applying your knowledge of contraception in the clinical setting jan shepherd, md, facog florida...
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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
ean
Val
ue
•
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.
05
1015202530
Impl
ants
Vas
ecto
my
DM
PA
Cop
per I
UD
Pro
gest
in
IUD Tu
bal L
igat
ion
OC
sC
ondo
mD
iaph
ragm
With
draw
alS
perm
icid
es
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.”