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Preventing Unintended Pregnancy: Prescription and Management of Contraception PowerPoint Presentation

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Description : Check out this medical presentation on sexual health by Amy Whitaker, MD, MS, Assistant Professor, Department of Obstetrics and Gynecology, Section of Family Planning and Contraceptive Research, The University of Chicago. This medical PPT titled "Preventing Unintended Pregnancy: Prescription and Management of Contraception" is about contraceptive methods with patients, from most to least effective.

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Slide 1-

Preventing Unintended Pregnancy:Prescription and Management of Contraception Amy Whitaker MD MS Assistant Professor Department of Obstetrics and Gynecology Section of Family Planning and Contraceptive Research The University of Chicago ACHA Annual Clinical Meeting, May 2012
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Financial Disclosures I have NO actual or potential conflict of interest in relation to this educational activity or presentation. I have no affiliation with any of the companies whose products are mentioned in this presentation.
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Learning Objectives At the end of this session, you should be able to: Discuss contraceptive methods with patients, from most to least effective. Evaluate patients to help them select a contraceptive method that will maximize correct use and continuation. Manage side effects of contraception. Identify appropriate patients for use of long-acting reversible contraception (LARC).
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Unintended pregnancy Unintended Intended Abortion: 43% of unintended Unintended birth: 57% of unintended 49%: 51% 3.2 million unintended pregnancies per year in the U.S. 54% of women having abortions report using contraception in the month they became pregnant Finer LB, et al. Contraception 2011;84:478
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Unintended Pregnancy Sexually active young adult women are at high risk for unintended pregnancy Highest rate among young adult women & older teens 107 / 1,000 women age 20-24 / year 103 / 1,000 women age 18-19 / year That’s 10% per year! Finer LB, et al. Contraception 2011;84:478
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CDCMedical Eligibility Criteria Definition No restriction for use of the method Advantages of using the method generally outweigh the theoretical or proven risks Theoretical or proven risks usually outweigh the advantages of using the method An unacceptable health risk if the contraceptive method is used Systematic review of evidence – Released 2010 Category 1 4 3 2
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Long-acting Reversible ContraceptionLARC
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Etonogestrel ImplantSingle Rod – Effective for 3 years
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Etonogestrel Implant Single 40-mm  2-mm rod Rod is made of ethylene vinyl acetate copolymer Contains 68 mg of etonogestrel active metabolite of desogestrel releases 60 mcg daily Effective for 3 years
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Contraceptive Mechanism of Action Mishell J Reprod Medicine 1996
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Etonogestrel Implant Efficacy More effective than permanent sterilization 0.05% typical (and perfect-use) failure No pregnancies during 1200 woman-years of exposure (Pearl Index, 0; 95% CI 0.0-0.2) American study of 330 women aged 18-40 no pregnancies in 2 years Croxatto HB. Eur J Contracept Reprod Health Care. 2000;5(suppl 2):21 Funk et al. Contraception 2005;71:319 Trussell. Contraception 2011;83:397
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Etonogestrel implant insertion and removal Inserted as outpatient average time 0.5 minutes mandatory training by manufacturer timing of insertion Insert any time in cycle; rule out pregnancy Back up method if not within the 1st 5 days of menses Average removal time 3.5 minutes Funk et al. Contraception 2005;71:319.
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Implanon® and Nexplanon®
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Etonogestrel ImplantBleeding Patterns Total number of bleeding/spotting days decreased or similar for majority of users Key difference: irregularity and unpredictability ~20% amenorrhea in 1st year Increases to 30-40% after 1st year Mansour et al. Eur J Contr Reprod Health Care 2008;13S1:13
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Etonogestrel implant bleeding patterns Funk et al. Contraception 2005;71:319.
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Management of bleeding Mansour et al. Contraception 2011;83:202
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Management of bleeding Mansour et al. Contraception 2011;83:202 1st Choice Daily COC for 21 days, followed by 7-day break. Use for up to 3 months. 2nd Choice High-dose progestin for 21 days with 7-day break (e.g. medroxyprogesterone acetate 10mg twice daily). Use for up to 3 months.
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Management of bleeding Mansour et al. Contraception 2011;83:202
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Dronavalli S. 2007
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Other Side Effects Acne 17% reported acne 1.3% of women discontinued for acne 61% of women with acne at baseline reported improvement, and only 8% worsened Funk et al. Contraception 2005;71:319.
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Other Side Effects Weight gain Overall increase in BMI 0.7kg/m2 Not a significant increase 12.7% of women reported weight gain 3.3% of women discontinued for weight gain Funk et al. Contraception 2005;71:319.
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Efficacy in overweight women No clinical trial data Women >130% ideal body weight excluded Only total of 134 women > 70kg: no failures Small pharmacokinetics study indicates projection of hormone levels sufficient to inhibit ovulation Not contraindicated in obese women or girls Edelman A. SFP Guidelines. Contraception 2009;80:583. Gilliam et al. Contraception. 2011;published abstract
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Bone Mineral Density & Etonogestrel Implant Implanon does not suppress estrogen levels to extent that Depo-Provera® does Randomized trial of Implanon and copper IUD No differences in BMD changes between the two groups during one year of use Beerthuizen et al. Human Reproduction 2000;15:118
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Etonogestrel implant continuation Bleeding irregularity is the most common reason for discontinuation U.S. studies: 13-14% Overall U.S. continuation rate: 75%-84% Casey et al. Contraception 2011;3:426
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Very few contraindications SLE with anti-phospholipid antibodies Hepatocellular adenoma Discontinue if develops during use: Migraines with aura Unexplained vaginal bleeding suspicious for serious condition, before evaluation
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Appropriate patients Women desiring highly effective, confidential, “forgettable” contraception Women who cannot use estrogen Tolerant of irregular bleeding The importance of counseling
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Intrauterine Contraception Copper T 380A (Paragard®) Levonorgestrel-Releasing Intrauterine System (Mirena®)
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Intrauterine Contraception Paragard™ (TCu380A) Copper IUD Use up to 10 years Heavier periods No hormonal side effects Mirena™(levonorgestrel- releasing IUS) Local Progestin Use up to 5 years Lighter periods Irregular for 3-6 months Some systemic effects
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Copper-releasing IUDs:Mechanism Mass effect, like plastic IUDs Copper alters uterine and tubal fluid Hinders spermatozoa function / motility Inhibits fertilization Not an abortifacient Hatcher, 1998
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Progestin-releasing IUDs:Mechanism Impairs spermatozoa motility / function Inhibits conception Unable to recover fertilized ova Not an abortifacient Thickens cervical mucus Atrophy of endometrium Impairs tubal motility 85% of women are ovulatory Lahteenmaki, 2000
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Levonorgestrel-releasing IUS Releases 20 mcg per day of Levonorgestrel Hormonal side effects are rare Endometrial concentrations 200-800x higher than in blood Lähteenmäki et al. Steroids 2000
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Increasing IUD use among young women 2008: current IUD use 3.6% of contraceptors aged 15-19 years from 0% in 2002 5.9% of 20-24 year olds from 1.8% in 2002 ACOG Committee Opinion December 2007 IUDs should be offered as a “first-line choice” for contraception in both nulliparous and parous adolescents Mosher et al. National Center for Health Statistics. Vital Health Stat 2010;23(29)
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Efficacy Highly effective: >99% typical use
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Risks – younger patients Insertion may be more difficult in nulliparous women Higher expulsion in adolescents May have higher rates of copper IUD removals due to bleeding and pain No evidence this occurs with the LNG-IUS Deans et al. Contraception 2009 Behringer et al. Contraception 2011;84:e5 Hubacher D. Contraception 2007;75:S8
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Misoprostol for insertion Commonly used for nulliparous patients 50% of providers use it 20% do so with all insertions empirically Trials in nulliparous patients Most showed no difference in success Most report increased patient pain & side effects Not studied specifically in nulliparous adolescents Ward et al. Contraception 2011;84:594
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Copper IUDs – menstrual changes Increased menstrual flow Increased amount and duration Usually no change in hemoglobin Increased dysmenorrhea Management Patience and reassurance NSAIDS around clock, start 1 day before menses
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Progestin IUDs – side effects Hormonal side effects are rare & not more common than in general population Nonetheless, they are reasons given for discontinuation No weight gain
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IUD’s Bad Rap Dalkon Shield 1970 Introduced 1973 High incidence of PID recognized 1975 Removed from market 1983-1988 No IUDs sold in U.S.
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IUD Use in the US from 1965-1995 Hubacher, Contraception, 2004
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IUD and Pelvic Inflammatory Disease RiskEvidence-Based? Re-analysis excluding the Dalkon Shield and addressing bias = no increased risk 3 types of bias in observational studies: Inappropriate comparison groups Over diagnosis of PID among IUD users Inability to control for confounding factors WHO analysis of 22,900 women over 8 yrs Increased risk in first 20 days after insertion No increased risk with continued use Grimes D. Lancet 2000;356:1013 Farley TM, Lancet 1992;339: 785
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What about infertility in nulliparous women? Case-control study: 1895 women Compared women with tubal infertility to 2 separate control groups Non-tubal infertility (infertile controls) Primigravid (pregnant controls) NO association with past use of Copper IUD Adjusted OR 1.0 and 0.9, respectively Hubacher et al. NEJM 2001
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IUD candidates Prior STI or PID: NOT a contraindication Contraindicated: current PID or within the past 3 months / Current cervicitis High risk women: screen for infection with GC or CT prior to insertion Adolescence and nulliparity are not contraindications CDC category 2 for age < 20 years & nulliparity CDC: U.S. Medical Eligibility Criteria for Contraceptive Use. May 2010.
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Depot Medroxyprogesterone Acetate
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Depo-Provera 150 mg of depot medroxyprogesterone acetate; administered deep intramuscular or 104 mg subcutaneous Q 3 months Initiate anytime in cycle; rule out pregnancy Back up method for 7 days if injection is not within 5 days of start of menses
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DMPA Benefits: Highly effective: 96% Little compliance required Easily concealed No decreases in efficacy in overweight women Risks and Side Effects: Bleeding irregularities Delayed return of fertility Weight gain Decrease in bone mineral density
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DMPA Pharmacokinetics Mishell J Reprod Medicine 1996
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DMPA – bleeding patterns Irregular bleeding 70% in the first year; 10% thereafter Usually light; hemoglobin levels rise Most common reason for discontinuation Up to 25% in the first year of use Management Similar to management with Implanon
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DMPA – bleeding patterns Bleeding and spotting decrease progressively with each reinjection Amenorrhea: 55% at one year 70% at 2 years 80% at 5 years
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DMPA and Weight Gain Adult women: 4.3 kg increase over 5 years Compared to 1.8 kg increase in copper IUD users Early weight gain may predict excessive gain Weight gain greater in adolescents who are overweight (BMI >30) when initiating DMPA 20 lb weight gain over 18 months in obese teens Bahamondes et al. Contraception 2001;64:223. Le et al. Obstet Gynecol 2009;114:279. Bonny et al. Arch Pediatr Adolesc Med 2006;160:40.
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FDA Black Box Warning Women who use Depo-Provera Contraceptive Injection may lose significant bone mineral density. Bone loss is greater with increasing duration of use and may not be completely reversible. It is unknown if use of Depo-Provera Contraceptive Injection during adolescence or early adulthood, a critical period of bone accretion, will reduce peak bone mass and increase the risk of osteoporotic fracture in later life. Depo-Provera Contraceptive Injection should be used as a long-term birth control method (eg, longer than 2 years) only if other birth control methods are inadequate (see WARNINGS).
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DMPA & Bone Mineral Density (BMD) Use of DMPA is associated with loss of BMD After stopping, recovery of BMD is seen return to baseline in 1-4 years No data on fracture risk in women who have used DMPA in the past Berenson et al. Obstet Gynecol 2004;103 Scholes et al. Arch Pediatr Adolesc Med 2005;159:139 Harel et al. Contraception 2010;81:281
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DMPA and BMD Position papers: WHO1 ACOG2 Society of Adolescent Medicine3 NONE recommend restricted initiation or continuation NONE recommend routine BMD testing 1 WHO Epidemiological Record No. 35, 2005 2 ACOG Practice Bulletin No. 73, 2006 3 Cromer BA et al. J Adolesc Health 2006;39:296
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Depo-Provera Few contraindications Similar to progestin implant Severe hypertension (>160/>100) Diabetes with vascular disease and / or > 20 years disease
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Appropriate patients Women desiring effective, confidential, method and who can return for injections Women who cannot use estrogen Tolerant of irregular bleeding Special populations Sickle cell disease Epilepsy
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Combined Hormonal Contraceptives
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Combined Hormonal Contraceptives Safe for most young women Added benefit of regulation of menses “Typical-use” effectiveness ~ 92% (Do not quote perfect use ~ 99%)
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Oral Contraceptive Pills Commonly reported as most effective method 54% of 15-19 year olds who use contraception 48% of 20-24 year olds Poor continuation Up to 50% discontinue within first 3 cycles One study found discontinuation 88% at one year College students: only 29% still using at 6 months Mosher et al. National Center for Health Statistics. Vital Health Stat 2010;23(29) Rosenberg MJ, et al. Contraception 1995;52:137 Zibners A, et al. J Pediatr Adolesc Gynecol 1999;12:90
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Contraceptive patch Weekly transdermal patch 20 mcg EE + 150 mcg norelgestromin daily Continuous delivery Area “under the curve” is 60% > in a 35 mcg pill Possible increase in estrogen side effects such as VTE Less effective if body weight > 90 kg Contraception 2005 Sep;72(3):168-74 Abma et al. National Center for Health Statistics. Vital Health Stat 2010;23(30)
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The vaginal ring 3 weeks with 1 week ring-free interval or 24-4, or continuous Lowest ethinyl estradiol dose (15 mcg EE, 120 mcg etonorgestrel daily) Continuous dosing Use back-up method if out for > 3 hours Abma et al. National Center for Health Statistics. Vital Health Stat 2010;23(30)
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Pharmacokinetics of patch, ring and OCPs
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Potential advantages of new delivery systems Compliance Patch > pill in some studies…but not in others Satisfaction No consistent differences Side effects Ring with some improvement in nausea and cycle control Continuation and efficacy O’Connell et al. Clin Obstet Gynecol 2007;50:918 Brache et al. Contraception 2010;82:418.
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The bad news
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The bad news Raine et al. Obstet Gynecol. 2011
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Weight andCombined Hormonal Contraceptives CHC and Weight gain –  NO LINK Gallo et al. Cochrane Dbase of Systematic Reviews 2008, Issue 4. Art. No.: CD003987. DOI: 10.1002/14651858.CD003987.pub3.
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Weight and Contraceptive Efficacy SFP Guidelines. Contraception 2009. Holt et al. Obstet Gynecol 2002. Women in the highest body weight quartile (70.5 kg or more) had a significantly increased risk of OC failure (RR 1.6, 95% CI 1.1, 2.4) compared with women of lower weight. (controlled for parity)
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Weight and Contraceptive Efficacy SFP Guidelines. Contraception 2009. Brunner et al. Am J Epidemiol 2007. NSFG Analysis. No effect of weight on OCP effectiveness when controlled for age, parity, race.
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Weight and Contraceptive Efficacy SFP Guidelines. Contraception 2009. Zieman et al. Fertil Steril 2002. 5 of 15 pregnancies in 3 clinical trials occurred in the 3% of women > 90kg. [abstract]
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Weight and Contraceptive Efficacy SFP Guidelines. Contraception 2009. Westhoff et al. Obstet Gynecol 2005. No effect of weight on efficacy of NuvaRing. [abstract only]
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Weight and Contraceptive Efficacy SFP Guidelines. Contraception 2009.
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Alternate regimens Many options beyond standard 21-7 24-4 (e.g. Yaz, Loestrin® 24 Fe) 3-month [84-7] (e.g. Seasonale, Seasonique) 12-months (e.g. Lybrel) Advantages Decreased follicular activity Potential for increased efficacy Fewer bleeding days More breakthrough bleeding in first several months
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Breakthrough bleeding Common reason for discontinuation With time, improved with extended regimens Higher rates in women who smoke with cervical infections Management: If near end of cycle, discontinue early If severe, consider exogenous estrogen
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Acne All pills studied reduced acne compared to placebo Arowojoluet al. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD004425. DOI: 10.1002/14651858.CD004425.pub4 No consistent results regarding different types of progestins Cyproterone (pregnane) may be better than LNG LNG may be better than desogestrel (!)
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Shulman LP. J Reprod Med. 2003. Chang J. In: Surveillance Summaries. 2003. Incidence of VTE per 100,000 woman-years 0 20 40 60 Pregnancy High-dose OC Low-dose OC General Population Comparative Risks of VTE
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Combined Hormonal Contraception:Contraindications History of a venous thromboembolism Known thrombogenic mutations Migraines with aura Hypertension, esp. if poorly controlled Lupus with antiphospholipid antibodies CDC. Medical Eligibility Criteria for Contraceptive Use
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Barrier Methods
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Condoms Safe for all young women Only method that offers PROTECTION FROM STIs Not effective enough for contraception Typical-use failure is 15% Counsel for dual protection from pregnancy & STIs 15%
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Summary Unplanned pregnancy is common The implant and IUDs provide greater: Convenience Efficacy Discontinuation of all methods is high Counseling in advance is vital