Transcript 401.

Update on Contraception
2014
Catherine Waits, MSN, APRN
KCNPNM Conference
April 2014
OBJECTIVES:
1.
Recognize that unintended pregnancy is a primary health concern
2.
List varieties of contraceptive methods.
3.
Identify risks, benefits and side effects of the various contraceptive
methods.
4.
Identify contraceptive methods that are safe to use with certain medical
conditions.
5.
Review principals of emergency contraception
Why do we care?
“No woman is completely free unless she is
wholly capable of controlling her fertility
and… no baby receives its full birthright
unless it is born gleefully wanted by its
parents.” –
Alan F. Guttmacher 1898-1974
Percentage of Women Experiencing Unintended
Pregnancy in First Year of Using Contraceptive
* Standard Days Method: 5%, Two Day Method: 4%
Hatcher RA. Contraceptive Tech. 19th ed. 2007.
•
•
•
•
FP-1 Increase the proportion of pregnancies that are intended
Intended pregnancy (females 15–44 years)
2002 Baseline: 51.0%
2020 Target: 56.0%
http://healthypeople.gov/2020/topicsobjectives2020/objectivelist.aspx?topicid=13
Graph: Center on Children and Families at Brookings Report, Policy for Preventing Unplanned Pregnancy March 2012
Counseling Considerations
• Future pregnancy plans
▫
“When do you plan to get pregnant?”
• Patient’s health history
▫
▫
Consider special needs
U.S. Medical Eligibility Criteria for Contraceptive Use 2010 (US MEC)
http://www.cdc.gov
• Efficacy of contraceptive
▫
Review the typical failure rate of the methods
• Patient Preference
▫
▫
Reduce barriers to contraception
U.S. Selected Practice Recommendations for Contraceptive Use (US SPR)
http://www.cdc.gov
Menstrual Cycle
The Menstrual Cycle
Chart copied from http.//gettingpregnant.com/menstrual-cycle
Hatcher RA & Namnoum AB (2004)
Contraceptive Hormonal Effects
ESTROGEN
PROGESTIN
• ↓ follicle-stimulating hormone release
• ↓ luteinizing hormone secretion
• Suppresses LH surge
• Blocks ovulation
• Blocks ovulation
• Thickens cervical mucus
• Endometrial effects
• Slows tubal motility
• ↑ HDL cholesterol
• Induces endometrial atrophy
• ↓ LDL cholesterol
• ↑ LDL
• Triglycerides levels are slightly ↑
• ↑ liver production of serum globulins
involved in coagulation
• ↓ HDL & Triglycerides
• No effect on coagulation factors
Contraceptive Mechanism of Action
Suppress ovulation
Reduce sperm transport
in upper genital tract
(fallopian tubes)
Change endometrium
making implantation less
likely
Thicken cervical mucus
(preventing sperm
penetration)
Hatcher & Namnoum (2004
Contraceptive Options:
Hormonal Contraceptives
Barrier Methods
Natural
CONTRACEPTIVE OPTIONS:
HORMONAL
NON-HORMONAL
• ORAL CONTRACEPTIVES
•
•
•
•
•
•
•
• VAGINAL RING
• TRANSDERMAL
• IMPLANT
• INTRAUTERINE
• INJECTION
•
•
•
•
CONDOMS (male and female)
DIAPHRAM
CERVICAL CAP
SPONGE
FOAM
NATURAL FAMILY PLANNING
CERVICAL MUCUS OVULATION
DETECTION METHOD
LACTATIONAL AMENORRHEA METHOD
WITHDRAWAL
INTRAUTERINE COPPER IUD
STERILIZATION
Combined Hormonal Contraceptive Methods
“CHC”
4 mm
54
mm
•
Ethinyl Estradiol + one of 7 different
Progestins
•
Efficacy Rate:
•
Perfect Use=0.1 pregnancies / 100 women
•
Typical Use=3 pregnancies / 100 women
•
“Low Dose” is 35 mcg or less
•
Monophasic or Multiphasic Pills
•
Extended Dose 24 day/ 91 day
•
Vaginal Ring (NuvaRing)
•
Transdermal Patch (Ortho-Evra)
•
Convenient, easy to use, user control
•
Does not interfere with intercourse
Dickey RP (2010)
Zieman M (2010-2012
Combined Hormonal Contraceptives
Benefits
 Improvement of cycle-related
conditions:
• Acne
• Irregular menstrual cycles
• Dysmenorrhea
• Menorrhagia
• Anemia
• Functional ovarian cysts
 Reduction in cancer of certain organs:
• Ovary
• Endometrium
• Colon and rectum
Side Effects
 Early side effects
• Nausea
• Breast tenderness
• Headache
• Oily skin (acne may worsen or improve)
 Mood changes
 Weight gain
 Breakthrough bleeding
 Other side effects
• Thromboembolic effects (rare)
CONTRAINDICATIONS:
COMBINED HORMONAL CONTRACEPTIVES
 THROMBOEMBOLIC DISORDERS
 Deep Vein Thrombosis; Pulmonary Embolism
 Blood Clotting Disorders i.e. Factor V Leiden
 Family History of thrombophilias
 CARDIOVASCULAR DISEASE
 MIGRAINE WITH AURA
 UNCONTROLLED HYPERTENSION >140/90
 MAJOR SURGERY WITH PROLONGED IMMOBOLIZATION
 CIGARETTE SMOKING IN WOMEN GREATER THAN 35 YEARS
 BREAST CANCER: CURRENT OR PAST
)
Reproductive Health Access Project (2012
Combined Hormonal Contraceptive
Key Points
• CHC contain ESTRIDIOL and one of seven available PROGESTINS
▫ Low Dose Estrogen is safe, effective, convenient, rapidly reversible
• Extended-cycle regimens decrease menstrual bleeding and symptoms
associated with the traditional hormone-free interval
• CHC benefits:
▫
▫
▫
▫
▫
Cycle control: less bleeding, less cramping, suppression of endometriosis
Fewer ovarian cysts
Decreased fibrocystic breast changes
Favorable impact on lipids: increased HDL and reduces LDL
Decreased risk of ovarian and endometrial cancers
OCP FORMULATIONS
Progestins in Combination Contraceptives
1st
Generation
• Norethindrone (Junel 1/20)
• Medroxyprogesterone acetate (Depo
Provera)
2nd
Generation
• Levonorgestrel (Lo Seasonique)
• Norgestrel (Cryselle)
3rd
Generation
• Desogestrel (Apri, Desogen)
• Etonogesterol (Nuva ring, Nexplanon)
4th
Generation
• Drospirenone (Yaz)
• Dienogest (Natazia)
• Nomegestrol Acetate (Patch)
Davtyan (2012)
Oral Contraceptive Products
Name
Ethinyl Estradiol
Progestin
Characteristics
LoSeasonique
Loestrin 1/20
20 mcg
20 mcg
Levonorgestrel 0.1 mg
Norethindrone acetate 1 mg
Regular or light menses 2-4 d
Mircette
Ortho Tricyclen Lo
20 mcg
25 mcg
Desogestrel 0.15 mg
Norgestimate
Regular or mod. menses 4-6 d
Mild or no cramps
Moderate cramps
0.180/ 0.215/0.250
Ovral
(Norinyl 1/35)
50 mcg
35 mcg
Norgestrel 0.5 mg
Norethindrone 1.0 mg
Regular Heavy menses 6+ d
Alesse
Yaz
20 mg
20 mg
Levonorgestrel 0.1 mg
Drospirenone 3.0 mg
Irregular menses. Acne, oily
skin, hirsutism
LoSeasonique
Ortho-Micronor
20 mcg
----0---
Levonorgestrel 0.1 mg
Norethindrone 0.35 mg
H/O excessive nausea &
edema during pregnancy
Alesse
Ortho Tricyclen Lo
20 mcg
25 mcg
Levonorgestrel 0.1 mg
Norgestimate
H/O excessive pregnancy
0.180/ 0.215/0.250
Severe cramps
H/O fibroids; fibrocystic breasts
weight gain & varicose veins
Depression;
Premenstrual edema
Ortho Tricyclen Lo
Ortho Novum 777
25 mcg
35 mcg
Norgestimate
Norethindrone
Weight less than 110 pounds
Ovral
(Ortho Novum 777)
50 mcg
35 mg
Norgestrel 0.5 mg
Weight more than 160 #
Dickey RP (2010) pg125-144
Transdermal
Contraceptive Patch
Transdermal Contraceptive Patch:
Application

Size: 4.5 cm square patch

Ethinol Estridiol 20 mcg plus
Norelgestromin 150 mcg

Efficacy may be diminished with
women over 198#

Apply weekly for 3 weeks then 1 week
off for withdrawal bleeding

Apply to

buttocks

upper outer arm

lower abdomen

upper torso (excluding the breast)
Transdermal Contraceptive Patch
Advantages
 Weekly application encourages
compliance
 Easy verification of presence
reassures user of continued
protection
 Does not require vaginal insertion
 Contraceptive effects are rapidly
reversible
 Excellent cycle control after 3
months
Disadvantages
 Application site reactions
 Not as effective in women
weighing >198 pounds
 Side effects are similar to oral
contraceptives except for:
 Higher rates of breast pain during
first 2 months
 Higher rates of dysmenorrhea
 May be difficult to conceal
 No protection against HIV or other
sexually transmitted infections
Vaginal Contraceptive Ring
Vaginal Contraceptive Ring:
• Provides continuous delivery of:
 Ethinyl estradiol 15 mcg —
 lower dose of estrogen than used in OCP’s
 Etonogestrel 120 mcg—the active metabolite of desogestrel
•
•
•
•
The vaginal ring is flexible, easy to insert and remove.
The ring is worn for three weeks then discarded.
A new ring is inserted one week later for a 28- day cycle.
Initiate with “quick start” if reasonably certain pt is not pregnant
Vaginal Contraceptive Ring: Insertion
There is no wrong way to insert the ring.
If it lies comfortably in the vagina,
it has been placed correctly.
Vaginal Ring
Advantages
Disadvantages
 Self-administered
 Shorter, lighter periods
 Patient does not have to take daily
 Some breast tenderness
 Low dose estrogen
 Weight neutral
 Less side estrogenic side effects
generally no nausea, or breast
tenderness
 Increase in vaginal discharge
 Headache
 Does not affect lipoproteins
 Vaginitis
 Effective for all body types
 Must digitally self insert
 Steady-state hormone levels
Drug Interactions
• Interactions between CHC and other medications may
occur.
• Interactions resulting in reduced contraceptive efficacy
are of most concern.
• Spotting or breakthrough bleeding may occur.
• Advise to use back-up method if using antibiotic
Side Effect Management
• Break Through Bleeding
▫ Any woman beginning a new form of hormonal contraception
 For adolescents, breakthrough bleeding may discourage continued
use
• Women who inconsistently use oral contraceptives or miss
doses
• Skipping even one pill can result in BTB
• CHC users who have chlamydial cervicitis and/or endometritis
• Consider infection if BTB occurs after several cycle uses
▫ Smokers have a 30% increase in BTB due to anti-estrogenic
effects
Burkman RT (2007)
Lohr PA & Creinin MD (2007)
Barr NG (2010)
Side Effect Management
• Nausea
▫ Take pill at bedtime, or at a meal
▫ Use low estrogenic activity pill
• Fluid Retention
▫ Change to low estrogenic activity
pill
• Increased Appetite/Weight Gain
▫
Change to Low Estrogen Activity and
Low Androgenic Activity Pill
▫ Low Estrogenic Pills:

Any 20 mcg EE pill
▫ Low Progestin Pills:


Alesse,
TriNorinyl, OrthoTriCyclen Lo
• Menstrual Migraine
Headaches
▫ Change to OCP with Low
Estrogenic Activity
▫ Progesterone Only OCP
▫ Continuous cycle
• Major Depression
▫
Use OCP with Low Progestin Activity
▫ Low Adrogenic Pills:





Orthotricyclen Lo
Ortho Cyclen
Mircette,
Natazia,
Yaz
Dickey 2010 (14th Ed)
Oral Contraceptives and the Risk of Cardiovascular Event: Stroke, MI, VTE
•
Helping Your Patients Decide: Making Informed Health Choices About Hormonal Contraception (June 2006)
Association of Reproductive Health Professionals –[email protected]
Side Effect Management
• Hypertension
▫ If previous HTN during pregnancy, use with caution and
monitor
▫ B/P relatively well-controlled==use CHC with caution
▫ Consider Progestin-Only or Non-Hormonal Method
Reproductive Health Access Project (2013)
Oral Contraceptives and the Risk of Breast Cancer
• “Our analyses suggest that associations between ever use of OCs and
ovarian and breast cancer among women who are BRCA1 or BRCA2
mutation carriers are similar to those reported for the general
population” Moorman PG, et al. (2013)
• “No significant increase in breast cancer risk associated with COC
use has been found in case-control studies in BRCA1 (OR: 1:08; p=0.250), in BRCA2 (OR: 0.80; p=0.147).” Cibula D, Sikan M, Dusek L, Majek O. (2011).
• “In a majority of studies there is no increase in the risk of breast
cancer reported in OC users.” Cibula D, et al. (2010)
• “In our study oral contraception was not associated with a
significantly increased risk of any cancer.” Hannaford, PC et al (2007)
Progestin-Only Contraceptives
Progestin Effects of Contraceptive
Hormones
• Decreases luteinizing hormone secretion
• Blocks ovulation
• Thickens cervical mucus
• Slows tubal motility
• Induces endometrial atrophy
• Increases LDL
• Decreases HDL & Triglycerides
• No effect on coagulation factors
Candidates for Progestin-Only
Contraceptives
• Women with contraindications for combination
hormonal contraceptives, including a history of:
▫
▫
▫
▫
Venous thrombosis
Vascular disease
Hypertension
Heavy smoking (>35 years)
• Lactating women
Progestin-Only Oral Contraceptives
•
“Mini-Pill” or “POP”
•
Two formulations: Norethindrone & Norgestrel
•
Efficacy Rate:
▫
▫
•
Perfect Use= 0.5 pregnancies / 100 women
Typical Use= 3 pregnancies / 100 women
Consistently timed ingestion is required
▫
Plasma levels fall to baseline after 24 hours
▫
If ingestion occurs more than 3 hours after a
required dose, back-up contraception should
be used for 48 hours
Dickey RP (2010)
Zieman M, et al. (2010-2012)
Progestin Only Methods
Advantages
 Estrogen-free
 Safe in breast-feeding
 Can be used in sickle-cell disease,
HTN, Lupus, stroke, migraine,
smokers >35 years
 Self-administered for POP
 Long Acting Reversible Contraception
(Injection, Implant and Intrauterine)
 NO change in ovulation and menses
after stopping Implant or IUS
Disadvantages
 Oral must be taken every day at the
same time
 Every pill is an active pill,
 Irregular bleeding (70% in first year)
 Increased risk of developing ovarian
cysts
 Increased risk of developing DM with
past history of Gestational DM
 Delay in ovulation and menses after
stopping injections
 Decreases HDL cholesterol
 Weight gain
 Depression
 Drug interactions: Dilantin, Tegretol
Carbatrol, Rifampicin, St. John’s Wort
Progestin-Only Injection
Depo Provera
Medroxyprogesterone 150 mg IM every 11-13 weeks
Efficacy Rate:
 Perfect Use=0.3 pregnancies / 100 women
 Typical Use=<1 pregnancies / 100 women
Mechanism:




Thickens cervical mucus
Blocks the LH/FSH surge
Slows tubal motility
Thins endometrial lining
Initiate method:
 First week of menses or
 Quick Start if reasonably certain not pregnant
Dickey RP (2010)
Zieman M et.al. (2010-20120
Contraceptive Injection
Advantages
Disadvantages
 Decreased menstrual bleeding/ cramping
•
Irregular bleeding
 Improvement with endometriosis
•
Amenorrhea
 Reduces risk of endometrial cancer
•
Hypoestrogenism
 Reduces risk of ovarian cancer
▫
Vaginal dryness
 Safe to use with blood clotting disorders
▫
Acne
 Good with seizure disorder
▫
Hirsutism
 Effective for physically challenged
•
Return to fertility may be delayed
 Decreases ectopic pregnancies
•
No protection from STI
 Breast feeding is not compromised
•
Weight gain
▫
 Private
•
Average of 5.4# in first year
Bone mineral density effect
▫
▫
▫
Calcium either diet or supplement
Weight bearing exercise
Avoid Cigarette use
Zieman M, et al (2010)
Depo-Provera (medroxyprogesterone acetate injectable
suspension
• Audience: Reproductive and other healthcare professionals
• FDA and Pfizer notified healthcare professionals of the addition of a
• BOXED WARNING along with revisions to the WARNINGS, INDICATIONS AND
USAGE, PRECAUTIONS and POSTMARKETING EXPERIENCE sections of the
prescribing information to include information on the loss of significant bone mineral
density.
• Depo-Provera Contraceptive Injection is indicated only for the prevention of
pregnancy in women of child-bearing potential. Bone loss is greater with increasing
duration of use and may not be completely reversible. Depo-Provera Contraceptive
should be used as a long-term birth control method (eg, longer than 2 years) only if
other birth control methods are inadequate.
[November 18, 2004 - Dear Healthcare Professional Letter1 - Pfizer]
[November 18, 2004 - Dear Healthcare Organization Leader Letter2 - Pfizer]
[November, 2004 - Label3 - Pfizer]
ACOG Committee Opinion
Number 415, September 2008
Committee on Adolescent Health Care Committee on Gynecologic Practice
“Conclusion
• Depot medroxyprogesterone acetate is a safe and effective means
of long-term contraception, which has likely contributed to a
decrease in adolescent pregnancy rates over the past decade.
Concerns regarding the effect of DMPA on BMD should neither
prevent practitioners from prescribing DMPA nor limit its use to 2
consecutive years. Appropriate counseling with a discussion of
current medical evidence should occur before the initiation of this
medication and during prolonged use. Practitioners should not
perform BMD monitoring solely in response to DMPA use because
any observed short-term loss in BMD associated with DMPA use
may be recovered and is unlikely to place a woman at risk of
fracture during use or in later years. Effective long-term
contraceptive methods that have no effect on BMD and have high
continuation rates, such as contraceptive implants and intrauterine
devices, should also be considered as first-line methods for
adolescents.”
Key Points: Injection
• First of the Long Acting Reversible Contraceptives
• Irregular bleeding is common side effect –counsel patients to expect
• Safe immediately postpartum
• Bone density reverts to normal after discontinuation of use
▫ May safely use for longer than 2 years
▫ Unnecessary to give supplemental estrogen
▫ Bone Density Testing is not recommended
• Weight gain is a common side effect
▫ Encourage daily exercise, calcium and vitamin D intake
Contraceptive Implant
NEXPLANON™
• Single-rod implant (4 cm in length and 2 mm in diameter) made of ethylene
vinyl acetate and contains 68 mg of etonogestrel
▫ Initially progestin is released at rate of 60 mcg per day
▫ Decreases to 25-30 mcg/ day by end of first year
 Efficacy Rate:
▫ Perfect Use=0.3 pregnancies/ 100 women
▫ Typical Use=0.3 pregnancies / 100 women
• Mechanism of Action:
▫ Thickens cervical mucus
▫ Inhibits ovulation
▫ Atrophy of endometrium
 Initiation of method:
 Withinn 7 days of last menstrual period; no back up method needed
 May insert anytime in the cycle, use backup for 7 days
 MUST BE A CERTIFIED PROVIDER TO INTALL DEVISE

“Clinical Training Program for NEXPLANON” ideveloped by Merck
Dickey RP (2010)
Zieman M et.al. (2010-20120
Contraceptive Implant
Advantages
 Active for three years
 Estrogen-free
 Safe in breast-feeding
 Can be used in sickle-cell disease and
seizure disorder
 Patient does not have to take daily
 Can be removed at any time
 Rapid return of fertility
 Inconspicuous
 Serum levels of etonogestrel are
detectable within hours of insertion
Disadvantages
 Irregular bleeding
 No periods at all
 Requires clinician visit for insertion and
removal
 Does not protect against sexually
transmitted infections
Key Points: Implant
• Easy and quick to insert and remove
• Efficacy equivalent to sterilization
• Safe and rapidly reversible
• Irregular bleeding patterns may be a problem for some patients
• Majority of reproductive-age women are candidates, including
adolescents
• Appropriate option for those preferring a long-term progestin-only
method and do not want injections or an intrauterine device
Summary
• Progestin-only-contraceptives are safe and effective
methods of contraception
▫ Long –Acting-Reversible Contraception (LARC)
▫ Orals require consistently timed ingestion of dose for maximum
efficacy
▫ Most common side effects are bleeding irregularities and weight
gain
▫ Very few contraindications for use—almost always a MEC 1 or 2
• Progestin-only emergency contraception (Plan B One Step)
is approved for over-the-counter sales to women over 15
years of age
Intrauterine Contraceptives
Mirena®
• Levonorgestrel 20 mcg releases
every 24 hrs System (LNG-IUS)
Levonorgestrel-Releasing
Intrauterine
• Efficacy Rate:
▫
Perfect Use=0.3 pregnancies/ 100 women
▫
Typical Use=0.3 pregnancies/ 100 women
• Mechanism of Action:
▫
Thickens cervical mucus
• Indicated for dysmenorrhea and
heavy bleeding
▫
Tubal fluid changes impair sperm & ovum
migration
• Endometrial protection during
hormone or tamoxifen therapy
▫
Suppresses endometrium
▫
Inhibits ovulation
• Long-Acting Reversible
Contraception
• Initiate method:
▫
▫
Insert within 7 days of LMP; no backup
needed
Insert anytime in cycle and use backup
method for 7 days
• Duration of use: 5 years
ParaGard® T380A
Copper-Releasing Intrauterine Contraceptive
•
Polyethylene device with 380 mm3 of exposed
copper
•
Efficacy Rate:
•
•
Perfect Use=0.8 pregnancies per 100 women
•
Typical Use=3 pregnancies per 100 women
Mechanism of Action:
▫ Spermicide
 Copper ions inhibit motility and viability
of sperm
 Inflammatory reaction of endometrium
▫
Inhibition of implantation is a secondary
mechanism
• Initiate Method:
▫ Anytime in cycle; NO backup needed
▫ May remove & insert in same visit
▫ STI screening on day or insertion is
acceptable
• Duration of use: 10 years
• Indicated for emergency contraception
Intrauterine Contraception
Counseling Topics
•
•
•
•
•
Effectiveness of intrauterine contraception
Mechanism of action
No protection against HIV or other sexually transmitted infections
Noncontraceptive benefits
Side effects
▫ At insertion—variable pain, cramping, vasovagal reaction
▫ First few days—light bleeding, mild cramping
▫ First few months—intermenstrual bleeding, cramping
 Copper IUD: Heavier or prolonged menses
 LNG-IUS: Gradual decrease in menstrual flow
• Instructions on how to check the IUD string
• Return for follow-up appointment 4-6 weeks after placement
Intrauterine Contraception
Advantages
• Highly effective birth control
• Long lasting
• No daily, weekly, monthly
responsibility
• With Mirena, bleeding changes
• Weight neutral
• Cost effective
• May be used with nulliparous
Disadvantages
•
•
•
•
Painful to insert
Possibility of perforation
Possibility of expulsion
Professional assistance to insert
and remove
• Amenorrhea or Dysmenorrhea
• Ovarian cysts
• No protection against STI
Male and Female Barrier Contraceptives
Efficacy of Contraceptives
Barrier
Contraceptives
Efficacy
Male Condom
82% effective with typical use
Female Condom
During first year of use, 21% of women experience an unintended
pregnancy
Diaphram
In 28-week multicenter randomized, parallel group study of unadjusted
typical use, probability of pregnancy is 7.9%
Spermicide
• Six- month probability of an unintended pregnancy is 10-22%,
depending on dose and formulation
• Use of spermicidal in combination with another barrier method
improves efficacy to using either alone
Sponge
12- mo. cumulative life table pregnancy rate = 17.4%
Parity affects failure rate:
•Nulliparous: 9% to 10%
•Parous: 19%- 21%
Male Condom
Latex condom
 Advantages
 Highly effective against most
STI’s
 More resistant to breakage than
polyurethane condoms
 Disadvantages
 Cannot be used if have latex
allergy
 Do not use with oil-based
lubricants
 Degraded by heat, light, and
oxidation
Polyurethane condom
 Advantages
Safe to use with latex allergy
Thinner material than latex
Odorless/colorless
May  sensation of body heat
during intercourse
 Can be used with all lubricants




 Disadvantages
 Not as effective in protecting
against STI’s as the latex condom
 Expensive
Female Condom
Advantages
Disadvantages
 Some protection against STI’s
 No Rx required
 Can be inserted up to 8 hrs before
intercourse*
should be removed shortly after
 Made of polyurethane
o
o
o
o
o
o
May not be as effective against
pregnancy as the male condom
Must be inserted and removed by
woman
Available in only one size
Single use only
May be noisy
Outer ring may be visually
unappealing and uncomfortable
*Division of Reproductive Health, National Center for Chronic Disease and Prevention and Health Promotion, 2013
Sponge
Advantages






Made of latex-free material
(polyurethane)
One size fits all
Does not require a prescription
Preloaded with nonoxynol-9
spermicide
Can be inserted up to 24 hours before
intercourse
Can be left in place for up to 30 hours
Disadvantages

Vaginal insertion and removal

Should remain in place for six hours
after last intercourse

May increase risk of urinary tract
infections and toxic shock syndrome

Not recommended for use more than
once per day

Reduced efficacy among parous
women
Effective
Spermicide
Advantages
 No prescription required
Disadvantages

Some spermicides must be applied
10 to 15 minutes before initiation of
intercourse

Must be reapplied every 1 to 2 hours

Do not protect against sexually
transmitted infections

Increases risk for urinary tract
infections

May cause irritation

May be messy or leak
 Increased lubrication during
intercourse
 VCF Film convenient and discreet
•
•
Available as creams, gels, film,
foam, and suppositories
containing nonoxynol-9
Used alone or with a barrier
method
Diaphragm
Advantages
• Can be inserted hours before
intercourse
• Does not require removal between acts
of intercourse
Disadvantages
•
Some are made of rubber, a potential
allergen
•
Must be prescribed and fitted by a clinician
•
Requires vaginal insertion and removal
•
Spermicide must be reapplied before each
act of intercourse
•
Must be worn for at least 6 hours after last
intercourse, but not more than 24 hours
•
May increase risk of urinary tract infections
and toxic shock syndrome
• Low Cost
Used with a spermicide
Key Points: Barrier Methods
• A number of prescription-only and over-the-counter barrier
methods are available
• Some methods provide protection against sexually-transmitted
infections
• Barrier methods are less effective than hormonal methods
• Devices must be placed before coitus, reducing spontaneity
• May require cooperation of partner
• Nonoxynol-9 does not prevent sexually transmitted infections but
does kill sperm
Natural Contraceptive Methods
Efficacy of Contraceptives
Natural
Contraceptives
Efficacy
Abstinence
Perfect Use: 1-9/ 100; Typical Use= 20 pregnancies/ 100 women
Breastfeeding/ LAM
Perfect use: 2/100 Typical use: 5/100 women will get pregnant
Effectiveness rates only apply to women who are exclusively
breastfeeding for the first 6 months postpartum.
(Lactational Amenorrhea Method)
Fertility Awareness
Perfect Use = 1-9/ 100 Typical Use=12-25/100 women
Best if combine Basal Body Temperature/ Calendar/ Cervical Mucus
Methods
Coitus Interruptus
“Withdrawal”
Perfect Use=4/100; Typical Use=27/pregnancies / 100 women
ZiemznM, et al (2010)
Samra-Laff OM & Wood E (2009)
Stacy,D (2012)
Lactational Amenorrhea Method (LAM)
Mechanisms of Action
Frequent intense suckling
disrupts secretion of
gonadotrophin releasing
hormone (GnRH)
Irregular secretion of GnRH interferes
with release of follicle stimulating
hormone (FSH) and luteinizing
hormone (LH)
Decreased FSH and LH disrupts
follicular development in the
ovary to suppress ovulation
LAM: Benefits vs. Limitations
Benefits
Limitations
•
Effective (1-2 pregnancies per 100
women during first 6 months of use)
•
•
Effective immediately
User-dependent (requires following
instructions regarding breastfeeding
practices)
•
Does not interfere with sexual
intercourse
•
May be difficult to practice due to
social circumstances
•
No systemic side effects
•
•
No medical supervision necessary
Highly effective only until menses
return or up to 6 months
•
No supplies required
•
•
No cost involved
Does not protect against STDs (e.g.,
HBV, HIV/AIDS)
Methods of Fertility Awareness/NFP
•
•
•
•
Calendar/Standard Days
Basal Body Temperature (BBT)
Cervical Mucus (Billings)
Symptothermal (BBT + cervical mucus)
Natural Family Planning (NFP)
Mechanism of Action
Conditions Requiring Precaution
For contraception:
• Irregular menses
• Persistent vaginal discharge
• Breastfeeding
▫ Avoid intercourse during the
fertile phase of the menstrual cycle
when conception is most likely.
For conception:
▫ Plan intercourse near mid-cycle
(usually days 10-15) when
conception is most likely.
Natural Family Planning (NFP
Benefits
Limitations
•
•
Requires daily record keeping
•
Vaginal infections make cervical
mucus difficult to interpret
•
Basal thermometer needed for some
methods
•
Does not protect against STDs (e.g.,
HBV, HIV/AIDS)
Can be used to prevent or achieve
pregnancy
•
No method-related health risks
•
No systemic side effects
•
Inexpensive
Withdrawal
A traditional method of family planning in which the man completely removes his penis from
the woman’s vagina before he ejaculates
Sperm do not enter the vagina and fertilization is prevented
Benefits
• Effective immediately
• Does not affect breastfeeding
• Can be used as backup to other
methods
Limitations
• Effectiveness depends on willingness
of couple to use method with every act
of intercourse
• Always available
• Effectiveness may be further
decreased by sperm from a recent (<
24 hours) ejaculation remaining in the
penis (urethra)
• No cost involved
• May diminish sexual pleasure
• No method-related health risks
• Does not protect against STDs (e.g.,
HBV, HIV/AIDS)
Abstinence
• Mechanism
▫ excludes sperm from female reproductive tract
• Effectiveness
▫ 0% failure rate
• Complications
▫ recent data have shown an increase in teen sexual activity and
pregnancy if no education is given on contraception
Ideal for adolescents at high risk for pregnancy
and STD’s including HIV
Sterilization Methods
Female Sterilization: Mechanism of Action
By blocking the fallopian
tubes (tying and cutting,
rings, clips or
electrocautery), sperm
are prevented from
reaching ova and
causing fertilization.
Non-Surgical Tubal Occlusion
 Brand name: Essure®
• Tubal sterilization through hysteroscopic
placement of micro-coil in fallopian tubes
Sterilization
Advantages
• Ideal for those desiring no more
children
• Quick recovery
Disadvantages
• Permanence
▫ Reversal is expensive, requires
major surgery, and is not
guaranteed
• Lack of significant long-term effects
• Regret for the decision
• Cost-effective
• Expense at time of procedure
• No need to remember to use
contraception before intercourse
• Procedure requires aseptic conditions,
surgical equipment, trained clinicians,
and anesthesia
• No need for partner compliance
• High degree of safety; low mortality
rates
• Does not protect against HIV or other
sexually transmitted infections
Male Sterilization: Vasectomy
• Mechanism of Action:
▫ Blocks vas deferens (ejaculatory duct)
▫ Sperm are not present in the ejaculate
• Types
▫ No-scalpel technique (preferred)
▫ Incisional
Sterilization: Counseling Guidelines
• Discuss other contraceptive options, that in addition to sterilization,
provide effective long-term protection from pregnancy
▫
▫
▫
▫
▫
Side effects, risks
Suitability for the patient
Failure rates, stressing that no contraceptive method is 100% effective
Recovery
Permanence and potential for reversibility
• Allow sufficient time between patient counseling, decision making,
and the sterilization procedure to ensure a thoughtful and informed
decision (especially for patients considering a postpartum or
postabortion sterilization) 30 days is required by law for
patients with Federally subsided insurance.
Sterilization:
Legal and Ethical Issues
• Informed consent
• Spousal/partner consent is not required
• For federally funded sterilizations, the patient must:
▫ be at least 21 years of age
▫ be mentally competent
▫ wait 30 days after signing an informed consent form before
undergoing the sterilization procedure
What If…?
…the condom
broke or
slipped off...
…you forgot
your regular
birth control...
…you were
forced to
have sex...
Emergency Contraception
Levonorgestrel products
inhibit ovulation
Ulipristal inhibits follicular
rupture
Paragard used as EC inhibits
implantation
Best if used within 72 hours
of unprotected intercourse
 Plan B- One Step
(Levonorgestrel 1.5 mg)
▫ One time dose
▫ Over-the-Counter
 Ella
(Ulipristal Acetate 30 mg)
▫ One time dose
▫ Prescription only
 Paragard
(Cu T380)
▫ Inserted up to 5 days after
unprotected intercourse
▫ Is most effective EC but least
used
▫
Trussell J; Raymond EG; Cleland K (2014)
Choosing Contraceptives
Patient Needs & Concerns:
• “How important is it to avoid pregnancy right now?”
• “Do you want your use of contraception to be private?”
• “Do you have concerns about a particular
contraceptive?”
• “What side effects are you willing to accept?”
• “What methods have you used in the past?”
• “Do you have new health issues?”
Hormonal Contraceptives:
Coexisting Medical Conditions
CDC United States Medical Eligibility Criteria for
Contraceptive Use (US MEC)
• MEC 1: Can use. No restriction.
• MEC 2: Can use with closer medical supervision
• MEC 3: Should not use.
 Method of last choice with regular monitoring.
• MEC 4: Should not use.
 Unacceptable health risk.
US MEC with Certain Medical Conditions
TCu-380A
POC
CHC
Medical Conditions
Hypertension (controlled=140/90)
1
3
2
History of DVT or pulmonary embolism
1
4
2
Varicose veins
1
2
1
Stroke
1
4
2
Severe valvular heart disease (complicated)
2
4
2
HIV infection
2
1
1
2
Check drug
interactions
2
Headaches-migraine with aura
1
4
2
Postpartum not breast feeding < 21 days
1
3/4
2
Smoker > 35 y/o
1
4
1
AIDS (clinically well on antiretroviral therapy)
US Medical Eligibility Criteria for Contraceptive Use. 2010
Cardiovascular Disease:
Conditions that increase risk of CVD
• Diabetes
• HTN
• Thrombophilias
• Obesity
• Migraine headaches
• Immbolization
• Valvular Disease
Diabetes
Are combination hormonal contraceptives (CHC) safe for women with
diabetes?
YES
• CHCs do not significantly
affect glycemic control
• CHCs do not accelerate
diabetic vascular disease
• CHCs do not precipitate the
risk of developing DM
DO NOT LIMIT USE OF CHC
Non-SMOKERS
Otherwise healthy:
ø
ø
ø
ø
HTN
nephropathy
neuropathy
vascular disease
Headache
What kind of HEADACHE is it?
Migraine w/ Aura
• Visual disturbance in both eyes
• Unilateral numbness
• Flashing or moving scotoma
•
"Pins & needles" in extremities
• Unilateral weakness
• Aphasia or other speech difficulties
Migraine
• Nausea/ Vomiting
• Photophobia
• Watery Eyes
• Taste or smell sensations
What to prescribe with Headaches?
Condition
COC +
Patch & Ring
Depo-Provera
Mirena
Implanon
Progestin-only
pills
Non-migraine
headaches
1/2
1
1
Migraine w/o
aura, age <35
2/3
2
1/2
Migraine w/o
aura, age >35
3/4
2
1/2
Migraine with
aura, any age
4
2/3
2/3
U.S Medical Eligibility Criteria for Contraception. 2010
Postpartum and Breastfeeding
CHC
Progestin
Implant
DMPA
Cu-IUD
LNGIUS
4
3
3
*
*
3
1
1
1
1
Postpartum
< 21 days
3
1
1
3
3
3-4 wks
1
1
1
3
3
1
1
1
1
1
Breastfeeding
< 6 weeks PP
 6 weeks to 6
months PP
> 4 wks
* See below.
Seizure Disorders
Interactions Between Anticonvulsants and Combination Contraceptives
•Anticonvulsants that decrease serum steroid levels
▫Barbiturates (including Phenobarbital and primidone [Mysoline]
▫Carbamazepine (Tegretol) and oxcarbazepine (Trileptal)
▫Felbamate (Felbatol)
▫Phenytoin (Dilantin)
▫Topiramate (Topamax
Anticonvulsants that do not decrease serum steroid levels
•Gabapentin (Neurontin)
•Lamotrigine (Lamictal)
•Levetiracetam (Keppra)
•Tiagabine (Gabitril)
•Valproic acid (Depakene)
•Zonisamide (Zonegran)
Improving Contraceptive Compliance
Contraceptive Counseling
• Start visit with discussion of future fertility plans
▫ What are your childbearing plans?
• Discuss the patient’s preferences
▫ What has worked for you before?
▫ What is your partner’s preference?
• Consider patient’s medical history
▫ Choose contraceptive for both safety and efficacy
Quick Start Method
Patient Follow-up
• Schedule a recheck visit
• Ask:
 Are you satisfied with your contraceptive method?
 Is there anything you would change?
 Are you having bleeding problems or other side
effects?
Missed Pills (combined OCs)
Action Advised
Take Missed dose
ASAP
Take “make-up”
dose
Use backup
contraception
Begin next cycle
<12 hrs
(late for
dose)
12-24 hrs
(missed 1
pill)
>24 hrs
(missed 2
pills)
>48 hrs
(>2 pills
missed)
Yes
Yes
Yes
NA1,2
Yes1,2
Yes1
No2
No
No1,2
No1
Yes – 7
days2
Yes – 7
days1,2
Yes – 7
days1,2
No change
No change
No change
In wk 3 -begin day 22
Yes
1,2
“A-C-H-E-S”
• Abdominal pain (severe)
• Chest pain (severe, cough, SOB, sharp pain on inhaling
• Headache (severe) or if accompanied by dizziness, weakness, or
numbness, especially if one-sided
• Eye problems (vision loss or blurring) or speech problems
• Severe leg pain (in calf or thigh)
Drug Interactions and OC
Mechanism
Action
Recommended
Antibiotics (broad
spectrum) penicillins,
teracyclines. Griseofulvin
Alteration of the steroid gut
metabolism due to changes in the
intestinal flora
Use of an alternative or backup method during antibiotic
therapy is recommended.
Acitretin (soratane)
Mechanism unknown. Reduces
the efficacy of progestin only
pills. Unknown if interaction is
seen with COC.
Use alternative or additional
form of contraception.
Agent
Drug Interactions and OC (cont)
Agent
Mechanism
Action
Recommended
Anticonvulsants
(phenytion,
carbamazepine,
phenobarbital, primidone)
Cytochrome P450 interaction
(CYP3A4 induction)
Use higher estrogen
formulations or an alternative
method or a secondary
method
Rifamycins (rifabutin,
rifampin, rifapentine)
Cytochrome P450 interaction
(CYP3A4 induction)
Non-hormonal contraception
during therapy and for one
cycle after treatment ends.
Using a higher dose estrogen
formulation is possible but
less desirable.
Drug Interactions and OC (cont)
Agent
Mechanism
Action
Recommended
Antiviral protease inhibitors
Cytochrome P450 interaction
(CYP3A4 induction)
Use higher estrogen
formulations or an
alternative/secondary method
Benzodiazepines
Metabolism of agents that
undergo oxidation may be
decreased resulting in increased
benzodiazepam effects.
May need to lower doses of
benzodiazepines if CNS
symptoms occur.
Drug Interactions and OC (cont)
Agent
Mechanism
Action
Recommended
Specific hypoglycemics
Decreased contraceptive effect
Use an alternative method or
as a secondary method.
Ascorbic acid
Increased concentration of
estrogen with possible increase in
side effect.
Avoid high doses of Vitamin C.
Use low doses of estrogen.
(Vitamin C doses of 1
gm or more daily)
“For most women, including women who
want to have children, contraception is
not an option; it is a basic health care
necessity.”
Representative Louise Slaughter,
US Congresswoman, New York
www.brainyquote.com/quotes/authors/l/louise_slaughter.html#cLSMDXSjFSZPF43Z.99