1. ADOLESCENT CONTRACEPTIVE CARE Eliza Buyers, MD, FACOG Kaiser Permanente Department of OB/GYN elizabuyers@msn.com Office: 303-360-1576 COAPPP’s Raising the Bar Conference October 8&9, 2009

2. Disclosures  Eliza Buyers has no significant financial interests or other relationships with industry relative to the topics that will be discussed.

3. Learning objectives  Describe some of the common barriers that the adolescent population faces in obtaining reproductive health care and contraception.  Discuss common misperceptions about adolescent contraceptive care.  Describe the advantages, expected side effects, and contraindications of various methods.  Describe why long-acting methods are optimal for many adolescent patients.

4. Adolescent Contraceptive Care OVERVIEW  Background on adolescent pregnancy and the barriers to contraceptive care  Specific methods and overcoming barriers to care  Emergency Contraception (EC)  Quick Start  Extended/Continuous use OCPs/ring/patch  Update on Depo-Provera  IUDs (Levonorgestrel IUD)  Single-rod contraceptive implant (Implanon)

5. Adolescent Pregnancy OVERVIEW Teen pregnancy outcomes 57% 29% 14% Birth Abortion Miscarriage Guttmacher Institute, Facts on American Teens’ Sexual and Reproductive Health, Sept, 2006 - Almost 1 million pregnancies. - 82% unplanned - 3 in10 girls pregnant by age 20 - 1 in 3 end in abortion

6. Adolescent Pregnancy OVERVIEW Talking about Reproductive Health

7. September 6, 2008 Charles M. Blow OP-ED COLUMNIST Let ’ s Talk About Sex By CHARLES M. BLOW Published: September 6, 2008

8. Providers’ Perspectives: Perceived Barriers to Contraceptive Use in Youth and Young Adults 1. Lack of provider training. 2. Outdated protocols and lack of continuing education. 3. Restrictive reimbursement procedures. 4. Lack of social marketing that promotes contraception. 5. Inadequate reproductive health services for men. www.thenationalcampaign.org/resources/pdf/BarrierstoContraception_FINAL.pdf

9. Barriers to Care: Lack of Confidentiality Talking about Reproductive Health  MAJOR OBSTACLE: CONFIDENTIALITY  Most teens want care but NOT if their parents know.  If parents were notified: nearly 50% would not seek care but 99% would still have sex.  Assure confidentiality at the start of your visit.  Colorado law: minors have access to confidential services for contraception and STD testing.  Unless suicidal, homicidal or abuse involved.  Explain your office procedures to maintain this right.  Beware of billing and coding, private insurance.

10. Barriers to Care: How To Ask About Sex Talking about Reproductive Health  First, assure confidentiality  Open-ended and open-minded  “Are you dating anyone or hooking up?” (how old?)  “Are your friends dating people?”  “Do you (or your friends) have any questions about sex?”  “Do you have sex with girls or boys or both?”  “I am so happy that you came in today. It is so important that you take responsibility for your own health and this includes your reproductive health.”

11. Barriers to Care: Magical Thinking Talking about Reproductive Health  Assure confidentiality, Open-ended, open-minded  Address magical thinking: “I can’t get pregnant”  A sexually active teen who does not use contraception has a 90% chance of becoming pregnant in a year.  1 in 3 girls pregnant at least once before age 20  A single act of sexual intercourse: 8% chance of pregnancy.  Teens with a negative pregnancy test: 58% pregnant at least once within next 18 months.  Health care provider (YOU!) may be the ONLY source of accurate information.

12. Barriers to Care: Accurate Information Talking about Reproductive Health  Parents beliefs about condoms and oral contraceptives  What parents think about condoms:  47% effective in preventing HIV/STDs (fact: 98-100% )  40% effective to prevent pregnancy (fact: 97% perfect use)  What parents think about oral contraceptives:  52% “highly effective” to prevent pregnancy (fact: 94- 99%)  39% thought almost all teens can use pills safely (fact: all healthy teens can!)  39% thought teens could use pills as consistently as other age groups (fact: just as well!)

13. Adolescent Pregnancy OVERVIEW Talking about Reproductive Health www.stayteen.org (National Campaign) www.sexetc.org (Answer, from Rutgers Univ.) www.teenwire.com (Planned Parenthood) www.scarleteen.com (private funding)

14. Adolescent Pregnancy OVERVIEW STDs  19 million cases of STDs each year: One-half in persons ages 15-24  1 in 10 sexually active female adolescents have chlamydia  Chlamydia screening rates unacceptably LOW  15-25 year olds: only 6.8% routine visit, 16% preventive visit, 23% at pap smear  50% of new HIV infections in the US are among persons less than age 25 STD DIAGNOSIS = TEACHABLE MOMENT

15. Comparing effectiveness of methods Most effective Least effective Generally 2 or fewer pregnancies per 100 women in one year About 15 pregnancies per 100 women in one year About 30 pregnancies per 100 women in one year Need repeat injections every 1 to 3 months Must take a pill each day Must use every time you have sex; requires partner’s cooperation. Must follow LAM instructions Must abstain or use condoms on fertile days; requires partner’s cooperation. How to make your method most effective One-time procedures. Nothing to do or remember. Must use every time you have sex Must use every time you have sex; requires partner’s cooperation. Injectables Pill s LAM Male Condoms Female Condom Diaphragm Spermicides IUD Implants Female Sterilization Vasectomy Fertility Awareness-Based Methods

16. Methods of Contraception and Overcoming Barriers  Emergency Contraception  Quick Start  Extended/Continuous use methods  Update on Depo-Provera  IUDs in adolescents  Single rod implant

17. Emergency Contraception (EC)  Over-the-counter for women 18 years and older.  PRESCRIPTION REQUIRED for women younger than 18 years.  The provision of EC does not alter adolescent sexual or contraceptive behavior.  If EC is available, it is more likely to be used in the event of unprotected intercourse and it is more likely to be used earlier.

18. Emergency Contraception (EC)  Plan B ® (progesterone-only EC)  2 pills containing 0.75 levonorgestrel  Take as one dose or 12-24 hours apart  Primary mechanism of action is delay of ovulation  Should use as soon after unprotected intercourse as possible to maximize efficacy (reduced chance of pregnancy by 60-94%)  Offer up to 120 hours (5 days) after unprotected intercourse  If taken within 3 days: reduces chance of pregnancy from 8% to 1%

19. Emergency Contraception (EC)  No deaths or serious complications have been linked to use  No drug interactions  WHO: no medical conditions where the risks of EC outweigh the benefits of use  MAY USE if breastfeeding, history of ectopic, liver disease, cardiovascular disease, migraines, history of DVT…

20. Emergency Contraception (EC)  No clinical exam or testing is required before EC is provided  Anti-emetics are not necessary for progesterone-only EC (Plan B)  EC may be used repeatedly, even within the same menstrual cycle  Offer an EC prescription with every pregnancy test, every STD evaluation…

21. Oral Contraceptive Pills (OCPs)  Most popular method of hormonal contraception.  The only method that many providers and patients consider. Overcoming Barriers:  “Quick start” over conventional start.  Highlight non-contraceptive benefits.  Offer extended and continuous use.  Think about access/refill issues.  All women can be “excellent” OCP users.

22. Contraceptive Use at Last Sex Among Sexually Active, Unmarried Women, NSFG 2002

23. Oral Contraceptive Pills (OCPs) Barrier: Getting Started  Why do 24% of adolescents never take the first pill after receiving the pack?  Confusion about starting instructions.  Waning motivation.  Become pregnant while waiting to start.

24. Oral Contraceptive Pills (OCPs) Quick Start (also for ring, patch, Depo)  If negative pregnancy test: swallow first pill under direct observation during visit (regardless of menstrual day).  Give Emergency Contraception if indicated (and usually Quick Start the next day).  Use back-up with condoms for 1 week.  Repeat pregnancy test if no withdrawal bleed, or follow-up pregnancy test in 2-4 weeks.

25. Quick Start Don’t fear rejection!  Women prefer it. (81%- 97%)  Higher initiation/continuance rates.  No bleeding differences based on day of initiation Westhoff. Bleeding Patterns, OC Compared With Vaginal Ring. Obstet Gynecol 2005.

26. Quick Start Unintended pregnancy (not “missed” pregnancy) is the issue.  Urine pregnancy tests are very good:  Implantation produces HCG (6-12 days after ovulation)  HCG detected at 20-50 mIU/mL.  No need for serum HCG  Very low pregnancy rates in first cycle with quick start even if recent unprotected intercourse (3% or lower).  Consider the impact on initiation rate:  100% with observed quick start.  About 75% if pills dispensed (even lower if RX only)  Hormonal contraceptives are not teratogenic (or abortifacients) even if pregnancy does occur.

27. Oral Contraceptive Pills (OCPs) Number of OC Packs Dispensed Foster et al, 2006  82,000 women who received birth control pills.  Women were given a complete one, three, or 13- month supply of OCPs.  Women who received 13 cycles were 28% more likely to continue using oral contraceptives after 15 months than women who obtained a 3-month supply.  13 cycle group: fewer gaps in OCP coverage than women prescribed shorter cycles  Only 4% had gaps compared to 16% (1 month) and 19% (3-month group)

28. Dispel Myths!  “It isn’t that safe.”  “The pill makes you fat.”  “The pill makes it harder to get pregnant later on.”  “It’s good to take a break from the pill.”  “It’s not safe because breast cancer runs in my family.”  “She’s too young to be on the pill.”  “It doesn’t really work.”  “I’ll need to use condoms anyway because I take antibiotics a lot.”

29. Oral Contraceptive Pills (OCPs) Which Pill for Adolescents?  No pill is inherently “better” than any other pill  All U.S. pills contain the same type of estrogen  EE = ethinyl estradiol  Differences are in type of progestin  Typical “low-dose” pill: 30-35 mcg EE  “ultra low-dose” pill: 20 mcg EE  NO DIFFERENCE IN EFFICACY 20ug vs. 30ug

30. Oral Contraception Pills (OCPs) Consider Cost  Intermediate progestational and low estrogenic activity  Generic substitute for Seasonale  $30/pack  Low progestational/androgenic and intermediate estrogenic (generic Ortho-Cyclen)  Good choice for acne, PCOS  TARGET: $9/pack; or $24 for 3 packs  High progestational and low estrogenic activity (amenorrhea is common)- ultra-low 20 mcg EE  Good choice for concerns about nausea, breast pain  $27/pack LEVORA PORTIA SPRINTEC JUNEL MICROGESTIN 1/20

31. Oral Contraceptive Pills (OCPs) Extended and Continuous Products  NOT a new therapy!  Patients have been prescribed OCPs “as directed” for decades  EXTENDED  Take active pills for longer than the traditional 21 days  CONTINUOUS  Active pill every day (no placebo breaks)  FDA Approved  Seasonale, ® Seasonique, ™ Lybrel ™

32. Oral Contraceptives: Extended Use Counseling on Safety  Standard/traditional pill is 21 days active pills and 7 days placebo (21/7 regimen)  No medical rationale for 21/7  Monthly withdrawal bleeding is designed to make the pill cycle feel “natural” But, there is no ovulation on the pill And, no menstrual lining “build up”

33. Oral Contraceptives: Extended Use Perceived Benefits of Menstruation  Myths about monthly menstruation  Necessary for “cleansing the system”  A “natural” state  A symbol of femininity, fertility, and youth  A sign a woman is not pregnant  Address safety concerns of the patient (her parents or partner) before prescribing extended OCPs.

34. Oral Contraceptives: Extended Use Who might benefit from reduced frequency of menstruation?  Women with menstrual-related disorders  dysmenorrhea, menorrhagia, PMS, menstrual migraines, cyclic breast pain…  Athletes  Women in the military  Developmentally delayed women  Any woman who chooses to bleed less frequently

35. Oral Contraceptives (any type, patch, ring) Review: Non-contraceptive Indications for Use  Dysmenorrhea  Menorrhagia (anemia)  Acne  Pelvic pain (unexplained and endometriosis-related)  Polycystic Ovarian Syndrome  PMS  Bone loss  Benign breast disease  Prevents cancer of the uterus and ovary

36. Oral Contraceptives: Extended Use MORE STUDIES NEEDED  Continuous administration of pills may improve OCP success  Especially in “poor” pill takers  Continuous administration of pills may help prevent ovarian follicular development (cysts).

37. Oral Contraceptives: Extended Use Patient Counseling  Unpredictable breakthrough bleeding (BTB) similar to conventional OCPs  Will improve with each cycle of use  Take the pill the same time every day to prevent BTB  Never hesitate to do a pregnancy test  Tailor the extended regimen to your bleeding  On average >70% of patients satisfied with extended use of OCPs

38. Oral Contraceptives: Extended/Continuous  FDA approved: Seasonale, Seasonique, Lybrel  Can use ANY combined OCP  Sprintec, Necon, Zovia…  Can even use a triphasic but not sure why?  In one study of continuous users, norethindrone acetate OCs (Microgestin) were associated with less bleeding than levonorgestrel OCs (Levora) Edelman et al. Obstet Gynecol 2006.

40. Medical Options for Reducing Menstruation  Extended-use OCPs  Contraceptive vaginal ring: NuvaRing   Trans-dermal contraceptive patch: Ortho Evra   Injectable progestin-only contraception (DMPA)  Progestin-releasing intrauterine device (Mirena ® )  Oral progestins (norethindrone acetate, Aygestin ® )  Danazol (Danocrine ® )  Gonadotropin-releasing hormone analogues (e.g., Leuprolide Acetate, Lupron Depot ® ) Kaunitz.. Contraception 2000.

41. Ring and Patch for Continuous/Extended Use  The contraceptive ring can be left in for 4 weeks and replaced immediately with another ring.  The patch can be used for more than 3 consecutive weeks. (“apply new patch each week x 9 weeks…”)

42. Oral Contraception: Extended Use Conclusions  Many women would prefer to menstruate less if they knew it was safe.  Any OCP can be taken in an extended or continuous fashion (or use the ring/patch).  Expect breakthrough bleeding which will improve over time.

43. Depo-Provera: Update  Still the best option for many of our patients.  EFFICACIOUS  (Almost) Forgettable  Non-contraceptive benefits (1 yr: 50% amenorrhea)  ACOG: “Concerns regarding…BMD should neither prevent practitioners from prescribing DMPA nor limit its use to 2 consecutive years.”  No role for DEXA scans  Partial or full recovery (like pregnancy, breastfeeding)  No data showing increase fracture risk

44. Depo and Weight Gain  Weight gain not explained only by Depo and different for each woman. ( Westhoff, Contraception, 2003)  Black and/or obese women, postpartum adolescents may be at increased risk.  According to package insert, averages:  5.4 lbs in 1 st year; 13.8 lbs after 4 yrs  “Early” gainers (5% of body weight at 6 mo) will continue to gain at a higher rate (Le, 2009)  Risk factors for early weight gain: BMI < 30, parity≥1, self-reported increased appetite

45. Bleeding with progestin-only methods How to treat it?  REASSURANCE and SUPPORT  Estrogen alone  OCPs  NSAIDs  Doxycycline (for Implanon)  Tranexamic acid  Antiprogestins (mifepristone)

46. IUD and Adolescents Recommendations and benefits of use  World Health Organization (WHO)  American College of Obstetricians and Gynecologists (ACOG)

47. IUDs and Adolescents Why is IUD use is limited in the U.S.? COMMON MISPERCEPTIONS  “IUDs increase PID and STDs”  “They cause infertility”  “IUDs can’t be used in nulligravids”  “IUDs can’t be used in a woman with a previous ectopic pregnancy”

48. IUDs and Adolescents Debunk the myths  The IUD does not increase an adolescent’s risk of PID and STDs.  Past experience with the Dalkon Shield has perpetuated this myth.  Studies that showed a causal relationship between IUDs and PID were fraught with methodological errors.

49. IUDs and Adolescents Debunk the myths WHAT IS TRUE: The risk of PID is increased at the time of insertion.  Within the first 20 days of use  Risk of PID 9.7 per 1,000 women-years in users  Risk of PID 1.4 per 1,000 women-years in non- users

50. IUDs and Adolescents Debunk the myths  IUD is not related to infertility  Chlamydia is related to infertility Tubal infertility by previous copper T IUD use and presence of chlamydia antibodies, nulligravid women Hubacher D, et al. NEJM. 2001.

51. Worldwide Use of IUDs Population Reference Bureau. 2002.; Mosher WD, et al. 2004. Asia 18 Europe 15 Latin America & Caribbean 8 Africa 5 Oceania 2 North America 1 % Use for Married Women of Reproductive Age

52. What if you could design the perfect birth control?  No maintenance required  Highly effective  Decreases menstrual flow  Can treat heavy bleeding and bad cramps  Reversible  Immediate return to fertility

53. Use of IUDs by Female Ob/Gyns vs. All Women in the United States Population Reference Bureau. 2002. The Gallup Organization. 2004. Forrest JD. Obstet Gynecol Surv. 1996. Female Ob/Gyn Physicians General Population 18 0.7 % Using IUDs

54.  T-shaped piece of plastic that releases small amounts of levonorgestrel each day  Primary mechanisms: inhibits sperm movement, progestin thins the endometrial lining, thickens cervical mucus  Typically does not prevent ovulation (low systemic levels of progesterone )  Approved for 5 years of use: remove any time, immediate return to fertility Levonorgestrel IUD (Mirena)

55. Copper T IUD (ParaGard)  Primary mechanism is prevention of fertilization  Reduce motility and viability of sperm  Approved for 10 years of use but can be removed any time Alvarez F, et al. Fertil Steril. 1988; Segal SJ, et al. Fertil Steril. 1985; ACOG. Statement on Contraceptive Methods. 1998.

56. CANDIDATES FOR INTRAUTERINE DEVICE USE WHO: Medical eligibility criteria for contraceptive use  Multiparous and nulliparous women at low risk for sexually transmitted diseases  Women who desire long-term reversible contraception  Women with the following medical conditions, for which an intrauterine device may be an optimal method:  Diabetes  Thromoboembolism (Levonorgestrel)  Menorrhagia/dysmenorrhea (Levonorgestrel)  Breastfeeding  Breast cancer (Copper T)  Liver Disease (Copper T)

57. CONTRAINDICATIONS TO INTRAUTERINE DEVICE USE WHO: Medical eligibility criteria for contraceptive use  Pregnancy  Pelvic inflammatory Disease (current or within the last 3 months)  Sexually transmitted disease (current)  Puerperal or post-abortion sepsis (current or within last 3 months)  Undiagnosed abnormal vaginal bleeding  Malignancy of the genital tract  Known uterine abnormalities or fibroids distorting the cavity in a way incompatible with IUD insertion  Allergy to any component of the IUD (Copper T)  Wilson’s Disease (Copper T)

58. IUDs and Adolescents Topics for patient counseling  Effectiveness  Duration of use  goal: at least 3 years  Bleeding changes  Insertion and removal procedures  Do GC/CT now or with insertion  Side effects and possible complications  Use of condoms with new partners

59. IUDs and Adolescents Non-contraceptive benefits of the Levonorgestrel IUD Good evidence  Heavy bleeding  Dysmenorrhea and pain Some evidence  Endometriosis  Fibroids  Adenomyosis  Endometrial hyperplasia or cancer Varma R, et al. Eur J Obstet Gynecol Reprod Biol. 2006. Gupta B, et al. Int J Gynecol Obstet. 2006.

60. IUDs and Adolescents Managing side-effects  Amenorrhea/hypomenorrhea with Levonorgestrel IUD (Mirena) is expected  Most common side effects: pain and abnormal bleeding  Rule out perforation, infection, pregnancy  Treat with NSAIDS and reassurance

61. IUD Summary  Two options available in United States  Levonorgestrel IUD (Mirena) widely used for its non-contraceptive effects  IUD efficacy equivalent to sterilization  Can be inserted in nulligravid women including adolescents

62. Single-rod contraceptive implant Reinprayoon D, et al. Contraception. 2000. Diaz S. Contraception. 2000.  One 4cm x 2mm rod  Contains etonogestrel (progestin) and no estrogen  Suppresses ovulation and thickens cervical mucus  Highly effective for 3 years  Not user dependent and only 1 visit  Very discreet and rapidly reversible  Can be used during lactation

63. Single-rod contraceptive implant Contraindications  Known or suspected pregnancy  Current or past history of thrombosis or thromboembolic disorders (CLASS LABELING)  Hepatic tumor or active liver disease  Undiagnosed abnormal genital bleeding  Known or suspected carcinoma of the breast or history of breast cancer  Hypersensitivity to the components of the implant Implanon Physician Insert, 2006. World Health Organization. 2004.

64. Single-rod contraceptive implant Insertion Insertion is VERY WELL tolerated Supine position Nondominant arm, flexed and externally rotated Subdermal groove Hold applicator up (vertical) before insertion

65. Single-rod contraceptive implant Efficacy YearCyclesPregnancy 110,8670 285850 334920 Implanon Physician Insert, 2006 6 pregnancies occurred shortly after removal

66. Single-rod contraceptive implant Patient counseling  Irregularly irregular bleeding  80% of users report decrease in dysmenorrhea  Amenorrhea is common  Acne may improve  Minor to no weight change  No reduction in bone mineral density  No increased risk of DVT  Little pain at insertion site  Cost: about $700 if no coverage

67. Single-rod Contraceptive Implant Patient selection and conclusions Women who desire  Long-term contraception  High effectiveness  Rapid reversibility  Estrogen-free contraception Presenter’s note: efficacy and convenience of use is more important than cycle control!

68. Final Messages…  Forgettable methods are most effective.  You are the reality check.  Motivate women and their partners.  Recognize and reduce barriers.  Anticipate problems.

69. CASE PRESENTATIONS Adolescent Contraceptive Care

70. Case #1: Amber  Amber is a 14 year-old healthy female seeing you for a physical exam. When you ask about sexual activity she reports that she has intercourse with her 16 year-old boyfriend. Sometimes they use condoms and sometimes he withdraws. You notice that she has moderate cystic acne.  What are her options for birth control?  Her LMP was 14 days ago and she had unprotected sex last night - what now?  What is the most likely side effect she will have on her new method and how will you treat it?

71. Case #1: Amber Options for all healthy teens Abstinence 0/100 No method 85/100 Condoms 15/100 (2% perfect use) Spermicides 30/100 Withdrawal 30/100 Sponge 16 (nullip)-32(parous)/100 OCPs8/100 (.3% perfect use) Depo-Provera 3/100 (.3% perfect use) Implanon.05/100 IUD.2/100 (unintended pregnancy in1 year of typical use)

72. Case #1: Amber  Are there any non-contraceptive conditions to treat?  OCPs to treat acne ? Sprintec (35mcg EE/ norgestimate)  Will take 3 months for full effect on acne lesions 6 months for full effect on hirsutism

73. Case #1: Amber  IC last night was unprotected  Prescribe Emergency Contraception (EC) to use today  Start OCPs tomorrow If no EC, start pills today and observe 1 st pill Use back-up (condoms) for 1 week  If no period during placebo pills, check pregnancy test  Or, return in 2 weeks; check pregnancy test and satisfaction with method.

74. Case #2: Maria  Your receive a telephone call from Maria’s mom. Can Maria have an excuse for school today? Maria has horrible cramps and can’t get out of bed. She failed ibuprofen and needed to take Vicodin (which you prescribed 2 months ago after she left a soccer tournament with severe cramping). Reviewing Maria’s chart, you see there is a letter written every other month for Maria to miss school because of her dysmenorrhea.  Does Maria need any tests?  What are Maria’s options to treat her dysmenorrhea?

75. Case #2: Maria  Primary dysmenorrhea  If history consistent- no test or pelvic exam needed  Options:  Pain meds (NSAIDs first-line, narcotics if severe)  Heating pad  OCPs- 21/7, extended, continuous

76. Case #2: Maria OCPs - which pill?  Are there any non-contraceptive conditions to treat? (besides dysmenorrhea)  May also have hypermenorrhea? PMS? Breast pain before periods?  Does having periods interfere with soccer tournaments?  One option: Seasonale (generic: LEVORA/LEVLEN) Low estrogenic pill Extended use to minimize bleeding Continuous pills always an option

77. Oral Contraceptives: Extended Use Frequent menstruation is a relatively new biologic state Eaton et al. Q Rev Biol 1994.

78. Case #3: Tina  Tina is 17 years old. She is in your office today because she has a cold. You review her current meds and see she is using OCPs for birth control. She sometimes forgets pills and she is worried about getting pregnant again. She used Depo-Provera before but gained 10 pounds. Her first pregnancy resulted in early miscarriage and she had an abortion 6 months ago. She has been dating her boyfriend for 1 year and she has never had an STD.  What are Tina’s options for birth control?  What is the most effective method available to her?  What if she ends up getting an STD with her new method?

79. Case #3: Tina Options for all healthy teens Abstinence 0/100 No method 85/100 Condoms 15/100 (2% perfect use) Spermicides 30/100 Withdrawal 30/100 Sponge 16 (nullip)-32(parous)/100 OCPs8/100 (.3% perfect use) Depo-Provera 3/100 (.3% perfect use) Implanon.05/100 IUD.2/100 (unintended pregnancy in1 year of typical use)

80. Case #3: Tina Which method? “Pelvic exams are no big deal” “I have a friend with an IUD and she loves it” Thinking IUD? Consider patient preferences, screen for STDs Mirena (LNG IUD) = 1 st 3-6 months spotting then 50% amenorrhea in 1 yr Paraguard (Copper T) = no hormones; more bleeding/cramps in 1 st year

81. Case #3: Tina Management of STDs with IUD If STD diagnosed:  IUD removal not necessary.  Treat infection.  Counsel patient about prevention of STD transmission.  Routine GC/CT screening can be done at the same time as IUD insertion.

82. Case #3: Tina Management of PID If PID diagnosed:  Consultation with an OB/GYN if possible.  IUD removal is not necessary.  Treat infection.  Recommendations to remove IUD are not evidence-based. Grimes D. Lancet. 2000.

83. Case #3: Tina Management of missing threads  Probe for threads in cervical canal  try an endocervical brush used for paps  Rule out pregnancy  Prescribe back-up contraceptive method  Transvaginal ultrasound to locate IUD

84. Case #3: Tina Pregnancy with IUD in situ  Determine site of pregnancy (intrauterine or ectopic).  IUD use decreases the overall risk of having an ectopic pregnancy, but if a pregnancy does occur, it is more likely to be an ectopic.  Positive pregnancy test: remove IUD if threads available. UK Family Planning Research Network. Br J Fam Plann. 1989.; Foreman H, et al. Obstet Gynecol. 1981. Atrash HK, et al. 1994.

85. Case #4: Katie  Your nurse is waiting at your door to ask you about Katie, a healthy 16 year-old patient. She is 2 weeks late for her Depo-Provera shot. Katie says she is usually late for everything, and has been late for her Depo before. She has been on this method for almost 2 years and is happy with it overall because she could never remember to take pills. She says she drinks 3 glasses of milk every day and she is a cheerleader.  Can Katie get her Depo today?  Are there any other BC options she should consider?

86. Case #4: Katie  Can you give the Depo?  Get sexual history in last 2 weeks  Pregnancy test  Weigh benefits vs. risks  Depo is not a teratogen  Can give EC too  Can she stay on Depo for more than 2 years?  Risks and benefits  ACOG says YES if best option (Sept 2008 Opinion)

87. Bone Mineral Density and Single-rod Implant  Unlike Depo-Provera, implants are not associated with a decrease in BMD  Changes in bone mineral density similar in study of 44 women with single-rod implant and 29 with non-medicated IUD  Lumbar spine BMD improved with single-rod Beerthuizen R, et al. Hum Reprod. 2000.

88. Case #4: Katie  Most effective methods = least user dependent methods  Single-rod implant (Implanon)  IUDs  Implanon counseling  1 visit for insertion  3 years of very effective contraception  Accept potential for amenorrhea and irregular bleeding over the entire 3 years

89. THANK YOU Eliza Buyers, MD, FACOG Kaiser Permanente Department of OB/GYN elizabuyers@msn.com Office: 303-360-1576