OBGYN - Family Planning
From Iusmicm
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