1. Contraception: Update on the Evidence

2. Objectives  Use WHO/CDC categories for eligibility  Counsel patients about contraceptive efficacy for successful prevention of unintended pregnancy  Address systems practices which can affect contraceptive initiation and continuation rates

3. Nearly Half of Pregnancies in the United States are Unintended. Approximately 6.4 million pregnancies per year Frost JJ, Darroch JE and Remez L, Improving contraceptive use in the United States, In Brief, New York: Guttmacher Institute, 2008, No. 1. http://www.guttmacher.org/pubs/2008/05/09/ImprovingContraceptiveUse.pdf. July 9, 2014.

4. The Problems Guttmacher 2010

5. One Year Failure Rates EffectivenessBirth Control Type Typical-Use Pregnancy Rate Perfect-Use Rate IneffectiveChance85% Less EffectiveCondoms14%3% More EffectivePill, patch, ring8%1-3% Highly Effective IUDs0.8%-2%0.8-2% Injectible (Depo)0.1-0.3% Implant/Sterilization0.1-0.3% Zieman M, Hatcher RA. Managing Contraception. Tiger, Georgia: Bridging the Gap Foundation, 2010.

6. Contraceptive Methods: US Contraceptive Use in the United States. Guttmacher Institute. https://guttmacher.org/pubs/fb_contr_use.html. June 2014 (from 2008 data).

7. Yolanda 16 year-old high school student, c/o UTI symptoms Had unprotected sex 4 days ago Urine pregnancy test is negative. What do you do next?

8. Opportunity knocks! (1) Ask about contraceptive needs (2) Get medical history (negative)

9. Hormonal Contraceptives: What is needed before prescribing? Medical history REQUIRED Blood pressure RECOMMENDED Pap smear Pelvic/breast exam STI testing Hemoglobin NOT REQUIRED Stewart F, et al. Clinical breast and pelvic examination requirements for hormonal contraception: Current practice vs evidence. JAMA. 2001;285:2232-9.

10. Hormonal Contraceptives: Which Women/Teens Can’t Use Estrogen? Estrogen contraindications: Migraine with aura Uncontrolled hypertension Postpartum < 3 weeks History of DVT Centers for Disease Control and Prevention. U.S. Selected Practice Recommendations for Contraceptive Use, 2013. MMWR 2013;62. http://www.cdc.gov/mmwr/pdf/rr/rr62e0614.pdf. June 14, 2013.

11. Antibiotics and Oral Contraceptives? Only Rifampin and Rifabutin decrease efficacy Centers for Disease Control and Prevention. U.S. Selected Practice Recommendations for Contraceptive Use, 2013. MMWR 2013;62. http://www.cdc.gov/mmwr/pdf/rr/rr62e0614.pdf. June 14, 2013.

12. Emergency Contraception: Levonorgestrel (Plan B) Decreases risk of unintended pregnancy by 58-89% Does not disrupt or harm an implanted pregnancy – Looses efficacy at BMI > 25 No medical contra-indications! Population Council. Emergency Contraception’s Method of Action Clarified. Population Briefs. 2005 May;11(2). http://www.popcouncil.org/publications/popbriefs/pb11(2)_3.html Glasier A, et al Contraception 2011Oct 84(4) 363-7 Zieman M, Hatcher RA. Managing Contraception. Tiger, Georgia: Bridging the Gap Foundation, 2010.

13. Ulipristal Acetate: A New Emergency Contraceptive Option Decreases risk of unintended pregnancy by 90% Maintains nearly full efficacy up to 5 days after unprotected intercourse Looses efficacy at BMI > 35 Zieman M, Hatcher RA. Managing Contraception. Tiger, Georgia: Bridging the Gap Foundation, 2010 Glasier A, et al Contraception 2011Oct 84(4) 363-7.

14. Highest Efficacy EC: Copper IUD

15. What Does She Want? What has she heard about birth control? What are her friends using?

16. Impact of Choice Pariani S, Heer D, van Arsdol M. Does choice make a difference to contraceptive use? Stud Fam Plann 1991;22(6):384-390.

17. Does it Matter Which Pill? Mostly all the same, despite marketing Cycle control better with 30-35 EE than 20mcg Extended cycle decreases days of bloating and menstrual cramping No difference w acne, weight gain, adverse effects (conflicting studies) Szabo KA, Schaff E Oral Contraceptives, Does Formulation Matter? J Fam Prac 2013 Oct 62(10) E1-12

18. Yolanda is Eligible for the Pill: When should she start? Westhoff C et al. Quick start: novel oral contraceptive initiation method. Contraception. 2002 Sep;66(3):141-5. Westhoff C et al. Bleeding patterns after immediate vs. conventional oral contraceptive initiation: a randomized, controlled trial. Fertil Steril. 2003 Feb;79(2):322-9.

19. . Should Yolanda get a prescription for EC, too? Advance EC Prescribing Zieman M, Hatcher RA. Managing Contraception. Tiger, Georgia: Bridging the Gap Foundation, 2012.

20. Liz 21-year-old healthy college student, works evenings and weekends Using oral contraceptive, but forgets pills often Has trouble getting refills with her schedule

21. Adherence with OCs: What Women Do! Percent of Women (%) Number of pills missed Potter et al. Measuring Compliance Among Oral Contraceptive Users. Fam Plann Perspect 1996; 28(4):154-158.

22. Estrogen/Progestin Ring or Patch Quick-Start same as with OCs CDC risk levels same as pill (remember – pregnancy risk always greater!) Theoretically better adherence due to not daily Ring has hormone levels 35 days, patch for 9 days 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.

23. How Many Refills Should We Give to Liz? And Dispense at one time?

24. Resa 16 years old Doesn’t want to get pregnant until she finishes school Wants contraception that she can hide from her mom What are her choices?

25. Back to the Problem 1) Increase use of highly effective methods: IUDs, Depo-Provera, Implanon 2) Improve adherence with less effective methods 3) Reduce gaps in use 4) Catch non-users Zieman M, Hatcher RA. Managing Contraception. Tiger, Georgia: Bridging the Gap Foundation, 2010.

26. Highly Effective Methods 3% 0.05% NOT USER DEPENDENT Effectiveness Group Family Planning Method Typical-Use Rate of Pregnancy Perfect-Use Rate of Pregnancy Highly Effective (for all users) Male and female sterilization 0.2%-0.5%0.1%-0.5% Implants0.05% Hormone shot3%0.3% Intrauterine devices 0.8% Zieman M, Hatcher RA. Managing Contraception. Tiger, Georgia: Bridging the Gap Foundation, 2012.

27. Progestin-Only Injection Hatcher, R et al. A Pocke

28. Depo Provera & Bone Density Weighing risks and benefits: No need to restrict Depo Provera use Risk “2” - benefits outweigh risks Centers for Disease Control and Prevention. U.S. Selected Practice Recommendations for Contraceptive Use, 2013. MMWR 2013;62. http://www.cdc.gov/mmwr/pdf/rr/rr62e0614.pdf. June 14, 2013.

29. Quick Start Depo Depo is the one method shown to prevent unintended pregnancies with Quick Start If pregnant - not a teratogen For return depo visits – keep in mind it works for 16 weeks Rickert VI et al. Depo Now: preventing unintended pregnancies among adolescents and young adults.J Adolesc Health. 2007 Jan;40(1):22-8.

30. Quick Start Algorithm Quick Start Algorithm. Reproductive Health Access Project. http://www.reproductiveaccess.org/fact_sheets/downloads/QuickstartAlgorithm.pdf. March 2013.

31. Quick Start Algorithm, Continued Quick Start Algorithm. Reproductive Health Access Project. http://www.reproductiveaccess.org/fact_sheets/downloads/QuickstartAlgorithm.pdf. March 2013. www.ReproductiveAccess.org

32. Amy 36-year-old G0P0 Smoker (1 ppd)

33. Developed by WHO to define risk of birth control use with common medical conditions Adopted by CDC for US in 2010 Risk of unintended pregnancy with given condition weighed against risk of method WHO / CDC Medical Eligibility Criteria for Contraceptive Use Centers for Disease Control and Prevention. U.S. Selected Practice Recommendations for Contraceptive Use, 2013. MMWR 2013;62. http://www.cdc.gov/mmwr/pdf/rr/rr62e0614.pdf. June 14, 2013.

34. Full reports condensed into summary table: www.reproductiveaccess.org Risk levels 1-4: WHO / CDC Medical Eligibility Criteria for Contraceptive Use Medical Eligibility for Initiating Contraception: Absolute and Relative Contraindications. The Reproductive Health Access Project. http://www.reproductiveaccess.org/contraception/downloads/chart.pdf. March 2013.

35. Smoking and Contraceptive Use Medical Eligibility for Initiating Contraception: Absolute and Relative Contraindications. The Reproductive Health Access Project. http://www.reproductiveaccess.org/contraception/downloads/chart.pdf. March 2013.

36. Intrauterine Devices Hubacher D et al. A Pocket Guide to Managing Contraception, 2012.

37. IUD Myths Debunked IUDs can be used safely by nulligravid women and teens! IUDs DO NOT raise risk of PID. IUDs DO NOT raise risk of infertility. IUDs DO NOT raise risk of ectopic pregnancy. ACOG Committee Opinion 539 Adolescents and long acting reversible contraception Obstet Gynecol 2012 Oct 120(4) 983-8

38. OK to insert IUD at any point in the menstrual cycle OK to insert immediately post-partum or following surgical abortion OK to test for STIs at time of insertion (& treat infections with IUD in place) US Selected Practice Recommendations for Contraceptive Use 2013 MMWR June 21;62 (1-60). IUD Myths Debunked

39. How Long for Each IUD? Levonorgestrel IUD – 7 years Copper IUD – 12 Years Wu JP, Pickle S Extended Use of the Intrauterine Device Contraception 2014 June 89(6) 495-503

40. Progestin Implant Highly effective and rapidly reversible Not user-dependent Contain no estrogen Can be used during lactation Active hormone: etonorgestrel (68 mg) Hubacher D et al. A Pocket Guide to Managing Contraception, 2012

41. Counseling to Enhance Adherence LISTEN to her ideas about the best method. EXPLORE lifestyle issues that impact adherence. ENCOURAGE her to call you with problems/concerns.

42. Inconsistent Pill Use: Linked to Low Level of Satisfaction with Provider & Low Continuity of Care Landry, David. Public and private providers involvement in improving their patients contraceptive use Contraception 2008 Jul 78 (1) 42-51. Percent of pill users who missed one or more pills during the past three months

43. Office Barriers to Adherence

44. Feeling Unable to Reach a Provider With Questions is Linked to Contraceptive Non-Use % of at-risk women experiencing contraceptive non-use in the past year Landry, David. Public and private providers involvement in improving their patients contraceptive use Contraception 2008 Jul 78 (1) 42-51.

45. Electronic Health Records

46. Break Down Office Barriers for Same Day Insertions of IUD

47. Practice Recommendations DE-LINK pap smears from birth control prescriptions. ROUTINELY prescribe 1-year supply with 3 packs at a time. Ask about contraceptive needs at all types of visits. Emphasize high-efficacy methods, but honor women’s choice whenever possible.

48. Practice Recommendations 2 Use evidence-based guidelines (like CDC MEC) Remember BMI when giving emergency contraception Encourage use of LARC (non user dependent methods!) Use QuickStart Allow for extended use where there is evidence: –Depo Provera can be used indefinitely –Mirena for up to 7 years –Paragard for up to 12 years Easy access to refills: refill without an office appointment if BP normal

49. Last but Not Least: Don’t Forget About Vasectomy!

50. Questions?

51. References Hatcher et al, Contraceptive Technology 2007 Centers for Disease Control and Prevention (CDC). U.S. Medical Eligibility Criteria for Contraceptive Use, 2010. MMWR Recom Rep. 2010 Jun 18;59(RR-4):1-86. Managing Contraception – book online @ www.managingcontraception.org www.managingcontraception.org CDC/WHO Medical Eligibility Criteria for Contraceptive Use 2010 www.who.int/reproductive-health Association of Reproductive Health Professionals www.arhp.orgwww.arhp.org Alan Guttmacher Institute www.agi-usa.orgwww.agi-usa.org Planned Parenthood www.plannedparenthood.orgwww.plannedparenthood.org The Cochrane Collaboration www.cochrane.orgwww.cochrane.org www.Not-2-Late.com Reproductive Health Access Project www.reproductiveaccess.orgwww.reproductiveaccess.org