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Objectives of Lecture: Review of Contraceptive Counseling,
Risk Assessment and Method Initiation
Discussion of Conceptive methods including Emergency Contraception
Discussion of new Guidelines regarding Contraceptive Usage
Contraception Needs in US ~60 million women between ages of 15-44
60% use contraception 33% don’t have a need for contraception 7.3% who are at risk are not using any method
6 million pregnancies yearly in US 50% of pregnancies are unintended 1 million pregnancies occurred on OCP’s 1.4 million abortions performed yearly in US
Counseling Efficacy Availability Costs Ease of Use Privacy Reversibility Side Effect and Medical Risks Patient and Partner Desires Informed Decision Making
Contraceptive Efficacy Pearl Index: Theoretical Definition of Method
Failure Rate based on “Perfect Usage”: Number of Failures / 100 Women-years
of exposure (x1200 if based on months) (x1300 if based on cycles)
“Typical or Usage Failure Rate” based on actual usage activity from Life Table Method
Contraceptive MethodsCombined Hormonal Methods (COC)
Oral Contraception Nuva Ring Ortho Evra Patch
Progestin Only Methods (POP) The Mini Pill Depo-Provera Implanon
Non Hormonal Contraception - IUDBarrier Methods
Male / Female CondomsSterilizationEmergency Contraception
Pre-Assessment & Evaluation Discussion of Patient’s Life and Health
Plans Reproductive Life Plan Childbearing Goals Birth Spacing
Pre-conceptual Health Assessment and Counseling
Extensive Personal Medical History and Family History
Pre-Assessment History
Personal History: Medical History of Hormonal contra-indications: (HTN, MI, Cardiac Dz, DM, CVA, DVT, PE, other) Liver Disease Migraine headache with aura or neurologic
complaints; Seizure history Tobacco Usage Current Medications
Surgical History
Pre-Assessment History Gyn History:
Menstrual History including LMP Breast Issues including new or unevaluated
masses Uterine fibroids or other anatomic
abnormalities STD history, prior and current risk (?)
Familial History of Thrombophilia (1st degree relative)
Pre-Assessment & Evaluation Physical Exam not necessary prior to
initiation of any birth control method Vital Signs, Weight Breast Exam*, Pelvic Exam (??)
Laboratory Testing Factor V Leiden, Anti-phospholipid evaluation,
Glucose, and Lipids if there is a concerning personal or family history
STD screening prior to IUD placement (?)
CDC and Contraception Medical Eligibility WORLD Health Organization (WHO)
established an evidence based guideline for contraceptive usage
Global review of the 19 different contraceptive methods for women and men
4th version was revised 2010 (available since
1996)
COC Physiologic Effects Hormonal Effect
Estrogen (ethinyl estradiol) and Progesterone alter FSH/LH secretion via negative feedback
Follicle development and Ovulation are suppressed
Endometrial thinning Cervical mucous thickening
Reduced sperm transport Progestin is the dominant hormone
COC or OCP’s 10.7 million women use OCP
(~27% of BC users) Most popular, reversible BCM in the US 21 day cycle, 24 day cycle Extended regimens Monophasic, Biphasic, Triphasic,
Quadiphasic (Quailara@) 20mcg, 35 mcg, 50 mcg pill regimens
(based on Estrogen dosage)
OCP Failure Failure rate is 0.1% Usage Failure rate is 8/100
woman-years Adherence with OCP – 50% of women miss 1-3 pills
a cycle Missing Pills within the 1st week of the pack –
breakthrough ovulation
Drug Interactions – Anti-seizure medications (G450 activation) Antibiotics – Rifampin, Griseofulvin Anti-viral medications - Norvir
OCP’s concerns Alterations in the Menstrual Cycle
Breakthrough bleeding Amenorrhea 0.8% per year
Health Risks Headaches and Elevated Blood
pressure Weight Gain Breast Cancer risk
Risk of Thrombo-embolic events*
Non Contraceptive Benefits Acne and Hirsuitism therapy Menstrual Regulation occurs with
decreased Menstrual Blood Loss Dysmenorrhea, endometriosis
symptoms are improved Rates of Ovarian cysts, ectopic
pregnancy, and salpingitis are reduced. Ovarian and Endometrial Cancer rates
are reduced with past usage of at least one year
Contra-indications to COC usage Medical History
Personal H/o Thrombo-embolism (DVT, PE, CVA, MI)or
Familial History of inherited thrombophilia (DVT, PE, CVA, MI)
Uncontrolled HTN (>160/100) Hepatic Dysfunction Diabetes Breast Cancer Smokers over the age of 35** (#) Unexplained vaginal bleeding or Pregnancy
Contra-indications to COC usage
Postpartum patients* <21 days, Cardiac Disease including h/o ischemic
heart disease, valvular heart dz, peripartum cardiomyopathy and multiple risks factors for heart disease*
H/o Solid Organ Transplant, complicated H/o Gastric Bypass*
CDC – Medical Eligibility Criteria, 2010
Pos tpartum Contraception WHO Revised guideline 7/2011 PP, 22-84X greater risk of DVT, PE or VTE Ovulation can occur as early at 25 days in non
lactating women 21 days pp - No COC or CHC 42 days pp – Non COC or CHC
Obesity, Post Cesarean Delivery, Preeclampsia, PP hemorrhage, Transfusion at Delivery, Immobility, Age > 35, Tobacco Users, BMI > 30, Prior h/o VTE, Thrombophilia)
POP methods are acceptable immediately
Drug Interactions and OCP’s Anti-Malarial Meds: Rifampicin /
Rifabutin
Anticonvulsant Medications: Lamotrigine*Phenytoin, Carbamazepine, Barbituates, Primidone, Topiramate and Oxcarbazepine
Antiretroviral therapy (ARV):Ritonavir-boosted protease inhibitors
Ortho-Evra Weekly Transdermal patch of a hormonal matrix
150 mcg ethinyl estradiol 20 mcg norelgestromin Worn 3 weeks out of 4 weeks per cycle
Sites of usage: Back, Upper arm, Abdomen, or Chest Sunday Start or 1st day Start Patch Change Date within 48 hours of scheduled date
Failure rate: 1%
Not recommended for hormonally naïve patients, smokers*, or patient with h/o skin sensitivity or weights above 198 lbs
NuvaRing Ethylene vinyl acetate polymer ring
15 mcg of Ethinyl estradiol 120 mcg Etonogestrel Intra-vaginal placement Worn ¾ weeks per cycle with option of
one week Menstrual Cycles regulated 98.5% of cycles Failure rate: 0.65-1.18/100 women-years Vaginal Discharge and placement issues
Progesterone only Contraception
Progestin-only pills - POP or “Mini pills” Norethindrone or norgestrel
Continuous usage (no pill free interval) Hormone must be taken daily at the same time
(25% circulating levels of OCP’s / 22hr effect)Ovulation seen in 40-50% of POP users
Mechanism of action: Cervical Mucous thickening, Thinning of endometrium, reduced sperm transport
Failure Rate: 1.1 to 9.6 / 100 women-years Backup method – Barrier Method / Breast feeding
Depo-Provera@ or DMPA 150milligrams of Medroxyprogesterone acetate IM dose every 11-13 weeks
Deltoid or Gluteus Maximus Inhibits LH/FSH surge
Ovulation and endometrial proliferation are inhibited New Guidelines regarding missed doses
WHO 2009 – Delayed Dosages can be given up to 4 weeks from date originally scheduled
Failure Rate: 0.3 – 3% Long lasting but reversible
Return to fertility – 50% by 9 months (max – 18 months)
DMPA Contra-indications:
Breast Cancer Safe if contra-indications to COC’s
exist: Tobacco, HTN, SLE, CVA, Thromboembolic events (DVT/PE),
Liver Disease (????) Improved Outcomes in Certain Populations:
Sickle Anemia / Trait; Seizure Disorder Endometriosis, Dymenorrhea and Pelvic Pain Adolescents, Developmentally Delayed Women
DMPA Risks Bone Density alteration due to estrogen
deficiency Limited Risk: Bone changes resolve with cessation of
DPMA Menstrual Changes
70% have increased bleeding days per month 75% experience amenorrhia after one year of usage
Weight Gain More in Women who are Obese at initiation of method 5lbs by year One; 16 lbs by year Five
Mood Disorders and Psychiatric Issues
Implanon Subdermal, single rod progestin implant
Etonogestrel release 3 year duration of use
Ovulation suppression and endometrial thinning Failure rate: no failures reported in 4103 women
/ 70,000 cycles Menstrual pattern alteration – 80%
Irregular or prolonged bleeding (3-5 days per cycle) Total Overall Blood loss decreased Treat with NSAIDS, OCP’s or estrogen
Intra Uterine Device – Paraguard@ IUD
Long acting, low maintenance, rapidly reversible contraception
Copper T380A - 3.6cm long T shaped device made of polyethylene plastic
Length of usage – 10-12 years Prevention of pregnancy via Endometrial
inflammatory response and anti sperm activity Failure rate = 0.8% (up to 3% at 10 years) Risk of PID, Expulsion/perforation at insertion
and Dysmenorrhea/Menorrhagia
Mirena@ IUD 3.2cm long, T-shaped device with an inner reservoir
Levonorgestrel 20 mcg per day Cervical Mucous thickening and Endometrial
atrophy Ovulation still occurs in 85% of the cycles Failure rate: 0.14 per 100 women–years
0.71% (5 year failure rate) Menstrual irregularity during the first three months
Menorrhagia/Endometrial Cancer treatment
IUD Safety Safe Profile proven with recent studies
Safe for Adolescents and Nulliparous Females Limited increased risk of PID/Infection within
the first 30 days post placement Screen for STI and BV pre-placement if Risk factors Treat STI and allow 3 months from therapy prior to
IUD placement Recommend Condom usage
IUD can be left in place if cervicitis or PID diagnosed
Barrier Methods Male Condoms
Latex condoms – STI protection Failure rate – 3% (Actual – 12%) Breakage rates: 1% of heterosexual acts Nonoxynol 9 no longer recommended
Polyurethane or Non latex condoms Female Condoms
Polyurethane pouch with two rings Can insert up to 8 hours prior to intercourse Female controlled and allows Labia protection
Barrier Methods, Other Cervical Cap:
Thimble shaped rubber device that fits over the cervix Fitted by gynecologist Can be left in vagina for 48 hours Vaginal Discharge Failure rate: 9% in nulliparous; 20% in parous within 1 year
Diaphragm: Dome shaped rubber cups create a barrier over the cervix Use with spermicide May place in vagina up to 6 hours prior to intercourse and remain
in place for 8 hours (max 24 hours) Failure rate: 6% / 12% UTI risks
Permanent Sterilization - Female Female Sterilization is the most common
method used in US for married couples 10 million women in US 100 million women worldwide Overall Failure rates: 1.85% over 10 years but
differs slightly by method and provider experience
Drawbacks: Regret, Failures, Ectopic pregnancy(CREST study – NEJM 2001)
Permanent Sterilization - Female
Laparoscopic Methods: Bipolar Cautery, Sialastic Bands / Falope Ring, Filshie or Hulka Clips,
Open Procedure / Minilaparotomy: Pomeroy/Modified Pomeroy, Parkland,
Irvine, Uchida, Fimbrectomy
Hysteroscopic Methods: Essure, Adiana
Male MethodsSterilization - Vasectomy
Conventional Vasectomy “No Scapel Vasectomy” - In Office
Procedure for occlusion of the Vas Deferens
Limited Risks: No Missed Work, Minimal Pain Need 2 negative Sperm Analysis Costs: $350 – $1,000
Failure Rate: < 1% Reversibility:
Emergency Contraception – “EC”Post coital Contraception - Pregnancy
prevention
Yuzpe method, 1970’s 100mcg estrogen/500mcg Levonegestrel - (2) doses in 12hrs
Drawbacks: nausea, vomitting
More than 20 brands of OCP can now be used as EC*
Reduction in unintended pregnancy rates post EC:
95% if taken with 12 hours; 89% if taken with 5 days
IUD
Emergency Contraception – “EC” Plan B, available since 2000
1.5mg Levonorgestrel Single dose (2 pills) versus 2 One pill
dose protocol every 12hrs Available over the counter (Age >17)
since 2009 Well tolerated
Next Choice- progestin only EC, OTC available since 2010
Emergency Contraception – “EC”
Reduction in unintended pregnancy – 95% if taken with 12 hours; 75% if taken within 72 hours
May use EC up to 120 hours after intercourse*
If, no menses within 2-4 weeks or persistent irregular bleeding post EC, rule out pregnancy
Contraceptive Method Initiation Quick start, Sunday start, Menses Day 1 start LMP to r/o pregnancy needed with Quick start Backup needed for 7 days after initiation –
Quick start and Sunday start Altered Menses may be seen with all
methods Combination methods – Important
Condoms/Barrier methods with hormonal method Emergency Contraception
Postpartum
Pos tpartum Contraception WHO Revised guideline 7/2011 PP, 22-84X greater risk of DVT, PE or VTE Ovulation can occur as early at 25 days in non
lactating women 21 days pp - No COC or CHC 42 days pp – Non COC or CHC
Obesity, Post Cesarean Delivery, Preeclampsia, PP hemorrhage, Transfusion at Delivery, Immobility, Age > 35, Tobacco Users, BMI > 30, Prior h/o VTE, Thrombophilia)
POP methods are acceptable immediately
Adolescents
Confidentiality Issues
Recommend Informed Adult regarding medication
Return office appt for contraception re-enforcement and assessment