Contraception

Dr Arlene Smalls, MDAugust 5, 2011

Lankenau Medical Center Department of OB GYN

Objectives of Lecture: Review of Contraceptive Counseling,

Risk Assessment and Method Initiation

Discussion of Conceptive methods including Emergency Contraception

Discussion of new Guidelines regarding Contraceptive Usage

Contraception Needs in US ~60 million women between ages of 15-44

60% use contraception 33% don’t have a need for contraception 7.3% who are at risk are not using any method

6 million pregnancies yearly in US 50% of pregnancies are unintended 1 million pregnancies occurred on OCP’s 1.4 million abortions performed yearly in US

Counseling Efficacy Availability Costs Ease of Use Privacy Reversibility Side Effect and Medical Risks Patient and Partner Desires Informed Decision Making

Contraceptive Efficacy Pearl Index: Theoretical Definition of Method

Failure Rate based on “Perfect Usage”: Number of Failures / 100 Women-years

of exposure (x1200 if based on months) (x1300 if based on cycles)

“Typical or Usage Failure Rate” based on actual usage activity from Life Table Method

Contraceptive MethodsCombined Hormonal Methods (COC)

Oral Contraception Nuva Ring Ortho Evra Patch

Progestin Only Methods (POP) The Mini Pill Depo-Provera Implanon

Non Hormonal Contraception - IUDBarrier Methods

Male / Female CondomsSterilizationEmergency Contraception

Pre-Assessment & Evaluation Discussion of Patient’s Life and Health

Plans Reproductive Life Plan Childbearing Goals Birth Spacing

Pre-conceptual Health Assessment and Counseling

Extensive Personal Medical History and Family History

Pre-Assessment History

Personal History: Medical History of Hormonal contra-indications: (HTN, MI, Cardiac Dz, DM, CVA, DVT, PE, other) Liver Disease Migraine headache with aura or neurologic

complaints; Seizure history Tobacco Usage Current Medications

Surgical History

Pre-Assessment History Gyn History:

Menstrual History including LMP Breast Issues including new or unevaluated

masses Uterine fibroids or other anatomic

abnormalities STD history, prior and current risk (?)

Familial History of Thrombophilia (1st degree relative)

Pre-Assessment & Evaluation Physical Exam not necessary prior to

initiation of any birth control method Vital Signs, Weight Breast Exam*, Pelvic Exam (??)

Laboratory Testing Factor V Leiden, Anti-phospholipid evaluation,

Glucose, and Lipids if there is a concerning personal or family history

STD screening prior to IUD placement (?)

CDC and Contraception Medical Eligibility WORLD Health Organization (WHO)

established an evidence based guideline for contraceptive usage

Global review of the 19 different contraceptive methods for women and men

4th version was revised 2010 (available since

1996)

COC Physiologic Effects Hormonal Effect

Estrogen (ethinyl estradiol) and Progesterone alter FSH/LH secretion via negative feedback

Follicle development and Ovulation are suppressed

Endometrial thinning Cervical mucous thickening

Reduced sperm transport Progestin is the dominant hormone

COC or OCP’s 10.7 million women use OCP

(~27% of BC users) Most popular, reversible BCM in the US 21 day cycle, 24 day cycle Extended regimens Monophasic, Biphasic, Triphasic,

Quadiphasic (Quailara@) 20mcg, 35 mcg, 50 mcg pill regimens

(based on Estrogen dosage)

OCP Failure Failure rate is 0.1% Usage Failure rate is 8/100

woman-years Adherence with OCP – 50% of women miss 1-3 pills

a cycle Missing Pills within the 1st week of the pack –

breakthrough ovulation

Drug Interactions – Anti-seizure medications (G450 activation) Antibiotics – Rifampin, Griseofulvin Anti-viral medications - Norvir

OCP’s concerns Alterations in the Menstrual Cycle

Breakthrough bleeding Amenorrhea 0.8% per year

Health Risks Headaches and Elevated Blood

pressure Weight Gain Breast Cancer risk

Risk of Thrombo-embolic events*

Non Contraceptive Benefits Acne and Hirsuitism therapy Menstrual Regulation occurs with

decreased Menstrual Blood Loss Dysmenorrhea, endometriosis

symptoms are improved Rates of Ovarian cysts, ectopic

pregnancy, and salpingitis are reduced. Ovarian and Endometrial Cancer rates

are reduced with past usage of at least one year

Contra-indications to COC usage Medical History

Personal H/o Thrombo-embolism (DVT, PE, CVA, MI)or

Familial History of inherited thrombophilia (DVT, PE, CVA, MI)

Uncontrolled HTN (>160/100) Hepatic Dysfunction Diabetes Breast Cancer Smokers over the age of 35** (#) Unexplained vaginal bleeding or Pregnancy

Contra-indications to COC usage

Postpartum patients* <21 days, Cardiac Disease including h/o ischemic

heart disease, valvular heart dz, peripartum cardiomyopathy and multiple risks factors for heart disease*

H/o Solid Organ Transplant, complicated H/o Gastric Bypass*

CDC – Medical Eligibility Criteria, 2010

Pos tpartum Contraception WHO Revised guideline 7/2011 PP, 22-84X greater risk of DVT, PE or VTE Ovulation can occur as early at 25 days in non

lactating women 21 days pp - No COC or CHC 42 days pp – Non COC or CHC

Obesity, Post Cesarean Delivery, Preeclampsia, PP hemorrhage, Transfusion at Delivery, Immobility, Age > 35, Tobacco Users, BMI > 30, Prior h/o VTE, Thrombophilia)

POP methods are acceptable immediately

Drug Interactions and OCP’s Anti-Malarial Meds: Rifampicin /

Rifabutin

Anticonvulsant Medications: Lamotrigine*Phenytoin, Carbamazepine, Barbituates, Primidone, Topiramate and Oxcarbazepine

Antiretroviral therapy (ARV):Ritonavir-boosted protease inhibitors

Ortho-Evra Weekly Transdermal patch of a hormonal matrix

150 mcg ethinyl estradiol 20 mcg norelgestromin Worn 3 weeks out of 4 weeks per cycle

Sites of usage: Back, Upper arm, Abdomen, or Chest Sunday Start or 1st day Start Patch Change Date within 48 hours of scheduled date

Failure rate: 1%

Not recommended for hormonally naïve patients, smokers*, or patient with h/o skin sensitivity or weights above 198 lbs

NuvaRing Ethylene vinyl acetate polymer ring

15 mcg of Ethinyl estradiol 120 mcg Etonogestrel Intra-vaginal placement Worn ¾ weeks per cycle with option of

one week Menstrual Cycles regulated 98.5% of cycles Failure rate: 0.65-1.18/100 women-years Vaginal Discharge and placement issues

Progesterone only Contraception

Progestin-only pills - POP or “Mini pills” Norethindrone or norgestrel

Continuous usage (no pill free interval) Hormone must be taken daily at the same time

(25% circulating levels of OCP’s / 22hr effect)Ovulation seen in 40-50% of POP users

Mechanism of action: Cervical Mucous thickening, Thinning of endometrium, reduced sperm transport

Failure Rate: 1.1 to 9.6 / 100 women-years Backup method – Barrier Method / Breast feeding

Depo-Provera@ or DMPA 150milligrams of Medroxyprogesterone acetate IM dose every 11-13 weeks

Deltoid or Gluteus Maximus Inhibits LH/FSH surge

Ovulation and endometrial proliferation are inhibited New Guidelines regarding missed doses

WHO 2009 – Delayed Dosages can be given up to 4 weeks from date originally scheduled

Failure Rate: 0.3 – 3% Long lasting but reversible

Return to fertility – 50% by 9 months (max – 18 months)

DMPA Contra-indications:

Breast Cancer Safe if contra-indications to COC’s

exist: Tobacco, HTN, SLE, CVA, Thromboembolic events (DVT/PE),

Liver Disease (????) Improved Outcomes in Certain Populations:

Sickle Anemia / Trait; Seizure Disorder Endometriosis, Dymenorrhea and Pelvic Pain Adolescents, Developmentally Delayed Women

DMPA Risks Bone Density alteration due to estrogen

deficiency Limited Risk: Bone changes resolve with cessation of

DPMA Menstrual Changes

70% have increased bleeding days per month 75% experience amenorrhia after one year of usage

Weight Gain More in Women who are Obese at initiation of method 5lbs by year One; 16 lbs by year Five

Mood Disorders and Psychiatric Issues

Implanon Subdermal, single rod progestin implant

Etonogestrel release 3 year duration of use

Ovulation suppression and endometrial thinning Failure rate: no failures reported in 4103 women

/ 70,000 cycles Menstrual pattern alteration – 80%

Irregular or prolonged bleeding (3-5 days per cycle) Total Overall Blood loss decreased Treat with NSAIDS, OCP’s or estrogen

Intra Uterine Device – Paraguard@ IUD

Long acting, low maintenance, rapidly reversible contraception

Copper T380A - 3.6cm long T shaped device made of polyethylene plastic

Length of usage – 10-12 years Prevention of pregnancy via Endometrial

inflammatory response and anti sperm activity Failure rate = 0.8% (up to 3% at 10 years) Risk of PID, Expulsion/perforation at insertion

and Dysmenorrhea/Menorrhagia

Mirena@ IUD 3.2cm long, T-shaped device with an inner reservoir

Levonorgestrel 20 mcg per day Cervical Mucous thickening and Endometrial

atrophy Ovulation still occurs in 85% of the cycles Failure rate: 0.14 per 100 women–years

0.71% (5 year failure rate) Menstrual irregularity during the first three months

Menorrhagia/Endometrial Cancer treatment

IUD Safety Safe Profile proven with recent studies

Safe for Adolescents and Nulliparous Females Limited increased risk of PID/Infection within

the first 30 days post placement Screen for STI and BV pre-placement if Risk factors Treat STI and allow 3 months from therapy prior to

IUD placement Recommend Condom usage

IUD can be left in place if cervicitis or PID diagnosed

Barrier Methods Male Condoms

Latex condoms – STI protection Failure rate – 3% (Actual – 12%) Breakage rates: 1% of heterosexual acts Nonoxynol 9 no longer recommended

Polyurethane or Non latex condoms Female Condoms

Polyurethane pouch with two rings Can insert up to 8 hours prior to intercourse Female controlled and allows Labia protection

Barrier Methods, Other Cervical Cap:

Thimble shaped rubber device that fits over the cervix Fitted by gynecologist Can be left in vagina for 48 hours Vaginal Discharge Failure rate: 9% in nulliparous; 20% in parous within 1 year

Diaphragm: Dome shaped rubber cups create a barrier over the cervix Use with spermicide May place in vagina up to 6 hours prior to intercourse and remain

in place for 8 hours (max 24 hours) Failure rate: 6% / 12% UTI risks

Permanent Sterilization - Female Female Sterilization is the most common

method used in US for married couples 10 million women in US 100 million women worldwide Overall Failure rates: 1.85% over 10 years but

differs slightly by method and provider experience

Drawbacks: Regret, Failures, Ectopic pregnancy(CREST study – NEJM 2001)

Permanent Sterilization - Female

Laparoscopic Methods: Bipolar Cautery, Sialastic Bands / Falope Ring, Filshie or Hulka Clips,

Open Procedure / Minilaparotomy: Pomeroy/Modified Pomeroy, Parkland,

Irvine, Uchida, Fimbrectomy

Hysteroscopic Methods: Essure, Adiana

Male MethodsSterilization - Vasectomy

Conventional Vasectomy “No Scapel Vasectomy” - In Office

Procedure for occlusion of the Vas Deferens

Limited Risks: No Missed Work, Minimal Pain Need 2 negative Sperm Analysis Costs: $350 – $1,000

Failure Rate: < 1% Reversibility:

Emergency Contraception – “EC”Post coital Contraception - Pregnancy

prevention

Yuzpe method, 1970’s 100mcg estrogen/500mcg Levonegestrel - (2) doses in 12hrs

Drawbacks: nausea, vomitting

More than 20 brands of OCP can now be used as EC*

Reduction in unintended pregnancy rates post EC:

95% if taken with 12 hours; 89% if taken with 5 days

IUD

Emergency Contraception – “EC” Plan B, available since 2000

1.5mg Levonorgestrel Single dose (2 pills) versus 2 One pill

dose protocol every 12hrs Available over the counter (Age >17)

since 2009 Well tolerated

Next Choice- progestin only EC, OTC available since 2010

Emergency Contraception – “EC”

Reduction in unintended pregnancy – 95% if taken with 12 hours; 75% if taken within 72 hours

May use EC up to 120 hours after intercourse*

If, no menses within 2-4 weeks or persistent irregular bleeding post EC, rule out pregnancy

Contraceptive Method Initiation Quick start, Sunday start, Menses Day 1 start LMP to r/o pregnancy needed with Quick start Backup needed for 7 days after initiation –

Quick start and Sunday start Altered Menses may be seen with all

methods Combination methods – Important

Condoms/Barrier methods with hormonal method Emergency Contraception

Postpartum

Pos tpartum Contraception WHO Revised guideline 7/2011 PP, 22-84X greater risk of DVT, PE or VTE Ovulation can occur as early at 25 days in non

lactating women 21 days pp - No COC or CHC 42 days pp – Non COC or CHC

Obesity, Post Cesarean Delivery, Preeclampsia, PP hemorrhage, Transfusion at Delivery, Immobility, Age > 35, Tobacco Users, BMI > 30, Prior h/o VTE, Thrombophilia)

POP methods are acceptable immediately

Adolescents

Confidentiality Issues

Recommend Informed Adult regarding medication

Return office appt for contraception re-enforcement and assessment

Resources U.S. Medical Eligibility Criteria for

Contraceptive Use, 2010www.cdc.gov/mmwr/pdf/rr/rr59e0528.pdf

World Health Organizationhttp://www.who.int/en/

Guttmacher Institutewww.guttmacher.org/pubs/psrh/full/3809006.pdf