CLO Contraception PPT

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CONTRACEPTION Medicine-Ambulatory Presentation

description

Overview of contraception options

Transcript of CLO Contraception PPT

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CONTRACEPTION

Medicine-Ambulatory Presentation

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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

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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.

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HOW CAN WE PREVENT UNINTENDED PREGNANCY?

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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

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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

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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

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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

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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

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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)

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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

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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

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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

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VAGINAL RINGNUVARING

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

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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

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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

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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.

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PROGESTIN-ONLY CONTRACEPTION

Progestin-only pills (POP)

Injectable DMPA

Sub-dermal implant

Levonorgestrel-releasing IUD

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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)

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

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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

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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

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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

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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)

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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

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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

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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

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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

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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)

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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

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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

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CONTRACEPTIVE CHOICE PROJECT

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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

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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

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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

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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?

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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)

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IUDS:DISADVANTAGES

High up-front cost

Requires office procedure for insertion and removal

Patient may have limited access or insurance coverage

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THE END

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