Applying Your Knowledge of Contraception in the Clinical

Setting

Applying Your Knowledge of Contraception in the Clinical

Setting

Jan Shepherd, MD, FACOG

Florida State University College of Medicine

Contraceptive Use in the US Contraceptive Use in the US Contraceptive Use in the US Contraceptive Use in the US

Pill

Tubal sterilization

Male condom

Injectable

Vasectomy

Withdrawal

IntrauterinePeriodic

abstinence Other

Diaphragm

Combination Oral ContraceptivesCombination Oral ContraceptivesCombination Oral ContraceptivesCombination Oral Contraceptives

• Progestin – the dominant component– Inhibits LH surge and ovulation– Thickens cervical mucous– Many different progestins available

• Estrogen– Inhibits follicular development– Stabilizes endometrium– Almost always ethinyl estradiol but dose varies

COC Risk: EstrogenCOC Risk: Estrogen Coagulation CoagulationCOC Risk: EstrogenCOC Risk: Estrogen Coagulation CoagulationM

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•

Cardiovascular Risks of OC UseCardiovascular Risks of OC UseCardiovascular Risks of OC UseCardiovascular Risks of OC Use

• 3- to 4-fold increased risk of VTE among all OC users

ACOG Committee Opinion # 540, November 2012.

Cardiovascular Risks of OC UseCardiovascular Risks of OC UseCardiovascular Risks of OC UseCardiovascular Risks of OC Use

• Relative risk of MI or stroke : 0.9-1.7 with 20 μg estrogen pills, 1.3-2.3 with 30 μg estrogen pills*

• Increased risk of MI primarily in smokers and

those with pre-existing arterial vascular disease

• Minimal increased risk of stroke in healthy, nonsmoking OC users. Risk heightened in certain populations (classic migraines, bp).

*N Engl J Med 2012;366(24):2257-2266.

Contraindications to Contraindications to Estrogen-Containing MethodsEstrogen-Containing Methods

Contraindications to Contraindications to Estrogen-Containing MethodsEstrogen-Containing Methods

• Unexplained vaginal bleeding• Pregnancy 3 weeks postpartum• History of venous thrombotic disease• History of arterial vascular disease• Smoker > 35• Untreated hypertension• Migraines with focal neurologic signs• Personal history of breast cancer• Marked impairment of liver function

~ 2% of women

Menstrual CycleMenstrual CycleBenefitsBenefitsMenstrual CycleMenstrual CycleBenefitsBenefits

ImprovedImprovedQuality of LifeQuality of Life

•

0.70.7

0.40.4

0.70.7

0.50.5

0.60.6

Decreased Risk OfDecreased Risk Of

PMSPMS

Menstrual-Related ProblemsMenstrual-Related Problems

DysmenorrheaDysmenorrhea

IrregularityIrregularity

MenorrhagiaMenorrhagia

Iron-Deficiency AnemiaIron-Deficiency Anemia

Relative RiskRelative Risk

=

AdditionalAdditionalBenefitsBenefitsAdditionalAdditionalBenefitsBenefits

↓ ↓ MorbidityMorbidityand Mortalityand Mortality==

0.50.5

0.30.3

0.40.4

0.50.5

0.10.1

0.50.5

Decreased Risk OfDecreased Risk Of Relative RiskRelative Risk

Endometrial cancerEndometrial cancer

Ovarian cancerOvarian cancer

Functional ovarian cystsFunctional ovarian cysts

PIDPID

Ectopic pregnancyEctopic pregnancy

Benign breast diseaseBenign breast disease

Contraceptive Ring and PatchContraceptive Ring and PatchContraceptive Ring and PatchContraceptive Ring and Patch

• More convenient for many women – may increase adherence to method, i.e. efficacy

• Same hormones as oral contraceptives – Similar efficacy with perfect use– Similar side effects– SAME CONTRAINDICATIONS

Progestin-Only MethodsProgestin-Only MethodsProgestin-Only MethodsProgestin-Only Methods

Progestin-Only MethodsProgestin-Only MethodsProgestin-Only MethodsProgestin-Only Methods

• Especially useful for patients with – Contraindications to estrogen– Intolerable side effects from estrogen

• High-dose– Depo Provera

• Low-dose– Progestin-only pill, also known as “Mini-pill”– Subdermal Implant

Depo ProveraDepo Provera Depo ProveraDepo Provera

• Highly Effective

(.3 pregnancy rate)• Easy to use• Anonymous• Can use when

estrogen contraindicated

• No drug interactions

• Amenorrhea• Prolonged pituitary

suppression – Median time to pregnancy

is 9–10 months– Up to 18 months is within

normal limits

• Sexual issues• Adverse effect on lipids• ↓ Bone density

Positives Negatives

Subdermal Implant: NexplanonSubdermal Implant: Nexplanon®®

Subdermal ImplantSubdermal ImplantSubdermal ImplantSubdermal Implant

• Lasts 3 years• Most effective method• Can use when

estrogen contraindicated

• No bone density• Immediate recovery of

fertility

• Insertion and removal require minor surgical procedure

• Unpredictable bleeding pattern

• Other mild side effects

Positives Negatives

LLong-ong-AActingctingRReversibleeversibleCContraceptionontraception

LLong-ong-AActingctingRReversibleeversibleCContraceptionontraception

Subdermal ImplantIntrauterine Contraception

U.S. Pregnancies: U.S. Pregnancies: Unintended vs. Intended Unintended vs. Intended

U.S. Pregnancies: U.S. Pregnancies: Unintended vs. Intended Unintended vs. Intended

Guttmacher Institute; January 2012.Guttmacher Institute; January 2012.

Unintended

Intended

Unintended births

Elective abortions

49%

29%

20%

51%

Contraceptive Use andContraceptive Use andUnintended PregnancyUnintended PregnancyContraceptive Use andContraceptive Use andUnintended PregnancyUnintended Pregnancy

• 52% of unintended pregnancies attributable to sexually active women using no method

• 48% of unintended pregnancies — women using some form of birth control

Guttmacher Institute; January 2012.Guttmacher Institute; January 2012.

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Perfect Use Typical Use

First Year Contraceptive Failure: First Year Contraceptive Failure: Perfect Use vs Typical UsePerfect Use vs Typical Use

First Year Contraceptive Failure: First Year Contraceptive Failure: Perfect Use vs Typical UsePerfect Use vs Typical Use

Hatcher RA. Contraceptive Technology.

WHO Method ComparisonWHO Method Comparison

Intrauterine Contraception Intrauterine Contraception (IUC)(IUC)

Intrauterine Contraception Intrauterine Contraception (IUC)(IUC)

Debunking Myths Debunking Myths About Intrauterine ContraceptionAbout Intrauterine Contraception

Debunking Myths Debunking Myths About Intrauterine ContraceptionAbout Intrauterine Contraception

• IUCs are abortifacients

• IUCs cause pelvic inflammatory disease (PID)

• IUCs cause infertility

• IUCs cannot be used in nulliparous women

Copper T 380A (ParagardCopper T 380A (Paragard®®))Copper T 380A (ParagardCopper T 380A (Paragard®®))

• On US market since 1988• High efficacy

(failure rate .5-.8% per year)• Approved for 10 years use• Changes in menstrual

bleeding– Increase in flow and cramping

(Usually temporary)– Controlled by NSAIDS

Levonorgestrel IUS (MirenaLevonorgestrel IUS (Mirena®®))Levonorgestrel IUS (MirenaLevonorgestrel IUS (Mirena®®))

• High efficacy (failure rate .2% per year)

• Approved for 5 years use

• Low systemic levels of levonorgestrel

• Changes in menstrual bleeding– Irregular bleeding at first,

then decreased flow or amenorrhea (20%)

levonorgestrel20-10 g/day

Steroid Steroid reservoirreservoir32

mm

32 mm

Small Levonorgestrel IUS (SkylaSmall Levonorgestrel IUS (Skyla®®))Small Levonorgestrel IUS (SkylaSmall Levonorgestrel IUS (Skyla®®))

• High efficacy (failure rate .4%/year)

• Effective for 3 years • Smaller, thin inserter,

lower hormone dose• Approved for nullips• Changes in menstrual

bleeding– Irregular bleeding at

first, then infrequent irregular bleeding

Levonorgestrel 14-5 μg/day

Contraindications to Contraindications to Intrauterine ContraceptionIntrauterine Contraception

Contraindications to Contraindications to Intrauterine ContraceptionIntrauterine Contraception

• Acute PID• Postpartum or postabortion endometritis• Mucopurulent cervicitis• Distortion of uterine cavity• Mirena/Skyla

– History of breast cancer• Paragard

– Allergy to copper– Wilson’s Disease

Risks of Intrauterine ContraceptionRisks of Intrauterine ContraceptionRisks of Intrauterine ContraceptionRisks of Intrauterine Contraception

• Expulsion - 3.5-5%

• Perforation – 1/1,000-2,000

• Embedment

• Infection/PID

• If pregnancy occurs, rule out ectopic

– 1 of 2 with Mirena and Skyla

– 1 of 16 with Paragard

Which IUC?Which IUC?Which IUC?Which IUC?• LNG IUS

– Woman with heavy flow or cramps– Anyone who desires bleeding/amenorrhea

• Cu T 380A– Woman who prefers regular predictable cycles– Wants/Needs to avoid hormones– Prefers longer duration (10 years)

• Low-dose LNG IUS– Lighter, less painful, less frequent flow– Lower systemic hormone exposure

Role of LARC: CHOICE ProjectRole of LARC: CHOICE ProjectRole of LARC: CHOICE ProjectRole of LARC: CHOICE Project

• LNG IUS – 45%• Copper IUD - 10%• Implant – 13%• Depo Provera – 8%• OCPs – 23%

Method Chosen

Obstet Gynecol 2011;117:1105-13.

Continuation: CHOICE ProjectContinuation: CHOICE ProjectContinuation: CHOICE ProjectContinuation: CHOICE Project1 year1

• LNG IUS – 88%• Copper IUD – 85%• Implant - 83%• Depo Provera – 57%• OCPs – 55%

• LARC – 87%• Non-LARC – 57%

2 year2

• LNG IUS – 79%• Copper IUD – 77%• Implant - 68%• Depo Provera – 38%• OCPs – 43%

• LARC – 77%• Non-LARC – 41%

1. Obstet Gynecol 2011;117:1105-13. 2. Obstet Gynecol 2013;122:1083-91.

Efficacy of LARC: CHOICE ProjectEfficacy of LARC: CHOICE ProjectEfficacy of LARC: CHOICE ProjectEfficacy of LARC: CHOICE Project

• 22X more effective than pill, patch or ring (0.27 vs. 4.27 pregnancies per 100 women)

• Double this effect in teens

• Rate of teenage birth in the CHOICE cohort 6.3/1000 vs. 34.3/1000 nationally

• Rate of abortion less than half the regional and national average

1. N Engl J Med 2012;366;1998-2007. 2. Obstet Gynecol 2012;120:11291-7.

Improved Contraceptive CounselingImproved Contraceptive Counseling

Reproductive Life PlanReproductive Life Plan

Improved Contraceptive CounselingImproved Contraceptive Counseling

Reproductive Life PlanReproductive Life Plan

• Being intentional about preparing for and starting pregnancies

• Making conscious decisions about – When to have children– How many to have– Ensuring the healthiest pregnancies and families

CDC

Reproductive Life Plan =Reproductive Life Plan =True True ““Family PlanningFamily Planning”” Reproductive Life Plan =Reproductive Life Plan =True True ““Family PlanningFamily Planning””

• Encouraging clients to think about contraception – In terms of

• Planning for when they do want children• Protecting themselves until that time

– Not just for this year or this relationship

Reproductive Life PlanReproductive Life PlanReproductive Life PlanReproductive Life Plan

• Clinicians help clients make a Reproductive Life Plan by asking:– Do you hope to have children? More children?– How many?– When?

Every woman, every year

Reproductive Life PlanReproductive Life PlanReproductive Life PlanReproductive Life Plan

• Avoiding unintended pregnancy– More effective use of contraception– First-line option for many

LARC: Long Acting Reversible Contraception

– Fertility-preserving behavior

• Planning for desired pregnancies

– Preconception care

Case #1Case #1Case #1Case #1

• A 16-year-old, newly sexually active, presents to the clinic for her first appointment, requesting contraception.

• Do you plan to have children? Yes

• How many? Two or three

• When? Not until I finish high school and college

QuestionsQuestionsQuestionsQuestions

• What contraceptives will you suggest for this patient?

• What contraindications do you have to rule out?

• What additional guidance will you give her?

Case #2Case #2Case #2Case #2

• A 22-year old g2p2, 6 weeks postpartum, breastfeeding, presents for routine follow up.

• Do you plan to have more children? Yes

• How Many? Probaby one more

• When? In a year or two

QuestionsQuestionsQuestionsQuestions

• What is the Healthy People 2020 goal for optimal spacing of pregnancies?

• What contraceptives will you suggest for this patient?

• How will the fact that she’s breastfeeding affect her choices?

Case #3Case #3Case #3Case #3

• 35-year-old married g1p0ab1 presents for annual exam, OCP renewal. Had an abortion this year due to hectic schedule, forgot some pills.

• Do you plan to have children? I think so.

• How many? When? I’m not sure.

QuestionsQuestionsQuestionsQuestions

• What contraceptives will you suggest for this patient?

• What contraindications do you have to rule out?

• What additional guidance will you give her?

Case #4Case #4Case #4Case #4

• A 45-year-old divorced g3p3 presents for evaluation of heavy menstrual periods.

• Do you plan to have any more children? NO!

• Are you currently in a heterosexual relationship? Yes

QuestionsQuestionsQuestionsQuestions

• Is this patient likely still fertile?

• What contraceptives will you suggest for her?

• What contraindications do you have to rule out?

• What additional guidance will you give this patient?

Goals and RecommendationsGoals and RecommendationsGoals and RecommendationsGoals and Recommendations

• The U.S. Department of Health and Human Services Healthy People 2020: “reduce unintended pregnancy to 44% of all pregnancies in the United States”

• The Institute of Medicine: “All pregnancies should be intended—that is, they should be consciously and clearly desired at the time of conception.”