OBGYN - Family Planning

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(Created page with 'Introduction to Clinical Medicine Women’s Healthcare Contraception John Stutsman MD familyplanning Reality Objectives • Review basic statistics conce…')
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Introduction  to  Clinical Medicine Women’s Healthcare  Contraception  
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=Contraception=
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==Objectives==
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*Review basic statistics concerning population growth and pregnancy rates
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*Review basic contraceptive options
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John Stutsman MD
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*Review sterilization options
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==World population growth==
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*Population growth is logarithmic since around 1950.
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*The world is growing at about 1.8% each year.
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*Every minute, a woman dies of pregnancy / childbirth complications.
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**99% of these deaths occur in developing countries.
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**1 million children left motherless.
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*Maternal mortality rates vary from 1/7 (Niger) to 1/17.4k (Sweden).
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familyplanning
 
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Reality
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*Birth control is controversial for three reasons:
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**Personal issues
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**Religious issues
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**Political issues
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==Counseling==
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*Counseling about contraception is important.
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*10% of women don't use birth control.
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*53% of unintended pregnancies result from these 10% of women (who aren't using birth control).
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*Abortions are highest in those less than 15yo.
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**Abortions decrease as the woman ages to 30-34.
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**Abortions increase again from 35 and up.
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Objectives
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*In 2002 there were 6.4 million pregnancies.
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**51% were intended
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**49% were unintended
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***22% were unintended ''births''
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***20% were elective abortions
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***7% were fetal losses
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Review basic statistics concerning population growth and pregnancy rates
 
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*Of unintended pregnancies that proceed to live births,
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Review basic contraceptive options
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**1/4 are '''"unwanted"'''
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**3/4 are '''"mistimed"'''
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Review sterilization options
 
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*Of unintended pregnancies that proceed to live births, about 40% of women were using contraceptives at the time of conception.
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==Abortion rates==
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*The United States of America aborts 22.9 of each 1000 fetuses.
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*Australia: 22.2 / 1000
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World Population Growth
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==Birth Control: Mode of Action==
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*There are two categories of birth control
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*There are many options:
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**OCPs
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United Nations Millennium Goals
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**Norplant
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**Depo-Provera
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**Condoms
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Quick Facts from the UN
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**Diaphragm
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•Every minute, a woman dies of complications related to pregnancy and childbirth or 500K/yr – 99% live and die in developing countries
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**Foam
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**Rhythm
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•Maternal Mortality Rates: in Niger (1 in 7) vs Sweden (1 in 17.4K)
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**IUDs
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•Every year, more than 1 million children are left motherless because of maternal death.
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Controversial
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Personal
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Religious
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Political
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Revision as of 17:55, 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 Control: Mode of Action

  • There are two categories of birth control
  • There are many options:
    • OCPs
    • Norplant
    • Depo-Provera
    • Condoms
    • Diaphragm
    • Foam
    • Rhythm
    • IUDs

42

Why Counseling is Important

• Abortion Rates, by age group, per 1000 births (2000 Stats)

• 10% of women don’t use contraception – These account for 53% of unintended pregnancies




34


Unintended%20pregnancy

prams_1

prams_2




General Mode of Action

• Prevention of Conception – OCPs, Norplant, Depo-Provera, Condom, Diaphragm, Foam, Rhythm, IUDs



• Prevention of Implantation – IUDs, “Morning After Pills”




18

Worldwide Use of Contraceptive Types

• Prevalence of Selected forms of Contraception in Developed and Developing Countries

• Projected Use of Contraception in Developing Countries for 2000


24 25

Barrier Methods

• Spermacides

• Condoms

• Diaphragm & Cervical Caps

• Sponges



Spermacides

• Active Ingredient – Either Nonoxynol 9 or Actoxynol-3



• Failure Rate – 15 to 35%



• Patient Compliance – HIGH




Spermacide1

Condoms

• Male Condom – Slippage/Breakage Rate: 5-8%

– Failure Rate: 5-15%



• 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

Diaphragms


Diaphragm6 Diaphragm6 Diaphragm3

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%


elaine01-black_dress

Hormonal Contraceptives

• OCPs

• Injectable – Combined Injectable Contraceptives (CICs)

– Depo-Provera

– Norplant

– Implanon



• New Types – Ring

– Patch




OCPs

• Types – Combination of estrogen & progesterone

– Progesterone Only




OCP1

OCPs

• Mechanism of Action – Decrease FSH & LH

– No LH surge

– Alter Cervical Mucus

– Alter Endometrial Lining




11 OCP2

OCPs

• Benefits – Contraceptive • Failure Rate: 1% or less



– Non-Contraceptive




OCP3

OCPs


OCP4

OCP Effectiveness

• Efficacy – Perfect use vs. actual or typical use

– Combined OCP • 99.7% perfect use vs 92% actual use

• Currently, there are 10 million women using the pill – Each 1% decrease in efficacy = 100K unintended pregnancies each year







• Or, about 3 Jumbo jets crashing each and every day



OCPs

• Contraindications – Absolute • Hx/o Vascular Dz – PE, DVT, CVA



• Systemic Dz – SLE, cHTN, Active Liver Dz, HyperChol, MiHAs with Auras







–Relative •Tob Use, >35yrs, Depression, MiHAs without Auras




09 10

Injectables

• Mechanism of Action – Suppress ovulation, thicken cervical mucus, alter endometrium



• Types – CICs

– Depo-Provera

– Norplant

– Implanon



• Failure Rates – CICs: 0.1 – 1%

– Depo-Provera 0.1 - 0.6%

– Norplant/Implanon: • 

0.2 - 0.6%





PICs1

Injectables


CIC5 CIC5

Newest Additions

• Contraceptive Ring

• Contraceptive Patch



Contraceptive Ring

• NuvaRing – 2 inch diameter

– 120mg etonogestrel & 15mg ethinyl estradiol

– As effective as OCPs

– One Ring/Cycle • 3 wks in/1 wk out

• Not a Barrier





nuvaring nuvaring

Contraceptive Patch

• Ortho Evra – 20-cm patch

– 150mg Norelgestromin & 20mg ethinyl estradiol

– “Superior” compliance rate vs/ OCP users (90% vs/ 77%)

– As effective as OCPs

– Three Rings/Cycle • 1 patch/wk x3wks

• 1 wk off





Patch2

IUDs

• Types – Three Types in US



• Mechanism of Action – Contraceptive vs/ Abortative



• Advantages – Non-Hormonal

– Failure Rate: 0.2% to 3% by type



• Disadvantages

• Contraindications


Mirena1 21 08 IUD1 IUD2 IUD3

IUD


IUD6 IUD4

Sterilization

• Most Common Method Among Married Couples

• Approximately 1% Regret Rate

• Failure Rate:

• 1-2/100 over 10 yrs

• Vasectomy – Chosen by 10% of couples

– Failure Rate: 0.1%




05 07

Sterilization


Steilization2 Steilization2

Miscellaneous

• Lactation – Failure Rate:1-2/100 for 1st 6 months



• NFP/Rhythm – Requires highly motivated couples

– Failure Rate: 1-45%



• Withdrawal – One of the oldest methods

– Failure Rate: 20-25%




NFP1

NFP


basal_temp_graph1 Lactation1 Lactation2

Emergency Contraception

• “Morning After” – Contraceptive or Abortifacent



• IUD – Abortifacent




“Morning After Pill”

• Yuzpe Method or Preven – 2 tablets of 0.25mg levonogestrol/ 0.05mg ethinyl estradiol at 0 hrs and 12hrs



• “Plan B” – 

1 tablet of 0.75 mg  Levonorgestrel taken at 0 and 12hr

– Just as effective as Juzpe with less Nausea & Vomitting

– Decreases pregnancy rate from 8% to <1%





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




Male Alternatives

• Modern Methods – Vas Occlusion • “reversible” vasectomy

• Problem: lower efficacy



– 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.

Mi ik






Male Alternatives

• 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




Male Alternatives

• Ancient Romans

• South Pacific



02 03 01



Conclusions


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