Contraception Update. Pregnancies in the U.S. 52 % Intended 25 % Unintended Used Contraception 23 %...

44
Contraception Update

Transcript of Contraception Update. Pregnancies in the U.S. 52 % Intended 25 % Unintended Used Contraception 23 %...

Contraception

Update

Pregnancies in the U.S.

52 % Intended

25 % Unintended

Used Contraception

23 % Unintended

No Contraception

Unintended Pregnancy A Major Public Health Issue

The 2002 National Survey of Family Growth reported that

50% of U.S. women experience at least one unintended pregnancy

The vast majority of women reported using some form of birth control

2002 National Survey of Family Growth

Abortion Rates diverge

In the 70’s, abortion rates of wealthy and poor groups of women were about the same

By 2000, poor women’s abortion rate doubled that of wealthy women

Ethnic/racial differences in rates diminish when income level is controlled

Economic disparities in abortion rate parallel the widening gap between rich and poor in access to basic health care

Mandy

17 y/o girl with normal sports physical 4 years ago

LMP 3 weeks ago Here today for pregnancy test She had unprotected sex 4 days ago. Her urine pregnancy test is negative.

Emergency Contraception:Levonorgestrel (Plan B)

Sig: 2 tabs at once, up to 5 days after unprotected sex

Emergency Contraception (EC)WILL NOT DISRUPT AN IMPLANTED PREGNANCY

Inhibits ovulation

Traps sperm in thickened cervical mucus

Inhibits tubal transport of egg or sperm

Prevents implantation

May interfere with fertilization, early cell division, or transport of embryo

Emergency Contraception (EC)

EC use doubles when provided in advance1

Easy access to EC does not lead to decreased use of usual contraceptive method2

Easy access does not increase STIs or unprotected intercourse2

Direct Pharmacy Access in following states: Washington, Maine, California, Alaska, New Mexico &

Hawaii

1.Bissel et al Soc Sci Med.2003;57:2367-2378 2 Raine et al JAMA.2005;293:54-62

EC treatmentsimplified (progestin only)

OLD : 2 doses of 1 Plan B pill First dose within 72 hours after intercourse Second dose 12 hours later

NEW : 1 dose of 2 Plan B pills As soon as possible – but up to 120 hours

after intercourse

“Quick Start” 1

As many as 25% of women do not start prescribed OCPs with Sunday or 1st day start

“Quick Start”1 – first pill on day of visit at any time of the month. Confirm HCG neg. If she needs EC, start contraception w/in 24 hrs of EC. More women using pill in 3rd cycle No increased spotting or bleeding2

1. Westhoff et al Contraception 2002 2. Westhoff et al Fertil Steril 2003

Mandy, later

Mandy gets a 4-month supply of birth control pills.

She calls 4 months later requesting a 1-year renewal prescription.

She has never had a Pap smear.

FDA Advisory Committee Recommendation.FDA Advisory Committee Recommendation.

FDA Advisory Committee’s Recommendation on Delay of Pelvic Exam

“Physical examination may be deferred until after initiation of

oral contraceptives if requested by the

woman and judged appropriate by the

clinician.”

www.contraceptiononline.org

Does a woman need a pap before getting OCPs?

Why tie PAP to birth control? Would you ask a man to have a prostate exam before giving him condoms?

What is Required Before Prescribing Hormonal Methods? Medical History: Required

BP: Helpful

Breast exam, Pelvic exam, Pap, Hemoglobin, other lab tests, STI testing:

NOT REQUIRED!

Stewart F, et al. JAMA. 2001;285:2232-2239

Morgan

24 y/o G0P0 Does not like hormones, cause nausea Does not like condoms either 246 lbs, normal BP, LMP 2 wks ago Normal Pap/STI tests 1 year ago Needs birth control before next week’s

anniversary celebration

Intrauterine Devices 2 options today: Copper T 380A (ParaGard) and

Levonorgestrel releasing system (Mirena)

United States has lagged behind other countries in adopting the IUD: in 2002, only 2 percent of contraceptive users in the United States chose IUDs. By comparison, IUDs were used by over 50 percent of contracepting women in parts of Asia and 6 to 27 percent of female contraceptive users in Europe

New interest and surge of use in US

1.Hubacher Contraception 2004;69:437-446

IUD Myths IUDs DO NOT cause Abortion:

IUDs thicken cervical mucus, suppress endometrium; progestin IUD has some anovulatory effect

IUDs DO NOT increase risk of PID: IUD itself carries no risk of infection. Transient risk w/ insertion .1

Progestin IUD: may protect against PID, 5-year PID associated removal risk 0.8. 2

IUDs DO NOT increase risk of ectopic pregnancy In fact IUDs: DO NOT cause pelvic infection DO NOT decrease the chance of future pregnancies CAN be used for women who have not been pregnant

1. Grimes 2.Andersson Contraception 1994;49:56-72

More IUD Myths

May insert at any point in the menstrual cycle

Okay to use in nulliparous women

No need for prophylactic antibiotics

OK to do STI testing at time of insertion (& treat infections w/ IUD in place)

FDA Changes

The copper IUC revised its package label (September 2005) to remove the prior section on "recommended patient profile" that included multiparity, mutually monogamous relationship and history of PID.

Leslie

34 y/o G3P1 Having an abortion today in your office Used condoms in the past Which contraceptive methods can she start

today?

Post-abortion birth control optionsWHO guidelines suggest the following methods

without restriction after an early abortion: estrogen/progestin pills, patch, ring; progestin-only injection, implants; IUDs

That is, anything goes!

IUD issues post-abortion

Expulsion rate only slightly increased for IUDs inserted right after early aspiration abortion1

No increased risk of infection

1. Grimes et al, Cochrane Review 2004 2. Weibe, Communication 4/05

Estrogen/progestin vaginal ring Low estrogen dose: 15 mcg

2 inch flexible soft ring

No wrong placement

May remove up to 3 hours

Most don’t notice during sex

Dieben, Ob Gyn, 2002

Vaginal Ring Expulsion Vaginal Ring Expulsion Spontaneous expulsion infrequent- 2.6%

Occurred only once in almost all cases

If expelled or removed, wash with warm water and reinsert within 3 hours

Monthly: Contraceptive Vaginal Ring

Very effective! Failure rate 1.2% May suppress ovulation to 35 d

Ortho Evra Patch

Daily release: 20 µg ethinyl estradiol Contraceptive Patch

ORTHO EVRA ™

150 µg norelgestromin (NGMN) *

* the active metabolite of norgestimate

1 patch each week Regimen:

3 weeks of use / 1 patch-free week 4.5 cm x 4.5 cm square

Implanon

Implanon subdermal implant approved by FDA 7/06. Clinicians train 3 hours before obtain.

One rod 4cm by 0.2 cm inserted into the armLasts 3 years; irregular unpredict bleedingProgesterone only, etonogestrel 68 mgPrimary mechanism of action is suppression of

ovulation, changes cervical mucousRapidly reversible, no bone mineral density

changes

Wanda

24 yo G3P2Tab1

Currently using OCP, but admits to frequently forgetting to take pill

Wants to try the patch because her friends like it

Adherence with OCPs:What Women Say

0

10

20

30

40

50

60

70

80

90

15-19 20-24 25-29 30-44Age

Per

cen

tage

100% Compliance

Missed 1 Pill

Missed >2 Pills

NFSG Survey, 1997NFSG Survey, 1997

Adherence with OCPs:What Women Do!

Potter L et al, Fam Plann Perspect. 1996.

Perc

en

t of

Wom

en

(%

)

Active Pills Missed

Initiation of All Hormonal Methods Initiation of All Hormonal Methods

If starting after the 5th day of menses, use back-up method for 7 days

If switching from OCP, start any time in cycle: NO NEED TO COMPLETE PILL PACK

If switching from depot progestin, start on or prior to next injection date (2 week window)

If switching from IUD between menses, start one week prior to removal

Blanca

Blanca is a 43yo G6P4 Tab2 heavy painful menses anemia fibroid on pelvic ultrasound

Progestin IUD’s Medical Advantages:

Cramps & menorrhagia improve 90% decrease in overall blood loss Decreases number of hysterectomies & other

invasive treatments for DUB, fibroids 1

DECREASES risk for ectopic pregnancy Protect against endometrial CA

1. Hurskainen et al Lancet.2001

Progestin IUD - Mirena FDA Approved 12/ 2000 Used in Europe >10 years Very low systemic levels

levonorgestrel FDA approved for 5 yrs of use, Lowest 5-yr costs of all

contraceptive methods 2 Highest continuation rates-

81-93% at 1 yr (CuT 78%, CHC 68%)

1. Sivin Contraception 1991 2. Chiou et al Contraception.2003;68(1):3-10

Progestin IUD - Side Effects

Spotting and bleeding: Increased in 1st 3 months Amenorrhea: 20% of users by 1 yr, 60% by 5

yrs Expulsion: 2-12% in 1st year. Perforation: <.01% @ time of insertion Headaches, acne, mastalgia: < 3% in 1st months

Managing Contraception and Hatcher et al Contraceptive Technology 2004

Lifetime Number of Menstrual Cycles

Adapted from Coutinho EM. Is Menstruation Obsolete? 1999.

Number of

Cycles

500

50

100

150

200

250

300

350

400

450

Prehistoric

160

Colonial America

450

Modern

500

OCP’s 21 day on/ 7 day off cycle chosen to: Mimic physiologic menstrual cycle Reassurance that not pregnant

No clinical trial shows that monthly menses is healthier, safer, or easier to tolerate

Convenience May improve:

endometriosis, anemia, dysmenorrhea, metorrhagia, PMS, menstrual migraines

Extended Cycle Regimens- Why?Fewer menses per year

May increase efficacy and adherence Symptoms associated w/ OCP worse

during withdrawal bleed1

Brief manipulation of a cycle

12 month Perfect vs. Typical Failure & Continuation Rates

Extended Cycle Regimens

1. Sulak et al Obstet Gynecol. 2000;95:261-266

Continuous use 3 months, then a week off Seasonale ™ - FDA- approved 12 weeks on, 1

week off . Lybrel continuous use. Shortened pill-free interval

Well-tolerated, small amount of breakthrough bleeding

Established BC Methods

Barrier methods Lactation Progesterone only pills DMPA injections Vasectomy Tubal Obstruction or Ligation postpartum, coag, rings, clips

Essure: Hysteroscopic Tubal Sterilization

Meds like for AB covered for health plan Requires hysteroscopy

at 3 months

Resources Hatcher et al, Contraceptive Technology Managing Contraception – book online @ (www.managingcontraception.org) Medical Eligibility Criteria for Contraceptive Use 2004

by WHO (www.who.int/reproductive-health) Association of Reproductive Health Professionals

(ARHP) (www.arhp.org) Alan Guttmacher Institute (www.agi-usa.org) www. contraceptiononline.org www.plannedparenthood.org www.Not-2-Late.com