1. Contraception Update

2. Pregnancies in the U.S. 52 % Intended 25 % Unintended Used Contraception 23 % Unintended No Contraception

3. Unintended Pregnancy A Major Public Health Issue The 2002 National Survey of Family Growth reported that 50% of U.S. women experience at least one unintended pregnancy The vast majority of women reported using some form of birth control 2002 National Survey of Family Growth

4. Abortion Rates diverge In the 70’s, abortion rates of wealthy and poor groups of women were about the same By 2000, poor women’s abortion rate doubled that of wealthy women Ethnic/racial differences in rates diminish when income level is controlled Economic disparities in abortion rate parallel the widening gap between rich and poor in access to basic health care

5. Mandy 17 y/o girl with normal sports physical 4 years ago LMP 3 weeks ago Here today for pregnancy test She had unprotected sex 4 days ago. Her urine pregnancy test is negative.

6. Emergency Contraception: Levonorgestrel (Plan B) Sig: 2 tabs at once, up to 5 days after unprotected sex

7. Emergency Contraception (EC) WILL NOT DISRUPT AN IMPLANTED PREGNANCY  Inhibits ovulation  Traps sperm in thickened cervical mucus  Inhibits tubal transport of egg or sperm  Prevents implantation  May interfere with fertilization, early cell division, or transport of embryo

8. Emergency Contraception (EC) EC use doubles when provided in advance 1 Easy access to EC does not lead to decreased use of usual contraceptive method 2 Easy access does not increase STIs or unprotected intercourse 2 Direct Pharmacy Access in following states:  Washington, Maine, California, Alaska, New Mexico & Hawaii 1.Bissel et al Soc Sci Med.2003;57:2367-2378 2 Raine et al JAMA.2005;293:54-62

9. EC treatment simplified (progestin only) OLD : 2 doses of 1 Plan B pill First dose within 72 hours after intercourse Second dose 12 hours later NEW : 1 dose of 2 Plan B pills As soon as possible – but up to 120 hours after intercourse

10. “Quick Start” 1 As many as 25% of women do not start prescribed OCPs with Sunday or 1 st day start “Quick Start” 1 – first pill on day of visit at any time of the month. Confirm HCG neg. If she needs EC, start contraception w/in 24 hrs of EC.  More women using pill in 3 rd cycle  No increased spotting or bleeding 2 1. Westhoff et al Contraception 2002 2. Westhoff et al Fertil Steril 2003

11. Mandy, later Mandy gets a 4-month supply of birth control pills. She calls 4 months later requesting a 1-year renewal prescription. She has never had a Pap smear.

12. FDA Advisory Committee Recommendation. 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.” www.contraceptiononline. org

13. Does a woman need a pap before getting OCPs? Why tie PAP to birth control? Would you ask a man to have a prostate exam before giving him condoms?

14. What is Required Before Prescribing Hormonal Methods? Medical History:Required BP:Helpful Breast exam, Pelvic exam, Pap, Hemoglobin, other lab tests, STI testing: NOT REQUIRED! Stewart F, et al. JAMA. 2001;285:2232-2239

15. Morgan 24 y/o G0P0 Does not like hormones, cause nausea Does not like condoms either 246 lbs, normal BP, LMP 2 wks ago Normal Pap/STI tests 1 year ago Needs birth control before next week’s anniversary celebration

16. Intrauterine Devices 2 options today: Copper T 380A (ParaGard) and Levonorgestrel releasing system (Mirena) United States has lagged behind other countries in adopting the IUD: in 2002, only 2 percent of contraceptive users in the United States chose IUDs. By comparison, IUDs were used by over 50 percent of contracepting women in parts of Asia and 6 to 27 percent of female contraceptive users in Europe New interest and surge of use in US 1.Hubacher Contraception 2004;69:437-446

17. IUD Myths 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 w/ insertion. 1 Progestin IUD: may protect against PID, 5-year PID associated removal risk 0.8. 2 IUDs DO NOT increase risk of ectopic pregnancy In fact IUDs: DO NOT cause pelvic infection DO NOT decrease the chance of future pregnancies CAN be used for women who have not been pregnant 1. Grimes 2.Andersson Contraception 1994;49:56-72

18. More IUD Myths May insert at any point in the menstrual cycle 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)

19. FDA Changes The copper IUC revised its package label (September 2005) to remove the prior section on "recommended patient profile" that included multiparity, mutually monogamous relationship and history of PID.

20. Leslie 34 y/o G3P1 Having an abortion today in your office Used condoms in the past Which contraceptive methods can she start today?

21. 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!

22. IUD issues post-abortion Expulsion rate only slightly increased for IUDs inserted right after early aspiration abortion 1 No increased risk of infection 1. Grimes et al, Cochrane Review 2004 2. Weibe, Communication 4/05

23. Estrogen/progestin vaginal ring Low estrogen dose: 15 mcg 2 inch flexible soft ring No wrong placement May remove up to 3 hours Most don’t notice during sex Dieben, Ob Gyn, 2002

24. Vaginal Ring Expulsion Spontaneous expulsion infrequent- 2.6%  Occurred only once in almost all cases If expelled or removed, wash with warm water and reinsert within 3 hours

25. Monthly: Contraceptive Vaginal Ring Very effective! Failure rate 1.2% May suppress ovulation to 35 d

26. Ortho Evra Patch

27. Daily release:  20 µg ethinyl estradiol Contraceptive Patch ORTHO EVRA ™  150 µg norelgestromin (NGMN) * * the active metabolite of norgestimate 1 patch each week Regimen:  3 weeks of use / 1 patch-free week  4.5 cm x 4.5 cm square

28. Implanon

29. Implanon subdermal implant approved by FDA 7/06. Clinicians train 3 hours before obtain. One rod 4cm by 0.2 cm inserted into the arm Lasts 3 years; irregular unpredict bleeding Progesterone only, etonogestrel 68 mg Primary mechanism of action is suppression of ovulation, changes cervical mucous Rapidly reversible, no bone mineral density changes

30. Wanda 24 yo G3P2Tab1 Currently using OCP, but admits to frequently forgetting to take pill Wants to try the patch because her friends like it

31. Adherence with OCPs: What Women Say NFSG Survey, 1997

32. Adherence with OCPs: What Women Do! Potter L et al, Fam Plann Perspect. 1996. Percent of Women (%) Active Pills Missed

33. Initiation of All Hormonal Methods If starting after the 5 th day of menses, use back-up method for 7 days If switching from OCP, start 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

34. Blanca Blanca is a 43yo G6P4 Tab2 heavy painful menses anemia fibroid on pelvic ultrasound

35. Progestin IUD’s Medical Advantages: Cramps & menorrhagia improve 90% decrease in overall blood loss Decreases number of hysterectomies & other invasive treatments for DUB, fibroids 1 DECREASES risk for ectopic pregnancy Protect against endometrial CA 1. Hurskainen et al Lancet.2001

36. Progestin IUD - Mirena FDA Approved 12/ 2000 Used in Europe >10 years Very low systemic levels levonorgestrel FDA approved for 5 yrs of use, Lowest 5-yr costs of all contraceptive methods 2 Highest continuation rates-  81-93% at 1 yr (CuT 78%, CHC 68%) 1. Sivin Contraception 1991 2. Chiou et al Contraception.2003;68(1):3-10

37. Progestin IUD - Side Effects Spotting and bleeding: Increased in 1 st 3 months Amenorrhea: 20% of users by 1 yr, 60% by 5 yrs Expulsion: 2-12% in 1 st year. Perforation: <.01% @ time of insertion Headaches, acne, mastalgia: < 3% in 1 st months Managing Contraception and Hatcher et al Contraceptive Technology 2004

38. Lifetime Number of Menstrual Cycles Adapted from Coutinho EM. Is Menstruation Obsolete? 1999. Number of Cycles 50 0 100 150 200 250 300 350 400 450 Prehistoric 160 Colonial America 450 Modern 500

39. OCP’s 21 day on/ 7 day off cycle chosen to:  Mimic physiologic menstrual cycle  Reassurance that not pregnant No clinical trial shows that monthly menses is healthier, safer, or easier to tolerate Convenience May improve:  endometriosis, anemia, dysmenorrhea, metorrhagia, PMS, menstrual migraines Extended Cycle Regimens- Why? Fewer menses per year

40. May increase efficacy and adherence Symptoms associated w/ OCP worse during withdrawal bleed 1 Brief manipulation of a cycle 12 month Perfect vs. Typical Failure & Continuation Rates Extended Cycle Regimens 1. Sulak et al Obstet Gynecol. 2000;95:261-266

41. Continuous use 3 months, then a week off Seasonale ™ - FDA- approved 12 weeks on, 1 week off. Lybrel continuous use. Shortened pill-free interval Well-tolerated, small amount of breakthrough bleeding

42. Established BC Methods Barrier methods Lactation Progesterone only pills DMPA injections Vasectomy Tubal Obstruction or Ligation postpartum, coag, rings, clips

43. Essure: Hysteroscopic Tubal Sterilization Meds like for AB covered for health plan Requires hysteroscopy at 3 months

44. Resources Hatcher et al, Contraceptive Technology Managing Contraception – book online @ (www.managingcontraception.org)www.managingcontraception.org Medical Eligibility Criteria for Contraceptive Use 2004 by WHO (www.who.int/reproductive-health) Association of Reproductive Health Professionals (ARHP) (www.arhp.org)www.arhp.org Alan Guttmacher Institute (www.agi-usa.org)www.agi-usa.org www. contraceptiononline.org www.plannedparenthood.org www.Not-2-Late.com