Download Contraception Abortion Care

Contraception
Dr Arlene Smalls, MD
August 5, 2011
Lankenau Medical Center
Department of OB GYN
Objectives of Lecture:
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Review of Contraceptive Counseling,
Risk Assessment and Method Initiation
Discussion of Conceptive methods
including Emergency Contraception
Discussion of new Guidelines regarding
Contraceptive Usage
Contraception Needs in US
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~60 million women between ages of 15-44
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60% use contraception
33% don’t have a need for contraception
7.3% who are at risk are not using any method
6 million pregnancies yearly in US
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50% of pregnancies are unintended
1 million pregnancies occurred on OCP’s
1.4 million abortions performed yearly in US
Counseling
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Efficacy
Availability
Costs
Ease of Use
Privacy
Reversibility
Side Effect and Medical Risks
Patient and Partner Desires
Informed Decision Making
Contraceptive Efficacy
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Pearl Index:
Theoretical Definition of Method Failure
Rate based on “Perfect Usage”:
Number of Failures / 100 Women-years
of exposure
(x1200 if based on months)
(x1300 if based on cycles)
“Typical or Usage Failure Rate” based on
actual usage activity from Life Table Method
Contraceptive Methods
Combined Hormonal Methods (COC)
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Oral Contraception
Nuva Ring
Ortho Evra Patch
Progestin Only Methods (POP)
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The Mini Pill
Depo-Provera
Implanon
Non Hormonal Contraception - IUD
Barrier Methods
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Male / Female Condoms
Sterilization
Emergency Contraception
Pre-Assessment & Evaluation
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Discussion of Patient’s Life and Health Plans
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Reproductive Life Plan
Childbearing Goals
Birth Spacing
Pre-conceptual Health Assessment and
Counseling
Extensive Personal Medical History and Family
History
Pre-Assessment History
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Personal History:
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Medical History of Hormonal contra-indications:
(HTN, MI, Cardiac Dz, DM, CVA, DVT, PE, other)
Liver Disease
Migraine headache with aura or neurologic
complaints; Seizure history
Tobacco Usage
Current Medications
Surgical History
Pre-Assessment History
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Gyn History:
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Menstrual History including LMP
Breast Issues including new or unevaluated
masses
Uterine fibroids or other anatomic abnormalities
STD history, prior and current risk (?)
Familial History of Thrombophilia
(1st degree relative)
Pre-Assessment & Evaluation
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Physical Exam not necessary prior to initiation
of any birth control method
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Laboratory Testing
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Vital Signs, Weight
Breast Exam*, Pelvic Exam (??)
Factor V Leiden, Anti-phospholipid evaluation,
Glucose, and Lipids if there is a concerning
personal or family history
STD screening prior to IUD placement (?)
CDC and Contraception
Medical Eligibility
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WORLD Health Organization (WHO) established
an evidence based guideline for contraceptive usage
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Global review of the 19 different contraceptive
methods for women and men
4th version was revised 2010 (available since 1996)
COC Physiologic Effects
Hormonal Effect
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Estrogen (ethinyl estradiol) and Progesterone alter
FSH/LH secretion via negative feedback
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Follicle development and Ovulation are suppressed
Endometrial thinning
Cervical mucous thickening
Reduced sperm transport
Progestin is the dominant hormone
COC or OCP’s
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10.7 million women use OCP
(~27% of BC users)
Most popular, reversible BCM in the US
21 day cycle, 24 day cycle
Extended regimens
Monophasic, Biphasic, Triphasic, Quadiphasic
(Quailara@)
20mcg, 35 mcg, 50 mcg pill regimens
(based on Estrogen dosage)
OCP Failure
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Failure rate is 0.1%
Usage Failure rate is 8/100 womanyears
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Adherence with OCP – 50% of women miss 1-3 pills a
cycle
Missing Pills within the 1st week of the pack –
breakthrough ovulation
Drug Interactions –
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Anti-seizure medications (G450 activation)
Antibiotics – Rifampin, Griseofulvin
Anti-viral medications - Norvir
OCP’s concerns
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Alterations in the Menstrual Cycle
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Health Risks
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Breakthrough bleeding
Amenorrhea 0.8% per year
Headaches and Elevated Blood pressure
Weight Gain
Breast Cancer risk
Risk of Thrombo-embolic events*
Non Contraceptive Benefits
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Acne and Hirsuitism therapy
Menstrual Regulation occurs with decreased
Menstrual Blood Loss
Dysmenorrhea, endometriosis symptoms are
improved
Rates of Ovarian cysts, ectopic pregnancy,
and salpingitis are reduced.
Ovarian and Endometrial Cancer rates are
reduced with past usage of at least one year
Contra-indications to COC usage
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Medical History
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Personal H/o Thrombo-embolism (DVT, PE, CVA, MI)
or
Familial History of inherited thrombophilia (DVT, PE, CVA,
MI)
Uncontrolled HTN (>160/100)
Hepatic Dysfunction
Diabetes
Breast Cancer
Smokers over the age of 35** (#)
Unexplained vaginal bleeding or Pregnancy
Contra-indications to COC usage
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Postpartum patients* <21 days,
Cardiac Disease including h/o ischemic heart
disease, valvular heart dz, peripartum
cardiomyopathy and multiple risks factors for
heart disease*
H/o Solid Organ Transplant, complicated
H/o Gastric Bypass*
CDC – Medical Eligibility Criteria, 2010
Postpartum Contraception
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WHO Revised guideline 7/2011
PP, 22-84X greater risk of DVT, PE or VTE
Ovulation can occur as early at 25 days in non
lactating women
21 days pp - No COC or CHC
42 days pp – Non COC or CHC
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Obesity, Post Cesarean Delivery, Preeclampsia, PP
hemorrhage, Transfusion at Delivery, Immobility, Age > 35,
Tobacco Users, BMI > 30, Prior h/o VTE, Thrombophilia)
POP methods are acceptable immediately
Drug Interactions and OCP’s
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Anti-Malarial Meds:
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Anticonvulsant Medications:
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Antiretroviral therapy (ARV):
Rifampicin / Rifabutin
Lamotrigine*
Phenytoin, Carbamazepine, Barbituates, Primidone,
Topiramate and Oxcarbazepine
Ritonavir-boosted protease inhibitors
Ortho-Evra
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Weekly Transdermal patch of a hormonal matrix
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150 mcg ethinyl estradiol
20 mcg norelgestromin
Worn 3 weeks out of 4 weeks per cycle
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Sites of usage: Back, Upper arm, Abdomen, or Chest
Sunday Start or 1st day Start
Patch Change Date within 48 hours of scheduled date
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Failure rate: 1%
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Not recommended for hormonally naïve patients, smokers*, or
patient with h/o skin sensitivity or weights above 198 lbs
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NuvaRing
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Ethylene vinyl acetate polymer ring
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15 mcg of Ethinyl estradiol
120 mcg Etonogestrel
Intra-vaginal placement
Worn ¾ weeks per cycle with option of
one week
Menstrual Cycles regulated 98.5% of cycles
Failure rate: 0.65-1.18/100 women-years
Vaginal Discharge and placement issues
Progesterone only Contraception
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Progestin-only pills - POP or “Mini pills”
Norethindrone or norgestrel
Continuous usage (no pill free interval)
Hormone must be taken daily at the same time
(25% circulating levels of OCP’s / 22hr effect)
Ovulation seen in 40-50% of POP users
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Mechanism of action:
Cervical Mucous thickening, Thinning of
endometrium, reduced sperm transport
Failure Rate: 1.1 to 9.6 / 100 women-years
Backup method – Barrier Method / Breast feeding
Depo-Provera@ or DMPA
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150milligrams of Medroxyprogesterone acetate
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IM dose every 11-13 weeks
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Inhibits LH/FSH surge
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Ovulation and endometrial proliferation are inhibited
New Guidelines regarding missed doses
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Deltoid or Gluteus Maximus
WHO 2009 – Delayed Dosages can be given up to 4 weeks
from date originally scheduled
Failure Rate: 0.3 – 3%
Long lasting but reversible
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Return to fertility – 50% by 9 months (max – 18 months)
DMPA
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Contra-indications:
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Breast Cancer
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Safe if contra-indications to COC’s exist:
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Tobacco, HTN,
 SLE, CVA, Thromboembolic events (DVT/PE),
Liver Disease (????)
Improved Outcomes in Certain Populations:
 Sickle Anemia / Trait; Seizure Disorder
 Endometriosis, Dymenorrhea and Pelvic Pain
 Adolescents, Developmentally Delayed Women
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DMPA Risks
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Bone Density alteration due to estrogen
deficiency
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Menstrual Changes
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70% have increased bleeding days per month
75% experience amenorrhia after one year of usage
Weight Gain
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Limited Risk: Bone changes resolve with cessation of DPMA
More in Women who are Obese at initiation of method
5lbs by year One; 16 lbs by year Five
Mood Disorders and Psychiatric Issues
Implanon
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Subdermal, single rod progestin implant
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Etonogestrel release
3 year duration of use
Ovulation suppression and endometrial thinning
Failure rate: no failures reported in 4103 women /
70,000 cycles
Menstrual pattern alteration – 80%
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Irregular or prolonged bleeding (3-5 days per cycle)
Total Overall Blood loss decreased
Treat with NSAIDS, OCP’s or estrogen
Intra Uterine Device – Paraguard@ IUD
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Long acting, low maintenance, rapidly reversible
contraception
Copper T380A - 3.6cm long T shaped device made of
polyethylene plastic
Length of usage – 10-12 years
Prevention of pregnancy via Endometrial
inflammatory response and anti sperm activity
Failure rate = 0.8% (up to 3% at 10 years)
Risk of PID, Expulsion/perforation at insertion and
Dysmenorrhea/Menorrhagia
Mirena@ IUD
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3.2cm long, T-shaped device with an inner reservoir
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Levonorgestrel 20 mcg per day
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Cervical Mucous thickening and Endometrial atrophy
Ovulation still occurs in 85% of the cycles
Failure rate: 0.14 per 100 women–years
0.71% (5 year failure rate)
Menstrual irregularity during the first three months
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Menorrhagia/Endometrial Cancer treatment
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IUD Safety
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Safe Profile proven with recent studies
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Safe for Adolescents and Nulliparous Females
Limited increased risk of PID/Infection within the
first 30 days post placement
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Screen for STI and BV pre-placement if Risk factors
Treat STI and allow 3 months from therapy prior to IUD
placement
Recommend Condom usage
IUD can be left in place if cervicitis or PID
diagnosed
Barrier Methods
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Male Condoms
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Latex condoms – STI protection
Failure rate – 3% (Actual – 12%)
Breakage rates: 1% of heterosexual acts
Nonoxynol 9 no longer recommended
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Polyurethane or Non latex condoms
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Female Condoms
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Polyurethane pouch with two rings
Can insert up to 8 hours prior to intercourse
Female controlled and allows Labia protection
Barrier Methods, Other
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Cervical Cap:
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Thimble shaped rubber device that fits over the cervix
Fitted by gynecologist
Can be left in vagina for 48 hours
Vaginal Discharge
Failure rate: 9% in nulliparous; 20% in parous within 1 year
Diaphragm:
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Dome shaped rubber cups create a barrier over the cervix
Use with spermicide
May place in vagina up to 6 hours prior to intercourse and remain in place
for 8 hours (max 24 hours)
Failure rate: 6% / 12%
UTI risks
Permanent Sterilization - Female
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Female Sterilization is the most common
method used in US for married couples
10 million women in US
100 million women worldwide
Overall Failure rates: 1.85% over 10 years but differs
slightly by method and provider experience
Drawbacks: Regret, Failures, Ectopic pregnancy
(CREST study – NEJM 2001)
Permanent Sterilization - Female
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Laparoscopic Methods:
Bipolar Cautery, Sialastic Bands / Falope
Ring, Filshie or Hulka Clips,
Open Procedure / Minilaparotomy:
Pomeroy/Modified Pomeroy, Parkland, Irvine,
Uchida, Fimbrectomy
Hysteroscopic Methods: Essure, Adiana
Male Methods
Sterilization - Vasectomy
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Conventional Vasectomy
“No Scapel Vasectomy” - In Office Procedure
for occlusion of the Vas Deferens
Limited Risks:
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No Missed Work, Minimal Pain
Need 2 negative Sperm Analysis
Costs: $350 – $1,000
Failure Rate: < 1%
Reversibility:
Emergency Contraception – “EC”
Post coital Contraception - Pregnancy prevention
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Yuzpe method, 1970’s
100mcg estrogen/500mcg Levonegestrel - (2) doses in 12hrs
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Drawbacks: nausea, vomitting
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More than 20 brands of OCP can now be used as EC*
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Reduction in unintended pregnancy rates post EC:
95% if taken with 12 hours;
89% if taken with 5 days
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IUD
Emergency Contraception – “EC”
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Plan B, available since 2000
 1.5mg Levonorgestrel
 Single dose (2 pills) versus 2 One pill dose
protocol every 12hrs
 Available over the counter (Age >17) since
2009
 Well tolerated
Next Choice- progestin only EC, OTC
available since 2010
Emergency Contraception – “EC”
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Reduction in unintended pregnancy –
95% if taken with 12 hours;
75% if taken within 72 hours
May use EC up to 120 hours after intercourse*
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If, no menses within 2-4 weeks or persistent
irregular bleeding post EC, rule out
pregnancy
Contraceptive Method Initiation
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Quick start, Sunday start, Menses Day 1 start
LMP to r/o pregnancy needed with Quick start
Backup needed for 7 days after initiation –
Quick start and Sunday start
Altered Menses may be seen with all methods
Combination methods – Important
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Condoms/Barrier methods with hormonal method
Emergency Contraception
Postpartum
Postpartum Contraception
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WHO Revised guideline 7/2011
PP, 22-84X greater risk of DVT, PE or VTE
Ovulation can occur as early at 25 days in non
lactating women
21 days pp - No COC or CHC
42 days pp – Non COC or CHC
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Obesity, Post Cesarean Delivery, Preeclampsia, PP
hemorrhage, Transfusion at Delivery, Immobility, Age > 35,
Tobacco Users, BMI > 30, Prior h/o VTE, Thrombophilia)
POP methods are acceptable immediately
Adolescents
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Confidentiality Issues
Recommend Informed Adult regarding
medication
Return office appt for contraception
re-enforcement and assessment
Resources
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U.S. Medical Eligibility Criteria for
Contraceptive Use, 2010
www.cdc.gov/mmwr/pdf/rr/rr59e0528.pdf
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World Health Organization
http://www.who.int/en/
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Guttmacher Institute
www.guttmacher.org/pubs/psrh/full/3809006.pdf