The right contraceptive for the right woman

The right contraceptive for the right woman
Prof Johannes Bitzer MD Chairman Dep Obstet Gynecology University Hospital Basel

The Contraceptive Toolbox
Hormonal Contraceptives Nonhormonal Contraceptives Combined Oral Contraceptives Non-daily (non-oral) Contraceptives Clinician dependent Estrogen dose 15 µg 20 µg 25 µg 30 µg 35 µg > 50 µg Estrasdiol Progestogen type Norethisterone Levonorgestrel Gestodene Chlormadinone Acetate Desogestrel Drospirenone Cyproterone acetate NOMAC Progesterone only pills Progestogen type Norethisterone Ethynodiol diacetate Levonorgestrel Desogestrel Not clinician dependent Long Acting Reversible Contraceptives

How to tailor contraception ?
The 3 Steps Approach

Use opportunity to give first information
3 Step Approach Step 1 Use opportunity to give first information

Listen and encourage, excluding methods not wanted
Absolute need to prevent pregnancy in context of life situation Pregnancy not absolutely unwanted, but not now Spacing of pregnancies Family planning fulfilled; no more children wanted I do not want a foreign body inside Subjective part Wishes, values, objectives, concepts Natural method Easy to use Independent of partner Involvement of partner Safety is high priority Fear of health risks A pregnancy would be a terrible threat…………

Tailoring Contraception
Step 1 Step 2 Inform and educate

Assess the biopsychosocial profile
Findings Hypertension Obesity Diabetes Thyroid dysfunction Myoma Ovarian cysts Depression Anxiety Drug abuse Somatoform Disorder Sexual Dysfunction Health risks Age Cardiovascular risks Neoplastic risks Metabolic risks STI risks Hyperandrogenic signs Bone risk General behavioural risks Smoking Alcohol Objective part Risks, resources Complaints Irregular bleeding Dysmenorrhea Hypermenorrhea Hyperandrogenic signs Dyspareunia PMS PMDD

Assess the life context of your patient
Sociocultural Background Life Phase Language Migration Religion Norms Values Adolescence Postpartum Peri-menopause Relationship New, beginning Long standing Changing partners Conflict and crisis No relationship

Apply biomedical eligibility criteria
Woman Medical Eligibility Criteria for contraceptive methods WHO Category With Clinical Judgement With Limited Clinical Judgement 1 Use method in any circumstances Yes (Use the method) 2 Generally use the method 3 Use of method not usually recommended unless other more appropriate methods are not available or not acceptable No (Do not use the method) 4 Method not to be used Age Weight Cardiovascular risks Neoplastic risks Metabolic risks STI risks Hyperandrogenic signs Bone risk

Apply biopsychosocial eligibility criteria
Woman Medical Eligibility Criteria for contraceptive methods WHO Category With Clinical Judgement With Limited Clinical Judgement 1 Use method in any circumstances Yes (Use the method) 2 Generally use the method 3 Use of method not usually recommended unless other more appropriate methods are not available or not acceptable No (Do not use the method) 4 Method not to be used Age Expected compliance Religious norms Accessability Mood disorders Previous contraceptive history Repeated abortions

Tailoring Contraception
Step 1 Step 2 Step 3

Consider comorbidities and complaints, quality of life and convenience
Ease of use Facilitate compliance under stressful life conditions Enhance effectiveness of typical use Independent of gastrointestinal problems Comorbidities and Complaints Irregular bleeding Dysmenorrhea Hypermenorrhea Hyperandrogenic signs PCO Endometriosis Dyspareunia PMS PMDD Prevention Risk of osteoporosis Anemia PCO Family risk of ovarian carcinoma 14

Choose methods with additional health
benefits and increased compliance Risk of osteoporosis Anemia PCO Komb.30 Komb.20 Komb.15 POP Family risk of ovarian carcinoma Ease of use Facilitate compliance under stressful life conditions CVR Patch DepoG . Implanon Enhance effectiveness of typical use Independent of gastrointestinal problems LNG Ketog Gest NGM Irregular bleeding Drosp Dien Cypr Chlor Dysmenorrhea , Hypermenorrhea Hyperandrogenic signs PCO, Endometriosis Mirena PCC Dyspareunia PMS, PMDD

The Middle Aged Women 20-40 Years of Age
Increase and decrease of fertility Pregnancies, Spacing of pregnancies Endometriosis, Chronic pelvic pain Ovarian cysts, Functional and endometriotic Development of fibromas Cervical dysplasia and neoplasia PMS, PMDD Metabolic risks (Metabolic syndrome, etc) Biomedical characteristics Stressful professional life; Smoking, Drugs, Alcohol Family building Care for small children These women are often ambivalent about getting pregnant; Fertility concerns Very often they are in a stable relationship or in sequential monogamy Psychosocial characteristics

Contraceptive Needs of Women Aged 20-40 Years
Effective Protect against STI and HIV Independent of compliance Make them feel good No negative impact on body image and appearance Preserve and enhance fertility No or little cardiovascular risks No weight gain or negative metabolic effects Under the control of the woman (independent of partner) Additional benefits Endometriosis Bleeding Irregularities Dysmenorrhea Suppression of ovarian cysts Should or must

VT Risk Increases with Age and COC Use
PFZ EST 12/17/2017 VT Risk Increases with Age and COC Use Absolute risk of VT associated with current oral contraceptive use by age category Ref25/Vlieg/p3/table 2/ Incidence of VT (I0) per 10,000 person-years* Slide ID: 039 Notes: In a recent MEGA case-control study, researchers found that both the relative risk and absolute risk of venous thrombosis in women not using oral contraceptives increases with age, which indicates that the absolute risk of venous thrombosis associated with oral contraceptive use increases with age.1 Reference: Van Hylckama Vlieg A et al. The venous thrombotic risk of oral contraceptives, effects of oestrogen dose and progestogen type: results of the MEGA case-control study. BMJ. 2009;339:b2921. Ref25/Vlieg/p4/ col1/¶2/L10-14 *I0 is based on incidence published by Naess et al. Non-users of OC are used as the reference category VT = Venous thrombosis Van Hylckama Vlieg A, Helmerhorst FM, Vandenbroucke JP, Doggen CJM, Rosendaal FR. The venous thrombotic risk of oral contraceptives, effects of oestrogen dose and progestogen type: results of the MEGA case-control study. BMJ. 2009;339:b2921. 19 19 19

Very Effective Preserve and enhance fertility No or little cardiovascular risks No weight gain or negative metabolic effects Additional benefits Endometriosis Bleeding Irregularities Dysmenorrhea Suppression of ovarian cysts Protection against endometrial and ovarian Ca Combined Oral Contraceptives Non-daily (non-oral) Contraceptives Absolute thrombotic risk increases with age WHO 1 Women who want control without specific risks Consider lowest dose of estrogen and LNG as progestogen

Effective Preserve and enhance fertility No cardiovascular risks No weight gain or negative metabolic effects Additional benefits Endometriosis Bleeding Irregularities Dysmenorrhea Some women get acne or feel depressed Progesterone only pills Bleeding? No thrombotic risk The woman with cardiovascular or thrombotic risk who wants control and is compliant WHO 1

Long Acting Reversible progestogen Contraceptives Very effective Independent of compliance No cardiovascular risks Additional benefits Endometriosis Dysmenorrhea Menstrual migraine Heavy Menstrual Bleeding The woman with vascular risks and/or compliance problems and/or additional clinical conditions WHO 1

Contraceptive Needs of Women Aged 20-40 Years - LARCs
Cost Bleeding Weight Bone Long term use may reduce BMI in some women reversible High rate of predictable amenorrhea In some women weight gain Very low to low No negative impact High to very high Irregularities ; unpredictable No significant weight gain Medium rate of predictable amenorrhea No significant weight gain No negative impact High to very high

Very effective Independent of compliance No or little cardiovascular risks No weight gain or negative metabolic effects Additional benefits Protects against ovarian cancer Hyper- and Dysmenorrhea The woman with CI for hormones and or compliance problems WHO 1

Medium effective Protect against STI and HIV (Condom) Preserve and enhance fertility No or little cardiovascular risks No weight gain or negative metabolic effects Additional benefits none High demand on compliance Dependent on partner The woman with medical risks (cardiovascular, especially STI)

The Premenopausal Woman
Decline in fertility, ovarian aging Increase in miscarriage, chromosomal abnormalities, pregnancy complications Progesterone decline and estrogen fluctuation Irregular and heavy bleeding Climacteric symptoms Bone demineralization Risk increase for cardiovascular diseases Risk increase for gynecologic neoplasia Biomedical characteristics Family planning ambivalence Remain childless Late child Enough children Adolescent children, care for parents Professional career challenges at maximum and decline in energy Burn-out and depression Loss of sexual desire Psychosocial characteristics

Contraceptive Needs of Premenopausal Women
Effective Protect against STI and HIV Independent of compliance Preserve and enhance fertility No or little cardiovascular risks No weight gain or negative metabolic effects Additional benefits Climacteric symptoms Heavy menstrual bleeding Bone demineralization Perimenopausal depression Should

Very Effective Additional benefits Climacteric symptoms Heavy menstrual bleeding Protection against bone demineralization Perimenopausal depression Combined Oral Contraceptives Age dependent increase in thrombotic risk Non-daily (non-oral) Contraceptives WHO 1 The woman who already used CHC/ has no risk factors/ needs additional benefit

Very effective No or little cardiovascular risks No weight gain or negative metabolic effects Additional benefits Climacteric symptoms Heavy menstrual bleeding Progesterone only pills May lead to irregular bleeding WHO 1 The woman with cardiovascular risk

Very Effective Independent of compliance No cardiovascular risks No weight gain or negative metabolic effects Additional benefits Protection against ovarian and endometrial carcinoma Hypermenorrhea, Pain PID? Copper IUD The woman with cardiovascular risk / wish for long acting, no additional needs WHO 1

Very Effective Independent of compliance No or little cardiovascular risks Additional benefits Climacteric symptoms? Heavy menstrual bleeding LNGIUS Bleeding ? Personal Preference and Cost WHO 1 The woman with cardiovascular risk / wish for long acting contraception

Conclusions Different reproductive life phases are characterized by different contraceptive and reproductive health needs of women The Health Care Professional (HCP) should try to tailor the contraceptive method in a process of shared decision making, taking into account The wishes and values of the woman, her lifestyle and priorities Her biopsychosocial profile The specific characteristics of the methods to Assure efficacy Minimize health risk Realize additional health benefits

The right contraceptive for the right woman

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