OBGYN - Family Planning

From Iusmicm

(Difference between revisions)
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*Australia: 22.2 / 1000
*Australia: 22.2 / 1000
-
==Birth Control: Mode of Action==
+
==Birth Controls==
-
*There are two categories of birth control
+
*There are two categories of birth control: contraception (prevent conception) and implant preventors.
-
*There are many options:
+
*Contraceptions include:
**OCPs
**OCPs
**Norplant
**Norplant
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**Rhythm
**Rhythm
**IUDs
**IUDs
-
*
+
*Implant preventors include IUDs and morning after pills.
-
42
 
-
Why Counseling is Important
+
*The most commonly used birth control is tubal ligation making up nearly 50% of contraception use in "non-developed" countries.
-
•
+
===Barrier methods===
-
Abortion Rates, by age group, per 1000 births (2000 Stats)
+
*Barrier methods include: spermacides, condoms, diaphragms / cervical caps, and sponges
-
•
 
-
10% of women don’t use contraception –
 
-
These account for 53% of unintended pregnancies
 
 +
*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
-
34
 
-
+
*The sponge
-
Unintended%20pregnancy
+
**Mechanism: contains spermicide
 +
**Benefits: small, disposible, works for 24 hours (regardless of coitus count)
 +
**Reintroduced to market in 2009.
 +
**Failure rate: 26-40%
-
prams_1
 
-
prams_2
+
===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
-
General Mode of Action
+
=====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.
-
•
 
-
Prevention of Conception –
 
-
OCPs, Norplant, Depo-Provera, Condom, Diaphragm, Foam, Rhythm, IUDs
 
 +
=====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.''
-
•
 
-
Prevention of Implantation –
 
-
IUDs, “Morning After Pills” 
 
 +
=====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
-
18
 
-
Worldwide Use of Contraceptive Types  
+
*Types of injectable birth controls include:
 +
**CICs (like OCPs)
 +
**Depo-Provera
 +
**Norplant
 +
**Implantation
-
•
 
-
Prevalence of Selected forms of Contraception in Developed and Developing Countries
 
-
•
+
*Failure rate for injectables:
-
Projected Use of Contraception in Developing Countries for 2000
+
**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.
-
24
 
-
25
 
-
Barrier Methods
+
*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===
-
Spermacides
+
*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===
-
Condoms
+
*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)==
-
Diaphragm & Cervical Caps
+
*'''Failure rate of 0.2-3%'''
-
•
 
-
Sponges
 
 +
*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
-
Spermacides
 
-
•
+
*IUD contraindications
-
Active Ingredient –
+
**Pregnancy (risk of ectopic pregnancy)
-
Either Nonoxynol 9 or Actoxynol-3
+
**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 –
+
**'''Failure rate of vasectomy is 0.1%'''
-
15 to 35%  
+
 +
==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)
-
•
 
-
Patient Compliance –
 
-
HIGH
 
 +
*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
-
Spermacide1
 
-
Condoms
+
*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
-
•
 
-
Male Condom –
 
-
Slippage/Breakage Rate: 5-8%
 
-
–
 
-
Failure Rate: 5-15%
 
 +
=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
•
•
-
Female Condom –
+
Pubarche upper teens
-
Slippage/Breakage Rate: 3%  
+
 
 +
•
 +
Breastfed 3-4 yrs
 +
 
 +
•
 +
50% reached teens –
 +
Disease
–
–
-
Failure Rate: 5-15%
+
Starvation 
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-
40
 
-
43
 
-
FCondom
 
-
FCondom2
 
-
Copy of FCondom7
 
-
39
 
-
Diaphragms
+
… and Now…
 +
world-population-historical-small
-
•
+
7 Billion and counting!
-
Mechanism of Action
+
World-Population-1800-2100
-
•
+
Adolescent Pregnancy
-
Failure Rate: 10-20%
+
birthrategraph2
 +
US CDC: Recent Trends in Teenage Pregnancy in the United States
-
•
+
Adolescent Pregnancy
-
Benefits
+
-
•
 
-
Precautions
 
-
•
+
preggraph
-
Patient Compliance: –
+
Kmietowicz Z, BMJ 2002, June 8; 324 (7330):1354
-
Inserted 1 hr before
+
-
–
 
-
Left in place for 6-8 hrs post-coitus
 
 +
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?
 +
-
37
+
Essential Components of Contraceptive Counseling
-
Diaphragm1
+
bcp 1.jpg
-
Diaphragms
+
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
   
   
-
Diaphragm6
 
-
Diaphragm6
 
-
Diaphragm3
 
-
The Sponge
+
Cumulative Annual Failure Rates
-
•
+
 
-
Small, disposable; contains spermacide
+
 
 +
5-Yr Costs Associated with Contraceptive Methods in the Managed Payment Model
 +
Macintosh HD:Users:crmyers:Desktop:stutsman:Fig. 13-1.tif
 +
 
 +
Barrier Methods
•
•
-
Once in place, can provide contraception for 24hrs no mater how often coitus occurs
+
Spermacides
•
•
-
Today Sponge off US market in 1995 but reintroduced in May ‘09
+
Condoms
•
•
-
Other Brands available worldwide
+
Diaphragm & Cervical Caps
•
•
-
Failure Rate: 26-40%
+
Sponges
-
elaine01-black_dress
+
chastity
-
 
+
-
Hormonal Contraceptives
+
 +
Spermacides
•
•
-
OCPs
+
Active Ingredient –
-
 
+
Either Nonoxynol 9 or Actoxynol-3
-
•
+
-
Injectable –
+
-
Combined Injectable Contraceptives (CICs)
+
–
–
-
Depo-Provera
+
15 mins before, up to one hour
-
–
 
-
Norplant
 
-
–
 
-
Implanon
 
 +
•
 +
Failure Rate –
 +
15 to 35%
-
•
 
-
New Types –
 
-
Ring
 
-
–
 
-
Patch 
 
 +
•
 +
Patient Compliance –
 +
HIGH
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-
OCPs
+
36
 +
Spermacide1
 +
vcf2
 +
The Sponge
•
•
-
Types –
+
Small, disposable; contains spermacide
-
Combination of estrogen & progesterone
+
-
–
+
•
-
Progesterone Only
+
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%
-
OCP1
+
sponges
-
 
+
elaine01-black_dress
-
OCPs
+
 +
Condoms
•
•
-
Mechanism of Action –
+
Male Condom –
-
Decrease FSH & LH
+
Slippage/Breakage Rate: 5-8%
–
–
-
No LH surge
+
Failure Rate: 5-15%
–
–
-
Alter Cervical Mucus
+
80% male US teens use condom w/1st act •
 +
CDC, Oct. 12, 2011
-
–
 
-
Alter Endometrial Lining
 
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-
 
-
11
 
-
OCP2
 
-
 
-
OCPs
 
•
•
-
Benefits –
+
Female Condom –
-
Contraceptive •
+
Slippage/Breakage Rate: 3%  
-
Failure Rate: 1% or less
+
-
 
+
-
 
+
-
 
+
–
–
-
Non-Contraceptive
+
Failure Rate: 5-15%
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-
OCP3
+
40
 +
43
 +
FCondom
 +
FCondom2
 +
Copy of FCondom7
 +
39
-
OCPs
+
Diaphragms
-
+
•
-
+
Mechanism of Action
-
OCP4
+
-
OCP Effectiveness
+
•
 +
Failure Rate: 10-20%
•
•
-
Efficacy –
+
Benefits
-
Perfect use vs. actual or typical use
+
-
–
+
•
-
Combined OCP •
+
Precautions
-
99.7% perfect use vs 92% actual use
+
•
•
-
Currently, there are 10 million women using the pill –
+
Patient Compliance: –
-
Each 1% decrease in efficacy = 100K unintended pregnancies each year 
+
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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•
•
-
Or, about 3 Jumbo jets crashing each and every day
+
Transdermal Patch (Ortho Evra)
-
 
+
-
 
+
-
 
+
-
 
+
-
OCPs
+
•
•
-
Contraindications –
+
Contraceptive Vaginal Ring (NuvaRing)
-
Absolute •
+
-
Hx/o Vascular Dz –
+
-
PE, DVT, CVA
+
-
 
+
-
 
+
-
 
+
•
•
-
Systemic Dz –
+
Injectable –
-
SLE, cHTN, Active Liver Dz, HyperChol, MiHAs with Auras
+
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 
-
 
-
–Relative •Tob Use, >35yrs, Depression, MiHAs without Auras
 
Line 421: Line 750:
 +
Mechanism of Action of Hormonal Contraception
 +
hpopic
 +
•
 +
Ovulation prevention
 +
•
 +
Tenacious cervical mucous
-
09
+
•
-
10
+
Decrease uterine and fallopian tube motility
-
 
+
-
Injectables
+
•
•
-
Mechanism of Action –
+
Decrease endometrial glycogen stores
-
Suppress ovulation, thicken cervical mucus, alter endometrium
+
 +
Secondary Benefits of OCP
•
•
-
Types –
+
Effective contraception –
-
CICs
+
Fewer ectopic pregnancies and abortions
-
 
+
-
–
+
-
Depo-Provera
+
-
 
+
-
–
+
-
Norplant
+
-
 
+
-
–
+
-
Implanon
+
Line 452: Line 776:
•
•
-
Failure Rates –
+
Regulate menses –
-
CICs: 0.1 – 1%
+
Less flow/anemia, less dysmenorrhea
–
–
-
Depo-Provera 0.1 - 0.6%
+
Prolonged/continuous dosing
-
–
 
-
Norplant/Implanon: •
 
-
0.2 - 0.6%
 
Line 466: Line 787:
 +
•
 +
Less salpingitis/PID w/ +GC/CT
 +
•
 +
Less acne and hirsuitism
 +
•
 +
Decrease benign breast disease
 +
•
 +
Decrease risk of endometrial cancer
-
PICs1
+
•
 +
Decrease risk of ovarian cancer 
-
Injectables
 
-
 
-
CIC5
 
-
CIC5
 
-
Newest Additions
 
 +
Contraindications to CHC
•
•
-
Contraceptive Ring
+
Pregnancy
•
•
-
Contraceptive Patch
+
Smoking (>15/day) and age >35
 +
•
 +
Prior DVT or high risk group –
 +
Prolonged immobility
-
Contraceptive Ring
 
•
•
-
NuvaRing –
+
Uncontrolled/poorly controlled HTN
-
2 inch diameter
+
-
–
+
•
-
120mg etonogestrel & 15mg ethinyl estradiol
+
Current breast or hepatic cancer
-
–
+
•
-
As effective as OCPs
+
Peripartum cardiomyopathy
-
–
+
•
-
One Ring/Cycle •
+
Migraine with aura
-
3 wks in/1 wk out
+
•
•
-
Not a Barrier
+
Vascular disease –
 +
h/o MI or CVA
Line 514: Line 841:
-
 
+
Intrauterine Device…Contraceptive…System
-
 
+
-
nuvaring
+
-
nuvaring
+
-
 
+
-
Contraceptive Patch
+
-
 
+
•
•
-
Ortho Evra –
+
Two types in US –
-
20-cm patch
+
LNG IUS
–
–
-
150mg Norelgestromin & 20mg ethinyl estradiol
+
Copper T (380 A)
-
–
 
-
“Superior” compliance rate vs/ OCP users (90% vs/ 77%)
 
-
–
 
-
As effective as OCPs
 
-
–
 
-
Three Rings/Cycle •
 
-
1 patch/wk x3wks
 
•
•
-
1 wk off
+
Mechanism of action –
 +
----------------------.
-
 
-
 
-
 
-
 
-
 
-
 
-
Patch2
 
-
 
-
IUDs
 
•
•
-
Types –
+
Very effective –
-
Three Types in US
+
0.2-0.8 failure rate annually = BTL
-
•
 
-
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  
IUD  
-
 
   
   
   
   
Line 599: Line 876:
IUD4
IUD4
-
Sterilization
+
Emergency Contraception Options
-
 
+
•
•
-
Most Common Method Among Married Couples
+
EE and progestin –
 +
Up to 72 hrs postcoital
-
•
 
-
Approximately 1% Regret Rate
 
-
•
 
-
Failure Rate: 
 
-
•
 
-
1-2/100 over 10 yrs
 
•
•
-
Vasectomy –
+
Levonorgestrel –
-
Chosen by 10% of couples
+
Up to 72 hrs postcoital
-
–
 
-
Failure Rate: 0.1%
 
-
 
-
 
-
 
-
 
-
05
 
-
07
 
-
 
-
Sterilization
 
-
 
-
 
-
Steilization2
 
-
Steilization2
 
-
 
-
Miscellaneous
 
•
•
-
Lactation –
+
Ulipristal acetate –
-
Failure Rate:1-2/100 for 1st 6 months
+
Up to 120 hrs postcoital
Line 644: Line 899:
•
•
-
NFP/Rhythm –
+
IUD –
-
Requires highly motivated couples
+
Up to 120 hrs postcoital
-
–
 
-
Failure Rate: 1-45%
 
-
•
 
-
Withdrawal –
 
-
One of the oldest methods
 
-
–
 
-
Failure Rate: 20-25% 
 
Line 664: Line 912:
-
 
+
Emergency Contraception: Indications
-
NFP1
+
-
 
+
-
NFP
+
-
 
+
-
+
-
basal_temp_graph1
+
-
Lactation1
+
-
Lactation2
+
-
 
+
-
Emergency Contraception  
+
-
 
+
•
•
-
“Morning After” –
+
Intercourse within past 72-120 hours without contraceptive protection (independent of time in the menstrual cycle)
-
Contraceptive or Abortifacent
+
-
 
+
-
 
+
-
 
+
•
•
-
IUD –
+
Contraceptive mishap –
-
Abortifacent
+
Barrier method dislodgment/breakage
 +
–
 +
Expulsion of IUD
 +
–
 +
Missed oral contraceptive pills
-
 
+
•
-
“Morning After Pill”
+
Sexual assault
•
•
-
Yuzpe Method or Preven –
+
Exposure to teratogens (eg, cytotoxic drug)
-
2 tablets of 0.25mg levonogestrol/ 0.05mg ethinyl estradiol at 0 hrs and 12hrs
+
 +
ACOG Practice Bulletin. Int J Gynecol Obstet. 2002;78:191-198.
 +
Hormonal Emergency Contraception
•
•
-
“Plan B” –
+
Not new concept –
-
1 tablet of 0.75 mg  Levonorgestrel taken at 0 and 12hr
+
1920’s- Veterinarians used high doses of estrogen for dogs and horses
–
–
-
Just as effective as Juzpe with less Nausea & Vomitting
+
1960’s- DES and other estrogens prescribed for human postcoital use
–
–
-
Decreases pregnancy rate from 8% to <1%
+
1972- “Yuzpe method” •
 +
100 mcg ethinyl estradiol
 +
•
 +
0.5 mg levonorgestrel
Line 719: Line 960:
-
Male Alternatives
 
-
•
 
-
Traditional Methods –
 
-
Periodic Abstinence •
 
-
High contraceptive efficacy if rules followed perfectly.
 
-
•
+
Plan B  (levonorgestrel 0.75 mg)
-
Typical 1st year failure rate: 20%
+
 +
EC Methods
•
•
-
Limited Acceptability: low reliability, inflexibility
+
Hormonal –
 +
Yuzepe – up to 72 hours postcoital •
 +
100 mcg EE + 50 mcg LNG po q 12 hrs x 2
Line 736: Line 974:
–
–
-
Non-Vaginal Ejaculation •
+
Levonorgestrel – up to 72 hours postcoital •
-
Historically the major pre-industrial method of family planning
+
0.75 mg q 12 hrs x 2, or 1.5 mg po x 1
-
 
+
-
•
+
-
Limited Reliability: requires skill and self-control
+
-
 
+
-
•
+
-
Typical 1st year failure rate: 20%
+
Line 749: Line 981:
–
–
-
Vasectomy •
+
Ulipristal acetate – up to 120 hours postcoital •
-
Relative Contraindications: bleeding disorders, allergy to anesthestics, scrotal pathology
+
30 mg po
-
•
 
-
Excises a segment of vas deferens
 
-
•
 
-
Failure Rate: 0.1% - wait as long as three months
 
-
–
 
-
Condom
 
 +
•
 +
IUD (Copper T) –
 +
Place up to 120 hours postcoital
Line 770: Line 999:
-
Male Alternatives
 
-
•
+
Proportion of Pregnancies Prevented by Levonorgestrel vs. Yupze, by Timing of Treatment
-
Modern Methods –
+
-
Vas Occlusion •
+
-
“reversible” vasectomy
+
-
•
 
-
Problem: lower efficacy
 
 +
Task Force on Postovulatory Methods of Fertility Regulation.  Lancet. 1998;352:428-433.
 +
Levonorgestrel Yuzpe
 +
Timing of Treatment (hours)
-
–
 
-
Heating •
 
-
Principle: brief elevations of testicular temperature suppresses spermatogenesis
 
-
•
 
-
Concept: tight scrotal support – remains to be clinically proven
 
 +
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
 +
-
–
 
-
Immunocontraception •
 
-
Sperm Vaccination – men and women
 
 +
Permanent Birth Control Options
 +
•
 +
Vasectomy   
 +
•
 +
Tubal ligation   
 +
•
 +
Hysteroscopic Tubal Sterilization
-
–
 
-
Chemical [non-hormonal] •
 
-
Target the rapidly proliferating germinal epithelium with drugs, heat, ionising radiation, thereby disrupting mitosis and/or meiosis.
 
-
Mi ik
 
-
 
 +
Image 3
 +
Image 2
Line 815: Line 1,074:
 +
Essure micro-insert in  fallopian tube after 3 months
-
Male Alternatives
 
-
•
 
-
Hormonal –
 
-
WHO Studies utilized weekly testosterone enanthate injections •
 
-
Provides both gonadotropin suppression and androgen replacement
 
 +
Essure Placement
-
–
 
-
Contraceptive Failure Rate of about 8%
 
-
–
+
Elective Abortions
-
Adverse Affects: cardiovascular & prostatic diseases, mood changes
+
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
 +
-
–
+
•
-
Other Studies looked at Androgen Combination regimens: non-androgens [estrogen, progestins] to suppress gonadotropins with testosterone; GnRH Blockades with testosterone add-back; FSH Blockades
+
1961 – 300 abortion-related maternal deaths –
 +
2006 = 6 abortion-related maternal deaths
-
 
-
 
-
 
-
 
-
Male Alternatives
 
•
•
-
Ancient Romans
+
Abortion related maternal death rate = 0.72-1.0/100,000
•
•
-
South Pacific
+
Maternal Mortality Rate = 15.1/100,000
-
 
-
02
 
-
03
 
-
01
 
-
+
Number of Abortions per 1,000 Women aged 15-44 in US
-
Conclusions
+
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
   
   
-
35
+
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.


  • 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
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