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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.