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Contraceptive Update. Lydia D. Nightingale, MD, FACOG University of Oklahoma Health Sciences Center Department of Obstetrics and Gynecology October 23, 2013. Objectives. I have no financial relationships to disclosure At the end of this lecture you will be able to discuss

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contraceptive update

Contraceptive Update

Lydia D. Nightingale, MD, FACOG

University of Oklahoma Health Sciences Center

Department of Obstetrics and Gynecology

October 23, 2013

  • I have no financial relationships to disclosure
  • At the end of this lecture you will be able to discuss
    • The epidemiology of unintended pregnancies in the US and the role for contraception
    • An overview of contraception that is available and its
      • Mechanism of Action
      • Efficacy
      • Contraindications
      • Management of Side Effects
    • The mechanism of Emergency Contraception and its benefits
  • Nearly 50% of all pregnancies in the United States are unintended or unplanned
  • Women younger than 19 years
    • Significant risk for unintended pregnancy
    • 80+% of teenaged women describe their pregnancy as unintended
      • Accounts for 1/5th of all unintended pregnancies
  • Disproportionately high among women with low educational attainment and low incomes
  • Race and ethnicity are also associated with unintended pregnancy
  • Definition
    • Intentional prevention of conception or impregnation through the use of various devices, agents, drugs, sexual practices, or surgical procedures
  • Obstacles to obtaining contraception
    • Political
    • Religious
    • Social
hormonal methods of contraception
Hormonal Methods of Contraception
  • Combined Estrogen-Progestin
    • Combined Oral Contraceptive Pills (COCs)
    • Transdermal Patch (Ortho-Evra)
    • Vaginal Ring (Nuva-Ring)
  • Progestin-only Methods
    • Oral Contraceptive Pills
    • Injectables (Depo Provera)
    • Subdermal Implants (Nexplanon)
    • Progestin-containing Intrauterine Device (LNG-IUD, Mirena)
non hormonal methods of contraception
Non-Hormonal Methods of Contraception
  • Permanent Sterilization
    • Vasectomy
    • Tubal Ligation
    • Tubal Occlusion
  • Copper IUD (Copper T380-A, Paragard)
  • Barrier Methods
    • Condoms
      • Male and Female
      • Only contraceptive method that also protects against STIs
    • Vaginal sponges
    • Diaphragms
    • Cervical Caps
  • Natural Family Planning
  • Coitus Interruptus (withdrawal)
    • Very Ineffective
    • Within one year, 27% of women will become pregnant
  • Varies greatly by type but also by use
  • “Perfect use” vs. “Typical use”
  • Tiers of efficacy
    • Top-tier
      • Permanent sterilization
      • LARC methods
    • Next tier
      • Combined hormonal methods
    • Lowest tier
      • Barrier methods
hormonal contraception
Hormonal Contraception
  • Combined Estrogen-Progestin
    • Combined Oral Contraceptive Pills (COCs)
    • Transdermal Patch (Ortho-Evra)
    • Vaginal Ring (Nuva-Ring)
  • Progestin-only Methods
    • Oral Contraceptive Pills
    • Injectables (Depo Provera)
    • Subdermal Implants (Nexplanon)
    • Progestin-containing Intrauterine Device (LNG-IUD, Mirena)
combined hormonal contraceptives mechanism of action
Combined Hormonal Contraceptives Mechanism of Action
  • Progesterone  negative feedback to LH 

inhibits ovulation

  • Estrogen  negative feedback on FSH  inhibits emergence of dominant follicle
secondary mechanism of action
Secondary Mechanism of Action
  • Progesterone
    • Thins endometrial lining
    • Thickens cervical mucus
    • Decreases motility of fallopian tubes
efficacy hormonal methods
Efficacy: Hormonal Methods
  • Influenced by patient adherence
    • Remembering to take a pill, etc.
  • Combined hormonal methods: Typical failure rate averages 8% at 1 year
  • Progestin-only pills: 10% failure rate
  • Injectable: 3% failure rate
benefits of combined hormonal contraceptives
Benefits of Combined Hormonal Contraceptives
  • Alleviates dysmenorrhea
    • Decreases uterine prostaglandin production
    • Inhibits ovulation
  • Cycle control
    • Improves anemia
    • Makes menstrual cycles more predictable
    • Decreases risk of uterine hyperplasia or malignancy in women with anovulatory cycles
  • Treatment of PMS
  • Treatment of hirsutism and acne
    • Increased sex hormone-binding globulin
    • Suppressed ovarian androgen production
benefits of combined hormonal contraceptives1
Benefits of Combined Hormonal Contraceptives
  • Decreases cancer risk
    • Endometrial cancer is decreased by 50%
    • Ovarian cancer
      • Risk is decreased by 27% among ever users of COCs
      • Longer use is associated with risk reduction up to 50%
    • Decreased risk for colorectal cancer by 18%
    • No consensus on recommending this medication for cancer prevention
  • Improves symptoms that are exacerbated by fluctuations in hormone levels
    • Sickle cell crisis
    • Menstrual Migraines
benefits of combined hormonal contraceptives2
Benefits of Combined Hormonal Contraceptives
  • Increased bone density
  • Decreased risk of ectopic pregnancy
  • Improved endometriosis symptoms
  • Reduction in benign breast diseases
  • Prevention of atherogenesis
  • Decreased incidence and severity of acute salpingitis
  • Decreased activity of rheumatoid arthritis
risks of combined hormonal contraceptives
Risks of Combined Hormonal Contraceptives
  • Small increased risk for venous thromboembolism (VTE)
    • Most risk occurs in the first year of use
  • Baseline risk for VTE in the population is 4-5/10,000 women years
  • Pregnancy risk 48-60/10,000
  • Combined hormonal contraceptive risk is 12-20/10,000
    • Slightly higher in older women or obese women
    • Dose not increase with history of smoking or hypertension
    • Risk is eliminated within 30 days of discontinuation
risks of progestins
Risks of Progestins
  • Fourth generation (Drospirenone) has attracted attention for an associated increased risk for VTE when compared to the second-generation progestins
  • Research suggests that the rate of VTE in drospirenone users remains low (53/100 000) compared with 30.6/100 000 for norgestrel or 27/100 000 for levonorgestrel
  • SIGNIFICANTLY lower than the risk for VTE among pregnant women
risk for vte and stroke
Risk for VTE and Stroke
  • World Health Organization (WHO) study
    • Smokers, women older than age 40, and obese women do have a slightly increased risk for an arterial blood clot
    • Women with uncontrolled HTN have a 10-fold higher than baseline risk for hemorrhagic stroke
    • Smokers older than age 35 had a 15-20X higher risk for ischemic stroke
    • Women who have migraines with aura have a slightly higher risk for stroke
  • Increase is not seen in women younger than 35 years, regardless of smoking or HTN status
risk for breast cancer
Risk for Breast Cancer
  • Repeated studies
    • Women using the low-dose COCs (≤ 35 mcg) with no personal history of breast cancer have no increased risk for breast cancer
  • No additional risk among women with BRCA1 or BRCA2 mutations or a strong family history of breast cancer
combined hormonal contraceptives absolute contraindications
Combined Hormonal Contraceptives ABSOLUTE Contraindications
  • Thrombophlebitis
  • Thromboembolic disease
  • Cerebral vascular disease
  • Coronary Occlusion
  • Smokers >35 years old
  • Impaired liver function
  • Hepatic neoplasm
  • Congenital hyperlipidemia
  • Known or suspected breast cancer
  • Undiagnosed abnormal vaginal bleeding
  • Known or suspected pregnancy
  • Migraine with aura
combined hormonal contraceptives relative contraindications
Combined Hormonal Contraceptives Relative Contraindications
  • Severe vascular headache (classic migraine, cluster)
  • Severe hypertension
  • Diabetes mellitus
  • Gallbladder disease
  • Obstructive jaundice in pregnancy
  • Epilepsy
  • Morbid obesity
combined oral contraceptive pills cocs
Combined Oral Contraceptive Pills (COCs)
  • Perfect use (0.3%)
  • Typical use (8%)
decreased effectiveness of cocs
Decreased Effectiveness of COCs
  • Drugs
    • Barbiturates
    • Benzodiazepines
    • Phenytoin
    • Carbamazepine
    • Rifampin
    • Sulfonamides
side effects and management
Side Effects and Management
  • Breakthrough bleeding (BBT) and spotting
    • Due to low-dose COCs
    • Bleeding begins after day 14 of active pills
      • Early withdrawal bleeding
      • Increase progesterone component
    • Bleeding begins during the first 14 days of active pills
      • Thin / atrophic endometrial lining
      • Increase estrogen component
side effects and management bbt continued
Side Effects and Management: BBT continued
  • Need for increased estrogen
    • Menses continues into the active pill cycle
    • Absence of withdrawal bleeding
  • Causes of increased endometrial activity
    • More adrenergic progestins
    • Multiphasic COCs
    • Different ratios of estrogen to progesterone
  • Switch to a 28 day cycle instead of an extended cycle
side effects and management1
Side Effects and Management
  • Amenorrhea
    • Rule out pregnancy
    • Ensure pills are being taken correctly
    • Consider increasing the estrogen dose or adding supplemental estrogen
    • Consider decreasing the progestin dose
    • Does not have to be addressed if the patient is satisfied
  • Dysmenorrhea or menorrhagia
    • Switch to higher progestational and androgenic concentrations
    • Decrease estrogen component
side effects and management2
Side Effects and Management
  • Breast fullness or tenderness
    • Occurs in 11%
    • Perform breast examination
    • Usually resolves by fourth month of use
    • Consider possible mammography or ultrasonography if persists
    • Consider lowering estrogen dose
side effects and management3
Side Effects and Management
  • Nausea
    • Take with food or at bedtime
    • Should resolve by the 3rd month
    • If persists, switch to a preparation with decreased estrogen component and decrease carbohydrates
    • Symptoms of hypoglycemia then decrease progesterone component
side effects and management4
Side Effects and Management
  • Depression
    • Consider other alternatives for contraception
  • Vascular headache or severe migraine
    • Continuous hormone administration with only occasional withdrawal bleeding
    • Avoid phasic formulations
    • May need to consider other method of contraception
    • Discontinue use if migraines are newly diagnosed after patient begins combined oral contraceptives
transdermal contraceptive patch
Transdermal Contraceptive Patch
  • Ortho-Evra
  • Perfect Use 0.3%
  • Typical Use 8%
transdermal contraceptive patch1
Transdermal Contraceptive Patch
  • Decreased efficacy over 198 lbs (90kgs)
  • If detached or off for <24 hours then reapply and no backup needed
  • If detached for >24 hrs then new 4 week cycle should be started immediately and use additional contraception for 7 days
  • No withdrawal bleed
    • Pregnancy test
    • Ultrasound to determine endometrial thickness
      • >10 mm- endometrial biopsy
      • Do not add OCPs or progesterone
risks of transdermal patch
Risks of Transdermal Patch
  • Black Box warning
    • Early 2000s
    • Increased risk of VTE
  • Examination of the data suggests that the risk may not be as high as originally believed
  • Several studies comparing patch to other combined methods did not find a significant difference
  • May develop irritation at the patch site
vaginal ring
Vaginal Ring
  • NuvaRing
  • Perfect use 0.3%
  • Typical use 8%
vaginal ring1
Vaginal Ring
  • Lowest steady state hormonal levels of estrogen
    • Compared to patch and OCPs
  • Decreased incidence of breakthrough bleeding
  • Can be removed for up to 3 hours
  • May decrease vaginal yeast and bacterial infections due to local estrogen effect
  • May increase leukorrhea
  • Patients may describe vaginal irritation or discharge
hormonal contraception1
Hormonal Contraception
  • Combined Estrogen-Progestin
    • Combined Oral Contraceptive Pills (COCs)
    • Transdermal Patch (Ortho-Evra)
    • Vaginal Ring (Nuva-Ring)
  • Progestin-only Methods
    • Oral Contraceptive Pills
    • Injectables (Depo Provera)
    • Subdermal Implants (Nexplanon)
    • Progestin-containing Intrauterine Device (LNG-IUD, Mirena)
side effects
Side Effects
  • Progestin-only methods are not associated with increased risks for VTE
  • Subdermal implant and LNG-IUD are associated with irregular bleeding or intermenstrual spotting
  • LNG-IUD users will have a range of bleeding patterns from light monthly menses to amenorrhea but irregular spotting will resolve
depo medroxyprogesterone acetate
Depo medroxyprogesterone acetate
  • Depo-Provera
  • Perfect Use: 0.3%
  • Typical Use: 3%
mechanism of action depo provera
Mechanism of Action: Depo Provera
  • Prevents pregnancy by inhibiting the secretion of pituitary gonadotropins resulting in anovulation, amenorrhea, and a decreased production of serum estrogen
side effects depo provera
Side Effects: Depo Provera
  • Average weight gain of 5.4 pounds
  • Transient and reversible loss of bone mineral density
    • No increased risk for fractures
  • Associated with intermenstrual spotting
  • Delayed return of fertility
    • Average return is 10 months
depo provera indications
Depo-Provera Indications
  • Compliance with other methods has been problematic
  • Breastfeeding
  • Estrogen-containing preparations are contraindications
  • Seizure disorders
  • Sickle cell anemia
  • Anemia secondary to menorrhagia
benefits of depo provera
Benefits of Depo-Provera
  • Decreased risk of endometrial carcinoma
  • Decreased risk of iron-deficiency anemia
  • Decreased pain
    • Associated with endometriosis
    • Associated with endometrial hyperplasia
    • Associated with dysmenorrhea
  • Improved compliance
  • Improved symptoms of menorrhagia
  • Used for cycle control
contraindications for depo provera
Contraindications for Depo-Provera
  • High risk for osteoporosis
  • Known or suspected pregnancy
  • Undiagnosed vaginal bleeding
  • Known or suspected malignancy of the breast
  • Active thromboembophlebitis
  • History of thromboembolic disorders
  • History of cerebral vascular disease
  • Liver dysfunction or disease
  • Known sensitivity to Depo Provera or any of its other ingredients
bone health and depo provera
Bone Health and Depo-Provera
  • Concern for effect on bone mineral density especially in adolescence
  • FDA: “use beyond 2 years should be carefully considered and alternative contraceptive methods be evaluated”
  • Careful use in those women at special risk for osteoporosis
  • Not considered an indication for dual-energy absorptiometry (DEXA) or other tests that assess bone mineral density
depo provera and irregular bleeding
Depo-Provera and Irregular Bleeding:
  • Education is key
  • Irregular bleeding
    • Decreases with each injection
    • 80% of patients develop amenorrhea
  • Discontinuation rate of 25% in the first year
    • Secondary to irregular bleeding
    • Consider 7 days with conjugated estrogen (1.25mg/day) to assist with irregular bleeding
  • After discontinuation
    • 50% resume regular menses within 6 months
    • 25% do not resume menses for more than 1 year
      • Should be evaluated to detect other possible causes
progestin only pills
Progestin-Only Pills
  • Mini-pill
  • Norethindrone .35
  • Perfect Use: 0.5%
  • Typical Use: 8%
progestin only pills1
Progestin-Only Pills
  • Thickens cervical mucous and inhibits ovulation
  • No hormone free interval
    • Take in a continuous fashion
  • MUST take at the same time each day
    • More than 3 hours of delay should be considered a missed pill and back up method should be used
  • More variable bleeding patterns
  • Can be used in breastfeeding women without decrease in breast milk
  • Decreases menorrhagia and associated anemia and cramps
  • Offers some protection against endometrial cancer
  • May reduce the risk of PID secondary to cervical mucous thickening
long acting reversible contraception larc methods
Long Acting Reversible Contraception (LARC) Methods
  • Levonorgesterel IUD (LNG-IUD)
    • Inserted in to the uterus
    • FDA approved for five years
    • Prevents pregnancy by thinning the endometrial lining of the uterus, thickening cervical mucus and slowing tubal motility, which prevent sperm passage
  • Subdermal Implants
    • Placed in the arm between the bicep and triceps muscles
    • Lasts for 3 years
    • Suppresses ovulation
  • Nonhormonal Copper IUD (Copper T380-A)
    • Inserted into the uterus
    • Lasts for 10 years
    • Creates a sterile inflammatory state rendering the uterus inhospitable to sperm or ova
acog committee opinion larc
ACOG Committee Opinion: LARC
  • “High unintended pregnancy rates in the United States may in part be the result of relatively low use of long-acting reversible contraceptive (LARC) methods, specifically the contraceptive implant and intrauterine devices.”
  • “Because of these advantages and the potential to reduce unintended pregnancy rates, LARC methods should be offered as first-line contraceptive methods and encouraged as options for most women. To increase use of LARC methods, barriers such as lack of health care provider knowledge or skills, low patient awareness, and high upfront costs must be addressed.”
larc use
  • LARC methods have few contraindications
  • Almost all women are eligible for implants and intrauterine devices
  • Because of these advantages and the potential to reduce unintended pregnancy rates, LARC methods should be offered as first-line contraceptive methods and encouraged as options for most women
  • Less than 5% of women in the USA have ever used a LARC device
efficacy larc
Efficacy: LARC
  • Rivals permanent sterilization
  • IUD
    • Copper IUD: 0.8% failure rate at 1 year
    • LNG-IUD: 0.1% failure rate at 1 year
  • Subdermal implant: failure rate 0.05% or less
    • Most effective of all contraception
benefits of larc
Benefits of LARC
  • LARC
    • LNG-IUD and subdermal implant
      • Improve dysmenorrhea and other symptoms of endometriosis
    • LNG-IUD
      • Effective for menorrhagia
      • Reduces blood loss by up to 50%
    • Subdermal implant may also improve menorrhagia, with 30-60% of women being amenorrheic at 1 year of use
    • LNG-IUD and copper IUD decrease endometrial cancer risk
progestin only implant
Progestin Only Implant
  • Nexplanon (previously known as Implanon)
  • Perfect Use: 0.05%
  • Typical Use: 0.05%
  • MOST effective
  • Thickens cervical mucous and inhibits ovulation
  • Does NOT affect bone mineral density
  • Irregular, unpredictable vaginal bleeding
  • Nexplanon: radio-opaque
    • Previous generation (Implanon) was not radio-opaque
  • Insertion of the subdermal implant has a very low risk for site infection
intrauterine device
Intrauterine Device
  • LNG-IUD (Mirena)
    • Perfect use: 0.1%, Typical use: 0.2%
  • Copper IUD (ParaGard)
    • Perfect use: 0.6%, Typical use: 0.8%
intrauterine device indications
Intrauterine Device Indications
  • Women who desire long-term reversible contraception
    • Multiparous or nulliparous
  • LNG-IUD or Copper IUD
    • Diabetes
    • Thromboembolism
    • Breastfeeding
  • Copper only
    • Breast cancer
    • Liver disease
    • Menorrhagia / dysmenorrhea
intrauterine device contraindications
Intrauterine Device Contraindications
  • Pregnancy
  • Pelvic inflammatory disease
    • Current or within the last 3 months
  • Puerperal or post abortion sepsis
    • Current or within the last 3 months
  • Purulent cervicitis
  • Undiagnosed abnormal vaginal bleeding
  • Malignancy of the genital tract
  • Known uterine anomalies or fibroids distorting the cavity
  • Allergy to any component of the IUD
    • i.e. Wilson’s disease
risks intrauterine devices
Risks: Intrauterine Devices
  • IUDs may be associated with cramping during the first several months after insertion
  • Small risk for spontaneous expulsion
    • Young age
    • Previous IUD expulsion
    • Nulliparity
  • Risk of uterine perforation at time of placement
    • Approximately 1/1000
  • Very low risk for uterine damage (0.01%)
risks intrauterine device
Risks: Intrauterine Device
  • Expulsion Rate
    • Around 2-3% if placed for contraception
    • Potentially increased up to 20% if placed immediately postpartum, however new data is coming out that suggests this may be lower if placed in the first two hours postpartum
  • Uterine Perforation: 1/1,000
  • Use of an IUD does not appear to increase the absolute risk of ectopic pregnancy
    • Rate of 0-0.5 per 1,000 women-years among women using either device
    • Rate of 3.25-5.25 per 1,000 women-years among women who do not use contraception
sexually transmitted infections iuds
Sexually Transmitted Infections & IUDs
  • It is reasonable to screen for STIs and place the IUD on the same day
    • Administer treatment if the test results are positive
  • Risk of PID with IUD placement
    • 0-2% when no cervical infection is present
    • 0-5% when insertion occurs with an undetected infection
  • Small but increased risk for upper genital tract infection at the time of insertion
    • Approximately 1/1000
      • 0-2% when no cervical infection is present
      • 0-5% when insertion occurs with an undetected infection
    • Risk decreases 20 days after insertion
  • If an STI is diagnosed after the IUD is in place, it may be treated without removing the IUD
  • Routine antibiotic prophylaxis is not recommended before IUD insertion
iud side effects
IUD Side Effects
  • Copper IUD is associated with increased monthly bleeding and cramping
    • Symptoms may be treated with nonsteroidal anti-inflammatory drugs
  • No increased risk of pelvic inflammatory disease or infertility in IUD users
hormonal risks to the fetus
Hormonal Risks to the Fetus
  • NO risks to a fetus if it is exposed to oral contraceptives
  • NO evidence that early exposure to oral contraceptives causes fetal anomalies, spontaneous miscarriage, preterm delivery, birth defects, or compromised fertility of the offspring
  • IUDs can (and should) be removed if pregnancy is identified
  • Continuing a pregnancy with an IUD in place increases risk of spontaneous abortion and septic abortion
permanent sterilization women
Permanent Sterilization: Women
  • Extremely effective
  • Tubal Ligation
    • Excellent choice
    • Surgery required; carries surgical and anesthetic risks
    • NO patient should choose sterilization believing that it can be reversed
  • Tubal Occlusion
    • Essure (intrauterine microinsert) approved in 2002
    • Hysteroscopic placement
      • Can be performed in the office
    • Must rely on another method of contraception for at least 3 months after the microinsert placement
    • HSG required to confirm bilateral occlusion
permanent sterilization men
Permanent Sterilization: Men
  • Vasectomy
    • More effective than tubal ligation
    • Generally considered safer
      • Routinely performed in the office
      • No anesthesia risk
    • Not sterile immediately
      • Azospermia must be confirmed at 12 weeks
efficacy permanent sterilization
Efficacy: Permanent Sterilization
  • Varies by type of procedure performed
  • Rates of failure for vasectomy are 0.01% at 5 years
  • CREST study
    • Investigated failure rates over 14 years
    • Most effective (7.5/1000)
      • Postpartum tubal ligation (i.e. partial salpingectomy via mini-laparotomy or at the time of cesarean delivery
      • Tubals performed using unipolar cautery
    • Least effective (52-54/1000)
      • Tubals performed using Bipolar cautery
      • Titanium clips
    • Overall: 18.5/1000 procedures
permanent sterilization
Permanent Sterilization
  • Decreased risk of ovarian cancer
    • Possibly due to decreased risk of ascending carcinogens from the fallopian tubes
  • No protection against STIs
  • Additional CREST study data
    • 7 ectopic pregnancies/1,000 procedures
    • Regret expressed
      • 20% of women less than the age of 30 at the time of sterilization
      • 5% of women over the age of 30 at the time of sterilization
efficacy barrier methods
Efficacy: Barrier Methods
  • Least effective
  • Limited to user compliance
    • Using with every sexual encounter
    • Using the device at the proper time
  • Typical-use failure rates approach 15%
barrier contraceptives
Barrier Contraceptives
  • Male Condoms
    • Decreases risk of transmission of HIV and other infections including gonorrhea, chlamydia, and trichomonas
    • Does not cover all exposed areas and may not be as effective in preventing infections transmitted by skin to skin contact (i.e. HSV, HPV)
barrier contraceptives1
Barrier Contraceptives
  • Female Condom
    • May provide extra protection from skin to skin contact
barrier contraceptives2
Barrier Contraceptives
  • Diaphragm
    • Placed posterior to pubic symphisis and deep into the cul de sac
    • Used in conjunction with spermicide and should be left in place for 6 hours after intercourse
    • Women with uterine prolapse or structural abnormalities of the reproductive tract may not be able to use the diaphragm
    • May decrease STD transmission
    • May increase UTI
    • Should be replaced every 2 years
    • Requires fitting by health care provider and a Rx
barrier contraceptives3
Barrier Contraceptives
  • Cervical Cap
    • Covers the cervix
    • Used in conjunction with spermicide
    • Decreased efficacy in parous women
natural family planning
Natural Family Planning
  • Also known as fertility awareness
  • Uses the body’s natural and normal functioning to determine the days of the month a women is most like to get pregnant
  • Does not use any drugs or devices
  • Combines the calendar / rhythm method, the basal body temperature method, and the cervical mucus method
emergency contraception ec
Emergency Contraception (EC)
  • “Morning After Pill”
  • Any method of contraception after sexual intercourse has already occurred
  • COC regimens (Yuzpe)
    • More side effects
    • Must be taken within 72 hours of unprotected sex
    • Dosage adjusted based on formulation
  • Levonorgesterel (Plan B)
    • More effective
    • Reduce the risk for pregnancy by 89%
    • Up to 5 days (most effective when taken soon as possible)
emergency contraception ec1
Emergency Contraception (EC)
  • Copper IUD
    • Most effective
    • Insert within 5 days of unprotected intercourse
    • Can reduce the risk for pregnancy by 99%
  • Ulipristal acetate (ellaOne)
    • Selective progesterone-receptor modulator
    • Maintains efficacy up to 5 days after unprotected sex
    • Available only by prescription
barriers to access
Barriers to Access
  • Misconceptions
    • Mechanism of Action
      • This does not cause abortion
      • Inhibition or delay of ovulation is the principal mechanism of action
      • Cannot prevent implantation of a fertilized egg
    • Effect of Risky Sexual Behavior
      • Studies have shown that this concern is unfounded
    • Safety of Repeated Use
  • Financial Barriers
    • Out of pocket ranges from $25 to 60 for oral EC
  • Education and Practice Barriers
    • Many women and providers remain unfamiliar with the method or are unaware that a PE is not required (nor is a pregnancy test)
  • Facilities
  • Pharmacy Barriers
provider considerations
Provider Considerations
  • Primary care providers have a unique role in the care of women of reproductive age
  • You are often first clinician to encounter young women who are medically complicated and in need of contraception
  • You may also need to prescribe teratogenic medication to young women of reproductive age
provider considerations1
Provider Considerations
  • Primary care providers should feel comfortable discussing reproductive health and the importance of contraception with their patients of reproductive age
  • Frequently the first-line providers for ill women, you should remember that even sick women are likely to be sexually active and make sure a discussion about contraception occurs at each visit
provider considerations2
Provider Considerations
  • You should feel comfortable to prescribe contraception for medically uncomplicated women
  • Women who have medical problems (such as thrombotic disorders, SLE, etc.) can be referred to an Ob-Gyn for assistance with contraception concerns
  • Pregnancy (especially unintended pregnancy) has much great risk and complications than most contraception options
acog committee opinion dec 2012
ACOG Committee Opinion Dec. 2012
  • “Unintended pregnancy remains a major public health problem in the United States. Access and cost issues are common reasons why women either do not use contraception or have gaps in use. A potential way to improve contraceptive access and use, and possibly decrease unintended pregnancy rates, is to allow over-the-counter access to oral contraceptives (OCs). Screening for cervical cancer or sexually transmitted infections is not medically required to provide hormonal contraception. Concerns include payment for pharmacist services, payment for over-the-counter OCs by insurers, and the possibility of pharmacists inappropriately refusing to provide OCs. Weighing the risks versus the benefits based on currently available data, OCs should be available over-the-counter. Women should self-screen for most contraindications to OCs using checklists.”
  • ACOG Practice Bulletin. Use of Hormonal Contraception in Women With Coexisting Medical Conditions. Number 73, June 2006
  • ACOG Practice Bulletin. Noncontraceptive Benefits of Combined Oral Contraceptives. Number 110, January 2010
  • ACOG Practice Bulletin. Long-Acting Reversible Contraception: implants and Intrauterine Devices. Number 121. July 2011.
  • Dickey, Richard. Managing Contraceptive Pill Patients. 13th Edition. 2007
  • Hurt et al. The Johns Hopkins Manual of Gynecology and Obstetrics. 4th Edition
  • Speroff, Leon and Philip Darney. A Clinical Guide for Contraception. Philadelphia, PA. 2006
  • Schorge JO, Schaffer JI, Pietz J, Halvorson LM, Hoffman BL, Bradshaw KD, Cunningham FG. Chapter 5. Contraception and Sterilization. Williams Gynecology. New York: McGraw-Hill; 2008.
  • Woodham, EJ, In the Clinic. Contraception. Annals of Internal Medicine. 2012.
  • ACOG Committee Opinion Number 458, 544
  • Hacher, RA, Managing Contraception On The Go. 2012-2014.
  • Lydia-Nightingale@