helping make a contraceptive choice - health sciences...
TRANSCRIPT
Birth Control Options - Helping patients
make an informed choice Herbert L. Muncie, Jr. M.D.
Professor of Family Medicine
LSU School of Medicine – New Orleans
Ms. J
• 17 year old woman comes in to discuss
contraception
– Senior in HS; plans to attend State
University in the fall
– Physical exam normal; BP 110/64; BMI –
20.6 kg/m2
– LMP 2 weeks ago; non-smoker; no
headaches
– Currently using condoms regularly
Decision to delay pregnancy
• A woman’s decision to delay pregnancy
or prevent an unintended pregnancy is
very personal – the decision:
– Is influenced by her social norms &
cultural environment
– Her economic situation
– Her long-term goals
– Her personal uniqueness
Health Care Provider’s Role
• The health care provider’s role in the
woman’s decision process is to:
– Be knowledgeable about all options
– Provide unbiased nonjudgmental
information
– Listen to the woman’s concerns &
questions
– Give the best advice for that unique
patient
Contraceptive Success
• A woman’s ability to delay pregnancy &
prevent an unintended pregnancy
involves four components:
– Choosing and acquiring a contraceptive
method
– Accurately using the method
– Consistently using the method
– Switching methods correctly
Ms. J’s Birth Control Options
• Abstinence
• Condom
• Diaphragm/cervical
cap
• Natural family
planning
• Oral contraceptive
• Contraceptive Patch
• Hormonal vaginal
ring
• Injection q 3 months
• IUD
• Contraceptive rod
Abstinence
• Abstinence
– Delaying the onset of sexual activity until
older
– Safest way to avoid pregnancy and STD
– No randomized trials have shown efficacy
of physician counseling delaying onset
• Cultural norm establishes the prevalence of
delaying onset of sexual activity
– Still reasonable to discuss option to reduce
risk of undue peer pressure
Condoms
• Condoms
– Only method proven effective
for prevention of STDs
– Combine with more effective
method with new sexual partner
– Use may increase if discussed
as additional protection from
pregnancy (not prevent STD)
– Must be used at time of sexual
activity
Diaphragm & cervical cap
• Diaphragm & cervical cap
– Combined with contraceptive gel
– Can be put in several hours before
intercourse
– Must be left in 8 hours after intercourse
– Increased risk of UTIs (diaphragm)
Natural Family Planning
• Natural family planning
– No medication side effects
– Efficacy highly dependent on compliance
Ms. J’s Birth Control Options
• Abstinence
• Condom
• Diaphragm/cervical
cap
• Natural family
planning
• Oral contraceptives
• Contraceptive Patch
• Hormonal vaginal
ring
• Injection q 3 months
• IUD
• Contraceptive rod
What about an cOCP for Ms. J?
• Would a combination oral contraceptive
pill (cOCP) be appropriate for Ms. J?
– Does Ms. J have any contraindications to
using a cOCP?
cOCP Contraindications
• Smoking and ≥ age 35
• Uncontrolled hypertension
– Only clinical exam needed before starting
OCP is BP measurement (no pelvic exam)
– If >160/>100 do not use them
– If 140-159/90-99 or controlled “generally”
should not use them
• Migraine with aura (classic migraine)
cOCP Contraindications
• History of DVT, PE or arterial clotting
• A positive family history (FH) of clotting or
thrombotic events (relative contraindication)
–A positive FH is:
• If one parent or sibling ever had VTE < age 50 or
• If 2 relatives (either parents or siblings) had VTE at
any age
• Undiagnosed genital bleeding
cOCP Contraindications?
• Pregnancy – not harmful, just too late
• Sickle cell (SS) or sickle C (SC) disease
not absolutely contraindicated
– DMPA may be preferable for SS disease
– Associated with reduced risk of crisis
Which combination pill is best?
• cOCPs are a combination of an
estrogen & a progesterone -
– Primarily 3 estrogens & 9 progestins in
varying amounts & various combinations
Estrogen Dosages
• Ethinyl etradiol (EE) is most common estrogen used
• EE dosage is always ≤ 50 mcg – Most commonly prescribed pills have 30 - 35
mcg
– 20 mcg pill in randomized trial had reduced breast tenderness and bloating
– However, 20 mcg pills had a higher failure rate with missed pills
– 10 mcg pill approved (Lo-Loestrin®)
cOCP - Progesterones
Progesterone Class Family Examples
• Ethynodiol diacetate
• Norethindrone
• Norethindrone
acetate
1st
Generation
Estrane
(short
½ life)
Demulen® 1/35 Norinyl® 1/35,
Loestrin®
• Levonorgestrel (LNg)
• Norgestrel
2nd
Generation
Gonane
(longer
½ life)
Alesse®, Lybrel®,
Seasonale®,
Ovral®, Lo-Ovral®
• Desogestrel
• Norgestimate
• Dienogest
3rd
Generation
Gonane Desogen®, Mircette®,
Ortho Tri-Cyclen®
Natazia
Choosing the cOCP
• No pill has clinically significant advantage
– Low EE dosage may have fewer side effects
but may have higher failure rate
– Choice of estrogen or progesterone not critical
• Generally choose low to moderate dose
estrogen with 2nd generation progestin
– Then change pill if not tolerated
Benefits that could influence
choosing a cOCP
• Decreased dysmenorrhea
• Reduced menstrual flow
• Reduced risk of anemia
• Improves acne
• Eliminate mittelschmerz
• Decreased risk of
ectopic pregnancy
• Decreased risk of PID
• Decreased sxs of PMS
• Improvement in
endometriosis
• Suppression of ovarian
& breast cyst formation
cOCP – Cancer Benefit
• Endometrial cancer risk reduced
– 50% reduction if used in prior 12 months
– Maximum protection if use continues for
3 years
– Protection lasts for 15 + years
– High or low dose pills provide protection
cOCP – Cancer Benefit
• Ovarian cancer risk reduced
– 40% reduction in risk over nonusers
• High dose or low dose pills - same benefit
– Begins after 3-6 months of use
• 80% reduction after 10 years of use
– Reduced risk with family history ovarian
CA & 4-8 yrs. use
cOCP Risks
• What would be Ms. J’s risks in using a
cOCP?
cOCP & VTE Risk
• VTE Risk
– 3-6 fold increased risk VTE, highest first
6-12 months of use (SOR B)
– Older women have greater risk
• > age 39 - 100/100,000 women/year
• Adolescents - 25/100,000 women/year
• Pregnancy - 200/100,000 women/year
– Obesity doubles the risk
– Risk decreases with longer duration of use
VTE Risk & dropirenone/desogestrel
• Increased VTE Risk
– For same estrogen dose – drospirenone
(Yasmin®,Yaz®) & desogestrel (Desogen®, Mircette®)
have significantly higher VTE risk
• Absolute risk is low
• No study has found a reduced risk
• However, for women on these progestins would
need to change 10,000 to prevent 1 VTE
cOCP & Cardiovascular Risk
• Increased MI risk in smokers > age 35
– No increased MI risk with low dose pill for
non-smoking women, without hypertension
or migraine with aura at any age
• Increased risk of ischemic stroke
– 2-6 fold increase of ischemic stroke with
history of migraine with aura
• No increased vascular risk with progestin
only contraception
Cervical Cancer Risk
• Risks (SOR B)
– Increase in cervical cancer after 8 or more
years of use after adjusting for HPV infection
– Risk of CIN 2 or 3 with oncogenic HPV
• Decreased with depot-medroxyprogesterone (DMPA
- Depo-Provera®)
• No increase with cOCPs
cOCP & SLE
• cOCP use associated with increased risk
of developing systemic lupus
erythematosus (SLE)
– Especially if recently started
– However, very low absolute risk
• However, in women with previously
diagnosed SLE which is stable
– Starting a cOCP did not increase the risk of
flares
Not cOCP Risks
– No increased risk of weight gain (SOR A)
• Weight gain does occur with DMPA –
average of 5.1 kg
– No increased risk breast cancer (SOR B)
– No increased risk of death later in life
• In fact a net benefit was found
Frequency of menstruation?
• Before prescribing a cOCP ask how often
a woman wants to menstruate?
– Monthly? (every 4 weeks)
– Bimonthly? (Bicycling) (every 2 months)
– Quarterly? (Tricycling) (Every 91 days)
– Never?
Menstruate monthly or bimonthly
• Monthly (every 4 weeks)
–Use standard 28 pill cOCP
• Bimonthly (bicycling)
– Use 2 standard 28 pill cOCPs but skip the
placebo pills with the 1st pack
Menstruate Quarterly (Tricycling)
• Seasonale®
– 84 active pills [LNg (0.15 mg) & EE (30 mcg)] 7
placebo
– Increased risk of unsuspected bleeding first 6 months
of use
• Quartette® – increasing dosages of EE [LNg dosage
uniform (0.15 mg/day)]
– 42 days with 20 mcg EE
– 21 days with 30 mcg EE
– 21 days with 35 mcg EE
Menstruate never
• Lybrel® approved for continuous use
– 365 days active pills
– EE 20 mcg & levonorgestrel 0.09 mg every
day
cOCP - Other Formulations
OCP Active Placebo EE
Standard 21 7 0
Mircette® 21 2 5
Seasonique® 84 0 7
Lo-Seasonique® (20 mcg EE) 84 0 7
Loestrin® 24 Fe 24 4 0
Yaz® (20 mcg EE) 24 4 0
Femcon® Fe (chewable pill) 21 7 0
Natazia® 26 2 0
Beyaz ® (Yaz with folate); Safyral® (Yasmin
with folate)
24 4 0
What is the best way to
initiate a cOCP?
Starting cOCP – Sunday Start
“Sunday start” – take the 1st pill of the 1st
pack the 1st Sunday after onset of next
menses
– Reduces menses on weekend
– If start > 5 days from onset of menses
either abstain or use additional
contraception 1st 7 days of pills
Starting cOCP – 1st day Start
“First-day start” - take the 1st pill of the 1st
pack the 1st day of next menses
– Easier for patients to remember & to
explain to patient
– As long as start < 5 days from onset of
menses no additional contraceptive
needed
– Less breakthrough bleeding
Starting cOCP – Visit day start
“Visit day start” - take the 1st pill of the
1st pack the day of the visit
– “Quick start” - watch patient take 1st pill
• Negative pregnancy test & no intercourse prior
2 weeks, no immediate follow-up
• If intercourse within prior 2 weeks, repeat
pregnancy test in 2 weeks
• Additional contraception the first 7 days
Quick-Start Benefit
• Main benefit is reduced time explaining how to
start pills
– No evidence reduced risk of pregnancy or
discontinuation rates for OCPs
– Fewer women on quick-start Depo-Provera became
pregnant than women who started another method
• Other than the IUD, can start any contraceptive
immediately without UPT
– Can do UPT 2 – 4 weeks later if concerned about
pregnancy
Writing the OCP Prescription
• Ordering 13 packs at the
visit lead to better
continuation rates &
decreased cost
– Also were more likely to have
PAP & chlamydia screening
• Had fewer pregnancies
RX
Dr. Fleur de Lis
New Orleans, LA
Ms. R
Sig: 13 OCP Packs
Refill: x 0
Another OCP Prescription Option?
• Giving 7 packs lead to a
greater continuation rate
compared to giving 3
packs
• Women who received a
prescription were not more
likely to continue
compared to having the
packs in hand
RX
Dr. Fleur de Lis New Orleans, LA Ms. R
Giving 7 packs of pills at time of visit (not an Rx)
Missed Pills
Some women are excellent at taking the
pill consistently & some are not
No demographic characteristic can identify
which patient will remember consistently
Compliance was not enhanced with group
motivation, structured, peer or
multicomponent counseling or intensive
reminders
How many pills are missed?
Using electronic monitoring an average of
2.6 pills were missed each cycle.
However, in a text-messaging trial, the
average number of missed pills was
4.9 per cycle
No pregnancies occurred with this level of
non-compliance
Missed pill instructions
• First ask which pill was missed:
– If placebo pill just skip it
• If active pill and < 24 hrs late
– Take immediately
• If active pill and ≥ 24 but < 48 hrs late
– Take missed pill immediately & other pill at
usual time (may mean both at same time)
– Additional contraception not required
> 2 Missed pills
• If > 2 consecutive active pills missed
– Take most recent missed pill immediately (discard other missed pills)
– Take remaining pills at usual time (may mean two pills on the same day)
• If missed pills were in the last week of hormones (day 15 – 21), omit placebos and start new pack instead of placebos
– Use additional contraceptive method for 7 days
> 2 Missed pills (Cont.)
• If > 2 consecutive active pills missed
– Should consider emergency contraception if unprotected intercourse in previous 5 days or if missed pills during the 1st week
• May be considered at other times
– Discuss alternative contraceptive options that do not require daily compliance
Most Dangerous pill to miss?
• Most dangerous pill to miss
is the 1st pill of the new pack
– Pill free > 7 days increases
risk ovulation
• If miss 1st pill use additional
form of contraception until taken
7 consecutive active pills
• Stress compliance with starting
each new pack
Special Populations & cOCP
Postpartum
Breastfeeding
Seizure disorder on medication
Migraine headaches
Antibiotic concomitant use
Obesity
Postpartum
• ACOG guideline
– No cOCP < 21 days postpartum
(high risk of VTE)
– If not breastfeeding may start after 21 days if
no increased VTE risk (e.g. C-section)
– If C-section must wait 42 days (6 weeks) to
start cOCP
• For delivery of < 20 weeks gestation -
can begin cOCP immediately
Breastfeeding
• Progestin only pills are often recommended for women breastfeeding because:
– No effect on quality or quantity of breast milk
• They work by thickening cervical mucous & preventing sperm ascending through os
– However, erratic ovulation suppression
• Irregular bleeding common
Progestin only pills
• Daily compliance crucial
– Must take same time every day (> 3 hr difference can allow ovulation)
– If >3 hr delay occurs take pill immediately & use additional contraception until taken at correct time for 2 consecutive days
– Consider EC if unprotected intercourse
• Not contraindicated in smokers > age 35
• No increased risk of VTE
cOCP & Breast feeding
• Can start cOCP > 4 weeks post-partum
(PP) if lactation is well established &
other forms of contraception are not
acceptable
• If exclusively breastfeeding (> 85% of
feeds) no medical contraception needed*
*MMWR June 21, 2013
Seizure Disorder on Medication
• Some anticonvulsants reduce efficacy cOCP by increasing metabolism of EE & progesterone – Avoid cOCP with phenytoin, carbamazepine,
barbiturate, primidone, topiramate, oxcarbazepine
– Mirena®, Skyla® & Depo-Provera® not effected by these medications
– If cOCP is used with these medications, WHO advises either 50 µg EE pill or continuous cOCP
• These anticonvulsants do not effect cOCPs – – Gabapentin (Neurontin®), lamotrigine (Lamictal®),
levetiracetam (Keppra®), tiagabine (Gabitril®)
– However, cOCPs may lower lamotrigine levels
Migraine Headaches & cOCPs
• For migraine without aura cOCPs:
– May increase or decrease headaches
• Can give trial of cOCP and see what happens
– If HAs persist with normal BP & no deficit
• Lower dosage of estrogen, progestin or both (no
studies reported) SOR - C
– If HAs persist with increased BP or deficit
• Discontinue cOCP
• For migraine with aura cOCPs are
contraindicated
cOCPs & Concomitant Antibiotic
• CDC guideline – most antibiotics have no
effect on cOCP effectiveness
– No additional contraceptive method needed
– Except with griseofulvin & rifampicin
Contraception & Obesity
• What contraception is most effective for
obese women (BMI > 30 kg/m2)?
– Depo-Provera® & NuvaRing® are not affected
by body weight (SOR B)
– Obese women using cOCP or patch have
increased risk of pregnancy (SOR B)
HORMONAL CONTRACEPTION
TRANSDERMAL
TRANSVAGINAL
Contraceptive Patch (Transdermal)
• Ortho Evra® (EE 20 mcg; norelgestromin
150 mcg/day)
– Apply abdomen, buttocks upper torso
(exclude breast) or upper outer arm
– One patch a week for 3 weeks, 4th week
patch free
– Can use continuous patches for 12 weeks
Contraceptive Patch
(Transdermal)
• Equally efficacious to cOCP
– Less effective - women > 90 kg
• Side effects
– Breast discomfort, headache, nausea &
cramps – perhaps more than with cOCP
Hormonal vaginal ring (Transvaginal)
• NuvaRing® (EE 15 mcg & etonogestrel 12 mcg/day)
– One ring for three weeks
• No ring for one week
– Does not have to be in specific position
• Hormones absorbed anywhere in vagina
– If ring is out > 3 hours use additional
contraception until ring in place for 7 days
Hormonal vaginal ring
• NuvaRing®
– Contraceptive hormone levels last for 35 days
– Alternative regimen
• One ring every 30 days (once a month)
• Same day of the month (e.g. 12th of every month)
• Reduces number of menses & hormonal
withdrawal side effects
Patch or Ring vs cOCP?
• Cochrane review found:
– Patch caused more side effects than cOCP
– Ring caused fewer side effects than cOCP
• Except for vaginal discharge & vaginitis
• Compared to non-users same age, ring/patch
users had 6.5-7.9x increased risk VTE
– Increased SHBG & protein C sensitivity
– However, would need to switch 2000 ring or
1250 patch users to cOCP with levonorgestrel to
prevent 1 VTE
Ms. J’s Birth Control Options
• Abstinence
• Condom
• Diaphragm/cervical
cap
• Natural family
planning
• Oral contraceptive
• Contraceptive Patch
• Hormonal vaginal
ring
• Injection q 3 months
• IUD
• Contraceptive rod
Injection every 3 months
• Medroxyprogesterone acetate IM Q90D (Depo-Provera®; Depo-subQ Provera 104®)
– Associated with weight gain
– Irregular bleeding and most women are
amenorrheic at one year
– May have better compliance than cOCP
– FDA Black-Box Warning – Increased risk
of decreased BMD with > 2 years use
Ms. J’s Birth Control Options
• Abstinence
• Condom
• Diaphragm/cervical
cap
• Natural family
planning
• Oral contraceptive
• Contraceptive Patch
• Hormonal vaginal
ring
• Injection q 3 months
• IUD
• Contraceptive rod
Long-acting Reversible
Contraception (LARC) - IUD
• IUD – levonorgestrel
– 5 years duration (Mirena®)
– 3 years duration (Skyla®)
• Smaller & perhaps easier to insert
• IUD – intrauterine copper
– 10 years duration (ParaGard®)
– Can be used for emergency contraception up
to 5 days after unprotected intercourse
– Discrete method since will not effect
menstrual cycle regularity
LARC - Implant
• Etonogestrel SD (Implanon®; Nexplanon®-
radiopaque)
– Single subdermal rod for 3 years duration
LARC - Indications
• Indications
– Can be used in almost any female who
desires the most effective contraceptive
method
LARC – not contraindications
• Not contraindications to LARC are:
– Nulliparity
– Age – neither too young or too old
– Prior STD
– Prior ectopic pregnancy
– Prior PID
IUD Contraindications (risk>benefits)
• IUD contraindications – never to use
– Distorted uterine cavity
– Gestational trophoblastic disease
– SLE with positive antiphospholipid antibodies (exception ParaGard®)
– Pelvic tuberculosis
IUD Contraindications to Initiate
Use
• IUD contraindications to initiating use until
condition is treated
– Cervical cancer awaiting treatment or uterine
cancer
– AIDS, until clinically well on antiretrovirals
– Current PID or purulent cervicitis
– Postabortal or postpartum sepsis
– Unexplained or unevaluated vaginal bleeding
– Complicated solid organ transplant
– SLE with severe thrombocytopenia (exception
Mirena®)
Indications to Remove IUD
• Indications to remove IUD
– Headaches with aura that develop with use (exception ParaGard®)
– Ischemic heart disease that develops during
use (exception ParaGard®)
Implant contraindications
• Contraindications to ever using
– SLE with positive antiphospholipid
antibodies
• Contraindications (initiation of use) until
condition treated
– Unexplained or unevaluated vaginal
bleeding
Indications to remove implant
• Indications to remove implant
– Headaches with aura that develop with
use
– Ischemic heart disease that develops
during use
– Stroke during use
Advising a Contraceptive Method
• Before advising a woman regarding
contraception assess two things:
– First, how important is it to her that she not
become pregnant?
• The more important it is
• The more important to advise the most effective
method for her
– Second, what is her understanding of the
effectiveness of contraceptive options?
• She may have unrealistic understanding
Contraceptive Failure*
1000 women
No method
850
Withdrawal
Periodic abstinence
220
Condom
180
Diaphragm
120
cOCP
Patch
Ring
90
IUD
2
Implant
0.5
*Number of pregnancies during one year of typical use
The Contraceptive Recommendation
• Women overestimate the effectiveness of pills,
patch, ring or condom
• Risk of pregnancy is 20x greater for pill, patch,
or ring users compared to IUD, implants
– And women < 21 yo were 2x more likely than older
women to get pregnant with pill, patch or ring
• If delaying pregnancy is strongly desired
– Recommend IUD or implant (LARC)
• No clear best way to present this evidence to
women that allows for an informed choice
Providing Effective Counseling
• Characteristics of effective counseling:
– Demonstrate expertise, trustworthiness &
accessibility
– With adolescents address confidentiality
and parent’s role in the decision process
– Engage the woman in the learning process
– Address choosing the method, correct
use, consistent use and method switching
– Give priority to more effective methods
Providing Effective counseling (continued)
• Determine if method fits her lifestyle
(social norms, image, stigma, etc.)
• Recommend condom use with any
method as “extra” protection from
pregnancy (does reduce risk of STD)
• Discuss how to avoid inconsistent use
• Address side effects at the beginning
Key Points
• Multiple contraceptive options exist with
moderate to excellent efficacy
– Moderate – cOCP, patch, ring, depo
– Excellent – IUD, implant
• Know the main benefits and risks for
each method
– If prescribe a cOCP use “visit day” start
Key Points
• Generally recommend a LARC method
for women whom delaying pregnancy &
preventing unintended pregnancy is
highly valued
– Essentially very few contraindications to
LARC methods
• Provide “effective” counseling
Ms. J’s Conclusion
• Ms. J strongly does not want to become
pregnant in the near future
• After reviewing her options she
chooses to have an implant placed
Questions