3Disclosure of Commercial Support This program has received financial support from the Society of Obstetricians and Gynaecologists of Canada and the Foundation for Sexual and Reproductive Health in the form of an unrestricted educational grant.This program has received in-kind support from the Society of Obstetricians of Canada in the form of logistical support.Potential for conflict(s) of interest:Dr. Dustin Costescu has not received payment from any organization supporting this program of from organizations whose products are being discussed in this program.The Society of Obstetricians and Gynaecologists of Canada holds the copyright to this presentation.
4Mitigating Potential Bias Potential Biases are mitigated as follows:Grants were provided by medical organizations in an unrestricted fashion.Content was reviewed by six national experts in contraception to minimize bias.No pharmaceutical company has had prior access or editorial input into contentQuestions and cases were derived from consultations through our contraception clinic, and were not provided from external sources
5Learning ObjectivesAt the end of this session, the participant will be able to:Separate fact from myth with respect to common beliefs about birth controlIdentify opportunities to change contraceptive practices, reduce failure, and improve satisfactionReassure patients about the relative safety of contraception and provide information with confidence
6OverviewPatients are bombarded by complex messages about birth control and reproduction:Media ReportsSociocultural ExpectationsAdvice from Healthcare ProvidersThe challenge of contraceptive management lies in anticipating and addressing patient concerns, while ensuring that advice is based upon high-quality evidence.
8Question 1. The only contraceptive jelly available in Canada for use with caps and diaphragms has equivalent efficacy to older, Nonoxynol-9 containing products.TrueFalse
9FALSE The currently available jelly is not a spermicide. There are no published studies on efficacyThere are no head to head trials comparing Lactic Acid-Based products to NN-9.The one-year failure rate for a diaphragm without spermicide is 29%Even if ContraGel is as effective as NN-9, the failure rate is 12%Hatcher et al. “Contraceptive Technology” 20th ed p.397
10Question 2. What is the primary mechanism of contraception of the Levonorgestrel-Releasing Intrauterine System (LNG-IUS)?Change in cervical mucusEndometrial AtrophyOvulatory SuppressionApoptosis of gametes
11Cervical MucusLike all progestin-only methods, the central mechanism of action of the LNG-IUS is mediated by cervical mucus.The LNG-IUS primarily acts prior to fertilizationThe increased viscosity of the mucus may explain the decreased risk of PID seen in LNG-IUS users compared to copper IUD users.J. Toivonen, T. Luukkainen, H. Allonen. “Protective effect of intrauterine release of levonorgestrel on pelvic infection: three years' comparative experience of levonorgestrel- and copper-releasing intrauterine devices” Obstet Gynecol, 77 (1991), pp. 261–264
12Question 3. Men who find condoms to be too loose should look for products that offer what feature? “Snug”“Thin”“Sensitive”“Latex Free”
13Snug = Smaller CondomsSelf-reported penile measurements are associated with condom “Fit and Feel” problems.For men who complain of condoms feeling too loose, where there is difficulty in sustaining erection, or where self-reported penile size is small, suggest condoms that offer a “snug” fit.Condom size varies by country, and men can order many different sizes via the internet.Reece M, Herbenick D, Dodge B. “Penile dimensions and men’s perceptions of condom fit and feel” Sex Transm Infect 2009;85:127-31
14Question 4. VTE risk is decreased in users of the vaginal contraceptive ring because of the elimination of first-pass effect.TrueFalse
15FALSEAlthough the first-pass is avoided, there is sufficient drug in second and third passes to cause changes in the coagulation cascade.VTE risks are roughly similar between users of transdermal, vaginal, or oral combined hormonal contraception.Cedars MI, Judd HL Nonoral routes of estrogen administration. Obstet Gynecol Clin North Am 1987;14:Liddegaard Ø, Hougaard Nielsen L, Wessel Skovlund C, Løkkegaard E. “Venous thrombosis in users of non-oral hormonal contraception: follow-up study, Denmark ” BMJ 2012;344:e2990
16Question 5. Because of its effects on cytochrome P450, grapefruit juice can be associated with breakthrough bleeding with the combined oral contraceptive pill.TrueFalse
17TRUEEthinyl Estradiol is metabolized through the CYP450 pathway, as is grapefruit juice.Grapefruit juice may potentiate Ethinyl Estradiol (increasing bioavailability). Infrequent grapefruit consumers may experience breakthrough bleeding from fluctuations in EE levels.Contraceptive Efficacy is preserved, because EE levels increase, not decrease.Weber A, Jager R, Borner A et al. “Can grapefruit juice influence ethinylestradiol bioavailability?” Contraception 1996;53:41-7.
18Question 6. How soon following a term delivery can a woman who is not breastfeeding ovulate? Two weeksFour weeksSix weeksTwelve weeks
19Ovulation can occur by 26 days postpartum In just over 3 weeks, a woman’s fertility may be restored.Many couples do not wait for permission to resume intercourse.Contraceptive planning should take place prior to discharge, or at an interval visit before the traditional 6-week follow-up.Speroff L, Mishell DR. “The postpartum visit: it’s time for a change in order to optimally initiate contraception” Contraception 2008;78”:90-8.
20Discussion Case 1There are various strategies for determining if and when, during a woman’s menstrual cycle, that intrauterine contraceptives can be placed.E.G. Some providers only insert IUDs during menses.What strategy do you currently employ?Does this strategy create access barriers to patients?How would you counsel patients who are at risk of pregnancy and want an IUD inserted?
21When to insert IUDsAccording to the monograph, it is recommended that the Nova-T is inserted at the end of menses; the LNG-IUS should be inserted within seven days of the onset of menses.This potentially creates barriers due to scheduling, access for multiple visits, and the chance of interval pregnancy if the woman is inadequately protected.According to the WHO-SPR, a copper IUD can be inserted in all women up until day 12 of the cycle, and day 7 for LNG-IUS. It can also be inserted in women if she is reasonably certain not to be pregnant.
22Ruling out Pregnancy*You can be reasonably certain that the woman is not pregnant if no symptoms of pregnancy and meets any criterion:has not had intercourse since last normal menseshas been correctly and consistently using a reliable method of contraceptionis within the first 7 days after normal mensesis within 4 weeks postpartum for non-lactating womenis within the first 7 days postabortion or miscarriageis fully or nearly fully breastfeeding, amenorrheic, and less than 6 months postpartum* Some clinics and hospitals require a negative urine pregnancy test.
23WHO Selected Practice Recommendations (SPR) Provides practical information about contraceptive management – initiation, follow-up, and discontinuation.Designed for use in high and low-resource settings.Download it here!WHO Website
24Question 7. In a woman switching from condoms (which she is using consistently) to a Levonorgestrel-IUS, for how long should she bridge/ backup with condoms?None is needed2 Days5 Days7 Days
257 Days7 days are recommended, according to the WHO Selected Practice Recommendations for Contraceptive Use.The LNG-IUS may not be immediately effective, as time is needed to increase levels of LNG.LNG-IUS has not been demonstrated to have post-coital effects, so caution is needed when inserting a device mid-cycle.WHO. Selected Practice Recommendations for Contraceptive Use, 2nd Ed 2004.Natavio et al. Temporal Changes in cervical mucus after insertion of the levonorgestrel-releasing intrauterine system. Contraception 2013;87:
26Question 8. Your patient is going to be away the week she is due for her DMPA injection. The SOGC recommends that, relative to the last injection, the next is given:Within 13 weeksWithin 14 weeksWithin 16 weeksWithin 17 weeks
2714 weeks Women should receive their injections on time when possible. The SOGC recommends that repeat doses are given within 14 weeks post injection, as ovulation is unlikely to occur in that time.In low-resource countries, the WHO has revised its recommendation to within 16 weeks, as pregnancies are still rare.Women should receive their injections on time when possible.However, if a woman is late, she can be reassured by the “grace period”Otherwise, she may not return at all, assuming that a failure is likely.Guilbert E, Black A, Dunn S et al. “SOGC Committee Opinion. Missed Hormonal Contraceptives: New Recommendations” JOGC 2008; 30:WHO. Selected Practice Recommendations for Contraceptive Use, 2nd Ed 2004.
28Question 9. Oral contraceptives containing Cyproterone Acetate (CPA/EE) increase the risk of VTE compared to similar users of second-generation (LNG/EE) combined hormonal contraceptives.TrueFalse
29FALSEThere have been no recently reported deaths related to CPA/EE. Health Canada and the European Medicines Agency have concluded that the benefits of CPA/EE outweigh risks.Most evidence suggests no increased risk of VTEVTE risk increases with EE dose, and CPA/EE contains 35 mcgA significant confounding variable in CPA/EE users is by indication. As an anti-androgen, CPA is used for the management of hirsutism and acne, which is increased in conditions such as Polycystic Ovarian Syndrome (PCOS).Women with PCOS are at increased risk of VTE.SOGC “Position Statement: Diane-35 and Risk of Venous Thromboembolism (VTE).
30Question 10. In perimenopausal women without contraindications to estrogen, at what age should contraception be stopped?52535455
31Stop Contraception at 55 Based on expert opinion Probability of pregnancyCardiovascular Risk/BenefitNon-Contraceptive BenefitsHormone Therapy is inadequate to act as a contraceptive!European Society of Human Reproduction and Embryology. Female contraception over 40. Hum Reprod Update 2009;15: 599–612.
32Question 11. Which laboratory test is most reliable in the management of a woman taking the OCP who wishes to stop prior to 55?Day 3 FSH testing x 2 cyclesFSH testing on last day of HFI x 2 cyclesSwitch to Progestin-only method and check FSH after 6 weeks x 2 cyclesUse barrier methods and if amenorrheic x 6 months, stop.
33FSH testing and Discontinuation of Contraception As Estrogen inhibits FSH, day 3 testing is unreliable.Day 7 testing (at end of HFI) can be done, but if FSH is low, this may be due to hormonal suppression.Progestins do not have a significant effect on FSH, therefore switching to a POP and performing FSH testing is the most reliable indicator and is the most correct answer.Women should be amenorrheic for a year before discontinuing contraception – six months is inadequate.FSRH, 2010 “Contraception for Women aged over 40 years”
34Question 12. Which woman is at risk of contraceptive failure from lactational amenorrhea? 7 months postpartum, amenorrheic, exclusively breastfeeding.5 months postpartum, amenorrheic, pumping every 4 hours in day, sleeping through the night.4 months postpartum, scant bleeding three weeks ago, not as heavy as a period, breastfeeding exclusively.All of the above
35All of the Above Only women who are Exclusively breastfeeding No more than 4 hours between feeds in day and 6 at nightLess than 6 months postpartum, andAmenorrheiccan rely on LAM.
36Question 13. Levonorgestrel-Only Emergency Contraception (LNG-EC) is effective throughout the menstrual cycle.TrueFalse
37FALSE LNG-EC blocks the LH surge and ovulation. It is only effective in the follicular phase.EC should be used liberally as many women have difficulty knowing when they are ovulating when they are not deliberately tracking cycles in an attempt to conceiveNoe G, Croxatto HB, Salvatierra AM, et al. “Contraceptive Efficacy of emergency contraception with levonorgetrel given before and after ovulation” Contraception 2011;84:
38Question 14. Which is the ONLY anti-epileptic drug that must be dose-adjusted if a woman starts combined hormonal contraception?CarbamazepineValproic AcidPhenobarbitolLamotrigine
39Lamotrigine is special! Due to glucuronidation of the drug, which is potentiated by EE metabolism.Clearance increased by 50% and can lead to loss of seizure control.Slight decrease in progestin concentration, likely no effect on efficacyIf CHC is stopped the dose must be decreased.Sidhu J, Job S, Singh S, Philipson R. The pharmacokinetic and pharmacodynamic consequences of the co-administration of lamotrigine and a combined oral contraceptive in healthy female subjects. Br J Clin Pharmacol. 2006;61:191-9.
40Discussion Case 2. By which means do you perform STI screening in women prior to insertion of an Intrauterine Contraceptive?Screen all patients the day of insertion.Screen selected patients, based on risk factors, the day of insertion.Screen at the first visit, and insert once negative result obtained.Routine antibiotic prophylaxisDo not offer IUD for patients at risk of STI
41STI screening and IUDsRecent data suggests the risk of PID with insertion of an IUD is very low – 0.5%.Same day screening by risk factor (<25, multiple partners), is as effective at reducing infection as two-day screening without the added barrier of multiple visits.Avoid insertion is overt signs of infection.SBE prophylaxis not indicated.Sufrin CB, Postlethwaite D, Armstrong MA, Merchant M, Wendt JM, Steinauer JE. Neisseria gonorrhea and Chlamydia trachomatis screening at intrauterine device insertion and pelvic inflammatory disease. Obstet Gynecol. 2012;120:
42Question 15. Measurement of the uterine cavity can assist in determining whether or not a “small” or “short” IUD should be used.TrueFalse
43FALSEThere is no clear association between uterine cavity size and expulsion for “normal” size CuIUD or LNG-IUS.The uterine cavity of a nulliparous woman is only about 0.28cm shorter than a parous uterus, which is of uncertain significanceThe decision to use smaller-sized IUDs is based on clinical judgement, not evidence-based criteria.Canteiro R, Bahamondes MV, dos Santos Fernandes A, Espejo-Arce X, Marchi NM, Bahamondes L. Length of the endometrial cavity as measured by uterine sounding and ultrasonography in women of different parities. Contraception Jun;81(6):515-9.
44Question 16. Taking a “Pill Vacation” (periodically taking a month off) decreases exposure to estrogen and VTE risk.TrueFalse
45FALSEVTE risk is highest in the first 3 months following initiation of estrogen.Due to fluctuations in coagulation factors which return to normal thereafter.Following discontinuation of estrogen for ≥4 weeks, there is a new alteration in coagulation factors with resumption, and VTE risk increases as well.Dinger J, Mohner S, Minh TD. Early Use Effects on the Risk of Venous Thromboembolism After the Initiation of Oral Contraceptive Use. Presented at 11th ESC Congress May , Netherlands.
46Question 17. Women with a laparoscopic adjustable gastric band (“Lap Band”) should avoid oral contraceptives.TrueAvoid for one year, then no contraindicationAvoid for two years, then no contraindicationFalse
47FALSEWomen with restrictive procedures (sleeve gastrectomy, laparoscopic adjustable gastric band, vertical banded gastroplasty) have no restrictionsUSMEC – 1However any procedure with a malabsorptive component (Roux en Y, Duodenal Switch, Biliopancreatic Diversion) are not recommended, largely based on theoretical risk.USMEC - 3CDC. “U.S. Medical Eligibility Criteria for Contraceptive Use, 2010” MMWR 2010:59(RR04):1-6.
48Medical Eligibility Criteria for Contraceptive Use Helpful when deciding if a medical condition precludes the use of certain contraceptive methods.1 = No Contraindication2 = Benefit generally > Risk3 = Risk generally > Benefit4 = ContraindicatedQR CODE FOR US-MECApp Store – AppleWebsite – Other Device
49Question 18. Bone mineral density changes of the spine and hip are NOT observed with the Etonorgestrel Implant*TrueFalse* Not Available in Canada at present time.
50TRUEThere is less gonadotropin and estrogen suppression in implant users than DMPA.Studies comparing implant users to non-users fail to show differences in BMD for hip and spine.One study showed a decrease in ulnar but not radial BMD in etonorgestrel, but this is of limited clinical significance.Sarfatib J, de Vernejoula MC. Impact of combined and progestogen-only contraceptives on bone mineral density. Joint Bone Spine. 2009;76:134-8.
51Question 19. Family History of VTE is a simple and sensitive means to assess a patient’s risk of inherited thrombophilia.TrueFalse
52FALSE Sensitivity of Family History is 16-63% Positive Predictive Value is 6-50%Family history of VTE is no better than flipping a coin as a screening tool for thrombophilia, and is not useful in determining suitability for contraception.Grimes DA, Stuart GS, Levi EE. Screening women for oral contraception: can family history identify inherited thrombophilias? Obstet Gynecol 2012;120:
53Does my patient need thrombophilia testing? Patients who have a family history of VTE (genotype) AND relatives with a known inherited thrombophilia (phenotype) may benefit from testing.Personal Hx of VTE or Thrombophilia are contraindications to Estrogen-containing contraception (USMEC- 4)Otherwise, benefits outweigh risk (USMEC – 2)Screening is not cost effectiveMust test 666 female relatives of a proband with Factor V Leiden to prevent one case of VTE related to OCP use.Middeldorp S. “Evidence-based approach to thrombophilia testing”J Thromb Thrombolysis 2011;31:
54Question 20. Sufficient evidence now exists to conclude that contraceptives containing Drospirenone (DRSP/EE) are associated with increased risk of VTE when compared to those containing Levonorgestrel (LNG/EE).TrueFalse
55???Several retrospective studies using data from administrative databases suggest a small increased risk of VTE among users of DRSP/EE compared to LNG/EE containing pills.Two large, adequately powered prospective studies have failed to show differences in VTE.If a true difference exists, it is no higher than “third generation” desorgestrel- or gestodene-containing pills.If a true difference exists, the attributable risk is 0.024%One additional VTE per 4167 women using 4th generation instead of 2ndBitzer J et al. “Statement on combined hormonal contraceptives containing third- or fourth-generation progestogens or cyproterone acetate, and the associated risk of thromboembolism” J Fam Plann Reprod Health Care doi: /jfprhc
56Discussion Case 3There are many factors that influence the decision to seek tubal sterilization, notably differences in race, socioeconomic status, and family experience (women whose mother’s had a tubal ligation are more likely to request one).Because of the advent of highly acceptable LARC methods (many of which can be used beyond their monograph-recommended durations), the informed consent process has changed.What strategies do you find effective in helping women choose between LARC and Tubal Sterilization (or vasectomy)? What are the key aspects of informed consent that you cover if a woman still desires tubal sterilization?
57Evaluation (For future program development) The Society of Obstetricians and Gynaecologists of Canada (SOGC) | Annual Clinical Meeting | Calgary, Alberta | June 11-14, 2013
58The questions in this presentation were: Too hard to enjoy the talkHard, but encouraged learning on the subjectEasy, but encouraged learning and discussionToo easy to enjoy the talk
59The questions in this presentation were free from commercial bias: Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
60There is interest in making an easier talk for those seeking a more general review of contraceptive myths. Such a program would be:Not usefulPotentially useful to providers I work with or receive referrals from.Potentially useful for me and my peersUseful for a large audience such as this
61Thank you! This program is made possible by: The Foundation for the Promotion of Sexual and Reproductive HealthThe Society of Obstetricians and Gynaecologists of CanadaContraception Awareness Project