1. Patient-centered Contraception:
Updates on the Evidence

2. Objectives
Discuss rates of unintended pregnancy and contraceptive use in the US
Apply evidence-based guidelines to contraceptive provision using the CDC MEC
Provide contraceptive options using patient-centered care
Before we go on, lets dig a little on these issues.
Lets start with abortion: what do people say about women who get abortions? Who can do them? Where are they provided?
What about contraception? Does it work? Who uses it?

3. Nearly half (45%) of pregnancies in the US are unintended
Nearly half (45%) of all pregnancies among U.S. women in 2011 were unintended
In 2011, nearly half (45% or 2.8 million) of the 6.1 million pregnancies in the United States each year were unintended.
An unintended pregnancy is one that was either mistimed or unwanted (45% of all pregnancies).
- Mistimed- patient did not want to become pregnant at time pregnancy occurred, but wants to become pregnant in future
- Unwanted – patient did not want to become pregnant then or any time in future. If a woman did not want to become pregnant at
References:
Finer LB and Zolna MR, Declines in unintended pregnancy in the United States, 2008–2011, New England Journal of Medicine, 2016, 374:843–852.

4. Unintended pregnancy by consistency of contraception use
In 2008, the two-thirds of U.S. women at risk of pregnancy who used contraceptives consistently accounted for only 5% of unintended pregnancies.
Nonuse- women who are sexually active but did not use any method of contraception
Inconsistent use – women who used a method in all months that they were sexually active, but missed taking some pills, skipped use or used incorrectly
Consistent use- women without any gaps in use, used method consistently and correctly
References:
 Sonfield A, Hasstedt K and Gold RB, Moving Forward: Family Planning in the Era of Health Reform, New York: Guttmacher Institute, 2014.

5. One year failure rates Effectiveness Contraceptive Typical-use
Pregnancy rate
Perfect-use
Ineffective
Chance
85%
Less effective
Condoms
14% 3%
More effective
Pill/patch/Ring 8%
1-3%
Highly effective
IUDs
0.8 – 2%
Injectable
0.1 – 0.3%
Implant
Sterilization
(male and female)
User dependent methods are much more likely to have inconsistent or incorrect use
Talk about differences between typical and perfect use, and as more highly effective there is no real difference between the two
References:
Sonfield A, Hasstedt K and Gold RB, Moving Forward: Family Planning in the Era of Health Reform, New York: Guttmacher Institute, 2014.

6. Contraceptive Methods in the U.S.
-Highly effective methods of contraception are still underuse, but gaining traction.
-In 2012, about 12% of women using contraceptives relied on a long-acting reversible contraceptive method, or LARC. The proportion using LARCs has risen over the past decade, from 2% in 2002 to 6% in 2007 and 9% in 2009.
-An overall decrease in unplanned pregnancies is likely due to an increased use of more effective contraception, like LARC
*RHAP recognizes that not only women can get pregnant. Instances in which gendered language is used is a reflection of the methods used by researchers when conducting studies.
References:
Daniels K, Daugherty J and Jones J, Current contraceptive status among women aged 15–44: United States, 2011–2013, National Health Statistics Reports, 2014, No. 173, 
Kavanaugh ML, Jerman J and Finer LB, Changes in use of long-acting reversible contraceptive methods among United States women, 2009–2012, Obstetrics & Gynecology, 2015, 126(5):917–927.
Finer LB, Jerman J and Kavanaugh ML, Changes in use of long-acting contraceptive methods in the United States, 2007–2009, Fertility and Sterility, 2012, 98(4):893–897.

7. US Medical Eligibility Criteria (MEC)
The MEC
US Medical Eligibility Criteria (MEC)
CDC recommendations for specific contraceptive methods with certain medical conditions
*Ideally participants will download the app prior to the talk, also recommend to provide copies of the Summary Chart for those without app access.

8. MEC Categories of Safety

9. Notice all the green!

10. There is an APP for that!
Can be downloaded on iOS and Android operating systems (
Participants will need the MEC App or Summary Chart for the talk, they will use it now!
SPR = Selected Practice Recommendations

11. Another helpful APP Contraceptive Point-of-Care App
Available for both I-phones and androids, free
Evidenced-based, user friendly resources including
How to use Quick Start
How to choose and adjust birth control pills
How to prevent gaps in coverage when switching methods.
A link to the MEC
Collaboration between RHAP and UHS Wilson Family Medicine Residency faculty clinicians Dr. Joshua Steinberg and Dr. Katherine Holmes. 
To access: type in “contraceptive point-of-care” on users device and look for above icon.

12. In contraceptive management
CASES
In contraceptive management

13. Yolanda What do you do next?
16 year old G0P0 presents with UTI symptoms
Had unprotected sex 4 days ago
Urine pregnancy test is negative
What do you do next?
Yolanda comes into your office as a walk-in for a UTI
She asks for a pregnancy test and a prescription for birth control pills
Her pregnancy test is negative
On further questioning, she says she had sex without a condom 4 days ago
What do you do?
Photo accessed:

14. Opportunity knocks! Get a medical history
Ask about contraceptive or preconception needs
Yolanda is G0P0, doesn’t have any current medical illnesses, and is not taking any medication. She occasionally smokes cigarettes. Her BMI is 23 and her blood pressure is 110/76.
She’s not ready to become a parent just yet, and wants to know her contraceptive options

15. Emergency Contraception
Factors that will affect the efficacy of the emergency contraception (EC) pill:
LMP
Last unprotected sex
BMI
Plan B (Levonorgestrel) – effective up to 3 days after unprotected sex, doesn’t work as well in women > 165 pounds.
Ella (ulipristal acetate) – more effective than Plan B, maintains nearly full efficacy on 4th and 5th day. Used up to 5 days after unprotected sex.
Copper IUD- most effective, can be placed up to 5 days post-unprotected sex.

16. Yolanda choses her EC Yolanda chooses Ella
But also wants to start contraception
When should she start?
Yolanda chooses to start ELLA as she doesn’t want to risk an unintended pregnancy. You agree on Ella because her last unprotected sex was 4 days ago and wants the most effective method, and she’s not interested in a Copper IUD.
When to start contraception?
If EC copper IUD, no need
If EC ulipristal, wait 5 days to start any method – ACOG rec based on one study and theoretical interaction – often not practical
Use shared decision making, and if Yolanda wants to start a method the same day, counsel on risks of early pregnancy and recommend taking a pregnancy test in 2 weeks
If EC levonorgestrel, start ASAP– can put in progesterone IUD same day as EC

17. Reproductive Health Access Project: Quick Start Algorithm
Accessed:
Explain Quick Start with pills:
After a negative ucg:
Pills started on the day of the visit instead of the Sunday after the next period
Westoff studies showed more women on the pill by month 3, and fewer pregnancies
-If OCs are prescribed with Sunday or 1st-day-of-menses start, as many as 25% of women do not start.
-No increased bleeding or spotting
-Most birth control methods are not teratogenic
-Can use quickstart immediately following miscarriage or abortion
References:
Westhoff C, Kerns J, Morroni C, Cushman LF, Tiezzi L, Murphy PA. Quick start: novel oral contraceptive initiation method. Contraception Sep;66(3):141-5.
Westhoff C, Morroni C, Kerns J, Murphy PA. Bleeding patterns after immediate vs. conventional oral contraceptive initiation: a randomized, controlled trial. Fertil Steril Feb;79(2):322-9.

18. Contraceptives: What is needed before providing?
Pap smear
Pelvic/breast exam
STI testing
Hemoglobin
NOT REQUIRED
Medical history
REQUIRED
A complete medical history is needed in order to rule out contraindications to hormonal contraception.
Physical exam, STI screening, Pap smear, etc… NOT REQUIRED. These interventions may be helpful for other reasons– but are not needed in order to prescribe hormonal contraception safely.
This applies to young teenagers who may be embarrassed or afraid of having a physical exam, and is particularly helpful in new patient visits.
References:
Stewart F, et al. Clinical breast and pelvic examination requirements for hormonal contraception: Current practice vs evidence. JAMA. 2001;285:
Blood pressure
RECOMMENDED

19. What about estrogen? Estrogen absolute contraindications:
Migraine with aura
Uncontrolled hypertension
History of DVT/PE
Tobacco use*
CDC MEC Categories for use of CHCs
- Migraine with aura: category 4
Uncontrolled hypertension:
Systolic or diastolic – category 3
Systolic > 160 or diastolic > 100 – category 4
Postpartum < 21 days: Category 4
History of DVT/PE: category 4
Tobacco use:
Age < 35 – MEC category 2
Age > 35, <15 cigarettes/day – MEC category 3
Age > 35, > 15 cigarettes/day – MEC category 4
References:
Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use: Updated July 2016.

20. Medications and COCs?
Give participants idea of the overview- mostly green, only a few pink. AND NO RED.
Antiretroviral- mostly safe
Anticonvulsants- mostly safe
Antimicrobials- - ONLY RIFAMPIN AND RIFABUTIN DECREASE EFFICACY
SSRIs/St Johns wart- all effective
References:
Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use: Updated July 2016.

21. What does Yolanda want?
Presenter should ideally open this up to audience participation.
Shared decision making is when a healthcare navigator provides balanced and unbiased information to patients with the goal of empowering patient decisions and building trust.
What has she heard about birth control?
Has she ever been on it, if so what kinds? Do her friends or family have any experiences? Who helps her makes decisions
What kind of control does she want over her birth control?
Is it important for her to be able to stop and start when she wants? Is she ok with requiring providers to place or remove birth control?
Does she care about having her period regularly?
Is she ok with potentially having spotting or no periods at all?
Is she ok with having hormones or devices in her body?
Does she want or need to hide this from anyone?
- Parents? Partner?

22. Yolanda decides to start the pill
Does it matter which pill she starts?
Mostly all the same, despite marketing
Cycle control better with EE than 20mcg – more breakthrough bleeding. But lower estrogen can reduce estrogen related side effects.
Extended cycle decreases days of bloating and menstrual cramping. Preparations can range from 84 to 365 days.
First generation progesterones have higher discontinuation rates than 2nd/3rd generation and worse cycle control.
Monophasics recommended over di/tri phasics – no differences in side effects.
No differences with acne, weight gain, adverse effects (conflicting studies)
References:
Szabo KA, Schaff E Oral Contraceptives, Does Formulation Matter? J Fam Prac 2013 Oct 62(10) E1-12

23. The patch and ring are also similar options…
The patch is changed weekly, the ring changed every 3-4 weeks (with menstruation occurring the 4th week)
Theoretically better adherence due to not daily
Ring has active hormone levels up to 35 days, patch up to 9 days.
References:
Dieben TO, Roumen FJ, Apter D. Efficacy, cycle control and user acceptability of a novel combined contraceptive vaginal ring. Obstet Gynecol Sep;100(3):
Lesnewski R et al Preventing gaps when switching contraceptives 2011 Am Fam Phy Mar 1;83 (5)567-70
Zieman M, Hatcher RA. Managing Contraception. Tiger, Georgia: Bridging the Gap Foundation, 2012.

24. How many refill should we give Yolanda
How many refill should we give Yolanda? Should we dispense one at a time?
To increase adherence, write for a full year’s supply: even if Yolanda needs a follow-up visit.
That’s a 3-month supply with 3 refills.
The more pills that are given, the longer the method is continued.
We have been taught to link refills to follow-up visits: but this stems from an authoritarian model of care.
Patient-centered practice = many refills on chronic medications.

25. Should Yolanda get a prescription for EC too?
Women under 18 need a prescription for EC except for one formulation: Plan B (state dependent)
Advance prescription doubles the rate of use
Having EC available does NOT decrease the use of the usual contraceptive method
Using EC does not increase the rate of STIs or unprotected intercourse, even in teens
Even teens who are given an ongoing prescription for pills might need EC, if they forget several days of pills or start their next pack late
References:
Bissel et al. Supplying emergency contraception via community pharmacies in the UK: reflections on the experiences of users and providers. Soc Sci Med.2003;57:
Raine et al. Direct access to emergency contraception through pharmacies and effect on unintended pregnancy and STIs: a randomized controlled trial. JAMA.2005;293:54-62.
Trussell J, Koenig J, Ellertson C, Stewart F. Preventing unintended pregnancy: the cost-effectiveness of three methods of emergency contraception. Am J Public Health 1997;87:932-7.
Gold, MA, Wolford JE, Smith KA, Parker AM The effects of advance prescription of emergency contraception on adolescent women’s sexual and contraceptive behaviors. J Pediatr Adolesc Gynecology 17(2):87-96.

26. Liz
25 year old, G0P0
Doesn’t want to get pregnant until she finishes school
Wants a contraception that she can hide from her mom
Hates remembering to take pills
What are her choices?
Lifestyle factors have a big impact on contraceptive choice.
Many patients have to hide their sexual activity from parents or other family members.
Some patients have limited privacy – they can’t risk having pill packs for someone to discover.
Photo accessed:

27. Highly effective methods NOT USER DEPENDENT
Effectiveness
Contraceptive
Typical-use pregnancy rate
Perfect-use pregnancy rate
Highly effective
IUDs
0.8 – 2%
Injectable
0.1 – 0.3%
Implant
Sterilization
The most highly effective methods are those that are not user-dependent.
They keep working regardless of what the user does.

28. Progestin-Only Injection
DEPO:
Highly effective - 0.3% failure rate!
QuickStart: if urine pregnancy negative, no need to wait for menses!
Amenorrhea: 50% by one year, 80% by 5 years
Private, not user-dependent
Users come to clinic ~ every 3 months, but now home injection available which may increase adherence

29. Depo Provera and Bone Density
Weighing risks and benefits:
No need to restrict Depo Provera use
Black box warning 2004: Depo-Provera use >2 years associated with BMD loss
No evidence, however, of increased in future fracture or osteoporosis risk
BMD loss temporary, recovers after discontinuation
Teen pregnancy causes more bone loss than teen Depo Provera use
Other lifestyle factors have greater impact on BMD: exercise, diet, weight
References:
ACOG Committee Opinion. Number 602, June 2014, reaffirmed 2016

30. Intrauterine Devices
There are 2 types of IUDS available in the US: the copper IUD and the progestin IUD.
Copper IUD (paragard) – non-hormonal, lasts 12 years
Hormonal IUD (levonogestrel - mirena 52mg 7 years, liletta 52mg 5 years, kylena 19.5mg, skyla 13.5mg 3 years)
They’re both safe and highly effective.
Because IUDs’ side effects & advantages differ, RHAP uses a simple info sheet to help patients choose between the 2 types.
Accessed at:
References:
Sivin, et al. Prolonged intrauterine contraception: a seven-year randomized study of the levonorgestrel 20 mcg/day (LNg 20) and the Copper T380 Ag IUDS. Contraception Nov;44(5):
Chiou CF, Trussell J, Reyes E, Knight K, Wallace J, Udani J, Oda K, Borenstein J. Economic analysis of contraceptives for women. Contraception. 2003;68(1):3-10.
Hubacher D, Cheng D. Intrauterine devices and reproductive health: American women in feast and famine. Contraception Jun;69(6):
Hatcher RA, Zieman M et al. A Pocket Guide to Managing Contraception. Tiger, Georgia: Bridging the Gap Foundation, 2004 .

31. IUD considerations Nulliparity STI Screening Timing of placement
Things to consider
NULLIPARITY – not a contraindication to IUD , but important to keep in mind for your procedure (complications of difficulty with internal os, first pelvic exam, etc)
Screen for GCCT – universal screening (Grade B Recommendation USPSTF), concern for STI infection not contraindication for insertion or pull of IUD (however current PID yes per CDC MEC guidelines)
Do NOT need to wait for a woman to be menstruating to insert an IUD (may medicate with misoprostol if especially difficult, or return to care, but not common). IUDs can also be safely placed immediately post partum or 6 weeks post partum, or post abortion
References:
Grimes DA. Intrauterine device and upper-genital-tract infection.Lancet Sep 16;356(9234):
Andersson K, Odlind V, Rybo G. Levonorgestrel-releasing and copper-releasing (Nova T) IUDs during five years of use: a randomized comparative trial. Contraception Jan;49(1):56-72.
Grimes D, et al, Immediate post-partum insertion of intruterine devices, Cochrane 2003 (1).
Hubacher D et al. Use of copper IUDs and the risk of infertility among nulligravid women NEJM, 2001, 108;
Grimes DA, Schulz KF. Antibiotic prophylaxis for intrauterine contraceptive device insertion. Cochrane Database Syst Rev. 2001;(1):CD
Selected practice recommendations for contraceptive Use, 2nd edition, Geneva: WHO 2005.

32. IUD Considerations Family planning timeline Medication cost
Risk of ectopic
Things to consider
IUDs duration anywhere from 3 to 12 years, but can be removed at ANY time and not affect ability for pregnancy
Personal control can be barrier to IUD insertion, so important to make women feel like she has autonomy, no coercion in placing or maintaining IUD
If cost a barrier, look for a Title X family planning clinic near you, cost of Liletta is $50-$75
Ectopic pregnancy: The very few pregnancies that occur with an IUD in place are more likely to be ectopic; but the overall pregnancy rate is so low that this scenario is rare.
References:
Andersson K, Odlind V, Rybo G. Levonorgestrel-releasing and copper-releasing (Nova T) IUDs during five years of use: a randomized comparative trial. Contraception Jan;49(1):56-72.
Hubacher D et al. Use of copper IUDs and the risk of infertility among nulligravid women NEJM, 2001, 108;
Grimes DA, Schulz KF. Antibiotic prophylaxis for intrauterine contraceptive device insertion. Cochrane Database Syst Rev. 2001;(1):CD
Selected practice recommendations for contraceptive Use, 2nd edition, Geneva: WHO 2005.

33. Progestin Implant Highly effective and rapidly reversible Discreet
Duration: 4 years
Can be used during lactation
Causes spotting
The challenging features of implants include the associated irregular vaginal bleeding and the need for clinician visits for insertion and removal.
As a reminder, implants, like other non-barrier forms of contraception, do not protect from sexually transmitted diseases, including HIV infection.
~ 20% of women get it prematurely removed because of bleeding
After discussion, Liz decides to choose the copper IUD, and you are able to place it with no complication that day.
References:
Peipert, J. F., Zhao, Q., Allsworth, J. E., Petrosky, E., Madden, T., Eisenberg, D., & Secura, G. (2011). Continuation and satisfaction of reversible contraception. Obstetrics and gynecology, 117(5), 1105.
Ravi, A., Prine, L., deFiebre, G., & Rubin, S. E. (2017). Beyond the Surface: Care Seeking Among Patients Initiating Contraceptive Implant in an Urban Federally Qualified Health Center Network. Journal of primary care & community health, 8(1),

34. Jamie
Jamie is a 28 year old transgender male. He is interested in preventing pregnancy, and has both male and female partners. He has not had any surgeries, and is not on hormone therapy but may be interested in the future.
What are Jamie’s options?
Jamie should be offered all contraceptive options that are medically safe and conducive to his goals.
Considerations when providing contraceptive options in transgendered care:
Multiple barriers exist for medical care for patients on the gender spectrum, including physical discomfort, emotional and gender dysphoria related discomfort, insurance difficulties, stigmatization and discrimination by other patients, staff, and medical providers.
Individuals on the gender spectrum are extremely variable in their gender expressions, identities and experiences within the medical community. Its important to not make assumptions and ask open ended questions. Being open, having clear and unbiased communication, and providing the patient with the most control will contribute to a successful visit. It’s ok to make mistakes, just recognize and apologize for any miscommunications
Language tips: ask about pronouns preferred (he/she/zie), anatomical term preferences (ie instead of vagina, use genital opening), avoiding words with violent or sexual connotations (ie- exam bed, use table instead)
Special issues to keep in mind regarding contraception options:
Interactions with cross-gender hormonal therapy, ie- if on testosterone may not want estrogenic effects of birth control
Desire to have or not have monthly menses
Apprehension about pelvic exam, history of trauma
History of uterine or pelvic reconstructive surgery
Reference: Potter, J., Peitzmeier, S. M., Bernstein, I., Reisner, S. L., Alizaga, N. M., Agénor, M., & Pardee, D. J. (2015). Cervical cancer screening for patients on the female-to-male spectrum: a narrative review and guide for clinicians. Journal of general internal medicine, 30(12),
Photo credit:  

35. Take home message: Be proactive with contraception!
Ask about contraceptive or preconception needs at all types of visits
Discuss all methods - always honor a patient’s choice
De-link pap smears from contraception prescriptions
Prescribe 1 year supply with 3 packs at a time
Use Quick Start
Ask about contraceptive or preconception needs at all types of office visits: including asking male patients
Provide patient-centered options counseling, using balanced information and avoiding coercion
Break the link between contraception and Pap smears
Break down barriers to same-day initiation of contraception
Write 90-day prescriptions with 3 refills if possible: always write for 1-year supply
Dispense contraceptives if possible
Use Quickstart methods

36. Exercises with the MEC App
What are the contraception options?
26 year old with seizures on phenytoin
19 year old being treated for cystitis with nitrofurantoin
27 year old with depression on fluoxetine
35 year old with migraine with aura (vs without)
30 year old with history of Roux and Y bariatric surgery
43 year old with history of diabetes, HTN, dyslipidemia who smokes a pack per day
17 year old with BMI of 36
24 year old post MVA abortion
Have participants do these on their own, discuss at end
26 yo F on phenytoin – Level 3 for POP, CHCs
19 year old being treated for cystitis with nitrofurantoin (can use ANYTHING, including COCs… Rifampin only abx that can affect POP/CHCs)
27 year old with depression (all methods, although popular now, poor evidence for worsening depression)
35 year old with migraine with aura (vs without) – anything but COCs, vs COC level 2
43 year old with history of diabetes, HTN, dyslipidemia who smokes- DMPA level 3, CHCs 3-4.
17 year old with BMI of 36 (category 1 except CHCs category 2)
24 year old post abortion (any method)

37. reproductiveaccess.org