1. Patient Counselling and Management
Contraception
Patient Counselling and Management

2. Introduction
Most women spend approximately 36 years in the reproductive stage of life (ages 15-44)
They try to avoid pregnancy at some point in this interval
~30% of pregnancies are unintended
14% of births are unwanted
Annually, ~2% of women have an induced abortion
Spacing children decreases infant morbidity and mortality and the risk of spontaneous abortion
Successful family planning has a positive impact on women, couples, families, and society 2

3. Contraception Benefits often outweigh health risks
Side effects can often be managed or relieved
Variety of options available
Combination hormonal or progestin -only – pill, patch, vaginal ring
Injectable – long-acting, depot, or implant progestin
IUD – copper or levonorgestrel
Barrier methods – condom, diaphragm, vaginal cap, spermicide
Sterilization – female, male
Fertility awareness; withdrawal 3

4. Health Benefits Barrier effect Endometrial cancer Ovarian cancer
Condoms reduce transmission of infectious agents
Endometrial cancer
Risk significantly reduced with combination oral contraceptives, depot medroxyprogesterone acetate (DMPA) and non-medicated IUDs
Ovarian cancer
Risk reduced by combination oral contraceptives
Even in women with BRCA1 and BRCA2 mutations 4

5. Other Benefits Withdrawal bleeding and dysmenorrhea
Regulated and reduced with use of combination oral contraceptives
Menstrual blood loss in menorrhagia
Reduced with use of combination oral contraceptives, or levonorgestrel IUD
Acne
Treated with combination oral contraceptives
Perimenopause
Lighter, predictable bleeding; vasomotor symptom relief; positive effect on bone mineral density 5

6. Hormonal Contraceptives
Combination hormonal – pill, patch, vaginal ring
Oral contraceptives are the most commonly used method in the US
Available in various dose and cycle combinations of estrogen and progestin
Progestin-only – pill, long-acting/depot injection, implant, levonorgestrel IUD
Candidates include women with cardiovascular risk factors, diabetes, lipid disorders, estrogen-related side effects, migraine headaches,2 are post-partum or breastfeeding 6

7. Combination Oral Contraceptives
Relatively effective: 8% failure rate during first year of use, since most women do not take them perfectly
Fertility returns soon after discontinuation 7

8. Combination Oral Contraceptive Health Risks
Today’s lower-dose OC Formulations (< 50 mcg estrogen) Are Safe for Most Healthy Women and Have Been Extensively Studied
Breast Cancer : Large( British, US , and Canadian) studies found no increased risk with former or current use 8

9. Combination Oral Contraceptive Health Risks
Venous Thromboembolism (VTE)
Varying reports regarding risk associated with estrogen dose or type of progestin
Pregnancy, childbirth and puerperium are associated with risk of VTE higher than that associated with the use of OCs:
Low-Dose
OC Users1
Pregnant
Women9
Postpartum Women9
VTE Incidence
per 100,000 Woman-Years
511
VTE risk is further increased with OCs if there are specific thromboembolic risk factors or underlying diseases 9

10. Combination Oral Contraceptive Health Risks
Stroke
Low-dose formulations do not increase risk of thrombotic or hemorrhagic stroke in healthy, nonsmoking women
Risk increased in women with underlying predisposing diseases or other risk factor
Myocardial Infarction
Risk of MI substantially increased among OC users over 35 who smoke; smoking and OCs act synergistically to increase risk
Metabolic Effects
Oral estrogen increases triglyceride levels 10

11. Contraceptive Patch and Ring
Alternative combined hormone delivery systems, used on a 28-day cycle
1 patch applied weekly x 3, then removed for one patch-free week
1 ring inserted and left for 3 weeks, then removed for one ring-free week
Time to achieve steady state hormone levels - back- up contraceptive may be needed 11

12. Progestin-Only Contraceptives
Candidates include women with cardiovascular risk factors, diabetes, lipid disorders, estrogen-related side effects or contraindications, migraine headaches, are post-partum or breastfeeding
In lactating women, no decrease in milk production has been shown with progestin-only contraceptives
Irregular bleeding and spotting are the most common side effects 12

13. Progestin-Only Contraceptives
Pill – Norethindrone 0.35 mg
Depot medroxyprogesterone actetate Injection, Given every 3 months by injection: deep IM (150 mg of Depo-Provera)1 or SC (104 mg of depo-subQ provera 104) 3% first year failure rate with typical use; 0.3% first year failure rate with consistent use. 3% first year failure rate with typical use; 0.3% first year failure rate with consistent use
Implant – Etonogestrel 68 mg, Overall 3-year failure rate is 0.38%

14. Counseling for Hormonal Contraception
Provide information about all available products
Long-term options (IUD, depot injection, implant) are most effective, especially for women with difficulty managing their contraception (e.g., due to access, privacy issues, lack of follow-up) 14

15. Counseling for Hormonal Contraception
OCs need to be taken consistently for contraceptive efficacy and reduced side effects
If combined OC pills are missed, patient to take pills according to the following schedule:
1 tablet missed – take as soon as remembered and continue taking remainder of tablets at the same time daily as before
2 tablets missed – take 2 tablets as soon as remembered, then 2 on the following day, use back-up contraception for 7 days, take remainder of tablets at the same time daily as before
More than 2 consecutive tablets missed - continue taking 1 tab at the same time daily as before, use backup contraception (e.g., condoms and spermicide) until current pill pack is finished 15

16. Counseling for Hormonal Contraception
OC Side Effects
Commonly include nausea, breast tenderness, menstrual changes (e.g., amenorrhea, unscheduled bleeding, and spotting)
Breakthrough bleeding occurs in about 25% of women within the first three months of use, becoming less frequent with time
Advise patients that side effects are most likely to occur during first three months of use and that these symptoms are not dangerous; with regular and consistent pill-taking, side effects should abate 16

17. Counseling for Hormonal Contraception
OC Side Effects
Unscheduled bleeding continuing after 3 months of OC use, should be evaluated for other potential causes, including cervical or endometrial infection or neoplasia, pregnancy, polyps, fibroids, or use of medications that interfere with estrogen metabolism (e.g., smoking, antiepileptics, rifampin, St. John’s Wort)
Chlamydial cervicitis has been reported as a cause of late-onset unscheduled bleeding in OC users
If prolonged spotting/bleeding (ie, seven days or more) on an extended use OC, take a 3-day pill holiday; this is more effective than continuing the contraceptive 17

18. Counseling for Hormonal Contraception
OC Side Effects
Some long-term OC users may experience amenorrhea, which is not medically harmful
Inadvertent use of OCs during early pregnancy is not associated with an increased risk for fetal anomalies or miscarriage
There are no consistent data to suggest associations between weight gain or headaches and OC use
If problems or noncompliance due to side effects, a formulation adjustment can be made 18

19. Barrier Methods
Have assumed greater importance in recent years due to their ability to reduce the risk of sexually transmitted infections
Are commonly used with other methods of contraception, e.g., with OCs – the pill and condom are the most common contraceptive method combination
Male Condom, female condom, diaphragm, cervical cap, sponge, spermicides 19

20. Intrauterine Devices (IUDs)
Highly effective; convenient; have non-contraceptive benefits
Two IUDs are available in the US:
Copper T 380A – for up to 10 years of use; cumulative ten-year pregnancy rate is about 2%
Levonorgestrel-releasing IUD – for up to 5 years of use; cumulative five-year pregnancy rate is <1%
Can be inserted at any time in the menstrual cycle, provided the woman is not pregnant 20

21. Intrauterine Devices (IUDs)
Earlier concerns about infection and infertility are no longer appropriate:
Cohort studies have identified rapid return to fertility after IUD discontinuation
Prophylactic antibiotics at time of insertion appear unwarranted except in populations of women with a high prevalence of sexually transmitted diseases
Case controlled studies revealed no increase risk of upper genital tract infection in women who had undetected chlamydial infections at the time of IUD insertion 21

22. Intrauterine Devices (IUDs)
Benefits
Non-medicated and copper IUDs are associated with a 40% reduction in the risk of endometrial cancer, prevention that is statistically significant and clinically important
The levonorgestrel device reduces measured blood loss by about 90% in heavy menstrual bleeding, providing comparable benefit to endometrial ablation techniques2 and superior benefit to oral medications, such as progestins and NSAIDs
The levonorgestrel device can be used to prevent endometrial hyperplasia during menopausal treatment with estrogen 22

23. Emergency Contraception
Intended to prevent pregnancy after intercourse
Prevent pregnancy by:
Inhibiting or delaying ovulation
Hormones may alter sperm or ovum transport
Hormones may alter the endometrium, making it inhospitable to the implantation of an embryo
Hormonal ECs do not affect an established pregnancy, nor do they harm a fetus if taken inadvertently during early gestation
Begin within 72 hours of unprotected sex to reduce risk of pregnancy by at least 75% 23

24. Emergency Contraception
Emergency contraceptives (ECs) have included: progestins only, combination estrogen-progestin oral contraceptives, synthetic estrogens and conjugated estrogens, antiprogestins, and insertion of a copper-releasing intrauterine device
If menses are delayed more than a week, it may indicate that the EC has failed
Women using intermediate or high failure rate contraception should be educated and encouraged to keep an advance supply of EC, and given a prescription for Plan B 24

25. Surgical Contraception Sterilization
The most common form of contraception reported by US females aged 35 to 44 years
The types of procedures, in order of frequency: tubal sterilization, vasectomy, hysterectomy
Female - Tubal Sterilization
Actions taken on the fallopian tubes: ligation with excision, occlusion with rings, clips or insertion of coils, and electrocoagulation/cautery of a portion of the tubes
Male – Vasectomy Ligation of the vas deferens under local anesthesia in the office setting 25

26. Contraception in Women with Medical Problems
WHO lists conditions where pregnancy may exacerbate risk to a woman’s health
Need to determine contraceptive methods that are safest, given a woman’s underlying diseases or conditions
ACOG Practice Bulletin Number 73 provides a consolidated summary of “clinical considerations and recommendations” 26

27. Contraception in Women with Medical Problems
In general, hormonal contraception is not contraindicated in women with migraines, however need to review predisposing factors and migraine patterns before prescribing it
Appropriate alternatives include progestin-only, intrauterine and barrier methods

28. Contraception in Women with Medical Problems
Drug Interactions
Hepatic enzyme inducers (most commonly antiepileptic medications) decrease contraceptive blood levels, of estrogen and progestin, in users of combined OC and patch, progestin-only pill and implant
Simplest option may be to change to contraceptive where reduced efficacy has not been demonstrated: DMPA or an IUD (copper or levonorgestrel
Antiepileptic Drugs that May Reduce Contraceptive Efficacy via Enzyme Induction
carbamazepine
felbamate
oxcarbazepine
phenobarbital
phenytoin
primidone
topiramate 28

29. Contraception in Women with Medical Problems
Drug Interactions
Rifampin, a known enzyme inducer, reduces OC hormone levels; herbal medications can also have an effect on OC metabolism
Various antiviral agents (for treatment of HIV) can have different hepatic enzyme effects, being substrates, inducers, or inhibitors, therefore contraceptive methods that bypass the potential for drug interactions are recommended, ie., IUDs 29

30. Contraindications to Contraceptives (adapted from WHO1)
Condition/Personal Characteristics
Contraindicated Contraceptive Methods
Breastfeeding < 6 weeks postpartum
Combination OC, patch, ring
Smoker > 35 years old
High blood pressure
(systolic >160 mm Hg; diastolic > 100 mm Hg)
Vascular disease
Previous or current DVT or pulmonary embolism;
thrombogenic mutations; stroke or previous cerebrovascular accident
Major surgery with prolonged immobilization
Previous or current ischaemic heart disease;
complicated valvular heart disease
Migraine with aura
Distorted uterine cavity
Copper and progestin IUD 30

31. Contraindications to Contraceptives (adapted from WHO1)
Condition/Personal Characteristics
Contraindicated Contraceptive Methods
Breast cancer
All combination estrogen-progestin and progestin-only methods
Active viral hepatitis;severe decompensated cirrhosis;hepatoma
Combination OC, patch, ring
Malignant gestational trophoblastic disease
Copper and progestin IUD
Puerperal sepsis; postseptic abortion;
Pelvic infections
- do not initiate; monitor devices already in situ
Pregnancy
All forms of contraception
Allergies
To any component(s) in any form of contraception
Medical eligibility criteria for contraceptive use. WHO; 2004. 31

32. Patient-Centered Contraceptive Decision Making
Appropriate Contraceptive Selection Should Take Several Variables Into Account:
Effectiveness (typical use failure rate); side effects
Perceptions and misperceptions about risks and benefits of contraceptive use and pregnancy
Likelihood and ability to comply with the regimen
Frequency of intercourse
Age
Cost of the method and ability to pay for it
Concomitant drug use; health status and habits
Desired duration of contraception; reversible vs. non-reversible method 32

33. Q???