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Contraception and Sterilization

Contraception and Sterilization. UNC School of Medicine Obstetrics and Gynecology Clerkship Case Based Seminar Series. Objectives for Contraception and Sterilization . Describe the mechanism of action and effectiveness of contraceptive methods

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Contraception and Sterilization

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  1. Contraception and Sterilization UNC School of Medicine Obstetrics and Gynecology Clerkship Case Based Seminar Series

  2. Objectives for Contraception and Sterilization • Describe the mechanism of action and effectiveness of contraceptive methods • Counsel the patient regarding the benefits, risks, and use for each contraceptive method • Describe barriers to effective contraceptive use and to the reduction of unintended pregnancy • Describe the methods of male and female surgical sterilization • List the risks and benefits of female surgical sterilization procedures

  3. Intended Contraception is important because unintended pregnancy in the U.S. is common • 6.3 million pregnancies Unintended 22% 51% Birth 22% 49% 20% Abortion 20% Fetal Loss 7% 7%

  4. Current contraceptive Methods available in the US Most effective Prevents pregnancy >99% of the time Male/Female Sterilization IUD/IUS Implants Moderately effective Prevents pregnancy ~81-90% of the time Male/Female Condom Sponge Diaphragm Very effective Prevents pregnancy ~91-99% of the time Pills Injectables Patch Ring Effective Prevents pregnancy up to 80% of the time Fertility awareness Cervical cap Spermicide

  5. Distribution of contraception use by women in the US % of US women 15-44 years Mosher, et al. 2010.

  6. Consistent use, method failed, 5% Nonuse, 52% Inconsistent or incorrect use, 43% 3.1 million unintended pregnancies, by women's contraceptive use during month of conception Unintended Pregnancy and Contraceptive Use Frost JJ, Darroch JE, Remez L. In Brief. 2008.

  7. Direct counseling to focus on effectiveness http://www.fhi.org/nr/shared/enFHI/Resources/EffectivenessChart.pdf

  8. Resources for contraceptive counseling and prescribing • Evidence based guidance for the use of contraception with health conditions • U.S. Medical Eligibility Criteria • http://www.cdc.gov/mmwr/pdf/rr/rr59e0528.pdf

  9. USMEC Definitions http://www.cdc.gov/mmwr/pdf/rr/rr59e0528.pdf

  10. Using USMEC; (e.g. for hypertension) • Pages 12-13 for HTN with combined oral contraceptives • Risks generally outweigh the benefits and alternative methods exist • Increased risk of stroke among women with HTN and on COC’s compared to women not on COC’s • P 35-36 for HTN and progestin contraceptives • Benefits generally outweigh the risks • P.53 for HTN and IUC • Benefits outweigh the risks

  11. Cost • Basically all are remarkably similar • Implants and intrauterine contraceptive most cost effective • Hormonal contraception – about $30-$40/month ($360-$480 per year) • Mirena® - $750/7 years ($108/year) • Cu-T380a IIUD - @$600/12 yrs ($50/year)

  12. Current Contraceptive Options Most effective Prevents pregnancy >99% of the time Male/Female Sterilization IUD/IUS Implants Moderately effective Prevents pregnancy ~81-90% of the time Male/Female Condom Sponge Diaphragm Very effective Prevents pregnancy ~91-99% of the time Pills Injectables Patch Ring Effective Prevents pregnancy up to 80% of the time Fertility awareness Cervical cap Spermicide

  13. Male sterilization (permanent contraception) Most effective Prevents pregnancy >99% of the time Male Sterilization • Vasectomy • Failure rate 5/1000 in first year of use • 0.1 – 0.15 in first year • Absence of sperm should be documented • Cost about $200

  14. Male sterilization (permanent contraception) Most effective Prevents pregnancy >99% of the time Male Sterilization • Surgeons who do more than 10/year have lower complication rates • Successfully reversed only 50% of time • Rare side effects • Hematomas and infection • No increased risk of prostate or testis cancer • No adverse health consequences

  15. Female sterilization Methods Most effective Prevents pregnancy >99% of the time Female Sterilization • Laparoscopy • Coagulation • Filschie clips • Minilaparotomy • Postpartum • Used by 27% of couples in US

  16. Female sterilization Benefits and Risks Most effective Prevents pregnancy >99% of the time Female Sterilization • Mortality lower than childbearing (1.5/100,000 compared to 8/100,000) • Failure rate 0.2 -0.4 per 100 women in first year • Cost about $2000

  17. Levonorgestrel Intrauterine System (LNG IUS) Most effective Prevents pregnancy >99% of the time IUD/IUS

  18. Levonorgestrel Intrauterine System (LNG IUS) • Brand name: Mirena® • 20 mcg levonorgestrel/day • Approved for 5 years use, evidence supports use up to 7 years • Decreased menstrual bleeding in 80% users by 1 year • Amenorrhea in ~20% of users by 1 year

  19. LNG IUS Mechanism of action • Progestin results in decreased tubal motility) • Thickened cervical mucus • Endometrium becomes decidualized with atrophy of the glands • Cycles are ovulatory in 50-75% of women

  20. LNG IUS Benefits and Risks • Decreases menstrual blood loss by 40-50% • Decreases amenorrhea • Can treat and prevent endometrial hyperplasia • One of the most effective methods • “Forgettable” • Rapidly reversed upon removal • 5% risk of expulsion in first year • 1/1000 risk of perforation at insertion • <1/1000 risk of infection in first 20 days after insertion

  21. Levonorgestrel Intrauterine System Contraindications • Contraindications – all are relative, and involve counseling of risks vs. benefits • Prior ectopic (progestin results in decreased tubal motility) • Active cervical or reproductive organ infection • Undiagnosed abnormal uterine bleeding

  22. Copper-T IUD Most effective Prevents pregnancy >99% of the time Cu-T380a IUD • ParaGard® • Copper T-380a • Labeled for 10 years of continuous use • Evidence supports use up to 12 years continuous use

  23. Copper-T IUD Mechanism of action • Copper induces a spermicidal environment in the uterus

  24. Copper-T IUD Benefits and risks • “Forgettable” contraception • Lasts for 12 years • Highly effective • May cause slightly heavier menses in the first three months of use • Expulsion up to 5% in the first year • 1/1000 risk of perforation at time of insertion

  25. Copper-T IUD • Contraindications • VERY FEW • Wilson’s Disease • Active cervical or pelvic infection

  26. Intrauterine contraception (IUC) Busting myths and misconceptions • Can be used in nulliparous women • Can be used in adolescents • Can be used for 7-12 continuous years (method dependent) • Can be placed without waiting for a GC/Chl screen result

  27. Intrauterine contraception (IUC) Busting myths and misconceptions • Can be used in a woman with a history of pelvic inflammatory disease • No antibiotics required at placement • An STI or PID with IUC in place doesn’t require IUC removal for treatment

  28. Brand name: Implanon® Releases 60 mcg etonogestrel per day Effective for 3 years Subdermal Implant Most effective Prevents pregnancy >99% of the time Implants Implanon insert: Diaz S., Contraception, 2002: Trussel J, Contraceptive Technology, 2007 Croxatto HB, Contraception, 1998; Diaz S, Contraception, 2002; Funk S, Contraception, 2005. Implanon Prescribing Information. et al.

  29. Ovulation suppression Subdermal Implant Mechanism of action Implanon insert: Diaz S., Contraception, 2002: Trussel J, Contraceptive Technology, 2007 Croxatto HB, Contraception, 1998; Diaz S, Contraception, 2002; Funk S, Contraception, 2005. Implanon Prescribing Information. et al.

  30. “Forgettable” Rapidly reversible upon removal Decreased menstrual bleeding Good for persons who don’t want something in their uterus Unpredictable vaginal bleeding for duration of use Menstrual bleeding is highly variable Subdermal Implant Benefits and risks

  31. Some antiepileptic drugs Inability to manage irregular and unpredictable menses Subdermal Implant Contraindications

  32. Depot Medroxyprogesterone Acetate (DMPA) Very effective Prevents pregnancy ~91-99% of the time Injectables • Brand name: Depo-Provera® • Intramuscular or subcutaneous injection every 13 weeks Trussel J. Contraceptive Technology. 2007. Cromer BA. Am J Obstet Gynecol. 2005. Trussel J. Contraception. 2004.; Westhoff C. Contraception. 2003. et al.

  33. Injectable Mechanism of action Very effective Prevents pregnancy ~91-99% of the time Injectables • Thickens cervical mucus so it becomes impervious to sperm • Ovulation suppression • Makes the endometrium inhospitable to ovum

  34. Injectable Benefits and risks Very effective Prevents pregnancy ~91-99% of the time Injectables • Redose every three months • Only 6 failures per 100 women in the first year of use • Irregular bleeding for first 3-6 months • Amenorrhea after 6 months of use • Not associated with long term bone loss • Encourage women to eat healthy and be active to help avoid weight gain. • Consider future fertility plans – can take up to 18 months for regular monthly menses to resume.

  35. DMPA Contraindications Very effective Prevents pregnancy ~91-99% of the time Injectables • Minimal • Inability to manage irregular and unpredictable menses in first 6 months of use • Inability to tolerate amenorrhea • Desire to become pregnant within two years • Severe coagulation disorders • History of sex hormone induced liver adenoma

  36. The medical literature demonstrates that bone mineral density (BMD) loss associated with DMPA is substantially reversed after discontinuation in premenopausal women after DMPA treatment for up to 5 years ACOG and WHO support long-term use of DMPA for contraception for women 18 to 45 years old ACOG and WHO state the advantages of DMPA likely outweigh the theoretical and safety concerns Special consideration DMPA and bone loss

  37. Brand name: NuvaRing® Flexible, unfitted ring placed in vagina Can be difficult for women to start using this method, but once they start they are pleased with it Leave in for 3 weeks Can take out for longer than 3 hrs in one 24 hour period without decrease in effectiveness Vaginal Ring Very effective Prevents pregnancy ~91-99% of the time Ring NuvaRing Prescribing Information. Organon. 2001: Timmer CJ. Clin Pharmacokinet. 2000. Herndon EJ. Am Fam Physician. 2004: Dieben TO. Obstet Gynecol. 2002: Linn ES. Int J Fertil. 2003. et al.

  38. Anovulation by suppressing LH and FSH Thickening of the cervical mucus so impervious to sperm Alteration of endometrial lining so no longer receptive to ovum Vaginal Ring Mechanism of action Very effective Prevents pregnancy ~91-99% of the time Ring

  39. Failure rate 1/100 in first year Lasts for three weeks Steady state of medications Decreased intermenstrual bleeding compared to pills Vaginal Ring Benefits and risks Very effective Prevents pregnancy ~91-99% of the time Ring

  40. Contraindicated in women who are over 35 and smoke, who have hypertension, who have a history of VTE Pharmacokinetic profile theoretically similar to OCP, although minimal evidence to support Theoretically there is a bypass of first pass metabolism. Vaginal Ring Contraindications Very effective Prevents pregnancy ~91-99% of the time Ring

  41. Contain estrogen & progestin 20 – 35 mcg of ethinylestradiol and One of eight synthetic progestins Formulations 28-day 84 day Extended (longer than three months) Combined Oral Contraceptives Very effective Prevents pregnancy ~91-99% of the time Pills Trussel J. Contraceptive Technology. 2007:Rosenberg MJ. Reprod Med. 1995: Potter L. Fam Plann Perspect. 1996; Mosher WD. AdvanceData. 2004. Hardman JG. McGraw-Hill. 1996.: Goldzieher JW. Fertil Steril. 1971.: Moghissi KS. Fertil Steril. 1971.

  42. Combined Oral Contraceptives Mechanism of action Very effective Prevents pregnancy ~91-99% of the time Pills • Anovulation by suppressing LH and FSH • Thickening of the cervical mucus so impervious to sperm • Alteration of endometrial lining so no longer receptive to ovum

  43. Combined Oral Contraceptives Counseling • If using monthly dosing the most important pill to not forget is the first pill of anew pack • Not teratogenic • If menses are missed don’t stop taking the pill: • Take a urine pregnancy test • Continue taking the pill as directed • If test positive then call MD Very effective Prevents pregnancy ~91-99% of the time Pills

  44. Easy to dispense Easy to store Effectiveness highly dependent upon adherence by the user Slight increased risk of venous thromboembolic events – but this risk is much lower than the risk of a VTE in pregnancy Combined Oral Contraceptives Benefits and risks Very effective Prevents pregnancy ~91-99% of the time Pills Trussel J. Contraceptive Technology. 2007:Rosenberg MJ. Reprod Med. 1995: Potter L. Fam Plann Perspect. 1996; Mosher WD. AdvanceData. 2004. Hardman JG. McGraw-Hill. 1996.: Goldzieher JW. Fertil Steril. 1971.: Moghissi KS. Fertil Steril. 1971.

  45. Absolute contraindications Older than 35 and smoking (increased risk of MI 11x) Prior history of VTE Relative contraindications Relative Contraindications Migraines with aura Hypertension Use the MEC to guide your decision making Combined Oral Contraceptives Contraindications Very effective Prevents pregnancy ~91-99% of the time Pills

  46. Extended Hormonal Contraception • Delays or eliminates menstruation • Menstrual and nonmenstrualbenefits • Extended methods: • Continuous use of COCs, transdermal patch & vaginal ring • Seasonale® , Seasonique & Lybrel - dedicated extended OC regimen Anderson FD. Contraception. 2003. Kaunitz AM. Contraception. 2000. ARHP. 2003. NuvaRing Product Information. 2001. Stewart FH. Obstet Gynecol. 2005. Kwiecien M. Contraception. 2003. Sulak PJ. Am J Obstet Gynecol 2002.

  47. Extended contraception Women generally like having fewer menses Never Every 6 Months Every 3 Months Every Other Month 40% Every Month 16% 13% ARHP Greenberg Quinlan Rosner Survey 2005.

  48. Extended Contraception Candidates for Reduced Menstruation • Women with menstrual-related disorders or anemia • Adolescents • Perimenopausal women • Athletes • Women in the military • Developmentally delayed women • Any woman who chooses to bleed less frequently

  49. Generic Contraceptives • Pharmacies may provide different substitutions each month • May/may not ↓costs for those paying out of pocket

  50. Brand name: OrthoEvra® Beige-colored patch applied once per week Transdermal Patch Very effective Prevents pregnancy ~91-99% of the time Patch Abrams LS. Fertil Steril. 2002: Ortho Evra Prescribing Information. Archer DF, et al. Fertil Steril. 2002.; Zacur HA, et al. Fertil Steril. 2002.; Zieman M, et al. Fertil Steril. 2002.; Archer DF, et al. Contraception. 2004.; Audet MC, et al. JAMA. 2001.

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