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Provider Education and Training to Increase Use of Intrauterine Contraception

Provider Education and Training to Increase Use of Intrauterine Contraception. Association of Reproductive Health Professionals www.arhp.org. Acknowledgment. This program was made possible through educational grants from Bayer HealthCare Pharmaceuticals and Teva Pharmaceuticals.

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Provider Education and Training to Increase Use of Intrauterine Contraception

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  1. Provider Education and Training to Increase Use of Intrauterine Contraception Association of Reproductive Health Professionals www.arhp.org

  2. Acknowledgment This program was made possible through educational grants from Bayer HealthCare Pharmaceuticals and Teva Pharmaceuticals.

  3. Disclosure Declarations

  4. Learning Objectives • Explain the differences between the three forms of intrauterine contraception available in the United States • Select appropriate candidates for intrauterine contraception • Describe two possible side effects of each type of intrauterine contraceptive more…

  5. Learning Objectives (continued) • Describe pain management strategies during and after insertion • Discuss strategies for follow-up of intrauterine contraceptive users • Develop skills required for proper insertion techniques for the three methods of intrauterine contraception

  6. Terms for Intrauterine Contraception

  7. Unintended Pregnancy in the US 6.8 million pregnancies over one year Unintended: 49% Intended: 51% Unintended births 23% 51% 21% 5% Elective abortions Fetal losses Finer LB. Contraception. 2011; Finer LB. Fertil Steril. 2012; Finer LB. Perspect Sex Reprod Health. 2006; Henshaw SK. Fam Plann Perspect. 1998.

  8. Presentation Outline • Contraceptive Use Globally and in the United States • Overview of Current IUC Methods • Patient Screening and Counseling for IUC • Case presentations • IUC Insertion and Management • Hands-on Practicum

  9. Contraceptive Use Globally and in the United States

  10. Worldwide Use of IUC Use for Married Women of Reproductive Age % Using IUCs NorthAmerica Asia Europe Latin America & Caribbean Africa Oceania Population Reference Bureau. 2002; Mosher WD. Vital Health Stat. 2010.

  11. History of Successful IUC Use 1988: Copper T 380 IUD available in the United States 2013: LNG 13.5 IUS available in the United States 1967: T-shaped device developed 1976: Copper T 200 becomes first copper IUD 1909: Grafenberg develops ring-shaped IUC device 1968: Contraceptive action of intrauterine copper reported 1962: First international conference on IUC; designs for plastic spiral and plastic loop presented 1980: LNG IUC tested in randomized clinical trials 2001: LNG 52 IUS available in the United States Richter R. Deutsche Med Wochenschr. 1909; Grafenberg E. 1930; Ishihama A. Yokohama Med Bull. 1959; Oppenheimer W. Am J Obstet Gynecol. 1959; Berelson B. 1964; Marguiles LC. 1962; Lippes J. 1962; Hubacher D. Contraception. 2004; Lee NC. Obstet Gynecol. 1983; Mosher WD. 2004.

  12. Need for Effective Reversible Methods There is a need for effective contraceptive methods that are “forgettable” 1 in 5 20% of women selecting sterilization at age 30 years or younger express regret later pregnancies endsin abortion Finer LB. Perspect Sexual Reprod Health. 2003; Stanwood NL. Obstet Gynecol. 2002; Hillis SD. Obstet Gynecol.1999.

  13. Why an Update on IUC? • Myths exist about IUC • Selection of candidates is unduly restrictive • Misinformation about IUC among providers and patients is common Stanwood NL. Obstet Gynecol. 2002; Weiss E. Contraception. 2003.

  14. Why IUC Is Underused in the United States • Lack of awareness of method among women • Myths about IUC safety • Negative publicity • Misconceptions • Upfront cost • Lack of positive marketing • Fear of litigation Stanwood NL. Obstet Gynecol. 2002; Steinauer JE. Fam Plann Perspect. 1997; Weir E. CMAJ. 2003.

  15. Use of IUC by Female Ob/Gyns vs. All Women in the United States % Using IUC Female Ob/Gyn Physicians General Population Population Reference Bureau. 2002; The Gallup Organization. 2004.

  16. Effectiveness Side effects Convenience Duration of action and childbearing plans Patient choice Reversibility Non-contraceptive benefits Cost Privacy Considerations in Choice of Contraceptive Methods

  17. Overview of Current IUC Methods

  18. Characteristics of IUC • Highest patient satisfaction among methods • Rapid return of fertility • Safe • Immediately effective • Long-term protection • Highly effective Fortney JA. J Reprod Med. 1999; Belhadj H. Contraception. 1986; Skjeldestad F. Adv Contracept. 1988; Arumugam K. Med Sci Res. 1991; Tadesse E. East Afr Med J. 1996.

  19. Dispelling Myths About IUC In fact, IUDs: • Are not abortifacients • Do not cause ectopic pregnancies • Do not cause pelvic infection • Do not decrease the likelihood of future pregnancies • Are not large in size • Canbe used by nulliparous women • Canbe used by women who have had an ectopic pregnancy • Do not need to be removed for PID treatment • Do not have to be removed if inflammatory changes are noted on a Pap test Duenas JL. Contraception. 1996; Forrest JD. Obstet Gynecol Surv. 1996; Hubacher D. N Engl J Med. 2001; Lippes J. Am J Obstet Gynecol. 1999; Otero-Flores JB. Contraception. 2003; Penney G. J Fam Plann Reprod Health Care. 2004; Stanwood NL. Obstet Gynecol. 2002; WHO. 2009.

  20. IUC Available in the United States • Copper T 380A IUD • Copper ions • Approved for 10 years of use more… ParaGard®PI. 2013; Teva. 2013.

  21. IUC Available in the United States (continued) • LNG52 IUS • Releases 20 μg of LNG per day • Approved for 5 years of use • LNG 13.5 IUS • Releases 14 μg of LNG per day • Approved for 3 years of use Mirena®PI. 2013; SkylaTM PI. 2013.

  22. IUC Mechanism of Action Ortiz ME. Contraception. 2007; Alvarez F. Fertil Steril. 1988; Segal SJ. Fertil Steril. 1985; ACOG. 1998; Jonsson B. Contraception. 1991; Silverberg SG. Int J Gynecol Pathol. 1986.

  23. Efficacy: First-Year Failure Rates of Selected Contraceptives (Typical Use) LNG IUS Sterilization—female Copper T IUD Injectable (DMPA) Pills/patch/ring Condom—male Spermicides No contraception Percent Trussell J. 2011; WHO. 1987; Peterson HB. Am J Obstet Gynecol. 1996.

  24. 100 80 IUC OC Diaphragm Other methods 60 Pregnancies (%) 40 20 0 12 18 24 30 36 42 0 Months After Discontinuation Return to Fertility (Reversibility) Vessey MP. Br Med J. 1983; Andersson K. Contraception. 1992; Belhadj H. Contraception. 1986.

  25. Continuation Rates at 1 Year 84% of Copper T IUD users 55% of Non-LARC* users 88% of LNG 52 IUS users VS. *LARC = long-acting reversible contraception. Non-LARC methods include the contraceptive pill, patch, and ring. The Contraceptive Choice Project. 2013; Rosenstock JR. Obstet Gynecol. 2012; Peipert JF. Obstet Gynecol. 2011.

  26. Potential Side Effects Type During insertion First few days During insertion Inter-menstrual cramping Cramping Copper T: Heavier or prolonged menses LNG IUS: Gradual decrease in menstrual flow Variable pain and/or cramping Vasovagal reactions Light bleeding Mild cramping Silverberg SG. Int J Gynecol Pathol. 1986; Sivin I. Contraception. 1991; Hidalgo M. Contraception. 2002; Crosignani PG. Obstet Gynecol. 1997.

  27. IUC Non-contraceptive Benefits Andersson JK. Br J Obstet Gynaecol. 1990; Hurskainen R, et al. Lancet. 2001; Hurskainen R. JAMA. 2004; Hill DA. Int J Cancer. 1997; Rosenblatt KA. Contraception. 1996; Skyla™ PI. 2013.

  28. LNG 52 IUS Non-contraceptive Uses Good evidence: • Heavy menstrual bleeding* • Dysmenorrhea and pain • Endometrial protection during hormone or tamoxifen therapy in perimenopausal and postmenopausal women *FDA-approved indication. Varma R. Eur J Obstet Gynecol Reprod Biol. 2006; Gupta B. Int J Gynecol Obstet. 2006; Backman T. Obstet Gynecol. 2005.

  29. Costs for Patients • Patient costs are a factor in choosing a contraceptive method. • Up-front costs concern some women. • The costs of side effects associated with some contraceptives are high compared with those for IUC. • Public clinics and patient assistance programs offered by pharmaceutical companies can be explored for low-income or uninsured patients.

  30. Safety: Overview Recent data continue to demonstrate the safety of current methods of IUC. Hubacher D. N Engl J Med. 2001; Nelson AL. Obstet Gynecol Clin North Am. 2000; Meirik O. Obstet Gynecol. 2001.

  31. Safety: Medical Eligibility Criteria for Contraceptive Use CDC. MMWR Recomm Rep. 2010; WHO. 2009.

  32. Safety: Medical Eligibility Criteria for Contraceptive Use (continued) CDC. MMWR Recomm Rep. 2010; WHO. 2009.

  33. Safety: Medical Eligibility Criteria for Contraceptive Use (continued) CDC. MMWR Recomm Rep. 2010; Goodman S. Contraception. 2008; Grimes DA. Cochrane Library. 2000; Pakarinen P. Contraception. 2003; WHO. 2009.

  34. Safety: Medical Eligibility Criteria for Contraceptive Use (continued) CDC. MMWR Recomm Rep. 2010; WHO. 2009.

  35. Safety: IUC Does Not Cause PID or Infertility • PID incidence among IUC users is similar to that among the general population • Risk is increased only during the first month after insertion • Preexisting STI at time of insertion, not IUC itself, increases risk • Chlamydial infection, not use of IUC, is associated with increased risk of tubal occlusion Svensson L. JAMA. 1984; Sivin I. Contraception. 1991; Farley TM. Lancet. 1992; Andersson K. Contraception. 1994; Hubacher D. N Engl J Med. 2001.

  36. Patient Screening and Counseling for IUC

  37. Screening & Counseling Goals for Providers • Review contraceptive options with patients • Allow patients to hold devices • Promote successful use of method • Allow time for questions • Provide written materials in the appropriate language and literacy level

  38. Female Sterilization Vasectomy Implant Injectable Patch Ring Pills Female Condoms Male Condoms Spermicides Fertility Awareness–Based Methods Comparing Typical Effectiveness of Contraceptive Methods More effective How to make your method most effective <1 pregnancy per 100 women in 1 year After procedure, little or nothing to do or remember Vasectomy: Use another method for first 3 months after procedure. IUC Injections: Get repeat injections on time. Pills: Take a pill each day. Patch, ring: Keep in place, change on time. Diaphragm: Use correctly every time you have sex. 6-12 pregnancies per 100 women in 1 year Sponge Condoms, sponge, withdrawal, spermicides: Use correctly every time you have sex. Fertility awareness–based methods: Abstain or use condoms on fertile days.Newest methods (Standard Days Method and Two-Day Method) may be the easiest to use and consequently more effective. Diaphragm Withdrawal Trussell J. 2011; WHO. 2007. Chart adapted from WHO 2007. Less effective ≥18 pregnancies per 100 women in 1 year

  39. Outcomes for Women Referred for Sterilization 15% did not attend clinic 29% chose alternative method 54% had sterilization N = 100 women Smith RA. J Fam Plann Reprod Health Care. 2006.

  40. Appropriate Candidates for IUC • Women of any reproductive age seeking long-term, highly effective contraception Women of any reproductive age seeking long-term, highly effective contraception

  41. Appropriate Candidates for IUC ParaGard®PI. 2013; Mirena®PI. 2013; SkylaTM PI. 2013.

  42. Contraindicationsto IUC There are few contraindications to IUC use • Known or suspected pregnancy • Puerperal sepsis • Immediate post-septic abortion • Unexplained vaginal bleeding • Uterine fibroids that interfere with placement • Uterine distortion (congenital or acquired) • Active purulent cervicitis/PID CDC. MMWR; 2010. WHO. 2009.

  43. IUC Use for Adolescents • Appropriate for properly selected and counseled adolescents • Follow-up and side-effect monitoring are important • Encourage use of condoms with new partners The Contraceptive Choice Project. 2013; Eisenberg D. J Adolesc Health. 2013; Rosenstock JR. Obstet Gynecol. 2012; Secura GM. Am J Obstet Gynecol. 2010; Tomas A. J Pediatr Adolesc Gynecol. 2006.

  44. Copper T IUD Labeling Does Not Exclude Nulliparous Women Copper T labeling change was approved in 2005 to include more potential candidates beyond women who have had one child and are in a mutually monogamous relationship ParaGard® PI; Mirena PI.

  45. Case Presentation: Nulligravid Adolescent • “Anna,” 17-year-old high-school senior • Has been sexually active with boyfriend for 3 months • Has been using condoms for birth control • Does not want to use hormonal method of contraception Consider: Copper T IUD, LNG 13.5 IUS, or LNG 52 IUS* *After the first few months, very little LNG enters the circulation.

  46. Nulligravid Adolescent: Clinical Considerations • Insertion may be difficult (smaller cervical os and uterus than in parous woman) • Insertion pain • Possible increased risk of STIs (chlamydia) and PID (because of age <25 years) Deans EI. Contraception. 2009; Grimes DA. Lancet. 2000.

  47. Nulligravid Adolescent: Practice Tips • Can do same-day STI testing (with normal clinical exam): • No need to wait for test results before insertion • Positive tests should prompt treatment without need to remove device Clinical Pearl more…

  48. Nulligravid Adolescent: Practice Tips (continued) • Non-pharmacologic pain management: • Reassure patient about the procedure • “Verbicain” or distraction therapy • Pharmacologic pain management: • NSAID before procedure • Paracervical block Clinical Pearl more… Czarnecki ML. Pain Manag Nurs. 2011; Reproductive Health Access Project. 2012; Edelman AB. Contraception. 2011; Grimes DA. Cochrane Database Syst Rev. 2006; Hubacher D. Am J Obstet Gynecol. 2006; Allen RH. Cochrane Database Syst Rev. 2009; Rabin JM. Obstet Gynecol. 1989; Speroff L. 2005; Swenson C. Obstet Gynecol. 2012.

  49. Nulligravid Adolescent: Counseling Points Follow-up and side effect monitoring important Counsel regarding signs of of expulsion Encourage use of condoms with new partners Hubacher D. Contraception. 2007; Tomas A. J Pediatr Adolesc Gynecol. 2006; Grimes DA. Cochrane Database Syst Rev. 2006.

  50. IUD Insertion After Spontaneous or Induced Abortion • IUD may be safely inserted immediately after spontaneous or induced abortion • IUD insertion is not recommended after septic abortion. Grimes D. Cochrane Libr. 2000; WHO. Stud Fam Plann. 1983; ParaGard®PI.

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