+ Contraceptive Methods Alison Pittman PGY2 Family Medicine Civic Family Health Team

+ Outline Introduction Choosing a Method of Contraception Natural Methods Non-Hormonal Methods Hormonal Methods

+ Contraception Patients often have questions about contraception but aren’t sure which type they want Some reasons why patients will ask about contraception: Control over timing of pregnancy Avoidance of unintended pregnancy Protection from STI infection Noncontraceptive health benefits (hormonal options) Discuss all forms with patients to find which method will fit their needs

+ Choosing a Method Convenience Duration Reversibility Efficacy Cost Side effects Accessibility STI protection Effect on uterine bleeding Noncontraceptive benefits Contraindications

+ Natural Methods Abstinence Fertility Awareness/Natural Family Planning Rhythm (Calendar) Method Withdrawal

+ Non-Hormonal Methods Surgery Tubal Ligation Vasectomy Barriers Male Condom Intrauterine Contraceptive Device (Copper IUD) Others Spermicide Contraceptive sponge Lea contraceptive Cervical Cap Diaphragm

+ Copper IUD T-shaped device with copper wire that is inserted into the uterus Changes intrauterine chemistry, prevents fertilization and destroys sperm Efficacy Fails in <1 in 100 users per year

+ Copper IUD Benefits: Up to 5 years of contraception No need to remember pills Can use while breast feeding No hormone exposure Decreased risk of endometrial ca

+ Copper IUD Relative Contraindications High risk for STIs Immunocompromised Ovarian cancer Absolute Contraindications Pregnancy Current or recent PID or STI Distorted uterine cavity Unexplained vaginal bleeding Cervical or endometrial cancer Copper allergy

+ Copper IUD Side effects Increased bleeding Dysmenorrhea Risks Uterine perforation Infection Expulsion Failure Risk of ectopic pregnancy

+ Copper IUD Who could benefit? Postpartum and breastfeeding Hormone concerns Difficulty remembering pills

+ Hormonal Methods Combined oral contraceptive Contraceptive patch Vaginal ring Progestin-only oral contraceptive Injection Hormonal IUD

+ Combined Oral Contraceptive Pills Combined OCPs contain estrogen and progestin Multiple mechanisms of action Efficacy 99.9% with perfect use User failure rates 3-8%

+ OCP – Non-Contraceptive Benefits Cycle regulation  menstrual flow  BMD  dysmenorrhea  perimenopausal symptoms  acne  hirsutism  ovarian cancer  endometrial cancer  risk of fibroids Fewer ovarian cysts

+ OCP – Absolute contraindications Pregnancy <6 weeks postpartum (if breastfeeding) Smokers >35y/o (>15 cig/day) Hypertension (>160/100) History of VTE IHD Previous CVA Valvular heart disease Migraine headache with neurologic symptoms Breast cancer (current) Severe cirrhosis Liver tumour

+ OCP – Relative Contraindications Smokers >35y/o (<15 cig/day) Controlled hypertension Migraines >35y/o Symptomatic gallbladder disease Mild cirrhosis Contraindicated medications

+ OCP – Side Effects and Risks Side Effects Irregular bleeding Breast tenderness Nausea Weight gain Mood changes Risks VTE MI CVA Gallbladder disease Breast cancer Cervical cancer

+ OCP - Disadvantages Compliance issues No STI protection Effectiveness may be affected by other medications

+ OCP – Who could benefit? Irregular cycles Heavy bleeding Dysmenorrhea Acne Otherwise healthy Good compliance

+ Contraceptive Patch Transdermal patch that continuously releases estrogen and progestin into the bloodstream Each patch is worn for 7 days. Week 4 is patch-free 99.7% effectiveness with perfect use 91% effectiveness with typical use

+ Contraceptive Patch Advantages Improved adherence Serum hormone levels remain in contraceptive range for up to 9 days Reversible Disadvantages Not as effective >90kg Possible skin irritation

+ Vaginal Ring Flexible, transparent ring placed in the vagina that delivers estrogen and progestin over a 3 week period 99.7% effective with perfect use 91% effective with typical use

+ Vaginal Ring Advantages Convenient Compliance Reversible Disadvantages Vaginal irritation Breakthrough bleeding

+ Patch and Ring Who could benefit? Difficulty remembering pills No contraindications Not interested in IUD

+ Progestin-only oral contraceptive Daily pill that does not contain any estrogen, just progestin Thickens cervical mucous and changes the lining of the uterus, affecting implantation 40% of women continue to ovulate 99.5% effective with perfect use 90-95% effective with typical use

+ Progestin-only oral contraceptive Absolute contraindications Pregnancy Current breast cancer Relative contraindications Active viral hepatitis Liver tumours

+ Progestin-only oral contraceptive Non-contraceptive benefits May decrease menstrual flow May decrease menstrual cramping and PMS Advantages Use in women who can’t take estrogen Women >35 who smoke Breastfeeding

+ Progestin-only oral contraceptive Side effects Irregular bleeding Hormonal side effects Headache/bloating/acne/ breast tenderness Disadvantages Must be taken at the same time every day No STI protection

+ Injection Injectable progestin (Depo-Provera) inhibits secretion of pituitary gonadotropins, suppressing ovulation 99.7% effective Absolute contraindications Pregnancy Current breast cancer Relative contraindications Severe cirrhosis Active viral hepatitis Benign hepatic adenoma

+ Injection Non-contraceptive benefits Amenorrhea (in 50%) with decreased dysmenorrhea Decreased risk of endometrial cancer, endometriosis symptoms, PMS, chronic pelvic pain Advantages Injection only needed every weeks Can be used while breastfeeding

+ Injection Side effects Weight gain Mood effects Hormonal side effects Risks Delayed return to fertility ~9 months Decreased BMD VTE; CAD; CVA

+ Hormonal IUD Intrauterine small T-shaped frame with levonorgestrel No estrogen Slowly releases hormone Endometrial decidualization, glandular atrophy, thickened cervical mucous 99.9% effective 5 years (Mirena) or 3 years (Jaydess)

+ Hormonal IUD Side effects Reduction in menstrual blood loss More bleeding soon after insertion, which decreases Some hormonal effects Depression, acne, headache, tenderness Functional ovarian cysts Advantages Effective Compliance Disadvantages Requires trained clinician for insertion and removal

+ In conclusion… There are many contraceptive options available to our patients Take a patient’s health, lifestyle, cultural beliefs and compliance habits into account when discussing their options Be familiar with side effects and contraindications

+ Questions?

+ References The Society of Obstetricians and Gynaecologists of Canada (SOGC) (2012) Birth Control Association of Reproductive Health Professionals ( June 2014) Choosing a Birth Control Method resources/quick-reference-guide-for-clinicians/choosinghttps:// resources/quick-reference-guide-for-clinicians/choosing Black, A., Francoeur, D., Rowe, T. et al. (2004) Canadian Contraception Consensus. JOGC, Volume 143 (part 1 of 3; February 2004) Black, A., Francoeur, D., Rowe, T. et al. (2004) Canadian Contraception Consensus. JOGC, Volume 143 (part 2 of 3; March 2004) 219 – 254 Trussell, J., Wynn, L. Reducing unintended pregnancy in the United States. Contraception. 2008;77(1):1

+ Tubal Ligation Surgical disconnection of the fallopian tubes Considered permanent Reversal is costly, difficult, and not guaranteed Benefits Most effective method for women Can be done at same time of c-section Risks Surgical risk Ectopic pregnancy more likely No STI protection

+ Vasectomy Surgical disconnection of the vas deferens Prevents sperm from entering the ejaculate Benefits Most effective male method Risks Surgical risks Possible sperm in ejaculate for up to 3 months No STI protection

+ Male Condom 97% effective When used properly and consistently Benefits Cheap Easy to use Some STI protection Disadvantages Latex allergies Breakage/slip off Poor use technique