CLO Contraception PPT
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Transcript of CLO Contraception PPT
CONTRACEPTION
Medicine-Ambulatory Presentation
TAKE HOME MESSAGES Unintended pregnancy is a significant
public health problem
There are a variety of hormonal and non-hormonal contraceptive methods available
The most effective methods of reversible contraception are IUDs and implants
Contraception should be individualized to the patient
PREGNANCIES IN THE US
5% of women of reproductive age had an unintended pregnancy
There 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%
62% of women aged 15 to 44 years are currently using some method of contraception
Trussell 2007NSFG data 2006-8
62%
5%
4%19%
2%
7%
Currently using contraceptionCurrently pregnant or postpartumTrying to conceiveNot sexually activeSterile
WOMEN AT RISK FOR UNINTENDED PREGNANCY AND NOT USING CONTRACEPTION MAKE UP MINORITY OF WOMEN, BUT ACCOUNT FOR ALMOST ½ OF UNINTENDED PREGNANCIES…
93%
7%
Contraceptors and othersAt risk
53%
47%
Contraceptors and othersAt risk
NSFG data 2006-8
Contraceptive method use among U.S. women who practice contraception
Method % of users
Pill 28.0
Tubal sterilization 27.0
Male condom 16.0
Vasectomy 9.9
IUD 5.5
Withdrawal 5.2
3-month injectable 3.2
Periodic abstinence (calendar) 1.2
Implant, patch 1.1
NSFG 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
FABM 25 5 51
Diaphragm 16 6 57
Condom 15 2 53
COC 8 0.3 68
DMPA 3 0.3 56
Copper IUC 0.8 0.6 78
LNG-IUC 0.2 0.2 80
Sub-dermal implant
0.05 0.05 84
Sterilization 0.5 0.5 100
Trussell 2007
REVERSIBLE CONTRACEPTION: HORMONAL
Estrogen and progestin = combined hormonal contraception Combined 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 ACTION 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
CRAP
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 RINGNUVARING
1 ring in for 21 days, out for 7 days Extended 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 HORMONAL CONTRACEPTION Menstrual benefits
Shorter, more regular menses
Treatment of menorrhagia Reduction in blood
loss (38-50%) Decreased anemia
Less dysmenorrhea 60-90% reduction in
symptoms
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: COMBINED HORMONAL CONTRACEPTION Bloating, nausea, breast
tenderness Usually subside in a few months
Drug interactions DVTs Cardiovascular Disease
CAD Related to thrombotic mech Related to smoking status
HTN RR 1.8 for current OC users and
1.2 for previous OC users
Stroke Less of a concern with low dose
estrogen
Risk of cervical ca RR for 5 yrs of use
1.9 (95% CI 1.69-2.12)
Liver disorders Focal nodular
hyperplasia Hepatic adenomas
Headaches
N Engl J Med. 1981;305(11):612.
PROGESTIN-ONLY CONTRACEPTION
Progestin-only pills (POP)
Injectable DMPA
Sub-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 motility
Some progestins inhibit release of FSH and LH which inhibits ovulation (i.e. DMPA, implant)
CONTRAINDICATIONS: PROGESTIN-ONLY CONTRACEPTION Current 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 useNeed for strict compliance“27-hour rule”
Similar noncontraceptive benefits No “pill-free interval”
active pill taken every day Side effects
irregular bleedingamenorrhea
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 Amenorrhea
20% at 1 year 50% at 5 years
Expulsion 5% risk over 5 years
Perforation Uncommon (approx 1 in 1000)
BENEFITS:PROGESTIN-ONLY CONTRACEPTION Treatment 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
Natural Family Planning Lactational amenorrhea Withdrawal Fertility Awareness methods
Standard Days (cycle beads) Calendar Rhythm Method
COPPER IUD (PARAGUARD)
Mechanism Creates sterile inflammatory environment
Increase 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)
$90Monthly cost of some brand-name versions of the pill ($1,080 a year)
$55Monthly cost of vaginal ring or birth-control patch ($660 a year)
$60Annual cost of using a diaphragm and spermicide, including mandatory doctor's exam
$150Annual cost of using condoms, twice a week
$220-$460Annual cost of getting a birth control shot (Depo-Provera)
$600-$1,000One-time cost of getting an intrauterine device (IUD) implanted (effective for up to 10 years)
$0Up-front cost of abstinence and "fertility awareness" (rhythm method)
CONTRACEPTIVE STATISTICS
5Percent of U.S. women who use an IUD, which is 99 percent effective
75Percent of participants in a 10,000-woman St. Louis study that chose IUDs from a range of free contraception options
80Percent of those IUD users who have stuck with the method after a year
50Percent 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 choice for 3 yrs Removed financial barriers to long term
contraception
CONTRACEPTIVE CHOICE PROJECT
WHY IS IUD UNDERUTILIZED IN THE US?
Myths exist about intrauterine contraception Concerns about PID and infertility
persist
Negative publicity a/w older IUD
Misinformation among providers and patients is common
Selection of patients by clinicians is unnecessarily restrictive Nulliparous, h/o STI or PID, non-
monogamous
BAD PRESS…
[THE IUD]… UNFORTUNATELY, IT CAUSES A LOT OF CRAMPING AND HEAVY BLEEDING. AND IN MANY CASES THIS FOREIGN BODY LEADS TO THE FORMATION OF PELVIC INFLAMMATORY DISEASE, AND INFECTION OF THE UTERUS AND TUBES THAT CAN CAUSE INFERTILITY PROBLEMS. AN IUD IS RECOMMENDED ONLY FOR WOMEN IN MONOGAMOUS RELATIONSHIPS BECAUSE THE DEVICE ACTS AS A HIGHWAY FOR SEXUALLY TRANSMITTED DISEASES.
Baby Time, Or Not? Your Birth Control OptionsTHURSDAY, JANUARY 11, 2007BY DR. MANNY ALVAREZ
IUD:CONTRAINDICATIONS General
Known or suspected pregnancy
Current gonorrhea or chlamydia cervicitis
Pelvic inflammatory disease in past 3 months
Postpartum or post-abortion endometritis in past 3 months
Uterine abnormalities/fibroids (that prevent placement)
Uterine cavity smaller than 6 cm
Levonorgestrel IUD Current or hx of breast cancer
Copper IUD Copper allergy
Wilson’s disease
Risk greatest 1st month after insertion in patients with cervicitis• 6-fold increase in risk• After insertion, there is no increase in risk
Screen for gonorrhea and chlamydia at time of placement
DO IUDS INCREASE RISK OF PID?
IUDS:ADVANTAGES
One of most effective reversible methods
“Forgettable”
Does not require regular compliance from user
Low cost over 5 to 10 years
Decreased menstrual flow (LNG-IUD)
No hormones (copper IUD)
IUDS:DISADVANTAGES
High up-front cost
Requires office procedure for insertion and removal
Patient may have limited access or insurance coverage
THE END
Any questions?