 62 million U.S. women are in their childbearing years (age 15-44)  43 million (7 out of 10) are sexually active and do not want to become pregnant  A typical woman wants only two children and will need to practice contraception for at least 30 years of her life  62% of women currently use a contraceptive ◦ 11% at risk of pregnancy and not using contraceptive ◦ Remaining women don’t need a method (infertile, pregnant, seeking pregnancy) Guttmacher Institute DataGuttmacher Institute Data (June 2014)

 64% use reversible methods, such as OCs or condoms; remaining women rely on sterilization  Pill (28%) and female sterilization (27%) are the leading methods  Vasectomies account for 10% making sterilization the overall #1 method (37%)  Guttmacher Institute Data Guttmacher Institute Data Mosher WD and Jones J, Use of contraception in the United States: 1982–2008, Vital and Health Statistics, 2010, Series 23, No. 29.

Approximately 6.4 million pregnancies per year If a woman did not want to become pregnant at the time the pregnancy occurred, but did want to become pregnant at some future time, the pregnancy is considered mistimed. If a woman did not want to become pregnant then or at anytime in the future, the pregnancy is considered unwanted.

 100% safe and effective  Independent of coitus  Easy to use  Quick return of fertility  Independent of the medical professional  Controlled by the woman  Protects against STDs  Free of adverse effects  Fits within patient religious beliefs

 Non-hormonal methods ◦ Sterilization ◦ Natural Family Planning ◦ Barrier Contraceptives ◦ Spermicides  Oral contraceptives: combined, progestin- only ◦ Hormonal patch and ring  Long-Acting: ◦ Injectable progestin ◦ Progestin implant ◦ IUD: Copper-T, progestin-containing  Emergency Contraception

 Contraceptive – prevents fertilization; includes barrier methods, spermicides, primary MOA of COCs and EC  Interceptive – does not prevent fertilization; prevents implantation of the fertilized egg in the uterus; some consider this a form of abortion  Back-up mechanism of COCs and EC, IUD  Abortifacient – pregnancy is terminated after implantation  Mifiprex, prostaglandins

 Perfect use, correct use or theoretical effectiveness ◦ The maximum effectiveness of a method if always used as intended  Typical use or use effectiveness ◦ How patients usually use the method; includes patient error such as forgetting to take pills or not using spermicide with a diaphragm  Example – COCs are theoretically >99% effective but may be ~95% effective in practice

MethodPerfect UseTypical Use Spermicide1828 Natural family planning0.4 – Withdrawal422 Male condom218 Diaphragm612 Combination pill0.39 Injectable0.26 Implant0.05 IUD0.6/0.20.8/0.2

 Pregnancy can be prevented by: ◦ Douching after intercourse ◦ Urinating after intercourse ◦ Having intercourse while standing up or with the female on top ◦ The woman not having an orgasm ◦ Unprotected first intercourse ◦ Taking a bath or shower after intercourse Cleveland Clinic Foundation. Available at: info/docs/2400/2425.asp?index=9137&src=news. info/docs/2400/2425.asp?index=9137&src=news

◦ Quick recovery ◦ Lack of significant long-term effects ◦ Cost-effective ◦ No compliance issues ◦ High degree of safety; low mortality rates ◦ Protects against ovarian cancer

 Permanence ◦ Reversal is expensive, requires major surgery, and is not guaranteed  Regret  Expense  Requires aseptic conditions, surgical equipment, trained clinicians, anesthesia  Does not protect against HIV or other sexually transmitted infections

9% 3%-4% 2% Theoretical Number of Unintended Pregnancies Per Year With Correct Use Natural Family Planning

 Adolescents ◦ Anovulatory cycles ◦ Difficulty in maintaining abstinence  Premenopausal/perimenopausal women ◦ Erratic and anovulatory cycles  Postpartum/breastfeeding women ◦ Erratic cycles ◦ Time of ovulation return

Advantages  No side effects  Private  No or low cost  No health-care provider  Enhances intimacy and respect  Heightens awareness of abnormal cycles Disadvantages  Cumbersome  No protection from sexually transmitted diseases  Inaccurate in women with irregular cycles  Requires abstinence or another form of birth control during fertile periods

 These methods are truly contraceptive, inexpensive and free of side effects  Efficacy of natural family planning is generally lower than hormonal or permanent methods  Effectiveness requires understanding of the reproductive cycle and willingness to tolerate periods of abstinence

Prescription  Diaphragm  Cervical Cap Nonprescription Female Condom Male Condom Spermicides Vaginal Sponge Slide Source: ContraceptionOnline

 No hormonal side effects  Some methods available without prescription  Some reduce sexually transmitted infections Slide Source: ContraceptionOnline

 Not as effective as hormonal methods  Most require concomitant spermicide  Efficacy depends on consistent and correct use  Some require partner cooperation  Vaginal insertion and removal may be unacceptable  ↑ risk of UTI when used with a spermicide  Some require fitting by a clinician  Most are less effective in parous women Slide Source: ContraceptionOnline

 Urinary tract infection ◦ Particularly increased by exposure to spermicide  Toxic shock syndrome ◦ Rare complication of prescription female barrier methods ◦ Associated with extended time between device insertion and removal ◦ Associated with use during menses

 Most widely used reversible contraceptive worldwide ◦ 12% of women worldwide ◦ 8% of women in the U.S. ◦ Mostly used by ages 25-39, married and cohabiting  Negative publicity in the early 1980s  Misconceptions held by healthcare providers and the public  Fear of litigation  Historically restrictive product labeling

 Quick onset and return to fertility  May be used for 5 to 10 years  Efficacy is comparable to sterilization ◦ 5-year gross failure rates are <1% ◦ Safe  Highest degree of patient satisfaction among contraceptive methods ◦ 99% of users are “very” or “somewhat” satisfied

LNG-IUS,Mirena  Releases 20 µg levonorgestrel every 24 hrs  Duration of use: 5 years  0.1% experience unintended pregnancy in 1st year of use Copper-Releasing Intrauterine Contraceptive (ParaGard® T380A) Polyethylene device with 380 mm3 of exposed copper Polyethylene device with 380 mm3 of exposed copper Duration of use: 10 years Duration of use: 10 years 0.7% experience unintended pregnancy in 1st year of use 0.7% experience unintended pregnancy in 1st year of use LNG-IUS, Skyla Releases 14µg levonorgestrel every 24 hrs Duration of use: 3 years 0.6% experience unintended pregnancy in 1st year of use LNG-IUS = levonorgestrel intrauterine system LNG-IUS, Liletta Releases 16µg levonorgestrel every 24 hrs Duration of use: 3 years 0.55% experience unintended pregnancy in 1st year of use

(LNG-IUS, Mirena, Skyla and Liletta) ◦ Inhibits fertilization ◦ Thickens cervical mucous ◦ Inhibits sperm function ◦ Thins and suppresses the endometrium Copper-Releasing Intrauterine Contraceptive (ParaGard® T380A) Inhibits fertilization Inhibits fertilization Releases copper ions (Cu2+) that reduce sperm motility Releases copper ions (Cu2+) that reduce sperm motility May disrupt the normal division of oocytes and the formation of fertilizable ova May disrupt the normal division of oocytes and the formation of fertilizable ova Source: Barr Pharmaceuticals, Inc.

IUDs:  are abortifacients  cause ectopic pregnancies and, therefore, cannot be used in women with a history of ectopic pregnancy  cause pelvic inflammatory disease (PID)  need to be removed to treat PID  cannot be used in nulliparous women  cause infertility

 decrease the risk for endometrial cancer  (LNG-IUS) can be used as a first-line option to treat menorrhagia ◦ May be used in the presence of fibroids that don’t significantly distort or enlarge the uterine cavity ◦ 97% ↓ in menstrual blood loss  Can be used for EC (copper IUD only)

 Healthy women of any reproductive age  Nulliparous or multiparous women  Women at low risk for STIs  Women who seek long-term reversible contraception  Women who desire very effective contraception

 Pregnancy  Undiagnosed abnormal vaginal bleeding  Malignancy of the genital tract  Anomalies or fibroids incompatible with IUD insertion  Recent uterine infection or septic abortion  Current pelvic inflammatory disease, purulent cervicitis, chlamydial infection, or gonorrhea, pelvic tuberculosis  Allergy to components of IUD or Wilson's disease (for copper-containing IUDs)

 No protection against HIV or other sexually transmitted infections  Cite noncontraceptive benefits  Side effects ◦ At insertion—variable pain, cramping, vasovagal reaction ◦ First few days—light bleeding, mild cramping ◦ First few months—intermenstrual bleeding, cramping  Copper IUD: Heavier or prolonged menses  LNG-IUS: Gradual decrease in menstrual flow  Use NSAIDs to treat if mild to moderate  Instructions on how to check the IUD string

 Any time during menses  Any other time during a woman’s cycle if: ◦ She used appropriate contraception; ◦ She was not sexually active, or ◦ Her pregnancy test was negative  Any time after a pregnancy, a spontaneous abortion, a miscarriage, or an induced abortion if a woman has not engaged in unprotected intercourse

P Period late (pregnancy); abnormal spotting or bleeding A Abdominal pain, pain with intercourse I Infection exposure (STI); abnormal vaginal discharge N Not feeling well, fever, chills S String missing, shorter or longer