Patient-centered Contraception

1. Patient-centered Contraception

2. Nearly half of pregnancies in the United States are unintended. Nearly half of pregnancies in the United States are unintended—they occur earlier than desired (29%) or after women have reached their desired family size (20%). In 2005, such pregnancies resulted in 1.4 million unplanned births and 1.2 million induced abortions (plus an estimated 400,000 miscarriages). By age 45, more than half of U.S. women have had one or more unintended pregnancy. Nearly half of pregnancies in the United States are unintended—they occur earlier than desired (29%) or after women have reached their desired family size (20%). In 2005, such pregnancies resulted in 1.4 million unplanned births and 1.2 million induced abortions (plus an estimated 400,000 miscarriages). By age 45, more than half of U.S. women have had one or more unintended pregnancy.

3. Outcomes of Unintended PregnanciesApproximately 3.0 Million Annually Unintended Pregnancy Statistics: A woman who has an unintended pregnancy is almost as likely to carry it to term as to have an abortion. Four in 10 of unintended pregnancies end in an unplanned birth. Source: Finer LB and Henshaw SK, Disparities in rates of unintended pregnancy in the United States, 1994 and 2001; Perspectives on Sexual and Reproductive Health 2006, 38(2):90–96. Unintended Pregnancy Statistics: A woman who has an unintended pregnancy is almost as likely to carry it to term as to have an abortion. Four in 10 of unintended pregnancies end in an unplanned birth. Source: Finer LB and Henshaw SK, Disparities in rates of unintended pregnancy in the United States, 1994 and 2001; Perspectives on Sexual and Reproductive Health 2006, 38(2):90–96.

4. Most unintended pregnancies occur when women fail to use contraceptives or use their method inconsistently. Slightly more than half of unintended pregnancies occur among women who used no method of contraception during the month in which they conceived, and more than four in 10 occur among women who used a method inconsistently or incorrectly. Only one in 20 are attributable to method failure. Slightly more than half of unintended pregnancies occur among women who used no method of contraception during the month in which they conceived, and more than four in 10 occur among women who used a method inconsistently or incorrectly. Only one in 20 are attributable to method failure.

5. Half of women at risk are not fully protected from unintended pregnancy. Combining the information on nonuse of contraceptives and inconsistent use, we can classify all women who are at risk of unintended pregnancy according to their practices during the past year: Half of women were protected from unintended pregnancy by their consistent use of contraceptives, including use of long-acting methods; 8% were nonusers all year; 15% had a gap in use when they remained sexually active and not trying to be pregnant And, 27% used their method inconsistentlyCombining the information on nonuse of contraceptives and inconsistent use, we can classify all women who are at risk of unintended pregnancy according to their practices during the past year: Half of women were protected from unintended pregnancy by their consistent use of contraceptives, including use of long-acting methods; 8% were nonusers all year; 15% had a gap in use when they remained sexually active and not trying to be pregnant And, 27% used their method inconsistently

6. Unintended pregnancy rate by race/ethnicity/income Recent trends in unintended pregnancy: Overall, teen pregnancy in the US has declined over the past decade. However, unintended pregnancy rates have increased among low-income teens and women. The gap between rich & poor women’s abortion rates has widened steadily since 1987. Abstinence-only education has been shown not to reduce teen pregnancy rate. Source: Finer LB and Henshaw SK, Disparities in rates of unintended pregnancy in the United States, 1994 and 2001; Perspectives on Sexual and Reproductive Health 2006, 38(2):90–96. Recent trends in unintended pregnancy: Overall, teen pregnancy in the US has declined over the past decade. However, unintended pregnancy rates have increased among low-income teens and women. The gap between rich & poor women’s abortion rates has widened steadily since 1987. Abstinence-only education has been shown not to reduce teen pregnancy rate. Source: Finer LB and Henshaw SK, Disparities in rates of unintended pregnancy in the United States, 1994 and 2001; Perspectives on Sexual and Reproductive Health 2006, 38(2):90–96.

7. Why do women experience unintended pregnancies? Fill in answers below if audience doesn’t come up with them: Contraceptive failures--No method is perfect. For example, even after surgical sterilization, one woman out of every 200 becomes pregnant. Contraceptives are not easy to use exactly right--pregnancies happen when condoms break, or pills stay in their package. Contraceptives are unavailable, difficult to obtain or too expensive—For ex. a woman may run out of birth control pills or not be able to get refill promptly; insurance may not cover her birth control or she may be uninsured. Lack of understanding of reproduction/fertility –Many women do not understand when risk of pregnancy is greatest. Sexual assault/abuse/coercion A woman’ s religion or her partner may forbid her to use contraception Emotional/psychological reasons: Denial about the possibility of getting pregnant, ambivalence about having a child or the desire to be sure she is fertile sometimes lead women to have unplanned pregnancies. Finally: Many women still don’t know about or aren’t able to get emergency contraception! which we’ll talk about more in a few minutes Fill in answers below if audience doesn’t come up with them: Contraceptive failures--No method is perfect. For example, even after surgical sterilization, one woman out of every 200 becomes pregnant. Contraceptives are not easy to use exactly right--pregnancies happen when condoms break, or pills stay in their package. Contraceptives are unavailable, difficult to obtain or too expensive—For ex. a woman may run out of birth control pills or not be able to get refill promptly; insurance may not cover her birth control or she may be uninsured. Lack of understanding of reproduction/fertility –Many women do not understand when risk of pregnancy is greatest. Sexual assault/abuse/coercion A woman’ s religion or her partner may forbid her to use contraception Emotional/psychological reasons: Denial about the possibility of getting pregnant, ambivalence about having a child or the desire to be sure she is fertile sometimes lead women to have unplanned pregnancies. Finally: Many women still don’t know about or aren’t able to get emergency contraception! which we’ll talk about more in a few minutes

8. Efficacy: Numbers & Categories Table“Less Effective Methods” One of the problems is that the contraceptives that are available without a prescription are the lower efficacy ones.One of the problems is that the contraceptives that are available without a prescription are the lower efficacy ones.

9. Yolanda 17 year-old high school senior Requests pregnancy test, birth control pill Had unprotected sex 4 days ago Urine pregnancy test is negative. What do you do next? Yolanda comes into your office as a walk-in. She asks for a pregnancy test and a prescription for birth control pills. Her pregnancy test is negative: phew! On further questioning, she says that she had sex without a condom 4 days ago. What do you do? Yolanda comes into your office as a walk-in. She asks for a pregnancy test and a prescription for birth control pills. Her pregnancy test is negative: phew! On further questioning, she says that she had sex without a condom 4 days ago. What do you do?

10. Emergency Contraception:Levonorgestrel (Plan B) Levonorgestrel is a progestin. It works by delaying ovulation. It doesn’t disrupt an implanted pregnancy, and it’s not teratogenic. Its efficacy declines over the 5-day window after unprotected intercourse: the sooner it’s taken, the more effective it is. New forms, generic and “One Step” - remember that patients under age 17 need a prescription. References: Rodrigues I, Grou F and Joly J, Effectiveness of emergency contraceptive pills between 72 and 120 hours after unprotected intercourse, American Journal of Obstetrics and Gynecology, 2001, 184(4):531-537. von Hertzen H, Piaggio G, Ding J, Chen J, Song S, Bártfai G, Ng E, Gemzell-Danielsson K, Oyunbileg A, Wu S, Cheng W, Lüdicke F, Pretnar-Darovec A, Kirkman R, Mittal S, Khomassuridze A, Apter D, Peregoudov A. Low dose mifepristone and two regimens of levonorgestrel for emergency contraception: a WHO multicentre randomized trial. Lancet 2002;360:1803-1810. Population Council. Emergency Contraception’s Method of Action Clarified. Population Breifs. 2005 May;11(2). Available  http://www.popcouncil.org/publications/popbriefs/pb11(2)_3.html (the Population Council on the Chilean study showing implantation is not a mechanism of EC) Levonorgestrel is a progestin. It works by delaying ovulation. It doesn’t disrupt an implanted pregnancy, and it’s not teratogenic. Its efficacy declines over the 5-day window after unprotected intercourse: the sooner it’s taken, the more effective it is. New forms, generic and “One Step” - remember that patients under age 17 need a prescription. References: Rodrigues I, Grou F and Joly J, Effectiveness of emergency contraceptive pills between 72 and 120 hours after unprotected intercourse, American Journal of Obstetrics and Gynecology, 2001, 184(4):531-537. von Hertzen H, Piaggio G, Ding J, Chen J, Song S, Bártfai G, Ng E, Gemzell-Danielsson K, Oyunbileg A, Wu S, Cheng W, Lüdicke F, Pretnar-Darovec A, Kirkman R, Mittal S, Khomassuridze A, Apter D, Peregoudov A. Low dose mifepristone and two regimens of levonorgestrel for emergency contraception: a WHO multicentre randomized trial. Lancet 2002;360:1803-1810. Population Council. Emergency Contraception’s Method of Action Clarified. Population Breifs. 2005 May;11(2). Available  http://www.popcouncil.org/publications/popbriefs/pb11(2)_3.html (the Population Council on the Chilean study showing implantation is not a mechanism of EC)

11. Levonorgestrel EC:Mechanism of Action There has been lots of controversy regarding EC’s mechanism of action. Many people mistakenly consider EC an abortifacient. Progestin-only EC DOES NOT DISRUPT AN IMPLANTED PREGNANCY– instead, it: Inhibits ovulation Traps sperm in thickened cervical mucus Inhibits tubal transport of egg or sperm May interfere with fertilization or early cell division Ulipristal,too, seems to work mainly by inhibiting ovulation. References: Gemzell-Danielsson K, Marions L. Hum Reprod Update. 2004 Jul;10(4):341-8. Epub 2004 Jun 10.Mechanisms of action of mifepristone and levonorgestrel when used for emergency contraception.Gemzell-Danielsson K, Marions L. Population Council. Emergency Contraception’s Method of Action Clarified. Population Breifs. 2005 May;11(2). Available  http://www.popcouncil.org/publications/popbriefs/pb11(2)_3.html  (the Population Council on the Chilean study showing that disrupting implantation is not a mechanism of EC) There has been lots of controversy regarding EC’s mechanism of action. Many people mistakenly consider EC an abortifacient. Progestin-only EC DOES NOT DISRUPT AN IMPLANTED PREGNANCY– instead, it: Inhibits ovulation Traps sperm in thickened cervical mucus Inhibits tubal transport of egg or sperm May interfere with fertilization or early cell division Ulipristal,too, seems to work mainly by inhibiting ovulation. References: Gemzell-Danielsson K, Marions L. Hum Reprod Update. 2004 Jul;10(4):341-8. Epub 2004 Jun 10.Mechanisms of action of mifepristone and levonorgestrel when used for emergency contraception.Gemzell-Danielsson K, Marions L. Population Council. Emergency Contraception’s Method of Action Clarified. Population Breifs. 2005 May;11(2). Available  http://www.popcouncil.org/publications/popbriefs/pb11(2)_3.html  (the Population Council on the Chilean study showing that disrupting implantation is not a mechanism of EC)

12. Ulipristal is a mixed progestin agonist/antagonist. It can be taken up to 5 days after unprotected intercourse. In contrast to levonorgestrel, it maintains nearly full efficacy on the 4th and 5th day. It’s available only by prescription. Like levonorgestrel, it works by delaying ovulation. For Yolanda, it’s a better idea than Plan B/levonorgestrel, because its efficacy is much higher on day 4.Ulipristal is a mixed progestin agonist/antagonist. It can be taken up to 5 days after unprotected intercourse. In contrast to levonorgestrel, it maintains nearly full efficacy on the 4th and 5th day. It’s available only by prescription. Like levonorgestrel, it works by delaying ovulation. For Yolanda, it’s a better idea than Plan B/levonorgestrel, because its efficacy is much higher on day 4.

13. Hormonal Contraceptives What is needed before prescribing? A complete medical history is needed in order to rule out contraindications to hormonal contraception. Physical exam, STI screening, Pap smear, etc… NOT REQUIRED. These interventions may be helpful for other reasons– but are not needed in order to prescribe hormonal contraception safely. This applies to young teenagers who may be embarrassed or afraid of having a physical exam, and is particularly helpful in new patient visits. References: Stewart F, et al. Clinical breast and pelvic examination requirements for hormonal contraception: Current practice vs evidence. JAMA. 2001;285:2232-9. A complete medical history is needed in order to rule out contraindications to hormonal contraception. Physical exam, STI screening, Pap smear, etc… NOT REQUIRED. These interventions may be helpful for other reasons– but are not needed in order to prescribe hormonal contraception safely. This applies to young teenagers who may be embarrassed or afraid of having a physical exam, and is particularly helpful in new patient visits. References: Stewart F, et al. Clinical breast and pelvic examination requirements for hormonal contraception: Current practice vs evidence. JAMA. 2001;285:2232-9.

14. 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 Smoking: Absolute contraindication in women over age 35 who smoke MORE than 15 cigarettes/day Relative contraindication in women over age 35 who smoke LESS than 15 cigarettes/day Smoking: Absolute contraindication in women over age 35 who smoke MORE than 15 cigarettes/day Relative contraindication in women over age 35 who smoke LESS than 15 cigarettes/day

15. Yolanda is eligible for the pill.When should she start? Explain Quick Start: After a negative ucg: Pills started on the day of the visit instead of the Sunday after the next period Westoff studies showed more women on the pill by month 3, and fewer pregnancies -If OCs are prescribed with Sunday or 1st-day-of-menses start, as many as 25% of women do not start. -No increased bleeding or spotting -OCPs not teratogenic -Can use quickstart immediately following miscarriage or abortion References: Westhoff C, Kerns J, Morroni C, Cushman LF, Tiezzi L, Murphy PA. Quick start: novel oral contraceptive initiation method. Contraception. 2002 Sep;66(3):141-5. Westhoff C, Morroni C, Kerns J, Murphy PA. Bleeding patterns after immediate vs. conventional oral contraceptive initiation: a randomized, controlled trial. Fertil Steril. 2003 Feb;79(2):322-9. Explain Quick Start: After a negative ucg: Pills started on the day of the visit instead of the Sunday after the next period Westoff studies showed more women on the pill by month 3, and fewer pregnancies -If OCs are prescribed with Sunday or 1st-day-of-menses start, as many as 25% of women do not start. -No increased bleeding or spotting -OCPs not teratogenic -Can use quickstart immediately following miscarriage or abortion References: Westhoff C, Kerns J, Morroni C, Cushman LF, Tiezzi L, Murphy PA. Quick start: novel oral contraceptive initiation method. Contraception. 2002 Sep;66(3):141-5. Westhoff C, Morroni C, Kerns J, Murphy PA. Bleeding patterns after immediate vs. conventional oral contraceptive initiation: a randomized, controlled trial. Fertil Steril. 2003 Feb;79(2):322-9.

16. Should Yolanda get a prescription for EC, too? Teens under age 17 need a prescription for EC. Advance prescription doubles the rate of use. Having EC available does NOT decrease the use of the usual contraceptive method. Using EC does not increase the rate of STIs or unprotected intercourse, even among teens. Even teens who are given an ongoing prescription for pills might need EC, if they forget several days of pills or start their next pack late. References: Bissel et al. Supplying emergency contraception via community pharmacies in the UK: reflections on the experiences of users and providers. Soc Sci Med.2003;57:2367-2378. Raine et al. Direct access to emergency contraception through pharmacies and effect on unintended pregnancy and STIs: a randomized controlled trial. JAMA.2005;293:54-62. Trussell J, Koenig J, Ellertson C, Stewart F. Preventing unintended pregnancy: the cost-effectiveness of three methods of emergency contraception. Am J Public Health 1997;87:932-7. Gold, MA, Wolford JE, Smith KA, Parker AM The effects of advance prescription of emergency contraception on adolescent women’s sexual and contraceptive behaviors. J Pediatr Adolesc Gynecology 17(2):87-96. Teens under age 17 need a prescription for EC. Advance prescription doubles the rate of use. Having EC available does NOT decrease the use of the usual contraceptive method. Using EC does not increase the rate of STIs or unprotected intercourse, even among teens. Even teens who are given an ongoing prescription for pills might need EC, if they forget several days of pills or start their next pack late. References: Bissel et al. Supplying emergency contraception via community pharmacies in the UK: reflections on the experiences of users and providers. Soc Sci Med.2003;57:2367-2378. Raine et al. Direct access to emergency contraception through pharmacies and effect on unintended pregnancy and STIs: a randomized controlled trial. JAMA.2005;293:54-62. Trussell J, Koenig J, Ellertson C, Stewart F. Preventing unintended pregnancy: the cost-effectiveness of three methods of emergency contraception. Am J Public Health 1997;87:932-7. Gold, MA, Wolford JE, Smith KA, Parker AM The effects of advance prescription of emergency contraception on adolescent women’s sexual and contraceptive behaviors. J Pediatr Adolesc Gynecology 17(2):87-96.

17. Jessyka Jessyka was given OC’s for her PMS symptoms. This helped, but not enough: she still misses 1-2 days of work each month due to PMS symptoms. Suggestions?Jessyka was given OC’s for her PMS symptoms. This helped, but not enough: she still misses 1-2 days of work each month due to PMS symptoms. Suggestions?

18. Let’s get rid of Jessyka’s periods! May increase efficacy and adherence Decrease some OC and menstrual cycle-related side effects Can be used for brief manipulation of a cycle (for example, to avoid menses during a vacation) Can use any OC, patch, ring – just skip placebo week Now there are dedicated products w/ 3 months active pills, 1 week off, 4 menses per year And a product with no breaks for menses Caveat: some women are attached to their periods, and will not feel comfortable with extended cycles. References: Sulak et al. Hormone withdrawal symptoms in oral contraceptive users. Obstet Gynecol 2000 Feb;95(2):261-6. http://www.contraceptiononline.org/contrareport/pdfs/14_01_pu.pdf – excellent patient education sheet on extended cycle use Let’s get rid of Jessyka’s periods! May increase efficacy and adherence Decrease some OC and menstrual cycle-related side effects Can be used for brief manipulation of a cycle (for example, to avoid menses during a vacation) Can use any OC, patch, ring – just skip placebo week Now there are dedicated products w/ 3 months active pills, 1 week off, 4 menses per year And a product with no breaks for menses Caveat: some women are attached to their periods, and will not feel comfortable with extended cycles. References: Sulak et al. Hormone withdrawal symptoms in oral contraceptive users. Obstet Gynecol 2000 Feb;95(2):261-6. http://www.contraceptiononline.org/contrareport/pdfs/14_01_pu.pdf – excellent patient education sheet on extended cycle use

19. Liz 21-year-old healthy college student Takes oral contraceptive, but forgets pills often Has trouble getting refills while at college, and now the pills are too expensive Multiple factors limit adherence to oral contraceptives. It’s hard for everyone to remember to take a pill every day. For women in transition, adherence is even more difficult.Multiple factors limit adherence to oral contraceptives. It’s hard for everyone to remember to take a pill every day. For women in transition, adherence is even more difficult.

20. Adherence with OCs:What Women Do! For many women, oral contraceptives are an excellent choice for pregnancy prevention. But the misuse or discontinuation of oral contraceptives—a method for which effectiveness is dependent on the degree to which it is used correctly and consistently—leads to over 1 million unwanted or mistimed pregnancies each year in the United States. One study found that 30 percent to 51 percent of women missed taking their oral contraceptives at least three days per month. 103 women in a 2/3 university health setting and 1/3 public health setting. 93% >high school edu, 74% white and 93% unmarried References: Potter et al. Measuring Compliance Among Oral Contraceptive Users. Fam Plann Perspect 1996; 28(4):154-158.For many women, oral contraceptives are an excellent choice for pregnancy prevention. But the misuse or discontinuation of oral contraceptives—a method for which effectiveness is dependent on the degree to which it is used correctly and consistently—leads to over 1 million unwanted or mistimed pregnancies each year in the United States. One study found that 30 percent to 51 percent of women missed taking their oral contraceptives at least three days per month. 103 women in a 2/3 university health setting and 1/3 public health setting. 93% >high school edu, 74% white and 93% unmarried References: Potter et al. Measuring Compliance Among Oral Contraceptive Users. Fam Plann Perspect 1996; 28(4):154-158.

21. What are the common reasons for missing pills? Irregular schedule Sleeps at more than one place Has to hide the pills Can’t get to the pharmacy for refills Can’t reach the doctor to get refills Just forgetsIrregular schedule Sleeps at more than one place Has to hide the pills Can’t get to the pharmacy for refills Can’t reach the doctor to get refills Just forgets

22. Back to Liz… She would like to try something easier to remember. What information do you need? Here is a good place to talk about what pre-conceived notions Liz might have about contraception, and how important it is to elicit this history. It is not helpful to push a prescription on a patient who has a fixed belief (even if you know it’s medically not factual) that something is harmful.Here is a good place to talk about what pre-conceived notions Liz might have about contraception, and how important it is to elicit this history. It is not helpful to push a prescription on a patient who has a fixed belief (even if you know it’s medically not factual) that something is harmful.

23. Efficacy: Numbers & Categories Table“Effective Methods” The ring & the patch may be more efficacious because they are easier to remember – but there are no head-to-head studies yet.The ring & the patch may be more efficacious because they are easier to remember – but there are no head-to-head studies yet.

24. 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 NuvaRing® contains the progesterone etonogestrel and the estrogen ethinylestradiol. NuvaRing is a flexible, soft, transparent ring made of evatane, with an outer diameter of 54 mm and a cross-sectional diameter of 4 mm. Standard directions: One ring is to be used for one cycle which consists of a 3–week period of ring use followed by a ring-free period of one week. Each ring releases 15 mcg ethinylestradiol and 120 mcg etonogestrel per day over the 3-week period of use. The active hormone lasts longer: up to 35 days. References: Dieben TO, Roumen FJ, Apter D. Efficacy, cycle control and user acceptability of a novel combined contraceptive vaginal ring. Obstet Gynecol. 2002 Sep;100(3):585-93.NuvaRing® contains the progesterone etonogestrel and the estrogen ethinylestradiol. NuvaRing is a flexible, soft, transparent ring made of evatane, with an outer diameter of 54 mm and a cross-sectional diameter of 4 mm. Standard directions: One ring is to be used for one cycle which consists of a 3–week period of ring use followed by a ring-free period of one week. Each ring releases 15 mcg ethinylestradiol and 120 mcg etonogestrel per day over the 3-week period of use. The active hormone lasts longer: up to 35 days. References: Dieben TO, Roumen FJ, Apter D. Efficacy, cycle control and user acceptability of a novel combined contraceptive vaginal ring. Obstet Gynecol. 2002 Sep;100(3):585-93.

25. 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… Efficacy of the patch is comparable to oral contraceptives There are conflicting data about the risk of DVT. References: Gallo MF, Grimes DA, Schulz KF. Skin patch and vaginal ring versus combined oral contraceptives for contraception. The Cochrane Database of Systematic Reviews 2003, Issue 1. Efficacy of the patch is comparable to oral contraceptives There are conflicting data about the risk of DVT. References: Gallo MF, Grimes DA, Schulz KF. Skin patch and vaginal ring versus combined oral contraceptives for contraception. The Cochrane Database of Systematic Reviews 2003, Issue 1.

26. How many refills should we give Liz? To increase adherence, write for a full year’s supply: even if Liz needs a follow-up visit. That’s a 3-month supply with 3 refills. We have been taught to link refills to follow-up visits: but this stems from an authoritarian model of care. Patient-centered practice = many refills on chronic medications.To increase adherence, write for a full year’s supply: even if Liz needs a follow-up visit. That’s a 3-month supply with 3 refills. We have been taught to link refills to follow-up visits: but this stems from an authoritarian model of care. Patient-centered practice = many refills on chronic medications.

27. Resa 16 years old Doesn’t want to get pregnant until she finishes school Wants contraception that she can hide from her mom What are her choices? Lifestyle factors have a big impact on contraceptive choice. Many teens have to hide their sexual activity from parents or other family members. Some teens have limited privacy – they can’t risk having pill packs for someone to discover.Lifestyle factors have a big impact on contraceptive choice. Many teens have to hide their sexual activity from parents or other family members. Some teens have limited privacy – they can’t risk having pill packs for someone to discover.

28. Highly Effective MethodsNOT USER DEPENDENT The most highly effective methods are those that are not user-dependent. They keep working regardless of what the user does.The most highly effective methods are those that are not user-dependent. They keep working regardless of what the user does.

29. Progestin-Only Injection DEPO: Highly effective - 0.3% failure rate! QuickStart: if urine pregnancy negative, no need to wait for menses! Amenorrhea: 50% by one year, 80% by 5 years Private, not user-dependent DEPO: Highly effective - 0.3% failure rate! QuickStart: if urine pregnancy negative, no need to wait for menses! Amenorrhea: 50% by one year, 80% by 5 years Private, not user-dependent

30. Depo Provera & Bone Density Weighing risks and benefits: No need to restrict Depo Provera use Black box warning 2004: Depo-Provera use >2 years associated with BMD loss No evidence, however, of increased in future fracture or osteoporosis risk BMD loss temporary, recovers after discontinuation Teen pregnancy causes more bone loss than teen Depo Provera use Other lifestyle factors have greater impact on BMD: exercise, diet, weight Black box warning 2004: Depo-Provera use >2 years associated with BMD loss No evidence, however, of increased in future fracture or osteoporosis risk BMD loss temporary, recovers after discontinuation Teen pregnancy causes more bone loss than teen Depo Provera use Other lifestyle factors have greater impact on BMD: exercise, diet, weight

31. Amy Teens aren’t the only patients who need to hide their contraception. Discuss California study on role of partners in unintended pregnancies - sabotage, etcTeens aren’t the only patients who need to hide their contraception. Discuss California study on role of partners in unintended pregnancies - sabotage, etc

32. Intrauterine Devices There are 2 IUDS available in the US: the copper IUD and the progestin IUD. They’re both safe and highly effective. They’re both underused – especially in poor women & teens. Because IUDs’ side effects & advantages differ, we use a simple info sheet to help patients choose between the 2 types. Copper IUD can be used for 7 days as emergency contraception after unprotected sex. Progestin IUD CANNOT be used for EC. References: Hubacher D, Cheng D. Intrauterine devices and reproductive health: American women in feast and famine. Contraception. 2004 Jun;69(6):437-46. Hatcher RA, Zieman M et al. A Pocket Guide to Managing Contraception. Tiger, Georgia: Bridging the Gap Foundation, 2004 Mirena: 5 yr cumulative failure rate is .7% 7 yr cumulative failure rate is 1.1% References: Sivin, et al. Prolonged intrauterine contraception: a seven-year randomized study of the levonorgestrel 20 mcg/day (LNg 20) and the Copper T380 Ag IUDS. Contraception. 1991 Nov;44(5):473-80. Chiou CF, Trussell J, Reyes E, Knight K, Wallace J, Udani J, Oda K, Borenstein J. Economic analysis of contraceptives for women. Contraception. 2003;68(1):3-10. . There are 2 IUDS available in the US: the copper IUD and the progestin IUD. They’re both safe and highly effective. They’re both underused – especially in poor women & teens. Because IUDs’ side effects & advantages differ, we use a simple info sheet to help patients choose between the 2 types. Copper IUD can be used for 7 days as emergency contraception after unprotected sex. Progestin IUD CANNOT be used for EC. References: Hubacher D, Cheng D. Intrauterine devices and reproductive health: American women in feast and famine. Contraception. 2004 Jun;69(6):437-46. Hatcher RA, Zieman M et al. A Pocket Guide to Managing Contraception. Tiger, Georgia: Bridging the Gap Foundation, 2004 Mirena: 5 yr cumulative failure rate is .7% 7 yr cumulative failure rate is 1.1% References: Sivin, et al. Prolonged intrauterine contraception: a seven-year randomized study of the levonorgestrel 20 mcg/day (LNg 20) and the Copper T380 Ag IUDS. Contraception. 1991 Nov;44(5):473-80. Chiou CF, Trussell J, Reyes E, Knight K, Wallace J, Udani J, Oda K, Borenstein J. Economic analysis of contraceptives for women. Contraception. 2003;68(1):3-10. .

33. IUD Myths Debunked IUDs can be used safely by nulligravid women and teens! IUDs DO NOT raise risk of PID. IUDs DO NOT raise risk of infertility. IUDs DO NOT raise risk of ectopic pregnancy. PID: Transient increased risk with insertion (if the patient has an active gonorrhea or chlamydia infection at the time of insertion) Progestin IUD may protect against PID Ectopic pregnancy: The very few pregnancies that occur with an IUD in place are more likely to be ectopic; but the overall pregnancy rate is so low that this scenario is rare. References: Grimes DA. Intrauterine device and upper-genital-tract infection.Lancet. 2000 Sep 16;356(9234):1013-9. Andersson K, Odlind V, Rybo G. Levonorgestrel-releasing and copper-releasing (Nova T) IUDs during five years of use: a randomized comparative trial. Contraception. 1994 Jan;49(1):56-72. PID: Transient increased risk with insertion (if the patient has an active gonorrhea or chlamydia infection at the time of insertion) Progestin IUD may protect against PID Ectopic pregnancy: The very few pregnancies that occur with an IUD in place are more likely to be ectopic; but the overall pregnancy rate is so low that this scenario is rare. References: Grimes DA. Intrauterine device and upper-genital-tract infection.Lancet. 2000 Sep 16;356(9234):1013-9. Andersson K, Odlind V, Rybo G. Levonorgestrel-releasing and copper-releasing (Nova T) IUDs during five years of use: a randomized comparative trial. Contraception. 1994 Jan;49(1):56-72.

34. IUD Myths Debunked IUDs DO NOT cause abortion. OK to insert IUD at any point in the menstrual cycle. OK to insert immediately post-partum or following surgical abortion OK to test for STIs at time of insertion (& treat infections with IUD in place) IUDs DO NOT cause abortion Thickens cervical mucus, suppresses endometrium Copper IUD spermicidal Progestin IUD some anovulatory effect References: Medical eligibility criteria for contraceptive use. 3nd edition, Geneva: WHO, 2004. Grimes D, et al, Immediate post-partum insertion of intruterine devices, Cochrane 2003 (1). Hubacher D et al. Use of copper IUDs and the risk of infertility among nulligravid women NEJM, 2001, 108;304-14. Grimes DA, Schulz KF. Antibiotic prophylaxis for intrauterine contraceptive device insertion. Cochrane Database Syst Rev. 2001;(1):CD001327. Selected practice recommendations for contraceptive Use, 2nd edition, Geneva: WHO 2005.IUDs DO NOT cause abortion Thickens cervical mucus, suppresses endometrium Copper IUD spermicidal Progestin IUD some anovulatory effect References: Medical eligibility criteria for contraceptive use. 3nd edition, Geneva: WHO, 2004. Grimes D, et al, Immediate post-partum insertion of intruterine devices, Cochrane 2003 (1). Hubacher D et al. Use of copper IUDs and the risk of infertility among nulligravid women NEJM, 2001, 108;304-14. Grimes DA, Schulz KF. Antibiotic prophylaxis for intrauterine contraceptive device insertion. Cochrane Database Syst Rev. 2001;(1):CD001327. Selected practice recommendations for contraceptive Use, 2nd edition, Geneva: WHO 2005.

35. Blanca Blanca has heavy, painful menses Anemic Has fibroid on pelvic ultrasound What contraceptive options might be best suited for Blanca? Blanca has heavy, painful menses Anemic Has fibroid on pelvic ultrasound What contraceptive options might be best suited for Blanca?

36. Progestin IUD (MIRENA) Very low serum levels of levonorgestrel Reduces menorrhagia, dysmenorrhea Reduces risk of ectopic pregnancy Highly effective and rapidly reversible Contains no estrogen 80 % of women continue at 1 year (Sivin I, Tatum HJ. Four years of experience with the T Cu 380A intrauterine contraceptive device. Fertil Steril. 1981;36:159-163)Very low serum levels of levonorgestrel Reduces menorrhagia, dysmenorrhea Reduces risk of ectopic pregnancy Highly effective and rapidly reversible Contains no estrogen 80 % of women continue at 1 year (Sivin I, Tatum HJ. Four years of experience with the T Cu 380A intrauterine contraceptive device. Fertil Steril. 1981;36:159-163)

37. Progestin Implant Highly effective and rapidly reversible Discreet Not user-dependent Contain no estrogen Can be used during lactation Active hormone: etonogestrel (68 mg) These are some of the features of contraceptive implants that make them an ideal choice for many women. Because contraceptive implants do not contain estrogen, they can be used during lactation as soon as six weeks postpartum. This feature may be especially attractive to women with young infants who want highly effective contraception that does not require daily action. Sources: Reinprayoon D, Taneepanichskul S, Bunyavejchevin S, et al. Effects of the etonogestrel-releasing contraceptive implant (Implanon) on parameters of breastfeeding compared to those of an intrauterine device. Contraception 2000;62(5):239-246. Diaz S. Contraceptive implants and lactation. Contraception 2002;65:39-46. These are some of the features of contraceptive implants that make them an ideal choice for many women. Because contraceptive implants do not contain estrogen, they can be used during lactation as soon as six weeks postpartum. This feature may be especially attractive to women with young infants who want highly effective contraception that does not require daily action. Sources: Reinprayoon D, Taneepanichskul S, Bunyavejchevin S, et al. Effects of the etonogestrel-releasing contraceptive implant (Implanon) on parameters of breastfeeding compared to those of an intrauterine device. Contraception 2000;62(5):239-246. Diaz S. Contraceptive implants and lactation. Contraception 2002;65:39-46.

38. Features of Progestin Implants Causes spotting Requires certified clinician visits for insertion and removal The challenging features of implants include the associated irregular vaginal bleeding and the need for clinician visits for insertion and removal. As a reminder, implants, like other non-barrier forms of contraception, do not protect from sexually transmitted diseases, including HIV infection. The challenging features of implants include the associated irregular vaginal bleeding and the need for clinician visits for insertion and removal. As a reminder, implants, like other non-barrier forms of contraception, do not protect from sexually transmitted diseases, including HIV infection.

39. Counseling to Enhance Adherence LISTEN to her ideas about the best method. EXPLORE lifestyle issues that may impact adherence. ENCOURAGE her to call you with problems/concerns. Always discuss high-efficacy methods Respect patients’ ideas about what will work best Anticipate common side effects Educate patients about EC use if method is used incorrectly Write prescription with enough refills for an entire year If possible, write RX in 90-day increments Even better, DISPENSE pill packsAlways discuss high-efficacy methods Respect patients’ ideas about what will work best Anticipate common side effects Educate patients about EC use if method is used incorrectly Write prescription with enough refills for an entire year If possible, write RX in 90-day increments Even better, DISPENSE pill packs

40. Impact of Choice Women who are able to use their method of choice are more likely to continue use. A retrospective study of contraceptive discontinuation among 1,945 Indonesian women seen in family planning clinics in 1987–88 found that of 341 who discontinued use of the prescribed method within the first 12 months, 72.2% did not receive their method of choice. Only 8.9% of women who did receive their method of choice had discontinued use within 12 months. These findings imply that contraceptive continuation may be greater when providers pay more attention to the stated preferences of their clients or when policy allows clients to use their method of choice. Source: Pariani S, Heer D, van Arsdol M. Does choice make a difference to contraceptive use? Evidence from East Java. Stud Fam Plann 1991;22(6):384-390.Women who are able to use their method of choice are more likely to continue use. A retrospective study of contraceptive discontinuation among 1,945 Indonesian women seen in family planning clinics in 1987–88 found that of 341 who discontinued use of the prescribed method within the first 12 months, 72.2% did not receive their method of choice. Only 8.9% of women who did receive their method of choice had discontinued use within 12 months. These findings imply that contraceptive continuation may be greater when providers pay more attention to the stated preferences of their clients or when policy allows clients to use their method of choice. Source: Pariani S, Heer D, van Arsdol M. Does choice make a difference to contraceptive use? Evidence from East Java. Stud Fam Plann 1991;22(6):384-390.

41. Inconsistent pill use is linked to:low level of satisfaction with provider & low continuity of care. In addition, pill users who reported that they were not ‘very’ satisfied with their contraceptive service provider or that they did not usually see the same clinician at every contraceptive visit, were more likely to have been inconsistent in their pill use. Reference: Landry 2008In addition, pill users who reported that they were not ‘very’ satisfied with their contraceptive service provider or that they did not usually see the same clinician at every contraceptive visit, were more likely to have been inconsistent in their pill use. Reference: Landry 2008

42. Office barriers to adherence Improve access to refills - phone refills, write for 12, don’t hold hostage to pap smear Improve access to highly efficacious methods Improve acces to EC - have a phone in protocol for teens under 18, have a list of pharmacies that carry it, use advance prescriptions at every opportunityImprove access to refills - phone refills, write for 12, don’t hold hostage to pap smear Improve access to highly efficacious methods Improve acces to EC - have a phone in protocol for teens under 18, have a list of pharmacies that carry it, use advance prescriptions at every opportunity

43. Feeling unable to call a provider with questions is linked to contraceptive non-use. Although providers universally report that they (or their staff) are available to answer contraceptive use questions phoned in by their patients, this is not the perception of all women. Six percent feel that they cannot call their provider with questions, and these women are more likely than those who feel otherwise to have a gap in method use while they are at risk. Landry 2008Although providers universally report that they (or their staff) are available to answer contraceptive use questions phoned in by their patients, this is not the perception of all women. Six percent feel that they cannot call their provider with questions, and these women are more likely than those who feel otherwise to have a gap in method use while they are at risk. Landry 2008

44. Electronic Health Records EHRs can help us lower the barriers to contraceptive adherence: Electronic prescribing eliminates the need for patients to come into the office to get a written RX. Messaging makes it easier for patients to ask questions about side effects. EHRs can help us lower the barriers to contraceptive adherence: Electronic prescribing eliminates the need for patients to come into the office to get a written RX. Messaging makes it easier for patients to ask questions about side effects.

45. Take-home message:Be pro-active with contraception! Break the link between contraception and Pap smears Break down barriers to same-day initiation of contraception Educate office staff about importance of preventing unintended pregnancy Develop nursing protocols that facilitate phone-in contraception refills Ask about contraceptive needs at all types of office visits: especially for highest-risk patients Write 90-day prescriptions with 3 refills if possible: always write for 1-year supply Dispense contraceptives if possibleBreak the link between contraception and Pap smears Break down barriers to same-day initiation of contraception Educate office staff about importance of preventing unintended pregnancy Develop nursing protocols that facilitate phone-in contraception refills Ask about contraceptive needs at all types of office visits: especially for highest-risk patients Write 90-day prescriptions with 3 refills if possible: always write for 1-year supply Dispense contraceptives if possible

46. References and Resources Hatcher et al, Contraceptive Technology 2007 Managing Contraception – book online @ www.managingcontraception.org Medical Eligibility Criteria for Contraceptive Use 2010 by WHO www.who.int/reproductive-health Association of Reproductive Health Professionals www.arhp.org Alan Guttmacher Institute www.agi-usa.org Planned Parenthood www.plannedparenthood.org The Cochrane Collaboration www.cochrane.org www.Not-2-Late.com Reproductive Health Access Project www.reproductiveaccess.org Hatcher et al, Contraceptive Technology 2004 Managing Contraception – book online @ (www.managingcontraception.org) Medical Eligibility Criteria for Contraceptive Use 2004 by WHO (www.who.int/reproductive-health) Association of Reproductive Health Professionals (ARHP) (www.arhp.org) Alan Guttmacher Institute (www.agi-usa.org) www. contraceptiononline.org www.plannedparenthood.org www.cochrane.org www.Not-2-Late.com Hatcher et al, Contraceptive Technology 2004 Managing Contraception – book online @ (www.managingcontraception.org) Medical Eligibility Criteria for Contraceptive Use 2004 by WHO (www.who.int/reproductive-health) Association of Reproductive Health Professionals (ARHP) (www.arhp.org) Alan Guttmacher Institute (www.agi-usa.org) www. contraceptiononline.org www.plannedparenthood.org www.cochrane.org www.Not-2-Late.com