1. Reproductive Health Update: Encouraging Students to Use Contraceptives John Kulig, MD, MPH Lead Medical Specialist Sara Mackenzie, MD Regional Medical Specialist March 28, 2013

2. Overview Goals: This webinar will provide an update on contraceptive methods, including long-acting reversible methods. Additionally, presenters will provide strategies to promote consistent use of contraceptives by students. Objectives: After this presentation, participants will be able to: Implement a comprehensive family planning program for female and male students on center. Counsel students about delaying pregnancy and parenting in support of employability. Counsel students about current contraceptive options and provide access to all methods.

3. Family Planning Program PRH 6.11 R4 A family planning program shall be provided to all students on a voluntary basis. At a minimum, this program shall include counseling, health promotion activities and medical services. The Center Director shall appoint a staff member to implement and monitor this program.

4. Sexual Health Misinformation One in five adolescents believe that birth control pills offer protection from STDs One in five adolescents believe that condoms are “not effective” in preventing STD transmission One in six adolescents believe that sex without a condom once in awhile is “no big deal” One in ten adolescents believe that “you do not need to use condoms unless you have a lot of sexual partners.” Half of adolescents believe that raising the subject of condoms raises suspicions about both partners’ sexual history Ref: Kaiser Family Foundation National Survey Ref: Kaiser Family Foundation National Survey

5. http://nahic.ucsf.edu//downloads/ReproHlth2007.pdf

11. Unintended pregnancy in U.S. (all age groups) 82% of teen pregnancies unintended 49% of all pregnancies unintended  29% mistimed  19% unwanted  43% end in abortion

12. Teen child bearing associated with: School dropout Infants of teens more likely to have low birth weight, lower academic achievement, and increased likelihood of becoming teen parent

13. Case 1: Student presents to wellness center requesting pregnancy test – worried she might be pregnant. You review chart and see prescribed oral contraceptives at entrance. She says: “I started it but my period started after a couple of weeks, so I stopped for a week, then started the next package but had bleeding again, so I stopped.”

14. Of teens with live birth: 50% not using contraception at time pregnancy – of these 1/3 thought could not get pregnant at that time 21% using highly effective contraceptive (although only 1% with IUD) 24% moderately effective contraceptive 5% rhythm or withdrawal method 5% rhythm or withdrawal method REF: Prepregnancy contraceptive use among teens with unintended pregnancies resulting in live births 2004-2008 MMWR v61/No.2 January 20, 2012

15. To decrease teen pregnancy: Reduce or delay onset of sexual activity Provide factual information about conditions in which pregnancy occurs Increase motivation and negotiation skills for prevention Increase access to contraceptives Increase use of most effective contraceptives REF: Prepregnancy contraceptive use among teens with unintended pregnancies resulting in live births 2004-2008 MMWR v61/No.2 January 20, 2012

16. Abstinence

18. Teenage Births teenage birth rate had fallen “below any level previously recorded in the US” as of 2005, but increased 3.4% in 2006 and 1.4% in 2007 (15-19 year-olds), then lower in 2008 30% overall decline in the past decade 40% decline among African American teenagers since 1991 abortion rate among women 15-19 declined from 40 per 1,000 in 1990 to 24 per 1,000 in 2000 attributed to less sexual activity and more effective use of contraception

19. Changes in marriage The proportion of 25-year-olds who have never been married has increased steadily since the 1970s. Source: The Brookings Institution, 2007

21. Oral Contraceptive Pills

22. Noncontraceptive Benefits of OCs decrease menstrual flow (lighter, shorter periods) decrease menstrual cramps (no ovulation) improve anemia (lighter, shorter periods) improve acne (estrogen effect) protect against ovarian and endometrial cancer decrease benign breast disease decrease ovarian cyst formation prevent ectopic pregnancy protect against some causes of PID protect against osteoporosis

23. Contraindications to Use of OCs deep vein thrombosis pulmonary embolism cerebrovascular disease coronary artery disease factor V Lyden mutation or other known thrombophilia migraine headache with aura or neurologic changes estrogen-dependent cancer active liver disease major surgery or immobilization pregnancy or breastfeeding

24. Drug Interactions with OCs carbamazepine (Tegretol) griseofulvin (Grifulvin) phenobarbital (Luminal) phenytoin (Dilantin) primidone (Mysoline) rifampin (Rifadin) rifabutin (Mycobutin) ritonavir (Norvir) St. John’s wort

25. Extended Cycling fewer and shorter menstrual periods – one or four per year shorter hormone-free intervals better ovarian suppression (PCOS) decreased premenstrual dysphoric disorder (PMDD), premenstrual syndrome (PMS), acne vulgaris, endometriosis, menstrual migraine preferred by athletes

26. Seasonale ® Seasonique ®

27. Seasonale ® extended regimen combined oral contraceptive pills with ethinyl estradiol 0.03 mg and levonorgestrel 0.15 mg 91 day cycles - 84 days on – 7 days off 4 menstrual cycles per year - one each season

28. Seasonique ® extended regimen combined oral contraceptive pills with ethinyl estradiol 0.03 mg and levonorgestrel 0.15 mg 91 day cycles - 84 days on both – 7 days on ethinyl estradiol 0.01 mg 7 days on ethinyl estradiol 0.01 mg 4 menstrual cycles per year - one each season

29. Oral Contraception: Red Flags Mnemonic: ACHES Abdominal pain (severe) Chest pain (severe), cough, shortness of breath Headache (severe), dizziness, weakness, or numbness Eye problems (vision loss or blurring), speech problems Severe leg pain (calf or thigh)

30. Emergency Contraception

31. Plan B

33. Does knowledge of EC alter adolescent sexual behavior? study of 916 male and 852 female students age 14-15 in 12 schools in UK single lesson on emergency contraception improved knowledge persisted six months later in comparison with controls no difference in sexual activity, intent to use EC or use of EC Ref: BMJ 2002:324:1179-1183 Ref: BMJ 2002:324:1179-1183

34. Contraceptive Patch

35. Ortho Evra 

36. seven day contraceptive patch 1 3/4 inch three-layer adhesive patch releases ethinyl estradiol 20 µg and norelgestromin 150 µg daily applied to the buttocks, lower abdomen or upper body – not breasts newly applied weekly for three weeks, then one week off for menses less effective in women over 198 pounds

37. Ortho Evra  The pharmacokinetic profile for the ORTHO EVRA patch is different from oral contraceptives in that it has higher steady state concentrations (60% higher) and lower peak concentrations (25% lower) of ethinyl estradiol (EE) compared with an oral contraceptive containing 35 mcg EE. Increased estrogen exposure may increase the risk of adverse events, including venous thromboembolism. Safety information added 2007

38. Ortho Evra  The results of epidemiologic studies evaluating the risk of venous thromboembolism (VTE) among women using ORTHO EVRA compared to those using oral contraceptives containing 30-35 mcg EE and either levonorgestrel or norgestimate reported odds ratios ranging from 0.9 (no increase in risk) to 2.4 (approximate doubling of risk). Safety information added 2007

39. Ortho Evra  Side effects leading to discontinuation: nausea (2%) moodiness (1.5%) headache (1.1%) breast discomfort (1%) irritation at application site (1.9%) Inadvertent detachment uncommon (1.9%), even with exercise, humid climates, saunas, hot tubs.

40. Contraceptive Vaginal Ring

41. NuvaRing 

42. contraceptive vaginal ring - 2 inch diameter worn for 21 days => removed for 7 days to allow menses => replaced with new ring releases 120 mcg of etonogestrel and 15 mcg of ethinyl estradiol daily one size only - does not require fitting cannot be inserted incorrectly no increase in vaginal infections/discharge 3 hour window for reinsertion after inadvertent removal

44. Long acting reversible contraceptives (LARCs) IUDs and contraceptive implants Highly effective and safe High satisfaction and continuation rates Underutilized in U.S. Recent study noted significant reduction in abortions, repeat abortions, teen birth rates with use of LARCs Preventing Unintended Pregnancies by Providing No-cost contraception; Obstetrics and Gynecology vol 120, no 6, 1291-1297 December 2012

45. Progestin-only Injectable Contraception

47. Depo Provera  depot medroxyprogesterone acetate 150 mg IM once every acetate 150 mg IM once every 12 weeks – highly effective 12 weeks – highly effective inhibits ovulation, thickens cervical mucus, thins the endometrium irregular bleeding/spotting => amenorrhea within 2 years (70%) amenorrhea within 2 years (70%)concerns: –weight gain (54%) –osteoporosis risk, reversible

48. Contraceptive Implant

49. Implanon  => Nexplanon  progestin-only contraceptive implant single flexible 4 cm rod inserted under the skin of the upper arm contains 68 mg etonogestrel – releases 40 mcg daily - 3 year efficacy no pregnancies in 73,000 monthly cycles irregular menstrual bleeding common clinician visit required for insertion and removal – new insertion device for Nexplanon Nexplanon is radiopaque

50. Implanon 

51. Nexplanon 

52. Intrauterine Contraceptive System

53. Mirena  levonorgestrel-releasing intrauterine system - 20 mcg daily - 5 year efficacy highest risk of PID within 20 days of insertion irregular menstrual bleeding common in first 3-6 months clinician visit required for insertion and removal

54. Mirena 

55. ParaGard ® T 380A copper-releasing IUD believed to work primarily by preventing sperm from reaching and fertilizing the egg 10 year efficacy irregular menstrual bleeding common in first 3-6 months clinician visit required for insertion and removal

56. ParaGard ® T 380A

57. Barrier Methods

59. Vaginal spermicides

60. FC2 Female Condom

61. Male latex condoms

62. Male polyurethane condoms

63. Factors influencing condom use availability partner negotiation low “cost” - reduction in pleasure high benefit - partner’s appreciation, belief that condoms prevent STDs favorable male attitude toward responsibility condom use declines with age and length of the relationship 23% of young men (17-22 yr) using condoms report at least one condom break during the previous year => emergency contraception

64. Condom use and hormonal contraception Consistent condom use OCs21% DMPA18% Norplant 9% Condom use at last intercourse hormonal contraception - 52% no hormonal contraception - 69%

65. Adherence assure privacy and confidentiality discuss options and personal preferences connect to education and employment counsel about side effects schedule monthly recall visits continue condom use!