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26-‐06-‐2013
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Andrew M. Kaunitz, M.D. Professor and Associate Chairman
Department of Obstetrics and Gynecology University of Florida College of Medicine -‐ Jacksonville
Skouby.debate.5.13.13b
Latin America/Caribbean All pregnancies (million) 17.1 Unintended 58%
Globally, Many Pregnancies Are SFll Unintended1
2
aExcludes Japan.
1. Singh S et al. Stud Fam Plann. 2010;41(4):241–250.
Asiaa
All pregnancies (million) 118.8 Unintended 38%
Europe All pregnancies (million) 13.21 Unintended 44% North America
All pregnancies (million) 7.2 Unintended 48%
Oceania All pregnancies (million) 0.9 Unintended 37%
Africa All pregnancies (million) 49.1 Unintended 39%
World All pregnancies (million) 208.2 Unintended 41%
Global Data (2008)
Unintended Pregnancy is a ParFcular Concern in Adolescents Worldwide
● Around the world, about 16 million girls and women aged 15 to 19 years give birth each year. – Most of these pregnancies are unintended.
World Health Organization. Making pregnancy safer. Adolescent pregnancy. www.who.int/making_pregnancy_safer/topics/adolescent_pregnancy/en/index.html. Accessed 21 November 2011.
Youngest Women Experience the Highest Rate of Unintended Pregnancy
Finer LB et al. Contraception. 2011;84:478–485.
Unintended Pregnancy in the United States (2006)
Age, years
Total Pregnancy Rate/
1,000 Women
Unintended Pregnancy Rate/
1,000 Women
Unintended Pregnancy
Rate, %
15–17 42 33 79
18–19 124 103 83
20–24 168 107 64
25–29 174 71 41
30–34 139 46 33
35–39 80 22 28
≥40 21 10 48
Reversible ContracepFves: First Year Failure Rates with Typical Use
J Trussell et al. Contraception 2004 K Kost et al. Contraception 2008 S Funk et al. Contraception 2005
Long-acting reversible methods: efficacy comparable to sterilization
*Estimates in lieu of actual data
Percent
Available Long-‐AcFng Reversible ContracepFves
Type Duration of Use
Intrauterine devices Replaced in 3, 5 , 10 years
Implants Replaced in 3 to 5 years
Injectable contracepKves InjecKons repeated every 8 or 12 weeks
National Institute for Health and Clinical Excellence. www.nice.org.uk/nicemedia/live/10974/29912/29912.pdf. Accessed 20 September 2011.
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Percent of all US Women Aged 15-‐44 Years Using Hormonal ContracepFves or IUDs (2006-‐2008)
Mosher WD, Jones J. Use of ContracepKon in the United States: 1982-‐2008. NaKonal Center for Health StaKsKcs. Vital Health Stat 23 (29). 2010.
OC All IUDs & Implants = 4.7
Use of Selected ContracepFves, by Country: Percent of Overall Hormonal ContracepFve Use: September 2012
IMS Midas ™
OC Progestin IUD & Implants
28.6 1.1 1.5 1.2
=
Clinicians Have QuesFons re LARCS in Teens
– IUDs o Desired by teens? -‐Placement feasible? o Safe? -‐ConKnuaKon rates? o Rates of unintended pregnancy / induced aborKon?
– Implants o Desired by teens? -‐ConKnuaKon rates?
– DMPA o Skeletal health safety? Jeffrey F. Peipert, MD, PhD
Objective: - To decrease unintended pregnancy by promoting the use of long-acting reversible contraception (LARC) in St. Louis, USA - Assess acceptability and continuation of a variety of contraceptive methods
Contraceptive Choice Project. http://www.choiceproject.wustl.edu/studyfindings.html. Last Accessed 12/20/2011.
IntroducFon to the ContracepFve CHOICE Project in the United States
● Sexually acKve women who wanted to avoid pregnancy but were not currently using a contracepKve or wanted to start a new reversible method were recruited.
● Counseling increased awareness of LARC methods.
● Each parKcipant was provided her contracepKve method of choice at no cost for 3 years.
● 9,250 women enrolled from 2007-‐2011. – CHOICE parKcipants diverse, similar to overall women in St. Louis region.
Secura GM et al. Am J Obstet Gynecol. 2010;203:115.e1–115.e7. Peipert JF et al. Obstet Gynecol. 2011;117(5):1105–1113.
What Method Did Women Choose?
Contraceptive Choice Project. http://www.choiceproject.wustl.edu/studyfindings.html. Last Accessed 12/20/2011.
• 75% of women chose a long-acting reversible contraception method (LARC: IUD or implant)
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LARCs and Teens
Contraceptive Choice Project. http://www.choiceproject.wustl.edu/studyfindings.html. Last Accessed 12/20/2011.
• Young women under the age of 21 were also interested in IUDs and implants
• > 40% of young women 14-‐17 years chose the implant • > 40% of young women 18-‐20 years chose an IUD
LARCs Associated With Highest ConFnuaFon and SaFsfacFon Rates at 12 Months
ConFnuaFon Rates and SaFsfacFon Levels1
1. Peipert JF et al. Obstet Gynecol. 2011;117(5):1105–1113.
0
20
100
Wom
en, %
60
40
80
Long-Acting (n=2,846)
Non–Long-Acting (n=1,321)
Continuation rate Very satisfied Somewhat satisfied Not satisfied
86.2
66.9
16.8 16.4
54.7
42.7
10.0
47.3
LARC=long-‐acKng reversible contracepKve.
CumulaFve Percentage of ParFcipants Who Had a ContracepFve Failure at 1, 2, or 3 Years
B Winner, JF Peipert, et al. N Engl J Med 2012
DMPA: women who returned for scheduled reinjections
Probability of Not Having an Unintended Pregnancy, According to ContracepFve Method and Age
B Winner, JF Peipert, et al. N Engl J Med 2012
Births Per 1,000 Females Aged 15-‐19
J Peipert, et al. Obstet Gynecol 2012
AborFon Rates per 1,000 Women & Adolescents, 2008
J Peipert, et al. Obstet Gynecol 2012
Authors estimate implementing CHOICE policies nationwide could prevent 62%-78% of induced abortions in US
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ACOG Practice Bulletin #121. July 2011
• IUDs do not increase adolescents’ risk of PID • IUDs may be placed without difficulty in most adolescents and nulliparous
women • IUD expulsion uncommon in adolescents • Adolescents should be screened for STIs at time of IUD placement
A Smaller Levonorgestrel IUD
● Smaller progesKn IUD approved for up to 3 years of use available in the US as of early 2013 – Incrementally thinner width of ‘T’ , shorter length and more narrow
gauge outer diameter of inserKon tube may facilitate inserKon in teens and nulliparous women
CumulaFve Percentage of ParFcipants Who Had a ContracepFve Failure at 1, 2, or 3 Years
B Winner, JF Peipert, et al. N Engl J Med 2012
DMPA
● Failures rare in consistent users – Low conKnuaKon rate can lead to higher failure rates – Amenorrhea the norm in long-‐term users
● Return to ferKlity may be delayed by 10-‐18 months aher disconKnuaKon
– Menses may not return for months aher disconKnuaKon
– A useful method for teens and other women who may not use other contracepKves consistently
– Not appropriate for women who may wish to conceive in the next 1-‐2 years
AM Kaunitz, Depot Medroxyprogesterone Acetate for Contraception, In UpToDate, Rose BD (Ed), Waltham MA
DMPA and Skeletal Health Concerns
● DMPA→ ↓ estradiol levels → lower bone mineral density (BMD)
● FDA: Black Box placed 2004 ● However
– Declines in BMD associated with DMPA are fully reversible in teens and adult women
– Prior use of DMPA not
associated with postmenopausal osteoporosis
MM Isely, AM Kaunitz. Rev Endocr Metab Disor 2011
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BMD Changes in Women IniFaFng DMPA
Clark MK et al. Fertil Steril. 2004;82:1580-1586
3-4% decline at one year 3-4% decline at one year
Is there a physiologic model for transient, estrogen-mediated declines in BMD in women?
BMD Changes With DMPA-‐IM 150 Mirror Those With LactaFon
Mea
n C
hang
e in
Spi
ne B
MD
(%)
Kalkwarf HJ et al. Obstet Gynecol. 1995;86:26-32.
During lactation and weaning
Months of Follow-Up
BMD declined 4-5% at 12 months
-6 -4 -2 0 2 4 6
0 12 24 36
During Lactation After Weaning Weaning Lactation Two recent case-‐control studies
found that DMPA users have more fractures than non-‐users
2008 Danish Case-‐control Study
P Vestergaard, et al. Contraception 2008
● OR for DMPA use = 1.44 (95% CI 1.01-‐2.06); ORs higher with longer-‐term DMPA use – OR for IUD use = 0.75 (95% CI 0.64-‐0.87)
● DMPA use rare in Denmark: only 0.1% of study populaKon used DMPA
– Alcoholism: 14% in DMPA users, 3% in IUD users
– Higher educaFon: 12% in DMPA users, 33% in IUD users
– Authors pointed out ‘…use of injectable contracepKon is so rare in Danish women that it is likely that baseline characterisKcs among DMPA users… do not reflect the characterisKcs of contracepKve users overall.’
2010 UK Case-‐control Study
● InvesKgators used General PracKce Research Database (GPRD)
● Cases w/ fractures (N=17,527) compared to controls (70,130)
● DMPA ever-‐use ~10%
● Adjusted ORs for DMPA use: 1.17 to 1.54
– ORs higher with longer-‐term DMPA use
C Meier, et al. J Clin Endocrinol Metab 2010
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2013 UK RetrospecFve Cohort Study of DMPA & Fractures Using the GPRD (Funded by Pfizer [markets DMPA])
● Fracture (fx) rate in DMPA users higher than in users of other hormonal contracepKves (predominantly OC)
● But cohort study design allowed separaKon of Kming of DMPA use and occurrence of fx
– Among women who later iniKated DMPA, fx rate higher (before DMPA iniKated) than in women who later iniKated other contracepKves (OC)
– Fx rate did not increase aher DMPA was started
– Fx rate did not increase with a greater number of DMPA injecKons
● Women who choose DMPA may be more likely to experience trauma (motor vehicle accidents, domesFc violence) resulFng in fx
LL Lanza, et al. Obstet Gynecol 2013
Summary: LARC=First-‐line ContracepFve Choice for Women of All Ages
● LARC contracepKve conKnuaKon and efficacy dramaKcally higher than for short-‐acKng methods, parKcularly in young women
– Greater use could substanKally ↓ unintended pregnancies/aborKons
● IUDs and implants safe in adult women and teenagers
● Placement of IUDs and implant safe and appropriate immediately postpartum/postaborKon
Madden T et al., Obstet Gynecol 2012 Tocce KM et al., Am J Obstet Gynecol 2012 Bednarek PH et al. N Eng J Med 2011
Summary: LARC=First-‐line ContracepFve Choice for Women of All Ages
● Injectable contracepKon/DMPA should be viewed not as a niche method for special needs women but rather as a first-‐line contracepKve choice for women of all ages
– BMD ↓s reversible
– DMPA does not cause osteoporosis/fractures QuesFons?
THANK YOU!