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Birth Control Options in 21 st Century

Birth Control Options in 21 st Century. Peter L. Stevenson, MD FACOG. Associate Clinical Professor Wayne State University School of Medicine Detroit Michigan. Contraception Overview. Barriers Chemicals BEST USED TOGETHER Hormones PG only E & PG Emergency Contraception

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Birth Control Options in 21 st Century

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  1. Birth Control Optionsin 21st Century • Peter L. Stevenson, MD FACOG Associate Clinical Professor Wayne State University School of Medicine Detroit Michigan

  2. Contraception Overview • Barriers • Chemicals BEST USED TOGETHER • Hormones • PG only • E & PG • Emergency Contraception • Sterilization • Other • IUD’s • Rhythm & Withdrawl • Termination & RU486 (mifepisterone)

  3. Contraceptive Efficacy • All methods are USER DEPENDANT • (OK, not IUD and sterilization) • Failures of ALL methods decrease with: • Increasing age • Increasing socioeconomic status • Increasing education • Increasing income • Lose sight of effectiveness • concerned w/ risk

  4. Contraceptive safety • Risk of Death on OCP’s ?? • Risk of Death from Pregnancy ?? • OCP’s & Breast Cancer • NOT Pseudo Pregnancy • DVT on 3rd Generation Progestin

  5. Contraceptive safety • Increased risk death from unintended pregnancy • Prior Breast cancer • Valvular heart disease • Diabetes: insulin-dependent Class N, R, T or D • Prior GYN cancer • Epilepsy • Hypertension (>160 / >100 mm Hg) • History of bariatric surgery within the past 2 years • HIV/AIDS • Ischemic heart disease • Peripartum cardiomyopathy

  6. Contraceptive safety • Increased risk death from unintended pregnancy • Malignant gestational trophoblastic disease • Severe (decompensated) cirrhosis • Sickle cell disease • Solid organ transplantation within the past 2 years • Stroke • Systemic lupus erythematosus • Thrombogenic mutations • Tuberculosis

  7. Contraceptive safety • Drug/OCP Interactions & Effectiveness • Myth of Antibx • Griseofulvin, Rifampin -- decreased maybe, but…? • NOT Amp, tetraC, cephalo, cipro, et al.

  8. Contraceptive safety • Drug -- Drug Interactions • Anti-Seizure meds maybe… • Old drugs (dilantin, phenobarb, etc) doubtful, only theory • Protease Inhibitors in HIV Pts YES • 3 T’s: potent cytochrome P450 inducers • Tegretol DECREASED EFFECTIVENESS • Tri-Leptal for BOTH OCP • Topamax & anti-seizure Rx

  9. Contraceptive safety • Drug/OCP Interactions & Effectiveness • Anti-Seizure Meds • Phenobarb, Tegretol, Dilantin -- doubtful • Topamax, Tri-leptal & Tegretol • -- DANGEROUS!! Seizures & Pregnancy!! • NO CHANGE TO OCP or Neuro Rx: • Gabapentin (Neurontin), lamotrigine (Lamictal), levetiracetam (Keppra), and tiagabine (Gabitril)

  10. ‘Future’ Contraceptives • Male Birth Control Pills • Bridge, for sale, great view • Vaccines • Pg Receptor Modulator • Shorter Lasting Implant • Implanon (lasts 3 years) • Vaginal Ring • NuvaRing (3 weeks, one ring)

  11. Barriers & Chemicals • Condoms • Diaphragm • Cervical Cap • All better with Spermicides • Spermicides • Nonoxinyl-9 • Surfactant – Soap! • Disrupts Acrosomal Membrane

  12. IUD’s • Safe & Effective NOT abortifacient! • Patient Selection • Mature • Monogamous • Multiparous • Poor choice if severe menses • Heavy bleeding OR Bad Cramps

  13. IUD’s • Safe & Effective • Copper Bearing: Paraguard 10 years • Inhibits ovulation • Thickens Cervical Mucous • Decidualizes Endometrium (hostile) • Interferes with tubal motility • KILLS SPERM!

  14. IUD’s • Safe & Effective • Progestin Containing: Mirena 5 years • Inhibits ovulation • Thickens Cervical Mucous • Decidualizes Endometrium (hostile) • MAY decrease mentrual bleeding & DUB!

  15. Sterilization • Permanent • Vasectomy • Easier • Safer • Cheaper • Quicker • Less Painful • Excellent method for ‘other men’

  16. Sterilization • Permanent • Tubal Occlusion • (nothing gets tied...) • Laparoscopic - Band, Clip, Ring, Cautery • Hysteroscopic - Dacron, Cautery • Open - Pomeroy, Yoshida, Irving • Salpingectomy, Fibriectomy

  17. Hormonal Contraception • Progestin Only • Micronor, Nor Q D • Depo Provera • Implanon • ? Weight Gain • ? Body Mass related failure

  18. Hormonal Contraception • Estrogen & Progestin • Monophasic • Ultra Low Dose ( ≤20 mcg) • Low Dose ( 30-35 mcg) • Multiphasic • Different Regimens • ? • Key Difference = Progestin Component

  19. Hormonal Contraception • Excess Estrogen • Nausea • Headache • Breast Tenderness • Blood Clots • MI & Stroke • Excess Progestin • Moodiness • Bloating • Weight Gain • Acne • Hair Loss

  20. Hormonal Contraception • Inadequate Estrogen • BTB • EARLY < day 10 • Don’t stop menses • Inadequate Progestin • BTB • LATE > day 15 • Start menses early

  21. Hormonal Contraception • Need spectrum of OCP’s to suit all pt’s • Dr. Dickey’s “Managing…Pill Patient” • Very few ‘name brand’ OCP’s on market • Very difficult to manage side effects… • All OCP’s help acne • All DAW OCP’s are equally effective • ? Generic 20 mcg OCP’s

  22. Hormonal Contraception • Spectrum of OCP’s • Estrogen: Low to High • Pg only OCP (no Estrogen) Micronor • Lo Lo Estrin ~10 • Mircette, Alesse, Levlite 20 • Cyclessa or Estrostep ~20 • Lo-Estrin 1/20 20 • Safyral, Desogen, Ortho Cept 30 • Femcon 35, O/N 1/35, Nordette 35 • Ovral or Ovcon 50 50

  23. Hormonal Contraception • Spectrum of OCP’s • Progestin: Low to High • Yasmin/Yaz • Desogen • Ovcon 35 • Lo-Estrin 1.5/30 • Safyral • Nordette,O/N 1/35,Norinyl • Ortho Cyclen • Lo Ovral • Ovral

  24. Hormonal Contraception • Problems with OCP’s • Unrelieved Dysmenorrhea • Menorrhagia • Amenorrhea • Acne • Moodiness • BTB

  25. Hormonal Contraception • Alternatives to OCP’s • Patch: Ortho Evra • Skin Irritation • Worse Cramps DVT 3X OCP • Glue Ring Death 3X DVT on OCP!!* • Headaches • *???Yaz and Yasmin? doubtful

  26. Hormonal Contraception • Alternatives to OCP’s • Vaginal Ring: Nuvaring • Body Friendly • Ring Toss • ?Continuous Cycling • Not 21days/7days • No ‘first pass’ effect => lower dose

  27. Hormonal Contraception • NUVARING

  28. Hormonal Contraception • Alternatives to OCP’s • Implant: Implanon • Single Rod - Upper Arm • ?Efficacy in Obese Women • Like all Pg-only, irregular bleeding • Effective 36 months

  29. Rate-controlling membrane: (0.06 mm) 100% EVA Core: 40% ethylene vinyl acetate (EVA) 60% etonogestrel (68 mg) IMPLANON™ 4 cm • IMPLANON™ is not radio-opaque 2 mm Release Rate: 60 μg/day to 70 μg/d initially then decreases to 25 μg/d to 30 μg/d by end of third year IMPLANON™ [package insert]. Roseland, NJ: Organon USA Inc; 2006.

  30. Hormonal Contraception • Emergency Contraception • Initiate < 72 hours after coitus ( < 24 hrs) • Plan B is high dose oral Pg only • Preven is high dose EE & Pg • Yuzpe Method: Ovral 2 PO BID • Ovral 2 PO BID x 2 days • Any 35mcg OCP 4 po BID x 1-2 days • 5mg EE x 5 days (huge dose!!) • Irregular Bleeding • 75% Effective

  31. Other Contraception • Termination of Pregnancy • First Trimester = Suction D & C • Second Trimester • D & E • Saline/PG Injection • RU-486 mifepisterone • High dose synthetic Prostaglandins (Cytotec) • Progesterone Receptor Blocker • Most effective (80%) in mid first trimester (<9 wks)

  32. Other Contraception • Termination of Pregnancy • Misoprostol (Cytotec) synthetic Prostaglandin • High dosage (200-1600mcg daily) • RU-486 mifepisterone • Progesterone Receptor Blocker • Usually given in combination with • High dose synthetic Prostaglandins (Cytotec) • Most effective (80%) in mid first trimester (<9 wks)

  33. Contraceptive Failure Rates

  34. 2009 CDC WHO Contraceptive Failure Rates

  35. Birth Control Optionsin 21st Century • Peter L. Stevenson, MD FACOG Associate Clinical Professor Wayne State University School of Medicine Detroit Michigan

  36. IMPLANON™ Applicator IMPLANON™ [package insert]. Roseland, NJ: Organon USA Inc; 2006.

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