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Contraception

Contraception. Alison Edelman, MD, MPH Associate Professor Co- Director, Family Planning Fellowship Obstetrics & Gynecology Oregon Health & Science University. Why do we care?. 29 % Unintended Despite method use. 51 % Intended. 20 % Unintended No method used.

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Contraception

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  1. Contraception Alison Edelman, MD, MPH Associate Professor Co-Director, Family Planning Fellowship Obstetrics & Gynecology Oregon Health & Science University

  2. Why do we care? 29 % Unintended Despite method use 51 % Intended 20 % Unintended No method used Frost JJ, Guttmacher Institute, 2008

  3. Typical effectiveness of contraceptive methods Vasectomy More effective Less than 1 pregnancy per 100 women in one year Female Sterilization Implant IUD About 3-8 pregnancies per 100 women in one year Injectables Pills Patch Ring Lactation Amenorrhea About 30 pregnancies per 100 women in one year Female Condoms Male Condoms Fertility-Awareness Based Methods Diaphragm Sponge Spermicide Withdrawal Less effective Emergency Contraception adapted with permission from the WHO 2006

  4. Method Choice in the U.S. (2002) *Other includes diaphragm, ring, gel/foam, rods, and EC Alan Guttmacher Institute, Facts In Brief, 2005.

  5. IUD use Worldwide Estimated Use Among Married Women of Reproductive Age %UsingIUD NorthAmerica Asia Europe Latin America & Caribbean Oceania Africa Population Reference Bureau, 2002.

  6. Hormonal birth control

  7. What are the hormones? • Progestin component • 1st norethindrone • 2nd levonorgestrel • 3rd desogestrel • 4thantimineralocorticoid activity (drospirenone) • Estrogen component • EthinylEstradiol • High (50 mcg) • Low (<30-35 mcg) • Very low (< 20 mcg)

  8. How do they work? • Progestin • Prevents ovulation by suppressing LH secretion • Thins (decidualizes) endometrial lining • Thickens cervical mucus • Estrogen • Prevents emergence of a dominant follicle by suppressing FSH secretion • Stabilizes the endometrium • Potentiates the action of the progestational agent

  9. Combined Oral Contraceptives

  10. Prescribing Precautions(Estrogen-related) • Smoking ≥ 35 year old • H/O thrombotic disease in self • CVD (with/without diabetes, SLE) • Uncontrolled hypertension • Migraine • With Aura or focal neuro symptoms at any age • With or with out ≥ 35yo • Breast cancer- current or recent (w/in 5 yrs) • Endometrial cancer • Unexplained vaginal bleeding • Hepatic dysfunction, carcinoma, adenoma www.who.int – medical eligibility criteria

  11. Combined TransdermalPatchOrtho evra Ortho-McNeil

  12. Contraceptive vaginal ringNuvaring

  13. Progestin-only Pills

  14. InjectablesDepoProvera IM OR SQ • Progestin-only • Two formulations • IM q 12 weeks • SQ q 12 weeks • Typical use Failure 3% • Pros • 50% amenorrhea at 1 year • Confidential • Highly effective • Cons • Irregular bleeding • Delayed return to fertility • Possible weight gain – especially in already obese teens

  15. Transdermal Implant Implanon (1 rod) 68 mg etonogestrel AKA keto-desogestrel

  16. Implanon: insertion

  17. LNG IUD

  18. Levonorgestrel Serum Concentrations of Oral, Subdermal and Intrauterine Delivery Data on file. Berlex Laboratories, Inc. 1999

  19. “Don’t get me wrong. I think the morning after pill is great. It’s just that right now my problem is lining up something for the night before.” The New Yorker, July 23, 1999

  20. Non-hormonal birth control

  21. Non- hormonal Intrauterine DeviceParagard/copper T

  22. Female-Controlled Barrier Methods • Diaphragm • Requires fitting by a clinician • Use with spermicide • Typical use failure rate16% • Sponge • OTC, non-latex • Typical use failure rate13-16% • Female condom • OTC • Typical use failure rate 21% • Cervical caps • Lea’s Shield, FemCap- non-latex • Use with spermicide • Typical use failure rate 16-32%

  23. Barrier Methods • Male condoms • Typical use failure rate 15% • Latex, polyurethane, natural membrane • Water-based lubricants only • Prevent HIV transmission, reduce the risk of other STI’s (ie. gonorrhea, chlamydia, trichomonas) • Spermicides • Nonoxynol-9 available OTC in U.S. • Typical use failure rate 29% • May increase risk of HIV • Spermicidal condoms are no longer recommended

  24. Fertility Awareness methods or periodic abstinence

  25. Lactional amenorrhea

  26. Abstinence • Typical use “efficacy” unknown • Requires negotiation skills • Provide condoms and EC as back-up • Correct use provides STI/HIV protection

  27. Sterilization

  28. Initiation Timing • Sunday start* • Anytime during menses* • Immediately (Quick start)* • Immediately after EC* • Immediately after abortion or miscarriage • 3-6 weeks postpartum *Backup method for 7-10 days is a good idea!

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