Transcript Contraception, Sterilization and Abortion

Contraception, Sterilization
and Abortion
Alternatives, Counseling and Management
Suzanne Trupin, MD
Women’s Health Practice
Clinical Professor of Obstetrics and Gynecology
Contraceptive Practices in USA
The typical American woman wants only two
children; she spends roughly five years
pregnant or trying to become pregnant, and
three decades trying to avoid unwanted pregnancy.
Yet many women find it difficult to practice
contraception consistently or correctly over the
course of their entire reproductive lives and lack
the information and services that would assist
them in doing so. As a result, roughly one in
three American women will have had an
abortion by age 45.
Counseling: GATHER
Greet the patient in a warm and friendly manner,
help her to feel at ease (Gather information on
what she knows)
Ask the patient about her needs and goals, STI
risks nondirective counseling improves outcomes
Tell the patient about her choices
Help her decide
Explain the correct use of the method or drug
being prescribed
Repeat important instructions and set up Return
appointments
World Population Growth
Oct 12th 1999
we reached 6
billion, US just
reached 300
million this
year
Mourning Picture for Polly Botsford and Her Children (c. 1813)
Medical Evaluation for
Contraception Prescription: WHO
Class A: Mandatory
 Pelvic for IUD, Cervical Cap and Diaphragm,
Sterilization
 STI risk for IUD
 BP screening for women getting sterilization
Class B: Contributes substantially to safe and
effective use, but consider context
 Hb for IUD and Sterilization
Class C: does not contribute substantially to
safe and effective use of the method
U.S. Pregnancies:
Unintended vs. Intended
Intended 51%
Unintended 49%:
Unintended births 22.5%
Elective Abortions 26.5%
Henshaw: Fam Plann Perspect 1998;30:24-29.
Incidence of Fatal
Complication
Pregnancy &
Childbirth
11
2.6
Laparoscopic
Sterilization
Hormonal
Contraception
1.5
1
6
11
Exposure Per 100,000 Woman Years
Ory Fam Plann Perspect 1983;15:50-56.
Long-Term Reversible Contraception: A dialogue among Andrew M. Kaunitz MD, David A. Grimes, MD, and Anita L. Nelson,
MD, held on October 29, 2006. OBG Management: S1-S10, December 2006.
Cost Estimates of Contraception &
Pregnancy over 5 Years: No method over 5 yrs:
4.25 unintended pg at cost of %14, 663
$5,700 $5,730
$6,000
$4,872
$5,000
$4,102
$4,000
$3,278 $3,450
$3,000
$2,424 $2,584
$1,784
$2,000
$1,000
$3,666
$2,042
$1,290
$540
$764
$850
$0
Copper-T IUD
Injectable
Male Condom
Periodic
Abstinence
Female
Condom
Trussel: Am J Public Health, 1995;85:494-503.
Categories of Contraceptive Risk
WHO Category 4 (old ‘contraindications’,
now ‘refrain from use’) Condition which represents an
unacceptable health risk if the contraceptive method
is used. Do not use the method.
WHO Category 3 (exercise caution) A condition where
the theoretical or proven risks usually outweigh the
advantages. Use of method is not usually
recommended
WHO Category 2 (advantages outweigh risks)
Generally use the method with clinical judgement
WHO Category 1 (no restrictions)
Use of Contraception with
Coexisting Medical Conditions
FDA package labeling is the same for POP as COC
without supporting evidence in many cases
Current labeling for Norethindrone POP no longer
lists history of thromobembolism as
contraindication but does for norgesterel POP
Conditions that expose a woman to
increased risk as a result of unintended
pregnancy
Breast cancer or Estrogen Dependent Neoplasia
Complicated valvular heart disease
Diabetes: Vascular Complications
WHO Category 4
most apply to COC, R, P
Known thromobegenic mutations
do not use COC or CIC
Uterine Fibroids with cavity
distortion do not use Cu-IUD or
LGN-IUD
PID or purulent cervicitis or active
GC or CT do not Initiate IUDs
For conditions of high risk of HIV
and AIDS spermacide use is a
category 4
Cerebrovascular or coronary
artery disease multiple risk
factors
Migraines with Aura or migraines
over the age of 35
Lactation (<6 weeks postpartum)
do not use COC, P, R
Liver disease
Headaches with focal neurologic
symptoms
Major surgery and prolonged
immobilization
Age >35 years and smoke >14
cigarettes per day or more do not
use COC, P, R
Hypertension (blood pressure of
>160/100 mmHg or concomitant
vascular disease)
Venous thromboembolism history
Major surgery with prolonged
immobilization
WHO Category 3
(exercise caution)
Postpartum <21 days
Lactation (6 weeks to 6 months)
Age >35 years and smoke <15 cigarettes per day
History of breast cancer but no recurrence in past 5
year
Interacting drugs (that affect liver enzymes)
Gallbladder disease
WHO Category 2
(advantages outweigh risks)
CIN
Severe headaches after
initiation of oral contraceptive
pills
Undiagnosed vaginal or uterine
bleeding
Diabetes mellitus
Major surgery without prolonged
immobilization
Sickle-cell disease or sickle-cell
hemoglobin C disease
Blood pressure of 140/100 to
159/109 mm Hg
Undiagnosed breast mass
Obesity
Age >40 years
High BP in Pregnancy
Conditions predisposing to
medication noncompliance
Family history of lipid disorders
Family history of premature
myocardial infarction or DVT
Uncomplicated valvular heart
disease
WHO Category 1 (no restrictions)
Postpartum >=21 days
Pos-tabortion, with abortion
performed in first or second
trimester
History of gestational diabetes
Varicose veins
Mild headaches
Irregular vaginal bleeding
patterns without anemia
Past history of PID
Current or recent history of PID
Current or recent history of STD
Vaginitis without purulent
cervicitis
Increased risk of STD
HIV-positive or at high risk for
HIV infection or AIDS
Benign breast disease
Family history of breast cancer
or endometrial or ovarian
cancer
Cervical ectropion
Viral hepatitis carrier
Uterine fibroids
Past ectopic pregnancy
Thyroid conditions
Oral Contraception
Oral Contraceptives and
Shorter Acting Steroid
Contraception
Contraceptive Cases
A 16 year old wants pills but refuses a pelvic, do you give them to
her?
19 year old U of I sophomore says her menses comes on Sunday, so
she wants to know does she start this Sunday or next?
To take a break from pills a 21 year old stops the pills for a month
while her partner is off visiting medical schools. How long a break
does she need?
A 16 year old presents with her mother requesting pills for acne, the
mother insists you give her the ones that are the cheapest, the
patient wants the ones she sees on TV that are good for your skin,
which do you choose?
A 23 year old is getting monthly PMDD, what do you advise?
A 55 year old comes in on birth control pills from her previous
physician, is this dangerous?
A 26 year old with three previous ME presents for contraceptive
advice, she has a sister and a mom with breast cancer and she
refuses to take the pills, can she use them?
Prescription of Oral Contraceptives
Counseling
 Begin COC or POP at any time if reasonably certain is
not pg
 If begun within 5 days of bleeding no extra protection
 If not within 5 days use back up for 7 days if on COC, and
for 2 days if on POP
 Begin immediately post abortion
 Rapidly reversible, within 2-3 months conceptions are
seen
Medical history and physical examination
Selection of a particular preparation
User instructions
 Missed pill instructions
 No evidence that obese patients suffer decreased efficacy
Establishing that a patient is
protected by her contraception
Mode of action for contraceptive protection
 Molecular: P suppresses LH, E suppresses FSH
 Cellular: E increases intracellular P receptors
 Reproductive Organs: Endometrial atrophy,
hostile cervical mucus
 Reproductive Processes
WHO in last report said that it is not reliably
known how accurately ultrasound findings,
hormonal measurements or evaluation of the
cervical mucus predict the risk of pregnancy during
most contraceptive use
Pharmacologic Actions of
Progestin and Estrogen
Progestin
Estrogen
Ovarian and pituitary
inhibition
Ovarian and pituitary
inhibition
Thickening of
cervical mucus
Thinning of/increase
in cervical mucus
Endometrial
atrophy/transformation
Endometrial
proliferation
Cycle control
Cycle control
Progestins in Oral
Contraceptives
19-Nortestosterone
Estranes
 Norethindrone
 Norethindrone
acetate
 Ethynodiol
diacetate
 Norethynodrel
 Lynestrenol*
Gonanes





Levonorgestrel
Norgestrel
Desogestrel
Norgestimate
Gestodene*
*Not available in the United States.
Adapted from Sulak PJ. OBG Management. 2004;Suppl:3-8.
Spironolactone
 Drospirenone
Multiphasic vs Monophasic
Preparations*
1.0
20
18
0.75
Norethindrone
(mg)
0.5
10
0.4
menses
0
0
7
14
Day of pill cycle
21
Endogenous
progesterone
(ng/mL)
5
28
Monophasic (Ovcon 35)
Multiphasic (Ortho Novum
7/7/7)
Endogenous progesterone
*
Ethinyl estradiol content is constant (35 µg) for
level 3rd ed.
Adapted from Goodman and Gilman’s The Pharmacological Basis of Therapeutics.
both preparations.
1996:1416.
Available Formulations
Monophasic: consistent dose in each active pill
Phasic Preparations: dosing of E/P varies through the cycle
 Biphasic
 Triphasic
Shortened pill-free interval
Progestogen only containing pills
 Greater percentage of cycles are ovulatory (>50%)
Typical Use Issues
 8/year
 Failure greater if pills are miss early in cycle
 Contraceptive Efficacy of all marketed pills are similar
0.3% failure perfect use about 8.0% failure typical use
 Benefits are identical in spite of package insert
Cardiovascular Impact of Risk
Factors
Venous= VTE
(DVT, PE)
Arterial= Strokes
and MI
• Obesity
• Smoking
• Pregnancy
• Diabetes
• Malignancy
• Hypertension
• Recent Surgery
• Obesity
Cases per 100,000 Woman-Years
CV Mortality Risk with Smoking
and OC Use
30
25
Oral contraceptive nonuser
Oral contraceptive user
20
15
10
5
0
Attributable
Risk/100,000
User-Years
Nonsmoker
Smoker
0.06
1.73
< 35 years of age
Nonsmoker
Smoker
3.03
19.4
≥ 35 years of age
Sherif K. Am J Obstet Gynecol. 1999;180(Pt 2):S343-S348.
Risks of Oral Contraceptives:
Nonfatal VTE
Estimated Average Risk/
100,000 Women/Year
100
80
60
40
20
0
Non-Oral
Contraceptive
Users
Oral Contraceptive
Users
Food and Drug Administration. FDA Talk Paper. Nov. 24, 1995.
Pregnant Women
Cardiovascular Impact of OCs
Venous
• No difference in risk
between 2nd- and 3rdgeneration progestins
• No difference in risk
among low-dose OCs
(20 µg to 35 µg)
• Increased clotting
factors
Arterial
• Estrogens increase
HDL
• Progestins lower HDL
• High E/P ratio
increases HDL
• Estrogen has a dilating
effect on arterial wall
Reproductive Tract Cancers
 1.24 risk of breast
cancer in OC users

Existing cancers
may have earlier
development
 Protective effect
Relative
risk of
cancer
T
BREAST
against colon cancer
 Endometrial and
ovarian cancer risk
reduction is greater
with increasing
duration of use
Duration of OC use
Oral Contraceptives and the
Risk of Breast Cancer
Results of a large epidemiologic study suggest that oral
contraceptives do not cause breast cancer
Breast cancer risk in women who have not taken oral
contraceptives for ≥10 years is the same as those who
have never used them
There is a slightly increased risk of diagnosis in current
users of oral contraceptives and in those who stopped
taking them ≤10 years ago
Tumors are more likely to be localized in oral
contraceptive users than in nonusers
Collaborative Group on Hormonal Factors in Breast Cancer. Lancet.
1996;347:1713-1727; Collaborative Group on Hormonal Factors in
Breast Cancer. Contraception. 1996;54:1S-106S.
Acne and Androgen Metabolism
Total testosterone
Sex hormonebinding globulin
Free testosterone
5-reductase
Dihydrotestosterone
AR
Sebum production
AR = androgen receptor within the sebaceous gland
Azziz R, et al. Semin Reproduct Endocrinol. 1989;7:246-254; Imperato-McGinley
J, et al. J Clin Endrocrinol Metab. 1993;76:524-528; Murphy AA, et al. Fertil Steril.
1990; 53:35-39; Pye RJ, et al. Br Med J. 1977;2:1581-1582.
Higher Bone Density
More Likely in OC Users
OC users
Non-OC users
100
80
60
40
20
0
4
1
2
3
(High)
(Low)
Bone Mineral Density Quartile
Kleerekoper M et al. Arch Intern Med. 1991;151:1971-1976.
Slide Source:
ContraceptionOnline
www.contraceptiononline.org
Noncontraceptive Benefits of
Oral Contraceptives
BENEFITS DUE TO
CONTINUOUS PROGESTIN
Less endometrial cancer
Less benign breast disease
50% reduction in breast tumors
Fewer uterine fibroids
Regular uterine bleeding
Less amount uterine bleeding
less anemia
less salpingitis
50% reduction in PID
Less cyclic mood changes (PMS)
BENEFITS DUE TO INHIBITION OF
OVULATION
Less ovarian cancer
Less ectopic pregnancies
Less functional ovarian cysts
Suppression better with 35 mcg EE
Less dysmenorrhea
OTHER BENEFITS
Less acne and hirsutism
Less rheumatoid arthritis
Increased bone density
Discontinuation of Oral
Contraceptives
% Discontinuing
12
10
8
6
4
2
0
Irregular
Bleeding
Nausea
Weight
Gain
Mood
Changes
Rosenberg MJ, et al. Am J Obstet Gynecol. 1998;179:577-582.
Breast
Tenderness
Headaches
Shortened Hormone-Free
Intervals
Brand Name
Estrogen
Dose
Progestin Dose
Regimen
Seasonale®
30 µg EE
150 µg levonorgestrel
84/7
SeasoniqueTM
30 µg EE
150 µg levonorgestrel
84/7*
*7 days 10 µg EE
Yaz
20 µg EE
3 mg drospirenone
24/4
Loestrin 24 Fe
20 µg EE
1 mg norethindrone acetate
24/4*
*4 days of iron
Lybrel
20 µg EE
90 µg levonorgestrel
365 days (non-cyclic
daily dosing)
EE= ethinyl estradiol
Median Number of Breakthrough
Bleeding/Spotting Days/Cycle
Breakthrough Bleeding and Spotting
and Extended Regimen
12
10
8
6
4
2
0
Cycle
Day
1
2
3
4
1-84
92-175
183-266
274-357
*30 µg ethinyl estradiol/150 µg levonorgestrel.
Anderson FD, Hait H. Contraception. 2003;68:89-96.
Vaginal Ring: NuvaRing
 NuvaRing releases 15 g of ethinyl
estradiol and 120 g of
etonogestrel daily
 Worn for 3 out of 4 weeks
 Self insertion and removal it is
about 2.1 inches in diameter
 Pregnancy rate 0.65 per 100
woman–years
 If removed for >3hrs use back up
method for 7 days
Roumen FJ, et al. Hum Reprod. 2001;16:469475.
www.contraceptiononline.
Vaginal Contraceptive Ring:
Administration
 If Ring Is removed
 If under three hours
reinsert
 If over three hours
4 mm
reinsert and use 1 week
of back up
 Only 2.6% of women
report ring expulsion
54 mm
www.contraceptiononline.
NuvaRing Compared to OC:
Intended Bleeding Pattern
®
75
**
**
NuvaRing®
*
COC
*
*
4
5
50
25
0
*P<0.01
**P<0.0001
1
2
3
Cycle
Bjarnadottir RI, et al. Am J Obstet Gynecol. 2002;186:389395.
www.contraceptiononline.
Contraceptive Patch: Ortho
Evra
Patch contains 6 mg norelgestromin and
0.75 mg ethinyl estradiol
Delivers continuous systemic doses of
hormones


150 -250 µg norelgestromin (NGMN)
20-25 µg ethinyl estradiol (EE)
Direct comparisons to oral contraceptive
delivery doses cannot be made but
compliance enhanced
Per day
If patch is removed for >24 hours apply a
new patch and use back up for 7 days and
the day of the week for patch change is now
the day you found the patch off
www.contraceptiononline.
Transdermal Patch:
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
-
Zieman M, et al. Fertil Steril. 2002;77(Suppl 2):S13-S18.
Patch:
Patient Counseling
Application:
 Use a new location for each patch
 Apply to clean, dry skin
 Apply where it won’t be rubbed by clothing: on buttocks, abdomen,
upper outer arm, upper torso
 Do not use on irritated or abraded skin
 Do not use on the breasts
 Avoid oils, creams, or cosmetics until after patch placement
 Bathe and swim as usual
Anticipate more breast discomfort during the first 2 months
Store at room temperature
Do not cut, alter or damage the patch as if may alter contraceptive
efficacy
Do not flush a used patch into the water system; fold the used patch in
half and place in the trash
Patch: Managing
28-Day Cycle (Days 1-28)
Patch #1
Patch #2
Patch #3
Days 1-7
Days 8-15
Days 16-21
Next 28-Day Cycle (Days 29-56)
No Patch
Patch #1
This patch was not removed:
• Remove immediately
• Start cycle on day 29
Patch application is 1 to 2 days late:
• Apply new patch immediately; Make this the new “patch change day”
• No backup protection is required
Patch application is >2 days late:
• Immediately start new 21-day application cycle
•Use backup protection for 7 days
•Consider emergency contraception
This patch was not applied:
• Apply a new patch immediately; this is the new “patch change day”
• Use backup protection for 7 days
• Consider emergency contraception
Breakthrough Bleeding and/or
Spotting:Patch Versus Pill
20
18.3
Percentage of
patients
18
Contraceptive Patch
16
Oral Contraceptive
14
11.4
12
10.0
10
8.8
9.5
7.1
8
7.1
6.7
6
4.6
5.5
4
2
0
1
3
Audet MC, et al. JAMA. 2001;285:2347-2354.
©2001, American Medical Association.
Cycle
6
9
13
Estrogen Exposure: Patch,
OCs, Ring
Ring (15 µg EE/day)
Patch (20 µg EE/day)
*
*
40
OC (30 µg EE/day)
*P<0.05 vs
ring and OC
30
180
*P<0.05 vs
patch and ring
150
†P<0.05
vs ring
†
120
20
90
60
10
0
30
AUC
0-21
(ng.h/mL)
0
Cmax (pg/mL)
OCs = oral contraceptive; EE = ethinyl estradiol
van den Heuvel, et al. Contraception. 2005;72:168-174.
Transdermal Contraceptive
Patch:Risk for VTE Events*
Relevant Studies
Odds Ratio
(95% Confidence Interval)
Jick SS, et al., 2006
0.9 (0.5–1.6)
Cole JA, et al., 2007
2.4 (1.1–5.5)
*Women should be counseled that all combined
contraceptive products increase the risk of venous
thromboembolic events; use of these products should
be discontinued if a patient becomes immobilized.
Jick SS, et al. Contraception. 2006;73:223-228;
Cole JA, et al. Obstet Gynecol. 2007;109:339-346.
What is Emergency
Contraception?
“A therapy for women who have had unprotected
sexual intercourse, including sexual assault.” –ACOG
Not just the “morning-after pill” – hormonal EC can
be given up to 72 hours after unprotected intercourse
 PREVEN, Plan B upto 120 hours post IC but
effective is reduced 150 mg of Levo
 Copper IUD (up to 5 days after ovulation)
 Mifepristone (off label, up to 120 hours after
unprotected sex)
ACOG Practice Bulletin. Int J Gynecol Obstet. 2002;78:191-198.
LaValleur J. Obstet Gynecol Clin North Am. 2000;27(4): 817-839.
EPC Effectiveness
If unprotected sex during wk 2 or 3
 8% will become pregnant if not treated
 2% will be pregnant following use of combined
ECP (equivalent to a 75% reduction)
 1% will become pregnant if use emergency POP
(equivalent to an 88% reduction)
 0.1% will become pregnant following emergency
copper IUD insertion (99% reduction)
Even late in the cycle a % chance of pregnancy is possible
There is an algorithm to predict when menses will
come
Long-Acting Steroid
Contraceptive Options
Contraceptive Cases
A 22 year old healthy patient wants to use DMPA
but she cannot get in to the office on her menstrual
week as that’s the week she travels, can she start
the shots any other time?
A 33 year old breast feeding mom wants DMPA
before leaving the hospital after her delivery, is
this permissible?
A woman has been on DMPA for greater than 2
years, should she continue? Should she get a Bone
Density test?
Depot-Medroxyprogesterone
Acetate
Depo-Provera - 150 mg of DMPA via deep intramuscular
injection in the gluteal or deltoid muscle
Depo-subQ Provera 104 - 104 mg of DMPA via
subcutaneous injection into the anterior thigh or abdomen
Mechanism of action:Duration of protection: 3 m(13 wks)
Inhibits ovulation

Suppresses levels of follicle-stimulating hormone and luteinizing
hormone

Eliminates surges in luteinizing hormone

Thickens cervical mucus

Prevents sperm penetration

Reduces sperm transport in the fallopian tubes
DMPA
depot-medroxyprogesterone
acetate
 =Atrophies
the endometrium
Slide Source:
Contraception Online
www.contraceptiononline.org
Percentage of Women Experiencing
an Unintended Pregnancy
Injectables: Failure Rate Among
Typical Users
10
9
8
8%
8%
8%
7
6
5
4
3%
3
2
0.1% 0.05% 0.5%
1
0
Combined Oral
Contraceptive
Patch
Ring
Injectable
Contraceptive
Hatcher R. In: Contraceptive Technology. 18th rev ed.
2004:461-494.
IUD
Implant
Female
Sterilization
Subcutaneous DMPA : Decreased
Bleeding Over Time
Bleeding Only
Spotting Only
Bleeding/Spotting
Amenorrhea
Percentage of Patients
Reporting
100%
80%
60%
40%
20%
0%
Month 3
Jain J, et al. Contraception. 2004;70:269-275.
Month 6
Month 12
Mean Change in Lumbar Spine
Bone Mineral Density (%)
DMPA: Changes in Bone Mineral
Density Over Time
DMPA (150 mg)
1
Nonhormonal contraceptive
0
-1
-2
*
-3
*
*
-4
*
*
-5
-6
*
24
48
96
*
*
144 192 240
Kaunitz AM, et al. Contraception. 2006;74:90-99.
48
96
Posttreatment
During Treatment
*P<0.001
24
(Weeks)
Return to Fertility
Cumulative Contraception
Rate (%)
120
100
80
50th
Percentile
60
40
DMPA users
20
Nonhormonal
contraceptive users*
0
0
5
10
15
20
25
30
35
Months after Removal or Since Last Injection
*Intrauterine
device or other barrier method.
Schwallie PC, Assenzo JR. Contraception. 1974;10:181-202.
Timing of DMPA
Initial injection:
 On day 1 to 5 of menstrual cycle
 Within first 5 days of the postpartum period if not
breastfeeding
 After the 6th postpartum week if breastfeeding
 Immediately or within the first 7 days after an
abortion
Reinjection:
 At week 11 to 13
 If injection is missed or late (+14 weeks), back-up
contraception should be used and absence of
pregnancy should be confirmed
Implants
Implanon
Contraceptive Implants:
Characteristics
Serum levels of etonogestrel are detectable within hours of insertion
Suppresses ovulation
 Occurs within 1 day of insertion
 Ovulation in <5% of users after 30 months of use
Rapid return of fertility
Menstrual cycle returns within three months
Continuous contraceptive protection for three years
Does not contain estrogen


Appropriate for lactating women after the fourth postpartum week
No fluctuating hormone levels
Inconspicuous
Requires clinician visit for insertion and removal
Does not protect against sexually transmitted infections

Croxatto HB Eur J Contracept Reprod Health Care. 2000;5 Suppl 2:21-28; Reinprayoon
D et al. Contraception. 2000;62:239-246; Diaz S. Contraception. 2002;65:39-46;
Mascarenhas L. Eur J Contracept Reprod Health Care. 2000;5 Suppl 2:29-34.
IMPLANON™
Single-rod implant (4 cm in length and 2 mm in diameter) made of
ethylene vinyl acetate and contains 68 mg of etonogestrel
Duration of use: 3 years
Pearl index: 0.38 with typical use
Croxatto HB. Eur J Contracept Reprod Health Care. 2000;5 Suppl 2:21-28; Le J,
Tsourounis C. Ann Pharmacother. 2001;35:329-336.
Slide Source:
Contraception Online
www.contraceptiononline.org
Contraceptive Implant:
Tolerability
A 2-year study investigated the efficacy and tolerability of
IMPLANONTM (N=330)
Reasons for discontinuing participation in the study:
 Irregular bleeding: 13%
 Other adverse events: 23%
Adverse events attributed to the study medication:
 Acne: 14.5%
 Emotional lability: 14.2%
 Headache: 12.7%
 Weight gain: 12.1%
 Dysmenorrhea: 9.7%
 Depression: 7.3%
Implant site symptoms:
 Mild pain of short duration: <5%
The IMPLANON US Study Group. Contraception. 2005;71:319-326.
Slide Source:
Contraception Online
www.contraceptiononline.org
Contraceptive Implant:
Noncontraceptive Benefits
Percentage change from baseline
Changes in Acne
(n=315)
50%
70%
40%
60%
50%
30%
40%
20%
30%
20%
10%
10%
0%
0%
Decrease
Changes in
Dysmenorrhea (n=315)
No
Increase
Change
Funk S, et al. Contraception. 2005;71:319-326.
Decrease
No
Increase
Change
Intrauterine Contracetion
IUD
IUS
IUC
Contraceptive Case
A patient wants to get her pap and her IUD but
the nurse insists she come on her period for the
IUD insertion, who is right?
A 29 year old exotic dancer comes for an IUD
insertion, her most frequent partner has offered to
pay for it, do you recommend this method for her?
The nurse asks you if you want to give the patient
antibiotics before or after IUD insertion?
A patient wants to know fertilization rates with
IUDs?
IUC History
Guidelines overly restrictive in the past. These obsolete
recommendations reflected concerns about infection and
resultant infertility. This cloud of suspicion concerning
infection has now been lifted from the IUD by data from both
cohort and case-control studies.
A landmark case-control study from Mexico City showed that
among nulligravid women, use of a copper IUD was not
associated with tubal infertility; in contrast, prior exposure to
Chlamydia trachomatis was associated with a significant
increase in risk.[1]
Cohort studies from Norway[2] and New Zealand[3] have
found that upon discontinuation of an IUD, women had
problems with unwanted fertility, not involuntary infertility.
Almost any woman interested in highly effective
contraception can use an IUD.
IUDs today are appropriate for women who have never been
pregnant as well as for those who have had upper genital
tract infection or a prior ectopic pregnancy.
For example, the World Health Organization Medical
Eligibility Criteria give nulliparity a category 2 rating,
meaning that, in general, the benefits of IUDs for such
women outweigh the potential harms. A few
contraindications exist, such as an established pregnancy,
undiagnosed uterine bleeding that might represent cancer,
mucopurulent cervicitis, etc.
Leukocytic Infiltration of Superficial Layers of
Endometrium in Contact with IUD: Day 16 of
Cycle
LNG-IUS (Mirena®)
Contraceptive efficacy due to
cervical mucus change and
sperm motility and function
inhibition plus weak foreign
body action.
20 mcg/d LNG (30 would
suppress ovulation).
5 year cumulative failure rate
0.71/100 in 12,000 US women.
Spotting for first 3-6 months of
use.
Low EP rate (0.2-0.6/1000)
Rapid return to fertility.
LNG IUS
1. As with other progestin-
only methods, persistent
follicles can occur (in less
than 8 % of women). They
do not require treatment.
2. Produces both cervical
barrier and intrauterine
barrier to fertilizaiton
Pakarinen et al. Fertil Steril 1997;68:59
Candidates for IUDs: ParaGard
T380
Nulliparous or parous women
No longer a requirement to be
mutally monogamous, but do avoid
if high risk for STD or PID.
Appropriate for all stages of
reproductive life whether young, pg
spacing or finished with
childbearing.
 Not for someone with post-pg or
post-ab infection within the
past three months
 Uterine or cervical cancer
 Cervical infection
 Allergies.
Possible Complications: IUS
Symptoms
Consider
Return of menstruation
Expulsion
Fever/chills
Infection
Continuous bleeding and/or pain
after first month post-insertion
Irregular bleeding and/or pain in
every cycle
Missing string
Perforation, infection,
or partial expulsion
Dislocation or
perforation
Dislocation or
perforation
PID Rate by Insertion
IUD
Combined WHO clinical trial data for all IUDs - 22,908 IUD insertions
8
(per 1000 woman years)
6
4
2
0
1
2
3
4
5
6
7
8
9
Month (first year)
10 11 12
2
3
4
5
6
7
8
Year
Time Since Insertion
Farley et al. Lancet 1992;339:785
IUD Counseling
No risk of infertility after discontinuing IUC
No increased risk of PID except in the first 20 days
after insertion
No difference in complications for parous or
nulliparous women
IUD Counseling, continued
Cu IUD at any time in the cycle if it is reasonably sure she is
not pg, no additional protection is necessary
 It is not known exactly how soon it becomes effective
If she is less than 48 hours postpartum she can have a CuIUD, or 4 or more weeks post partum and amenorrhoeic she
can have a either IUD inserted
Immediately post first trimester abortion and post second
trimester she can generally have the IUD inserted
Cu-IUD can be inserted within 5 days of unprotected
intercourse, not farther as the risk of serious pelvic infection
and septic spontaneous abortion
If the LNG-IUD has been inserted more than 7 days into the
cycle use protection for 7 days
Bleeding with IUD use
Spotting or light bleeding is common during first 3-6 months
for either IUD
 NSAIDs
Amenorrhea with Mirena doesn’t require treatment
Persistent problem work up for gynecologic causes
Heavier than normal menses with the Cu-IUD
 NSAIDs
 Tranexamic acid (a hemostatic agent)
 Do NOT use Asprin
 Treat anemia
 If anemia persists remove the IUD
Barrier Methods
Contraceptive Cases
A 18 year old reports that she and her partner
were mutually stimulating each other and
suddenly decided to have intercourse, she didn’t
want to fuss with her diaphragm so she inserted a
vaginal film immediately before penetration, was
she protected?
A woman’s cervical cap was discolored so she’s
been cleaning it with Listerine, is it ok?
Your patient is worried about HIV she makes her
partner use two condoms but he thinks this is
unsafe, who’s right?
Phases of the Cervical
Mucus Method
Calendar (or calculation)
method
Basal body temperature
(BBT) method
Cervical mucus method
(the Billings method)
Sympto-thermal method
Barrier Methods
Not as effective as hormonal methods
No hormonal side effects
Most require concomitant spermicide
Some methods available
without prescription
Efficacy is highly dependent on consistent
and correct use
Some require partner cooperation
Vaginal insertion and removal may be
unacceptable
Increased risk of urinary tract infection
when used with a spermicide
Some require fitting by a clinician
Most are less effective in parous women
Some reduce sexually
transmitted infections
Diaphragm
Efficacy:
In a 28-week multicenter, randomized,
parallel group study of unadjusted
typical use (with spermicide), the
probability of pregnancy was 7.9%
Advantages:
Can be inserted hours before intercourse
Does not require removal between acts of
intercourse
Cost:
Approximately $30.00
Mauck C, et al. Contraception. 1999;60:71-80; Trussell J, et al. Fam
Plann Perspect. 1993;25:100-105, 135; Cates W Jr, Raymond EG. In:
Contraceptive Technology. 18th rev ed. 2004:355-363; Cates W Jr,
Stewart FH. In: Contraceptive Technology. 18th rev ed. 2004:365-389.
Diaphragm: 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, based on the
package insert of the Ortho All-Flex®
diaphragm
Cates W Jr, Raymond EG. In: Contraceptive Technology. 18th rev ed.
2004:355-363; Cates W Jr, Stewart FH. In: Contraceptive Technology.
18th rev ed. 2004:365-389; Association of Reproductive Health Professionals.
Non-hormonal Contraceptive Methods: A Quick Reference Guide for Clinicians.
Available at: http://www.arhp.org/files/QRGNonHormonalContraception.pdf.
Inserting a Diaphragm and Correct Position of
a Diaphragm
Contraindications to Diaphragm
Use
Uterine prolapse
Large cystocele or rectocoele or poor pelvic
musculature
Retroversion of the uterus
History of toxic shock syndrome
 Insert up to 6 hrs prior, keep for 24 hrs
Current vaginitis or cervicitis
 Avoid antifungals, antibiotics, petrolum
products
Repeated urinary tract infections
Allergy to latex rubber or spermicide
 Must use 2 tlbs spoons ( 2/3 full)
Today® Sponge
Efficacy:
12-month cumulative life-table pregnancy rate is
17.4%
Parity affects failure rate:

Nulliparous – 9% to 10%

Parous – 19% to 21%
Advantages:
Made of latex-free material (polyurethane)
One size fits all
Cost:
$17.00 for pack
of six sponges
Does not require a prescription
Preloaded with nonoxynol-9 spermicide
Can be inserted up to 24 hr before intercourse
Can be left in place for up to 30 hours
Kuyoh MA, et al. Contraception. 2003;67:15-18;
Trussell J, et al. Fam Plann Perspect. 1993;25:100-105, 135.
Today® Sponge
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
Cates W Jr, Stewart FH. In: Contraceptive Technology. 2004:365-389;
Association of Reproductive Health Professionals. Non-hormonal
Contraceptive Methods: A Quick Reference Guide for Clinicians. Available at:
http://www.arhp.org/files/QRGNonHormonalContraception.pdf.
Types of Cervical Caps
Prentiff
Lea’s Shield (Yama Inc)
Oves Cervical Cap (Veos
plc)
FemCap (FemCap, Inc)
 Insert behind the pubic
bone as far as it can go
 If greater than 8 hours
since insertion give
some vaginal estrrogen
Female Condom
Efficacy:
.
During the first year of typical use, 21%
of women experience an unintended
pregnancy
Advantages:
Provides some protection against
sexually transmitted infections
Does not require a prescription
Can be inserted well before intercourse
Made of latex-free material
(polyurethane)
Trussell J, et al. Fam Plann Perspect. 1994;26:66-72.
Female Condom
Disadvantages:
May not be as effective against
pregnancy as the male condom
.
Must be inserted and removed by
woman
Available in only one size
Labeled for single use
May be noisy
Outer ring may be visually
unappealing and uncomfortable
Cates W Jr, Stewart F. In: Contraceptive Technology. 2004:365-389;
Association of Reproductive Health Professionals. Non-hormonal
Contraceptive Methods: A Quick Reference Guide for Clinicians. Available
at: http://www.arhp.org/files/QRGNonHormonalContraception.pdf.
Male Condom
Efficacy:
6-month typical-use pregnancy probability:
Two Types:
Latex
Polyurethane

Latex condom - 5.4%
Polyurethane condom – 9.0%
Advantages:
Provides greater protection against sexually
transmitted infections than any other method of
contraception
Provides substantial protection against
pregnancy when used with a spermicide
Does not require a prescription
Can be used with other methods
Inexpensive and widely available

Steiner, MJ, et al. Obstetrics & Gynecology 2003;101:539-547.
Association of Reproductive Health Professionals. Non-hormonal
Contraceptive Methods: A Quick Reference Guide for Clinicians.
Available at: http://www.arhp.org/files/QRGNonHormonalContraception.pdf.
Male Condom
Two Types:
Latex
Polyurethane
Disadvantages:
Can be used for only one act of
intercourse
Can tear or slip during use, but this is
less frequent with lubricated condoms
May decrease sexual pleasure
May interfere with spontaneity
Requires cooperation of male partner
Association of Reproductive Health Professionals. Non-hormonal
Contraceptive Methods: A Quick Reference Guide for Clinicians.
Available at: http://www.arhp.org/files/QRGNonHormonalContraception.pdf.
Contraception: Spermicides
N-9 (menfegol, benzalkonium chloride,
chlorhexidine, sodium dousate)
Surfactant that destroys sperm cell membrane in
concentrations ranging from 1-18%.
Insert no more than 1 hour prior to intercourse.
FDA mandates that warnings say this product
won’t protect against STDs or HIV
May damage vaginal mucosa or cervical
epithelium, and can and increase STI
vulnerability, and FDA mandates these products
warn that these products may increase the risk of
getting HIV/AIDS from an infected partner
Contraception
Condoms
Over 100 products available in the US
90% are made of latex
Animal skin products or polyurethane
make of the rest of the products
Most are lubricated
Note: anal intercourse doubles risk of
breakage
Extra thick condoms blunt sensation
and reduce premature ejaculation
$0.50 for latex, 0.80 for poly, several
dollars for designer condoms
Spermacide reduces shelf life to 2
years, 5 normally
Condoms, counseling
Latex are the best protection
against STI, including HIV
and HSV
Apply over an errect penis
immediately before
intercourse with half-inch
reservoir at the tip of the
condom should be created by
carefully pinching the tip of
the condom after placement
Withdrawal should occur
prior to loss of erection
Hold the rim during
withdrawal to prevent
spillage
Only water based lubricants
should be used with the latex
condoms
Putting it on inside out,
taking it out, flipping it
over and wearing during
intercourse.
Completely unrolling it
before wearing.
Removing the condom
during intercourse.
Putting the condom on
after IC has begun.
Using too large a condom.
Sterilization
Contraceptive Cases
A 25 year old after delivery wants to know how
likely it is she’ll regret it if she has you perform a
post partum tubal ligation.
A 20 year old G4 P4 says her previous doctor
refused to perform her tubal ligation, and she says
she’s got insurance from the state now and she
wants it done. What do you recommend?
A 33 year old wants permanent contraception what
technique should you select?
A woman wants to know what is her chance of
needing a hysterectomy if she gets a tubal?
% of Women Using Method
Usage of sterilization
Female Sterilization
Male Sterilization
Condom
Oral Contraceptive
Other Methods
Injection
60
50
40
30
20
10
0
15-19
20-24
25-29
30-34
Age
Chandra A, et al. Vital Health Stat. 2005;23(25).
35-39
40-44
Advantages of Sterilization







Ideal for those desiring no more children
Quick recovery
Lack of long-term effects
Cost-effective
No need to remember to use contraception before
intercourse
No need for partner compliance
High degree of safety; low mortality rates
 Failure rate 0.5 to 3.6%
Disadvantages of
Sterilization
Permanence
 Reversal is expensive, requires major surgery, and is
not guaranteed
Regret for the decision
Expense at time of procedure
Procedure requires aseptic conditions, surgical
equipment, trained clinicians, and anesthesia
Does not protect against HIV or other sexually
Complications Associated
With Sterilization
1 to 2 deaths/100,000 women when compared to a maternal
mortality rate of 12.1/100,000 live births
Procedural complications
 Excessive bleeding or hemorrhage
 Infection
 Anesthesia-related complications
 Trauma – tears, perforations, and burns to abdominal
organs
Ectopic pregnancy – but the risk is lower than for
nonsterilized women
Peterson HB, et al. Am J Obstet Gynecol. 1983;146:131-136
Female Sterilization:
Techniques
Clips – block the fallopian tubes by clamping down and
cutting off the blood supply, thereby causing scarring or
fibrosis
 Filshie clip – titanium with a silicone rubber lining
 Wolf (Hulka) clip – plastic
Rings – cinch a loop of the midportion of the fallopian tube
 Fallope ring – small Silastic band
Microinserts – two concentric expanding metal coils
surrounding PET mesh fibers that produce a local
inflammatory response
Hulka JF, et al. Am J Obstet Gynecol. 1976;125:1039-1043;
Yoon IB, et al. Am J Obstet Gynecol. 1977;127:109-112.
Hysteroscopic Placement of Permanent
Birth Control Micro-Insert Within Tubal
Lumen
Taken from Kerin, Carignan & Cher. The safety and effectiveness of a new hysteroscopic method
for permanent birth control. Aust N Z J Obstet Gynaecol 2001;41:364-370.
Regret After Sterilization
Years After Sterilization*
Characteristic
3
7
14
3.9
7.5
12.7
18-30
5.1
10.5
20.3
>30
2.6
4.8
5.9
No
4.5
9.4
20.4
Yes
3.6
6.8
10.2
White
3.5
6.0
7.4
Black
4.3
10.2
21.7
Postpartum – vaginal
5.6
10.2
17.8
Postpartum – cesarean
8.8
14.0
16.1
15 d-1 yr
3.3
8.8
17.6
2-3 yrs
4.5
8.2
12.6
4-7 yrs
3.4
7.0
9.5
Overall (N=744)
Age at
sterilization
Married
Race
Time between
birth of last
child and
sterilization
Interval
* Cumulative probability/100 procedures
Hillis SD, et al. Obstet Gynecol. 1999;93:889-895.
Surgical Abortion
Pregnancy Termination Counseling
• Discuss all options regarding pregnancy
• Discuss decision-making process
• Provide information
Offer medical abortion
• Review medical history and discuss previous procedures
• Referral for long-term counseling
•
Issues in Elective Termination of
Pregnancy
• Sonography
Need for more comprehensive evaluations
Neonatal advances
Fetal tissue research
Rise in infertility
Dearth of adoptive children
Advances in assisted reproductive technologies (ART)
Selective Termination
Rarely medically indicated
•
•
•
•
•
•
•
•
(Contraceptive) Cases
A 24 year old with NYHA Class 4 CVD presents
because she was told she “has to have an abortion,”
do you agree?
A 13 year old patient who has never had a pelvic
examination presents requesting an abortion
under general anesthesia, is this as safe as under
local anesthesia?
A 28 year old Russian woman presents for her 7th
surgical abortion, how do you counsel her?
Preoperative Evaluation
Targeted History
• Pelvic examination
 Falls within preset dating criteria
 Adequate cervical visualization and uterine palpation
 Patient suitable for local anesthesia
Rh typing
Hemoglobin
Sonography
GC/CT testing
Review counseling session and the contraceptive alternatives
Vacuum Aspiration
Complications
• Inability to dilate cervix
• Severe postoperative pain
 Endomyometritis
 Salpingitis
 Uterine subinvolution
• No tissue or villi obtained
• Obvious uterine perforation
• Immediate hemorrhage


Cervical
Uterine
•
•
•
•
Pregnancy continues
Ectopic gestation
Molar pregnancy
Ovarian cyst pathology
Medical Abortion
Abortion performed without primary
surgical intervention
Rachel Benson Gold discusses a particularly
troubling aspect of state laws in “The Implications
of Defining When a Woman is Pregnant,” which
appears in the same issue of TGR. According to
both the scientific community and long-standing
federal policy, a pregnancy is established when a
fertilized egg has implanted in the wall of a
woman’s uterus. However, definitions of pregnancy
in state law vary widely. And although they have
not yet been used to impede women’s access to
legal hormonal contraceptive methods, such
restrictions are a goal of at least some antiabortion
and anticontraception activists.
To date, 22 states have enacted one or more laws that include
a definition of “pregnancy.” The definitions found in 18 of
these laws are based on the idea that pregnancy begins at
fertilization or conception. The ongoing debate around
emergency contraception–a concentrated dosage of the same
hormones found in birth control pills–has brought the
question of when pregnancy prevention ends and disruption
of an existing pregnancy begins to the forefront of public
discussion. Attempts to define pregnancy as beginning before
implantation could have serious implications for women’s
access to both emergency contraceptives and other hormonal
contraceptive methods.
“The fact is the majority of Americans have sex
before marriage; virtually all U.S. women (98%)
use a contraceptive method at some point in their
lives; and most women rely on contraception, not
abstinence, to help them responsibly manage their
sexual lives in the long term,” says Dailard. “As
long as politicians continue to ignore the realities
of women’s lives, the United States will continue to
have the highest rates of unintended pregnancy
and abortion in the developed world–a dubious
honor that most Americans would prefer not to
have.”
(Contraceptive) Case
A 21 year old patient presents for an abortion but
she doesn’t have a positive pregnancy test, she
wants a medical abortion, what do you give her?
Medical Abortion Regimens
Prostaglandin
Mifepristone +
Antiprogesterone Misoprostol
Antimetabolite
Methotrexate +
Misoprostol
Medical Abortion
Advantages
Can be performed without delay
Avoids surgical and anesthetic risk
Potential to increase access through expanding
providers (not true)
Potential to shield abortion providers (also not
true)
Increases choice
Medical Abortion
Disadvantages
Longer waiting period for completion
Requires multiple visits (2-3)
Less effective than surgical (95% vs 99%)
Not available after about 7 weeks
Expense
(Cumbersome) regimen
Surgical Abortion
Advantages
More effective
Shorter time to completion
Fewer visits
Shorter bleeding duration
Always has pathologic confirmation
Can be performed in later gestation
Surgical Abortion
Disadvantages
More serious risks involved
Limited access
Requires more equipment and investment
Providers more vulnerable to risk
Medical Abortion Counseling
Desires termination of pregnancy
Usual method and efficacy of alternatives
Risks, side effects, tetarogenicity and adverse
events for each medication and for failed medical
Informed consent and administer the MifeprexTM
Medication Guide and Patient Agreement
Medical ascertainment of contraindications to the
medications
Clarify the amount of pain and the number of
visits and the possibility of need for outside
medical care at own expense
Mifepristone: Mechanism
Softens and dilates the cervix
Causes decidual necrosis by
affecting the capillary
endothelial cells of the decidua
and detachment of pregnancy
Increases prostaglandin
release
Increases uterine contractions
and sensitivity to exogenous
prostaglandin
Mifepristone + Misoprostol
Medical history and physical exam
Pregnancy dating (HCG titers if no sac)
Rh status and administration of Rhogam
Hematocrit or hemoglobin
Counseling/informed consent
 Offer surgical abortion
 Explain 4 hour waiting requirements of visit 2? FDA
wanted both drugs administered in the office
 Explain only placenta and blood will be visible to the
naked eye
Mifepristone + Misoprostol
Administer mifepristone 200 mg
Schedule the next visit

The literature supports home administration safety
for the misoprostol, the FDA is not supportive
Instructions on self care and how to contact the
clinic

Provision of emergency contact, verbal and written
use instruction
Mifepristone + Misoprostol
Confirm with sonography patient has not aborted (no decisive
HCG change for 10d)
6% complete abortion prior to misoprostol
If not completed abortion administer misoprostol 400 mcg PO in
two 200 mcg tablets (800 PV, done but not licensed in any
country)
(Observe for 4 hours about 50% will abort)
84% abort within the next 24 hours
Monitor patient for home administration
Pain medication for cramping and medication for GI symptoms
Mifepristone + Misoprostol
Return in 7-10 days to confirm abortion by sonography
Vaginal bleeding lasts for 17 +/-11 days and tapers off rapidly after
initial expulsion, tell patients to expect 9-20 days of bleeding
8-9% of women have bleeding >30 days
Pathologic confirmation: decide about tissue disposal if patient should
bring the tissue with her
Medical Abortion Overview
“Expected” side effects
“Expected” bleeding
“Expected” cramping
Medication requirements
Hospitalization rates
“Expected” Side Effects
GI: Nausea, Vomiting, Diarrhea
Mild temperature elevation (PD effect)
Cramping
Headache, dizziness
Bleeding
“Expected” Bleeding
Bleeding-moderate to heavy
Some clots-small to large
Onset average 2-4 hours after misoprostol
Heaviest bleeding may last 1-4 hours as pregnancy is
expelled
Contact us if 2 maxipads/hour for 2 hours: call (pads should
be ‘dripping wet’)
“Expected” Cramping
Cramps are light to heavy
Pain usually managed with ibuprofen 600-800 mg/4-6 hours
Prescription for acetaminophen with codeine may be given on
day 1 or day 3
Night cramping usually worse before expulsion
Ultrasonography
Ultrasonography
Diagnosis of Complete Abortion
Any abortion without suction curettage must have
a confirmatory examination before the patient’s
treatment course is complete
Ultrasound disappearance of the gestational sac
this usually mandates a transvaginal ultrasound
Negative pregnancy test (<50 mIU/ml in urine)
90% drop in b-HCG
Management of Complications
Pain: May assess on an Likart scale
Temperature: returns to normal 3-4 hours after misoprostol
Failure to bleed: Do not treat EP with this regimen
Heavy or prolonged bleeding: stops 1-2 hrs after passing
pregnancy



Rest, heating pads, NSAID or non-ASA
Plenty of non-alcoholic beverages
Clinician should call back 30-60 minutes to assess the
patient’s condition
Completion may take up to 3-4 weeks
Return visits are the only way to assure completion
80-85% will abort within two weeks with Mtx-Misoprostol and 9597% within two weeks with RU486-Misoprostol
Complication Rates
Surgical abortion: 9/100,000 overall with mortality <1/100,000
Most surgical complications result from instrumentation in the uterus and
from second trimester procedures
Medical abortion: complications are more difficult to assess: bleeding is
expected, it can be heavy, hemorrhage is a complication US Trial 1/859 Tx
adverse event rate of 0.17%
Specific AEs From Medical Abortions of first 80,000
 5 EP, one of which was fatal
 13 transfusions (one was EP case)
 117 had curettages, nearly all were non-emergent
 10 received antibiotics for presumed infection
 6 had allergic reactions
50 women had ongoing pregnancies, of which all but two terminated
surgically
Conclusions
Conclusions
Contraception is good primary prevention of
disease
Perceptions of safety and convenience
 Provider Education
 Reducing mythology
 Increasing knowledge of noncontraceptive benefits
Many methods available but cost and access seem
to still limit their use and increase risk of
unplanned pregnancy
Most women will use many methods
Abortion should be safe, legal and rare
“We
have not inherited the earth
from our grandparents, we have
borrowed it from our
grandchildren.”
---attributed to Ancient Chinese