Transcript Slide 1

Contraception:
Update on the
Evidence
Objectives
 Use WHO/CDC categories for eligibility
 Counsel patients about contraceptive efficacy for
successful prevention of unintended pregnancy
 Address systems practices which can affect
contraceptive initiation and continuation rates
Nearly Half of Pregnancies in the
United States are Unintended.
Approximately 6.4 million pregnancies per year
Frost JJ, Darroch JE and Remez L, Improving contraceptive use in the United States, In Brief, New York: Guttmacher Institute, 2008,
No. 1. http://www.guttmacher.org/pubs/2008/05/09/ImprovingContraceptiveUse.pdf. July 9, 2014.
The Problems
Guttmacher 2010
One Year Failure Rates
Effectiveness
Birth Control Type
Typical-Use
Pregnancy Rate
Perfect-Use Rate
Ineffective
Chance
85%
85%
Less Effective
Condoms
14%
3%
More Effective
Pill, patch, ring
8%
1-3%
IUDs
0.8%-2%
0.8-2%
Injectible (Depo)
0.1-0.3%
0.1-0.3%
Implant/Sterilization
0.1-0.3%
0.1-0.3%
Highly Effective
Zieman M, Hatcher RA. Managing Contraception. Tiger, Georgia: Bridging the Gap Foundation, 2010.
Contraceptive Methods: US
Contraceptive Use in the United States. Guttmacher Institute. https://guttmacher.org/pubs/fb_contr_use.html. June 2014 (from 2008
data).
Yolanda
• 16 year-old high school student, c/o UTI symptoms
• Had unprotected sex 4 days ago
• Urine pregnancy test is negative.
What do you do next?
Opportunity knocks!
(1) Ask about contraceptive needs
(2) Get medical history (negative)
Hormonal Contraceptives:
What is needed before prescribing?
Medical history
REQUIRED
Pap smear
Pelvic/breast exam
STI testing
Hemoglobin
NOT REQUIRED
Blood pressure
RECOMMENDED
Stewart F, et al. Clinical breast and pelvic examination requirements for hormonal contraception: Current practice vs evidence.
JAMA. 2001;285:2232-9.
Hormonal Contraceptives:
Which Women/Teens Can’t Use
Estrogen?
Estrogen contraindications:
• Migraine with aura
• Uncontrolled hypertension
• Postpartum < 3 weeks
• History of DVT
Centers for Disease Control and Prevention. U.S. Selected Practice Recommendations for Contraceptive Use, 2013. MMWR
2013;62. http://www.cdc.gov/mmwr/pdf/rr/rr62e0614.pdf. June 14, 2013.
Antibiotics and Oral
Contraceptives?
• Only Rifampin
and Rifabutin
decrease
efficacy
Centers for Disease Control and Prevention. U.S.
Selected Practice Recommendations for
Contraceptive Use, 2013. MMWR 2013;62.
http://www.cdc.gov/mmwr/pdf/rr/rr62e0614.pdf.
June 14, 2013.
Emergency Contraception:
Levonorgestrel (Plan B)
• Decreases risk of unintended
pregnancy by 58-89%
• Does not disrupt or harm an
implanted pregnancy –
• Looses efficacy at BMI > 25
• No medical contra-indications!
Population Council. Emergency Contraception’s Method of Action Clarified. Population Briefs. 2005 May;11(2).
http://www.popcouncil.org/publications/popbriefs/pb11(2)_3.html
Glasier A, et al Contraception 2011Oct 84(4) 363-7
Zieman M, Hatcher RA. Managing Contraception. Tiger, Georgia: Bridging the Gap Foundation, 2010.
Ulipristal Acetate:
A New Emergency Contraceptive Option
• Decreases risk of unintended
pregnancy by 90%
• Maintains nearly full efficacy up
to 5 days after unprotected
intercourse
• Looses efficacy at BMI >
35
Zieman M, Hatcher RA. Managing Contraception. Tiger, Georgia: Bridging the Gap Foundation, 2010
Glasier A, et al Contraception 2011Oct 84(4) 363-7
Highest Efficacy EC:
Copper IUD
What Does She Want?
• What has she heard about
birth control?
• What are her friends using?
Impact of Choice
Pariani S, Heer D, van Arsdol M. Does choice make a difference to contraceptive use? Stud Fam Plann 1991;22(6):384-390.
Does it Matter Which Pill?
• Mostly all the same, despite marketing
• Cycle control better with 30-35 EE than 20mcg
• Extended cycle decreases days of bloating and
menstrual cramping
• No difference w acne, weight gain, adverse effects
(conflicting studies)
Szabo KA, Schaff E Oral Contraceptives, Does Formulation Matter? J Fam Prac 2013 Oct 62(10) E1-12
Yolanda is Eligible for the Pill:
When should she start?
Westhoff C et al. Quick start: novel oral contraceptive initiation method. Contraception. 2002 Sep;66(3):141-5.
Westhoff C et al. Bleeding patterns after immediate vs. conventional oral contraceptive initiation: a randomized, controlled trial.
Fertil Steril. 2003 Feb;79(2):322-9.
Advance EC Prescribing
Should Yolanda get a prescription for EC, too?
.
Zieman M, Hatcher RA. Managing Contraception. Tiger, Georgia: Bridging the Gap Foundation, 2012.
Liz
• 21-year-old healthy college student, works evenings
and weekends
•Using oral contraceptive, but forgets pills often
•Has trouble getting refills with
her schedule
Adherence with OCs:
What Women Do!
Percent of Women (%)
Number of pills missed
Potter et al. Measuring Compliance Among Oral Contraceptive Users. Fam Plann Perspect 1996; 28(4):154-158.
Estrogen/Progestin Ring or Patch
• Quick-Start same as with OCs
• CDC risk levels same as pill
(remember – pregnancy risk always
greater!)
• Theoretically better adherence due to
not daily
• Ring has hormone levels 35 days,
patch for 9 days
Lesnewski R et al Preventing gaps when switching contraceptives 2011 Am Fam Phy Mar 1;83 (5)567-70
Zieman M, Hatcher RA. Managing Contraception. Tiger, Georgia: Bridging the Gap Foundation, 2012.
How Many Refills Should We Give
to Liz? And Dispense at one time?
Resa
• 16 years old
• Doesn’t want to get pregnant until
she finishes school
• Wants contraception that she can
hide from her mom
What are her choices?
Back to the Problem
1) Increase use of highly
effective methods:
IUDs, Depo-Provera,
Implanon
2) Improve adherence
with less effective
methods
3) Reduce gaps in use
4) Catch non-users
Zieman M, Hatcher RA. Managing Contraception. Tiger, Georgia: Bridging the Gap Foundation, 2010.
Highly Effective Methods
NOT USER DEPENDENT
Effectiveness
Group
Highly
Effective
(for all users)
Family
Planning
Method
Typical-Use
Rate of
Pregnancy
Perfect-Use
Rate of
Pregnancy
Male and
female
sterilization
0.2%-0.5%
0.1%-0.5%
Implants
0.05%
0.05%
Hormone shot 3%
Intrauterine
devices
0.8%
0.05%
3%
0.3%
0.8%
Zieman M, Hatcher RA. Managing Contraception. Tiger, Georgia: Bridging the Gap Foundation, 2012.
Progestin-Only Injection
Hatcher, R et al. A Pocke
Depo Provera & Bone Density
Weighing risks and benefits:
No need to restrict
Depo Provera use
Risk “2” - benefits
outweigh risks
Centers for Disease Control and Prevention. U.S. Selected Practice Recommendations for Contraceptive Use, 2013. MMWR
2013;62. http://www.cdc.gov/mmwr/pdf/rr/rr62e0614.pdf. June 14, 2013.
Quick Start Depo
• Depo is the one method shown to prevent unintended
pregnancies with Quick Start
• If pregnant - not a teratogen
• For return depo visits –
keep in mind it works
for 16 weeks
Rickert VI et al. Depo Now: preventing unintended pregnancies among adolescents and young adults.J Adolesc Health. 2007
Jan;40(1):22-8.
Quick Start Algorithm
Quick Start Algorithm. Reproductive Health Access Project.
http://www.reproductiveaccess.org/fact_sheets/downloads/QuickstartAlgorithm.pdf. March 2013.
Quick Start Algorithm, Continued
Quick Start Algorithm. Reproductive Health Access Project.
http://www.reproductiveaccess.org/fact_sheets/downloads/QuickstartAlgorithm.pdf. March 2013. www.ReproductiveAccess.org
Amy
• 36-year-old G0P0
• Smoker (1 ppd)
WHO / CDC Medical Eligibility Criteria
for Contraceptive Use
• Developed by WHO to define risk of birth control use with
common medical conditions
• Adopted by CDC for US in 2010
• Risk of unintended pregnancy with given condition weighed
against risk of method
Centers for Disease Control and Prevention. U.S. Selected Practice Recommendations for Contraceptive Use, 2013. MMWR
2013;62. http://www.cdc.gov/mmwr/pdf/rr/rr62e0614.pdf. June 14, 2013.
WHO / CDC Medical Eligibility Criteria
for Contraceptive Use
• Full reports condensed into summary table:
www.reproductiveaccess.org
• Risk levels 1-4:
Medical Eligibility for Initiating Contraception: Absolute and Relative Contraindications. The Reproductive Health Access Project.
http://www.reproductiveaccess.org/contraception/downloads/chart.pdf. March 2013.
Smoking and Contraceptive Use
Medical Eligibility for Initiating Contraception: Absolute and Relative Contraindications. The Reproductive Health Access Project.
http://www.reproductiveaccess.org/contraception/downloads/chart.pdf. March 2013.
Intrauterine Devices
Hubacher D et al. A Pocket Guide to Managing Contraception, 2012.
IUD Myths Debunked
• IUDs can be used safely by nulligravid
women and teens!
• IUDs DO NOT raise risk of PID.
• IUDs DO NOT raise risk of infertility.
• IUDs DO NOT raise risk of ectopic
pregnancy.
ACOG Committee Opinion 539 Adolescents and long acting reversible contraception Obstet Gynecol 2012 Oct 120(4) 983-8
IUD Myths Debunked
• OK to insert IUD at any point in the
menstrual cycle
• OK to insert immediately post-partum
or following surgical abortion
• OK to test for STIs at time of insertion
(& treat infections with IUD in place)
US Selected Practice Recommendations for Contraceptive Use 2013 MMWR June 21;62 (1-60).
How Long for Each IUD?
• Levonorgestrel IUD – 7 years
• Copper IUD – 12 Years
Wu JP, Pickle S Extended Use of the Intrauterine Device Contraception 2014 June 89(6) 495-503
Progestin Implant
• Highly effective and rapidly reversible
• Not user-dependent
• Contain no estrogen
• Can be used during lactation
• Active hormone: etonorgestrel (68 mg)
Hubacher D et al. A Pocket Guide to Managing Contraception, 2012
Counseling to Enhance Adherence
• LISTEN to her ideas about the best
method.
• EXPLORE lifestyle issues that
impact adherence.
• ENCOURAGE her to call you with
problems/concerns.
Inconsistent Pill Use:
Linked to Low Level of Satisfaction with
Provider &
Low Continuity of Care
Percent of pill users who missed one or more pills during the
past three months
Landry, David. Public and private providers involvement in improving their patients contraceptive use Contraception 2008 Jul 78 (1)
42-51.
Office Barriers to Adherence
Feeling Unable to Reach a Provider With
Questions is Linked to Contraceptive Non-Use
% of at-risk women experiencing contraceptive non-use in the past year
Landry, David. Public and private providers involvement in improving their patients contraceptive use Contraception 2008 Jul 78 (1)
42-51.
Electronic Health Records
Break Down Office Barriers for
Same Day Insertions of IUD
Practice Recommendations
• DE-LINK pap smears from
birth control prescriptions.
• ROUTINELY prescribe 1-year
supply with 3 packs at a time.
• Ask about contraceptive needs
at all types of visits.
• Emphasize high-efficacy
methods, but honor women’s
choice whenever possible.
Practice Recommendations 2
•
•
•
•
•
Use evidence-based guidelines (like CDC MEC)
Remember BMI when giving emergency contraception
Encourage use of LARC (non user dependent methods!)
Use QuickStart
Allow for extended use where there is evidence:
– Depo Provera can be used indefinitely
– Mirena for up to 7 years
– Paragard for up to 12 years
• Easy access to refills: refill without an office appointment
if BP normal
Last but Not Least:
Don’t Forget About
Vasectomy!
Questions?
References
• Hatcher et al, Contraceptive Technology 2007
• Centers for Disease Control and Prevention (CDC). U.S. Medical
Eligibility Criteria for Contraceptive Use, 2010. MMWR Recom Rep. 2010
Jun 18;59(RR-4):1-86.
• Managing Contraception – book online @
www.managingcontraception.org
• CDC/WHO Medical Eligibility Criteria for Contraceptive Use 2010
www.who.int/reproductive-health
• Association of Reproductive Health Professionals www.arhp.org
• Alan Guttmacher Institute www.agi-usa.org
• Planned Parenthood www.plannedparenthood.org
• The Cochrane Collaboration www.cochrane.org
• www.Not-2-Late.com
• Reproductive Health Access Project www.reproductiveaccess.org