Editing OBGYN - Family Planning
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**History of vascular disease: pulmonary embolism, deep vein thrombosis, coronary vascular atherosclerosis | **History of vascular disease: pulmonary embolism, deep vein thrombosis, coronary vascular atherosclerosis | ||
**Systemic disease: lupus, chronic hypertension, liver disease, hypercholesterolemia, migraine headaches ''with auras''. | **Systemic disease: lupus, chronic hypertension, liver disease, hypercholesterolemia, migraine headaches ''with auras''. | ||
- | |||
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*Relative contraindications include: | *Relative contraindications include: | ||
**Tobacco use | **Tobacco use | ||
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=Family Planning= | =Family Planning= | ||
- | + | Family Planning | |
- | + | John W. Stutsman, MD | |
- | + | Asst. Professor of Clinical OB/GYN | |
- | + | Medical Director, Planned Parenthood of Indiana | |
- | + | jostutsm@iupui.edu | |
- | + | December 12, 2011 | |
- | |||
- | |||
+ | In the Beginning…. | ||
+ | acm13 | ||
+ | • | ||
+ | Pubarche upper teens | ||
- | + | • | |
- | + | Breastfed 3-4 yrs | |
- | + | ||
- | + | ||
- | + | ||
- | + | ||
- | + | ||
+ | • | ||
+ | 50% reached teens – | ||
+ | Disease | ||
- | + | – | |
+ | Starvation | ||
- | |||
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- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | + | … and Now… | |
- | + | world-population-historical-small | |
- | + | ||
- | + | ||
- | + | ||
- | + | ||
- | + | ||
- | + | ||
- | + | ||
- | + | ||
- | + | ||
- | + | ||
- | + | ||
- | + | ||
- | + | ||
- | + | 7 Billion and counting! | |
+ | World-Population-1800-2100 | ||
- | + | Adolescent Pregnancy | |
- | + | birthrategraph2 | |
+ | US CDC: Recent Trends in Teenage Pregnancy in the United States | ||
+ | Adolescent Pregnancy | ||
- | |||
- | |||
+ | preggraph | ||
+ | Kmietowicz Z, BMJ 2002, June 8; 324 (7330):1354 | ||
- | |||
- | |||
- | |||
- | |||
- | |||
+ | Unintended Pregnancy in USA | ||
+ | At risk | ||
+ | # women | ||
+ | Unintended preg | ||
+ | Rate (per 1000) | ||
+ | |||
+ | + contraception | ||
+ | 38,106,259 | ||
+ | 1,488,800 | ||
+ | 39 | ||
+ | |||
+ | No contraception | ||
+ | 4,555,514 | ||
+ | 1,612,000 | ||
+ | 354 | ||
+ | |||
- | + | Outcome | |
- | + | # women | |
- | + | Avg $ | |
- | + | Total $ | |
- | + | ||
- | + | Birth | |
- | + | 1,364,000 | |
- | + | 2877 | |
+ | 3,924,228,000 | ||
+ | |||
+ | Abortions | ||
+ | 1,302,000 | ||
+ | 612 | ||
+ | 796,824,000 | ||
+ | |||
+ | Fetal loss | ||
+ | 434,000 | ||
+ | 612 | ||
+ | 265,608,000 | ||
+ | |||
+ | Total | ||
+ | 3,100,000 | ||
+ | 4,986,660,000 | ||
+ | |||
- | + | Trussell J, Contraception 2007; 75(3): 168-170 | |
- | + | ||
- | + | ||
- | + | ||
+ | Reproductive Health Plan | ||
+ | ? | ||
+ | How important is it to you to avoid pregnancy now? | ||
+ | |||
+ | ? | ||
+ | What would you do if you became pregnant now? | ||
+ | |||
+ | ? | ||
+ | What is your desired family size? | ||
+ | |||
+ | ? | ||
+ | What is your intended timing for pregnancy? | ||
+ | |||
+ | ? | ||
+ | Are there health issues that you need to address before you become pregnant? | ||
+ | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
+ | Essential Components of Contraceptive Counseling | ||
+ | bcp 1.jpg | ||
- | + | AutoShape 9_pptX | |
- | + | AutoShape 10_pptX | |
- | + | AutoShape 11_pptX | |
- | + | AutoShape 12_pptX | |
+ | AutoShape 13_pptX | ||
+ | Expert Clinical Advisory Committee for A Case-Based Approach to Addressing Hormonal Contraception. 2008. | ||
- | + | Method | |
- | + | Typical Use | |
- | + | Perfect Use | |
- | + | % using at 1 yr | |
- | + | ||
- | + | No method | |
- | + | 85 | |
- | + | 85 | |
- | + | ||
- | + | Spermicides | |
+ | 29 | ||
+ | 18 | ||
+ | 42 | ||
+ | |||
+ | Withdrawal | ||
+ | 27 | ||
+ | 4 | ||
+ | 43 | ||
+ | |||
+ | Rhythm methods | ||
+ | 25 | ||
+ | 5 | ||
+ | |||
+ | Diaphragm | ||
+ | 16 | ||
+ | 6 | ||
+ | 57 | ||
+ | |||
+ | Female condom | ||
+ | 21 | ||
+ | 5 | ||
+ | 49 | ||
+ | |||
+ | Male condom | ||
+ | 15 | ||
+ | 2 | ||
+ | 53 | ||
+ | |||
+ | OCP/POP | ||
+ | 8 | ||
+ | 0.3 | ||
+ | 68 | ||
+ | |||
+ | Transdermal CHC | ||
+ | 8 | ||
+ | 0.3 | ||
+ | 68 | ||
+ | |||
+ | CVR (CHC) | ||
+ | 8 | ||
+ | 0.3 | ||
+ | 68 | ||
+ | |||
+ | DMPA | ||
+ | 3 | ||
+ | 0.3 | ||
+ | 56 | ||
+ | |||
+ | Copper-T IUD | ||
+ | 0.8 | ||
+ | 0.6 | ||
+ | 78 | ||
+ | |||
+ | LNG IUS | ||
+ | 0.2 | ||
+ | 0.2 | ||
+ | 80 | ||
+ | |||
+ | ENG implant | ||
+ | 0.05 | ||
+ | 0.05 | ||
+ | 82 | ||
+ | |||
+ | Female sterilization | ||
+ | 0.5 | ||
+ | 0.5 | ||
+ | 100 | ||
+ | |||
+ | Male sterilization | ||
+ | 0.15 | ||
+ | 0.10 | ||
+ | 100 | ||
+ | |||
+ | Cumulative Annual Failure Rates | ||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
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- | |||
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- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
+ | 5-Yr Costs Associated with Contraceptive Methods in the Managed Payment Model | ||
+ | Macintosh HD:Users:crmyers:Desktop:stutsman:Fig. 13-1.tif | ||
- | + | Barrier Methods | |
- | + | ||
- | + | ||
- | + | ||
+ | • | ||
+ | Spermacides | ||
- | + | • | |
+ | Condoms | ||
+ | • | ||
+ | Diaphragm & Cervical Caps | ||
- | + | • | |
- | + | Sponges | |
- | + | ||
- | + | ||
+ | |||
+ | chastity | ||
+ | |||
+ | Spermacides | ||
+ | • | ||
+ | Active Ingredient – | ||
+ | Either Nonoxynol 9 or Actoxynol-3 | ||
+ | |||
+ | – | ||
+ | 15 mins before, up to one hour | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | • | ||
+ | Failure Rate – | ||
+ | 15 to 35% | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | • | ||
+ | Patient Compliance – | ||
+ | HIGH | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | 36 | ||
+ | Spermacide1 | ||
+ | vcf2 | ||
+ | |||
+ | The Sponge | ||
+ | • | ||
+ | Small, disposable; contains spermacide | ||
+ | |||
+ | • | ||
+ | Once in place, can provide contraception for 24hrs no mater how often coitus occurs | ||
+ | |||
+ | • | ||
+ | Today Sponge off US market in 1995 but reintroduced in May ‘09 | ||
+ | |||
+ | • | ||
+ | Other Brands available worldwide | ||
+ | |||
+ | • | ||
+ | Failure Rate: 26-40% | ||
+ | |||
+ | |||
+ | |||
+ | sponges | ||
+ | elaine01-black_dress | ||
+ | |||
+ | Condoms | ||
+ | • | ||
+ | Male Condom – | ||
+ | Slippage/Breakage Rate: 5-8% | ||
+ | |||
+ | – | ||
+ | Failure Rate: 5-15% | ||
+ | |||
+ | – | ||
+ | 80% male US teens use condom w/1st act • | ||
+ | CDC, Oct. 12, 2011 | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | • | ||
+ | Female Condom – | ||
+ | Slippage/Breakage Rate: 3% | ||
+ | |||
+ | – | ||
+ | Failure Rate: 5-15% | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | 40 | ||
+ | 43 | ||
+ | FCondom | ||
+ | FCondom2 | ||
+ | Copy of FCondom7 | ||
+ | 39 | ||
+ | |||
+ | Diaphragms | ||
+ | |||
+ | • | ||
+ | Mechanism of Action | ||
+ | |||
+ | • | ||
+ | Failure Rate: 10-20% | ||
+ | |||
+ | • | ||
+ | Benefits | ||
+ | |||
+ | • | ||
+ | Precautions | ||
+ | |||
+ | • | ||
+ | Patient Compliance: – | ||
+ | Inserted 1 hr before | ||
+ | |||
+ | – | ||
+ | Left in place for 6-8 hrs post-coitus | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | 37 | ||
+ | Diaphragm1 | ||
+ | Diaphragm2 | ||
+ | Diaphragm3 | ||
+ | Diaphragm6 | ||
+ | |||
+ | Hormonal Contraceptives | ||
+ | • | ||
+ | Oral Contraceptive Pills (OCPs) – | ||
+ | Combined oral contraceptives (COCs) | ||
+ | |||
+ | – | ||
+ | Progestin-only pills (POPs) | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | • | ||
+ | Transdermal Patch (Ortho Evra) | ||
+ | |||
+ | • | ||
+ | Contraceptive Vaginal Ring (NuvaRing) | ||
+ | |||
+ | • | ||
+ | Injectable – | ||
+ | Combined Injectable Contraceptives (CICs) • | ||
+ | Off US market 2002, Cyclofem in other markets | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | – | ||
+ | Depot medroxyprogesterone acetate (Depo-Provera) | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | • | ||
+ | Implant – | ||
+ | Norplant (not in USA) = levonorgestrel | ||
+ | |||
+ | – | ||
+ | Implanon -> Nexplanon = etonogestrel | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | Mechanism of Action of Hormonal Contraception | ||
+ | hpopic | ||
+ | • | ||
+ | Ovulation prevention | ||
+ | |||
+ | • | ||
+ | Tenacious cervical mucous | ||
+ | |||
+ | • | ||
+ | Decrease uterine and fallopian tube motility | ||
+ | |||
+ | • | ||
+ | Decrease endometrial glycogen stores | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | Secondary Benefits of OCP | ||
+ | • | ||
+ | Effective contraception – | ||
+ | Fewer ectopic pregnancies and abortions | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | • | ||
+ | Regulate menses – | ||
+ | Less flow/anemia, less dysmenorrhea | ||
+ | |||
+ | – | ||
+ | Prolonged/continuous dosing | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | • | ||
+ | Less salpingitis/PID w/ +GC/CT | ||
+ | |||
+ | • | ||
+ | Less acne and hirsuitism | ||
+ | |||
+ | • | ||
+ | Decrease benign breast disease | ||
+ | |||
+ | • | ||
+ | Decrease risk of endometrial cancer | ||
+ | |||
+ | • | ||
+ | Decrease risk of ovarian cancer | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | Contraindications to CHC | ||
+ | • | ||
+ | Pregnancy | ||
+ | |||
+ | • | ||
+ | Smoking (>15/day) and age >35 | ||
+ | |||
+ | • | ||
+ | Prior DVT or high risk group – | ||
+ | Prolonged immobility | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | • | ||
+ | Uncontrolled/poorly controlled HTN | ||
+ | |||
+ | • | ||
+ | Current breast or hepatic cancer | ||
+ | |||
+ | • | ||
+ | Peripartum cardiomyopathy | ||
+ | |||
+ | • | ||
+ | Migraine with aura | ||
+ | |||
+ | • | ||
+ | Vascular disease – | ||
+ | h/o MI or CVA | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | Intrauterine Device…Contraceptive…System | ||
+ | • | ||
+ | Two types in US – | ||
+ | LNG IUS | ||
+ | |||
+ | – | ||
+ | Copper T (380 A) | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | • | ||
+ | Mechanism of action – | ||
+ | ----------------------. | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | • | ||
+ | Very effective – | ||
+ | 0.2-0.8 failure rate annually = BTL | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | IUD | ||
+ | |||
+ | |||
+ | IUD6 | ||
+ | IUD4 | ||
+ | |||
+ | Emergency Contraception Options | ||
+ | • | ||
+ | EE and progestin – | ||
+ | Up to 72 hrs postcoital | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | • | ||
+ | Levonorgestrel – | ||
+ | Up to 72 hrs postcoital | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | • | ||
+ | Ulipristal acetate – | ||
+ | Up to 120 hrs postcoital | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | • | ||
+ | IUD – | ||
+ | Up to 120 hrs postcoital | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | Emergency Contraception: Indications | ||
+ | • | ||
+ | Intercourse within past 72-120 hours without contraceptive protection (independent of time in the menstrual cycle) | ||
+ | |||
+ | • | ||
+ | Contraceptive mishap – | ||
+ | Barrier method dislodgment/breakage | ||
+ | |||
+ | – | ||
+ | Expulsion of IUD | ||
+ | |||
+ | – | ||
+ | Missed oral contraceptive pills | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | • | ||
+ | Sexual assault | ||
+ | |||
+ | • | ||
+ | Exposure to teratogens (eg, cytotoxic drug) | ||
+ | |||
+ | |||
+ | |||
+ | ACOG Practice Bulletin. Int J Gynecol Obstet. 2002;78:191-198. | ||
+ | |||
+ | Hormonal Emergency Contraception | ||
+ | • | ||
+ | Not new concept – | ||
+ | 1920’s- Veterinarians used high doses of estrogen for dogs and horses | ||
+ | |||
+ | – | ||
+ | 1960’s- DES and other estrogens prescribed for human postcoital use | ||
+ | |||
+ | – | ||
+ | 1972- “Yuzpe method” • | ||
+ | 100 mcg ethinyl estradiol | ||
+ | |||
+ | • | ||
+ | 0.5 mg levonorgestrel | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | Plan B (levonorgestrel 0.75 mg) | ||
+ | |||
+ | EC Methods | ||
+ | • | ||
+ | Hormonal – | ||
+ | Yuzepe – up to 72 hours postcoital • | ||
+ | 100 mcg EE + 50 mcg LNG po q 12 hrs x 2 | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | – | ||
+ | Levonorgestrel – up to 72 hours postcoital • | ||
+ | 0.75 mg q 12 hrs x 2, or 1.5 mg po x 1 | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | – | ||
+ | Ulipristal acetate – up to 120 hours postcoital • | ||
+ | 30 mg po | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | • | ||
+ | IUD (Copper T) – | ||
+ | Place up to 120 hours postcoital | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | Proportion of Pregnancies Prevented by Levonorgestrel vs. Yupze, by Timing of Treatment | ||
+ | |||
+ | |||
+ | |||
+ | Task Force on Postovulatory Methods of Fertility Regulation. Lancet. 1998;352:428-433. | ||
+ | Levonorgestrel Yuzpe | ||
+ | Timing of Treatment (hours) | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | 58% | ||
+ | 31% | ||
+ | 36% | ||
+ | 85% | ||
+ | 95% | ||
+ | 77% | ||
+ | |||
+ | Emergency Contraception | ||
+ | |||
+ | |||
+ | |||
+ | Table 1. Efficacy of emergency contraception (UPA and LNG) in randomized controlled trials and meta-analyses according to time from unprotected intercourse to intake of emergency contraception. | ||
+ | LNG: Levonorgestrel; RCT: Randomized controlled trial; UPA: Ulipristal acetate. Adapted from [12]. | ||
+ | |||
+ | |||
+ | Trial type | ||
+ | Odds ratio and 95% CIs | ||
+ | p-value | ||
+ | |||
+ | RCT Creinin et al. 2006 n = 1546 | ||
+ | 0.50 (0.18–1.24) | ||
+ | 0.135 | ||
+ | |||
+ | RCT Glasier et al. 2010 n = 1899 | ||
+ | 0.57 (0.29–1.09) | ||
+ | 0.091 | ||
+ | |||
+ | Meta-analysis <24 h n = 1184 | ||
+ | 0.35 (0.11–0.93) | ||
+ | 0.035 | ||
+ | |||
+ | Meta-analysis <72 h n = 3242 | ||
+ | 0.58 (0.33–0.99) | ||
+ | 0.046 | ||
+ | |||
+ | Meta-analysis <120 h n = 3445 | ||
+ | 0.55 (0.32–0.93) | ||
+ | 0.025 | ||
+ | |||
+ | |||
+ | |||
+ | Permanent Birth Control Options | ||
+ | • | ||
+ | Vasectomy | ||
+ | |||
+ | • | ||
+ | Tubal ligation | ||
+ | |||
+ | • | ||
+ | Hysteroscopic Tubal Sterilization | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | Image 3 | ||
+ | |||
+ | |||
+ | Image 2 | ||
+ | |||
+ | |||
+ | |||
+ | |||
+ | |||
+ | Essure micro-insert in fallopian tube after 3 months | ||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
+ | Essure Placement | ||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
+ | Elective Abortions | ||
+ | Year | ||
+ | # Abortions | ||
+ | /1000 births | ||
+ | /1000 women | ||
+ | |||
+ | 1974 | ||
+ | 762,476 | ||
+ | 272 | ||
+ | 23.0 | ||
+ | |||
+ | 1990 | ||
+ | 1,429,577 | ||
+ | 345 | ||
+ | 24.0 | ||
+ | |||
+ | 2006 | ||
+ | 846,181 | ||
+ | 236 | ||
+ | 16.1 | ||
+ | |||
+ | 2007 | ||
+ | 827,609 | ||
+ | 231 | ||
+ | 16.0 | ||
+ | |||
- | + | • | |
- | + | 1961 – 300 abortion-related maternal deaths – | |
- | + | 2006 = 6 abortion-related maternal deaths | |
- | + | ||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | + | • | |
- | + | Abortion related maternal death rate = 0.72-1.0/100,000 | |
- | + | ||
- | + | ||
- | + | ||
+ | • | ||
+ | Maternal Mortality Rate = 15.1/100,000 | ||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | + | Number of Abortions per 1,000 Women aged 15-44 in US | |
- | + | ||
- | + | ||
- | + | Medication Abortion | |
- | + | Regimen | |
+ | Success (%) | ||
+ | Gest age (days) | ||
+ | |||
+ | RU486 600mg M 400mcg po | ||
+ | 92 | ||
+ | 49 | ||
+ | |||
+ | RU486 200mg M 800mcg vag | ||
+ | 95-99 | ||
+ | 63 | ||
+ | |||
+ | MTX 50mg/m2 | ||
+ | M 800mcg vag | ||
+ | 92-96 | ||
+ | 49 | ||
+ | |||
+ | M 800 vag (up to 3 doses) | ||
+ | 80-88 | ||
+ | 56 |