ContraceptionContraceptionContraceptionContraceptionLebanese Society of Family MedicineLebanese Society of Family MedicineLebanese Society of Family MedicineLebanese Society of Family Medicine

66th Annual Meetingth Annual MeetingNovember November 20072007

ObjectivesObjectivesObjectivesObjectives

List the most commonly utilized methods of List the most commonly utilized methods of

contraception in Lebanoncontraception in Lebanon

Counsel patients about the appropriate use ofCounsel patients about the appropriate use ofCounsel patients about the appropriate use of Counsel patients about the appropriate use of

each of these methodseach of these methodseach of these methodseach of these methods

Educate patients regarding the use of Educate patients regarding the use of

emergency contraception emergency contraception

What is the most commonly What is the most commonly d th d f t ti id th d f t ti iused method of contraception in used method of contraception in

Lebanon?Lebanon?Natural

Lebanon?Lebanon?Natural

BarrierSterilization

HormonalIntrauterine HormonalIntrauterine

Prevalence of contraceptive method Prevalence of contraceptive method currently used by evercurrently used by ever married womenmarried womencurrently used by evercurrently used by ever--married women married women

aged aged 15 15 -- 4949

________________________________________ ________________________________________ Data SourceData Source Beirut Beirut 84 84 Beirut Beirut 94 94 PAP Child PAP Child 96 96 Bekaa Bekaa 9898

N = N = 1104 1104 N = N = 626 626 N = N = 1730 1730 N = N = 364364Method Method %% %% %% % %

__________________________________________________________________________________________OCPOCP 26 26 1919 1616 1919IUDIUD 2020 2626 28 2928 29FAMFAM 2424 2222 1616 44Withdrawal Withdrawal 1616 1717 1919 2121OtherOther 1515 1717 2020 2727TotalTotal 100 100100 100 100100 100100______________________________________________________________________________________________C. Myntti et al. Challenging the stereotypes: men, withdrawal, and reproductive health in Lebanon. Contraception C. Myntti et al. Challenging the stereotypes: men, withdrawal, and reproductive health in Lebanon. Contraception 6565((20022002): ):

165 165 –– 170170..

Current use of contraceptionCurrent use of contraception

Any MethodAny MethodT i iT i i 6262 66

Modern MethodT i i 53 1Tunisia Tunisia 6262..66

Syria Syria 4646..66•Tunisia 53.1•Syria 35.1

Algeria Algeria 5757..00DjiboutiDjibouti 99..00

•Algeria 51.8•Djibouti 5 8Djibouti Djibouti 99..00

Yemen Yemen 2323..11L bL b 5858 00

Djibouti 5.8•Yemen 13.4L b 34 0Lebanon Lebanon 5858..00

Morocco Morocco 6363..00•Lebanon 34.0•Morocco 54.8

http://www.papfam.org/papfam/summery.htmhttp://www.papfam.org/papfam/summery.htm

Coitus interruptusCoitus interruptus“Withdrawal”“Withdrawal”

Perceived as natural, healthier and saferPerceived as natural, healthier and safer

Dislike side effects of other methodsDislike side effects of other methods

Fear of future infertilityFear of future infertility

C Myntti et al Challenging the stereotypes: men withdrawal and reproductive health in Lebanon ContraceptionC Myntti et al Challenging the stereotypes: men withdrawal and reproductive health in Lebanon ContraceptionC. Myntti et al. Challenging the stereotypes: men, withdrawal, and reproductive health in Lebanon. Contraception C. Myntti et al. Challenging the stereotypes: men, withdrawal, and reproductive health in Lebanon. Contraception 6565((20022002): ): 165 165 –– 170170..

Factors affecting choice of Factors affecting choice of contraceptioncontraception

M it l St tMarital Status

AgeCulture

Components of contraceptive Components of contraceptive successsuccess

Access

ContinuationCompliance

Counseling

Prevalence of contraceptive method Prevalence of contraceptive method currently used by evercurrently used by ever married womenmarried womencurrently used by evercurrently used by ever--married women married women

aged aged 15 15 -- 4949

________________________________________ ________________________________________ Data SourceData Source Beirut Beirut 84 84 Beirut Beirut 94 94 PAP Child PAP Child 96 96 Bekaa Bekaa 9898

N = N = 1104 1104 N = N = 626 626 N = N = 1730 1730 N = N = 364364Method Method %% %% %% % %

__________________________________________________________________________________________OCPOCP 26 26 1919 1616 1919IUDIUD 2020 2626 28 2928 29FAMFAM 2424 2222 1616 44Withdrawal Withdrawal 1616 1717 1919 2121OtherOther 1515 1717 2020 2727TotalTotal 100 100100 100 100100 100100______________________________________________________________________________________________C. Myntti et al. Challenging the stereotypes: men, withdrawal, and reproductive health in Lebanon. Contraception C. Myntti et al. Challenging the stereotypes: men, withdrawal, and reproductive health in Lebanon. Contraception 6565((20022002): ):

165 165 –– 170170..

Selected Practice Recommendations for Contraceptive Use; Second edition,World Health Organization, Geneva, 2004

WithdrawalWithdrawal

Only Only 44% failure if practiced correctly% failure if practiced correctlyMust urinate firstMust urinate firstPrePre--ejaculate rarely has sperm and these are ejaculate rarely has sperm and these are usually deadusually deadusually deadusually deadCheapCheapHas worked for centuriesHas worked for centuriesHas worked for centuriesHas worked for centuries

Rogow D, Horowitz S. Withdrawal: a review of the literature and an agenda for research. Stud Fam Rogow D, Horowitz S. Withdrawal: a review of the literature and an agenda for research. Stud Fam Plan Plan 19951995;;2626::140140--5353..

Fertility Awareness Method Fertility Awareness Method (FAM)(FAM)

Up to Up to 9898% effective% effective

Life of oocyte (Life of oocyte (24 24 hours)hours)

Life of sperm (Life of sperm (2 2 -- 5 5 days)days)

Standard days methodStandard days method

Two day methodTwo day method

Standard Days MethodStandard Days MethodStandard Days MethodStandard Days Method

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are needed to see this picture.

plannedparenthood.org

Two Day MethodTwo Day MethodTwo Day MethodTwo Day Method

“Did I notice any secretions today?”“Did I notice any secretions today?”

“Did I notice any secretions yesterday?”“Did I notice any secretions yesterday?”

Must distinguish between cervical secretions Must distinguish between cervical secretions

ddand semenand semen

Selected Practice Recommendations for Contraceptive Use; Second edition,World Health Organization, Geneva, 2004

Emergency contraceptionEmergency contraception“Morning After Pill”“Morning After Pill”

Within Within 120 120 hourshoursCOP (COP (7575%)%)(( ))POP (POP (8989%)%)

Norlevo (Norlevo (1616 000000 LL)LL)Norlevo (Norlevo (1616,,000 000 LL)LL)Copper IUD insertion Copper IUD insertion ((9494 -- 9999% effective)% effective)((94 94 -- 9999% effective)% effective)

Emergency ContraceptionEmergency ContraceptionMechanism of actionMechanism of action

Blunt LH surgeBlunt LH surgeI hibit f lli l tI hibit f lli l tInhibit follicle ruptureInhibit follicle ruptureInterfere with corpus luteum functionInterfere with corpus luteum functionTrap sperm in cervical mucusTrap sperm in cervical mucusInhibit fertilizationInhibit fertilizationInhibit fertilizationInhibit fertilizationInterfere with sperm, egg or embryo transportInterfere with sperm, egg or embryo transport

Brunton J and Beal M. Current inssues in emergency contraception: an overview for providers. JBrunton J and Beal M. Current inssues in emergency contraception: an overview for providers. JBrunton J and Beal M. Current inssues in emergency contraception: an overview for providers. J Brunton J and Beal M. Current inssues in emergency contraception: an overview for providers. J Midwifery Womens Health Midwifery Womens Health 20062006;;5151((66):):457457--6363..

LactationLactationLactationLactation

9898--9999% effective% effectivebreastbreast--feeding feeding ggexclusively exclusively feedings no more thanfeedings no more thanfeedings no more than feedings no more than 4 4 hrs aparthrs apartbaby <baby < 66 monthsmonthsbaby < baby < 6 6 months months No menses No menses 2525% ovulate before % ovulate before 11st st mensesmenses

OCPsOCPsMode of actionMode of action

OC’OC’s

Progest Estrogeng g

Suppress LH Suppress FSHDecidualize End Hostile Cx Mucus

OCPsOCPsPotential side effectsPotential side effects

NauseaLibido

AcneHeadaches

DepressionWeight Gain

Mastalgia Bleeding

Estrogen side effectsEstrogen side effectsEstrogen side effects Estrogen side effects

Breast tendernessBreast tendernessVaginal bleeding or spottingVaginal bleeding or spottingVaginal bleeding or spottingVaginal bleeding or spottingEnlarge fibroids Enlarge fibroids Migraine headachesMigraine headachesAbdominal bloatingAbdominal bloatingAbdominal bloatingAbdominal bloatingNauseaNauseaSkin rashesSkin rashes

Progestin side effectsProgestin side effectsProgestin side effectsProgestin side effects

AAAcneAcneHair growthHair growthggHeadacheHeadacheMastalgiaMastalgiaMastalgiaMastalgiaNauseaNauseaDizzinessDizzinessMoodMoodMoodMoodLibidoLibido

Progestin potency *Progestin potency *Progestin potency Progestin potency

ProgestinProgestin Progestational ActivityProgestational Activity Androgenic ActivityAndrogenic ActivityProgestinProgestin Progestational ActivityProgestational Activity((relative to relative to 1 1 mg of mg of

norethindrone)norethindrone)

Androgenic ActivityAndrogenic Activity((relative to relative to 1 1 mg of mg of

norethindrone)norethindrone)norethindronenorethindrone 11 mgmg 11 00 11 00norethindrone norethindrone 1 1 mgmg 11..00 11..00norethrindrone norethrindrone acetate acetate 1 1 mgmg

11..22 11..66

th di l di t tth di l di t t 11 44 00 66ethynodiol diacetate ethynodiol diacetate 1 1 mgmg

11..44 00..66

levonorgestrel levonorgestrel 1 1 mgmg 55..33 88..33dldl--norgestrel norgestrel 1 1 mgmg 22..66 44..22norgestimate norgestimate 1 1 mgmg 11..33 11..99norelgestromin norelgestromin 1 1 mgmg 11..33 11..99gg gg

desogestrel desogestrel 1 1 mgmg 99..00 33..44drospirenonedrospirenone 11 mgmg 11..55 00..00drospirenone drospirenone 1 1 mgmg 11..55 00..00

* - From Table 2 in Dickey RP: Individualizing oral contraceptive therapy. OBG Management Supplement October 2000, p 5.

Locally available OCPsLocally available OCPsLocally available OCPsLocally available OCPsNAME (Price)NAME (Price) ESTROGENESTROGEN PROGESTINPROGESTIN

Marvelon (Marvelon (77,,000000LL)LL) EE EE 30 30 mcgmcg Desogestrel Desogestrel 00..15 15 mgmg

DianeDiane 3535 ((1313 000000 LL)LL) EEEE 3535 mcgmcg CyproteroneCyproterone 22 mgmgDiane Diane 35 35 ((1313,,000 000 LL)LL) EE EE 35 35 mcgmcg Cyproterone Cyproterone 2 2 mgmg

Femovan (Femovan (1111,,000 000 LL)LL) EE EE 30 30 mcgmcg Gestodene Gestodene 00..075 075 mgmg

Gracial (Gracial (1313,,000 000 LL)LL) EE EE 40 40 mcgmcg Desogestrel Desogestrel 00..024 024 mgmg

Microgynon (Microgynon (3000 3000 LL)LL) EE EE 30 30 mcgmcg Levonorgestrel Levonorgestrel 00..15 15 mgmg

Y i (Y i (1616 000000 LL)LL) EEEE 3030 D iD i 33Yasmin (Yasmin (1616,,000 000 LL)LL) EE EE 30 30 mcgmcg Drospirenone Drospirenone 3 3 mgmg

Belara (Belara (88,,000 000 LL)LL) EE EE 30 30 mcgmcg Chlormadinone Chlormadinone 2 2 mgmg

Cerazette (Cerazette (99,,000 000 LL)LL) Desogestrel Desogestrel 75 75 mcgmcg

Side Effect/Problem Principal Pill SuggestionsSide Effect/Problem Principal Pill SuggestionsAcne higher estrogen, lower

androgen potencyYasmin, Diane 35 ,Microgynon, Marvelon

Break-through bleeding higher estrogen, higher Yasmin, Microgynon, Marvelon, Belaraprogestin potency, lowerandrogen potency

Absent or too lightmenstrual flow

higher estrogen, lowerprogestin potency

Microgynon, Marvelo, Belara

Depression lower progestin potency Microgynon, MarvelonMoodiness or irritability lower progestin potency Microgynon, MarvelonHeadaches (not

l i i )lower estrogen, lower progestin Microgynon

menstrual migraines) potencyBreast soreness lower estrogen, lower progestin

potencyMicrogynon

Weight gain lower estrogen, lower progestin Yasmin, Microgynon , Belarag g g , p gpotency

, gy ,

Severe menstrualcramps

higher progestin potency Yasmin, Marvelon, Diane 35

Endometriosis or lo er estrogen higher Yasmin Mar elon Diane 35 OrgametrilEndometriosis orendometriosisprevention

lower estrogen, higherprogestin potency, higherandrogen potency

Yasmin, Marvelon, Diane 35, Orgametril

Adapted from http://www.wdcyber.com/ncontr13.htm

Anticipatory GuidanceAnticipatory GuidanceAnticipatory GuidanceAnticipatory GuidanceIndividualizeIndividualize Emphasize nonEmphasize nonIndividualize Individualize counseling counseling Discuss changes in Discuss changes in

Emphasize nonEmphasize non--contraceptive contraceptive benefitsbenefitsgg

bleeding, weight and bleeding, weight and other expected side other expected side effectseffects

Cue pillCue pill--taking to taking to daily activitydaily activityDemonstrate how toDemonstrate how to

Stress that side effects Stress that side effects decrease over timedecrease over timeMention possibility ofMention possibility of

Demonstrate how to Demonstrate how to use the actual pill use the actual pill packpackDiscuss missedDiscuss missedMention possibility of Mention possibility of

switching to another switching to another brand in case of side brand in case of side ff tff t

Discuss missed Discuss missed pillspills“Don’t stop taking “Don’t stop taking

effectseffectsp gp g

the pills before the pills before calling me”calling me”

Return to fertilityReturn to fertilityReturn to fertilityReturn to fertility

“For women who “For women who do not like to take do not like to take

ororor or cannot take estrogens”cannot take estrogens”

POPPOPPOPPOP•Less effective than COCsess e ect e t a COCs•Slowing down egg transportation in the tubes•Cervical mucus impenetrability to sperm•Effect maintained up to 27 h after•Effect maintained up to 27 h after the tablet intake “3 hours missed-pill window”p•Ovulation inhibition incomplete: approximately 50% of cycles • Unpredictable bleeding pattern•Slightly increased risk of ectopic pregnancypregnancy

CerazetteCerazetteCerazetteCerazette

PrimaryPrimaryPrimary Primary Ovulation inhibition in up to Ovulation inhibition in up to 9999% of cycles% of cycles

SecondarySecondarySecondarySecondaryThickening of cervical mucusThickening of cervical mucus

Korver T et al. Contraception Korver T et al. Contraception 20052005

IUDIUD

C TC T380380AACopper TCopper T380380AAMirena Mirena (Levonorgestrel)(Levonorgestrel)(Levonorgestrel)(Levonorgestrel)Mode of actionMode of actionPID riskPID riskPID riskPID riskExpulsion riskExpulsion riskNulliparous womenNulliparous womenNulliparous womenNulliparous women

Peterson and Curtis. LongPeterson and Curtis. Long--acting methods of contraception. N Engl J acting methods of contraception. N Engl J Med Med 353 353 ((20022002): ): 2169 2169 –– 7575..

ACOG Practice Bulletin: Clinical management guidelines for ACOG Practice Bulletin: Clinical management guidelines for obstetricianobstetrician gynecologists Numbergynecologists Number 5959 JanuaryJanuaryobstetricianobstetrician--gynecologists Number gynecologists Number 5959, January , January 20052005.Intrauterine Device. Obstet Gynecol .Intrauterine Device. Obstet Gynecol 20052005;;105105::223223--232232//

OthersOthersOthersOthers

ImplanonImplanon

Vaginal ringVaginal ringVaginal ringVaginal ring

Injectable (Depo)Injectable (Depo)

Progestin ImplantProgestin ImplantProgestin ImplantProgestin Implant

Implanon (Etonorgestrel)Implanon (Etonorgestrel)33 yearsyears3 3 yearsyearsCost Cost 300300,,000 000 LL ($LL ($200200))

ConclusionsConclusionsConclusionsConclusions

Natural family planning is commonly practiced in Natural family planning is commonly practiced in Lebanon and the regionLebanon and the regionNatural family planning can be effectiveNatural family planning can be effectivePrimary care physicians should educate patientsPrimary care physicians should educate patientsPrimary care physicians should educate patients Primary care physicians should educate patients about the availability of emergency about the availability of emergency contraceptioncontraceptioncontraceptioncontraceptionCounseling is essential to decrease Counseling is essential to decrease contraceptive failurecontraceptive failurecontraceptive failure contraceptive failure