Download Case Studies for Module 3A - Contraception

Contraception Case Learning Objectives
After finishing this case you will have learned the following about contraception:
 Recommendations for contraceptive counseling and STD prevention
 Contraceptive options, including emergency contraception
 Efficacy of different types of contraception
 Cost effectiveness
Contraception Online Resources
The Alan Guttmacher Instititute
http://www.agi-usa.org
Emergency contraception information
http://ec.princeton.edu/
Planned Parenthood
http://www.plannedparenthood.com
National Family Planning & Reproductive Health Association website
http://www.nfprha.org
World Health Organization ’s Medical Eligibility Criteria
http://www.who.int/reproductivehealth/publications/RHR_00_2_medical_eligibility_
criteria_second_edition/index.htm
USPSTF recommendations for counseling to prevent unintended pregnancy
http://www.ahcpr.gov/clinic/uspstf/uspspreg.htm
USPSTF recommendations for screening for cervical cancer
http://www.ahcpr.gov/clinic/3rduspstf/cercan/cervcanrr.htm
USPSTF recommendations for screening for hypertension:
http://www.ahcpr.gov/clinic/3rduspstf/highbloodsc/hibloodrr.htm
A nineteen year old African American woman without a significant past medical
history presents to establish care. She is not taking any medications. She has regular
menstrual cycles; the last was two weeks ago. She is sexually active with one male
partner and currently they are not using contraception.
More than 40% of pregnancies, or close to 3 million, are unintended each year. Almost
half of these pregnancies (47%) occur in women who use no contraception. The
majority of unintended pregnancies among contraceptive users result from
inconsistent or incorrect use.
Pregnancies in the United States, 1999
From Facts in Brief: Contraceptive Use 1999; Alan Guttmacher Institute.
 A sexually active teenager who does not use contraceptives has a 90% chance
of becoming pregnant within one year.
 Each year, almost 1 million teenage women--10% of all women aged 15-19 and
19% of those who have had sexual intercourse--become pregnant.
All of these are options for emergency contraception.
 There are no relative or absolute contraindications to the use of emergency
hormonal contraception.
 In Washington and California both Plan B and Preven may be purchased
directly from participating pharmacies without a prescription or physician
visit but there may be an additional charge for associated counseling.
 Consider providing a prescription for levonorgestrel emergency contraception
to all women at risk of unintended pregnancy.
 Information about emergency hormonal contraception is available at:
http://ec.princeton.edu/
Table 1. Emergency Contraception Options
Agent
Mechanism of Action
Use
Copper T 380A IUD
Insertion
(Paragard®)*
Interrupts
implantation when
used as emergency
contraception
Insertion of IUD within
five days of unprotected
intercourse
Efficacy
Side Effects

99.9% effective in
preventing
unintended
pregnancy

1/1000 women will
become pregnant
with emergency
insertion.
Abdominal pain,
Bleeding, Infection,
Menorrhagia,
Uterine puncture
Levonorgestrel,
(Plan B®)
Combination
hormonal
emergency
contraception
(Preven Emergency
Contraceptive Kit®
or Yuzpe regimen)

May delay
or inhibit
ovulation

May prevent
implantatio
n of
fertilized egg
in uterine
wall

May delay
or inhibit
ovulation

May prevent
implantatio
n of
fertilized egg
in uterine
wall

One dose
taken up to
72 hours after
unprotected
intercourse, a
second taken
12 hours later

The earlier
taken, the
more effective

One dose
taken up to
72 hours after
unprotected
intercourse, a
second taken
12 hours later

The earlier
taken, the
more effective

Can be taken
up to 120
hours after
unprotected
intercourse

89% effective in
preventing
unintended
pregnancy

Reduces risk of
pregnancy from
8% to <1%

75% effective in
preventing
unintended
pregnancy

Reduces risk of
pregnancy from
8% to 2% when
initiated within 72
hours of
unprotected
intercourse
23% nausea, 6%
vomiting,
Menstrual
irregularities,
Breast tenderness,
Headache,
Abdominal pain &
cramps
Same as
Levonorgestrel
except: Nausea
50%, Vomiting
30%
Source: from PIER Web Site: Contraception
*Absolute contraindications include uterine anomalies, active cervicitis or vaginitis,
undiagnosed vaginal bleeding, copper allergy, significant anemia.
Levonorgestrel-Containing Emergency Contraception Options Available in the U.S.
After reviewing her treatment options, you prescribe Plan B to prevent pregnancy
from her recent unprotected intercourse and recommend that she schedule a return
visit for contraceptive counseling. She returns several weeks later. She has been tested
and is not pregnant. She wants to know what other situations would warrant use of
emergency contraception.
There are many indications for using emergency contraception as summarized in the
following list.
Potential Indications for Use of Emergency Contraception
 Lack of contraceptive use during coitus
 Mechanical failure of male condom (breakage, slippage, leakage)
 Dislodgment, breakage, or incorrect use of diaphragm, cervical cap, or female
condom
 Failure of a spermicide tablet or film to melt before intercourse
 Error in practicing withdrawal (coitus interruptus)
 Missed combined oral contraceptives (any two consecutive pills)
 Missed progestin-only pills (one or more)




Expulsion or partial expulsion of an intrauterine device
Exposure to potential teratogen (such as isotretinoin or thalidomide) while not
using effective contraception
Late injection of injectable contraceptive (>2 weeks late for progestin-only
formulation such as DMPA or >3 days late for a combined estrogen plus
progestin formulation)
Rape
Vasectomy and the levonorgestrel IUD (Mirena) have similar efficacy with pregnancy
rates of 0.15% and 0.1% per year respectively.
 Tubal ligation is reported to have a failure rate at least twice that of
vasectomy at 0.5% per year. Both tubal ligation and vasectomy should be
considered irreversible.
 Depo-Provera has a pregnancy rate of 0.3% per year for typical use, making it
slightly more efficacious than tubal ligation.
 The copper IUD (ParaGard®) has a pregnancy rate slightly higher than that
for tubal ligation at 0.8% per year for typical use.
 Norplant is not currently available in the United States.
Table 3. Percentage of women in the US experiencing an unintended pregnancy during the first year of typical use and perfect use of
contraception and the percentage continuing use at the end of the first year.
% of Women
Experiencing an
Unintended
Pregnancy
within the First
Year of Use
Method
Typical
Use1
Perfect
Use2
Chance
85
85
Spermicides4
26
6
Periodic Abstinence
25
% of Women
Continuing Use at One
Year 3
40
63
Calendar
9
Ovulation Method
3
Symptothermal5
2
Post-ovulation
1
Cap6
Parous women
40
26
42
Nulliparous women
20
9
56
Parous women
40
20
42
Nulliparous women
20
9
56
20
6
56
Sponge
Diaphragm6
Withdrawal
19
4
Female (Reality)
21
5
56
Male
14
3
61
Pill
5
71
Progestin only
0.5
Combined
0.1
IUD
Progesterone T
2.0
1.5
81
Copper T 380A
0.8
0.6
78
Lng 20
0.1
0.1
81
Depo-Provera
0.3
0.3
70
Norplant8
0.05
0.05
88
Female / Male Sterilization
0.5/0.15
0.5/0.1
100/100
Among typical couples who initiate use of a method, the percentage who experience
an accidental pregnancy during the first year if they do not stop use for any other
reason.
2 Among couples who initiate use of a methodand who use it perfectly, the percentage
who experience an accidental pregnancy during the first year if they do not stop use
for any other reason.
3 Among couples attempting to avoid pregnancy, the percentage who continue to use
a method for one year.
4 Foams, creams, gels, vaginal suppositories, and vaginal film.
5 Cervical mucus (ovulation) method supplemeneted by calendar in the pre-ovulatory
and basal body temperature in the post-ovulatory phases.
6 With spermicidal cream or jelly
7 Without spermicides.
8 Not currently available
1
She is interested in reversible methods of contraception but does not want an IUD.
She is hesitant to start Depo-Provera as she does not like shots. She requests more
information about barrier methods.
If used perfectly, the pregnancy rate is 3% per year with the condom and 6% per year
with the diaphragm. For the typical user, the rate of pregnancy with the condom is
14% per year and 20% per year with the diaphragm.
Barrier methods rely more heavily on user compliance making their effectiveness
partially dependent on the user. Particularly compliant or less fertile patients may
have pregnancy risk near that of "perfect use," while less compliant patients or more
fertile patients may have pregnancy risk which is higher than that represented by
"typical use" (See Table above).
To help patients choose appropriate contraception the provider must assess the
patient’s ability and willingness to practice the method consistently as well as their
likely fertility.
Condoms without spermicide are the most effective means of preventing STD’s.
 Recommend the use of male condoms to all sexually active patients to decrease
the risk of acquiring sexually transmitted infections, including HIV.
 Recommend condoms or other barrier methods in addition to highly effective
contraception for patients under the age of 25 at risk of pregnancy because of
their high risk of both sexually transmitted infections and unintended
pregnancy. In 2000, the highest rates of chlamydial and gonorrheal infection
were in women less than 24 years old.
 Counsel patients that other barrier methods and withdrawal decrease the risk
of STDs to a lesser degree.
 Nonoxynol-9 spermicide, the only spermicide available in the US, should not
be recommended to decrease the risk of STD’s. It may increase the rate of HIV
acquisition because of genital tract irritation. Its effect on rates of chlamydia
and gonorrhea is unclear. In January 2003 the FDA proposed new warning
labels for vaginal contraceptives containing nonoxynol-9.
She is reluctant to rely on a barrier method given the relatively high rate of
pregnancy for typical users. Several of her friends take oral contraceptives and she
thinks that might be the best option for her.
The rate of pregnancy with typical use of oral contraceptive pills is:
A. 0.1%
B. 1%
C. 3%
D. 5%
E. 9%
5% is the typical annual rate of pregnancy with oral contraceptives, both combined
and progestin only. The lowest expected rate of pregnancy for combined oral
contraceptives is 0.1% per year if used perfectly but climbs to 5% per year with
typical use because of missed pills. The progestin only pill is slightly less effective with
a per year pregnancy rate of 0.5% when used perfectly.
The Ortha Evra patch, NuvaRing, and Lunelle injections, newer delivery methods of
combination hormonal contraception, should be considered to improve compliance.
 They all have the same mechanism of action as combined oral contraceptives
but do not need to be administered on a daily basis; the patch is administered
every week, the vaginal ring and injection, once a month.
 The efficacy and cycle control of all three of these methods have been shown to
be comparable to that of combined oral contraceptives
 Compliance data shows the Ortho Evra patch to have a higher rate of perfect
adherence as compared to combined oral contraceptives, with rates of 88.7%
for patch users and 79.2% for oral contraceptive users
DMPA is the most cost-effective contraceptive. (The cost per year of use for DMPA is
approximately $210.) When considering expense, the costs associated with an
unintended pregnancy need to be included. This includes the cost for termination or
delivery if unintended pregnancy occurs. Because DMPA is very effective, these costs
are minimized. The IUD is similarly effective, but because of its high acquisition cost,
ranging from $300 to $500, it does not become cost effective until used for several
years. Oral contraceptives have a 5% typical failure rate which makes them
somewhat less cost effective than DMPA over one year of use.
All contraceptive options are cost effective as compared to no contraceptive method.
Direct medical costs including method use, side effects, and unintended pregnancies
associated with 15 contraceptive methods were modeled and found cost savings from
$8933 with barrier methods to $14,122 with copper-T IUD when used over five years.
Federally funded family planning clinics and Planned Parenthood provide various
contraceptive options at reduced cost to low income women.
 Planned Parenthood website http://www.plannedparenthood.org
 To find Title X funded family planning clinics for your patient, see the
National Family Planning & Reproductive Health Association website:
http://www.nfprha.org
It is important to review all of these with a patient prior to prescribing combined
contraceptives.
THROMBOEMBOLISM
Do not prescribe COC’s to women with a personal history of thromboembolism,
including DVT or PE. The absolute risk of venous thromboembolism increases from
baseline of one case per 10,000 person years to 3 to 4 cases per 10,000 person years
with COC use, but is markedly increased if the patient has a prior history of
thromboembolism.
SMOKING
Do not prescribe COC’s to women over 35 who smoke more than 15 cigarettes per day.
Advise women who smoke that there may be an increased risk of stroke with COC use.
1060 heavy smokers need to take COC’s for 1 year to cause one extra MI.
MIGRAINES
Do not prescribe COCs to women with focal neurological symptoms with their
headaches. Advise women with migraine headaches that there may be an increased
risk of ischemic stroke with COCs. The additional risk of thrombotic stroke
attributable to women with migraines using COCs has been estimated as increasing
from 2/100,000 in 20 year old women with migraine to 10/100,000 in 20 year old
women with migraines on COC’s. In 40 year old women, this risk is thought to be
increased ten-fold. The baseline risk of stroke in 40 year old migraneurs is estimated at
20/100,000; which increases to 100/100,000 for 40 year old women with migraines
using COC’s. . Consider other contraceptive methods in women with migraines who
are over the age of 35 or who smoke.
A PAP smear is not necessary prior to providing contraception. Pelvic and breast
examinations (including PAP smear) are unlikely to detect any contraindications to
contraception. Requiring them is likely to increase the risk of unintended pregnancy
by delaying initiation of effective contraception.
 The American Cancer Society recently published evidence-based cervical
cancer screening recommendations which have been endorsed by the American
College of Obstetrics and Gynecology.

The recommendation is that cervical cancer screening should begin
approximately 3 years after the onset of vaginal intercourse, but no later than
21 years of age. "It is critical that adolescents who may not need a cervical
cytology test obtain appropriate preventive health care, including assessment
of health risks, contraception, and prevention counseling, screening and
treatment of sexually transmitted diseases. The need for cervical cancer
screening should not be the basis for the onset of gynecologic care."
The US Preventive Services Task Force (USPSTF) has similar
recommendations.
USPSTF recommendations for counseling to prevent unintended pregnancy:
http://www.ahcpr.gov/clinic/uspstf/uspspreg.htm
USPSTF recommendations for screening for cervical cancer:
http://www.ahcpr.gov/clinic/3rduspstf/cervcan/cervcanrr.htm
Blood pressure should be measured prior to the initiation of oral contraceptives. An
evidence based review by the World Health Organization finds that oral
contraceptives are contraindicated if blood pressure is greater than 160/100 on three
or more occasions due to increased risk of stroke and MI as compared to non-users
Blood pressure measurement is recommended by the USPSTF at least every two
years in children and adults.