Transcript Update on Contraception

ADOLESCENT
CONTRACEPTIVE
CARE
Eliza Buyers, MD, FACOG
Kaiser Permanente
Department of OB/GYN
[email protected]
Office: 303-360-1576
COAPPP’s Raising the Bar Conference
October 8&9, 2009
Disclosures

Eliza Buyers has no significant financial interests or
other relationships with industry relative to the
topics that will be discussed.
Learning objectives




Describe some of the common barriers that the
adolescent population faces in obtaining
reproductive health care and contraception.
Discuss common misperceptions about adolescent
contraceptive care.
Describe the advantages, expected side effects,
and contraindications of various methods.
Describe why long-acting methods are optimal for
many adolescent patients.
Adolescent Contraceptive Care
OVERVIEW
Background on adolescent pregnancy and the
barriers to contraceptive care
 Specific methods and overcoming barriers to care

 Emergency
 Quick
Contraception (EC)
Start
 Extended/Continuous use OCPs/ring/patch
 Update on Depo-Provera
 IUDs (Levonorgestrel IUD)
 Single-rod contraceptive implant (Implanon)
Adolescent Pregnancy
OVERVIEW
Teen pregnancy outcomes
- Almost 1 million pregnancies.
- 82% unplanned
- 3 in10 girls pregnant by age 20
- 1 in 3 end in abortion
Miscarriage
Abortion
14%
29%
57%
Birth
Guttmacher Institute, Facts on American Teens’ Sexual
and Reproductive Health, Sept, 2006
Adolescent Pregnancy OVERVIEW
Talking about Reproductive Health
OP-ED COLUMNIST
Let’s Talk About Sex
By CHARLES M. BLOW
Published: September 6, 2008
September 6, 2008
Charles M. Blow
Providers’ Perspectives: Perceived
Barriers to Contraceptive Use in Youth
and Young Adults
1. Lack of provider training.
2. Outdated protocols and lack of continuing
education.
3. Restrictive reimbursement procedures.
4. Lack of social marketing that promotes
contraception.
5. Inadequate reproductive health services for men.
www.thenationalcampaign.org/resources/pdf/BarrierstoContraception_FINAL.pdf
Barriers to Care: Lack of Confidentiality
Talking about Reproductive Health



MAJOR OBSTACLE: CONFIDENTIALITY

Most teens want care but NOT if their parents know.

If parents were notified: nearly 50% would not seek
care but 99% would still have sex.
Assure confidentiality at the start of your visit.

Colorado law: minors have access to confidential
services for contraception and STD testing.

Unless suicidal, homicidal or abuse involved.
Explain your office procedures to maintain this right.

Beware of billing and coding, private insurance.
Barriers to Care: How To Ask About Sex
Talking about Reproductive Health


First, assure confidentiality
Open-ended and open-minded

“Are you dating anyone or hooking up?” (how old?)

“Are your friends dating people?”

“Do you (or your friends) have any questions about
sex?”

“Do you have sex with girls or boys or both?”

“I am so happy that you came in today. It is so
important that you take responsibility for your own
health and this includes your reproductive health.”
Barriers to Care: Magical Thinking
Talking about Reproductive Health


Assure confidentiality, Open-ended, open-minded
Address magical thinking: “I can’t get pregnant”
 A sexually active teen who does not use contraception
has a 90% chance of becoming pregnant in a year.
 1 in 3 girls pregnant at least once before age 20
 A single act of sexual intercourse: 8% chance of
pregnancy.
 Teens with a negative pregnancy test: 58% pregnant
at least once within next 18 months.
 Health care provider (YOU!) may be the ONLY source
of accurate information.
Barriers to Care: Accurate Information
Talking about Reproductive Health



Parents beliefs about condoms and oral contraceptives
What parents think about condoms:
 47% effective in preventing HIV/STDs (fact: 98-100% )
 40% effective to prevent pregnancy (fact: 97% perfect use)
What parents think about oral contraceptives:
 52% “highly effective” to prevent pregnancy (fact: 9499%)
 39%
thought almost all teens can use pills safely (fact: all
healthy teens can!)
 39%
thought teens could use pills as consistently as other
age groups (fact: just as well!)
Adolescent Pregnancy OVERVIEW
Talking about Reproductive Health
www.stayteen.org (National Campaign)
www.sexetc.org (Answer, from Rutgers Univ.)
www.teenwire.com (Planned Parenthood)
www.scarleteen.com (private funding)
Adolescent Pregnancy
OVERVIEW
STDs
19 million cases of STDs each year: One-half in
persons ages 15-24
 1 in 10 sexually active female adolescents
have chlamydia
 Chlamydia screening rates unacceptably LOW

 15-25
year olds: only 6.8% routine visit, 16%
preventive visit, 23% at pap smear

50% of new HIV infections in the US are among
persons less than age 25
STD DIAGNOSIS = TEACHABLE MOMENT
Comparing effectiveness of methods
Most effective
Generally
2 or fewer
pregnancies
per 100
women in
one year
How to make your
method most effective
Implants
Female
Sterilization
Vasectomy
Injectables
Pill
s
IUD
One-time procedures. Nothing to
do or remember.
Need repeat injections
every 1 to 3 months
Must take a pill each day
Must follow LAM instructions
LAM
About 15
pregnancies
per 100
women in
one year
Male
Condoms
Diaphragm
Fertility
Awareness-Based
Methods
effective
Must use every time
you have sex
Must use every time you have
sex;
requires partner’s cooperation.
Female
Condom
About 30
pregnancies
per 100
women in one
year Least
Must use every time you have sex;
requires partner’s cooperation.
Spermicides
Must abstain or use condoms on fertile
days; requires partner’s cooperation.
Must use every time
you have sex
Methods of Contraception
and Overcoming Barriers
Emergency Contraception
 Quick Start
 Extended/Continuous use methods
 Update on Depo-Provera
 IUDs in adolescents
 Single rod implant

Emergency Contraception (EC)
Over-the-counter for women 18 years and
older.
 PRESCRIPTION REQUIRED for women younger
than 18 years.
 The provision of EC does not alter adolescent
sexual or contraceptive behavior.
 If EC is available, it is more likely to be used in
the event of unprotected intercourse and it is
more likely to be used earlier.

Emergency Contraception (EC)

Plan B® (progesterone-only EC)
2 pills containing 0.75 levonorgestrel
 Take as one dose or 12-24 hours apart





Primary mechanism of action is delay of ovulation
Should use as soon after unprotected intercourse as
possible to maximize efficacy (reduced chance of
pregnancy by 60-94%)
Offer up to 120 hours (5 days) after unprotected
intercourse
If taken within 3 days: reduces chance of pregnancy
from 8% to 1%
Emergency Contraception (EC)
No deaths or serious complications have been
linked to use
 No drug interactions
 WHO: no medical conditions where the risks of
EC outweigh the benefits of use

 MAY
USE if breastfeeding, history of ectopic, liver
disease, cardiovascular disease, migraines, history
of DVT…
Emergency Contraception (EC)
No clinical exam or testing is required before
EC is provided
 Anti-emetics are not necessary for
progesterone-only EC (Plan B)
 EC may be used repeatedly, even within the
same menstrual cycle
 Offer an EC prescription with every pregnancy
test, every STD evaluation…

Oral Contraceptive Pills (OCPs)
Most popular method of hormonal contraception.
 The only method that many providers and
patients consider.
Overcoming Barriers:
 “Quick start” over conventional start.
 Highlight non-contraceptive benefits.
 Offer extended and continuous use.
 Think about access/refill issues.
 All women can be “excellent” OCP users.

Contraceptive Use at Last Sex Among Sexually Active,
Unmarried Women, NSFG 2002
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
86%
83% 82%
76%
Teen Girls
20-24 Years
25-29 Years
30-39 Years
55%
43%
39%
34%
32%
30%
21%
16%
Any
Method
Pill
20%
12%
7%
3%
Condom
Dual
Methods
Oral Contraceptive Pills (OCPs)
Barrier: Getting Started

Why do 24% of adolescents never take the
first pill after receiving the pack?
 Confusion about starting instructions.
 Waning motivation.
 Become pregnant while waiting to start.
Oral Contraceptive Pills (OCPs)
Quick Start (also for ring, patch, Depo)
If negative pregnancy test: swallow first pill
under direct observation during visit (regardless
of menstrual day).
 Give Emergency Contraception if indicated (and
usually Quick Start the next day).
 Use back-up with condoms for 1 week.
 Repeat pregnancy test if no withdrawal bleed,
or follow-up pregnancy test in 2-4 weeks.

Quick Start
Don’t fear rejection!



Women prefer it. (81%- 97%)
Higher initiation/continuance rates.
No bleeding differences based on day of initiation
Westhoff. Bleeding Patterns, OC
Compared With Vaginal Ring. Obstet
Gynecol 2005.
Quick Start
Unintended pregnancy (not “missed” pregnancy) is the issue.

Urine pregnancy tests are very good:
 Implantation
produces HCG (6-12 days after ovulation)
 HCG detected at 20-50 mIU/mL.
 No need for serum HCG


Very low pregnancy rates in first cycle with quick start
even if recent unprotected intercourse (3% or lower).
Consider the impact on initiation rate:
 100%
with observed quick start.
 About 75% if pills dispensed (even lower if RX only)

Hormonal contraceptives are not teratogenic (or
abortifacients) even if pregnancy does occur.
Oral Contraceptive Pills (OCPs)
Number of OC Packs Dispensed




Foster et al, 2006
82,000 women who received birth control pills.
Women were given a complete one, three, or 13month supply of OCPs.
Women who received 13 cycles were 28% more
likely to continue using oral contraceptives after 15
months than women who obtained a 3-month supply.
13 cycle group: fewer gaps in OCP coverage than
women prescribed shorter cycles
 Only
4% had gaps compared to 16% (1 month) and
19% (3-month group)
Dispel Myths!








“It isn’t that safe.”
“The pill makes you fat.”
“The pill makes it harder to get pregnant later on.”
“It’s good to take a break from the pill.”
“It’s not safe because breast cancer runs in my
family.”
“She’s too young to be on the pill.”
“It doesn’t really work.”
“I’ll need to use condoms anyway because I take
antibiotics a lot.”
Oral Contraceptive Pills (OCPs)
Which Pill for Adolescents?
No pill is inherently “better” than any other pill
 All U.S. pills contain the same type of estrogen
 EE = ethinyl estradiol
 Differences are in type of progestin
 Typical “low-dose” pill: 30-35 mcg EE
 “ultra low-dose” pill: 20 mcg EE
 NO DIFFERENCE IN EFFICACY 20ug vs. 30ug

Oral Contraception Pills (OCPs)
Consider Cost

LEVORA
PORTIA



SPRINTEC



JUNEL
MICROGESTIN 1/20


Intermediate progestational and low estrogenic activity
Generic substitute for Seasonale
$30/pack
Low progestational/androgenic and intermediate
estrogenic (generic Ortho-Cyclen)
Good choice for acne, PCOS
TARGET: $9/pack; or $24 for 3 packs
High progestational and low estrogenic activity
(amenorrhea is common)- ultra-low 20 mcg EE
Good choice for concerns about nausea, breast pain
$27/pack
Oral Contraceptive Pills (OCPs)
Extended and Continuous Products

NOT a new therapy!
 Patients
have been prescribed OCPs “as directed”
for decades

EXTENDED
 Take
active pills for longer than the traditional 21
days

CONTINUOUS


Active pill every day (no placebo breaks)
FDA Approved
 Seasonale,®
Seasonique,™ Lybrel™
Oral Contraceptives: Extended Use
Counseling on Safety

Standard/traditional pill is 21 days active pills and 7
days placebo (21/7 regimen)
 No
medical rationale for 21/7
 Monthly withdrawal bleeding is designed to make the pill
cycle feel “natural”
 But,
there is no ovulation on the pill
 And, no menstrual lining “build up”
Oral Contraceptives: Extended Use
Perceived Benefits of Menstruation

Myths about monthly menstruation
 Necessary
for “cleansing the system”
 A “natural” state
 A symbol of femininity, fertility, and youth
 A sign a woman is not pregnant

Address safety concerns of the patient (her
parents or partner) before prescribing
extended OCPs.
Oral Contraceptives: Extended Use
Who might benefit from reduced frequency of
menstruation?

Women with menstrual-related disorders
 dysmenorrhea,
menorrhagia, PMS, menstrual
migraines, cyclic breast pain…
Athletes
 Women in the military
 Developmentally delayed women
 Any woman who chooses to bleed less frequently

Oral Contraceptives (any type, patch, ring)
Review: Non-contraceptive Indications for Use

Dysmenorrhea
Menorrhagia (anemia)
Acne
Pelvic pain (unexplained and endometriosis-related)
Polycystic Ovarian Syndrome
PMS
Bone loss
Benign breast disease

Prevents cancer of the uterus and ovary







Oral Contraceptives: Extended Use
MORE STUDIES NEEDED

Continuous administration of pills
may improve OCP success
 Especially

in “poor” pill takers
Continuous administration of pills
may help prevent ovarian follicular
development (cysts)
.
Oral Contraceptives: Extended Use
Patient Counseling

Unpredictable breakthrough bleeding (BTB)
similar to conventional OCPs
 Will
improve with each cycle of use
 Take the pill the same time every day to prevent
BTB
 Never hesitate to do a pregnancy test
 Tailor the extended regimen to your bleeding

On average >70% of patients satisfied with
extended use of OCPs
Oral Contraceptives: Extended/Continuous
FDA approved: Seasonale, Seasonique, Lybrel
 Can use ANY combined OCP

 Sprintec,
Necon, Zovia…
 Can even use a triphasic but not sure why?

In one study of continuous users, norethindrone
acetate OCs (Microgestin) were associated with
less bleeding than levonorgestrel OCs (Levora)
Edelman et al. Obstet Gynecol 2006.
Medical Options for Reducing Menstruation
Extended-use OCPs

 Contraceptive vaginal ring: NuvaRing
 Trans-dermal contraceptive patch: Ortho Evra
 Injectable progestin-only contraception (DMPA)
 Progestin-releasing intrauterine device (Mirena®)




Oral progestins (norethindrone acetate, Aygestin®)
Danazol (Danocrine®)
Gonadotropin-releasing hormone analogues (e.g., Leuprolide
Acetate, Lupron Depot®)
Kaunitz.. Contraception 2000.
Ring and Patch
for Continuous/Extended Use


The contraceptive ring can be left in for 4 weeks
and replaced immediately with another ring.
The patch can be used for more than 3 consecutive
weeks. (“apply new patch each week x 9 weeks…”)
Oral Contraception: Extended Use
Conclusions
Many women would prefer to menstruate less if
they knew it was safe.
 Any OCP can be taken in an extended or
continuous fashion (or use the ring/patch).
 Expect breakthrough bleeding which will
improve over time.

Depo-Provera: Update


Still the best option for many of our patients.
 EFFICACIOUS
 (Almost) Forgettable
 Non-contraceptive benefits (1 yr: 50% amenorrhea)
ACOG: “Concerns regarding…BMD should neither
prevent practitioners from prescribing DMPA nor limit its
use to 2 consecutive years.”
 No role for DEXA scans
 Partial or full recovery (like pregnancy, breastfeeding)
 No data showing increase fracture risk
Depo and Weight Gain
Weight gain not explained only by Depo and
different for each woman. (Westhoff, Contraception, 2003)
 Black and/or obese women, postpartum
adolescents may be at increased risk.
 According to package insert, averages:

 5.4

lbs in 1st year; 13.8 lbs after 4 yrs
“Early” gainers (5% of body weight at 6 mo) will
continue to gain at a higher rate (Le, 2009)
 Risk
factors for early weight gain:
 BMI
< 30, parity≥1, self-reported increased appetite
Bleeding with progestin-only methods
How to treat it?







REASSURANCE and SUPPORT
Estrogen alone
OCPs
NSAIDs
Doxycycline (for Implanon)
Tranexamic acid
Antiprogestins (mifepristone)
IUD and Adolescents
Recommendations and benefits of use


World Health Organization (WHO)
American College of Obstetricians and
Gynecologists (ACOG)
IUDs and Adolescents
Why is IUD use is limited in the U.S.?
COMMON MISPERCEPTIONS
“IUDs increase PID and STDs”
 “They cause infertility”
 “IUDs can’t be used in nulligravids”
 “IUDs can’t be used in a woman with a previous
ectopic pregnancy”

IUDs and Adolescents
Debunk the myths



The IUD does not increase an adolescent’s risk
of PID and STDs.
Past experience with the Dalkon Shield has
perpetuated this myth.
Studies that showed a causal relationship
between IUDs and PID were fraught with
methodological errors.
IUDs and Adolescents
Debunk the myths
WHAT IS TRUE: The risk of PID is increased at the
time of insertion.

Within the first 20 days of use
 Risk
of PID 9.7 per 1,000 women-years in users
 Risk of PID 1.4 per 1,000 women-years in nonusers
IUDs and Adolescents
Debunk the myths


IUD is not related to infertility
Chlamydia is related to infertility
Odds Ratio
10
1
0.1
Hubacher D, et al. NEJM. 2001.
Tubal infertility by previous
copper T IUD use and
presence of chlamydia
antibodies, nulligravid women
Worldwide Use of IUDs
18
15
8
Asia
Europe
5
Africa
Latin
America
& Caribbean
2
1
Oceania
North
America
% Use for Married Women of Reproductive Age
Population Reference Bureau. 2002.; Mosher WD, et al. 2004.
What if you could design the perfect birth
control?
No maintenance required
 Highly effective
 Decreases menstrual flow
 Can treat heavy bleeding and bad cramps
 Reversible
 Immediate return to fertility

Use of IUDs by Female Ob/Gyns vs. All Women
in the United States
% Using IUDs
18
0.7
Female Ob/Gyn
Physicians
Population Reference Bureau. 2002.
The Gallup Organization. 2004.
Forrest JD. Obstet Gynecol Surv. 1996.
General
Population
Levonorgestrel IUD
(Mirena)
T-shaped piece of plastic that releases small
amounts of levonorgestrel each day
 Primary mechanisms: inhibits sperm movement,
progestin thins the endometrial lining, thickens
cervical mucus
 Typically does not prevent ovulation (low systemic
levels of progesterone )
 Approved for 5 years of use: remove any time,
immediate return to fertility

Copper T IUD (ParaGard)
Primary mechanism is
prevention of fertilization
 Reduce motility and viability
of sperm
 Approved for 10 years of use
but can be removed any time

Alvarez F, et al. Fertil Steril. 1988; Segal SJ, et al. Fertil Steril. 1985;
ACOG. Statement on Contraceptive Methods. 1998.
CANDIDATES FOR INTRAUTERINE DEVICE USE
WHO: Medical eligibility criteria for contraceptive use
Multiparous and nulliparous women at low risk
for sexually transmitted diseases
 Women who desire long-term reversible
contraception
 Women with the following medical conditions,
for which an intrauterine device may be an
optimal method:

Diabetes
 Thromoboembolism (Levonorgestrel)
 Menorrhagia/dysmenorrhea (Levonorgestrel)
 Breastfeeding
 Breast cancer (Copper T)
 Liver Disease (Copper T)

CONTRAINDICATIONS TO INTRAUTERINE DEVICE USE
WHO: Medical eligibility criteria for contraceptive use









Pregnancy
Pelvic inflammatory Disease (current or within the last
3 months)
Sexually transmitted disease (current)
Puerperal or post-abortion sepsis (current or within
last 3 months)
Undiagnosed abnormal vaginal bleeding
Malignancy of the genital tract
Known uterine abnormalities or fibroids distorting the
cavity in a way incompatible with IUD insertion
Allergy to any component of the IUD (Copper T)
Wilson’s Disease (Copper T)
IUDs and Adolescents
Topics for patient counseling
Effectiveness
 Duration of use
 goal: at least 3 years
 Bleeding changes
 Insertion and removal procedures

 Do
GC/CT now or with insertion
Side effects and possible complications
 Use of condoms with new partners

IUDs and Adolescents
Non-contraceptive benefits of the Levonorgestrel IUD
Good evidence
 Heavy bleeding
 Dysmenorrhea and pain
Some evidence
 Endometriosis
 Fibroids
 Adenomyosis
 Endometrial hyperplasia or cancer
Varma R, et al. Eur J Obstet Gynecol Reprod Biol. 2006.
Gupta B, et al. Int J Gynecol Obstet. 2006.
IUDs and Adolescents
Managing side-effects
Amenorrhea/hypomenorrhea with
Levonorgestrel IUD (Mirena) is expected
 Most common side effects: pain and abnormal
bleeding
 Rule out perforation, infection, pregnancy
 Treat with NSAIDS and reassurance

IUD Summary
Two options available in United States
 Levonorgestrel IUD (Mirena) widely used for its
non-contraceptive effects
 IUD efficacy equivalent to sterilization
 Can be inserted in nulligravid women including
adolescents

Single-rod contraceptive implant







One 4cm x 2mm rod
Contains etonogestrel (progestin) and no estrogen
Suppresses ovulation and thickens cervical mucus
Highly effective for 3 years
Not user dependent and only 1 visit
Very discreet and rapidly reversible
Can be used during lactation
Reinprayoon D, et al. Contraception. 2000.
Diaz S. Contraception. 2000.
Single-rod contraceptive implant
Contraindications
Known or suspected pregnancy
 Current or past history of thrombosis or
thromboembolic disorders (CLASS LABELING)
 Hepatic tumor or active liver disease
 Undiagnosed abnormal genital bleeding
 Known or suspected carcinoma of the breast or
history of breast cancer
 Hypersensitivity to the components of the
Implanon Physician Insert, 2006.
implant
World Health Organization. 2004.

Single-rod contraceptive implant
Insertion
• Insertion is VERY WELL
tolerated
• Supine position
• Nondominant arm, flexed
and externally rotated
• Subdermal groove
• Hold applicator up (vertical)
before insertion
Single-rod contraceptive implant
Efficacy
Year
Cycles
Pregnancy
1
10,867
0
2
8585
0
3
3492
0
6 pregnancies occurred shortly after removal
Implanon Physician Insert, 2006
Single-rod contraceptive implant
Patient counseling

Irregularly irregular bleeding
 80%
of users report decrease in dysmenorrhea
 Amenorrhea is common
Acne may improve
 Minor to no weight change
 No reduction in bone mineral density
 No increased risk of DVT
 Little pain at insertion site
 Cost: about $700 if no coverage

Single-rod Contraceptive Implant
Patient selection and conclusions
Women who desire
 Long-term contraception
 High effectiveness
 Rapid reversibility
 Estrogen-free contraception
Presenter’s note: efficacy and convenience of use is
more important than cycle control!
Final Messages…





Forgettable methods are
most effective.
You are the reality check.
Motivate women and their
partners.
Recognize and reduce
barriers.
Anticipate problems.
CASE PRESENTATIONS
Adolescent Contraceptive Care
Case #1: Amber

Amber is a 14 year-old healthy female seeing you for a
physical exam. When you ask about sexual activity she
reports that she has intercourse with her 16 year-old
boyfriend. Sometimes they use condoms and sometimes he
withdraws. You notice that she has moderate cystic acne.
 What are her options for birth control?
 Her LMP was 14 days ago and she had unprotected sex
last night - what now?
 What is the most likely side effect she will have on her
new method and how will you treat it?
Case #1: Amber
Options for all healthy teens
•
•
•
Abstinence
No method
Condoms
•
•
•
•
•
•
•
Spermicides
Withdrawal
Sponge
OCPs
Depo-Provera
Implanon
IUD
0/100
85/100
15/100 (2% perfect use)
30/100
30/100
16 (nullip)-32(parous)/100
8/100 (.3% perfect use)
3/100 (.3% perfect use)
.05/100
.2/100
(unintended pregnancy in1 year of typical use)
Case #1: Amber

Are there any non-contraceptive conditions to
treat?
 OCPs to treat acne
? Sprintec (35mcg EE/ norgestimate)
 Will take 3 months for full effect on acne
lesions
6 months for full effect on hirsutism
Case #1: Amber

IC last night was unprotected
 Prescribe
Emergency Contraception (EC) to
use today
 Start OCPs tomorrow
no EC, start pills today and observe 1st pill
 Use back-up (condoms) for 1 week
 If
 If
no period during placebo pills, check
pregnancy test
 Or, return in 2 weeks; check pregnancy test
and satisfaction with method.
Case #2: Maria

Your receive a telephone call from Maria’s mom. Can
Maria have an excuse for school today? Maria has
horrible cramps and can’t get out of bed. She failed
ibuprofen and needed to take Vicodin (which you
prescribed 2 months ago after she left a soccer
tournament with severe cramping). Reviewing Maria’s
chart, you see there is a letter written every other
month for Maria to miss school because of her
dysmenorrhea.
 Does Maria need any tests?
 What are Maria’s options to treat her
dysmenorrhea?
Case #2: Maria

Primary dysmenorrhea
 If
history consistent- no test or pelvic exam
needed

Options:
 Pain
meds (NSAIDs first-line, narcotics if
severe)
 Heating pad
 OCPs- 21/7, extended, continuous
Case #2: Maria
OCPs - which pill?

Are there any non-contraceptive conditions to treat?
(besides dysmenorrhea)
 May also have hypermenorrhea? PMS? Breast pain
before periods?
 Does having periods interfere with soccer
tournaments?
 One option: Seasonale (generic: LEVORA/LEVLEN)
 Low estrogenic pill
 Extended use to minimize bleeding
 Continuous pills always an option
Oral Contraceptives: Extended Use
Frequent menstruation is a relatively new biologic state
Average # Lifetime
Menstrual Cycles
500
450
400
300
200
160
100
0
Hunter-Gatherer
Women
Contemporary
Women
Eaton et al. Q Rev Biol 1994.
Case #3: Tina

Tina is 17 years old. She is in your office today because
she has a cold. You review her current meds and see she
is using OCPs for birth control. She sometimes forgets pills
and she is worried about getting pregnant again. She
used Depo-Provera before but gained 10 pounds. Her
first pregnancy resulted in early miscarriage and she had
an abortion 6 months ago. She has been dating her
boyfriend for 1 year and she has never had an STD.
 What are Tina’s options for birth control?
 What is the most effective method available to her?
 What if she ends up getting an STD with her new
method?
Case #3: Tina
Options for all healthy teens
•
•
•
Abstinence
No method
Condoms
•
•
•
•
•
•
•
Spermicides
Withdrawal
Sponge
OCPs
Depo-Provera
Implanon
IUD
0/100
85/100
15/100 (2% perfect use)
30/100
30/100
16 (nullip)-32(parous)/100
8/100 (.3% perfect use)
3/100 (.3% perfect use)
.05/100
.2/100
(unintended pregnancy in1 year of typical use)
Case #3: Tina
Which method?



“Pelvic exams are no big deal”
“I have a friend with an IUD and she loves it”
Thinking IUD?
 Consider patient preferences, screen for STDs
 Mirena (LNG IUD) = 1st 3-6 months spotting
then 50% amenorrhea in 1 yr
 Paraguard (Copper T) = no hormones; more
bleeding/cramps in 1st year
Case #3: Tina
Management of STDs with IUD
If STD diagnosed:
 IUD removal not necessary.
 Treat infection.
 Counsel patient about prevention of STD
transmission.
 Routine GC/CT screening can be done at the
same time as IUD insertion.
Case #3: Tina
Management of PID
If PID diagnosed:
 Consultation with an OB/GYN if possible.
 IUD removal is not necessary.
 Treat infection.
 Recommendations to remove IUD are not
evidence-based.
Grimes D. Lancet. 2000.
Case #3: Tina
Management of missing threads

Probe for threads in cervical canal
 try
an endocervical brush used for paps
Rule out pregnancy
 Prescribe back-up contraceptive method
 Transvaginal ultrasound to locate IUD

Case #3: Tina
Pregnancy with IUD in situ


Determine site of pregnancy (intrauterine
or ectopic).
 IUD use decreases the overall risk of having an
ectopic pregnancy, but if a pregnancy does occur,
it is more likely to be an ectopic.
Positive pregnancy test: remove IUD if threads
available.
UK Family Planning Research Network. Br J Fam Plann. 1989.;
Foreman H, et al. Obstet Gynecol. 1981.
Atrash HK, et al. 1994.
Case #4: Katie

Your nurse is waiting at your door to ask you about
Katie, a healthy 16 year-old patient. She is 2 weeks
late for her Depo-Provera shot. Katie says she is
usually late for everything, and has been late for her
Depo before. She has been on this method for almost
2 years and is happy with it overall because she could
never remember to take pills. She says she drinks 3
glasses of milk every day and she is a cheerleader.
 Can Katie get her Depo today?
 Are there any other BC options she should consider?
Case #4: Katie


Can you give the Depo?
 Get sexual history in last 2 weeks
 Pregnancy test
 Weigh benefits vs. risks
 Depo is not a teratogen
 Can give EC too
Can she stay on Depo for more than 2 years?
 Risks and benefits
 ACOG says YES if best option (Sept 2008 Opinion)
Bone Mineral Density and Single-rod Implant
Unlike Depo-Provera, implants are not
associated with a decrease in BMD
 Changes in bone mineral density similar in study
of 44 women with single-rod implant and 29
with non-medicated IUD
 Lumbar spine BMD improved with single-rod

Beerthuizen R, et al. Hum Reprod. 2000.
Case #4: Katie

Most effective methods = least user
dependent methods
 Single-rod
implant (Implanon)
 IUDs

Implanon counseling
1
visit for insertion
 3 years of very effective contraception
 Accept potential for amenorrhea and irregular
bleeding over the entire 3 years
THANK YOU
Eliza Buyers, MD, FACOG
Kaiser Permanente
Department of OB/GYN
[email protected]
Office: 303-360-1576