Editing OBGYN - Family Planning

=Contraception=

==Objectives==
*Review basic statistics concerning population growth and pregnancy rates
*Review basic contraceptive options
*Review sterilization options

==World population growth==
*Population growth is logarithmic since around 1950.
*The world is growing at about 1.8% each year.
*Every minute, a woman dies of pregnancy / childbirth complications.
**99% of these deaths occur in developing countries.
**1 million children left motherless.
*Maternal mortality rates vary from 1/7 (Niger) to 1/17.4k (Sweden).


*Birth control is controversial for three reasons:
**Personal issues
**Religious issues
**Political issues

==Counseling==
*Counseling about contraception is important.
*10% of women don't use birth control.
*53% of unintended pregnancies result from these 10% of women (who aren't using birth control).
*Abortions are highest in those less than 15yo.
**Abortions decrease as the woman ages to 30-34.
**Abortions increase again from 35 and up.


*In 2002 there were 6.4 million pregnancies.
**51% were intended
**49% were unintended
***22% were unintended ''births''
***20% were elective abortions
***7% were fetal losses


*Of unintended pregnancies that proceed to live births,
**1/4 are '''"unwanted"'''
**3/4 are '''"mistimed"'''


*Of unintended pregnancies that proceed to live births, about 40% of women were using contraceptives at the time of conception.


==Abortion rates==
*The United States of America aborts 22.9 of each 1000 fetuses.
*Australia: 22.2 / 1000

==Birth Controls==
*There are two categories of birth control: contraception (prevent conception) and implant preventors.
*Contraceptions include:
**OCPs
**Norplant
**Depo-Provera
**Condoms
**Diaphragm
**Foam
**Rhythm
**IUDs
*Implant preventors include IUDs and morning after pills.


*The most commonly used birth control is tubal ligation making up nearly 50% of contraception use in "non-developed" countries.

===Barrier methods===
*Barrier methods include: spermacides, condoms, diaphragms / cervical caps, and sponges


*Spermacides
**The active ingredient of spermacides is '''nonoxynol 9''' or '''actoxynol-3'''.
***Nonoxynol and actoxynol disrupt the spermatic cell membrane.
**The failure rate of spermacides is '''15-35%'''.
**Patient compliance is generally high.


*Condoms
**Male condom failure rate is 5-8% (slippage / breakage) or 5-15%
**Female condom failure rate is 3% (slippage / breakage) or 5-15%
**Mechanism of action is to physically block sperm.


*Diaphragms
**Mechanism of action is to physically block sperm from gaining access to upper reproductive tract (uterus and fallopian tube.
**Diaphragms can also hold spermicide.
**Device must be inserted 1 hour before intercourse.
**Diaphragm must remain in place for 6-8 hours post-coitus.
**Failure rate is 10-25%
**Benefits include:
***'''Some protection agains STDs'''
***Effective immediately
***Does not affect breast feeding
***Does not interfere with intercourse (can be inserted up to 6 hours pre-coitus).
***No health risks.
***No systemic side effects.
**Contraindications include:
***Hx of toxic shock syndrome
***Allergy to rubber
***Allergy to spermicides
***Repeat UTIs
***Uterine prolapse
***Vaginal stenosis
***Genital anomalies
**Patient compliance is difficult


*The sponge
**Mechanism: contains spermicide
**Benefits: small, disposible, works for 24 hours (regardless of coitus count)
**Reintroduced to market in 2009.
**Failure rate: 26-40%


===Hormonal contraceptives===
*Hormonal contraceptives come as oral pills, as injectables, and as an intravaginal ring or a supradermal patch.
*Injectable contraceptives include:
 **Combined injectible contraceptives (CICs)
**Depo-provera
**Norplant
**Implanon

====Oral contraceptive pills====
*'''Failure rate is <1%'''
*OCPs can be '''progesterone only''' or '''a combination of estrogen and progesterone''' (combined oral contraceptives; COCs).


*Oral contraceptive pills are taken 21 days with 7 days of placebo or no pill.
*Combined oral contraceptives come in three types depending on their phase:
**Monophasic: all 21 pills, all of which have some amount of estrogen / progesterone (E/P)
**Biphasic: 21 active pills, 2 different combinations of E/P
**Triphasic: 21 active pills, 3 different combinations of E/P


=====OCP mechanism of action=====
*Presence of progesterone decreases FSH and LH levels, including the LH surge.
*Without the LH surge, '''ovulation does not occur'''.
*Furthermore the '''endometrial lining is ''thinner'' which makes implantation less likely'''.
*The '''cervical lining is ''thickened'' which prevents spermatic penetration''' to the upper reproductive tract.


=====OCP Benefits=====
*Contraceptive benefits of OCP:
**Highly effective (failure rate <1%)
**Effective immediately if started by day 7 of menstrual cycle.
**Pelvic examination not required to initiate use.
**OCPs do not interfere with intercourse.
**Few side effects.
**Convenient and easy.
**Client can stop use at any time.
**Can be provided by trained medical staff.


*Non-contraceptive benefits of OCP:
**Decrease menstrual flow.
**Decrease menstrual cramps.
**Improve anemia (?).
**'''Protect against ovarian and endometrial cancer.'''
**'''Decrease bening breast disease and ovarian cysts.'''
**'''Prevent ectopic pregnancy.'''
**''Protect against some causes of pelvic inflammatory disease.''


=====OCP Effectiveness=====
*Perfect use is what is tested but then there is actual or typical use.
**OCP (combined versions) are 97% effective when taken perfectly.
**OCP (combined versions) are 92% effective upon actual use.
*10 million women are taking OCP; therefore each 1% decrease in effectiveness yields 100k unintended pregnancies
**8% decrease simply from perfect use to typical use.


=====OCP Contraindications=====
*Absolute contraindications include:
**History of vascular disease: pulmonary embolism, deep vein thrombosis, coronary vascular atherosclerosis
**Systemic disease: lupus, chronic hypertension, liver disease, hypercholesterolemia, migraine headaches  ''with auras''.
*Relative contraindications include:
**Tobacco use
**>35 yo
**Depression
**Seizures '''without auras'''


====Injectables====
*Mechanism of action:
**Suppress ovulation
**Thicken cervical mucosa
**Thin endometrium


*Types of injectable birth controls include:
**CICs (like OCPs)
**Depo-Provera
**Norplant
**Implantation


*Failure rate for injectables:
**CICs: 0.1-1%
**Depo-Provera: 0.1-0.6%
**Norplant / Implanton: 0.2-0.6%


*Injectable limitations
**Side effects include: nausea, dizziness, breast tenderness, headaches, spotting, light bleeding
**Effectiveness lowered in combination with other drugs
**Can delay return to fertility
**Serious side effects are possible
**'''Do not protect against STDs'''
**Change the menstrual bleeding pattern
**User-dependent; that is, the client must return every 30 days.


*Injectable benefits:
**Highly effective
**Effective immediately
**Pelvic examination not required before use (as with OCPs)
**Do not interfere with intercourse
**"Few side effects" (though more than OCPs)
**Can be provided by trained medical staff
**No supplies needed by the client

===Contraceptive Ring===
*NuvaRing
*2 inches in diameter
*120mg etonogestrel, 15mg ethinyl estradiol
*'''As effective as OCP'''
*One ring / cycle
**3 weeks in the vagina, 1 week without
*'''Not a barrier!'''

===Contraceptive patch===
*Ortho Evra
*150 mg norelgestromin, 20mg ethinyl estradiol
*'''As effective as OCPs'''
*'''Better compliance (90%) than OCPs (77%)'''
*Three patches / cycle, one each week for three weeks; 1 week without patch.

==Intra-uterine Devices (IUD)==
*'''Failure rate of 0.2-3%'''


*Mechanism of action '''can be contraceptive or abortive'''.
**Interferes with sperm ability to travel through uterine cavity.
**Thickens the cervical mucus.
**Intereferes with reproductive process before ova can reach the uterine cavity.
**Modifies the endometrial lining to decrease implantation.


*IUD advantages:
**Non-hormonal
**Failure rate of only 0.2-3%
**Effective immediately
**Long-term (up to 10 years)
**Does not interfere with intercourse
**Immediate return to fertility upon removal
**Does not affect breast feeding


*IUD contraindications
**Pregnancy (risk of ectopic pregnancy)
**Unexplained vaginal bleeding
**PID
**Purulent discharge
**Distorted uterine cavity
**Malignment trophoblast disease
**Pelvic TB
**Genital tract cancer
**GU tract infection


==Sterilization==
*Sterilization is '''the most common method of birth control among married couples'''.
*Sterilization is '''the most common method of birth control globally'''.
*Only 1% regret sterilization.
*'''Failure rate is 1-2% over 10 years'''


*10% of couples choosing sterilization choose vasectomy
**'''Failure rate of vasectomy is 0.1%'''

==Miscellaneous==
*Laction is a good birth control, too.
**'''Lactation failure rate is 2% for the first 6th months'''.
**Mechanism of action is disruption of GnRH release because of frequent, intense suckling at the nipple.
**Disrupted GnRH means disrupted LH / FSH release which means no ovulation.
**Limitations
***Does not protect against STDs
***No longer effective once menses begin again
***Hard to maintain because of social aspects of breast feeding


*NFP / Rhythm birth control
**Requires that couples be highly motivated to maintain compliance.
**'''Failure rate is 1-45%'''.
**NFP can be monitored by several methods: calendar, basal body temperature (BBT), cervical mucus method (Billings), or symptothermal (BBT + Billings)


*Withdrawal method birth control
**One of the oldest methods.
**Failure rate is 20-25%

==Emergency Contraception==
*"Morning after" pill
**Debates over whether it is a contraceptive or an abortifacent
*IUD
**Abortifacent

===Morning After Pill===
*There are two medicinal methods for emergency birth control:
**The Yuzpe method is 2 tablets of 0.25 mg loveonogestrol at 0 and 12 hours.
**The Plan B method is 1 tablet of 0.75 mg levonorgestrel at 0 and 12 hours.
***Plan B has less n / v
***'''Plan B is more effective'''


==Male alternatives==
*Traditional methods
**Periodic Abstinence
***High contraceptive efficacy if rules followed perfectly
***Typical 1st year '''failure rate: 20%'''
***Limited Acceptability: low reliability, inflexibility
**Non-Vaginal Ejaculation
***Historically the major pre-industrial method of family planning
***Limited Reliability: requires skill and self-control
***Typical 1st year '''failure rate: 20%'''
**Vasectomy
***Relative Contraindications: bleeding disorders, allergy to anesthestics, scrotal pathology
***Excises a segment of vas deferens
***'''Failure Rate: 0.1%''' - wait as long as three months
*Condom


*Modern methods
**Vas Occlusion
***"reversible vasectomy"
***Lower efficacy than true vasectomy
**Heating
***Principle: brief elevations of testicular temperature suppresses spermatogenesis
***Concept: tight scrotal support – remains to be clinically proven
**Immunocontraception
***Sperm Vaccination – men and women
**Chemical (non-hormonal)
***Target the rapidly proliferating germinal epithelium with drugs, heat, ionising radiation, thereby disrupting mitosis and/or meiosis


*Hormonal
**WHO Studies utilized weekly testosterone enanthate injections
***Provides both gonadotropin suppression and androgen replacement
***Contraceptive '''Failure Rate of about 8%'''
***Adverse Affects: cardiovascular & prostatic diseases, mood changes
**Other Studies looked at Androgen Combination regimens: 
***Non-androgens (estrogen, progestins) to suppress gonadotropins with testosterone
***GnRH Blockades with testosterone add-back
***FSH Blockades




=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  







… 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 



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
@@ Line 174: / Line 174: @@
 **History of vascular disease: pulmonary embolism, deep vein thrombosis, coronary vascular atherosclerosis
 **Systemic disease: lupus, chronic hypertension, liver disease, hypercholesterolemia, migraine headaches  ''with auras''.
 *Relative contraindications include:
 **Tobacco use
@@ Line 360: / Line 358: @@
 =Family Planning=
-*Historically:
+Family Planning
-**Pubarche occured in the upper teens
+John W. Stutsman, MD
-**Breastfed 3-4 yrs caused amennorhea which is an excellent, natural birth control
+Asst. Professor of Clinical OB/GYN
-**Only 50% reached the teens (reproductive age)
+Medical Director, Planned Parenthood of Indiana
-***Disease
+jostutsm@iupui.edu
-***Starvation
+December 12, 2011
-*Now:
-**7 Billion and counting
+In the Beginning….
+acm13
+•
+Pubarche upper teens
-*Adolescent Pregnancy:
+•
-**Pregnancy rate is decreasing
+Breastfed 3-4 yrs
-**Birth rate is decreasing
-**Abortion rate is decreasing
-**Adolescent pregnancy in general is decreasing.
-**Trends are across white, Hispanic, and African American races
-**US still has very high teen pregnancy rate compared to other countries
+•
+% reached teens –
+Disease
-*''Incidence'' of unintended pregnancy is similar with and without contraception but the ''risk'' is much higher for those without.
+–
+Starvation
-*Cost of unintended pregnancy:
-**birth, abortions, fetal loss.
-**5 billion dollars.
-==Contraception Counseling==
-*Should be part of any exam!
-*Process / questions:
-**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?
-*Lactation is effective for 6 months.
-**Must be exclusively breast feeding.
-*5-year cost of contraceptive methods
+… and Now…
-**Includes cost of unintended pregnancy.
+world-population-historical-small
-**Cheapest -> expensive
-***Copper IUD ($540)
-***Vasectomy
-***Injectable
-***OCP ($1784)
-***Condom ($2424)
-***Ligation
-***Withdrawal
-***Periodic abstinence ($3450)
-***Female condom
-***Sponge
-***Cervical cap ($5730)
-***None ($14663)
-==Types==
+Billion and counting!
+World-Population-1800-2100
-===Barrier methods===
+Adolescent Pregnancy
-*Keeps spermatozoa from meeting egg
+birthrategraph2
+US CDC: Recent Trends in Teenage Pregnancy in the United States
+Adolescent Pregnancy
-*Chemical (foams, spermicides)
-**Can come in sponges, films, or creams
+preggraph
+Kmietowicz Z, BMJ 2002, June 8; 324 (7330):1354
-*Physical (condoms)
-**Oldest were sheep skin
-**Female is expensive
-**Getting better at having adolescent males use them.
-**They protect from STDs!
+Unintended Pregnancy in USA
+At risk
+ # women
+ Unintended preg
+ Rate (per 1000)
++ contraception
+,106,259
+,488,800
+No contraception
+,555,514
+,612,000
-*Diaphragm
+Outcome
-**Made by one company
+ # women
-**Requires office visit for fitting
+ Avg $
-**Catches sperm
+ Total $
-**Fits behind pubic symphisis and behind the cervix
-**Pressure on ureter increases risk for UTI.
+Birth
-**Can use diaphragm to to catch blood of menses, too.
+,364,000
-***As long as no hx of toxic shock syndrome
+,924,228,000
+Abortions
+,302,000
+,824,000
+Fetal loss
+,000
+,608,000
+Total
+,100,000
+,986,660,000
-===Hormonal methods===
+Trussell J, Contraception 2007; 75(3): 168-170
-*The pill
-**OCP = oral contraceptive pills
-**Pill, patch, ring
+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?
-*Injection
-**Every 3 months
-**Slightly more effective
-**Weight gain common, irregular bleeding
-***Results in cessation
-**Cessation results in decreased effectiveness.
-**Can be used to treat heavy bleeding too.
+Essential Components of Contraceptive Counseling
+bcp 1.jpg
-*Implant
+AutoShape 9_pptX
-**Norplant had silicon and lawsuits caused it to be taken off the market.
+AutoShape 10_pptX
-**Implanon = Nexplanon
+AutoShape 11_pptX
-***A source of estrogen (etonogestrel)
+AutoShape 12_pptX
+AutoShape 13_pptX
+Expert Clinical Advisory Committee for A Case-Based Approach to Addressing Hormonal Contraception. 2008.
-====Mechanism of Hormonal contraceptions====
+Method
-*Ovulation is presented by providing feedback with progesterone to decrease LH surge.
+ Typical Use
-*Progesterone:
+ Perfect Use
-**Inhibits LH surge such that ovulation is decreased.
+ % using at 1 yr
-**Makes cervical mucus thick to inhibit sperm motility
-**Smooth muscle relaxant to decrease transport of sperm in the fallopian tube (which has SM and cilia helping to move the sperm toward the egg)
+No method
-**Decreases glycogen stores in the endometrium such that ovum is less likely to survive / implant
-*Estrogen:
-**decreases FSH such that there is little follicle development
-**increases progesterone receptors so as to potentiate the effect of the progesterone
+Spermicides
+Withdrawal
+Rhythm methods
+Diaphragm
+Female condom
+Male condom
+OCP/POP
+.3
+Transdermal CHC
+.3
+CVR (CHC)
+.3
+DMPA
+.3
+Copper-T IUD
+.8
+.6
+LNG IUS
+.2
+.2
+ENG implant
+.05
+.05
+Female sterilization
+.5
+.5
+Male sterilization
+.15
+.10
+Cumulative Annual Failure Rates
-*Bonus benefits
-**Decreased ectopic preg
-**Regulates menses
-***Good tx for irregular menses
-**Decrease PID / salpingitis risk
-***Good tx with gonorrhea and chlamydia
-**Less acne / hirsuitism
-***Because estrogen increases sex hormone binding globulin (SHBG) at the liver
-***Binds testosterone and decreases androgenic effect
-**Decreased androgen production, too
-***Because test is made in ovary and FSH is decreased
-**Decreased benign breast disease
-***Recall however that benign breast fibrosis has no increased risk for cancer
-**Decreased risk of endometiral cancer
-***50% risk
-***Last for 15 years!
-**Decreased risk of ovarian cancer
-***30%
-***30 years of protection
-===IUD===
-*Very good compliance
-*Good for long term use
-*Two types in US
-**LNG IUS
-**Copper T (380 A)
+-Yr Costs Associated with Contraceptive Methods in the Managed Payment Model
+Macintosh HD:Users:crmyers:Desktop:stutsman:Fig. 13-1.tif
-*Mechanism of action
+Barrier Methods
-**Impairs sperm motility through uterus via copper.
-**Impairs sperm motility via prosterone's increased thickness effect.
-**Inflammatory environment reaction in the uterus makes hostile to sperm.
+•
+Spermacides
-*Very low failure rate: 0.2-0.8%
+•
+Condoms
+•
+Diaphragm & Cervical Caps
-*Contraindications:
+•
-**Recent PID
+Sponges
-**Suspicion of genital cancer
-**Pelvic TB
+chastity
+Spermacides
+•
+Active Ingredient –
+Either Nonoxynol 9 or Actoxynol-3
+–
+mins before, up to one hour
+•
+Failure Rate –
+to 35%
+•
+Patient Compliance –
+HIGH
+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%
+–
+% male US teens use condom w/1st act •
+CDC, Oct. 12, 2011
+•
+Female Condom –
+Slippage/Breakage Rate: 3%
+–
+Failure Rate: 5-15%
+FCondom
+FCondom2
+Copy of FCondom7
+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
+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 –
+.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 –
+’s- Veterinarians used high doses of estrogen for dogs and horses
+–
+’s- DES and other estrogens prescribed for human postcoital use
+–
+- “Yuzpe method” •
+mcg ethinyl estradiol
+•
+.5 mg levonorgestrel
+Plan B  (levonorgestrel 0.75 mg)
+EC Methods
+•
+Hormonal –
+Yuzepe – up to 72 hours postcoital •
+mcg EE + 50 mcg LNG po q 12 hrs x 2
+–
+Levonorgestrel – up to 72 hours postcoital •
+.75 mg q 12 hrs x 2, or 1.5 mg po x 1
+–
+Ulipristal acetate – up to 120 hours postcoital •
+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)
+%
+%
+%
+%
+%
+%
+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
+.50 (0.18–1.24)
+.135
+RCT Glasier et al. 2010 n = 1899
+.57 (0.29–1.09)
+.091
+Meta-analysis <24 h n = 1184
+.35 (0.11–0.93)
+.035
+Meta-analysis <72 h n = 3242
+.58 (0.33–0.99)
+.046
+Meta-analysis <120 h n = 3445
+.55 (0.32–0.93)
+.025
+Permanent Birth Control Options
+•
+Vasectomy
+•
+Tubal ligation
+•
+Hysteroscopic Tubal Sterilization
+Image 3
+Image 2
+Essure micro-insert in  fallopian tube after 3 months
-===Emergency Contraception Options===
-*EE and progestin
-**Up to 72 hrs postcoital (3 days)
-*'''Levonorgestrel'''
-**Up to 72 hrs postcoital (3 days)
-**Includes Plan B; purchased over the counter
-*Ulipristal acetate (Ella)
-**Up to 120 hrs postcoital (5 days)
-**'''Requires Rx'''
-*IUD
-**Up to 120 hrs postcoital (5 days)
-**Requires visit to MD.
-*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)
-***Retinae
+Essure Placement
-*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 (high dose birth control pill)
-***0.5 mg levonorgestrel
+Elective Abortions
+Year
+ # Abortions
+ /1000 births
+ /1000 women
+,476
+.0
+,429,577
+.0
+,181
+.1
+,609
+.0
-*Yuzpe method:
+•
-**No better and maybe less effective than just using progestin alone.
+– 300 abortion-related maternal deaths –
-**High side effects (n/v)
+= 6 abortion-related maternal deaths
-**Requries prescription.
-===Permanent Birth Control===
-*Vasectomy
-**Office procedure
-**Ligation
-*Tubal ligation
-**In-hospital
-**Laproscopic or post-deliver with umbilical incision
-*Hysteroscopic Tubal Sterilization
-**Radiofrequency or silicon plug
-**Can be done in the office
-**Decreasing the cost of tubal ligation.
-**Requires follow-up via radiology.
-==Elective Abortions==
+•
-*'''Decrease in number and rate.'''
+Abortion related maternal death rate = 0.72-1.0/100,000
-*Decrease in abortion-related deaths.
-*Maternal mortality is actually increasing though (independent of abortions).
-*950% are done in the first trimester
+•
+Maternal Mortality Rate = 15.1/100,000
-*Two major methods:
-**Surgical: D&C
-**Medication
-***15% of abortions
-***RU486 = Mithacristone (600mg)
-***Can use lower doses but give more vaginally (for fewer side effects)
-***Methotrexate can also be used, but worse
-==Questions==
-*Slowest return to fertility:
-**Depot medroxyprogesterone acetate
-*Contraindications to CHC (combined hormone contraceptive):
+Number of Abortions per 1,000 Women aged 15-44 in US
-**DVT!
-**Not the smoker (until over 35yo), not the rheumatoid arthritic, not the well-controlled HTN (OK while controlled)
-*Contraindication to IUD:
+Medication Abortion
-**?
+Regimen
+ Success (%)
+ Gest age (days)
+RU486 600mg M 400mcg po
+RU486 200mg M 800mcg vag
+-99
+MTX 50mg/m2
+M 800mcg vag
+-96
+M 800 vag (up to 3 doses)
+-88