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© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
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© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
in the clinic
Contraception
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
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© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
Which women are most likely to become pregnant unintentionally?
Women <19 years old
80% teenagers describe their pregnancy as unintended
Women with low educational attainment or low income
Income < poverty line: unintended pregnancy rate 5x higher than if income >200% above it
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
Which women are most likely to become pregnant unintentionally?
Black women have highest unintended pregnancy rate
> 2x that for non-Hispanic white women
Type of contraception may play role
Hormonal methods = 2x higher rate of pregnancy vs. long-acting reversible methods (among adolescents)
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
What are the various types of contraceptives and how do they work?
Hormonal methods
Combined (ethinyl estradiol + progestin)
Oral contraceptive pills (COCs): daily by mouth
Transdermal patch: single patch weekly for 3 weeks, then off for week (for withdrawal bleed)
Vaginal ring: ring inserted in vagina for 3 weeks, then removed for a week; new ring each month
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
What are the various types of contraceptives and how do they work?
Hormonal methods
Progestin only
Oral contraceptive “mini-pill”: daily by mouth with no “off” week
Injectable: IM injection every 3 mo by health care provider; SQ may be self-injected
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
Long-acting reversible contraception methods (LARC)
Hormonal and nonhormonal
Subdermal implant: placed in upper arm by trained OB/GYN; used ≤3y
Levonorgestrel (LNG-IUD): placed in uterus, used ≤5y
Copper IUD: placed in uterus, used ≤10y
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
Barrier
Nonhormonal
Male, female condoms: protect against STDs; available OTC
Vaginal sponges: Available OTC
Diaphragm; cervical cap: must be fitted by a physician
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
How effective are contraceptives? Permanent sterilization and LARC: top tier methods
Vasectomy: failure rate 0.01%
Female sterilization: failure rate 0.5%
Copper IUD: failure rate 0.8% at 1y
LNG-IUD: failure rate 0.1% at 1y
Subdermal implant: failure rate 0.05%
Combined Oral Contraceptive pills, patch, ring, DMPA injection: next tier methods Efficacy influenced by adherence
COCs: perfect use failure rate 0.3% vs. typical use rate 8%
DMPA injection: failure rate 3%
Barrier: lowest tier methods Efficacy limited by user compliance
Typical-use failure rates ≈15%
All better than nothing…
85% of reproductive-age women having regular unprotected sex pregnant within 1y
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
What is meant by “emergency contraception”?
Any contraception method used after sexual intercourse
Doesn’t disrupt an established pregnancy
Levonorgestrel (Plan B, Plan B One-step) Levonorgestrel 0.75 mg (2 pills) or 1.5 mg (1 pill) within 5d
of unprotected intercourse Reduces risk for pregnancy by 89% Efficacy decreases slightly each day after unprotected sex Available without prescription if ≥17 years old
Ulipristal (ellaOne) Ulipristal acetate selective progesterone receptor
modulator (30 mg pill, given once) Reduces risk for pregnancy by 90% Maintains efficacy through days 1 through 5 By prescription only
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
Copper IUD
Inserted up to 5 days after contraceptive failure/nonuse
Reduces pregnancy risk by 99% (most effective method)
Patient should desire the device for contraception
Alternative: COC pill regimen
Number of pills varies depending on pill formulation
Compared with other options: more side effects, less effective, and must be taken within ≤72 hours
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
What is the role of tubal ligation and vasectomy in contraception?
Sterilization considered permanent
Patients should be certain they don’t want more children
Reversals are costly and frequently unsuccessful
Procedure carries surgical and anesthetic risks
Vasectomy more effective than tubal ligation + safer (however patient not sterile until ≈12 weeks after procedure)
LARC methods: may be more appropriate option
Subdermal implants or IUDs
As effective as sterilization for reducing pregnancy
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
CLINICAL BOTTOM LINE: Epidemiology and Efficacy…
50% of pregnancies in U.S. unplanned Poor, young, or minority women at highest risk
Contraception can prevent unplanned pregnancy Most effective: IUDs, subdermal implants, and sterilization User error adds to higher failure rate (≥10%) for pills, patch,
DMPA injection, vaginal ring Emergency contraception options
Copper IUD most effective
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
Are there beneficial effects to the use of contraception beyond pregnancy prevention ?
Combined hormonal methods (the pill, patch, or ring)
Alleviate dysmenorrhea
Control cycle
Reduce endometrial hyperplasia
Improve menorrhagia symptoms
Prevent premenstrual dysphoric disorder
Reduce hirsutism and acne
Decrease endometrial, ovarian, & colorectal cancer risk
Improve symptoms exacerbated by hormone fluctuations
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
Injectable contraception
Improves menorrhagia symptoms
Reduces endometrial cancer risk
Control cycle (if comfortable with amenorrhea)
LARC methods
Benefits similar to COCs
Subdermal implant and LNG-IUD: improve menorrhagia, and dysmenorrhea and other symptoms of endometriosis
LNG-IUD and copper IUD: decrease endometrial cancer risk
LNG-IUD: treat endometrial hyperplasia without atypia
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
What are the risks for combined hormonal contraceptives?
All combined hormonal contraceptives (≤35 mcg estrogen): Venous thromboembolism
Slightly elevated risk (most common in 1st year use)
Slightly higher for older women and obese women
Risk eliminated in ≤30d of discontinuation
Transdermal patch: black box but risk not higher
Hemorrhagic stroke, ischemic stroke
Increased risk if patient has uncontrolled hypertension, migraines with aura symptoms, or smokes
All combined methods contraindicated in these women
Arterial blood clot
Increased risk if smoker, >40 years old, obese
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
What are the risks of progestin-only and LARC methods?
Injectable medroxyprogesterone acetate Weight gain ( ≈5.4 pounds)
Loss of bone mineral density
Transient and reversible; no increased fracture risk
Intrauterine devices Cramping in 1st few months (more common w/ copper IUD)
Treat with NSAIDs
Spontaneous expulsion (risk <1%)
Genital tract infection at time of insertion
Prophylactic antibiotics don’t decrease risk
Uterine perforation at insertion (very low risk: 0.01%)
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
What are the risks to the fetus if pregnancy occurs when a woman is receiving oral contraceptives?
No risks
No evidence of fetal anomaliesspontaneous miscarriagepreterm deliverybirth defectscompromised fertility of offspring
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
CLINICAL BOTTOM LINE: Medical Considerations… Medical benefits of hormonal contraception
Cycle regulation, lighter periods Reduced premenstrual symptoms
Medical benefits of LNG-IUD and subdermal implant Decreased menstrual bleeding LNG-IUD only: improves endometrial hyperplasia
Medical risks of hormonal contraception Stroke: contraindicated if >35y old & smoker, or if migraines
+ aura VTE: slight increased risk (highest in first year of use)
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
When should women be counseled about contraception?
Before first sexual encounter
Average age of first sex in United States is 17
Repeat throughout reproductive years
Average U.S. woman spends 5 years attempting pregnancy, being pregnant or postpartum
Spends nearly 30 years avoiding pregnancy
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
Which women are at greatest risk for complications if they become pregnant?
Breast cancer Complicated valvular heart
disease Diabetes (especially type 1) Endometrial or ovarian cancer Epilepsy Hypertension Bariatric surgery in past 2y HIV/AIDS Ischemic heart disease Malignant gestational
trophoblastic disease
Medical Conditions Increasing Risk for Complications
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
Which women are at greatest risk for complications if they become pregnant?
Malignant liver tumors, hepato-cellular carcinoma of liver
Peripartum cardiomyopathy Pulmonary hypertension Schistosomiasis (liver fibrosis) Severe cirrhosis Sickle cell disease Solid organ transplantation Stroke Systemic lupus erythematosus Thrombogenic mutations Tuberculosis
Medical Conditions Increasing Risk for Complications
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
How does this affect their choice of contraception?
Encourage use of most effective method to decrease possibility of a risk
Often: LARC or sterilization (if finished childbearing)
Consult U.S. Medical Eligibility Criteria, from CDC
Comprehensive analysis of medical problems and risks associated with certain contraceptives
Helps determine which methods a patient could use
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
How should women go about choosing an appropriate contraceptive?
Lifestyle Unpredictable work schedule? may be hard to take pill at
same time every day Planning future pregnancy? STD protection? Condoms prevent pregnancy + STDs
Past use Unplanned pregnancy when using contraception in past? Unable to continue a method in past? (unlikely option)
Side effectsSuch as spotting with subdermal implant
Personal comfort Discomfort changing a vaginal ring? (will discourage use) Discomfort with amenorrhea from LNG-IUD ?
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
Are there forms of contraception a woman should avoid if she is considering pregnancy in the next year or so?
Injectable medroxyprogesterone acetate
Delayed return of fertility (≈10 months)
Not recommended if desiring pregnancy in near future
Other contraception methods allow rapid return to fertility (IUD, subdermal implant, combined hormonal)
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
What contraceptives can breastfeeding woman use?
If breastfeeding
Progesterone-only methods acceptable, safe
Can be started immediately after delivery
Delay estrogen-containing methods until 6 weeks post-partum and lactation well-established (elevated VTE risk)
Option: barrier method (refit diaphragm / cervical cap after delivery)
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
CLINICAL BOTTOM LINE: Counseling Considerations… Initiate contraception counseling before first sexual activity When choosing appropriate contraception…
Consider patient comfort, lifestyle, past method use Medical conditions (may increase risk for complicated or
dangerous pregnancy) Consult CDC Medical Eligibility Criteria Be aware return to fertility delayed after discontinuing
injectable medroxyprogesterone
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
What are the cost and cost-effectiveness of contraception? All more cost-effective
than unwanted pregnancyCost Combined methods: $8 - $80 per month
Medroxyprogesterone: $35 - $75 every 3 months (plus nursing visit for administration)
LARC methods: $300 - $800 without insurance
Cost effectiveness LARC and sterilization: highest up-front cost
But most cost-effective over time
Combined methods: less cost upfront but refills required
Less cost-effective given decreased efficacy vs LARC
Condoms: least cost-effective (but protect against STDs)
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
Are all forms of contraception covered by most health insurance plans?
Most insurance companies cover contraception
If there is a prescription drug benefit
Patient Protection and Affordable Care Act
Requires insurers to cover contraception without copay
Plans that existed when PPACA passed grandfathered in
Any significant changes or modifications to plans will mandate adoption of the new regulations
Exemptions for some religious employers
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
CLINICAL BOTTOM LINE: Cost Considerations… Most cost-effective form of contraception: LARC
Cost of contraception: covered by most insurance plans that include prescription drug benefit
PPACA: requires all insurance providers to cover contraception without copay
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
Should primary care physicians prescribe contraceptives or should they refer patients to other providers?
For medically uncomplicated women: Primary care physician may prescribe contraception
However few are well-trained in contraception provision
PCP often first-line providers for ill women, who may need counseling about contraception
Especially important if also prescribing teratogenic medication
For women with medical problems: refer to OB-GYN or family planning specialist
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
Are there programs to train internists in providing contraception?
Most training occurs during residency / fellowship
Subdermal implants: Manufacturer can provide formal training on placement
IUDs: Consider contacting local provider within your institution for training on insertion
In general, refer patient to experienced person for counseling and fitting of device
OB-GYN or family practice physician or nurse
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.
CLINICAL BOTTOM LINE: Provider Considerations… To prevent unintended pregnancy: provide contraception to all
sexually active reproductive-age women Internists should feel comfortable and responsible discussing
contraception with patients Especially if medically complicatedRefer to OB-GYN or family practice physician if patient has: Medical problems, an interest in LARC method, or if there is
difficulty identifying appropriate method