Reproductive Health- part 2 © 2009 McGraw-Hill Higher Education. All rights reserved.

Unintentional pregnancy in U.S. 50% of all pregnancies 80% of pregnancies to women <20 Associated with worse health outcomes Goal- reduce rates of unintended pregnancy – promote “family planning” © 2009 McGraw-Hill Higher Education. All rights reserved.

Percentage of High School Students Who Drank Alcohol or Used Drugs Before Last Sexual Intercourse,* by Sex** and Race/Ethnicity,*** 2007 * Among the 35.0% of students nationwide who had sexual intercourse with at least one person during the three months before the survey. ** M > F *** W, H > B National Youth Risk Behavior Survey, 2007

Unintended Pregnancy Options Carry the pregnancy to term and raise the child Carry the pregnancy to term and place the child in an adoptive family Terminate the pregnancy

© 2009 McGraw-Hill Higher Education. All rights reserved. Guttmacher Institute, Facts on Induced Abortion Worldwide, 10/08

The Guttmacher Institute; Sharing Responsibility: Women, Society and Abortion Worldwide; 1999 Induced Abortion –1/5 of pregnancy end in abortion –Reduced rates of abortion correspond with increased rates of contraception –Legal restrictions do not affect incidence of abortion

Induced Abortion Legal=safe Illegal= unsafe –In developed regions, 92% safe –In developing regions, 55% unsafe –Unsafe abortion can cause hemorrhage and sepsis and leads to 13% of maternal deaths (67,000 per year) The Guttmacher Institute; Sharing Responsibility: Women, Society and Abortion Worldwide; 1999

Family Planning Options Abstinence Condoms – male/female Emergency contraception Oral contraceptive pills  Monthly  Quarterly  Annually Contraceptive patch Contraceptive ring Contraceptive injection Contraceptive implant Intrauterine device Barrier methods Spermicides Sterilization

Abstinence Available to all Requires control Interrupts sexual expression Must agree on definition with partner Perfect use (0) vs actual use (?) © 2009 McGraw-Hill Higher Education. All rights reserved.

Barrier methods Male condom Female condom Diaphragm Cervical cap © 2009 McGraw-Hill Higher Education. All rights reserved.

Male Latex Condoms Perfect use – 2 % failure Actual use – 15% failure Male involvement Reduce risk STI

Male Polyurethane Condoms

FC2 Female Condom Perfect use: 5% failure Actual use: 21% failure

Barrier Methods Perfect use: 6 % failure Actual use: 16% failure

Emergency Contraception Plan B ® Reduces risk of pregnancy in case of rape, Unprotected sex, or failure of barrier Available over the counter for 18 and older

Emergency Contraception Single dose of levonorgestrel taken ASAP within 72 hours of exposure Safe for self-medication Same dose for all women Same medications safely used for contraception for decades Serious adverse effects do not occur No contraindications other than pregnancy

Hormonal methods: Available for 50+ years Many different formulations and ways to administer Daily use (or other) separates contraception from sexual act © 2009 McGraw-Hill Higher Education. All rights reserved.

Oral Contraceptive Pills Perfect use: 0.3% failure Actual use: 8% failure

Extended Cycling Fewer and shorter menstrual periods – one or four per year Shorter hormone-free intervals Better ovarian suppression (PCOS) Decreased premenstrual dysphoric disorder (PMDD), premenstrual syndrome (PMS), acne vulgaris, endometriosis, menstrual migraine Preferred by athletes

Noncontraceptive Benefits of OCs Decrease menstrual flow (lighter, shorter periods) Decrease menstrual cramps (no ovulation) Improve anemia (lighter, shorter periods) Improve acne (estrogen effect) Protect against ovarian and endometrial cancer Decrease benign breast disease Decrease ovarian cyst formation Prevent ectopic pregnancy Protect against some causes of PID Protect against osteoporosis

Contraindications to Use of OCs Deep vein thrombosis Pulmonary embolism Cerebrovascular disease Coronary artery disease Factor V Lyden mutation or other known thrombophilia Migraine headache with aura or neurologic changes Estrogen-dependent cancer Active liver disease Major surgery or immobilization Pregnancy or breastfeeding

Oral Contraception: Red flags Mnemonic: ACHES Abdominal pain (severe) Chest pain (severe), cough, shortness of breath Headache (severe), dizziness, weakness, or numbness Eye problems (vision loss or blurring), speech problems Severe leg pain (calf or thigh)

Ortho Evra  Transdermal Contraceptive Patch Perfect use: 0.3% failure Actual use: 8% failure

Ortho Evra  Seven day contraceptive patch 1 3/4 inch three-layer adhesive patch Releases estrogen and progesterone Newly applied weekly for three weeks, then one week off for menses Less effective in women over 198 pounds

NuvaRing 

Contraceptive vaginal ring - 2 inch diameter Worn for 21 days => removed for 7 days to allow menses => replaced with new ring Releases estrogen and progesterone One size only - does not require fitting Cannot be inserted incorrectly

Depo Provera  Perfect use: 0.3% Actual use: 3% failure

Depo Provera  Depot medroxyprogesterone injected once every 12 weeks – highly effective Irregular bleeding/spotting => amenorrhea within 2 years (70%) Concerns: –weight gain (54%) –osteoporosis risk, reversible

Long Acting Reversible Contraceptives (LACs) Increasing use in young women Well tolerated and very effective Perfect use and actual use same as one inserted- no effort required on part of user to maintain © 2009 McGraw-Hill Higher Education. All rights reserved.

Implanon  Progestin-only contraceptive implant Single flexible 4 cm rod inserted under the skin of the upper arm Contains progesterone - 3 year efficacy No pregnancies in 73,000 monthly cycles Irregular menstrual bleeding common Clinician visit required for insertion and removal Perfect use (0.05) actual use (0.05)

Implanon 

Mirena  Progesterone releasing intrauterine system 5 year efficacy Highest risk of PID within 20 days of insertion Irregular menstrual bleeding common in first 3-6 months Clinician visit required for insertion and removal Perfect use (0.2) Actual use (0.2)

Mirena  Intrauterine devices (IUDs)

ParaGard ® T 380A Copper-releasing IUD Believed to work primarily by preventing sperm from reaching and fertilizing the egg 10 year efficacy Irregular menstrual bleeding common in first 3-6 months Clinician visit required for insertion and removal Perfect use (0.6) Actual use (0.8)

ParaGard ® T 380A

Miscellaneous other forms: © 2009 McGraw-Hill Higher Education. All rights reserved.

Sterilization Vasectomy –Perfect use (0.1) actual use (0.15) –Difficult to reverse – consider permanent –No further action necessary Tubal ligation –Perfect use (0.5) actual use (0.5) –Difficult to reverse – consider permanent –No further action necessary © 2009 McGraw-Hill Higher Education. All rights reserved.

Vaginal Spermicides Perfect use (18) Actual use (29)

Sponge Perfect use (9%) Actual use (16%)

Withdrawal Very controversial as “method” Requires control and interruption of sex Perfect use (4%) Actual use (27%) © 2009 McGraw-Hill Higher Education. All rights reserved.