Contraception. Background Contraception and sexual health Office for National Statistics October...

ContraceptionContraception

BackgroundBackground

Contraception and sexual healthContraception and sexual healthOffice for National Statistics October 2009 www.statistics.gov.ukOffice for National Statistics October 2009 www.statistics.gov.uk

► Surveyed 4366 people (59% response)Surveyed 4366 people (59% response)

► 55% of women aged 16-49 had used family planning services in the last 5 55% of women aged 16-49 had used family planning services in the last 5 yearsyears

► Service use greatest among 25-29y (73%)Service use greatest among 25-29y (73%)

► Primary methods:Primary methods: Oral contraception (25%) Oral contraception (25%) Male condom (25%)Male condom (25%)

► Emergency contraception used by 7% of women in last yearEmergency contraception used by 7% of women in last year 42% obtained from a pharmacy (20% in 2001/2)42% obtained from a pharmacy (20% in 2001/2) 31% obtained from a GP or practice nurse (43% in 2001/2)31% obtained from a GP or practice nurse (43% in 2001/2) Condom failure cited as main reason for using EHCCondom failure cited as main reason for using EHC

Types and choice of contraceptionTypes and choice of contraception

Types of non-surgical contraceptionTypes of non-surgical contraceptionBNF 58; September 2009BNF 58; September 2009

► Hormonal contraceptionHormonal contraception Most effective method of fertility controlMost effective method of fertility control Has major and minor side effectsHas major and minor side effects

► Intrauterine devices (IUD)Intrauterine devices (IUD) Highly effectiveHighly effective May produce highly undesirable local effects eg menorrhagiaMay produce highly undesirable local effects eg menorrhagia Background risk of PIDBackground risk of PID May be used in women of all ages irrespective of parityMay be used in women of all ages irrespective of parity Less appropriate for those with increased risk of PIDLess appropriate for those with increased risk of PID Can be used as emergency contraceptionCan be used as emergency contraception

► Barrier methodsBarrier methods Less effectiveLess effective Suitable for well-motivated couples if used with spermicideSuitable for well-motivated couples if used with spermicide AccessibleAccessible SafeSafe

Contraceptive choiceContraceptive choiceContraception and sexual health 2008/9. www.statistics.gov.ukContraception and sexual health 2008/9. www.statistics.gov.uk

► At least one method (76%)At least one method (76%)► OC (25%)OC (25%)► Male condom (25%)Male condom (25%)► Male sterilisation (11%)Male sterilisation (11%)► Female sterilisation (6%)Female sterilisation (6%)► IUD (6%)IUD (6%)► Withdrawal (4%)Withdrawal (4%)► Injection / implant (4%)Injection / implant (4%)► Safe period (2%)Safe period (2%)► Hormonal IUS (2%)Hormonal IUS (2%)► Emergency contraception (1%)Emergency contraception (1%)► Cap (0%)Cap (0%)

Use of oral contraception with ageUse of oral contraception with age Contraception and sexual health 2008/9. www.statistics.gov.uk Contraception and sexual health 2008/9. www.statistics.gov.uk

► In general, proportion of women using the pill decreases with In general, proportion of women using the pill decreases with ageage

► Use of male condom more prevalent amongst younger couplesUse of male condom more prevalent amongst younger couples

Types of hormonal contraceptives (1)Types of hormonal contraceptives (1)

► Combined hormonal contraceptivesCombined hormonal contraceptives Combined oral contraceptive (COC)Combined oral contraceptive (COC)

►Usually ethinyloestradiol with a progestogenUsually ethinyloestradiol with a progestogen►1/2/3/4 generation1/2/3/4 generation

Transdermal preparationTransdermal preparation►Ethinyloestradiol with norelgestromin (an active Ethinyloestradiol with norelgestromin (an active

metabolite of norgestimate) (Evra)metabolite of norgestimate) (Evra) Vaginal preparationVaginal preparation

►Ethinyloestradiol with etonorgestrel (NuvaRing)Ethinyloestradiol with etonorgestrel (NuvaRing)


11stst generation generation 22ndnd generation generation 33rdrd generation generation 44thth generation generation

NoerthisteroneNoerthisterone(Loestrin)(Loestrin)

LevonorgestrelLevonorgestrel(Microgynon)(Microgynon)

DesogestrelDesogestrel(Mercilon)(Mercilon)(Marvelon)(Marvelon)

Drospirenone Drospirenone (Yasmin)(Yasmin)

Etynodiol diacetate Etynodiol diacetate (only in POP)(only in POP)

GestodeneGestodene(Femodette)(Femodette)(Femodene)(Femodene)

Dienogest (Qlaira Dienogest (Qlaira with estradiol with estradiol

valeratevalerate

NorgestimateNorgestimate(Cilest)(Cilest)


► Progestogen only contraceptivesProgestogen only contraceptives Progestogen only pill (POP)Progestogen only pill (POP)

► Suitable when COCs unsuitable (eg predisposition to VTE)Suitable when COCs unsuitable (eg predisposition to VTE)► Higher failure rate than COCsHigher failure rate than COCs► Norethisterone (Micronor)Norethisterone (Micronor)► Etynodiol diacetate (Femulen)Etynodiol diacetate (Femulen)► Levonorgestrel (Norgeston)Levonorgestrel (Norgeston)► Desogestrel (Cerazette)Desogestrel (Cerazette)

Parenteral progestogen-only contraceptiveParenteral progestogen-only contraceptive► InjectionInjection

Medroxyprogesterone acetate (Depo-Provera)Medroxyprogesterone acetate (Depo-Provera) Norethisterone enantate (Noristerat)Norethisterone enantate (Noristerat)

► ImplantImplant Etonorgestrel (Implanon)Etonorgestrel (Implanon)

Progestogen-only intra-uterine device (IUD)Progestogen-only intra-uterine device (IUD)► Levonorgestrel (Mirena)Levonorgestrel (Mirena)


► Emergency hormonal contraceptivesEmergency hormonal contraceptives Levonorgestrel (Levonelle)Levonorgestrel (Levonelle) Ulipristal acetate (ellaOne)Ulipristal acetate (ellaOne)

Effectiveness of different forms of Effectiveness of different forms of contraceptioncontraception

How do we measure effectiveness?How do we measure effectiveness?MeReC Bulletin 2006; 17: 1-9MeReC Bulletin 2006; 17: 1-9

► Judged by failure rates:Judged by failure rates: Mode of action of the methodMode of action of the method Ease of useEase of use

► Typical use vs. perfect useTypical use vs. perfect use

► Pearl Index (PI)Pearl Index (PI) No. of unintended pregnancies per 100 women yearsNo. of unintended pregnancies per 100 women years 1 woman year is 13 menstrual cycles1 woman year is 13 menstrual cycles PI=1.0 if 100 women use a contraceptive method for 13 cycles PI=1.0 if 100 women use a contraceptive method for 13 cycles

and 1 becomes pregnantand 1 becomes pregnant

Failure rates associated with different methods (1)Failure rates associated with different methods (1)MeReC Bulletin 2006; 17: 1-9MeReC Bulletin 2006; 17: 1-9

% of women experiencing unintended pregnancy in 1% of women experiencing unintended pregnancy in 1stst year of useyear of use

Typical use (%)Typical use (%) Perfect use (%)Perfect use (%)

No methodNo method 8585 8585

SpermicidesSpermicides 2929 1515

WithdrawalWithdrawal 2727 44

Periodic abstinencePeriodic abstinenceCalendarCalendarOvulation methodOvulation methodSympto-thermalSympto-thermalPost-ovulationPost-ovulation

252599332211

Cap plus spermicideCap plus spermicideParous womenParous womenNulliparous womenNulliparous women

32321616

262699

Sponge Sponge Parous womenParous womenNulliparous womenNulliparous women

32321616

202099

Diapragm plus spermicideDiapragm plus spermicide 1616 66

Failure rates associated with different methods (2)Failure rates associated with different methods (2)MeReC Bulletin 2006; 17: 1-9MeReC Bulletin 2006; 17: 1-9

% of women experiencing unintended pregnancy in 1% of women experiencing unintended pregnancy in 1stst year of useyear of use

Typical use (%)Typical use (%) Perfect use (%)Perfect use (%)

Female condom (without Female condom (without spermicide)spermicide)

2121 55

Male condom (without Male condom (without spermicide)spermicide)

1515 22

COC and POPCOC and POP 88 0.30.3

Evra patchEvra patch 88 0.30.3

Depo-Provera injectionDepo-Provera injection 33 0.30.3

MirenaMirena 0.10.1 0.10.1

Female sterilisationFemale sterilisation 0.50.5 0.50.5

Male sterilisationMale sterilisation 0.150.15 0.100.10

Pregnancy rates associated with LARC methodsPregnancy rates associated with LARC methodsMeReC Bulletin 2006; 17: 1-9MeReC Bulletin 2006; 17: 1-9

Pregnancy rate (%)Pregnancy rate (%)

Copper IUDCopper IUD <2 over 5 years, for IUDs with at least <2 over 5 years, for IUDs with at least 380mm copper380mm copper

Progestogen-only intrauterine systemProgestogen-only intrauterine system <1 over 5 years<1 over 5 years

Progestogen-only injectable contraceptivesProgestogen-only injectable contraceptives <0.4 over 2 years<0.4 over 2 years(when injections given at the (when injections given at the recommended intervals)recommended intervals)

Progestogen-only subdermal implantsProgestogen-only subdermal implants <0.1 over 3 years<0.1 over 3 years

What constitutes good prescribing?What constitutes good prescribing?Barber N. BMJ 1995; 310: 923-5Barber N. BMJ 1995; 310: 923-5

EFFECTIVEEFFECTIVEBenificenceBenificence

SAFESAFENon-malfeasanceNon-malfeasance

COSTCOSTJustice Justice

PATIENT FACTORSPATIENT FACTORSPatient autonomyPatient autonomy

Risks of contraceptionRisks of contraception

Increased risk of VTEIncreased risk of VTECurrent Problems in Pharmacovigilance 1999; 25: 12Current Problems in Pharmacovigilance 1999; 25: 12

Drug Safety Update Vol 1, Issue 9, April 2008Drug Safety Update Vol 1, Issue 9, April 2008

► All COCs increase the risk of VTEAll COCs increase the risk of VTE

► The risk associated with COCs containing desogestrel or The risk associated with COCs containing desogestrel or gestodene (gestodene (2.5 per 10000 women years2.5 per 10000 women years) is greater than that ) is greater than that associated with other COCs (associated with other COCs (1.5 per 10000 women years1.5 per 10000 women years) and ) and with never users (with never users (0.5-1.0 per 10000 women years0.5-1.0 per 10000 women years))

► The risk is still low and lower than the risk of VTE in pregnancy (The risk is still low and lower than the risk of VTE in pregnancy (6 6 per 10000 women yearsper 10000 women years))

What about VTE risk with Evra?What about VTE risk with Evra?Drug Safety Update Vol 1, Issue 9, April 2008Drug Safety Update Vol 1, Issue 9, April 2008

► The VTE risk in users of Evra may be slightly increased compared The VTE risk in users of Evra may be slightly increased compared with that of users of second-generation pillswith that of users of second-generation pills

What about VTE risk with Yasmin?What about VTE risk with Yasmin?Drug Safety Update Vol 1, Issue 9, April 2008Drug Safety Update Vol 1, Issue 9, April 2008

► The risk is somewhere between pills containing levonorgestrel The risk is somewhere between pills containing levonorgestrel (second generation) and those containing desogestrel or (second generation) and those containing desogestrel or gestodene (third generation)gestodene (third generation)

► The risk is lower than that of pregnancyThe risk is lower than that of pregnancy

Myocardial infarctionMyocardial infarction

► Absolute risk of an MI in young women is very lowAbsolute risk of an MI in young women is very low

► Smoking and OC use increases risk significantlySmoking and OC use increases risk significantly

StrokeStroke

► Absolute risk of stroke is very small (1 additional stroke per year Absolute risk of stroke is very small (1 additional stroke per year per 24000 non-smoking, normotensive women using a low-dose per 24000 non-smoking, normotensive women using a low-dose oestrogen)oestrogen)

Advice to older womenAdvice to older womenFaculty of Family Planning and Reproductive Healthcare Clinical Effectiveness Unit. Contraception for Faculty of Family Planning and Reproductive Healthcare Clinical Effectiveness Unit. Contraception for

women aged over 40 years. J Fam Plan Reprod Healthcare 2005; 31: 51-64women aged over 40 years. J Fam Plan Reprod Healthcare 2005; 31: 51-64

► Women aged over 40 can use combined hormonal Women aged over 40 can use combined hormonal contraception unless there are co-existing diseases or risk contraception unless there are co-existing diseases or risk factorsfactors

► The risks of using combined hormonal contraception outweight The risks of using combined hormonal contraception outweight the benefits for smokers aged ≥35 yearsthe benefits for smokers aged ≥35 years

► Women who smoke are best advised to discontinue combined Women who smoke are best advised to discontinue combined hormonal contraceptives and find another contraceptive hormonal contraceptives and find another contraceptive method at 35 yearsmethod at 35 years

CancerCancer

► OC use does not increase a woman’s overall risk of cancer and may OC use does not increase a woman’s overall risk of cancer and may slightly decrease itslightly decrease it

► The risk of individual cancers may be increased or decreased The risk of individual cancers may be increased or decreased depending on duration of use and length of time since last usedepending on duration of use and length of time since last use

► Small, if any, increased risk of breast cancer, but in addition to Small, if any, increased risk of breast cancer, but in addition to background risk which increases with agebackground risk which increases with age

► Small increased risk of cervical cancerSmall increased risk of cervical cancer

► Decreased risk of cervical cancerDecreased risk of cervical cancer

Newer agentsNewer agents

CerazetteCerazetteWhich POP? RDTC. Drug Update. Sep 2007Which POP? RDTC. Drug Update. Sep 2007

► Desogestrel 75mcgDesogestrel 75mcg

► Inhibits ovulation in addition to thickening cervical mucus, with Inhibits ovulation in addition to thickening cervical mucus, with theoretical improved contraceptive efficacy vs. standard POPstheoretical improved contraceptive efficacy vs. standard POPs

► Desogestrel has a 12h missed pill windowDesogestrel has a 12h missed pill window

► As desogestrel is more expensive than standard POPs, reserve As desogestrel is more expensive than standard POPs, reserve for women who find the strict regimen of standard POPs difficult for women who find the strict regimen of standard POPs difficult to keep to to keep to

YasminYasminMeReC Bulletin Volume 17, Number 2, November 2006MeReC Bulletin Volume 17, Number 2, November 2006

► Ethinyloestradiol 30mcg / drospirenone 3mgEthinyloestradiol 30mcg / drospirenone 3mg

► An option for those women suitable for a COC. Yasmin has no An option for those women suitable for a COC. Yasmin has no conclusive advantages over other standard strength COCsconclusive advantages over other standard strength COCs

EvraEvraMeReC Bulletin Volume 17, Number 2, November 2006MeReC Bulletin Volume 17, Number 2, November 2006

► Transdermal patch releasing ethinyloestradiol 33.9mcg and norelgestromin Transdermal patch releasing ethinyloestradiol 33.9mcg and norelgestromin 203mcg per 24h203mcg per 24h

► Option for some women wishing to use a reversible method of contraception Option for some women wishing to use a reversible method of contraception and who are experiencing compliance problems with COCsand who are experiencing compliance problems with COCs

► Evra vs. oral COCsEvra vs. oral COCs Better compliance with patchBetter compliance with patch No evidence of improved efficacy, pregnancy rates or safetyNo evidence of improved efficacy, pregnancy rates or safety Similar overall tolerability to COCsSimilar overall tolerability to COCs VTE risk may be higher with EvraVTE risk may be higher with Evra

NuvaRingNuvaRing

► Vaginal ring delivering ethinyloestradiol 15mcg and etonogestrel Vaginal ring delivering ethinyloestradiol 15mcg and etonogestrel 120mcg per 24h120mcg per 24h

► One ring inserted vaginally for 3 week duration followed by 7 One ring inserted vaginally for 3 week duration followed by 7 day ring-free breakday ring-free break

► Contraceptive efficacy similar to COCsContraceptive efficacy similar to COCs

► Possibly better cycle control than COCsPossibly better cycle control than COCs

QlairaQlaira

► Estradiol valerate / dienogest in complex quadriphasic dosage Estradiol valerate / dienogest in complex quadriphasic dosage regimenregimen

► First COC containing estradiolFirst COC containing estradiol

► Continuous 28 day cycle of 26 active tablets and 2 placeboContinuous 28 day cycle of 26 active tablets and 2 placebo

► Contraceptive effectiveness similar to COCs with comparable Contraceptive effectiveness similar to COCs with comparable side effects and tolerabilityside effects and tolerability

► Fewer have withdrawal bleedingFewer have withdrawal bleeding

Long acting reversible contraception (LARC) (1)Long acting reversible contraception (LARC) (1)NICE Clinical Guideline No 30, October 2005NICE Clinical Guideline No 30, October 2005

► Uptake lowUptake low 8% of women aged 16-49 in 2003-48% of women aged 16-49 in 2003-4 25% pill25% pill 23% male condoms23% male condoms

► LARC includes:LARC includes: Copper intrauterine devices (IUD)Copper intrauterine devices (IUD) Progestogen-only intrauterine systems (IUS) eg MirenaProgestogen-only intrauterine systems (IUS) eg Mirena Progestogen-only injectable contraceptives eg Dep-proveraProgestogen-only injectable contraceptives eg Dep-provera Progestogen-only subdermal implants eg ImplanonProgestogen-only subdermal implants eg Implanon

Long acting reversible contraception (LARC) (2)Long acting reversible contraception (LARC) (2)NICE Clinical Guideline No 30, October 2005NICE Clinical Guideline No 30, October 2005

► All currently available LARC methods are more cost effective All currently available LARC methods are more cost effective than COCs even at 1 year of usethan COCs even at 1 year of use

► IUDs, IUS and implants are more cost effective than the IUDs, IUS and implants are more cost effective than the injectable contraceptivesinjectable contraceptives

► Increasing the uptake of LARC methods will reduce the numbers Increasing the uptake of LARC methods will reduce the numbers of unintended pregnanciesof unintended pregnancies

Depo-Provera: effect on bonesDepo-Provera: effect on bonesMHRA, 18MHRA, 18thth November 2004 November 2004

► The CSM advised:The CSM advised: In adolescents may be used as first line contraception but In adolescents may be used as first line contraception but

only after discussion about other methodsonly after discussion about other methods In women of all ages, careful re-evaluation of the risks and In women of all ages, careful re-evaluation of the risks and

benefits of treatment should be carried out in those who benefits of treatment should be carried out in those who wish to continue use for more than 2 yearswish to continue use for more than 2 years

In women with significant lifestyle and/or medical risk factors In women with significant lifestyle and/or medical risk factors for osteoporosis other methods of contraception should be for osteoporosis other methods of contraception should be consideredconsidered

Emergency contraceptionEmergency contraception

► Levonelle (levonorgestrel 1.5mg)Levonelle (levonorgestrel 1.5mg) 1 tablet preferably taken within 12h but no later than 72h1 tablet preferably taken within 12h but no later than 72h

► Non-hormonal IUDNon-hormonal IUD

► EllaOne (ulipristal acetate 30mg)EllaOne (ulipristal acetate 30mg) 1 tablet ASAP but no later than 120h1 tablet ASAP but no later than 120h

Case studyCase study

► Nicola is a 35y old sales manager. Before the birth Nicola is a 35y old sales manager. Before the birth of her children she took marvelon for 12 years. She of her children she took marvelon for 12 years. She has a complete family and is about to return from has a complete family and is about to return from maternity leave to work in 2 weeks. She has a BMI maternity leave to work in 2 weeks. She has a BMI of 29kg/m² and smokes. She had a DVT in her of 29kg/m² and smokes. She had a DVT in her second pregnancy in her calf which was treated second pregnancy in her calf which was treated with heparinwith heparin

► She would like to recommence the COC. She has She would like to recommence the COC. She has gained weight since her children and is concerned gained weight since her children and is concerned the COC will cause more gain. She has heard the COC will cause more gain. She has heard yasmin does not have this side effectyasmin does not have this side effect

What type of COC is marvelon?What type of COC is marvelon?

► Third generation COC containing ethinyloestradiol and Third generation COC containing ethinyloestradiol and desogestreldesogestrel

Is there any evidence that Yasmin is less likely Is there any evidence that Yasmin is less likely to cause weight gain than other COCs?to cause weight gain than other COCs?

► For a woman concerned about weight gain with COCs, there is For a woman concerned about weight gain with COCs, there is no good evidence upon which to recommend Yasmin instead of no good evidence upon which to recommend Yasmin instead of other preparationsother preparations

What background questions would you ask in What background questions would you ask in order to identify a preferred method of order to identify a preferred method of

contraception for Nicola?contraception for Nicola?

► The primary goal is to allow choice of the method with which The primary goal is to allow choice of the method with which they feel most comfortable taking into account their lifestyle, they feel most comfortable taking into account their lifestyle, preferences and concernspreferences and concerns

► Effectiveness compared with alternativesEffectiveness compared with alternatives► How it worksHow it works► Correct useCorrect use► Health risks and benefitsHealth risks and benefits

► Medical historyMedical history Medical risk factors for / personal history of VTE?Medical risk factors for / personal history of VTE?

► Family historyFamily history Breast cancer in 1Breast cancer in 1stst degree relatives? degree relatives?

► Social circumstancesSocial circumstances Will she travel long distances by car?Will she travel long distances by car?

► Personal preferencesPersonal preferences As family is complete would she prefer the convenience and As family is complete would she prefer the convenience and

effectiveness of long-acting method?effectiveness of long-acting method?► Exclude pregnancyExclude pregnancy

Menstrual and sexual historyMenstrual and sexual history

► During further discussion, her job involves long car journeys of During further discussion, her job involves long car journeys of up to 4-5 hours. She has completed her family and is seeking a up to 4-5 hours. She has completed her family and is seeking a highly reliable form of contraceptionhighly reliable form of contraception

How would this new information influence How would this new information influence the advice which you might offer to her?the advice which you might offer to her?

The “pill scare” – Current Problems in The “pill scare” – Current Problems in Pharmacovigilance 1999; 25: 12Pharmacovigilance 1999; 25: 12

Risk of VTE associated with COC use and non-useRisk of VTE associated with COC use and non-use

CircumstanceCircumstance Risk of VTE per 100000 womenRisk of VTE per 100000 women

Healthy, non-pregnant women (not taking Healthy, non-pregnant women (not taking any oral contraceptive)any oral contraceptive)

5 cases per year5 cases per year

Women taking COCs containing Women taking COCs containing levonorgestrellevonorgestrel

15 cases per year of use15 cases per year of use

Women taking COCs containing desogestrel Women taking COCs containing desogestrel or gestodeneor gestodene

25 cases per year of use25 cases per year of use

► Risk of VTE in pregnancy 60 per 100000Risk of VTE in pregnancy 60 per 100000

► Risk of dying on the road 6 in 100000Risk of dying on the road 6 in 100000

► A family history of VTE and continuous travel of more than 3 A family history of VTE and continuous travel of more than 3 hours are both risk factors for VTEhours are both risk factors for VTE

► Obesity is also a risk factor Obesity is also a risk factor

► Her risk of VTE is increased by her personal history of VTE, she Her risk of VTE is increased by her personal history of VTE, she travels long distances, and she is overweighttravels long distances, and she is overweight

► There is also a small additional risk of MI and stroke from her There is also a small additional risk of MI and stroke from her age, smoking and body weightage, smoking and body weight

► She requests more information on LARCShe requests more information on LARC

What information and advice would you offer What information and advice would you offer her?her?

► Contraceptive efficacyContraceptive efficacy

► Duration of useDuration of use

► Risks and possible side effectsRisks and possible side effects

► Non-contraceptive benefitsNon-contraceptive benefits

► Procedure for initiation and removal / discontinuationProcedure for initiation and removal / discontinuation

► When to seek help when using the methodWhen to seek help when using the method

EndEnd

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