Contraception Lecture PDF

Reversible Contraception Jill Brown, MD MPH MHS FACOG CAPT (R) USPHS Department of Gynecologic Surgery and Obstetrics Uniformed Services University 1  Describe the mechanism of action of contraceptive methods...

Reversible Contraception Jill Brown, MD MPH MHS FACOG CAPT (R) USPHS Department of Gynecologic Surgery and Obstetrics Uniformed Services University 1  Describe the mechanism of action of contraceptive methods Discuss effectiveness, risks, and benefits of reversible contraceptive methods Objectives Describe barriers to initiation and maintenance of different contraceptive methods Familiarize with approach to non- directive counseling 2 3 Hormonal contraception mechanisms 4 5  Start at any time “reasonably certain” patient is not pregnant < 7 D from normal LMP No intercourse since start of LMP Correctly/consistently using reliable method of contraception (includes condoms) < 7 D after spontaneous or induced abortion Initiation Within 4 weeks postpartum > 85% feeds breastfeeds, amenorrheic, and < 6 months postpartum CHCs, POPs, implant – if > 5 days since LMP, use backup x 7D Depo, hormonal IUD – if > 7 days since LMP, use backup x 7D Copper IUD – no backup needed 6  Contraindications Distorted uterine cavity Active pelvic infection Known or suspected pregnancy LARCs - Unexplained vaginal bleeding IUDs Breast cancer (hormonal IUD) Wilson’s disease or copper allergy (copper IUD) 7 LARCs – Copper IUD Non-hormonal Mechanism of action: primarily prevent sperm from fertilizing the egg; foreign body effect of plastic frame and copper are toxic to sperm 99% effective Lasts 10-12 years Medical visit/procedure for insertion and removal Heavier bleeding and cramping common first 3-6 months; decreases with continued use Can offer short course of NSAIDs or tranexamic acid 8  Progestin only; mainly local effect on uterus Mechanism of action: primarily prevent fertilization - foreign body effect from LARCs – plastic frame and hormonal effect -> thicken cervical mucus, suppress Hormonal endometrium IUDs 99% effective (levonorgest Medical visit/procedure for insertion and removal rel) Lighter, shorter periods, or amenorrhea Irregular spotting common first 3-6 months 9 Hormonal IUDs Type FDA Total Initial End of use Insertion Amenorrhe approval progesti progestin/d progestin/d device a rate 1 n ay release ay release diameter year Skyla 3 years 13.5mg 14mcg 5mcg 3.8mm 6-12% Kyleen 5 years 19.5mg 17.5mcg 7.4mcg 3.8mm 12-20% a Liletta 8 years 52mg 20mcg 8.6mcg 4.4mm 20-40% Mirena 8 years 52mg 20mcg 10mcg 4.4mm 20-40% 10  Screen for GC/CT before or at placement if screening not current or risk factors Do not delay insertion for results Can treat if comes back positive Development of Pelvic Inflammatory IUD Disease (PID) consideratio Treat PID and leave IUD in place ns Consider IUD removal if not improving Pregnancy Ectopic – normally positioned IUD can be left in place Intrauterine – IUD should be removed 11 Nexplanon (etonogestrel implant 68mg) Progestin only Mechanism of action: primary = inhibit ovulation; secondary = inhibit fertilization by causing changes in cervical mucus and tubal motility that are unfavorable to sperm 99% effective FDA approved for 3 years; data showing same effectiveness up to 5 years of use No pelvic exam for insertion; placed inner upper arm 12  Changes in bleeding patterns common 22% amenorrhea, 34% infrequent bleeding, 18% prolonged bleeding, 7% frequent bleeding ~15% discontinuation due to unscheduled bleeding Favorable bleeding pattern in first 3 months Nexplanon predicts continued favorable pattern; those with unfavorable patterns have 50% chance of cont. improving If no other issue and patient wants to try treatment: NSAIDS x 5-10D or Low-dose OCPs cyclically for 1-6 months Oral conjugated estrogen 1.25mg or estradiol 2mg x 7D 13  Progestin only Mechanism of action: primary = inhibit ovulation; secondary = inhibit fertilization by causing changes in cervical mucus and tubal motility that are unfavorable to Depo Provera sperm (depot- Given by injection every 3 months medroxyprogeste IM 150mg (upper arm or buttock) rone acetate) SUBQ 104mg (anterior thigh or abdomen) Discrete, safe, effective (99% perfect use, 94% typical use) Requires office visit 14  Noncontraceptive benefits: protection against ovarian cancer, endometrial cancer, salpingitis, ectopic pregnancy, benign breast disease, acne, and iron deficiency Side effects: Depo, menstrual irregularities (irregular cont. bleeding common first few months, ~8% discontinuation due to bleeding, 50-75% amenorrhea at one year) weight gain (mean 30 due to VTE risk; Twirla less effective with BMI > 30 22  Nuvaring (etonogestrel/ethinyl estradiol ring); and Annovera (segesterone acetate/ethinyl estradiol ring) Both used for 3 weeks (left in vagina) and removed for one week for withdrawal bleed; Nuvaring changes to new ring, Vaginal Annovera reusable x 13 months Can stay in place during intercourse or with Ring tampon use Unplanned removal/expulsion can occur If < 48 hours -> reinsert ring asap, no additional steps If > 48 hours -> reinsert ring asap, use backup for 7D Associated with increased vaginal discharge 23  Can ovulate as soon as 4 weeks after delivery; unlikely to ovulate for first 6 months if > 85% feeds breastfeeds (lactational amenorrhea) Considerations: timing of initiation, breastfeeding, birth spacing All non-estrogen containing methods can be Postpartum started immediately CHC should start no sooner than 21D contracepti postpartum (VTE risk) WHO advises delaying CHC x 6 weeks if on breastfeeding (CDC -> ok after 30D) due to potential effects on breastfeeding performance IUD expulsion rate higher immediately postpartum (10-40%) Odds of using IUD 6 months postpartum 2X higher for postplacental IUD vs interval insertion 24  Norethindrone (0.35mg) and drosperinone (4mg) Mechanism of action: multiple -> thicken Progestin cervical mucus to inhibit sperm migration, suppress ovulation, lower midcycle FSH only pills and LH peaks, slow movement of an egg through the fallopian tubes, and thin the (POPs) endometrium. Norethindrone POPs do not consistently suppress ovulation (50%); drosperinone – ovulation suppression main MOA 25  Because of the short duration of action and short half-life of norethindrone (norethindrone T½ 7.7hrs; drosperinone 30 hrs), it must be taken at the same time each day to maximize contraceptive efficacy Dose considered missed if > 3 hours POPs cont. since should have been taken If missed, take pill asap and use back up until pills have been taken correctly, on time, for 2 days; consider EC if unprotected intercourse Drosperinone users can follow same instructions for missed pills as COC users 26  Nonhormonal reversible methods used at time of intercourse Condoms = true barrier contraceptives; Pericoital prevent lower genital-tract infections and HIV transmission contraceptio Diaphragm and cervical cap must be used n: condoms, with spermicide; may decrease risk of cervical and upper genital tract infection diaphragm, Diaphragm comes in different sizes, 70mm cervical cap, diaphragm fits most users, Caya diaphragm = single size sponge, Cervical cap comes in 3 sizes based on parity Phexxi Safe, user controlled Failure rates higher than for hormonal methods and IUDs (typical failure 13% for condoms, ~20% for other methods) 27  Phexxi (lactic acid-citric acid-potassium bitartrate) Vaginal pH regulator gel; 5g pre-filled applicator inserted vaginally no more than 1 hour before intercourse; dosing repeated with each sexual act Phexxi Maintains lower vaginal pH to immobilize sperm Pearl index 27.5 pregnancies per 100 users per year 20% report vulvovaginal burning, 11% itching 28  Avoid unprotected intercourse during fertile period (five days before ovulation to 24 hours after) Standard days: avoid unprotected intercourse D8-19 of cycle Fertility Cervical mucus/ovulation method: awareness evaluate CM to determine whether the day is potentially fertile methods TwoDay Method: avoid intercourse on all days when secretions noted + following day Billings/Creighton methods: user observes cervical secretions; avoid intercourse on days with wet, slippery, transparent, or stretchy secretions and 4 days after 29 Fertility awareness cont. Symptothermal method: evaluate CM several times per day, take temperature with basal body temperature [BBT] thermometer upon waking, avoid intercourse until 3D of higher temperatures have followed at least 6D of lower temperatures or the 4th Figure. A typical basal body temperature chart for day after the last day one menstrual cycle and the first day of with wet secretions, menstruation. Ovulation (on day 14 in this example) whichever happens later is marked by a slight dip in temperature, followed by a rise of at least 0.2°C (0.4°F) over the following 48 hours. 30 Natural cycles app FDA cleared Algorithm that calculates days of the month user is likely to be fertile based on daily body temperature readings and menstrual cycle information Have to take temperature each morning using basal body temp thermometer Clinical study with 15,570 people using app x 8 months Perfect use failure 1.8%; typical use 6.5% 31 Fertility awareness cont. Main advantage = no side effects Relative contraindications: irregular cycles, interruption of cycle with pregnancy, inability to track physiologic changes, lack of supportive partner Typical use failure ~24% Standard Days 32 Withdrawa l Commonly used, whether as sole method or in combination Costs nothing, no side effects Typical use failure ~20% Would typically encourage adding a more reliable method; at least discuss effectiveness and inform of options 33 Emergency contraception (EC) IUD Medication Most effective EC, not Less effective compared to IUD impacted by BMI UPA Can use copper or LNG 52mg Can use up to 120 hrs Requires visit for insertion Requires Rx Must wait 5D to start hormonal BC Provides ongoing contraception LNG Less effective than UPA, esp if BMI > 30 No back-up contraception Can use up to 72 hrs needed Available OTC in many places Can start hormonal BC at same time 34 Emergency contraception Copper or 52mg LNG IUD: prevents fertilization, prevents implantation if fertilization occurred LNG or Yuzpe: inhibit LH surge to delay/prevent ovulation - up to day before ovulation UPA (selective progesterone receptor modulator -> anti- progesterone): lowers LH to 35 delay or prevent ovulation  How do we talk about contraception? Listing Promotin all g certain methods methods 36 pted from RHEDI (Reproductive Health Education in Family Medicine): https://rhedi.org/patient-centered-contraceptive-counseling-slide-deck/ Limitations Listing all Methods Providing “objective” information May not elicit a patient’s reproductive health goals and preferences Promoting certain methods Tiered effectiveness or motivational interviewing Rooted in healthcare provider’s preferences or assumptions about patient priorities 37  Patient-Centered Contraceptive Counseling Full range of options Patient preferences Maximize access 38  So Many Options… How do you present them all? 39 Create a safe space by: Listening Not making assumptions Elicit and address patient priorities 40 Not making assumptions Ask about the patient’s preferences: Getting a period (or not) Hormones Easily Stopped Having something stay in your body Effectiveness 41 Not making assumptions Not taking for granted that you and the patient share the same feelings, beliefs, or understanding of medical terminology ASK permission to provide information about options You do not have The Answer, nor are you obligated to find it for the patient 42 QUESTIONS? 43