1. Applying Your Knowledge of Contraception in the Clinical Setting Jan Shepherd, MD, FACOG Florida State University College of Medicine

2. Contraceptive Use in the US Pill Tubal sterilization Male condom Injectable Vasectomy Withdrawal Intrauterine Periodic abstinence Other Diaphragm

3. Combination Oral Contraceptives Progestin – the dominant component –Inhibits LH surge and ovulation –Thickens cervical mucous –Many different progestins available Estrogen –Inhibits follicular development –Stabilizes endometrium –Almost always ethinyl estradiol but dose varies

4. COC Risk: Estrogen  Coagulation Mean Value

5. Cardiovascular Risks of OC Use 3- to 4-fold increased risk of VTE among all OC users ACOG Committee Opinion # 540, November 2012.

6. Cardiovascular Risks of OC Use Relative risk of MI or stroke : 0.9-1.7 with 20 μg estrogen pills, 1.3-2.3 with 30 μg estrogen pills* Increased risk of MI primarily in smokers and those with pre-existing arterial vascular disease Minimal increased risk of stroke in healthy, nonsmoking OC users. Risk heightened in certain populations (classic migraines,  bp). *N Engl J Med 2012;366(24):2257-2266.

7. Contraindications to Estrogen-Containing Methods Unexplained vaginal bleeding Pregnancy  3 weeks postpartum History of venous thrombotic disease History of arterial vascular disease Smoker > 35 Untreated hypertension Migraines with focal neurologic signs Personal history of breast cancer Marked impairment of liver function ~ 2% of women

9. Menstrual Cycle Benefits Improved Quality of Life 0.70.40.70.50.6 Decreased Risk Of PMS Menstrual-Related Problems DysmenorrheaIrregularityMenorrhagia Iron-Deficiency Anemia Relative Risk =

10. Additional Benefits ↓ Morbidity and Mortality = 0.50.30.40.50.10.5 Decreased Risk Of Relative Risk Endometrial cancer Ovarian cancer Functional ovarian cysts PID Ectopic pregnancy Benign breast disease

11. Contraceptive Ring and Patch More convenient for many women – may increase adherence to method, i.e. efficacy Same hormones as oral contraceptives –Similar efficacy with perfect use –Similar side effects –SAME CONTRAINDICATIONS

12. Progestin-Only Methods

13. Especially useful for patients with –Contraindications to estrogen –Intolerable side effects from estrogen High-dose –Depo Provera Low-dose –Progestin-only pill, also known as “Mini-pill” –Subdermal Implant

14. Depo Provera Depo Provera Highly Effective (.3 pregnancy rate) Easy to use Anonymous Can use when estrogen contraindicated No drug interactions Amenorrhea Prolonged pituitary suppression –Median time to pregnancy is 9–10 months –Up to 18 months is within normal limits Sexual issues Adverse effect on lipids ↓ Bone density Positives Negatives

15. Subdermal Implant: Nexplanon ®

16. Subdermal Implant Lasts 3 years Most effective method Can use when estrogen contraindicated No  bone density Immediate recovery of fertility Insertion and removal require minor surgical procedure Unpredictable bleeding pattern Other mild side effects Positives Negatives

17. Long- Acting Reversible Contraception Subdermal Implant Intrauterine Contraception

18. U.S. Pregnancies: Unintended vs. Intended Guttmacher Institute; January 2012. Unintended Intended Unintended births Elective abortions 49% 29% 20% 51%

19. Contraceptive Use and Unintended Pregnancy 52% of unintended pregnancies attributable to sexually active women using no method 48% of unintended pregnancies — women using some form of birth control Guttmacher Institute; January 2012.

20. 0 5 10 15 20 25 30 Implants Vasectomy DMPA Copper IUD Progestin IUD Tubal Ligation OCs Condom Diaphragm Withdrawal Spermicides Perfect UseTypical Use First Year Contraceptive Failure: Perfect Use vs Typical Use Hatcher RA. Contraceptive Technology.

21. WHO Method Comparison

22. Intrauterine Contraception (IUC)

23. Debunking Myths About Intrauterine Contraception IUCs are abortifacients IUCs cause pelvic inflammatory disease (PID) IUCs cause infertility IUCs cannot be used in nulliparous women

24. Copper T 380A (Paragard ® ) On US market since 1988 High efficacy (failure rate.5-.8% per year) Approved for 10 years use Changes in menstrual bleeding –Increase in flow and cramping (Usually temporary) –Controlled by NSAIDS

25. Levonorgestrel IUS (Mirena ® ) High efficacy (failure rate.2% per year) Approved for 5 years use Low systemic levels of levonorgestrel Changes in menstrual bleeding –Irregular bleeding at first, then decreased flow or amenorrhea (20%) levonorgestrel 20-10  g/day Steroid reservoir 32 mm

26. Small Levonorgestrel IUS (Skyla ® ) High efficacy (failure rate.4%/year) Effective for 3 years Smaller, thin inserter, lower hormone dose Approved for nullips Changes in menstrual bleeding –Irregular bleeding at first, then infrequent irregular bleeding Levonorgestrel 14-5 μg/day

27. Contraindications to Intrauterine Contraception Acute PID Postpartum or postabortion endometritis Mucopurulent cervicitis Distortion of uterine cavity Mirena/Skyla –History of breast cancer Paragard –Allergy to copper –Wilson’s Disease

28. Risks of Intrauterine Contraception Expulsion - 3.5-5% Perforation – 1/1,000-2,000 Embedment Infection/PID If pregnancy occurs, rule out ectopic –1 of 2 with Mirena and Skyla –1 of 16 with Paragard

29. Which IUC? LNG IUS –Woman with heavy flow or cramps –Anyone who desires  bleeding/amenorrhea Cu T 380A –Woman who prefers regular predictable cycles –Wants/Needs to avoid hormones –Prefers longer duration (10 years) Low-dose LNG IUS –Lighter, less painful, less frequent flow –Lower systemic hormone exposure

30. Role of LARC: CHOICE Project LNG IUS – 45% Copper IUD - 10% Implant – 13% Depo Provera – 8% OCPs – 23% Method Chosen Obstet Gynecol 2011;117:1105-13.

31. Continuation: CHOICE Project 1 year 1 LNG IUS – 88% Copper IUD – 85% Implant - 83% Depo Provera – 57% OCPs – 55% LARC – 87% Non-LARC – 57% 2 year 2 LNG IUS – 79% Copper IUD – 77% Implant - 68% Depo Provera – 38% OCPs – 43% LARC – 77% Non-LARC – 41% 1. Obstet Gynecol 2011;117:1105-13. 2. Obstet Gynecol 2013;122:1083-91.

32. Efficacy of LARC: CHOICE Project 22X more effective than pill, patch or ring (0.27 vs. 4.27 pregnancies per 100 women) Double this effect in teens Rate of teenage birth in the CHOICE cohort 6.3/1000 vs. 34.3/1000 nationally Rate of abortion less than half the regional and national average 1. N Engl J Med 2012;366;1998-2007. 2. Obstet Gynecol 2012;120:11291-7.

33. Improved Contraceptive Counseling  Reproductive Life Plan Being intentional about preparing for and starting pregnancies Making conscious decisions about –When to have children –How many to have –Ensuring the healthiest pregnancies and families CDC

34. Reproductive Life Plan = True “Family Planning” Encouraging clients to think about contraception –In terms of Planning for when they do want children Protecting themselves until that time –Not just for this year or this relationship

35. Reproductive Life Plan Clinicians help clients make a Reproductive Life Plan by asking: –Do you hope to have children? More children? –How many? –When? Every woman, every year

36. Reproductive Life Plan Avoiding unintended pregnancy –More effective use of contraception –First-line option for many LARC: Long Acting Reversible Contraception –Fertility-preserving behavior Planning for desired pregnancies –Preconception care

37. Case #1 A 16-year-old, newly sexually active, presents to the clinic for her first appointment, requesting contraception. Do you plan to have children? Yes How many? Two or three When? Not until I finish high school and college

38. QuestionsQuestions What contraceptives will you suggest for this patient? What contraindications do you have to rule out? What additional guidance will you give her?

39. Case #2 A 22-year old g2p2, 6 weeks postpartum, breastfeeding, presents for routine follow up. Do you plan to have more children? Yes How Many? Probaby one more When? In a year or two

40. QuestionsQuestions What is the Healthy People 2020 goal for optimal spacing of pregnancies? What contraceptives will you suggest for this patient? How will the fact that she’s breastfeeding affect her choices?

41. Case #3 35-year-old married g1p0ab1 presents for annual exam, OCP renewal. Had an abortion this year due to hectic schedule, forgot some pills. Do you plan to have children? I think so. How many? When? I’m not sure.

42. QuestionsQuestions What contraceptives will you suggest for this patient? What contraindications do you have to rule out? What additional guidance will you give her?

43. Case #4 A 45-year-old divorced g3p3 presents for evaluation of heavy menstrual periods. Do you plan to have any more children? NO! Are you currently in a heterosexual relationship? Yes

44. QuestionsQuestions Is this patient likely still fertile? What contraceptives will you suggest for her? What contraindications do you have to rule out? What additional guidance will you give this patient?

45. Goals and Recommendations The U.S. Department of Health and Human Services Healthy People 2020: “reduce unintended pregnancy to  44% of all pregnancies in the United States” The Institute of Medicine: “All pregnancies should be intended—that is, they should be consciously and clearly desired at the time of conception.”