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Contraception Basics for Health Educators Taylor Starr DO, MPH Assistant Professor Division of Adolescent Medicine Department of Pediatrics Golisano Children’s.

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Presentation on theme: "Contraception Basics for Health Educators Taylor Starr DO, MPH Assistant Professor Division of Adolescent Medicine Department of Pediatrics Golisano Children’s."— Presentation transcript:

1 Contraception Basics for Health Educators Taylor Starr DO, MPH Assistant Professor Division of Adolescent Medicine Department of Pediatrics Golisano Children’s Hospital The University of Rochester School of Medicine and Dentistry June 2014

2 Learning Objectives Review: Relevant statistics in NY and the US Female Reproductive Anatomy and Physiology Confidentiality in NY State Categorize contraception methods based on efficacy Explain: Mechanism of action of each method How each method is used Duration of method Common side effects of each method Ways to improve contraception initiation and use 2

3 YRBS QuestionNYUS % students ever had sex37.9%46.8% % students who had sex with at least one person within past 3 months (currently active) 27.9% 34% % currently sexually active students who used a condom at last sex 63.3%59.1% % who did use a method to prevent pregnancy during last sex 87.4%86.3% Comparing Student Sexual Activity in NY and the U.S. Youth Risk Behavior Survey, 2013 Source: Kann L, Kinchen S, et al. Youth Risk Behavior Surveillance--United States, Morbidity and Mortality Weekly Report. 2014, June 13;63(4):

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5 Comparing U.S. Teen Pregnancy Rates in Selected States (2010) New Hampshire2850 Connecticut4439 Pennsylvania4934 New Jersey5132 New York6314 New Mexico801 U.S Kost (2012). Source:guttmacher.org/pubs/USTPtrends10.pdf

6 Causes of Recent Decline in Teen Pregnancy Analysis concluded that for 15–19 year olds: Teen Pregnancy Decline 14% due to Decrease in Sexual Activity 86% due to Increase in Contraceptive Use Source: Santelli J, et al. Am J Public Health Jan;97(1):150–6.

7 Common Misconceptions If you don’t get periods, you can’t get pregnant In order to get contraception, you must get a pelvic examination You can’t get pregnant the first time you have sex Contraception is dangerous or can make you infertile Hormonal birth control provides protection against HIV/STIs Emergency contraception and medical abortion are the same

8 Female Reproductive Anatomy 8

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10 Minors’ Rights to Confidential Reproductive Care in New York State A minor who understands the risks and benefits of proposed and alternative treatments can consent to reproductive health care including: Pregnancy test Contraception Emergency contraception Abortion Pregnancy/prenatal care Labor and delivery STI testing and treatment 9. Guttmacher Institute (2012). 10. Mount Sinai Adolescent Health Center, NYCLU Reproductive Rights Project, & PRCH (2008).

11 Contraceptive Options DurationTypeHormone 5/10 yearsIUDY/NProgestin/ 3 YearsImplantYProgestin only 3 MonthsInjectionYProgestin only MonthlyRingYEstrogen and progestin WeeklyPatchYEstrogen and progestin DailyCombined pillsYEstrogen and progestin DailyProgestin-only PillYProgestin only Each sexM/F condomN Each sexDiaphragmN Each sexSpongeN Each sexCervical CapN Each sexSpermicideN Each sexWithdrawalN Each sexFertility awarenessN 11

12 Contraceptive Options Extremely effective (prevents pregnancy >99%) LARC (IUDs, Implant) Very effective (prevents pregnancy 91-99%) Injectable progesterone (Depo Provera) “the shot” Combined hormonal methods (Ring, Patch, Pills) Moderately effective (prevents pregnancy 81-90%) Condom, Sponge, Diaphragm, Withdrawal Effective (Prevents pregnancy up to 80%) Fertility awareness, Cervical cap, Spermicide

13 Contraceptive Options Extremely effective Effective >99% of the time Male/Female Sterilization LARC: IUDs & Implants Very effective Effective >92% of the time Injectable Patch Ring Pills Moderately effective Effective ~80% of the time Male/Female Condom Withdrawal Sponge Diaphragm Effective Effective up to 75% of the time Fertility Awareness Cervical cap Spermicide Source:www.arhp.org

14 Most effective Least effective < 1 pregnancy/ 100 women in 1 year >17 pregnancies/ 100 women in 1 year Injectable Pills Female Condoms Spermicides Female Sterilization Vasectomy Ring Patch Male Condoms Implant Diaphragm Fertility Awareness– Based Methods Withdrawal IUC Sponge 6−12 pregnancies/ 100 women in 1 year Typical Effectiveness of Contraceptive Methods Trussell J, et al. In: Hatcher RA, et al., eds. Contraceptive Technology Chart adapted from WHO 2007.

15 Birth Control Effectiveness in 10,000 Women Extremely Effective MethodsPregnancies per year Nexplanon5 Male Sterilization15 Mirena IUD (Progestin)20 Female Sterilization50 Paragard (Copper IUD)80 Methods with lower effectivenessPregnancies per Year Depo-Provera600 Minipill (progesterone only)900 Combination Oral Contraceptive Pill900 Condom1800 Withdrawal2200 No Method Source:www.reproductiveaccess.org

16 LARC: Long Acting Reversible Contraception 2 Methods: IUD Implant Safe, highly effective, long-acting Cost effective Rapid return of fertility Increasing use among adolescents American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 121: Long-acting reversible contraception: Implants and intrauterine devices. Obstet Gynecol. 2011;118(1): Dean G, Schwarz EB. Intrauterine Contraceptives. In: Hatcher RA TJ, Cates, W., Kowal, D., Policar, M., ed. Contraceptive Technology. 20th ed. New York: Ardent Media; 2011: Extremely Effective

17 IUDs Mirena: progestin What: T-shaped plastic shaped rod How to use: Provider places in uterus Duration: 5 years Mechanism: Inhibits fertilization Starts working: in 7 days Benefits: Reduced cramping and bleeding Common Side effects: Amenorrhea Paragard: copper (no hormone) What: T-shaped plastic rod How to use: Provider places in uterus Duration: 10 years Mechanism: Inhibits fertilization Starts working: immediately Benefits: no hormone Common Side effects: Increased cramping and bleeding Long-acting, reversible, and user-independent Extremely Effective

18 IUD placement: basic steps 18d Exam: determine position of uterus Place speculum, clean and stabilize cervixMeasure length of uterus Adjust IUD insertion tube to measurement of the uterus Place IUD using IUD insertion tube IUD strings are trimmed to 3 cm Approximate length of insertion procedure: 5 minutes

19 19 IUD Removal Place the speculum Visualize and grab the strings Remove IUD

20 Implant: NEXPLANON™ Long-acting, reversible, and user-independent What: thin plastic rod; brand name: NEXPLANON How to Use: Inserted under the skin of upper arm by a healthcare provider Mechanism: Inhibits ovulation Duration: 3 years Starts working: Use back up method for 7 days after insertion Common side effects: change in bleeding pattern irregular bleeding/nuisance bleeding amenorrhea Extremely Effective )

21 NEXPLANON™ Insertion Extremely Effective Approximate length of insertion procedure: 1 minute Position the arm Measure arm for insertion siteClean the insertion site Numb the insertion site Open implant insertion device Place implant using insertion device Palpate implant Place pressure bandage

22 Nexplanon Removal 22 Extremely Effective Satisfied: a new implant can be placed on day of removal Unsatisfied: provider will remove implant at any time; can start any other method the day of removal Approximate length of removal procedure: 3 minutes

23 Contraceptive Options Extremely effective Effective >99% of the time Male/Female Sterilization LARC: IUDs & Implants Very effective Effective >92% of the time Injectable Patch Ring Pills Moderately effective Effective ~80% of the time Male/Female Condom Withdrawal Sponge Diaphragm Effective Effective up to 75% of the time Fertility Awareness Cervical cap Spermicide Source:www.arhp.org

24 Injection: Depo-Provera Somewhat long-acting, reversible, and somewhat user dependent What: intramuscular injection of progestin How to use: provider gives injection in arm or buttock Duration: 3 months (12 weeks) Mechanism: inhibits ovulation Starts working: use condom for 7 days after initial injection Side Effects : Bleeding: irregular menses 3-6 months then amenorrhea Other: hair loss, weight gain, reversible decreased bone density Very Effective DepoIf more than 4 weeks late: use condoms for next 7 days Use EC within 5 days of unprotected sex

25 Vaginal Ring: NuvaRing ® What: small flexible unfitted ring with estrogen and progestin How to use: user places in vagina once a month Duration: 3 weeks Mechanism: inhibits ovulation Starts working: depends on cycle; use back up for 7 days Benefits: more regular, lighter and shorter menses, lower risk of uterine and ovarian cancer Common side effects: Estrogen related: breast tenderness, nausea, headaches Progestin related: bloating, spotting SourceNuvaRing Prescribing Information. Organon. 2001: Timmer CJ. Clin Pharmacokinet Herndon EJ. Am Fam Physician. 2004: Dieben TO. Obstet Gynecol. 2002: Linn ES. Int J Fertil et al. Very Effective

26 Placing and Removing Ring 26 Very Effective Removal Insertion Vaginal Ring Use back-up method for 7 days if: ring has been in >5 weeks falls out and is not reinserted within 3 hours ring has been out >7 days

27 What: beige-colored adhesive patch with estrogen and progestin How to use: user places a patch on clean dry skin weekly Duration: 1 week (9 days of hormone in each patch); change weekly Mechanism: inhibits ovulation Starts working: depends on cycle; use back up for 7 days Benefits: more regular, lighter and shorter menses, lower risk of uterine and ovarian cancer Common side effects: first 2-3 months: nausea, spotting between periods, breast tenderness Source: Abrams LS. Fertil Steril Ortho Evra Prescribing Information. Archer DF. Fertil Steril Zacur HA, et al. Fertil Steril Zieman M. Fertil Steril Archer DF. Contraception Audet MC. JAMA Transdermal Patch: OrthoEvra ® Very Effective

28 Placing the Patch 28 Very Effective Transdermal Patch Use back-up method for 1 week if : Patch falls off and is not reaffixed within 24 hours patch has been on >9 days off > 7 days

29 Combined Oral Contraceptives What: small pill containing estrogen and progestin How to use: take one pill at the same time daily Duration: 1 day Mechanism: inhibits ovulation Starts working: depends on cycle; use back up for 7 days Benefits: more regular, lighter and shorter menses, lower risk of uterine and ovarian cancer Common side effects: first 2-3 months: nausea, spotting between periods, breast tenderness Source: russel J. Contraceptive Technology Very Effective

30 Combined Oral Contraceptive Pills 30 Very Effective Oral Contraceptive Pills Forgot 1 pill: take missed pill ASAP, continue pack as directed Forgot 2 or more pills: take last missed pill ASAP, continue pack as directed Use back up for 7 days

31 Progestin-Only Oral Contraceptives What: small pill containing progestin How to use: take one pill at the same time daily; no placebo week Duration: 1 day Mechanism: inhibits ovulation Starts working: depends on cycle; use back up for 7 days Benefits: more regular, lighter and shorter menses, lower risk of uterine and ovarian cancer Common side effects: first 2-3 months: nausea, spotting between periods, breast tenderness Source: Apgar BS. AFP WHO MEC Contraception Report Apgar BS. AFP et al. Very Effective Progestin Only PillForgot one pill: take ASAP If >3 hours late: use condoms for 7 days Forgot 2 pills: take ASAP, continue pack as directed and use condoms for 7 days

32 Contraceptive Options Extremely effective Effective >99% of the time Male/Female Sterilization LARC: IUDs & Implants Very effective Effective >92% of the time Injectable Patch Ring Pills Moderately effective Effective ~80% of the time Male/Female Condom Withdrawal Sponge Diaphragm Effective Effective up to 75% of the time Fertility Awareness Cervical cap Spermicide Source:www.arhp.org

33 Male Condom What: single-use protective sheath placed over the penis Mechanism: barrier method; blocks sperm form reaching the egg Benefits: one of 2 methods that protect against STIs Source: Hatzell T. Sex Transm Dis Trussel J. Fam Plann Perspect Trussel J. Contraceptive Technology Moderately Effective

34 Female Condom What: single use loose thin tube with: closed end with inner ring that covers the cervix open end with outer ring that stays outside the vagina Mechanism: barrier method; blocks sperm from reaching the egg Benefits: one of 2 methods that protect against STIs Source: Hatzell T. Sex Transm Dis Trussel J. Fam Plann Perspect Trussel J. Contraceptive Technology Moderately Effective

35 Inserting and Removing Female Condom 35 Moderately Effective

36 Sponge What: single use, small, circular sponge placed over the cervix for contraception Mechanism: barrier method How to use: Sponge can be inserted up to 24 hours before intercourse It must be left in place for at least six hours after the last sex It should not be worn for more than 30 hours in a row Source: Engender Health Trussel J. Contraceptive Technology Moderately Effective

37 Insertion and Removal of the sponge INSERTION Before inserting, wet the sponge with at least two tablespoons of clean water. Squeeze the sponge to activate spermicide Fold the sides of the sponge upward and away from the loop; make it look long and narrow slide the sponge as far back into vagina as possible REMOVAL Put a finger inside the vagina and through the loop Pull the sponge out slowly and gently 37 Moderately Effective

38 Diaphragm What: reusable silicone cup that holds spermicide and covers the cervix Mechanism: barrier method How to use: Healthcare provider prescribed the appropriate size Insert the diaphragm into vagina up to six hours before sex It must be left in place for at least six hours after the last sex It should not be worn for more than 24 hours in a row Source: Fihn SD. JAMA D’Oro LC. Genitourin Med Trussel J. Contraceptive Technology Moderately Effective

39 Inserting Diaphragm 39 Moderately Effective

40 Withdrawal Method What: when a man withdraws penis from vagina before ejaculation Mechanism: prevents sperm form entering vagina 40 Moderately Effective

41 Contraceptive Options Extremely effective Effective >99% of the time Male/Female Sterilization LARC: IUDs & Implants Very effective Effective >92% of the time Injectable Patch Ring Pills Moderately effective Effective ~80% of the time Male/Female Condom Withdrawal Sponge Diaphragm Effective Effective up to 75% of the time Fertility Awareness Cervical cap Spermicide Source:www.arhp.org

42 Source: RHTP FemCap.com Trussell J. Contraceptive Technology Cervical Cap What: reusable silicone cup that holds spermicide and covers the cervix Mechanism: barrier method How to use: Healthcare provider prescribed the appropriate size Insert the cap into vagina up to 6 hours before sex It must be left in place for at least six hours after the last sex It should not be worn for more than 48 hours in a row Effective

43 Spermicide What: gel, cream, foam, film, or suppository placed inside the vagina Mechanism: stop sperm from moving How to use: Used alone, with a barrier method, or other method Roddy RE. N Engl J Med Trussel J. Contraceptive Technology Effective

44 Source: Arevalo M. Contraception CycleBeads Product Information. Fertility Awareness What: ways to track ovulation to prevent pregnancy How to use: Calendar Method: chart cycles on a calendar Temperature Method: take your temperature in the morning daily Cervical Mucus Method: check the changes in cervical mucus every day for the first part of your cycle until ovulation Mechanism: keep sperm out of vagina in days near ovulation Effective

45 Emergency Contraception What: used after unprotected sex to prevent pregnancy How to use: take medication within 3-5 days of unprotected sex, or Have copper IUD placed within 5 days of unprotected sex Mechanism: Levonorgestrel (LNG): high dose progestin that delays ovulation Ulipristal Acetate: progesterone receptor modulator Common side effects: delayed menses, spotting 45

46 Emergency Contraception Trussell 2011; Piaggio G. Lancet Task Force on Postovulatory Methods. Lancet Grimes DA. Ann Intern Med Croxatto HB. Contraceptin Raine T. Obstet Gynecol www.not-2-late.comwww.rhtp.org Gold MA. J Pediatr Adolesc Gynecol Grimes DA. Ann Intern Med

47 Emergency Contraception Pill Options Oral Progestin: Plan B One-Step: 1 pill by mouth Plan B: 2 pills by mouth More effective the sooner it is taken (within 72 hours) Over the counter or by prescription Progesterone receptor antagonist: Ullipristal Acetate Current brand name is Ella Maintains efficacy over 120 hours By prescription only More effective for women pounds

48 Emergency Contraception Website:

49 Improving Contraceptive Management: Advanced EC Prescription Key Points : Recommended for all sexually active females not on LARC Does not increase risk taking behaviors Increases EC use and decreases time to EC use after unprotected sex No limit to number of times a patient can use EC Not as effective as preventive (before sex) contraception American College of Obstetricians and Gynecologists. Practice Bulletin No. 112: Emergency contraception. Obstet Gynecol. 2010;115(5): Gold MA, Wolford JE, Smith KA, Parker AM. The effects of advance provision of emergency contraception on adolescent women's sexual and contraceptive behaviors. J Pediatr Adolesc Gynecol. 2004;17(2): Polis CB, Schaffer K, Blanchard K, Glasier A, Harper CC, Grimes DA. Advance provision of emergency contraception for pregnancy prevention: a meta-analysis. Obstet Gynecol. 2007;110(6):

50 Improving Contraceptive Initiation: Quick start Key Points : Opportunity to provide contraception at times of high motivation No need to wait for menses to begin method Initiate contraception immediately regardless of LMP or recent sex Use back-up method for 7 days Lara-Torre E. Contraception Leeman L. Obstet Gynecol Clin N Am Westoff C. Contraception

51 Dual Method Use What: Use of a condom plus another contraceptive Goal: May dramatically reduce the risk of both pregnancy and STIs 40. Cates & Steiner (2002). 41. Warner & Steiner (2011).

52 Decreasing Barriers to Contraception Pregnancy test Pelvic exam Pap smear STI screening Source: Leeman L. Obstet Gynecol Clin N Am. 2007

53 Start Birth Control Education With Highly Effective Methods Extremely effective Effective >99% of the time Male/Female Sterilization LARC: IUDs & Implants Very effective Effective >92% of the time Injectable Patch Ring Pills Moderately effective Effective ~80% of the time Male/Female Condom Withdrawal Sponge Diaphragm Effective Effective up to 75% of the time Fertility Awareness Cervical cap Spermicide Source:www.arhp.org

54 Resources cdc.gov youngwomenshealth.org youngmenshealthsite.org 54

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