OBGYN - Family Planning
From Iusmicm
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*Australia: 22.2 / 1000 | *Australia: 22.2 / 1000 | ||
- | ==Birth | + | ==Birth Controls== |
- | *There are two categories of birth control | + | *There are two categories of birth control: contraception (prevent conception) and implant preventors. |
- | * | + | *Contraceptions include: |
**OCPs | **OCPs | ||
**Norplant | **Norplant | ||
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**Rhythm | **Rhythm | ||
**IUDs | **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 | + | **'''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 | |
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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 | |
- | + | ||
- | + | ||
+ | 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 | ||
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- | + | 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 | ||
- | |||
- | |||
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- | |||
- | |||
- | |||
- | |||
- | |||
• | • | ||
- | + | Female Condom – | |
- | + | Slippage/Breakage Rate: 3% | |
- | + | ||
- | + | ||
- | + | ||
- | + | ||
– | – | ||
- | + | Failure Rate: 5-15% | |
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- | + | 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 | ||
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+ | 37 | ||
+ | Diaphragm1 | ||
+ | Diaphragm2 | ||
+ | Diaphragm3 | ||
+ | Diaphragm6 | ||
+ | Hormonal Contraceptives | ||
+ | • | ||
+ | Oral Contraceptive Pills (OCPs) – | ||
+ | Combined oral contraceptives (COCs) | ||
+ | – | ||
+ | Progestin-only pills (POPs) | ||
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• | • | ||
- | + | 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 | ||
- | |||
- | |||
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+ | 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 | |
- | + | ||
- | + | ||
- | + | ||
- | + | ||
- | + | ||
- | + | ||
- | + | ||
- | + | ||
- | + | ||
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• | • | ||
- | + | Regulate menses – | |
- | + | Less flow/anemia, less dysmenorrhea | |
– | – | ||
- | + | Prolonged/continuous dosing | |
- | |||
- | |||
- | |||
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+ | • | ||
+ | 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 | ||
Line 514: | Line 841: | ||
- | + | 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 | IUD | ||
- | |||
Line 599: | Line 876: | ||
IUD4 | 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 | |
Line 644: | Line 899: | ||
• | • | ||
- | + | IUD – | |
- | + | Up to 120 hrs postcoital | |
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
Line 664: | Line 912: | ||
- | + | Emergency Contraception: Indications | |
- | + | ||
- | + | ||
- | + | ||
- | + | ||
- | + | ||
- | + | ||
- | + | ||
- | + | ||
- | + | ||
- | Emergency Contraception | + | |
- | + | ||
• | • | ||
- | + | 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 | ||
Line 719: | Line 960: | ||
- | |||
- | |||
- | |||
- | |||
- | |||
- | + | 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 | ||
Line 736: | Line 974: | ||
– | – | ||
- | + | Levonorgestrel – up to 72 hours postcoital • | |
- | + | 0.75 mg q 12 hrs x 2, or 1.5 mg po x 1 | |
- | + | ||
- | + | ||
- | + | ||
- | + | ||
- | + | ||
- | + | ||
Line 749: | Line 981: | ||
– | – | ||
- | + | Ulipristal acetate – up to 120 hours postcoital • | |
- | + | 30 mg po | |
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
+ | • | ||
+ | IUD (Copper T) – | ||
+ | Place up to 120 hours postcoital | ||
Line 770: | Line 999: | ||
- | |||
- | + | 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 | ||
Line 815: | Line 1,074: | ||
+ | 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 |
Revision as of 21:20, 30 November 2011
Contents |
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.
- The active ingredient of spermacides is nonoxynol 9 or actoxynol-3.
- 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
- Periodic Abstinence
- 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
- Vas Occlusion
- 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
- WHO Studies utilized weekly testosterone enanthate injections
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