© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View

© Copyright Annals of Internal Medicine, 2012Ann Int Med. 157 (7): ITC4-1.

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in the clinic

Contraception


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Which women are most likely to become pregnant unintentionally?

Women <19 years old

80% teenagers describe their pregnancy as unintended

Women with low educational attainment or low income

Income < poverty line: unintended pregnancy rate 5x higher than if income >200% above it


Which women are most likely to become pregnant unintentionally?

Black women have highest unintended pregnancy rate

> 2x that for non-Hispanic white women

Type of contraception may play role

Hormonal methods = 2x higher rate of pregnancy vs. long-acting reversible methods (among adolescents)


What are the various types of contraceptives and how do they work?

Hormonal methods

Combined (ethinyl estradiol + progestin)

Oral contraceptive pills (COCs): daily by mouth

Transdermal patch: single patch weekly for 3 weeks, then off for week (for withdrawal bleed)

Vaginal ring: ring inserted in vagina for 3 weeks, then removed for a week; new ring each month


What are the various types of contraceptives and how do they work?

Hormonal methods

Progestin only

Oral contraceptive “mini-pill”: daily by mouth with no “off” week

Injectable: IM injection every 3 mo by health care provider; SQ may be self-injected


Long-acting reversible contraception methods (LARC)

Hormonal and nonhormonal

Subdermal implant: placed in upper arm by trained OB/GYN; used ≤3y

Levonorgestrel (LNG-IUD): placed in uterus, used ≤5y

Copper IUD: placed in uterus, used ≤10y


Barrier

Nonhormonal

Male, female condoms: protect against STDs; available OTC

Vaginal sponges: Available OTC

Diaphragm; cervical cap: must be fitted by a physician


How effective are contraceptives? Permanent sterilization and LARC: top tier methods

Vasectomy: failure rate 0.01%

Female sterilization: failure rate 0.5%

Copper IUD: failure rate 0.8% at 1y

LNG-IUD: failure rate 0.1% at 1y

Subdermal implant: failure rate 0.05%

Combined Oral Contraceptive pills, patch, ring, DMPA injection: next tier methods Efficacy influenced by adherence

COCs: perfect use failure rate 0.3% vs. typical use rate 8%

DMPA injection: failure rate 3%

Barrier: lowest tier methods Efficacy limited by user compliance

Typical-use failure rates ≈15%

All better than nothing…

85% of reproductive-age women having regular unprotected sex pregnant within 1y


What is meant by “emergency contraception”?

Any contraception method used after sexual intercourse

Doesn’t disrupt an established pregnancy

Levonorgestrel (Plan B, Plan B One-step) Levonorgestrel 0.75 mg (2 pills) or 1.5 mg (1 pill) within 5d

of unprotected intercourse Reduces risk for pregnancy by 89% Efficacy decreases slightly each day after unprotected sex Available without prescription if ≥17 years old

Ulipristal (ellaOne) Ulipristal acetate selective progesterone receptor

modulator (30 mg pill, given once) Reduces risk for pregnancy by 90% Maintains efficacy through days 1 through 5 By prescription only


Copper IUD

Inserted up to 5 days after contraceptive failure/nonuse

Reduces pregnancy risk by 99% (most effective method)

Patient should desire the device for contraception

Alternative: COC pill regimen

Number of pills varies depending on pill formulation

Compared with other options: more side effects, less effective, and must be taken within ≤72 hours


What is the role of tubal ligation and vasectomy in contraception?

Sterilization considered permanent

Patients should be certain they don’t want more children

Reversals are costly and frequently unsuccessful

Procedure carries surgical and anesthetic risks

Vasectomy more effective than tubal ligation + safer (however patient not sterile until ≈12 weeks after procedure)

LARC methods: may be more appropriate option

Subdermal implants or IUDs

As effective as sterilization for reducing pregnancy


CLINICAL BOTTOM LINE: Epidemiology and Efficacy…

50% of pregnancies in U.S. unplanned Poor, young, or minority women at highest risk

Contraception can prevent unplanned pregnancy Most effective: IUDs, subdermal implants, and sterilization User error adds to higher failure rate (≥10%) for pills, patch,

DMPA injection, vaginal ring Emergency contraception options

Copper IUD most effective


Are there beneficial effects to the use of contraception beyond pregnancy prevention ?

Combined hormonal methods (the pill, patch, or ring)

Alleviate dysmenorrhea

Control cycle

Reduce endometrial hyperplasia

Improve menorrhagia symptoms

Prevent premenstrual dysphoric disorder

Reduce hirsutism and acne

Decrease endometrial, ovarian, & colorectal cancer risk

Improve symptoms exacerbated by hormone fluctuations


Injectable contraception

Improves menorrhagia symptoms

Reduces endometrial cancer risk

Control cycle (if comfortable with amenorrhea)

LARC methods

Benefits similar to COCs

Subdermal implant and LNG-IUD: improve menorrhagia, and dysmenorrhea and other symptoms of endometriosis

LNG-IUD and copper IUD: decrease endometrial cancer risk

LNG-IUD: treat endometrial hyperplasia without atypia


What are the risks for combined hormonal contraceptives?

All combined hormonal contraceptives (≤35 mcg estrogen): Venous thromboembolism

Slightly elevated risk (most common in 1st year use)

Slightly higher for older women and obese women

Risk eliminated in ≤30d of discontinuation

Transdermal patch: black box but risk not higher

Hemorrhagic stroke, ischemic stroke

Increased risk if patient has uncontrolled hypertension, migraines with aura symptoms, or smokes

All combined methods contraindicated in these women

Arterial blood clot

Increased risk if smoker, >40 years old, obese


What are the risks of progestin-only and LARC methods?

Injectable medroxyprogesterone acetate Weight gain ( ≈5.4 pounds)

Loss of bone mineral density

Transient and reversible; no increased fracture risk

Intrauterine devices Cramping in 1st few months (more common w/ copper IUD)

Treat with NSAIDs

Spontaneous expulsion (risk <1%)

Genital tract infection at time of insertion

Prophylactic antibiotics don’t decrease risk

Uterine perforation at insertion (very low risk: 0.01%)


What are the risks to the fetus if pregnancy occurs when a woman is receiving oral contraceptives?

No risks

No evidence of fetal anomaliesspontaneous miscarriagepreterm deliverybirth defectscompromised fertility of offspring


CLINICAL BOTTOM LINE: Medical Considerations… Medical benefits of hormonal contraception

Cycle regulation, lighter periods Reduced premenstrual symptoms

Medical benefits of LNG-IUD and subdermal implant Decreased menstrual bleeding LNG-IUD only: improves endometrial hyperplasia

Medical risks of hormonal contraception Stroke: contraindicated if >35y old & smoker, or if migraines

+ aura VTE: slight increased risk (highest in first year of use)


When should women be counseled about contraception?

Before first sexual encounter

Average age of first sex in United States is 17

Repeat throughout reproductive years

Average U.S. woman spends 5 years attempting pregnancy, being pregnant or postpartum

Spends nearly 30 years avoiding pregnancy


Which women are at greatest risk for complications if they become pregnant?

Breast cancer Complicated valvular heart

disease Diabetes (especially type 1) Endometrial or ovarian cancer Epilepsy Hypertension Bariatric surgery in past 2y HIV/AIDS Ischemic heart disease Malignant gestational

trophoblastic disease

Medical Conditions Increasing Risk for Complications


Which women are at greatest risk for complications if they become pregnant?

Malignant liver tumors, hepato-cellular carcinoma of liver

Peripartum cardiomyopathy Pulmonary hypertension Schistosomiasis (liver fibrosis) Severe cirrhosis Sickle cell disease Solid organ transplantation Stroke Systemic lupus erythematosus Thrombogenic mutations Tuberculosis

Medical Conditions Increasing Risk for Complications


How does this affect their choice of contraception?

Encourage use of most effective method to decrease possibility of a risk

Often: LARC or sterilization (if finished childbearing)

Consult U.S. Medical Eligibility Criteria, from CDC

Comprehensive analysis of medical problems and risks associated with certain contraceptives

Helps determine which methods a patient could use


How should women go about choosing an appropriate contraceptive?

Lifestyle Unpredictable work schedule? may be hard to take pill at

same time every day Planning future pregnancy? STD protection? Condoms prevent pregnancy + STDs

Past use Unplanned pregnancy when using contraception in past? Unable to continue a method in past? (unlikely option)

Side effectsSuch as spotting with subdermal implant

Personal comfort Discomfort changing a vaginal ring? (will discourage use) Discomfort with amenorrhea from LNG-IUD ?


Are there forms of contraception a woman should avoid if she is considering pregnancy in the next year or so?

Injectable medroxyprogesterone acetate

Delayed return of fertility (≈10 months)

Not recommended if desiring pregnancy in near future

Other contraception methods allow rapid return to fertility (IUD, subdermal implant, combined hormonal)


What contraceptives can breastfeeding woman use?

If breastfeeding

Progesterone-only methods acceptable, safe

Can be started immediately after delivery

Delay estrogen-containing methods until 6 weeks post-partum and lactation well-established (elevated VTE risk)

Option: barrier method (refit diaphragm / cervical cap after delivery)


CLINICAL BOTTOM LINE: Counseling Considerations… Initiate contraception counseling before first sexual activity When choosing appropriate contraception…

Consider patient comfort, lifestyle, past method use Medical conditions (may increase risk for complicated or

dangerous pregnancy) Consult CDC Medical Eligibility Criteria Be aware return to fertility delayed after discontinuing

injectable medroxyprogesterone


What are the cost and cost-effectiveness of contraception? All more cost-effective

than unwanted pregnancyCost Combined methods: $8 - $80 per month

Medroxyprogesterone: $35 - $75 every 3 months (plus nursing visit for administration)

LARC methods: $300 - $800 without insurance

Cost effectiveness LARC and sterilization: highest up-front cost

But most cost-effective over time

Combined methods: less cost upfront but refills required

Less cost-effective given decreased efficacy vs LARC

Condoms: least cost-effective (but protect against STDs)


Are all forms of contraception covered by most health insurance plans?

Most insurance companies cover contraception

If there is a prescription drug benefit

Patient Protection and Affordable Care Act

Requires insurers to cover contraception without copay

Plans that existed when PPACA passed grandfathered in

Any significant changes or modifications to plans will mandate adoption of the new regulations

Exemptions for some religious employers


CLINICAL BOTTOM LINE: Cost Considerations… Most cost-effective form of contraception: LARC

Cost of contraception: covered by most insurance plans that include prescription drug benefit

PPACA: requires all insurance providers to cover contraception without copay


Should primary care physicians prescribe contraceptives or should they refer patients to other providers?

For medically uncomplicated women: Primary care physician may prescribe contraception

However few are well-trained in contraception provision

PCP often first-line providers for ill women, who may need counseling about contraception

Especially important if also prescribing teratogenic medication

For women with medical problems: refer to OB-GYN or family planning specialist


Are there programs to train internists in providing contraception?

Most training occurs during residency / fellowship

Subdermal implants: Manufacturer can provide formal training on placement

IUDs: Consider contacting local provider within your institution for training on insertion

In general, refer patient to experienced person for counseling and fitting of device

OB-GYN or family practice physician or nurse


CLINICAL BOTTOM LINE: Provider Considerations… To prevent unintended pregnancy: provide contraception to all

sexually active reproductive-age women Internists should feel comfortable and responsible discussing

contraception with patients Especially if medically complicatedRefer to OB-GYN or family practice physician if patient has: Medical problems, an interest in LARC method, or if there is

difficulty identifying appropriate method

Documents

© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 157 (7): ITC4-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View