Patient-centered Contraception

Nearly half of pregnancies in the United States are unintended. Approximately 6.4 million pregnancies per year

Outcomes of Unintended Pregnancies Approximately 3.0 Million Annually

Most unintended pregnancies occur when women fail to use contraceptives or use their method inconsistently.

Half of women at risk are not fully protected from unintended pregnancy. 28 million U.S. women at risk for unintended pregnancy

Unintended pregnancy rate by race/ethnicity/income Unintended pregnancies per 1,000 women

Why do women experience unintended pregnancies?

Efficacy: Numbers & Categories Table “Less Effective Methods” 85% No methodNo Method 3%14% Male latex condoms 5%21%Female condoms 9%-26%20%-40%Cervical cap 620%Diaphragm Perfect-Use Rate of Pregnancy Typical-Use Rate of Pregnancy Family Planning Method Effectiveness Group 1%-9%20%Fertility Awareness 4%19%Withdrawal 6%26%Spermicide Less effective

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?

Emergency Contraception: Levonorgestrel (Plan B) Take at once, up to 5 days after unprotected sex. Lowers risk of pregnancy by 58-89%

Levonorgestrel EC: Mechanism of Action Inhibits ovulation Does NOT cause abortion

Ulipristal acetate: a new emergency contraceptive option Decreases risk of unintended pregnancy by about 90% Maintains nearly full efficacy up to 5 days after unprotected intercourse

Hormonal Contraceptives What is needed before prescribing? Medical history REQUIRED Blood pressure RECOMMENDED Pap smear Pelvic/breast exam STI testing Hemoglobin NOT REQUIRED

Hormonal Contraceptives Which 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

Yolanda is eligible for the pill. When should she start?

. Should Yolanda get a prescription for EC, too? Advance EC prescrbing

Jessyka 21 year old waitress Had a medication abortion 1 week ago in your office Has severe PMS symptoms OCs helped just a bit

Extended Cycle Regimens

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

Adherence with OCs: What Women Do! Potter L et al Percent of Women (%) Number of pills missed

What are the common reasons for missing pills?

Back to Liz… She would like to try something easier to remember. What information do you need?

Efficacy: Numbers & Categories Table “Effective Methods” Perfect-Use Rate of Pregnancy Typical-Use Rate of Pregnancy Family Planning Method Effectiveness Group 0.1%-0.5%Unknown (8%)Vaginal ring 0.3%-0.8%Unknown (8%)Transdermal patch 0.1%-0.5%8%Birth control pills Effective

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

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… Gallo MF, et al. Cochrane Reviews. 2003, Issue 1. Art. No. CD Jick S, et al. Contraception 73 (2006)

How many refills should we give Liz?

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?

Highly Effective Methods NOT USER DEPENDENT 0.3% Hormone shot Perfect-Use Rate of Pregnancy Typical-Use Rate of Pregnancy Family Planning Method Effectiveness Group 0.6%-1.5%0.8%-2% Intrauterine devices 0.1% Implants 0.1%-0.5%0.2%-0.5% Male and female sterilization Highly Effective (for all users)

Progestin-Only Injection Hatcher, R et al. A Pocket Guide to Managing Contraception,

Depo Provera & Bone Density Weighing risks and benefits: No need to restrict Depo Provera use

Amy 21-year-old G4P2 New boyfriend wants her to get pregnant, but she doesn’t want a child now.

Intrauterine Devices

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.

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)

Blanca 36-year-old G6P4 Has fibroids and anemia

Progestin IUD (MIRENA)

Progestin Implant Highly effective and rapidly reversible Discreet Not user-dependent Contain no estrogen Can be used during lactation Active hormone: etonogestrel (68 mg) Reinprayoon. Contraception 2000 Diaz. Contraception 2000

Features of Progestin Implants Causes spotting Requires certified clinician visits for insertion and removal

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.

Impact of Choice Pariani. Stud Fam Plann, % of Women Continuing Contraceptive Use at 1 Year

Inconsistent pill use is linked to: low level of satisfaction with provider & low continuity of care. Percent of pill users who missed one or more pills during the past three months

Office barriers to adherence

Feeling unable to call a provider with questions is linked to contraceptive non-use. % of at-risk women experiencing contraceptive non-use in the past year

Electronic Health Records

Take-home message: Be pro-active with contraception! DE-LINK pap smears from birth control prescriptions. ROUTINELY prescribe 1-year supply with 3 packs at a time. Use Quickstart. Ask about contraceptive needs at all types of visits. Emphasize high-efficacy methods, but honor women’s choice whenever possible.

References and Resources Hatcher et al, Contraceptive Technology 2007 Managing Contraception – book Medical Eligibility Criteria for Contraceptive Use 2010 by WHO Association of Reproductive Health Professionals Alan Guttmacher Institute Planned Parenthood The Cochrane Collaboration Reproductive Health Access Project