Transcript Contraception through the ages
Contraception Update
CONTRACEPTION THROUGH THE AGES
Ulrike Sauer Lead for Brent Contraceptive Services Consultant in Sexual & Reproductive Health Margaret Pyke Centre May 2014
Objectives
Definition of Sexual health and rights • • • Choices of Contraception LARC • What has remained the same?
• What is new?
COC :Influences decision making Choices of Contraception in the different stages of reproductive life
Definition of Sexual Health
…..” a state of physical, emotional, mental and social well-being in relation
to sexuality; it is not merely the absence of disease, dysfunction or
infirmity.
Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.
For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.”
WHO, 2006
Definition of Sexual Rights
“The fulfilment of sexual health is tied to the extent to which human rights are respected, protected and fulfilled.
Sexual rights embrace certain human rights that are already recognized in international and regional human rights documents and other consensus documents and in national laws.
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includes the right to decide the number and spacing of one's children
Choices of Contraception in the different stages of reproductive life
Puberty to first sexual intercourse First sexual intercourse until childbirth Perimenopausal Spacing pregnancies after breast feeding During breast feeding Completed family
What has remained the same
Contraception is one of the most liberating interventions we have on offer for women.
Contraception is good for women’s health
Contraception is cost saving.
For every £1 invested £11 are saved.
Long acting reversible contraception
Why LARC?
Influences decision and update IUD/IUS :
New inserter for IUS and new IUS
DMPA :
late injections
Nexplanon
Why LARC ?
70 60 50 40 30 20 10 0 Contraception & Sexual Health, Office for National Statistics 2006-7 16-19 20-24 30-34 40-44
The pill is highly effective and with perfect use has a failure rate of 0.3% in the first year.
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But in practice failure is much higher— closer to 8% or 9%.
2 1 Trussell J. Contraceptive failure in the United States. Contraception 2004;70:89-96.
2 Kost K, Singh S, Vaughan B, Trussell J, Bankole A. Estimates of contraceptive failure from the 2002 national survey of family growth. Contraception 2008;77:10-21.
Cost per month Cost per year CVR Nuvaring £9.00
Patch EVRA £5.42
COC Cilest < £1 Rigdevidon < £ 1.00
Microgynon £1.00
POP Cerazette £2.95
Femulen £1.10
Injectable Depo provera £1.67
Implant IUT Implanon £6.75
TT 380 Slimline £0.98
Mirena £6.93
Yasmin £4.90
Micronor £0.59
Norgeston £0.78
NICE guideline LARC
If 7% of women switched from the pill to LARC methods (doubling current usage to 15%) the NHS could save approx. £100million each year by reducing unplanned pregnancies by 73,000
Accidental pregnancy in first year of use % LARC Trussell J. Contraceptive efficacy. In: Hatcher RA, Trussell J, Stewart R. Contraceptive Technology, ed 17. NY: Ardent Media, 1998;800-801
Department of Health :
A Framework for Sexual Health Improvement in England Teenage pregnancy rates have fallen to their lowest levels since record began ( Office for National statistics 2013) The use of LARC has increased : 28% from community contraception-service users in 2012/13 from 18% in 2003/2004 ( NHS Contraceptive services – England 2011-12, NHS Information Centre for Health and Social Care ) but Up to 50% of pregnancies are still unplanned Condom and pill remain the most popular method of contraception
Myth and Misconception IUDs are not only for women who....
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IUD/IUS can travel and reach the brain IUDs are abortifacients IUSs provide Relief for Women Suffering from Excessive Bleeding Breast cancer is a contraindication for IUD use IUD/IUS increase the risk for pelvic inflammatory disease (PID) IUD/IUS increase the risk of sexually transmitted infections (STIs) IUD/IUS increase the risk of ectopic pregnancy IUSs can’t be used as emergency contraception IUD/IUS are only for women who have completed their childbearing Nulliparity is a contraindication for IUDs o IUD /IUS use
Questions
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No No Yes No No No 6.
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No Yes No 10.
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yes or no
IUD/IUS Answers
IUS/Mirena Provides Relief for Women Suffering from Excessive Bleeding
7 In one study, only one out of 19 women diagnosed with anemia at the insertion of Mirena still had this condition after one year of use.
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IUD Provide Viable Options for Women Whose Health Conditions Limit Other Forms of Hormonal Contraceptives.
Some health conditions, including venous thromboembolism, severe dyslipidemia, liver disease, estrogen-dependent tumors, or poorly controlled hypertension prevent women from being able to use other forms of contraceptives. IUDs provide a viable option for these women.
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Just IUDs but not IUS can be used as emergency contraception
IUD problems
Perforation Expulsion Malposition Infection
IUD - Infection
IUD/IUS do not cause pelvic infection Risk higher than background only in three weeks after insertion (1:1000 with screening) Select women at low risk of STIs Take sexual history Screen for infection: chlamydia (+_ N gonorrhoea) Or consider prophylactic antibiotics If infection with IUD in situ, treat as PID, do not need to remove IUD (NB Pregnancy risk) Farley TM et al. Lancet 1992; 339: 785-88 FFPRHC Recommendations for Practice IUD 2004
IUD/IUS and Ectopic pregnancy
• • • Incidence of ectopic pregnancy 0.02 per 100 woman years. This represents an 80-90% reduction in risk compared with women not using contraception.
Between 5-50% of conceptions with the LNG IUS are ectopic.
What is new?- EVOinserter
What is different about this inserter?
The threads are now inside the inserter handle thereby eliminating the handling of threads The diameter of the insertion tube has been
reduced from 4.8mm to 4.4mm
There is now a centimetre scale on both sides The LNG-IUS cannot be reloaded into the inserter if it is released prematurely
What is new – IUS
Jaydess®
www.
fsrh
.org/pdfs/CEUProductReview
Jaydess
What is new – IUS
Jaydess®
Mirena® Jaydess® Insertion tube diameter Duration of use Dose Indications
3.80mm 3 years 13.5mg Contraception 4.40mm 5 years 52mg Contraception Idiopathic menorrhagia Endometrial protection in HRT In theory Jaydess may be easier to insert and result in less pain at insertion than Mirena but there have been no comparisons with the currently available Mirena product
What is new – IUS
Jaydess®
Women using Jaydess are less likely to experience amenorrhoea Higher failure rates and ectopic pregnancy rates have been reported in some trials of Jaydess but numbers are currently too small to confirm a significant difference Jaydess contains a silver ring (table 1) which distinguishes it from other intrauterine devices on ultrasound scan or x-ray The safety and efficacy of Jaydess have not been studied in women aged below 18 years The Summary of Product Characteristics (SPC) for Jaydess states that it is not first choice for contraception in nulliparous women as clinical experience is limited
DMPA: nothing new just a refresher of Late attenders
No additional precautions if up to 14 weeks – WHO & FRSH 12 weeks plus 5 days – Manufacturers Over 14 weeks, consider giving DMPA at same time as emergency contraception Long-term carbamazepine, phenytoin, primidone & sodium valproate associated with loss of BMD & fracture
Nexplanon
• Single semi-rigid rod 40x2mm • Releases 30-40µg etonogestrel daily • No skin incision required • Lasts 3 years • Radio-opaque (Xray, CT as well as USS, MRI)
Acceptability and user perceptions 43% of women stop using the SDI within three years; 33% because of irregular bleeding
UK Medical Eligibility Criteria (UKMEC) UKMEC Category 1 2 3 4 A condition for which there is no restriction for the use of the method A condition where the advantages of using the
method generally outweigh the theoretical or proven risks
A condition where the theoretical or proven
risks usually outweigh the advantages
A condition which represents an unacceptable health risk if the method is used
UKMEC guidance for LARC use according to age
UKMEC guidance
Depo – menarche to < 18 yrs = 2 18 to 45 yrs = 1 >45 yrs = 2 Nexplanon - menarche to >45 yrs = 1 IUD – menarche to < 20 yrs = 2 > 20 yrs = 1 IUS ( Mirena) - menarche to < 20 yrs = 2 > 20 yrs = 1
Other reversible contraception Influences decision
Combined hormonal contraception
Condoms
Acne , Hirsutism The pill gives you pimples, makes your hair oily and makes you hairy Young people may be advised that combined oral contraception (COC) use can improve acne.
Young women whose acne fails to improve with COC may wish to consider switching to a COC containing a less androgenic progestogen or one with a higher estrogen content.
Young people should be advised that the progestogen-only implant may be associated with improvement, worsening or onset of acne.
WEIGHT
“ Taking the Pill causes weight gain”
The limited data that exist suggest no clear effect on weight with COC use, and there is currently insufficient evidence to prove a clear causal association between most other hormonal contraceptives and weight gain except depot medroxyprogesterone acetate (DMPA) use may be associated with a gain of 2–3 kg in weight over 1 year
Smoking
You can not take hormones when you are a smoker
“COC can be used by women aged <35 years who smoke.
Excess mortality in heavy smokers becomes apparent from the age of 35 years, accounting for 0.7 deaths per 1000 woman years “.
“POC (progestogen-only contraception) does not appear to increase the risk of stroke or MI, and there is little or no increase in venous thromboembolism risk” Vessey M, Painter R, Yeates D. Mortality in relation to oral contraceptive use and cigarette smoking. Lancet 2003; 362: 185
– 191.
Faculty of Family Planning & Reproductive Health Care Clinical Guidance Contraception for Women Aged Over 40 Years
Cancer
The pill can cause cancer
A large UK cohort study has shown that oral contraception use is not associated with an overall increased risk of cancer, and indeed
oral contraception may reduce overall cancer risk.
Research suggests that women taking the combined contraceptive pill have a lower risk of ovarian cancer than the general population. ...The pill is also protective against endometrial cancer, but can slightly
raise the short-term risk of breast cancer and cervical cancer
BMJ. 2010;340:c927.
The evidence with regard to cancer risk and progestogen-only methods is more limited. There are no consistent associations between use of POP or injectable progestogens and breast cancer incidence. No studies were indentified in relation to use of the LNG-IUS or progestogen-only implant and risk of breast cancer in young women. As with other progestogen-only methods, any attributable risk is likely to be very small.
Hormone withdrawal symptoms
“The few studies that reported menstrual symptoms found that the extended cycle group fared better in terms of headaches, genital irritation, tiredness, bloating, and menstrual pain” 2 2.Edelman AB, Gallo MF, Jensen JT, Nichols MD, Schulz KF, Grimes DA. Continuous or extended cycle versus cyclic use of combined oral contraceptives for contraception. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD004695. DOI:10.1002/14651858.CD004695.pub2.
Drawbacks of the 21/7 regimen
1 Hormone withdrawal symptoms Lack of pituitary–ovarian suppression Unnecessary withdrawal bleeding 1.Patricia J Sulak, Continuous oral contraception: changing times, Best Practice & Research Clinical Obstetrics and Gynaecology (2007), doi:10.1016/j.bpobgyn.2007.08.004
2.Edelman AB, Gallo MF, Jensen JT, Nichols MD, Schulz KF, Grimes DA. Continuous or extended cycle versus cyclic use of combined oral contraceptives for contraception.
Cochrane Database of Systematic Reviews
2005, Issue 3. Art. No.: CD004695. DOI: 10.1002/14651858.CD004695.pub2.
Modifying the 21/7 OC regimen
Shortening the 7-day HFI 24/4 Reducing the frequency of the 7-day HFI ( tricycle) Eliminating the 7-day HFI Adding oestrogen to the 7-day HFI
Take pill every day until you are bleeding for 3 consecutive days Than stop the pill for Tailored regimens of Combined hormonal contraception
Condom myth
2 condoms are better than 1.
It's the man's responsibility to bring and wear a condom I can not use condoms because I am too big / I am allergic, etc CONDOMS PROTECT AGAINST ALL STIS condoms always break and don’t really work Condoms have small holes that allow disease, infection, and semen through.
Choices of Contraception in the different stages of reproductive life
• • Puberty to first sexual intercourse Contraception used for its non-contraceptive benefits Sex Education: promoting the possibility of having pleasurable and safe sexual experiences
Choices of Contraception in the different stages of reproductive life
Full choices IUD/IUS can be fitted if nulliparous Depo – fertility return time variable If adolescent – remember Depo and bone density Remember safe sex message
Breastfeeding
All LARC methods could be used if no contraindications Depo = UKMEC 2 if <6 weeks postpartum IUD / IUS = UKMEC 3 if 48 hours – 4/52 postpartum CHC contraindicated Lactational amenorrhoea – if exclusively breast feeding including night time feeds – 98% effective
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Choices of Contraception in the different stages of reproductive life
Perimenopause Still need for contraception HRT is not contraceptive IUS may be used as part of HRT regime – endometrial protection, licensed for 4 years use Stop Depo at age 50 yrs – risk of osteoporosis Nexplanon/IUS – use FSH to determine when to stop contraception Safer sex message – increase in incidence of STI in divorced, newly single older people
http://www.fpa.org.uk/helpandadvice/mycont raceptiontool http://www.fpa.org.uk/helpandadvice/ mycontraceptiontool
let's put birth control back on the agenda transcript ….
But one of the simplest and most transformative things we can do is to give everybody access to birth control methods
http://www.gatesfoundation.org/media-center/speeches/2012/04/melinda-gates-tedxchange-the-big-picture
Melinda Gates Contact details [email protected]
m: 07525045391