helping make a contraceptive choice - health sciences...
TRANSCRIPT
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Birth Control Options - Helping patients
make an informed choice Herbert L. Muncie, Jr. M.D.
Professor of Family Medicine
LSU School of Medicine – New Orleans
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Ms. J
• 17 year old woman comes in to discuss
contraception
– Senior in HS; plans to attend State
University in the fall
– Physical exam normal; BP 110/64; BMI –
20.6 kg/m2
– LMP 2 weeks ago; non-smoker; no
headaches
– Currently using condoms regularly
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Decision to delay pregnancy
• A woman’s decision to delay pregnancy
or prevent an unintended pregnancy is
very personal – the decision:
– Is influenced by her social norms &
cultural environment
– Her economic situation
– Her long-term goals
– Her personal uniqueness
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Health Care Provider’s Role
• The health care provider’s role in the
woman’s decision process is to:
– Be knowledgeable about all options
– Provide unbiased nonjudgmental
information
– Listen to the woman’s concerns &
questions
– Give the best advice for that unique
patient
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Contraceptive Success
• A woman’s ability to delay pregnancy &
prevent an unintended pregnancy
involves four components:
– Choosing and acquiring a contraceptive
method
– Accurately using the method
– Consistently using the method
– Switching methods correctly
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Ms. J’s Birth Control Options
• Abstinence
• Condom
• Diaphragm/cervical
cap
• Natural family
planning
• Oral contraceptive
• Contraceptive Patch
• Hormonal vaginal
ring
• Injection q 3 months
• IUD
• Contraceptive rod
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Abstinence
• Abstinence
– Delaying the onset of sexual activity until
older
– Safest way to avoid pregnancy and STD
– No randomized trials have shown efficacy
of physician counseling delaying onset
• Cultural norm establishes the prevalence of
delaying onset of sexual activity
– Still reasonable to discuss option to reduce
risk of undue peer pressure
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Condoms
• Condoms
– Only method proven effective
for prevention of STDs
– Combine with more effective
method with new sexual partner
– Use may increase if discussed
as additional protection from
pregnancy (not prevent STD)
– Must be used at time of sexual
activity
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Diaphragm & cervical cap
• Diaphragm & cervical cap
– Combined with contraceptive gel
– Can be put in several hours before
intercourse
– Must be left in 8 hours after intercourse
– Increased risk of UTIs (diaphragm)
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Natural Family Planning
• Natural family planning
– No medication side effects
– Efficacy highly dependent on compliance
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Ms. J’s Birth Control Options
• Abstinence
• Condom
• Diaphragm/cervical
cap
• Natural family
planning
• Oral contraceptives
• Contraceptive Patch
• Hormonal vaginal
ring
• Injection q 3 months
• IUD
• Contraceptive rod
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What about an cOCP for Ms. J?
• Would a combination oral contraceptive
pill (cOCP) be appropriate for Ms. J?
– Does Ms. J have any contraindications to
using a cOCP?
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cOCP Contraindications
• Smoking and ≥ age 35
• Uncontrolled hypertension
– Only clinical exam needed before starting
OCP is BP measurement (no pelvic exam)
– If >160/>100 do not use them
– If 140-159/90-99 or controlled “generally”
should not use them
• Migraine with aura (classic migraine)
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cOCP Contraindications
• History of DVT, PE or arterial clotting
• A positive family history (FH) of clotting or
thrombotic events (relative contraindication)
–A positive FH is:
• If one parent or sibling ever had VTE < age 50 or
• If 2 relatives (either parents or siblings) had VTE at
any age
• Undiagnosed genital bleeding
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cOCP Contraindications?
• Pregnancy – not harmful, just too late
• Sickle cell (SS) or sickle C (SC) disease
not absolutely contraindicated
– DMPA may be preferable for SS disease
– Associated with reduced risk of crisis
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Which combination pill is best?
• cOCPs are a combination of an
estrogen & a progesterone -
– Primarily 3 estrogens & 9 progestins in
varying amounts & various combinations
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Estrogen Dosages
• Ethinyl etradiol (EE) is most common estrogen used
• EE dosage is always ≤ 50 mcg – Most commonly prescribed pills have 30 - 35
mcg
– 20 mcg pill in randomized trial had reduced breast tenderness and bloating
– However, 20 mcg pills had a higher failure rate with missed pills
– 10 mcg pill approved (Lo-Loestrin®)
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cOCP - Progesterones
Progesterone Class Family Examples
• Ethynodiol diacetate
• Norethindrone
• Norethindrone
acetate
1st
Generation
Estrane
(short
½ life)
Demulen® 1/35 Norinyl® 1/35,
Loestrin®
• Levonorgestrel (LNg)
• Norgestrel
2nd
Generation
Gonane
(longer
½ life)
Alesse®, Lybrel®,
Seasonale®,
Ovral®, Lo-Ovral®
• Desogestrel
• Norgestimate
• Dienogest
3rd
Generation
Gonane Desogen®, Mircette®,
Ortho Tri-Cyclen®
Natazia
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Choosing the cOCP
• No pill has clinically significant advantage
– Low EE dosage may have fewer side effects
but may have higher failure rate
– Choice of estrogen or progesterone not critical
• Generally choose low to moderate dose
estrogen with 2nd generation progestin
– Then change pill if not tolerated
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Benefits that could influence
choosing a cOCP
• Decreased dysmenorrhea
• Reduced menstrual flow
• Reduced risk of anemia
• Improves acne
• Eliminate mittelschmerz
• Decreased risk of
ectopic pregnancy
• Decreased risk of PID
• Decreased sxs of PMS
• Improvement in
endometriosis
• Suppression of ovarian
& breast cyst formation
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cOCP – Cancer Benefit
• Endometrial cancer risk reduced
– 50% reduction if used in prior 12 months
– Maximum protection if use continues for
3 years
– Protection lasts for 15 + years
– High or low dose pills provide protection
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cOCP – Cancer Benefit
• Ovarian cancer risk reduced
– 40% reduction in risk over nonusers
• High dose or low dose pills - same benefit
– Begins after 3-6 months of use
• 80% reduction after 10 years of use
– Reduced risk with family history ovarian
CA & 4-8 yrs. use
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cOCP Risks
• What would be Ms. J’s risks in using a
cOCP?
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cOCP & VTE Risk
• VTE Risk
– 3-6 fold increased risk VTE, highest first
6-12 months of use (SOR B)
– Older women have greater risk
• > age 39 - 100/100,000 women/year
• Adolescents - 25/100,000 women/year
• Pregnancy - 200/100,000 women/year
– Obesity doubles the risk
– Risk decreases with longer duration of use
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VTE Risk & dropirenone/desogestrel
• Increased VTE Risk
– For same estrogen dose – drospirenone
(Yasmin®,Yaz®) & desogestrel (Desogen®, Mircette®)
have significantly higher VTE risk
• Absolute risk is low
• No study has found a reduced risk
• However, for women on these progestins would
need to change 10,000 to prevent 1 VTE
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cOCP & Cardiovascular Risk
• Increased MI risk in smokers > age 35
– No increased MI risk with low dose pill for
non-smoking women, without hypertension
or migraine with aura at any age
• Increased risk of ischemic stroke
– 2-6 fold increase of ischemic stroke with
history of migraine with aura
• No increased vascular risk with progestin
only contraception
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Cervical Cancer Risk
• Risks (SOR B)
– Increase in cervical cancer after 8 or more
years of use after adjusting for HPV infection
– Risk of CIN 2 or 3 with oncogenic HPV
• Decreased with depot-medroxyprogesterone (DMPA
- Depo-Provera®)
• No increase with cOCPs
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cOCP & SLE
• cOCP use associated with increased risk
of developing systemic lupus
erythematosus (SLE)
– Especially if recently started
– However, very low absolute risk
• However, in women with previously
diagnosed SLE which is stable
– Starting a cOCP did not increase the risk of
flares
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Not cOCP Risks
– No increased risk of weight gain (SOR A)
• Weight gain does occur with DMPA –
average of 5.1 kg
– No increased risk breast cancer (SOR B)
– No increased risk of death later in life
• In fact a net benefit was found
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Frequency of menstruation?
• Before prescribing a cOCP ask how often
a woman wants to menstruate?
– Monthly? (every 4 weeks)
– Bimonthly? (Bicycling) (every 2 months)
– Quarterly? (Tricycling) (Every 91 days)
– Never?
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Menstruate monthly or bimonthly
• Monthly (every 4 weeks)
–Use standard 28 pill cOCP
• Bimonthly (bicycling)
– Use 2 standard 28 pill cOCPs but skip the
placebo pills with the 1st pack
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Menstruate Quarterly (Tricycling)
• Seasonale®
– 84 active pills [LNg (0.15 mg) & EE (30 mcg)] 7
placebo
– Increased risk of unsuspected bleeding first 6 months
of use
• Quartette® – increasing dosages of EE [LNg dosage
uniform (0.15 mg/day)]
– 42 days with 20 mcg EE
– 21 days with 30 mcg EE
– 21 days with 35 mcg EE
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Menstruate never
• Lybrel® approved for continuous use
– 365 days active pills
– EE 20 mcg & levonorgestrel 0.09 mg every
day
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cOCP - Other Formulations
OCP Active Placebo EE
Standard 21 7 0
Mircette® 21 2 5
Seasonique® 84 0 7
Lo-Seasonique® (20 mcg EE) 84 0 7
Loestrin® 24 Fe 24 4 0
Yaz® (20 mcg EE) 24 4 0
Femcon® Fe (chewable pill) 21 7 0
Natazia® 26 2 0
Beyaz ® (Yaz with folate); Safyral® (Yasmin
with folate)
24 4 0
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What is the best way to
initiate a cOCP?
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Starting cOCP – Sunday Start
“Sunday start” – take the 1st pill of the 1st
pack the 1st Sunday after onset of next
menses
– Reduces menses on weekend
– If start > 5 days from onset of menses
either abstain or use additional
contraception 1st 7 days of pills
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Starting cOCP – 1st day Start
“First-day start” - take the 1st pill of the 1st
pack the 1st day of next menses
– Easier for patients to remember & to
explain to patient
– As long as start < 5 days from onset of
menses no additional contraceptive
needed
– Less breakthrough bleeding
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Starting cOCP – Visit day start
“Visit day start” - take the 1st pill of the
1st pack the day of the visit
– “Quick start” - watch patient take 1st pill
• Negative pregnancy test & no intercourse prior
2 weeks, no immediate follow-up
• If intercourse within prior 2 weeks, repeat
pregnancy test in 2 weeks
• Additional contraception the first 7 days
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Quick-Start Benefit
• Main benefit is reduced time explaining how to
start pills
– No evidence reduced risk of pregnancy or
discontinuation rates for OCPs
– Fewer women on quick-start Depo-Provera became
pregnant than women who started another method
• Other than the IUD, can start any contraceptive
immediately without UPT
– Can do UPT 2 – 4 weeks later if concerned about
pregnancy
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Writing the OCP Prescription
• Ordering 13 packs at the
visit lead to better
continuation rates &
decreased cost
– Also were more likely to have
PAP & chlamydia screening
• Had fewer pregnancies
RX
Dr. Fleur de Lis
New Orleans, LA
Ms. R
Sig: 13 OCP Packs
Refill: x 0
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Another OCP Prescription Option?
• Giving 7 packs lead to a
greater continuation rate
compared to giving 3
packs
• Women who received a
prescription were not more
likely to continue
compared to having the
packs in hand
RX
Dr. Fleur de Lis New Orleans, LA Ms. R
Giving 7 packs of pills at time of visit (not an Rx)
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Missed Pills
Some women are excellent at taking the
pill consistently & some are not
No demographic characteristic can identify
which patient will remember consistently
Compliance was not enhanced with group
motivation, structured, peer or
multicomponent counseling or intensive
reminders
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How many pills are missed?
Using electronic monitoring an average of
2.6 pills were missed each cycle.
However, in a text-messaging trial, the
average number of missed pills was
4.9 per cycle
No pregnancies occurred with this level of
non-compliance
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Missed pill instructions
• First ask which pill was missed:
– If placebo pill just skip it
• If active pill and < 24 hrs late
– Take immediately
• If active pill and ≥ 24 but < 48 hrs late
– Take missed pill immediately & other pill at
usual time (may mean both at same time)
– Additional contraception not required
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> 2 Missed pills
• If > 2 consecutive active pills missed
– Take most recent missed pill immediately (discard other missed pills)
– Take remaining pills at usual time (may mean two pills on the same day)
• If missed pills were in the last week of hormones (day 15 – 21), omit placebos and start new pack instead of placebos
– Use additional contraceptive method for 7 days
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> 2 Missed pills (Cont.)
• If > 2 consecutive active pills missed
– Should consider emergency contraception if unprotected intercourse in previous 5 days or if missed pills during the 1st week
• May be considered at other times
– Discuss alternative contraceptive options that do not require daily compliance
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Most Dangerous pill to miss?
• Most dangerous pill to miss
is the 1st pill of the new pack
– Pill free > 7 days increases
risk ovulation
• If miss 1st pill use additional
form of contraception until taken
7 consecutive active pills
• Stress compliance with starting
each new pack
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Special Populations & cOCP
Postpartum
Breastfeeding
Seizure disorder on medication
Migraine headaches
Antibiotic concomitant use
Obesity
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Postpartum
• ACOG guideline
– No cOCP < 21 days postpartum
(high risk of VTE)
– If not breastfeeding may start after 21 days if
no increased VTE risk (e.g. C-section)
– If C-section must wait 42 days (6 weeks) to
start cOCP
• For delivery of < 20 weeks gestation -
can begin cOCP immediately
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Breastfeeding
• Progestin only pills are often recommended for women breastfeeding because:
– No effect on quality or quantity of breast milk
• They work by thickening cervical mucous & preventing sperm ascending through os
– However, erratic ovulation suppression
• Irregular bleeding common
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Progestin only pills
• Daily compliance crucial
– Must take same time every day (> 3 hr difference can allow ovulation)
– If >3 hr delay occurs take pill immediately & use additional contraception until taken at correct time for 2 consecutive days
– Consider EC if unprotected intercourse
• Not contraindicated in smokers > age 35
• No increased risk of VTE
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cOCP & Breast feeding
• Can start cOCP > 4 weeks post-partum
(PP) if lactation is well established &
other forms of contraception are not
acceptable
• If exclusively breastfeeding (> 85% of
feeds) no medical contraception needed*
*MMWR June 21, 2013
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Seizure Disorder on Medication
• Some anticonvulsants reduce efficacy cOCP by increasing metabolism of EE & progesterone – Avoid cOCP with phenytoin, carbamazepine,
barbiturate, primidone, topiramate, oxcarbazepine
– Mirena®, Skyla® & Depo-Provera® not effected by these medications
– If cOCP is used with these medications, WHO advises either 50 µg EE pill or continuous cOCP
• These anticonvulsants do not effect cOCPs – – Gabapentin (Neurontin®), lamotrigine (Lamictal®),
levetiracetam (Keppra®), tiagabine (Gabitril®)
– However, cOCPs may lower lamotrigine levels
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Migraine Headaches & cOCPs
• For migraine without aura cOCPs:
– May increase or decrease headaches
• Can give trial of cOCP and see what happens
– If HAs persist with normal BP & no deficit
• Lower dosage of estrogen, progestin or both (no
studies reported) SOR - C
– If HAs persist with increased BP or deficit
• Discontinue cOCP
• For migraine with aura cOCPs are
contraindicated
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cOCPs & Concomitant Antibiotic
• CDC guideline – most antibiotics have no
effect on cOCP effectiveness
– No additional contraceptive method needed
– Except with griseofulvin & rifampicin
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Contraception & Obesity
• What contraception is most effective for
obese women (BMI > 30 kg/m2)?
– Depo-Provera® & NuvaRing® are not affected
by body weight (SOR B)
– Obese women using cOCP or patch have
increased risk of pregnancy (SOR B)
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HORMONAL CONTRACEPTION
TRANSDERMAL
TRANSVAGINAL
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Contraceptive Patch (Transdermal)
• Ortho Evra® (EE 20 mcg; norelgestromin
150 mcg/day)
– Apply abdomen, buttocks upper torso
(exclude breast) or upper outer arm
– One patch a week for 3 weeks, 4th week
patch free
– Can use continuous patches for 12 weeks
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Contraceptive Patch
(Transdermal)
• Equally efficacious to cOCP
– Less effective - women > 90 kg
• Side effects
– Breast discomfort, headache, nausea &
cramps – perhaps more than with cOCP
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Hormonal vaginal ring (Transvaginal)
• NuvaRing® (EE 15 mcg & etonogestrel 12 mcg/day)
– One ring for three weeks
• No ring for one week
– Does not have to be in specific position
• Hormones absorbed anywhere in vagina
– If ring is out > 3 hours use additional
contraception until ring in place for 7 days
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Hormonal vaginal ring
• NuvaRing®
– Contraceptive hormone levels last for 35 days
– Alternative regimen
• One ring every 30 days (once a month)
• Same day of the month (e.g. 12th of every month)
• Reduces number of menses & hormonal
withdrawal side effects
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Patch or Ring vs cOCP?
• Cochrane review found:
– Patch caused more side effects than cOCP
– Ring caused fewer side effects than cOCP
• Except for vaginal discharge & vaginitis
• Compared to non-users same age, ring/patch
users had 6.5-7.9x increased risk VTE
– Increased SHBG & protein C sensitivity
– However, would need to switch 2000 ring or
1250 patch users to cOCP with levonorgestrel to
prevent 1 VTE
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Ms. J’s Birth Control Options
• Abstinence
• Condom
• Diaphragm/cervical
cap
• Natural family
planning
• Oral contraceptive
• Contraceptive Patch
• Hormonal vaginal
ring
• Injection q 3 months
• IUD
• Contraceptive rod
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Injection every 3 months
• Medroxyprogesterone acetate IM Q90D (Depo-Provera®; Depo-subQ Provera 104®)
– Associated with weight gain
– Irregular bleeding and most women are
amenorrheic at one year
– May have better compliance than cOCP
– FDA Black-Box Warning – Increased risk
of decreased BMD with > 2 years use
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Ms. J’s Birth Control Options
• Abstinence
• Condom
• Diaphragm/cervical
cap
• Natural family
planning
• Oral contraceptive
• Contraceptive Patch
• Hormonal vaginal
ring
• Injection q 3 months
• IUD
• Contraceptive rod
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Long-acting Reversible
Contraception (LARC) - IUD
• IUD – levonorgestrel
– 5 years duration (Mirena®)
– 3 years duration (Skyla®)
• Smaller & perhaps easier to insert
• IUD – intrauterine copper
– 10 years duration (ParaGard®)
– Can be used for emergency contraception up
to 5 days after unprotected intercourse
– Discrete method since will not effect
menstrual cycle regularity
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LARC - Implant
• Etonogestrel SD (Implanon®; Nexplanon®-
radiopaque)
– Single subdermal rod for 3 years duration
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LARC - Indications
• Indications
– Can be used in almost any female who
desires the most effective contraceptive
method
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LARC – not contraindications
• Not contraindications to LARC are:
– Nulliparity
– Age – neither too young or too old
– Prior STD
– Prior ectopic pregnancy
– Prior PID
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IUD Contraindications (risk>benefits)
• IUD contraindications – never to use
– Distorted uterine cavity
– Gestational trophoblastic disease
– SLE with positive antiphospholipid antibodies (exception ParaGard®)
– Pelvic tuberculosis
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IUD Contraindications to Initiate
Use
• IUD contraindications to initiating use until
condition is treated
– Cervical cancer awaiting treatment or uterine
cancer
– AIDS, until clinically well on antiretrovirals
– Current PID or purulent cervicitis
– Postabortal or postpartum sepsis
– Unexplained or unevaluated vaginal bleeding
– Complicated solid organ transplant
– SLE with severe thrombocytopenia (exception
Mirena®)
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Indications to Remove IUD
• Indications to remove IUD
– Headaches with aura that develop with use (exception ParaGard®)
– Ischemic heart disease that develops during
use (exception ParaGard®)
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Implant contraindications
• Contraindications to ever using
– SLE with positive antiphospholipid
antibodies
• Contraindications (initiation of use) until
condition treated
– Unexplained or unevaluated vaginal
bleeding
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Indications to remove implant
• Indications to remove implant
– Headaches with aura that develop with
use
– Ischemic heart disease that develops
during use
– Stroke during use
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Advising a Contraceptive Method
• Before advising a woman regarding
contraception assess two things:
– First, how important is it to her that she not
become pregnant?
• The more important it is
• The more important to advise the most effective
method for her
– Second, what is her understanding of the
effectiveness of contraceptive options?
• She may have unrealistic understanding
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Contraceptive Failure*
1000 women
No method
850
Withdrawal
Periodic abstinence
220
Condom
180
Diaphragm
120
cOCP
Patch
Ring
90
IUD
2
Implant
0.5
*Number of pregnancies during one year of typical use
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The Contraceptive Recommendation
• Women overestimate the effectiveness of pills,
patch, ring or condom
• Risk of pregnancy is 20x greater for pill, patch,
or ring users compared to IUD, implants
– And women < 21 yo were 2x more likely than older
women to get pregnant with pill, patch or ring
• If delaying pregnancy is strongly desired
– Recommend IUD or implant (LARC)
• No clear best way to present this evidence to
women that allows for an informed choice
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Providing Effective Counseling
• Characteristics of effective counseling:
– Demonstrate expertise, trustworthiness &
accessibility
– With adolescents address confidentiality
and parent’s role in the decision process
– Engage the woman in the learning process
– Address choosing the method, correct
use, consistent use and method switching
– Give priority to more effective methods
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Providing Effective counseling (continued)
• Determine if method fits her lifestyle
(social norms, image, stigma, etc.)
• Recommend condom use with any
method as “extra” protection from
pregnancy (does reduce risk of STD)
• Discuss how to avoid inconsistent use
• Address side effects at the beginning
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Key Points
• Multiple contraceptive options exist with
moderate to excellent efficacy
– Moderate – cOCP, patch, ring, depo
– Excellent – IUD, implant
• Know the main benefits and risks for
each method
– If prescribe a cOCP use “visit day” start
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Key Points
• Generally recommend a LARC method
for women whom delaying pregnancy &
preventing unintended pregnancy is
highly valued
– Essentially very few contraindications to
LARC methods
• Provide “effective” counseling
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Ms. J’s Conclusion
• Ms. J strongly does not want to become
pregnant in the near future
• After reviewing her options she
chooses to have an implant placed
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Questions