Contraception Update

Dr Tracey Dibble Associate Specialist at Sheffield Contraception & Sexual Health

ServiceMarch 2012

Sponsored by HRA Pharma

“Family planning could provide more benefits to more people at less cost than any other single technology now available to the

human race” James Grant, Unicef Annual Report 1992

Aims

• UK Picture• Human Fertility• History Lesson• Current UK Use • Contraceptive Methods

– LARC – User Dependent– EC

• New Developments

Why is this important in the UK?

• High teenage pregnancy rates in Sheffield & UK (compared to Europe)

• Increasing abortion rate• Increasing repeat abortions

Teenage Pregnancy

2010 Figures • E & W rate is 35.5 / 1000• Lowest since 1969• ↓ 9.5% since 2009• Sheffield rate is 41.4 /1000

Teenage Pregnancy Rates 1998 - 2010

Abortion 2010 Figures

E & W• Total numbers 189,574 (↑0.3%

2009)• Rate 17.5 / 1000 women • Rate 16.5 / 1000 under 18sSheffield• Total numbers 1683• Rate 13.2 / 1000 all women• Rate 18 / 1000 under 18s

How fertile are human beings ?

• No breeding season• For women maximum desire corresponds

to most fertile phase • 350 million sperm / ejaculate• Sperm survive average 3-4 days (“super

sperm” 6-7 days)• Ovum needs to be fertilised within 12hrs • Most fertile days are 2-3 days prior to

ovulation

The menstrual cycle

Brief History Lesson

Development of Condoms• 1000BC - Egyptians used linen sheath

condoms for prevention of infection• 1500s - linen sheaths used in European

Syphilis epidemic – usefulness against pregnancy also discovered

• 1700s – animal intestine condoms available but expensive

• 1880’s – vulcanisation of rubber & mass production of rubber condoms, Goodyear & Hancock

Decline of Birth Rate in Victorian England – McLaren 1978

Years Children per marriage

1860’s 6.16

1870’s 5.8

1880’s 5.3

1890’s 4.13

1915 2.43

Consequence of birth control?-McLaren 1978

Year of birth Estimated proportion of women who control or attempt to control their

fertility

1831-1845 19.5%

1861-1870 42.7%

1902-1906 72%

What methods were available?

• Coitus interruptus “until at least WWII the most popular form of contraception in England”-McLaren 1978

• Temporary abstinence• Condoms• Abortion – although illegal it was common

Development of the pill

• Early 20th Century Feminists & Birth Control movement – Stopes, Sanger & McCormick

• Mexico 1950s – Marker & Djerassi

• 1960 1st pill marketed

Contraception in UK 2008/09, ONS

Method 1997/8 2008/09Pill 26% 25%

Sterilisation 21% 17%Condom 21% 25%IUD/IUS 4% 6% + 2%

Withdrawal 4% 4%Depo / Implanon 2% 3% +1%

Other method 2% 5%

Pregnant 4% 4%No relationship 14% 13%

LARC Methods From NHS Community Contraception Clinics

Characteristics of a good contraceptive

• Effective• Forgettable• Convenient• Reversible• Safe • Cheap • Few side effects

Source: CCP and WHO, 2007.

Oral contraceptives

Percentage of women pregnant in first year of use

Rate during typical use

Rate during perfect use

Female condom

Female sterilization

Implants

DMPA

Spermicides

Diaphragm w/spermicides

Male condom

IUD (TCu-380A)

0 10 15 20 255 30

Effectiveness

Cost Contraceptive Cost / year

Nuvaring £108

Evra patches £65.04

Yasmin £58.80

Cerazette £35.40

Implanon £27

Marvelon £20.10

Depo Provera £18.03

Mirena £16.63

Microgynon £11.96

Noriday £8.40

T Safe Cu 380 £1.00

Forgettable !

User Dependent Methods

• Condoms• Pills • Unfortunately are

very forgettable!! • Success depends

upon excellent compliance

Forgettable

User Independent Methods

• LARC methods • Sterilisation• Cannot be

forgotten therefore woman can relax - she is not going to get pregnant

Consequences of forgetting

Audit of contraception use in 200 vulnerable women at Sheffield TOP clinic, 2008

Contraception being used before pregnancy

• None 39%• Condoms 35%• Pill methods 27%• No LARC failures

What is LARC?• Long Acting Reversible

Contraceptives are methods of contraception which are administered less than once / month

Depo Provera

Pros• Effective• High dose progestogen

im injection• Inhibits ovulation• Every 12 weeks • Doesn’t interfere with sex• More under patient

control• Often causes

amenorrhoea

Depo Provera

Cons• Can be forgotten• Osteopenia / osteoporosis• Irregular / heavy bleeding• Weight gain• Low mood• Delay in fertility return –

average 1yr

Nexplanon

• Replaced Implanon in Oct 2010• Small rod in upper arm - inhibits ovulation

Pros• Very effective (0 – 0.07% ) • Lasts 3 yrs • Forgettable• Doesn’t interfere with sex• Very safe • Cost effective

NexplanonCons• Needs to be fitted &

removed by Dr or nurse• Some people don’t like

idea of foreign body in arm

• Irregular or heavy bleeding

• Amenorrhoea• Weight gain??

IUDs

Pros• Effective• Forgettable• Doesn’t interfere

with sex• Long lasting up to

10yrs• Good safety

record• No hormones

IUDs

Cons• Needs fitting /

removal by Dr or nurse

• Some patients do not like idea of IUD inside them

• Heavy bleeding • Risk of perforation/

expulsion/ infection• Not always tolerated

esp by nullips

Mirena IUS

Pros• Very effective• Forgettable• Doesn’t interfere

with sex• Long lasting –5yrs• Treatment of

menorrhagia• Used as part of

HRT

Mirena IUSCons• Needs fitting /

removal by Dr or nurse

• Some patients do not like idea of IUD inside them

• Irregular bleeding / spotting

• Risk of perforation/expulsion/ infection

• Not always tolerated esp by nullips

Sterilisation

Female Sterilisation• Irreversible • Under GA• Filshie Clips on

Fallopian tubes • Failure rate 1 in

200• Immediately

effective

Vasectomy• Irreversible• Under LA• Dissect Vas

deferens & remove a small piece

• Failure rate 1 in 2000

• Not immediately effective

User Dependent Methods

• Oral Contraceptives– COC– POP & Cerazette

• Barrier Methods– Condoms– Diaphragms

• Natural Family Planning

Combined Oral Contraceptive Pill

• Combines Oestrogen

& Progestogen • Very effective 0.2 – 3%• Good menstrual cycle

control • Not related to sexual

intercourse • Helps heavy / painful

periods

COC

Cons• Complicated pill rules • Difficult to remember • Minor side effects – nausea, breast

tenderness• Increased venous thrombosis, heart

disease, stroke but only if have pre-existing risk factors (e.g. obesity , smoking)

• Small increased risk of breast cancer

How safe is the pill?

Comparative Risks /100,000 women (Yr 2000)• Taking pill = 1 death• Home accidents = 3 deaths• Having a baby, UK = 6 deaths• Road accidents = 8 deaths• Smoking at age 35yr = 167 deaths, next yr• Having a baby, Rural Africa = 600-1000 deaths

Evra

• COC in patch form • Efficacy 0.99-1.24% failure rate• 20 cm patch • 4.6% patch detachment• Worn for 3 weeks with 1 week break • Each patch lasts 7 days • If forget to change patch - ok up to 2 days

late• Expensive £7.74 / month ( Compared to

COC £0.50 / month

Progestogen Only Pill

Pros• Very safe • Less effective (0.3 – 4%)• Relies on thickening cervical mucus • Inhibits ovulation in some women • OK if oestrogen is contraindicated • OK if breastfeeding

POP

Cons• Difficult to remember• Only 3 hour window• Higher failure rate • Poor cycle control – irregular bleeding

Cerazette

• New POP• Higher dose • Inhibits ovulation in 97% of cycles • Still very safe • More effective (0.7 – 1.1%)• 12hr window• Poor cycle control for some women –

irregular bleeding

Condoms

• Still best protection against STIs • Good for additional protection alongside

another contraceptive • User failure rates are high • Non latex versions available

Diaphragms

• Not very effective • Perfect Use 6%• Typical Use 16%• Useful to space children• Use in 40s • Irritation from spermicide

Emergency Contraception

Copper IUD • Most effective• Can be fitted up to 5 days after sex

Levonelle • High dose progestogen• Can be used up to 3 days after sex• Available OTC• Delays ovulation • Safe

ellaOne

• Licensed in Autumn 2009 • Progestogen blocker• Inhibits ovulation• More effective than Levonelle• Works up to 5 days after sex• Must not be used more than once in cycle

or if any earlier risk of pregnancy • May effect ongoing contraception • Expensive £ 16.95

New Developments

New Methods• Nuvaring• Qlaira

New Ways of Using Old Methods• Tricycling COC & reducing PFI

Nuvaring• Vaginal ring containing

hormones • Wear for 3 weeks, 1 week

off – withdrawal bleed• Stops ovulation• <1% failure rate • Well tolerated• Can be worn during sex• Periods lighter, regular,

shorter• Expensive

Tailored Pill Regimes

• Pill Free Interval is cause of high failure rate of COC

• Now out dated• Who needs a period?

Options

1. Reduce PFI to 4 days

2. Reduce frequency of PFI – only every 3 months