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© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View.

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Presentation on theme: "© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View."— Presentation transcript:

1 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View menu, select the Slide Show option * To help you as you prepare a talk, we have included the relevant text from ITC in the notes pages of each slide

2 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. in the clinic Contraception

3 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. Terms of Use  The In the Clinic ® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for- profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets constitutes copyright infringement.

4 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. Which women are most likely to become pregnant unintentionally?  Women <19 years old  80% teenagers describe their pregnancy as unintended  Women with low educational attainment or low income  Income 200% above it

5 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. Which women are most likely to become pregnant unintentionally?  Black women have highest unintended pregnancy rate  > 2x that for non-Hispanic white women  Type of contraception may play role  Hormonal methods = 2x higher rate of pregnancy vs. long- acting reversible methods (among adolescents)

6 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. What are the various types of contraceptives and how do they work? Hormonal methods  Combined (ethinyl estradiol + progestin)  Oral contraceptive pills (COCs): daily by mouth  Transdermal patch: single patch weekly for 3 weeks, then off for week (for withdrawal bleed)  Vaginal ring: ring inserted in vagina for 3 weeks, then removed for a week; new ring each month

7 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. What are the various types of contraceptives and how do they work? Hormonal methods  Progestin only  Oral contraceptive “mini-pill”: daily by mouth with no “off” week  Injectable: IM injection every 3 mo by health care provider; SQ may be self-injected

8 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. Long-acting reversible contraception methods (LARC)  Hormonal and nonhormonal  Subdermal implant: placed in upper arm by trained OB/GYN; used ≤3y  Levonorgestrel (LNG-IUD): placed in uterus, used ≤5y  Copper IUD: placed in uterus, used ≤10y

9 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. Barrier  Nonhormonal  Male, female condoms: protect against STDs; available OTC  Vaginal sponges: Available OTC  Diaphragm; cervical cap: must be fitted by a physician

10 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. How effective are contraceptives?  Permanent sterilization and LARC: top tier methods  Vasectomy: failure rate 0.01%  Female sterilization: failure rate 0.5%  Copper IUD: failure rate 0.8% at 1y  LNG-IUD: failure rate 0.1% at 1y  Subdermal implant: failure rate 0.05%  Combined Oral Contraceptive pills, patch, ring, DMPA injection: next tier methods  Efficacy influenced by adherence  COCs: perfect use failure rate 0.3% vs. typical use rate 8%  DMPA injection: failure rate 3%  Barrier: lowest tier methods  Efficacy limited by user compliance  Typical-use failure rates ≈15% All better than nothing… 85% of reproductive-age women having regular unprotected sex pregnant within 1y

11 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. What is meant by “emergency contraception”?  Any contraception method used after sexual intercourse  Doesn’t disrupt an established pregnancy  Levonorgestrel (Plan B, Plan B One-step)  Levonorgestrel 0.75 mg (2 pills) or 1.5 mg (1 pill) within 5d of unprotected intercourse  Reduces risk for pregnancy by 89%  Efficacy decreases slightly each day after unprotected sex  Available without prescription if ≥17 years old  Ulipristal (ellaOne)  Ulipristal acetate selective progesterone receptor modulator (30 mg pill, given once)  Reduces risk for pregnancy by 90%  Maintains efficacy through days 1 through 5  By prescription only

12 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1.  Copper IUD  Inserted up to 5 days after contraceptive failure/nonuse  Reduces pregnancy risk by 99% (most effective method)  Patient should desire the device for contraception  Alternative: COC pill regimen  Number of pills varies depending on pill formulation  Compared with other options: more side effects, less effective, and must be taken within ≤72 hours

13 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. What is the role of tubal ligation and vasectomy in contraception?  Sterilization considered permanent  Patients should be certain they don’t want more children  Reversals are costly and frequently unsuccessful  Procedure carries surgical and anesthetic risks  Vasectomy more effective than tubal ligation + safer (however patient not sterile until ≈12 weeks after procedure)  LARC methods: may be more appropriate option  Subdermal implants or IUDs  As effective as sterilization for reducing pregnancy

14 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. CLINICAL BOTTOM LINE: Epidemiology and Efficacy…  50% of pregnancies in U.S. unplanned  Poor, young, or minority women at highest risk  Contraception can prevent unplanned pregnancy  Most effective: IUDs, subdermal implants, and sterilization  User error adds to higher failure rate (≥10%) for pills, patch, DMPA injection, vaginal ring  Emergency contraception options  Copper IUD most effective

15 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. Are there beneficial effects to the use of contraception beyond pregnancy prevention ?  Combined hormonal methods (the pill, patch, or ring)  Alleviate dysmenorrhea  Control cycle  Reduce endometrial hyperplasia  Improve menorrhagia symptoms  Prevent premenstrual dysphoric disorder  Reduce hirsutism and acne  Decrease endometrial, ovarian, & colorectal cancer risk  Improve symptoms exacerbated by hormone fluctuations

16 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1.  Injectable contraception  Improves menorrhagia symptoms  Reduces endometrial cancer risk  Control cycle (if comfortable with amenorrhea)  LARC methods  Benefits similar to COCs  Subdermal implant and LNG-IUD: improve menorrhagia, and dysmenorrhea and other symptoms of endometriosis  LNG-IUD and copper IUD: decrease endometrial cancer risk  LNG-IUD: treat endometrial hyperplasia without atypia

17 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. What are the risks for combined hormonal contraceptives? All combined hormonal contraceptives (≤35 mcg estrogen):  Venous thromboembolism  Slightly elevated risk (most common in 1 st year use)  Slightly higher for older women and obese women  Risk eliminated in ≤30d of discontinuation  Transdermal patch: black box but risk not higher  Hemorrhagic stroke, ischemic stroke  Increased risk if patient has uncontrolled hypertension, migraines with aura symptoms, or smokes  All combined methods contraindicated in these women  Arterial blood clot  Increased risk if smoker, >40 years old, obese

18 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. What are the risks of progestin-only and LARC methods? Injectable medroxyprogesterone acetate  Weight gain ( ≈5.4 pounds)  Loss of bone mineral density  Transient and reversible; no increased fracture risk Intrauterine devices  Cramping in 1 st few months (more common w/ copper IUD)  Treat with NSAIDs  Spontaneous expulsion (risk <1%)  Genital tract infection at time of insertion  Prophylactic antibiotics don’t decrease risk  Uterine perforation at insertion (very low risk: 0.01%)

19 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. What are the risks to the fetus if pregnancy occurs when a woman is receiving oral contraceptives? No risks  No evidence of  fetal anomalies spontaneous miscarriage preterm delivery birth defects compromised fertility of offspring

20 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. CLINICAL BOTTOM LINE: Medical Considerations…  Medical benefits of hormonal contraception  Cycle regulation, lighter periods  Reduced premenstrual symptoms  Medical benefits of LNG-IUD and subdermal implant  Decreased menstrual bleeding  LNG-IUD only: improves endometrial hyperplasia  Medical risks of hormonal contraception  Stroke: contraindicated if >35y old & smoker, or if migraines + aura  VTE: slight increased risk (highest in first year of use)

21 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. When should women be counseled about contraception?  Before first sexual encounter  Average age of first sex in United States is 17  Repeat throughout reproductive years  Average U.S. woman spends 5 years attempting pregnancy, being pregnant or postpartum  Spends nearly 30 years avoiding pregnancy

22 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. Which women are at greatest risk for complications if they become pregnant?  Breast cancer  Complicated valvular heart disease  Diabetes (especially type 1)  Endometrial or ovarian cancer  Epilepsy  Hypertension  Bariatric surgery in past 2y  HIV/AIDS  Ischemic heart disease  Malignant gestational trophoblastic disease Medical Conditions Increasing Risk for Complications

23 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. Which women are at greatest risk for complications if they become pregnant?  Malignant liver tumors, hepato- cellular carcinoma of liver  Peripartum cardiomyopathy  Pulmonary hypertension  Schistosomiasis (liver fibrosis)  Severe cirrhosis  Sickle cell disease  Solid organ transplantation  Stroke  Systemic lupus erythematosus  Thrombogenic mutations  Tuberculosis Medical Conditions Increasing Risk for Complications

24 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. How does this affect their choice of contraception?  Encourage use of most effective method to decrease possibility of a risk  Often: LARC or sterilization (if finished childbearing)  Consult U.S. Medical Eligibility Criteria, from CDC  Comprehensive analysis of medical problems and risks associated with certain contraceptives  Helps determine which methods a patient could use

25 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. How should women go about choosing an appropriate contraceptive?  Lifestyle  Unpredictable work schedule? may be hard to take pill at same time every day  Planning future pregnancy?  STD protection? Condoms prevent pregnancy + STDs  Past use  Unplanned pregnancy when using contraception in past?  Unable to continue a method in past? (unlikely option)  Side effects  Such as spotting with subdermal implant  Personal comfort  Discomfort changing a vaginal ring? (will discourage use)  Discomfort with amenorrhea from LNG-IUD ?

26 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. Are there forms of contraception a woman should avoid if she is considering pregnancy in the next year or so?  Injectable medroxyprogesterone acetate  Delayed return of fertility (≈10 months)  Not recommended if desiring pregnancy in near future  Other contraception methods allow rapid return to fertility (IUD, subdermal implant, combined hormonal)

27 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. What contraceptives can breastfeeding woman use?  If breastfeeding  Progesterone-only methods acceptable, safe  Can be started immediately after delivery  Delay estrogen-containing methods until 6 weeks post- partum and lactation well-established (elevated VTE risk)  Option: barrier method (refit diaphragm / cervical cap after delivery)

28 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. CLINICAL BOTTOM LINE: Counseling Considerations…  Initiate contraception counseling before first sexual activity  When choosing appropriate contraception…  Consider patient comfort, lifestyle, past method use  Medical conditions (may increase risk for complicated or dangerous pregnancy)  Consult CDC Medical Eligibility Criteria  Be aware return to fertility delayed after discontinuing injectable medroxyprogesterone

29 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. What are the cost and cost-effectiveness of contraception? All more cost-effective than unwanted pregnancy Cost  Combined methods: $8 - $80 per month  Medroxyprogesterone: $35 - $75 every 3 months (plus nursing visit for administration)  LARC methods: $300 - $800 without insurance Cost effectiveness  LARC and sterilization: highest up-front cost  But most cost-effective over time  Combined methods: less cost upfront but refills required  Less cost-effective given decreased efficacy vs LARC  Condoms: least cost-effective (b ut protect against STDs)

30 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. Are all forms of contraception covered by most health insurance plans?  Most insurance companies cover contraception  If there is a prescription drug benefit  Pa tient Protection and Affordable Care Act  Requires insurers to cover contraception without copay  Plans that existed when PPACA passed grandfathered in  Any significant changes or modifications to plans will mandate adoption of the new regulations  Exemptions for some religious employers

31 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. CLINICAL BOTTOM LINE: Cost Considerations…  Most cost-effective form of contraception: LARC  Cost of contraception: covered by most insurance plans that include prescription drug benefit  PPACA: requires all insurance providers to cover contraception without copay

32 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. Should primary care physicians prescribe contraceptives or should they refer patients to other providers?  For medically uncomplicated women: Primary care physician may prescribe contraception  However few are well-trained in contraception provision  PCP often first-line providers for ill women, who may need counseling about contraception  Especially important if also prescribing teratogenic medication  For women with medical problems: refer to OB-GYN or family planning specialist

33 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. Are there programs to train internists in providing contraception?  Most training occurs during residency / fellowship  Subdermal implants: Manufacturer can provide formal training on placement  IUDs: Consider contacting local provider within your institution for training on insertion  In general, refer patient to experienced person for counseling and fitting of device  OB-GYN or family practice physician or nurse

34 © Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. CLINICAL BOTTOM LINE: Provider Considerations…  To prevent unintended pregnancy: provide contraception to all sexually active reproductive-age women  Internists should feel comfortable and responsible discussing contraception with patients  Especially if medically complicated  Refer to OB-GYN or family practice physician if patient has:  Medical problems, an interest in LARC method, or if there is difficulty identifying appropriate method


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