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contraception Nancy Kang PGY2
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objectives
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barrier method Latex condom most popular barrier method, also polyurethane, silicone and lambskin condoms available Polyurethane condoms: more sensitivity, feel thinner, compatible with oil-based lubricants. $$$ Lambskin condoms: not recommended for protection against STI
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barrier method Efficacy Perfect use: 97% effective within first year
Typical use: 86% effective Highest failure rate from age 20-24 STI rates in populations have been shown to decline when latex condoms are used. Decreases ADIS/HIV transmission by 85% Polyurethane and other plastic condoms: Equivalent levels of contraceptive protection, may confer less protection from STI due to increased frequency of breakage and slippage
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female condom Polyurethane sheath which acts as an intravaginal barrier 95% effective with perfect use. 80% effective with typical use Women empowerment! Can be inserted up to 8hrs prior to intercourse
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diaphragm Intravaginal barrier used in conjunction with a spermicide
94% effective with perfect use and 80% effective with typical use Potential protection from STIs by decreasing cervical exposure, but protection from HIV transmission is limited because of exposure to vaginal mucosa Pelvic exam required for fitting diaphragms
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diaphragm Side effects May increase risk of persistent/recurrent UTI
Increased risk of developing BV Can be associated with toxic shock syndrome
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cervical cap Used intravaginally in conjunction with spermicide
Efficacy in nulliparous women: 92% effective with perfect use, 80% effective with typical use. In multiparous women: 74% effective with perfect use and 60% effective with typical use Offers potential protection from cervical infections Must be fitted Should not be used in women with current vaginal/cervical infection, PID, cervical or uterine cancer or dysplasia. Can aggravate symptoms in women with STIs and vaginitis. Increased risk of toxic shock syndrome.
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contraceptive sponge Intravaginal one-size-fits-all barrier method, impregnated with spermicidal agents Efficacy: theoretical efficacy rate of 90% in nulliparous women, but actual rates ~80% for nulliparous women typical use and 60% for multiparous women typical use No STI protection! Provides contraception for 12hours after insertion Increased risk of TSS
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natural family planning
Primary fertility signs: changes in cervical mucus, basal body temperature and cervical position Efficacy estimates 20% failure rate for common use and 1-9% with perfect use
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combined oc Of Canadian women who use contraception, 32% use combined OCP as their method Monophasic (fixed amount of estrogen and progestin), biphasic (fixed amount of estrogen, amount of progestin increases in second half of cycle) or triphasic (estrogen may be fixed or variable, progestin increases in 3 equal phases)
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efficacy With perfect use, combined OCP is 99.9% effective
With typical use, failure rates range from 3-8% Poor patient compliance major factor: 30% of women missed 3 or more pills in the first cycle. Another study found 47% miss 1 or more pills and 22% miss 2 or more pills per cycle. ? Effect of body weight. One retrospective study found women weighing >70kg had significantly increased risk of combined OCP failure
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moa Main mechanism of action is to suppress gonadotropin secretion, thereby inhibiting ovulation Development of atrophy, making endometrium unreceptive to implantation Production of viscous mucus that impedes sperm transport Possible effect on secretion and peristalsis within fallopian tube, which interferes with ovum and sperm transport
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contraindications <6 weeks postpartum if breastfeeding
smoker over the age of 35 (> 15cig/day) HTN (> 160/100) current or past history of VTE Heart disease (ischemic or complicated valvular disease - PHTN, A Fib, history of bacterial endocarditis) history of CVA migraine headache with focal neurological symptoms current breast ca DM with retinopathy/nephropathy/neuropathy severe cirrhosis, liver tumor (adenoma or hepatoma) ** undiagnosed vaginal bleeding
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relative CI smoker over the age of 35 (< 15cig/day)
adequately controlled HTN HTN ( /90-99) migraine headache over age of 35 symptomatic gallbladder disease mild cirrhosis use of medications that may interfere with combined OCP metabolism
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relative Ci
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side effects Irregular bleeding: 10-30% in first month. Appears to improve with time Breast tenderness: Usually decreases with time. May occur less often using OCs containing less estrogen. Decreasing caffeine intake may be helpful. Nausea: Usually decreases with time. Decreasing estrogen content may be helpful or can try taking at hs or with food Weight gain: Trials have failed to show any association Mood changes: Trials have not demonstrated a significantly increased risk of mood changes
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troubleshooting Breakthrough bleeding
Encourage users to continue with expectation that irregular bleeding will subside If bleeding persists after third cycle or has a new onset, other causes must be ruled out - irregular pill taking, smoking, uterine or cervical pathology, pregnancy, use of concomitant medications and infection Supplemental estrogen therapy (1.25mg conjugated estrogen PO for 7 days) Therapeutic trial of another combined OC may be indicated - trial of OC containing a different type of progestin
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risks VTE: Rates 3-4x higher than non users. Absolute risk of VTE 1 to 1.5 per 10,000 users per year of use. Risk of VTE appears higher in first year of use MI: Rates increase 3 fold in women taking combined OC containing more than 50mcg ethinyl estradiol Stroke: Increased risk of stroke in users of combined OC containing more than 50mcg ethinyl estradiol. Some studies of low-dose OCs report no increased risk of stroke, others have reported an increased risk of up to 2-fold Gallbladder disease: Increases secretion of chalk acid in bile, potentially leading to a higher incidence of gallstone formation; however, does not appear to be a significantly increased risk of gallstone formation Breast cancer: Still controversial. More recent study of >9000 women, no significant association between use of combined OC and breast ca. Cervical cancer: One study suggests long-term combined OC may increase risk of cervical ca in women who are HPV positive. Long-term study published in 2002 concluded that, in well-screened population of HPV-positive women, combined OC use did not increase risk of cervical ca
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benefits cycle regulation decreased flow increased BMD
decreased dysmenorrhea and peri-menopausal symptoms decreased acne, hirsutism decreased endometrial and ovarian ca
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initiation Low dose preparation preferred (<35mcg ethinyl estradiol) Conventionally, started during first 5 days of menstrual cycle, or the first Sunday after menses begin (to avoid weekend period). If starting within 5 days, no backup method needed. Alternative is “quick start” method. Backup method needed for first 7 days.
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continuous use Advantages: decreased incidence of pelvic pain, headaches, bloating/swelling and breast tenderness if experienced during pill- free interval. Improved over symptoms of endometriosis and PCOS Disadvantages: little information on long-term safety (although long-term data for comparable total estrogen-progestin doses per month) Take combined OC for 2-4 pill packages with hormone-free interval of 4-5 days. BTB common reason for returning to 21-day combined OC regimen. BTB will decrease over time. Use of monophonic pill regimen or a 21-day OC regimen has been shown to decrease incidence of BTB
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transdermal patch Patch delivers 150mcg norelgestromin and 20mcg ethinyl estradiol systemically One patch is applied weekly for 3 consecutive weeks, followed by 1 patch- free week The patch is placed on 1 of 4 sites: the buttocks, upper outer arm, lower abdomen or upper torso (excluding the breast) Efficacy: % failure rate with perfect use, up to 9% with typical use Relative CI: women >90kg may find patch less effective Local skin reaction in up to 20% of patients. Does not decrease over time. Only 2% of patch users discontinue it for this reason
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vaginal ring Ring releases 15mg of ethinyl estradiol and 120mcg of progestin etonogestrel per day Each ring remains inserted for 3 consecutive weeks and then removed for a 1 week ring-free interval Efficacy: % failure rate with perfect use, up to 9% with typical use Relative CI: uterovaginal prolapse of vaginal stenosis if they prevent retention of ring Side effects: irregular bleeding - less common, but does not decrease with time. Vaginal symptoms of discharge and irritation
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injectable progestin Depot medroxyprogesterone acetate injection q12 weeks Highly effective: failure rate of less than 0.3%/year perfect use, typical use 3-6% MOA: inhibits the secretion of pituitary gonadotropins, suppressing ovulation. Also increases viscosity of cervical mucus and induces endometrial atrophy CI: pregnancy, unexplained vaginal bleeding and current diagnosis of breast ca. Relative CI: severe cirrhosis, active viral hepatitis and benign hepatic adenoma
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side effects Menstrual cycle disturbance: irregular bleeding or unwanted amenorrhea. Unpredictable bleeding common in first few months, but decreased in amount and frequency with time. ~60% amenorrheic at 12 months, ~70% at 24 months Hormonal side effects: headache, acne, decreased libido, nausea and breast tenderness Weight gain: 2.5kg in first year, 3.7kg after 2nd year and 6.3kg after 4th year of use. One study found 56% of users reported increase in weight while 44% either lost weight or were weight neutral Mood effects: Mood changes have been reported although prospective studies do not appear to demonstrate an increase in depressive symptoms
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risks Delayed return of fertility: average 9-month delay before restoration of full fertility after last injection Reduction in BMD: Prospective studies have found a mean loss of FMD at the lumbar spine of between 0.87% and 3.52%. Does not appear to induce osteoporosis. Studies suggest improvement in BMD after it is discontinued VTE, stroke, CVD: No apparent increase in risk at standard doses
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troubleshooting Irregular bleeding: if persists beyond first 6 months of use increase dose to 225 and 300mg IM for 2-3 injections decreasing interval between doses supplemental estrogen therapy (0.625mg conjugated equine estrogen PO for 28 days) NSAIDs for 10 days adding combined OCP for 1-3 months Late injection: If <14 weeks, give next injection. If >14 weeks, check for pregnancy, give next injection and backup method x 2 weeks
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Progestin-only Pill Efficacy: with perfect use, failure rate of ~0.5%. With typical use, failure rate between 5 and 10% MOA: through alterations in cervical mucus - reduce the volume of mucus, increase its viscosity and alter its molecular structure resulting in little or no sperm penetration. Ovulation may be suppressed or partially suppressed. POP must be taken at same time every day CI: pregnancy and current breast cancer. Relative CI include active viral hepatitis and liver tumours
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side effects Irregular bleeding: Spotting in ~12% of users in first month, decreases to <3% at 18 months. Hormonal side effects: headache, bloating, acne and breast tenderness occur less commonly
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initiation Can be started at any time as long as pregnancy excluded
A pill containing active hormone taken every day, no pill-free interval! Backup method should be used in first 7 days Contraceptive reliability requires pill-taking at same time every day (within 3 hours)
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IUd Highly effective - failure rate of copper IUD was 1.26 per 100 women years and rate of ectopic pregnancy was 0.25 per 100 WY. Failure rate of Mirena was 0.09 per 100 WY and ectopic pregnancy rate was 0.02 per 100WY MOA: Chief MIA appears to be prevention of fertilization. Copper IUD: presence of a FB and copper in endometrial cavity causes biochemical and morphological changes that adversely affect sperm transport. Ovulation not affected. Mirena: weak FB reaction and endometrial changes that include endometrial decidualization and glandular atrophy. Cervical mucus may become thickened. Ovulation may be inhibited in some women (not for the Jaydess).
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IUD
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contraindications Pregnancy
current, recurrent or recent (within 3 months) PID or STI Puerperal sepsis Immediate post-septic abortion Severely distorted uterine cavity Unexplained vaginal bleeding Cervical or endometrial cancer Malignant trophoblastic disease Copper allergy (for copper IUDs) Breast ca (for mirena and Jaydess)
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relative ci Risk factors for STIs or HIV
Impaired response to infection (HIV positive women or women undergoing corticosteroid therapy) From 48hours to 4 weeks postpartum Ovarian cancer Benign gestational trophoblastic disease
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non-contraceptive benefits
Menorrhagia responds favourable to the use of Mirena 2 studies of women scheduled to undergo hysterectomy for menorrhagia: 64-80% subsequently cancelled hysterectomy, compared to 9-14% randomized to receive other medical treatments
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side effects Bleeding copper IUD: increase in menstrual blood loss by up to 65% over non-users. NSAIDs or tranexamic acid may help Mirena: reduction in menstrual blood loss between 74 and 97%. Between 16 and 35% of users will become amenorrheic after 1 year of use Pain or dysmenorrhea: up to 6% of users will have discontinued use at 5 years because of pain Hormonal: depression, acne, headache and breast tenderness. Decrease over time. Weight neutral according to large trial over 5 years Functional ovarian cysts: Reported in up to 30% of mirena users. Resolve spontaneously so should be managed expectantly
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risks Uterine perforation: Rate of 0.6 to 1.6 per 1000 insertions. Risk factors include postpartum insertion, inexperienced operator and a uterus that is immobile, extremely anteverted or retroverted Infection: Relative risk of PID of 3.8 in first month after insertion, back to baseline risk after 4 months. Exposure to STIs and not the use of IUD itself is responsible for PID occurring Expulsion: Most common in first year of use. Risk factors: immediately postpartum, nulliparity and previous IUD expulsion (30% chance if previous expulsion) Failure: If a woman becomes pregnant with an IUD in situ, ectopic pregnancy must be excluded. Risk of SA increased in women who continue a pregnancy with an IUD in place
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troubleshooting Lost strings: speculum exam to look for strings followed by U/S and then plain x-ray Pregnancy with IUD in place: If wishes to terminate, keep in place until procedure. If wishes to continue with pregnancy, IUD should be removed if possible Amenorrhea or delayed menses: exclude pregnancy, investigation should be as for a woman without an IUD. Up to 35% of mirena users may experience amenorrhea Pain and abnormal bleeding: Rule out partial expulsion, perforation, pregnancy and infection. Treatment with NSAIDs may be helpful. Usually decreases over time.
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troubleshooting Difficulty removing IUD: grasping string with ring forceps and exerting gentle traction can usually accomplish removal. Uterine sound can be used, cervical dilation may be required. Direct visualization of IUD with U/S or hysteroscopy may be required. Paracervical block and occasionally GA may be needed STI with IUD in place: Treat STI. If suggestion of PID, device should be removed after pre-treating woman with abx Actinomycosis on pap: up to 20% of copper IUD users, up to 3% of mirena users. If asymptomatic, reasonable to leave in place and follow with yearly pap and pelvic exams. If symptomatic, IUD should be removed after antibiotic preloading
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perimenopause Contraception should be recommended until menopause confirmed clinically Combined OCs no longer CI in non-smoking women over age 35. May also help with menopausal symptoms IUD Progestin-only methods Barrier methods
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postpartum contraception
Combined OCs: may diminish quality and quantity of breast milk in postpartum period. Should not be used until lactation well established (usually 6 weeks pp) Progestin-only pills: Provides a small increase in milk production. Progestins administered within first 72hrs pp may theoretically interfere with the fall in serum progesterone levels that triggers lactogensis, but prospective study did not detect any adverse effect on breastfeeding Injectable progestin: Little or no effect on breast milk production or infant development. May be preferable to wait until breast milk established, otherwise first dose can be given immediately after birth IUD: Usually wait until 4-6 weeks postpartum since higher risk of expulsion and uterine perforation Lactational amenorrhea: Exclusively breastfeed at regular intervals (<4hrs during day), even during the night (<6hrs at night), have this contraception effect during first 6 months. Supplements increase the risk of ovulation in absence of menstruation.
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emergency contraception
Emergency contraceptive pills Plan B: 85% effective: 2 doses of 750mcg levonorgestrel 12 hours apart up to 72hrs after intercourse. May be preferred in women with significant CI to estrogen Yuzpe method: 75% effective: 2 doses of 100mcg etinyl estradiol and 500mcg levonorgestrel 12 hours apart up to 72hours after intercourse Side effects: Nausea, vomiting, dizziness and fatigue (Plan B better than Yuzpe). Antiemetic meclizine 50mg 1 hour before first dose Insertion of copper IUD: approaches 100% effective. Can be inserted up to 7 days after unprotected intercourse
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references Black A, Francoeur D, Rowe T et al. SOGC clinical practice guidelines: Canadian contraception consensus. J Obstet Gynaecol Can. 2004;26:219-96
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