Contraception Update for the Modern Day Woman

1. Contraception Update for the Modern Day Woman Patti Wheaton, APRN, CNP

2. Disclosures No commercial affiliations Just a proud new grandmother

3. Learning Objectives To become more aware of the history of contraception To be able to provide a brief contraceptive overview to patients Increase awareness of potential new male contraceptives

4. Objectives (Cont'd) To gain greater understanding of hormonal and non-hormonal contraceptives Mechanisms of action Prescribing Specifics Potential side effects Contraindications Effectiveness Suggested patient education Clinical Pearls

5. Contraceptive History

7. Ancient Egyptian writings from 1850BC refer to techniques using vaginal suppositories consisting of crocodile dung and fermented dough as well as plugs of gum, honey and acacia Writings of Soranus of Ephesus in early 2nd century Rome referred to vaginal sponges of wool infused with acidic concoction of fruits and nuts

9. And so it goes......

10. Why Should We Initiate the Conversation about Contraception?

11. How Are We Doing?

12. We Need to Present the Options

13. Start the Conversation When you review a patient's history initially or at follow up appointments, ask about contraception Many women don't consider their contraceptive method a medication and don't include it in their medication list Is there a question about contraception on your patient history forms?

14. Consider Your Patient's Needs Are you considering a pregnancy? When ? How important to you is it to not get pregnant? What have you used in the past that worked well for you? Have you completed your child bearing? Consider their lifestyle and how that would affect their method choices

15. Contraception Hits Home

16. Behavioral Methods Withdrawal Periodic Abstinence Lactation Amenorrhea Continuous Abstinence

17. Withdrawal 73-96% Effective (typical to perfect use) Requires high level of trust and self control May fail if there is sperm in the pre-ejaculate No cost and always available No protection against STDs and HIV

18. Periodic AbstinenceAKA – Rhythm and Fertility Awareness 75-88% effective (typical to perfect use) Involves tracking basal body temperature and checking consistency of cervical mucus Must track menstrual cycles Abstain or use barrier method 5 days before ovulation and 2 days after Must have regular and predictable cycles Using more than 1 method increases effectiveness No protection against STD's, HIV but no side effects

19. Lactational Amenorrhea 95-98 % effective (typical to perfect use) Breastfeed exclusively a minimum of every 4 hrs during the day and every 6 hrs at night Must discontinue if any one of the following occur 6 months postpartum 1st period comes Less frequent feedings No periods No protection again STD's or HIV

20. Continuous Abstinence Completely refraining from intercourse 100% effective No side effects No cost Prevents STDs and HIV Only works if you use it!

21. Barrier Methods Male Condom Female Condom Diaphragm Cervical Cap Spermicide

23. Male Condom 85 to 95% effectiveness (typical to perfect use) Cons Loss of sensation Inconvenience and interruption of sexual intercourse Slippage or breakage Pros Help protect against STDs and HIV PEARL Use water based lubricants only

25. Female Condom 75-95% effective (Typical to perfect use) Lubricated polyurethane pouch inserted into vagina Pros Helps prevent HIV and STDs Cons Loss of sensation Inconvenience and disruption of intercourse Higher rate of slippage and breakage than male condoms Friction and noise during intercourse

27. Diaphragm and Cervical Cap 84-94% effective (typical to perfect use) Must be fitted and prescribed by trained clinician Must be coated with spermicide and inserted prior to intercourse Subsequent episodes of intercourse within 6 hrs require insertion of more spermicide with device still in place Must be willing and able to locate cervix successfully Cons Possible skin irritation Increased risk of UTI with diaphragm Possible increased risk of HIV Doesn't protect against STDs and HIV

28. Spermicide Various forms - gels, suppositories, foams, sponge 71-85% effective (typical to perfect use) Must be inserted each time prior to intercourse Attacks the flagella and body of sperm, reducing mobility and fructolytic activity, inhibiting nourishment No longer thought to protect against STDs and HIV Pros Available over the counter Cons Possible skin irritation May actually increase risk of HIV transmission

30. Permanent Methods Male Vasectomy Female Bilateral Tubal Ligation Fallopian Tube Implants (Essure)

31. Vasectomy 99% Effective Outpatient or office procedure with local anesthesia Incision or puncture into scrotal sac Transection of Vas Deferens Occlusion of both ends with suture ligation or cautery Must use backup method until a “0” sperm count, usually rechecked at 12 weeks postop Risks – hematoma, bleeding, swelling, infection, pain, bruising, sperm granuloma (1-2% risk) No protection against STDs or HIV Consider post procedure regret, especially in younger men

32. Bilateral Tubal Ligation Bilateral fallopian tubes blocked with clips, bands, segmental destruction with cautery or suture ligation and/or partial salpingectomy 10 yr failure rate varies by method Clip 3.7% Bipolar coagulation 2.5% Interval partial salpingectomy 2% Silicone rubber bands 2% Postpartum Salpingectomy 0.8% Pros No hormones No change in libido No effect on breastfeeding Usually outpatient

33. Bilateral Tubal Ligation (cont'd) Cons General or regional anesthesia Usual surgical risks Post procedure regret can be greater in younger women No protection against STDs or HIV Occasionally becomes more involved procedure from laparoscopic to mini-lap with small incision Timing Post C/S through the same incision Post delivery with mini laparotomy Interval -doesn't coincide with recent pregnancy

34. Fallopian Tube Implants (Essure) Microinserts via hysteroscope into each fallopian tube as an office procedure, using local to general anesthesia Creates scar tissue, blocking tubes after about 3 months Must use backup method until confirmation of occlusion via hysteroscopy at 3 months post procedure Failure rate at 5 yrs is < 1:1000 Pros No hormonal influence No impact on libido, breastfeeding or periods Cons Incorrect placement can cause pain, bleeding and may require surgical removal No protection against STDs or HIV Post procedural regret for younger women

35. September of 2015, FDA investigated patient claims of harm secondary to the Essure No evidence of wrongdoing Suggested the company evaluate their long-term outcomes and provide additional training to clinicians New labeling now includes recommendations for patient selection process with a checklist Http://www.fda.gov/Medical/Devices/ResourcesforYou/Industry/UCM529254.htm

37. Emergency Contraception Use of drug or device to prevent pregnancy after unprotected intercourse Candidates Reproductive aged women having unprotected sex less than 120 hours previously Independent of menstrual cycle No absolute contraindications due to the short lived hormone exposure 2 methods available in US Copper T380 IUD Emergency contraception pills

38. Copper T380 IUD Can be inserted up to 5-7 days after unprotected sex Reduces risk of pregnancy by more than 99% Nearly 100% effective if inserted within 5 days of unprotected sex Cons Slight but transient risk of infection Heavier, more painful periods No protection from STDs or HIV Discomfort at the time of insertion, shortly after Can have limited availability Pros Also provides excellent long acting contraception No change in effectiveness with obese patients

39. Emergency Contraception Pills Progestin Only Progesterone Agonist/Antagonist Combined Hormone

40. Progestin Only – Plan B Delays ovulation up until the point of LH surge by inhibition of follicular development and maturation If taken within 72 hours of unprotected sex, the risk of pregnancy is reduced by 89% Pros No prescription required Cons Less effective over 72 hours Less effective if patient is > 165lbs General Side Effects – all Plan B Nausea/Vomiting Headaches Changes in Menses Dizziness Breast Tenderness Abdominal Pain

41. Plan B One Step Approved by FDA in June 2013 as nonprescription product No age restrictions Consists of enteric coated 1.5mg tablet of levonorgestrel Generic available February 2014 My Way Take Action Next Choice One-Dose Original Plan B 1 dose of 750mcg Levonogrestrel as soon as possible after unprotected sex Repeat no later than 72-120 hrs after unprotected sex Most effective at 72 hrs

42. Progestin Agonist/Antagonist Ulipristal Acetate - Ella Effects agonist and antagonist receptors of progesterone Possible mechanism of action includes delaying or preventing ovulation and changes of endometrium Reduces risk of pregnancy by 90% if taken within 5 days of unprotected sex Less reduction of effectiveness over time than other emergency contraception pills May be less effective for obese women If vomiting occurs within 3 hours of administration, repeat dose Side Effects: Headache, dizziness or abdominal Pain 1 30mg tablet within 120hrs of unprotected sex

43. Combined Emergency Contraception Pills Yuzpe Regimen one of the 1st methods but less common now Taking additional doses of oral contraceptives, usually from existing prescription Various methods available – www.bedsider.org If taken within 72hrs of unprotected sex, pregnancy risk is decreased by 75% May be contraindicated in women with cardiovascular risk factors Side Effects – nausea, vomiting, head/ache, changes in cycle, breast tenderness

44. Emergency Contraception FYI Won't disrupt an existing pregnancy Not intended to be used as an ongoing contraceptive method Effectiveness can be influenced by Timing of LMP and day of exposure Regular verses irregular periods and the effects on ovulation timing Existing pregnancies If greater than 1 episode of unprotected sex PEARL – taking anti-emetic 1 hr before helps prevent nausea and vomiting

45. Long Acting Reversible ContraceptionLARC Intrauterine Devices Hormonal Non-hormonal Implants

46. IUDs Timing of insertion Immediately postpartum or post AB up to 6wks Can be inserted at anytime in cycle that pregnancy can be reasonable excluded Copper IUD can be used as emergency contraception 5% risk for expulsion in 1st year if inserted immediately postpartum or post AB Common Side Effects Irregular bleeding up to 6 months post insertion Cramping, backache at time of insertion Risks of uterine perforation at insertion is 1%

47. Contraindications to IUDs Copper IUD – Wilson's Disease Undiagnosed uterine bleeding Known or suspected pregnancy Active cervical or endometrial infections Abnormal or distorted uterine cavity Cons Must be inserted or removed by trained clinician No protection against STDs or HIV Pros Rapid return to fertility Protection immediately and can be removed at any time Always protected, nothing to remember

48. Nonhormonal IUDs Copper T380 – Paragard Introduced in 1988 Offers 10 yrs of protection against pregnancy Creates a toxic intrauterine milieu,, preventing fertilization No effects on breastfeeding Can be used in women with contraindications to hormonal contraception 99% effective in preventing pregnancy

49. Hormonal IUDs T shaped IUD with levonorgestril Mechanism of Action Changes cervical mucus, altering sperm migration Uterotubal fluid and motility changes inhibit sperm migration Endometrial suppression First – Was Progestasert, good for 1 yr, no longer available Currently available Mirena –52mg providing 20mcg per day x 5yrs Liletta –52mg providing 19.5mcg per day x 4yrs Kyleena –19.5mg providing 17.5mcg per day x 5yrs Skyla – 13.5mg providing 14mcg per day x 3yrs Mirena has FDA approval for menorrhagia

50. 0.1% Failure rate No adverse systemic effects Decreased risks of endometrial and ovarian cancers Decreases menstrual flow and cramps. Approximately 20% experience amenorrhea 6 to 12 months after insertion Risks of PID decrease after first few months of use compared to noncontracepting women