Contraception Update. Pregnancies in the U.S. 52 % Intended 25 % Unintended Used Contraception 23 %...
-
Upload
beryl-allison -
Category
Documents
-
view
225 -
download
2
Transcript of Contraception Update. Pregnancies in the U.S. 52 % Intended 25 % Unintended Used Contraception 23 %...
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
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 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
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