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Contraception

Contraception. This presentation contains materials obtained from Linda Prine MD, Mark A. Goedecker , MD, Mark Deutchman MD and Laura Stein MD. Objectives. Role of the rural physician in contraception Assessing the patient’s desire and need for contraception Non-Hormonal contraception

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Contraception

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  1. Contraception This presentation contains materials obtained from Linda Prine MD, Mark A. Goedecker, MD, Mark Deutchman MD and Laura Stein MD

  2. Objectives • Role of the rural physician in contraception • Assessing the patient’s desire and need for contraception • Non-Hormonal contraception • Hormonal contraception • Emergency contraception • Male sterilization • Female sterilization • IUD video and lab

  3. Role of the rural physician in contraception • Office practice: individual patient visits • Consultant to health department • Information to concerned community members • Parents • Schools • Religious groups • News media • Overall: improve access to contraceptive information and direct services • Opportunity for health promotion and life skills counseling

  4. Assessing the patient’s desire and need for contraception • Full-time vs sporadic • Long term vs short term • STI protection • Sexuality concerns • Others………………

  5. Background: Importance of Contraception Unintended pregnancy

  6. Nearly half of pregnancies in the United States are unintended. Approximately 6.4 million pregnancies per year

  7. Outcomes of Unintended PregnanciesApproximately 3.0 Million Annually

  8. Most unintended pregnancies occur when women fail to use contraceptives or use their method inconsistently.

  9. Half of women at risk are not fully protected from unintended pregnancy. 28 million U.S. women at risk for unintended pregnancy

  10. Unintended pregnancy rate by race/ethnicity/income Unintended pregnancies per 1,000 women

  11. What are the lifetime considerations of unintended pregnancy ? How many can you think of?

  12. Efficacy of Contraceptive Methods

  13. Efficacy of “Less Effective Methods” Effectiveness Group Family Planning Method Typical-Use Rate of Pregnancy Perfect-Use Rate of Pregnancy No Method No method 85% 85% Less effective Male latex condoms 14% 3% Diaphragm 20% 6 Cervical cap 20%-40% 9%-26% Female condoms 21% 5% Spermicide 26% 6% Withdrawal 19% 4% Fertility Awareness 20% 1%-9%

  14. Efficacy of “Effective Methods” Effectiveness Group Family Planning Method Typical-Use Rate of Pregnancy Perfect-Use Rate of Pregnancy Effective Birth control pills 8% 0.1%-0.5% Transdermal patch Unknown (8%) 0.3%-0.8% Vaginal ring Unknown (8%) 0.1%-0.5%

  15. Highly Effective MethodsNot User-dependent Effectiveness Group Family Planning Method Typical-Use Rate of Pregnancy Perfect-Use Rate of Pregnancy Highly Effective (for all users) Male and female sterilization 0.2%-0.5% 0.1%-0.5% Implants 0.1% 0.1% Hormone shot 0.3% 0.3% Intrauterine devices 0.8%-2% 0.6%-1.5%

  16. Hormonal Contraception • Combination estrogen/progesterone pills • Sequential estrogen/progesterone • Biphasic • Triphasic • Progesterone only • Pills, Injection and subcutaneous capsule • Extended cycle • Transdermal patches • Vaginal ring • Hormone-containing IUD

  17. How do Oral Contraceptives Work? • Suppress, but not eliminate ovulation (Decrease FSH and LH by pituitary suppression) • Thin the endometrium • Thicken cervical mucous

  18. Hormonal Contraceptives What is needed before prescribing pills? Medical history REQUIRED Pap smear Pelvic/breast exam STI testing Hemoglobin NOT REQUIRED Blood pressure RECOMMENDED

  19. Estrogens in OCP’s • Most pills use ethinylestradiol (EE) as their estrogen (50 µg mestranol = 35 µg EE) • Doses range from 20 µg – 50 µg, but most are 20 µg – 35 µg • Lower dose estrogens have the benefits of less bloating and breast tenderness but may increase the rate of breakthrough bleeding especially in obese patients

  20. “Older” vs. “Newer” Progestins • Newer: • Less androgenic (minimizes side effects such as acne, hirsutism, nausea, and lipid changes) • Increase progestational effects • Levonorgestrel is the most androgenic available in US • First, second, third, and fourth generation progestins • Estranes and gonanes

  21. “Newer” Progestins • Minimal androgenic effects • Norgestimate • Increases HDL and decreases LDL • Desogestrel (etonogestrel) • Possible increase risk in venous thromboembolism (VTE) (Jick S et al. Contraception 2006:73:566-70. SORT B) • Drospirenone • Antimineralocorticoid activity • Theoretically could cause hyperkalemia • Essentially no androgenic activity

  22. Monophasics vs. Biphasics vs. Triphasics • There is insufficient data that biphasic or triphasic combined oral contraceptive pills are better than monophasic pills (effectiveness, bleeding patterns, or discontinuation rates) SORT B Cochrane Database of Systematic Reviews 2007 Van Vliet HAAM, Grimes DA, Lopez LM, Schulz KF, Helmerhorst FM. Triphasic versus monophasic oral contraceptives for contraception Van Vliet HAAM, Grimes DA, Helmerhorst FM, Schulz KF. Biphasic versus monophasic oral contraceptives for contraception

  23. Choosing the Right Pill • Low androgenic activity is desirable in most if not all • If patient weighs more than 160 pounds consider higher estrogen and progestin activity • Low dose estrogen if: • History of nausea, edema or hypertension in pregnancy • Uterine fibroids • Fibrocystic breasts • Heavy menses • Migraines

  24. Choosing the Right Pill • Low progesterone if: • History of preeclampsia, excessive weight gain, tiredness, or varicose veins during pregnancy, • Depression • Excessive premenstrual • If history of polycystic ovaries, high progestational and low androgenic

  25. Hormonal ContraceptivesWhich women/teens can’t use estrogen? Estrogen contraindications: Migraine with aura Uncontrolled hypertension Postpartum < 6 weeks History of DVT Smoking: NOT a contraindication in women/teens under age 35

  26. Newer Oral Contraceptive Pills on the Market

  27. FemconFe® • The new name for Ovcon Fe chewable • Chewable spearmint flavored tablet • EE 35 µg, norethindrone 0.4 mg (21 days) • Placebo contains 75 mg ferrous fumarate • ADVANTAGE: For those who cannot swallow pills (and need fresh breath)

  28. Yaz24/4® • Same ingredients as Yasmin but… • EE 20 µg (instead of 30 µg) • 3 mg of drospirenone • 24 days of active medication and 4 days of placebo (as compared to the usual 21/7) • ADVANTAGE: • Has an FDA indication for premenstrual dysphoric disorder (the only hormonal contraceptive with this) • Shorter periods

  29. Loestrin 24 Fe® • 24 days of hormones (similar to Yaz24/4®) • EE 20 µg, Norethindrone 1 mg • Placebo pills contain iron • ADVANTAGE: • Periods last less than 3 days • More pronounced suppression of follicular development

  30. Extended Cycle Regimens

  31. Extended Cycle Contraceptives • Seasonale®, Seasonique®, Lybrel® • Oral contraceptives taken continuously for more than 28 days compare favorably to traditional cyclic oral contraceptives (bleeding, discontinuation rates, and reported satisfaction) SORT A Edelman AB, Gallo MF, Jense JT, Nichols MD, Schulz KF, Grimes DA. Continuous Or extended cycle versus cyclic use of combined oral contraceptives for contraception. The Cochrane Database of Systematic Reviews 2007 Issue 2

  32. Seasonique® • Like Seasonale®: • EE 30 µg, levonorgestrel 0.15 mg for 12 weeks • But… • 13th week contains EE 10 µg (instead of placebo) • ADVANTAGES: • Low dose EE may reduce hormone withdrawal symptoms (migraines and dysmenorrhea) • May cause less breakthrough bleeding then with Seasonale (main reason women stop Seasonale)

  33. Lybrel® • Taken in a continuous 365-day regimen • EE 20 µg and levonorgestrel 0.09 mg • 28 pills in a pack • FDA approved and will be released July 2007 • ADVANTAGE: • No menstrual bleeding • During the 13 pill pack: • 59% of women achieve amenorrhea • 20% of women have spotting only • 21% of women required sanitary protection due to breakthrough bleeding • http://www.drugs.com/newdrugs/fda-approves-lybrel-first-low-combination-oral-contraceptive-offering-women-opportunity-period-free-491.html?printable=1

  34. Contraindications to Combined Oral Contraceptives • Unexplained VTE or VTE associated with pregnancy or exogenous estrogen use (unless on anticoagulants) • Women age 35 and older who smoke • Poorly controlled diabetes or diabetes with complications such retinopathy, nephropathy, or other vascular complications Level A Use of hormonal contraception in women with coexisting medical conditions. ACOG Practice Bulletin No. 73. American College of Obstetricians and Gynecologists. ObstetGynecol 2006: 107:1453-72.

  35. Contraindications to Combined Oral Contraceptives • OCP’s should be stopped one week prior to surgery or heparin prophylaxis should be considered • Women with CAD, CHF, or cerebral vascular disease • Use caution in obese women over the age of 35 • Poorly controlled HTN (or complications) • Patients with Factor V Leiden gene mutation or prothrombin gene mutations Level B Use of hormonal contraception in women with coexisting medical conditions. ACOG Practice Bulletin No. 73. American College of Obstetricians and Gynecologists. ObstetGynecol 2006: 107:1453-72.

  36. Patients Who it is OK to Use OCP’s • Benign breast disease or family history of breast cancer • Mild lupus with no antiphospholipid antibodies Level A Use of hormonal contraception in women with coexisting medical conditions. ACOG Practice Bulletin No. 73. American College of Obstetricians and Gynecologists. ObstetGynecol 2006: 107:1453-72.

  37. Patients Who it is OK to Use OCP’s • Healthy, non-smoking women can continue their OCP’s until age 50-55 • Well-controlled HTN <35 who do not smoke and are healthy • Well-controlled DM <35 who do not smoke and are healthy • Women with migraines who are healthy, do not smoke, and have no focal neurologic signs • Women with depressive disorders Level B Use of hormonal contraception in women with coexisting medical conditions. ACOG Practice Bulletin No. 73. American College of Obstetricians and Gynecologists. ObstetGynecol 2006: 107:1453-72.

  38. Estrogen / Progestin Patch 1 patch weekly for 3 weeks, then one week off Same efficacy & contraindications as OCs OK to shower, swim, exercise with patch on Failures in trials were in women over 198 pounds, but still rare Higher risk of clots? Conflicting studies… Gallo MF, et al. Cochrane Reviews. 2003, Issue 1. Art. No. CD003552. Jick S, et al. Contraception 73 (2006)

  39. Ortho Evra®TransdermalContraceptive Patch • EE 20 µg/d and norelgestromin 0.15 mg/d • One patch weekly for three consecutive weeks followed by one patch-free week • Mean serum concentrations are not affected by heat, humidity, exercise or cold-water immersion • Contraceptive failure is higher in women with body weight >90 kg

  40. Ortho Evra®TransdermalContraceptive Patch • Possible increased risk of venous thromboembolism (VTE) • This is due to the increased serum concentration • Peak serum estrogen concentration is 25% less than the peak level with the pill (30 µg) • But women with the patch are exposed to 60% more estrogen than taking the pill • NuvaRing – 3.4 times less estrogen exposure than patch and 2.1 less than the pill Thacker H, Falcone T, Atreja A, Jain A, Harris CM. How should we advise patients about the contraceptive patch given the FDA warning? Cleveland Clinic Journal of Medicine 2006: 73(1): 45-47.

  41. The Patch and VTE • Two-fold increase in the risk of VTE versus norgestimate-containing oral contraceptives with 35 µg of EE • Overall, the number needed to harm (NNH) was 4,444 (AMI, VTE, stroke) • There is a five-fold increase in risk of VTE in pregnancy • There is no increased risk for acute myocardial infarction or stroke Cole J, Norman H, Doherty M, Walker A. Venous thromboembolism, myocardial infarction, and stroke among transdermal contraceptive system users. ObstetGynecol 2007: 109(2):339-46.

  42. Injectable Contraceptives • Only one currently available is Depo-Provera® • Lunelle®was withdrawn from the US due to lack of demand and a recall (half-filled syringes)

  43. Depo-Provera® • Medroxyprogesterone 150 mg given IM every 11-13 weeks • New Depo-subQProvera 104® • Given every 12-14 weeks • Can be administered by the patient in the thigh or abdomen • Side effects are similar • Slow return to fertility (14 weeks to 9 months) • Irregular bleeding • Short-term loss of bone mineral density

  44. Depo-Provera®and Osteoporosis • FDA has required a black-box warning since 2004 • “only use as long-term birth control method(>2 years) if other methods inadequate” • It has not been associated with postmenopausal osteoporosis or fractures • Society for Adolescent Medicine, ACOG and WHO have recommended continuing Depo after appropriately counseling

  45. Estrogen/progestin vaginal ring Active for at least 3 weeks Lowest estrogen dose: 15 mcg / day Same efficacy and contraindications as OCs May remove for up to 3 hours QuickStart same as with OCs

  46. NuvaRing® • EE 15 µg/day and etonogestrel 0.12mg/day • Inserted into vagina and left in for three weeks • Removed for one week • Can be re-inserted if it has been out for less than three hours (rinse with cold or warm water, not hot) • 8/10 partners do not feel the ring during intercourse (can removed prior to intercourse) http://www.nuvaring.com/HCP/PrescribingNuvaRing/StartingYourPatients/index.asp

  47. Progestin Implant Highly effective and rapidly reversible Discreet Not user-dependent Contain no estrogen Can be used during lactation Active hormone: etonogestrel (68 mg) Reinprayoon. Contraception 2000Diaz. Contraception 2000

  48. Features of Progestin Implants Causes spotting Requires certified clinician visits for insertion and removal

  49. Implantable Contraceptives • Norplant®was on the US market from 1991-2002 • Six rods containing levonorgestrel • Several class action law suits over: • Failure to disclose side effects (irregular bleeding) • Difficulty removing rods

  50. Implantable Contraceptives • IMPLANON™ released August 2006 • One rod containing etonogestrel • Can be left in for up to three years • Only providers who have completed a “comprehensive practical training session” can insert IMPLANON™ (sponsored by Organon) • www.implanon-usa.com

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