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August 2008 Contraception Update. Contraceptive efficacy Pearl Index Life Table Analysis Perfect use Typical use.

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Presentation on theme: "August 2008 Contraception Update. Contraceptive efficacy Pearl Index Life Table Analysis Perfect use Typical use."— Presentation transcript:

1 August 2008 Contraception Update


3 Contraceptive efficacy Pearl Index Life Table Analysis Perfect use Typical use

4 Current use of contraception by age, 2005/6 ONS, 2007


6 LARC – NICE Guidelines Contraceptive service providers should be aware that: all currently available LARC methods (intrauterine devices [IUDs], the intrauterine system [IUS], injectable contraceptives and implants) are more cost effective than the combined oral contraceptive pill even at 1 year of use – IUDs, the IUS and implants are more cost effective than the injectable contraceptives – increasing the uptake of LARC methods will reduce the numbers of unintended pregnancies

7 7 LARC includes: Copper IUD Progestogen-only IUS Progestogen-only injectable Progestogen-only subdermal implant Combined vaginal rings

8 8 However Current LARC Usage is Low 7 7. Schering Data on File, 2006, WOMEN AGED 16 TO 44 %

9 9 Accidental Pregnancy in First Year of Typical Use 8 8 Trussell J. Contraceptive efficacy. In: Hatcher RA, Trussell J, Stewart R. Contraceptive Technology, ed 18. NY: Ardent Media, 2004 % of accidental pregnancy * Norplant and Norplant 2: Data is from USA where Implanon is not available

10 10 Discontinuation Rates of Contraceptive Methods 1 % Discontinuation

11 UK Medical Eligibility Criteria UKMEC1 No contraindication UKMEC2 Benefits usually outweigh risks UKMEC3 Risks usually outweigh benefits UKMEC4 Contraindicated

12 Sterilisation Permanent but no longer the most effective Can be reversed but no guarantee Lifelong failure rate 5/1000 (i.e.10 times failure of vasectomy) Requires invasive procedure

13 Types of Combined Contraception 20, 30 or 35 micrograms of ethinyloestradiol Different progestogens 21 day and every day formulations Fixed dose or phasic Combined patch – Evra 4 or 12 week withdrawal - Seasonale Continuous pill Combined Ring – Nuvaring

14 Hormonal contraception Combined oestrogen and progestogen –Combined pill (COC) –Evra transdermal patch –Nuva-Ring vaginal ring

15 Combined methods Advantages –Suppress ovulation –High efficacy –Give predictable periods Disadvantages –Increased risk of thrombosis –?? Increased risk of breast cancer –(Increased risk of hepatocellular cancer)

16 Constituents of COCs OestrogensEthinyloestradiolMestranolProgestogensNorethisteroneLevonorgestrelDesogestrelGestodeneNorgestimateDrospirenoneCyproterone


18 Limitations on Dose Reduction Loss of efficacy Loss of cycle control (depends on both oestrogen and progestin) Wide range of blood levels via oral route


20 Revised information from MCA May 99 Third generation pills can be prescribed first-line VTE risk in data sheets: 15 per 100,000 - second generation 25 per 100,000 - third generation

21 Breast cancer re-analysis results No effect of duration of use No dose response Cancers in pill users less advanced Causal association unlikely ? acceleration of tumour growth ? surveillance bias

22 Cervical cancer risk factors Human Papillomavirus Smoking Oral contraceptives ?

23 Benefits of the COC (1) Very effective, non-intercourse related contraception Reduction in menstrual disorders functional ovarian cysts x 92% functional ovarian cysts x 92% menorrhagia, irregular bleeding x 50% menorrhagia, irregular bleeding x 50% dysmenorrhoea x 40% dysmenorrhoea x 40% PMS PMS Iron deficiency anaemia x 50% Iron deficiency anaemia x 50% PID x 50% PID x 50% Ectopic pregnancy x 90% Ectopic pregnancy x 90%

24 Benefits of the COC (2) Fibroids x 30% Fibroids x 30% Benign breast disease x % Benign breast disease x % Symptomatic relief / treatment of endometriosis Symptomatic relief / treatment of endometriosis ? Duodenal ulcer ? Duodenal ulcer Rheumatoid arthritis x 50% Rheumatoid arthritis x 50% Endometrial cancer x 50% Endometrial cancer x 50% Ovarian cancer x 40% Ovarian cancer x 40% Colorectal cancer x 20% Colorectal cancer x 20%

25 Conception due to missed COCs 'only' occurs if this leads to lengthening of the pill - free interval NB - at either end

26 Missed pills – WHO Advice for COCS Just keep going Also if pill missed is in week 3 omit pill-free interval Also backup or abstinence for 7 days if following number of pills missed - Two for twenty - Three for thirty

27 Lamotrigine (Lamictal) and the pill Lamotrigine (Lamictal) and the pill Not an enzyme inducer Interaction reduces levels of both agents No evidence of reduced efficacy for COC No evidence on POP

28 Why take a break ? HistoryTricycling 25/3 may give better ovarian suppression Continuous

29 EVRA: EVRA: Simple administration schedule –20 mcg ethinyloestradiol and 150 mcg norelgestromin –Apply weekly for 3 weeks –Apply same day-of-the-week –1 week patch-free Sunday Patch # 1 Patch # 2 Patch # 3 28-day cycle Patch-free Sunday Start next cycle 28-day cycle Ref: Evra SmPC

30 EVRA Continuously Delivers EE Within Reference Ranges Days EE serum concentration (pg/mL) Patch removed Evra Cilest Adapted from Abrams Fertility and Sterility 2002

31 Dosing Reserve Results for ethinyl estradiol EE serum concentration (pg/mL) Days Patch changed on schedule Patch removal delayed Patch removed 3 days late Ref: Abrams et al Fertility and Sterility 2002,

32 Evra – is a patch really better ? Less variability in levels, but not a lower dose Effects on SHBG similar or greater ? Relevance of enzyme-inducers, antibiotics, etc ? Thrombosis risk

33 New Delivery System: Vaginal Ring Progestin: Etonogestrel: 120 µg/day Estrogen: Ethinyl estradiol: 15 µg/day Worn for three out of four weeks Self insertion & removal Pregnancy rate 0.65 per 100 woman–years Roumen FJ, et al. Hum Reprod. 2001;16(3):

34 Progestogen-only methods Advantages –Greater safety Variable efficacy (from extremely low to better than COC) Some measure of loss of cycle control (varies with route, type and dose)

35 Routes available Progestogen-only pill (POP) Emergency contraception (Levonelle) Injectable (Depo-Provera) Intrauterine (Mirena) Implant (Implanon)

36 Desogestrel POP (Cerazette) 75 micrograms Desogestrel Suppresses ovulation Lower failure rate Different rules for missed pills


38 Emergency Contraception Products –Levonelle One Step –Any copper IUD, including GyneFix Indications –Unprotected sex –Potential barrier failures –Potential pill failure 2 missed pills in first week 2 missed pills in first week 4 missed pills in mid-packet –Potential IUD failure –Increased risk of ectopic in failures Awareness of risk may not translate into action

39 Levonelle One Step 1500 micrograms levonorgestrel Within 72 hours Efficacy –< 24 hours95 % –24-48 hours85 % –49-72 hours58 %

40 Emergency Hormonal Contraception (EHC) Side effects –23 % nausea –6 % vomiting Contraindications –Established pregnancy

41 Depo-Provera 150 mg medroxyprogesterone acetate –IM –Every 12 weeks –Failure rate approx 0.5% –High incidence of amenorrhoea –Long-term use associated with reduced bone density which recovers with addback or discontinuation

42 Fertility awareness Depends on abstinence Requires high degree of motivation Failure rates high especially in new users Based on a number of false premises about fertility, therefore relatively high method failure rate as well as high user failure

43 IUD (Copper devices) Gold standard Copper T 380 Not user-dependant Good efficacy (failure rate 1% or less p.a.) Requires insertion and removal Some increased risk of infection in first 60 days especially when cervix colonised Periods may be heavier, longer, more painful


45 Intrauterine Mirena releases 20 mcg levonorgestrel daily for 5 years Failure rate equal to or less than female sterilisation Reduction in menstrual loss a beneficial side-effect


47 Mirena Good contraception Control of menorrhagia May help dysmenorrhoea Effective endometrial protection Some systemic absorption Irregular bleeding may persist Insertion not always easy

48 Implanon SubdermalEtonogestrel Menstrual irregularity common Failure rate far below that of sterilisation

49 49 The design of Implanon ® Progestogen only contraceptive The design of Implanon ® Progestogen only contraceptive Core Rate-controlling membrane (0.06 mm) 2 mm 40 mm Core: 40% EVA 60% etonogestrel Membrane:100% EVA

50 Implanon ® Mode of action Ovulation inhibition : primary effect Effect on cervical mucus: secondary effect

51 51 Contraception 1998;58: 99S- 107S



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