; • IUDs That is, anything goes!

  22. IUD issues post-abortion • Expulsion rate only slightly increased for IUDs inserted right after early aspiration abortion1 • No increased risk of infection 1. Grimes et al, Cochrane Review 2004 2. Weibe, Communication 4/05

  23. Estrogen/progestin vaginal ring • Low estrogen dose: 15 mcg • 2 inch flexible soft ring • No wrong placement • May remove up to 3 hours • Most don’t notice during sex Dieben, Ob Gyn, 2002

  24. Vaginal RingExpulsion • Spontaneous expulsion infrequent- 2.6% • Occurred only once in almost all cases • If expelled or removed, wash with warm water and reinsert within 3 hours

  25. Monthly: Contraceptive Vaginal Ring • Very effective! • Failure rate 1.2% • May suppress ovulation to 35 d

  26. Ortho Evra Patch

  27. Daily release: • 20 µg ethinyl estradiol Contraceptive PatchORTHO EVRA ™ • 150 µg norelgestromin (NGMN) ** the active metabolite of norgestimate • 1 patch each week • Regimen: • 3 weeks of use / 1 patch-free week • 4.5 cm x 4.5 cm square

  28. Implanon

  29. Implanon subdermal implant approved by FDA 7/06. Clinicians train 3 hours before obtain. One rod 4cm by 0.2 cm inserted into the arm Lasts 3 years; irregular unpredict bleeding Progesterone only, etonogestrel 68 mg Primary mechanism of action is suppression of ovulation, changes cervical mucous Rapidly reversible, no bone mineral density changes

  30. Wanda • 24 yo G3P2Tab1 • Currently using OCP, but admits to frequently forgetting to take pill • Wants to try the patch because her friends like it

  31. Adherence with OCPs:What Women Say NFSG Survey, 1997

  32. Adherence with OCPs:What Women Do! Percent of Women (%) Active Pills Missed Potter L et al, Fam Plann Perspect. 1996.

  33. Initiation of All Hormonal Methods • If starting after the 5th day of menses, use back-up method for 7 days • If switching from OCP, start any time in cycle: NO NEED TO COMPLETE PILL PACK • If switching from depot progestin, start on or prior to next injection date (2 week window) • If switching from IUD between menses, start one week prior to removal

  34. Blanca • Blanca is a 43yo G6P4 Tab2 • heavy painful menses • anemia • fibroid on pelvic ultrasound

  35. Progestin IUD’s Medical Advantages: • Cramps & menorrhagia improve • 90% decrease in overall blood loss • Decreases number of hysterectomies & other invasive treatments for DUB, fibroids 1 • DECREASES risk for ectopic pregnancy • Protect against endometrial CA 1. Hurskainen et al Lancet.2001

  36. Progestin IUD - Mirena • FDA Approved 12/ 2000 • Used in Europe >10 years • Very low systemic levels levonorgestrel • FDA approved for 5 yrs of use, • Lowest 5-yr costs of all contraceptive methods 2 • Highest continuation rates- • 81-93% at 1 yr (CuT 78%, CHC 68%) 1. Sivin Contraception 1991 2. Chiou et al Contraception.2003;68(1):3-10

  37. Progestin IUD - Side Effects • Spotting and bleeding: Increased in 1st 3 months • Amenorrhea: 20% of users by 1 yr, 60% by 5 yrs • Expulsion: 2-12% in 1st year. • Perforation: <.01% @ time of insertion • Headaches, acne, mastalgia: < 3% in 1st months Managing Contraception and Hatcher et al Contraceptive Technology 2004

  38. 500 450 450 400 350 300 250 200 160 150 100 50 50 0 Prehistoric Modern Colonial America Lifetime Number of Menstrual Cycles Number of Cycles Adapted from Coutinho EM. Is Menstruation Obsolete? 1999.

  39. Extended Cycle Regimens- Why? • Fewer menses per year • OCP’s 21 day on/ 7 day off cycle chosen to: • Mimic physiologic menstrual cycle • Reassurance that not pregnant • No clinical trial shows that monthly menses is healthier, safer, or easier to tolerate • Convenience • May improve: • endometriosis, anemia, dysmenorrhea, metorrhagia, PMS, menstrual migraines

  40. Extended Cycle Regimens • May increase efficacy and adherence • Symptoms associated w/ OCP worse during withdrawal bleed1 • Brief manipulation of a cycle 12 month Perfect vs. Typical Failure & Continuation Rates 1. Sulak et al Obstet Gynecol. 2000;95:261-266

  41. Continuous use 3 months, then a week off • Seasonale ™ - FDA- approved 12 weeks on, 1 week off . Lybrel continuous use. • Shortened pill-free interval • Well-tolerated, small amount of breakthrough bleeding

  42. Established BC Methods • Barrier methods • Lactation • Progesterone only pills • DMPA injections • Vasectomy • Tubal Obstruction or Ligation • postpartum, coag, rings, clips

  43. Essure: Hysteroscopic Tubal Sterilization • Meds like for AB • covered for health plan • Requires hysteroscopy at 3 months

  44. Resources • Hatcher et al, Contraceptive Technology • Managing Contraception – book online @ (www.managingcontraception.org) • Medical Eligibility Criteria for Contraceptive Use 2004 by WHO (www.who.int/reproductive-health) • Association of Reproductive Health Professionals (ARHP) (www.arhp.org) • Alan Guttmacher Institute (www.agi-usa.org) • www. contraceptiononline.org • www.plannedparenthood.org • www.Not-2-Late.com

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