Pro-Active Use of Contraception Linda Prine MD and Ruth Lesnewski MD Beth Israel Residency in Urban Family Practice

Thanks to: Alan Guttmacher Institute World Health Organization Association of Reproductive Health Professionals Contraceptive Technology Physicians for Reproductive Choice and Health Managing Contraception Our physician collaborators: Norma Jo Waxman, Panna Lossy, Lauren Oshman, Ana Tinio, Marissa Harris, Resa Singleton, Susan Rubin, Yolanda Tun-chiong, Asaf Cohen, Amy Pandya, Shibani Munshi, and Noa’a Shimoni

Learning Objectives At the end of this session, participants will be able to:  Describe how patient centered counseling affects contraception adherence  Explain “Quick Start” initiation of contraception  List three systems barriers impacting contraception adherence.

6.3 Million Pregnancies in the U.S. 52 % Intended 25 % Unintended Used Contraception 23 % Unintended No Contraception Henshaw SK. Fam Plann Perspect. 1998;30(1):24-9, 46. Rosenberg MJ, Waugh MS, Long S. J Reprod Med. 1995;40(5): Potter L, et al. Fam Plann Perspect. 1996;28(4):154-8.

Outcomes of Unintended Pregnancies (Approximately 3.0 Million Annually) Source: Henshaw, 1998 (1994 data)

Children born from unintended pregnancies are more likely to: Receive no prenatal care in utero Be exposed to tobacco, alcohol, and drugs in utero Have low birthweight Experience domestic violence Die during the first year of life Institute of Medicine Report 1995

The case for improving contraception access: Morbidity/ mortality of pregnancy & childbirth much higher than that of contraception Use of effective contraception could cut unintended pregnancy rate in half Increasing availability of contraceptive services for young people is associated with reduced pregnancy rates Henshaw Family Planning Perspectives 1998;30(1):24-29 NHS Centre for Reviews and Dissemination. Effective Health Care 1997; 3(1) 1-12.

Yolanda 18 year old patient here with a UTI LMP 3 weeks ago Also wants a pregnancy test She had unprotected sex 4 days ago Urine pregnancy test is negative She’s not on any contraception, but would like some, since she has a new partner

Emergency Contraception: Levonorgestrel (Plan B) Sig: 2 tabs at once, up to 5 days after unprotected sex Rodrigues I, et al. AJOG, 2001, 184(4): von Hertzen H, et al. Lancet 2002;360:

Progestin-only Emergency Contraception Mechanism of action: DOES NOT DISRUPT AN IMPLANTED PREGNANCY Inhibits ovulation Traps sperm in thickened cervical mucus Inhibits tubal transport of egg or sperm May interfere with fertilization or early cell division Gemzell-Danielsson K, Marions L. Hum Reprod Update Jul;10(4): Population Council. Population Briefs May;11(2).

“Quick Start” If OCs are prescribed with Sunday or 1 st -day-of- menses start, as many as 25% of women do not start. “Quick Start” = first pill taken on day of visit, at any point in the menstrual cycle. Confirm HCG neg. If she needs EC, start the pill the next day.  More women still on pill in 3 rd cycle w/ Quick Start  No increased spotting or bleeding Westhoff et al. Contraception 2002;66(3): Westhoff et al. Fertil Steril 2003;79(2):322-9.

Oral contraceptives are NOT teratogenic Meta-analysis of 12 prospective studies shows that estrogen/progestin oral contraceptives do not cause birth defects Bracken MB, Obstet Gynecol. 1990;76(3 Pt 2):552-7.

Emergency Contraception (EC): Advance Prescription When EC is provided in advance of need, its use doubles Easy access to EC does not lead to decreased use of usual contraceptive method Easy access does not increase STIs or unprotected intercourse (even among teens!) Standing orders can improve access to EC: nurses phone in prescription Direct Pharmacy Access in following states:  Washington, Maine, California, Alaska, New Mexico & Hawaii Bissel et al. Soc Sci Med.2003;57: Raine et al. JAMA.2005;293:54-62 Trussell J, et al. Am J Public Health 1997;87: Gold, MA, et al. J Pediatr Adolesc Gynecology 17(2):87-96.

Yolanda, later Yolanda received a one-year supply of birth control pills. She calls 12 months later requesting a renewal prescription. She started having sex 12 months ago, and she has never had a Pap smear. Her STI tests were negative & her blood pressure was normal a few months ago.

FDA. Dept of Health & Human Services FDA Advisory Committee’s Recommendation on Delay of Pelvic Exam “Physical examination may be deferred until after initiation of oral contraceptives if requested by the woman and judged appropriate by the clinician.”

USPSTF recommendation for cervical cancer screening: Within three years of the onset of sexual activity or at age 21, whichever comes first.

Lauren 30 y/o G3P2 Having an abortion today in your office Got pregnant because she couldn’t get a refill on her pills Which contraceptive methods can she start today?

Post-abortion birth control options WHO guidelines suggest the following methods without restriction after an early abortion: estrogen/progestin pills, patch, ring; progestin-only injection, implants; IUDs That is, anything goes!

IUD issues post-abortion Expulsion rate only slightly increased for IUDs inserted right after early aspiration abortion No increased risk of infection Expulsion may be more common after medication abortion – no published studies on this yet Grimes et al, Cochrane Library. 2004; Issue 4. Weibe, Communication 4/05.

Anna 22 year old, GoPo, calls you today Recently began having sex with her boyfriend You saw her 7 months ago for an exam and pap smear All was normal She has been using condoms She wants you to prescribe pills for her by phone

What is Required Before Prescribing Hormonal Contraception? Medical History:Required BP:Helpful Breast exam, Pelvic exam, Pap, Hemoglobin, other lab tests, STI testing: NOT REQUIRED! Stewart F, et al. JAMA. 2001;285:

Resa 21 y/o GoPo Does not like hormones b/o nausea Does not like condoms either 246 lbs, normal BP, LMP 2 wks ago Normal Pap/STI tests 1 year ago Needs birth control because boyfriend is coming back from Iraq next week Doesn’t want to have children soon

Intrauterine Devices 2 options today: Copper T 380A (ParaGard) and Levonorgestrel releasing system (Mirena) In 1995, IUDs were used by 11.9% of women worldwide, but by only 0.8% of US women (down from almost 10% of US women in the mid-70’s) New interest and surge of use in US Hubacher. Contraception 2004;69: Hatcher RA, Zieman M et al. A Pocket Guide to Managing Contraception

IUD Myths Debunked IUDs DO NOT cause Abortion:  IUDs thicken cervical mucus, suppress endometrium; progestin IUD has some anovulatory effect IUDs DO NOT increase risk of PID:  IUD itself carries no risk of infection. Transient risk with insertion.  Progestin IUD may protect against PID IUDs DO NOT increase risk of ectopic pregnancy Grimes DA. Lancet. 2000;356(9234): Andersson K, et al. Contraception 1994;49:56-72.

More IUD Myths Debunked May insert at any point in the menstrual cycle May insert immediately post-partum Okay to use in nulliparous women No need for prophylactic antibiotics OK to do STI testing at time of insertion (& treat infections w/ IUD in place) Medical eligibility criteria for contraceptive use. 3nd edition, Geneva: WHO, Grimes D, et al. Cochrane 2003 (1). Hubacher D et al. NEJM, 2001, 108; Grimes DA, Schulz KF. Cochrane Database Syst Rev. 2001;(1):CD Selected practice recommendations for contraceptive Use, 2nd edition, Geneva: WHO 2005.

Counseling to Enhance Adherence Patient-centered - listen to what she has heard about what is good and what isn’t. Explore how her lifestyle might affect her ability to methods correctly. Discuss methods with high efficacy. Encourage return visits and calls for problems – advise her to speak w/ you before stopping method. Explain use of EC if method re-started late.

Amy 24 yo G3P2Tab1 Currently using OC, but admits to forgetting pills often Why might she be missing pills?

WHY? Irregular schedule Stays over at different houses Has to hide the pills at her house Can’t get to the pharmacy for refill Just forgets Other ideas?

Adherence with OCPs: What Women Do! Potter L et al. Fam Plann Perspect..1996;28(4): Percent of Women (%)

Back to Amy… She would like to try the patch, since her friends like it What else do you want to discuss with her? What other hormonal options would be appropriate for her?

Contraceptive Patch (Evra) Apply weekly x 3 weeks, then one week off Failures in trials were in women over 198 pounds, but still rare Same efficacy & contraindications as OCs OK to shower, swim, exercise w/ patch on Does NOT have higher risk of clots Gallo MF, et al. Cochrane Reviews. 2003, Issue 1. Art. No. CD Jick S, et al. Contraception 73 (2006)

Depot Progestin Injections (DepoProvera) IM Injection of depot medroxyprogesterone acetate given every three months After one year of use, 50% women develop amenorrhea, 80% in five years Good option for women who cannot use estrogen Private - there are no visible clues that the woman is using it; no one else needs to know Hatcher, R et alA Pocket Guide to, Managing Contraception,

Depot progestin & bone density Black Box warning based on 3 small studies - new DMPA use in teens over 2 years - > 1 to 6% loss Loss of BMD happens in first 2 years Teen pregnancy causes more bone loss than teen DMPA use Recent studies show bone density recovers after discontinuation of progestin Other lifestyle factors have greater impact on BMD - exercise, diet, weight

Estrogen/progestin vaginal ring Lowest estrogen dose: 15 mcg No wrong placement May remove up to 3 hours Most don’t notice during sex Appears to have lower estrogen- related side effects than other hormonal methods Dieben TO, et a.l Obstet Gynecol 2002 Sep; 100(3):

Initiation of Hormonal Methods: Switching from one to another If switching from OC, start at any time in cycle: NO NEED TO COMPLETE PILL PACK If switching from depot progestin, start on or prior to next injection date (2-week window) If switching from IUD between menses, start one week prior to removal Hatcher RA, Zieman M et al. A Pocket Guide to Managing Contraception Selected practice recommendations for contraceptive use, 2nd edition, Geneva: WHO 2005.

Ava 29 y/o G2P2 4 months post-partum, exhausted Exclusively breastfeeding She conceived her 2 nd child while breastfeeding her 1 st She wants your recommendations on contraceptive options

What are Ava’s options? Essentially everything!

What is the evidence for combined contraception in lactation? WHO Recommendations:  Risk unacceptable < 6 weeks  Risk usually outweighs benefit 6 wks to 6 months  After 6 months, benefits generally outweigh risks Cochrane Conclusions :  Data insufficient to establish effect of hormonal contraception on milk quality and quantity or to make recommendations Medical eligibility criteria for contraceptive use. 3nd edition, Geneva: World HealtOrg, 2004 Truitt ST, et al. Cochrane Database Syst Rev. 2003;(2):CD

Progestin-only methods & lactation WHO advises: -risks may outweigh benefits during 1 st 6 weeks postpartum -no restrictions after 6 weeks PPFA advises: -no restrictions at any point postpartum

What about an IUD for Ava? Discontinuation rates for IUDs due to irregular bleeding are lower in post-partum women Expulsion risk increases w/ insertion from 48 hours to 6 weeks post-partum Non-patient-dependent method enhances adherence Chi, IC, et al, Performance of the copper T-380A intrauterine device in breastfeeding women, Contraception 39(6): Grimes, D et al. Immediate postpartum insertion of intrauterine devices. Cochrane Review, 2005

Daina Daina is a 33yo G6P4 Tab2 Heavy, painful menses Anemia Fibroid on pelvic ultrasound What contraceptive options might be best suited for Blanca?

Progestin IUD’s Medical Advantages: Cramps & menorrhagia improve - amenorrhea: seen in 20% of users after 1 yr, 60% by 5 yrs 90% decrease in overall blood loss Decreases number of invasive treatments for DUB, fibroids Decreases risk of ectopic pregnancy May protect against endometrial cancer Decreases perimenopausal symptoms Hubacher D, Grimes DA. Obstet Gynecol Surv. 2002;57(2): Crosignani PG, Vercellini P, Mosconi P, et al. Obstet Gynecol. 1997;90(2): Hurskainen R, Teperi J, Rissanen P, et al. Lancet. 2001;357: Varila E, Wahlstrom T, Rauramo I. Fertil Steril. 2001;76(5): Chiou CF, Trussell J, Reyes E, et al. Contraception. 2003;68(1):3-10.

Progestin IUD - Mirena Very low systemic levels levonorgestrel FDA approved for 5 years of use, but effective for 7 years Highest continuation rates % at 1 year (Copper IUD 78%, Pills 68%) Expulsion: 2-12% in 1 st year Sivin, et al. Contraception Nov;44(5): Chiou et al. Contraception.2003;68(1):3-10. Hatcher RA, Zieman M et al. A Pocket Guide to Managing Contraception Hatcher RA. Contraceptive technology. 18th rev. ed

Lee was given OC’s for her PMS symptoms and this has helped, but not enough What can we offer her?

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 Seasonale: dedicated product w/ 3 months active pills, 1 week off, 4 menses per year Extended Cycle Regimens Sulak et al. Obstet Gynecol. 2000;95:

Systemic Barriers What barriers may exist in our practice that affect contraceptive adherence?

Systemic Barriers  Patients’ trouble getting refills  Patients unable to contact providers about side effects  Provider linking provision of contraception with PAP testing  Time constraints on providers leading to incomplete contraceptive counseling  Requiring visits for emergency contraception  Provider comfort with full range of methods  Other?

Possible Solutions…… De-linking contraception refills f/ office visits/Pap smears Staff dedication to improving contraception access Have written materials available in exam room describing full range of contraception options – with common side effects, efficacy Prescribing EC by phone Provider workshops for contraceptive counseling

Pro-active Contraception - take home: Break down barriers to same-day initiation of contraception Use patient-centered counseling to enhance compliance with method Inform patients about high-efficacy methods - don’t be stingy with IUDs Don’t let systemic issues interfere with adherence Match contraceptive method to woman’s social/medical needs Educate about all contraceptive options

References and Resources Hatcher et al, Contraceptive Technology 2004 Managing Contraception – book Medical Eligibility Criteria for Contraceptive Use 2004 by WHO Association of Reproductive Health Professionals Alan Guttmacher Institute www. contraceptiononline.org Planned Parenthood The Cochrane Collaboration Reproductive Health Access Project