CONTRACEPTIONMedicine-Ambulatory Presentation

TAKE HOME MESSAGES Unintended

pregnancy is a significant public health problem are a variety of hormonal and nonhormonal contraceptive methods available most effective methods of reversible contraception are IUDs and implants

There

The

Contraception

should be individualized to the

patient

PREGNANCIES IN THE US

5% of women of reproductive age had an unintended pregnancyThere were 6.7 million pregnancies in the US in 2006 49% were unintended (3.2 million) 43% of the unintended pregnancies were terminated (1.7 million)

This occurred despite most women reporting use of some form of contraception

Contraception. 2011;84(5):478.

HOW CAN WE PREVENT UNINTENDED PREGNANCY?

CONTRACEPTIVE PREVALENCE

70% of reproductive age women are sexually active Chance of pregnancy in 1 year without contraception = 85%19%

2%

7%62%

62% of women aged 15 to 44 years are currently using some method of contraception

4%

5%

Currently using contraception Currently pregnant or postpartum Trying to conceive Not sexually active Sterile Not using contraception

Trussell 2007 NSFG data 2006-8

WOMEN AT RISK FOR UNINTENDED PREGNANCY ANDNOT USING CONTRACEPTION MAKE UP MINORITY OF WOMEN, BUT ACCOUNT FOR ALMOST OF UNINTENDED PREGNANCIES7%

47%

53%

93%

Contraceptors and others At risk

Contraceptors and others At riskNSFG data 2006-8

Contraceptive method use among U.S. women who practice contraceptionMethod % of users

Pill Tubal sterilization Male condom

28.0 27.0 16.0

VasectomyIUD Withdrawal 3-month injectable Periodic abstinence (calendar) Implant, patch

9.95.5 5.2 3.2 1.2 1.1NSFG data 2006-8

Contraceptive efficacy vs. effectiveness

Efficacy: How well can it work?

Ideal/perfect use: Method used exactly as prescribed Example: COC have efficacy of >99% Failure = 3:1000

Effectiveness: How well does it work?

Typical use: What happens in the real world Actual effectiveness of COC is 92% Failure rate = 8:100

One-year Failure Rates with Typical and Perfect Use for Common Contraceptive MethodsMethod Typical Use Perfect Use Continuation at 1 year

FABMDiaphragm Condom COC DMPA Copper IUC LNG-IUC Sub-dermal implant Sterilization

2516 15 8 3 0.8 0.2 0.05 0.5

56 2 0.3 0.3 0.6 0.2 0.05 0.5

5157 53 68 56 78 80 84 100Trussell 2007

REVERSIBLE CONTRACEPTION: HORMONAL

Estrogen and progestin = combined hormonal contraceptionCombined oral contraceptives (COC) Vaginal contraceptive ring Transdermal contraceptive patch

Progestin-only contraception

Progestin-only pills (POP) Injectable DMPA (Depo Provera) Sub-dermal implant (Implanon) Levonorgestrel-releasing IUD (Mirana)

COMBINED HORMONAL CONTRACEPTION: MECHANISM OF ACTIONCRA P

Estrogen

Suppress FSH, LH surge

No follicle recruitment in ovary / no ovulation

Suppression of ovarian hormone production

Progestin

Some ovarian suppression

40% on POP will ovulate

Thickens cervical mucus Thins endometrium

Impairs tubal motility

CONTRAINDICATIONS: COMBINED HORMONAL CONTRACEPTION

Smoker 35 years Personal history thrombotic event

(DVT/PE, MI, CVA)

Complicated diabetes Migraine with focal neurologic sx Hypertension (uncontrolled) Coronary artery disease Current or hx of breast cancer Active liver disease Genital tract cancer Unexplained vaginal bleeding

COMBINED ORAL CONTRACEPTIVES Many

different brands of pills

Most

contain ethinyl estradiol (EE)

Most are low dose (35 mcg EE)

Progestin varies

Usually

packaged as 21 days active pill, 7 days no or inactive pill

Also 24 day, extended, and continuous regimens

VAGINAL RING NUVARING

1 ring in for 21 days, out for 7 daysExtended regimens possible Can remove for up to 3 hours

CONTRACEPTIVE PATCH Wear

one patch x 7 days

21 days on, 7 days off

Side

effects:

2% detachment 20% site reaction Increased breast tenderness, nausea

Less

effective in obese women (>198lbs)

Accounted for 3% of study population, 33% of pregnancies

BENEFITS: COMBINED HORMONALCONTRACEPTION

Menstrual benefits

Shorter, more regular menses Treatment of menorrhagia

Reduction in blood loss (38-50%) Decreased anemia 60-90% reduction in symptoms

Less dysmenorrhea

May have decreased number of menses per year

Treatment of fibroid symptoms Suppression of endometriosis Improvement of acne Decreased risk of PID Treatment of PMDD Decreased risk of ovarian and endometrial cancers Improves bone density

SIDE EFFECTS: COMBINEDHORMONAL CONTRACEPTION

Bloating, nausea, breast tenderness

Risk of cervical ca

Usually subside in a few months

RR for 5 yrs of use 1.9

Drug interactions DVTs Cardiovascular Disease

(95% CI 1.69-2.12)

Liver disordersFocal nodular hyperplasia Hepatic adenomas

CAD

Headaches

Related to thrombotic mech Related to smoking status RR 1.8 for current OC users and 1.2 for previous OC users Less of a concern with low dose estrogen

HTN

Stroke

N Engl J Med. 1981;305(11):612.

PROGESTIN-ONLY CONTRACEPTION

Progestin-only pills (POP)

Injectable DMPASub-dermal implant Levonorgestrel-releasing IUD

PROGESTIN-ONLY CONTRACEPTION: MECHANISM OF ACTION

Thickens and decreases cervical mucus to prevent sperm penetration Endometrial changes, including development of atrophic endometrium

Alteration of tubal motilitySome progestins inhibit release of FSH and LH which inhibits ovulation (i.e. DMPA, implant)

CONTRAINDICATIONS: PROGESTIN-ONLY CONTRACEPTIONCurrent or hx of breast cancer Active liver disease Unexplained vaginal bleeding

PROGESTIN-ONLY PILLS Commonly

used for breastfeeding women May be less effective than COC with typical use

Need for strict compliance 27-hour rule

Similar

noncontraceptive benefits No pill-free intervalactive pill taken every day Side

effects

irregular bleeding amenorrhea

DEPO-MEDROXYPROGESTERONE ACETATE (DEPO PROVERA)

Injectable progestin only contraception

IM: 150 mg SC: 104 mg

Administered every 11-13 weeks Side Effects

Irregular bleeding Amenorrhea Weight gain

SUBDERMAL IMPLANT (IMPLANON)

Single rod Releases letonogestrel

60mcg/day

Implanted in upper arm 4cm long 3 years of protection, Side effects: irregular bleeding

Irregularly irregular Spotting, amenorrhea, bleeding

LEVONORGESTREL IUD (MIRENA)Intrauterine release of LNG Delivers 20 mcg LNG / day Effective for up to 5 years No long-term effect on fertility Reduces menstrual blood loss by 90% Side effects

Bleeding irregularities Amenorrhea20% at 1 year 50% at 5 years

Expulsion

5% risk over 5 years

Perforation

Uncommon (approx 1 in 1000)

BENEFITS: PROGESTIN-ONLY CONTRACEPTIONTreatment of menorrhagia and dysmenorrhea Decreased volume of bleeding and/or amenorrhea Treatment of fibroids, endometriosis Treatment of endometrial hyperplasia Decreased risk of endometrial cancer No known drug interactions

NON-HORMONAL: REVERSIBLE

Copper IUD Barrier methods

Condoms Diaphragm Cervical cap Vaginal sponge Lactational amenorrhea Withdrawal

Natural Family Planning

Fertility Awareness methods

Standard Days (cycle beads) Calendar Rhythm Method

COPPER IUD (PARAGUARD)

Mechanism

Creates sterile inflammatory environmentIncrease in Cu ions, PG, and macrophages Impairs sperm function and prevents fertilization

Side Effects

No systemic side effects Cramping/heaving bleeding

Most common in first 3 mo

Expulsion rate: 2-10% Perforation rate: 0.1%

Can be used as emergency contraception

NON-HORMONAL, REVERSIBLE: MECHANISM OF ACTION

Barrier

Physically keep sperm and egg apart

Fertility-awareness

Prevent exposure to sperm during fertile period For women who have a cycle 26-32 days in length (78% of cycles), the fertile window falls on days 8 to 19

COST OF BIRTH CONTROL

$9 Monthly cost of some generic versions of the birth control pill ($108 a year) $90 Monthly cost of some brand-name versions of the pill ($1,080 a year) $55 Monthly cost of vaginal ring or birth-control patch ($660 a year) $60 Annual cost of using a diaphragm and spermicide, including mandatory doctor's exam $150 Annual cost of using condoms, twice a week $220-$460 Annual cost of getting a birth control shot (Depo-Provera) $600-$1,000 One-time cost of getting an intrauterine device (IUD) implanted (effective for up to 10 years) $0 Up-front cost of abstinence and "fertility awareness" (rhythm method)

CONTRACEPTIVE STATISTICS5 Percent of U.S. women who use an IUD, which is 99 percent effective 75 Percent of participants in a 10,000-woman St. Louis study that chose IUDs from a range of free contraception options 80 Percent of those IUD users who have stuck with the method after a year 50 Percent of birth control pill users in the same study who've stuck with their choice after a year

CONTRACEPTIVE CHOICE PROJECT

Prospective cohort study of 10,000 women 14-45 years who want to avoid pregnancy for at least 1 year and are initiating a new form of contraception Provided contraceptive method of c