Introduction to Contraception Anita Jaynes, CNM, MS University of Nebraska Medical Center Obstetrics...

Introduction to Contraception

Anita Jaynes, CNM, MSUniversity of Nebraska

Medical CenterObstetrics & Gynecology

3,000,000 unintended pregnancies occur in the U.S. each year.

50% of U.S. pregnancies are unintended.

Women’s Reproductive Life Scan

The reproductive years are defined as ages 15-44.

Of the 39 years spent in the reproductive stages of life, women spend an average of 20 years trying to avoid pregnancy.

Who needs contraception?Every reproductive-age woman who is at risk for “sperm exposure” and who does not currently desire pregnancy.

Who does not need contraception?

women who self-identify as lesbiancelibate women

women who desire pregnancy

women who do not want

contraception − for any reason!

Don’t be an ass!Don’t ASSume

anything −

ASK!“Do you need

contraception?” not

“What kind of birth control do you use?

What is the “best” contraceptive method?

• The best contraceptive method for an individual woman is a method that is:– medically appropriate– effective in preventing pregnancy– used consistently and correctly– satisfactory to the woman at her stage of life

Life Stage: Menarche to First Intercourse

• Fertility goals:– postpone pregnancy– preserve future fertility

• Sexual behavior:– no intercourse yet– possibly experimenting

with kissing, petting, etc.

• Contraceptive need:– education

Life Stage: First Intercourse to First Birth

• Fertility goals:– postpone pregnancy– preserve future fertility

• Sexual behavior:– ? multiple partners– frequent intercourse– spontaneous, unpredictable

intercourse

• Contraceptive needs:– efficacy– reversibility– not coitus-linked– STI prevention

Life Stage: First Birth to Last Pregnancy

• Fertility goals:– space pregnancies– preserve future fertility

• Sexual behavior:– one partner (?)– moderate to low frequency of

intercourse– predictable intercourse

• Contraceptive needs:– efficacy– reversibility– ? OK if coitus-linked– ? need for STI prevention

Life Stage: Last Birth to Menopause

• Fertility goals:– no further pregnancies– no need to preserve fertility

• Sexual behavior:– one partner (?)– low to moderate frequency of

intercourse– predictable intercourse

• Contraceptive needs:– efficacy– may be irreversible– ? OK if coitus-linked– ? need for STI prevention

Contraceptive Options• Estrogen/progestin

– oral– transdermal– transvaginal– injectable

• Progestin only– oral– injectable– implants– intrauterine

• Non-hormonal IUD

• Barrier methods– male condom– female condom– diaphragm, cervical cap

• Periodic abstinence or fertility awareness

• Sterilization– tubal ligation– transcervical (Essure®)– vasectomy

• Emergency contraception

Contraceptive Use in the U.S.among reproductive-age women

0

5

10

15

20

25

30

Female sterilization

Pill

Male condom

Male sterilization

No method

Withdrawal

Injectable

Periodic abstinence

Diaphragm

IUD

Hatcher, R.A. et al. Contraceptive Technology. 18th revised edition, 2004.

Contraceptive Considerations

• Effectiveness• Frequency of

intercourse• Sexual behavior• Desire for future

fertility• Cost of method• Side effects

• Contraindications• Noncontraceptive

benefits• Patient’s perceptions

and misconceptions• Patient’s health status

and medical conditions

“The great question that has never been answered, and which I have not yet been able to answer, despite my thirty years of research into the feminine soul, is ‘What does a woman want?’” − Sigmund Freud

What does a woman want from a contraceptive?

• Is it safe?• Does it work?• Will my partner accept it?• Can I afford it?

And some women will ask −• Does it cause an abortion?

Is it safe?Voluntary risks in perspective

ACTIVITY CHANCE OF DEATH IN A YEAR Motorcycling 1 in 1,000Automobile driving 1 in 5,900Playing football 1 in 25,000Canoeing 1 in 100,000Age < 35, nonsmoker, OCP use 1 in 200,000IUD use 1 in 10,000,000Laparoscopic tubal ligation 1 in 38,500Vasectomy 1 in 1,000,000Pregnancy beyond 20 weeks 1 in 10,000

Percentage of women experiencing an unintended pregnancy during the first year of typical use and the first year of perfect

use of contraception in the United StatesMETHOD TYPICAL USE PERFECT USE

None 85% 85%

Spermicides 29% 18%

Withdrawal 27% 4%

Periodic abstinence

25% 4%

Diaphragm 16% 6%

Percentage of women experiencing an unintended pregnancy during the first year of typical use and the first year of perfect

use of contraception in the United StatesMETHOD TYPICAL USE PERFECT USE

Male condom 15% 2%

Pill, patch, ring 8% 0.3%

Depo-Provera 3% 0.3%

Paragard IUD 0.8% 0.6%

Female sterilization 0.5% 0.5%

Male sterilization 0.15% 0.10%

Combination Contraceptives (Estrogen & Progestin)


• Ingredients:– Estrogen (ethinyl estradiol) 20-50 mcg– Progestin (varying forms, doses, potency)

• Mechanisms of action:– Suppression of ovulation– Thickening of cervical mucus– Thinning of endometrium– Slowing of tubal and endometrial motility

Combination Contraceptives (Estrogen & Progestin)GENERAL ADVANTAGES

• Highly effective in preventing pregnancy when taken correctly

• Not related to coitus• Rapid return to fertility after discontinuation• Very safe when prescribed for appropriate

users• Can be used throughout the reproductive

years


HEALTH BENEFITS

• Fewer pregnancies = fewer maternal deaths• Reduction in risk of ectopic pregnancy• Decrease in dysmenorrhea• Decrease in menorrhagia• Reduction in PMS symptoms • Elimination of Mittelschmerz• Decreased anovulatory bleeding• Fewer ovarian cyst problems


HEALTH BENEFITS • Endometrial and ovarian cancer risk reduction• Decreased risk of benign breast conditions• Suppression of endometriosis• Improvement of androgen-sensitivity or androgen-

excess conditions (such as PCOS)• Improvement in hot flashes and hormonal fluctuation

symptoms in perimenopausal women

Combination Contraceptives (Estrogen & Progestin)GENERAL DISADVANTAGES

• Must be taken consistently and correctly to be effective

• Storage, access, lack of privacy• Can interfere with lactation• No protection against STIs• Common side effects include:

nausea, vomiting headaches

weight gain breast tendernessdecreased libido skin hyperpigmentation


COMPLICATIONS• Venous thromboembolism• Myocardial infarction and

stroke• Hypertension

DO NOT Rx TO WOMEN AGE > 35 WHO SMOKE!


CONTRAINDICATIONS• Personal history of thrombosis; known clotting

disorder (factor V Leiden mutation, etc.)• Personal history of stroke or MI• Labile hypertension• Estrogen-sensitive malignancy (such as breast CA)• Active liver disease• Migraines with focal neurologic symptoms

How to Take Birth Control PillsThe 28-day pack contains 21

active pills + 7 placebo pills.Getting started:

• “First day” start• Sunday start• “Quick Start”

Continuing: one pill per day, every day.

Withdrawal bleeding will occur during the placebo week. ≈ $35.00 per cycle

How to Use “The Patch”Each patch is worn for 7 days.

• Getting started: apply the first patch to clean, dry skin anywhere except the breast.

• On the same day of the 2nd week, remove the 1st patch and apply a new one to a different site.

• On the same day of the 3rd week, replace patch again.

• On the same day of the 4th week, remove the last patch. Do not apply a patch for 1 week. Withdrawal bleeding will occur.

Repeat this pattern every 4 weeks.≈ $40.00 per cycle

How to Use “The Ring”• Getting started: squeeze the ring

between your thumb and index finger. Insert it in the vagina.

• Leave the ring in place for 21 days (3 weeks).

• At the end of the 21 days, remove the ring by inserting a finger in the vagina and pulling it out.

• Discard the ring and wait 7 days. Withdrawal bleeding will occur.

• Repeat the pattern (3 weeks in, 1 week out) ≈ $40.00 per cycle

“Extended Use” Regimens

Monthly withdrawal bleeding is NOT necessary!

Seasonale provides 84 active pills followed by 7 placebo pills for 4 “periods” a year.

Any monophasic pill, the patch, or the ring can be used on an extended basis.

≈ $100.00 per pack

Progestin-Only Contraceptives


Mechanisms of action:• Inhibition of ovulation• Prevention of sperm penetration by thickening and decreasing the quantity of cervical mucus• Endometrial atrophy


ADVANTAGES OF ALL METHODS• No estrogen• Reversible• Amenorrhea or scanty bleeding• Improvement in dysmenorrhea, menorrhagia, PMS,

endometriosis symptoms• Decreased risk of endometrial or ovarian cancer• Decreased risk of PID• Compatible with breast-feeding


DISADVANTAGES OF ALL METHODS• Menstrual cycle disturbances• Weight gain• Depression• Lack of protection against STIs

Progestin-Only PillsCycle consists of 28 active pills;

there is no “placebo week”

Vulnerable efficacy! Each pill must be taken on time at 24-hour intervals.

Compatible with breast-feeding & recommended in combination with lactational amenorrhea.

BRAND NAMES:

Micronor

Nor-QD

Ovrette

≈ $45.00 per cycle

Depo-ProveraAdvantages:

• highly effective • discreet & private• use not linked to coitus• requires user to “remember” only 4 times a year

Disadvantages: • weight gain

• impossible to discontinue immediately• delayed return to fertility• adverse effects on lipids• decreased bone mineral density with long-term use

Depo-Provera = depot medroxyprogesterone acetate 150 mg IM q 12 weeks

Progestin ImplantsAdvantages: • highly effective • eliminate “user error” • long-term • reversibleDisadvantages: • high initial cost • insertion & removal require

specialized training • cannot be easily

discontinued

Norplant (off the market)

Implanon

FDA-approved & coming soon

Intrauterine Devices (IUDs)GENERAL ADVANTAGES • highly effective, no “user error” • convenient • long-lasting • reversible • discreet • cost-effective in the long run • low incidence of side effects • independent of coitus

Intrauterine Devices (IUDs)GENERAL DISADVANTAGES: • menstrual problems • discomfort with insertion • expulsion of the device • perforation of the uterus • requires office visit with trained

professional for insertion & removal • high initial cost • no protection from STIs

Intrauterine Devices (IUDs)MYTH: IUDs increase the risk of PID.FACT: IUDs have no effect on the risk of upper genital tract

infection. STIs cause PID − IUDs do not.MYTH: IUDs cause abortions.FACT: IUDs prevent fertilization and thus are true contra-

ceptives, not abortifacients.MYTH: IUDs increase the risk of ectopic pregnancy.FACT: IUDs reduce the risk of ectopic pregnancy because IUDs

prevent all types of pregnancy.MYTH: Only parous women are IUD candidates.FACT: Nulliparous women are more likely to expel the IUD and

insertion through the cervical os can be more difficult.

Copper T 380A IUD (Paragard)Contents: polyethylene, copper wire, &

barium sulfate for X-ray visibility, white threads

Mechanism of action: Causes increase in uterine &

tubal fluids containing copper ions, enzymes, prostaglandins, and macrophages that impair sperm function and prevent fertilization

Copper T 380A IUD (Paragard)

ADVANTAGES SPECIFIC TO THE Cu380A: • Can remain in place for up to 10 years • Nonhormonal • Normal menstrual pattern continues

DISADVANTAGES SPECIFIC TO THE Cu380A: • Can cause heavier menses with more severe cramping,

especially in the first few cycles

Levonorgestrel Intrauterine System (LNG-IUS) (Mirena)

Contents: polyethylene, levonorgestrel, barium

sulfate, dark-colored threads

Mechanisms of action: • thickening of cervical mucus • inhibiting sperm capacitation & survival • suppressing the endometrium • suppression of ovulation due to

systemic absorption of progestin

Levonorgestrel Intrauterine System (LNG-IUS) (Mirena)

ADVANTAGES SPECIFIC TO THE MIRENA: • can remain in place for up to 5 years • protective against endometrial cancer • reduces menstrual bleeding by 90%; 20% of users become

amenorrheic • low incidence of progestin side effects (only 10%

systemically absorbed)DISADVANTAGES SPECIFIC TO THE MIRENA: • irregular bleeding, especially during the first 6 months

Barrier Methods

Male CondomsMechanism of action: acts as a physical barrier;

prevents pregnancy by blocking passage of semen

Types available:• latex (natural rubber)• natural membrane (lamb intestine)• polyurethane• spermicidal 50¢-$1.00 each

Male CondomsADVANTAGES: • male participation • no Rx needed • very inexpensive • effective in preventing

pregnancy when used correctly

• minimal side effects • provide STI protection

(except for lambskin)

DISADVANTAGES: • reduce sensitivity • reduce spontaneity • erection problems • lack of cooperation • embarrassment about

purchasing • not very effective with

“typical use” • latex allergy

Male CondomsMINIMIZING USER ERROR

• Use with every act of intercourse• Use “from start to finish”• Unroll condom onto penis (do not

unroll first; do not test by filling with air or water first)

• Hold rim during withdrawal to prevent slippage or leakage

• Have several condoms available• Use appropriate lubricants• Store condoms correctly

FAILURE RATES:

perfect use 2%

typical use 15%

Female Condoms• No Rx needed• One-time use• Includes a lubricant • Spermicide not recommended• Can be inserted up to 8 hours prior to

intercourse; can remain in place for up to 8 hours

• Protects against STIs• Failure rates:

perfect use 5%typical use 21% ≈ $3.50 each

Diaphragms & Cervical CapsMechanism of action: • physical barrier to prevent sperm from

reaching the cervix • chemical to kill sperm (spermicide)Advantages: • no hormones • virtually no side effectsDisadvantages: • require professional fitting • require user skill and commitment • less effective than most other methods

SpermicidesMechanism of action:Nonoxynol-9 is a surfactant that

destroys the sperm cell membrane.Advantages:• available without Rx• easy to use, can use intermittently

without advance planningDisadvantages:• no protection against STIs• frequent (> 2x/day) use may cause

tissue irritation that could increase susceptibility to HIV

FAILURE RATES

(when used alone)

perfect use 18%

typical use 29%

$10-15 per package

Fertility Awareness / Periodic Abstinence

Mechanism of action: users identify the days in

each menstrual cycle when intercourse is most likely to result in pregnancy, then abstain from intercourse or use a barrier method during the “fertile window”


Methods: • ovulation method (assessment of

cervical mucus) • symptothermal methods (basal

body temperature + mucus) • calendar rhythm method • standard days method

(CycleBeads) • Creighton Model FertilityCare

System


Advantages:• No hormones• No side effects • Enables a woman to understand

her body’s cycles• Promotes cooperation between

partners • Can also be used to achieve

pregnancy or to identify infertility problems

• The only method approved by the Catholic Church

Disadvantages:• Methods require varying amounts of

training & cost• Detracts from spontaneity, causes

friction between partners if not in agreement

• Difficult to use if:− recent childbirth− breastfeeding− recent menarche− approaching menopause− recent discontinuation of a hormonal method− irregular cycles− unable to interpret fertility signs

Sterilization

Sterilization is chosen by 39% of couples who use contraception in the U.S.

28% of reproductive age women undergo tubal ligation and 10% of men undergo vasectomy.

Tubal Ligation

Mechanism of action: the fallopian tubes are cut or mechanically blocked to prevent the sperm and ovum from uniting

Can be performed laparo-scopically or through a suprapubic “mini-laparotomy” incision (or at C-section)

Failure rate: 0.5%

Tubal Ligation

Advantages:• permanent• highly effective• safe• quick recovery• lack of significant long-term side

effects• cost effective• partner cooperation not required• not coitus-linked

Disadvantages:• possibility of patient regret• difficult to reverse• future pregnancy could require

assistive reproductive tech-nology (such as IVF)

• more expensive than vasectomy

Transcervical SterilizationEssure™ Mechanism of

Action:Using a hysteroscopic approach, one

Essure micro-insert is placed in the proximal section of each fallopian tube lumen. The micro-insert expands upon release, acutely anchoring itself in the fallopian tube.

The micro-insert subsequently elicits a benign tissue response. Tissue in-growth into the micro-insert anchors the device and occludes the fallopian tube, resulting in sterilization.

FAILURE RATE:0.2% after 3 years

VasectomyMechanism of action: each

vas deferens is cut to prevent the passage of sperm into the ejaculated seminal fluid

FAILURE RATE: perfect use 0.10%typical use 0.15%

VasectomyAdvantages:• permanent• highly effective• safe• quick recovery• lack of significant long-term side

effects• cost effective; less expensive

than tubal ligation• no partner cooperation needed• removal of contraceptive burden

from the woman

Disadvantages:• reversal is difficult, expensive,

often unsuccessful• patient may regret decision• not effective until all sperm

cleared from the reproductive tract

• no protection from STIs

≈ $500.00

Emergency Contraception

Definition: emergency contraceptives are methods a woman can use after intercourse to prevent pregnancy

Methods: • Plan B − the only dedicated product marketed

specifically for emergency contraception• Off-label use of progestin-only contraceptive pills• Off-label use of combination estrogen-progestin pills• Insertion of a copper-releasing IUD

Emergency ContraceptionIndications for use:

• contraceptive failure (condom broke, pills forgotten)• error in withdrawal or periodic abstinence• rape• any unintended “sperm exposure”

Contraindications:• pregnancyEC could prevent about ½ of unintended pregnancies −

1.5 million pregnancies in the U.S. every year.

Emergency Contraception: Plan B

Contents: 750 µg levonorgestrel per pill

Directions:Take the first tablet as soon as

possible within 72 hours after unprotected intercourse.

Take the second tablet 12 hours later.

The sooner Plan B is taken, the better. It can be taken up to 120 hours after intercourse.

If taken within 72 hours as directed, Plan B reduces the risk of pregnancy from a single act of intercourse by 89%.

≈ $35.00 per pack

Emergency Contraception: Plan B Mechanisms of Action

• Disruption of development and maturation of ovarian follicles

• Disruption of egg maturation and ovulation

• Interference with corpus luteum function

• Alteration of cervical mucus, blocking sperm transport

• Disruption of development of the zygote, morula, & blastocyst

• Impaired transport in the fallopian tube & uterine cavity

• Interference with development of the endometrium to impede implantation

When does pregnancy start???The American College of Obstetricians and Gynecologists (ACOG), the Food and Drug Administration (FDA), and the National Institutes of Health (NIH) have defined implantation as the beginning of pregnancy.

If fertilization has occurred, implantation starts about 7 days after ovulation.

Plan B disrupts the events leading up to implantation.

After implantation, it has no effect.

Emergency Contraception: Plan B

Is Plan B an “abortion pill?”

No. The oral abortifacient is RU-486 (mifepristone, Mifeprex) which is an antiprogestin that blocks the effects of progesterone by binding to its receptors. It is usually given in combination with misoprostol (Cytotec) to medically induce abortion in gestational ages up to 49 days after LMP.

If implantation has occurred, Plan B will do nothing.


Alternatives to Plan B:20 tablets of a progestin-only pill (e.g., Micronor) x 2 doses, 12

hours apart

2 doses of a combined estrogen-progestin pill, 12 hours apartAlesse 5 pink pills (100 µg EE + 500 µg levonorgestrel)

Triphasil 4 yellow pills (120 µg EE + 500 µg levonorgestrel)

Ovral 2 white pills (100 µg EE + 500 µg levonorgestrel)

If you give estrogen, give an antiemetic also!


Standards of care:• providing information• providing post-coital

treatment• providing advance Rx

www.NOT-2-LATE.com

1-888-NOT-2-LATE

“Every woman, every visit.”

− ACOG

http://www.not-2-late.com/

Go get΄em!

Introduction to Contraception Anita Jaynes, CNM, MS University of Nebraska Medical Center Obstetrics...

Documents

Transcript of Introduction to Contraception Anita Jaynes, CNM, MS University of Nebraska Medical Center Obstetrics...