Contraception in Primary Care: Helping Your Patients Choose the Best Method

Transcription

1 Friday CME Breakfast Contraception in Primary Care: Helping Your Patients Choose the Best Method Rebecca Hart, MD Family Physician, South Shore Medical Center Co Chair, 2017 Annual Session & Primary Care Summit Treasurer, Texas Academy of Family Physicians League City, Texas Educational Objectives By the end of this educational activity, participants should be better able to: 1. Review available contraceptive methods and be able to better select the appropriate method of contraception for each patient. 2. Discuss the benefits and drawbacks of various contraceptive techniques. 3. Counsel the female patient on her choice of contraception. 4. Discuss contraceptive methods and the use of the vaginal ring, IUD, contraceptive patch, permanent in office sterilization, and long term pills. Speaker Disclosure Dr. Hart has disclosed that she has no actual or potential conflict of interest in relation to this topic. 1

2 Dr. Hart has disclosed that she has no actual or potential conflict of interest in relation to this topic. Rebecca Hart, MD Associate Clinical Professor, McGovern Medical School Family Physician, South Shore Medical Center, League City, Texas 2017 Annual Session & Primary Care Summit Friday, November 10, 2017 By the end of this activity, participants should be better able to: 1. Review available contraceptive methods and be able to select an appropriate method of contraception best suited for each patient. 2. Counsel the female patient on her choice of contraception. 3. Discuss the best new contraceptive methods including LARCs. 4. Guide the patient in using Emergency Contraception. In 2011, nearly half, 45% or 2.8 million, of the 6.1 million pregnancies in the United States were unintended. Decreased from 2001 stats-3.1 million unintended pregnancies in the US 2011 Pregnancies Unintended Intended Pregnancies Pregnancies (3.3 million) (2.8 million) Women at Risk Nonuse Inconsistent 41% of these unintended pregnancies result from people who use contraception inconsistently. Unintended Pregnancies Consistent Use 5% (Down from 48% in 2001) Nonuse 54% Inconsistent use 41% Consistent use Unintended Intended Source: Guttmacher Institute Guttmacher.org Consistent Use Inconsistent use Nonuse Inconsistent Use Nonuse Consistent Use 1

3 The states with the highest unintended pregnancy rates in 2010 were Delaware (62 unintended pregnancies per 1,000 women aged 15 44), Hawaii (61), New York (61) and Maryland (60). Top 2 since 1982 The Pill (OCP) Combined OCPs Progestin-Only Pills Long Term Pills Injectables Depo-Provera Sub-q Depo-Provera (medroxyprogesterone) Surgical Options Vasectomy Bilateral Tubal Ligation Devices IUDs The Patch Vaginal Ring The Implant Barrier Methods Spermicides The Sponge Condoms Male Condoms Female Condoms Diaphragm Fertility Awareness Basal body temperature Cervical mucus Calendar Lactational Amenorrhea Method Rhythm Withdrawal Emergency Contraception Pills Copper IUD < 1 Preg per 100 Women in a year Implant 0.05% Vasectomy 0.15% IUD LNG 0.2% Copper 0.8% Female Sterilization 0.5% 6-12 Preg per 100 Women Yrs Injectable 6% Pill 9% Ring Patch 9% 9% Diaphragm 12% 18 or more preg per100 Women Yrs LEAST EFFECTIVE Male condom 18% Any Calendar Method 24% Female Condom 21% Spermicide 28% Withdrawal 22% Sponge 24% Parous 12% Nullip 2

4 Implant $800 Depo Provera: $200/yr Male condom: $13/36 pack $156/yr Calendar Method: $0.00 IUD LNG $1000 Copper $700 Pill: Generic $8-15/m Brand $20-50/m $86-$600/ year Female Condom: $20/36 pack $240/year Spermicide: $1.00 per dose $120/year Male sterilization: $940 Ring: $150/mon $1800/year Patch: $100/mon $1200/year Withdrawal: $0 Chart assumes use 10X per month Female Sterilization $4023 Diaphragm $75 +spermicide= $195/year Sponge: $11/3 $396/year Sources: Health Care Blue Book and GoodRx Female Sterilization The Ring The Patch IUD Levonorgestrel Vasectomy Implant Copper IUD Brand OCP Sponge Female Condom Depo-Provera Inj. Condom Diaphragm and Spermicide Spermicide Alone Generic OCP Withdrawal/ Calendar $4023 $1800 $1200 $1000 $940 $800 $700 $600 $396 $240 $200 $195 $156 $120 $60 $0 Comparison: Typical Costs Per First Year of Contraceptives* *With no insurance or Medicaid Have patients rank their 3 best options for you to discuss with them First, ask patient what method she may want Dispel any myths that the patient may have Give clear, simple facts about methods pros and cons Allow a stirrup free environment Pap not necessary for the prescription EASY to use Simple for their lives Hard to forget Less confusing Highly effective at preventing pregnancy Not dependent on timing Most women forget to take their pills at some point Some women don t want the most effective method! Some are happy to take a chance If I get pregnant, that would be ok. When counseling, ask patient how she would feel if she got pregnant while on contraception. Choices can be driven by a woman s values and preferences Side effect profile and control over the contraceptive are also important Use Shared Decision Making Soc Sci Med

5 LARC: IUDs Progesterone Intrauterine Systems Copper IUDs Injections - medroxyprogesterone acetate Etonogestrel Implant Newest OCP options The Long Term Pills - 3 month and 1 year Vaginal Ring Contraceptive Patch The Essure Procedure Irreversible Natural Cycles App Long Acting Reversible Contraception Provide effective contraception for an extended period without requiring user action. They are the most effective reversible methods of contraception because they do not depend on patient compliance Intrauterine devices Injections Subdermal contraceptive implants An effective, long-acting and reversible method of birth control Was developed in the 1980s Licensed first for contraception in Finland in 1990 Licensed both for contraception and to control menorrhagia Mirena was first one now several others A Hormonal Intrauterine System (IUS) The advantage is that the IUS emits the hormone progestin as contraceptive protection. The first one released 20 mcg of levonorgestrel every 24 hours over 5 years. Inserted in the office 4

6 Contraindications: Uterine anomaly Acute PID (in the last 3 months) H/O ectopic pregnancy Multiple partners (risk of infection) The contraceptive effect of levonorgestrel-releasing intrauterine system is based on the local effects of levonorgestrel in the uterine cavity. Pros reversible, decrease in menses, low failure rate Cons uterine insertion requires office visit, spotting common early, high cost method, expulsion Expensive: about $500 to $1000 plus insertion fee. New Generic IUS less expensive, Medicaid covered in Texas Thins of the lining of the uterus Thickens cervical mucous Inhibits sperm movement Name Hormone Dose Approved For ParaGard N/A N/A 10/12 years* Uses copper Mirena Levonorgestrel 20 mcg/day (52 mg total in the device) 5/7 years* Liletta Levonorgestrel 18.6 mcg/day (52 mg total) 3/5 years* Kyleena Levonorgestrel 17.5 mcg/day (19.5 mg total) 5 years Skyla Levonorgestrel 14 mcg/day (13.5 mg total) 3 years Paragard Mirena Liletta Kyleena Skyla Copper Levo 20 mcg/d Levo 18.6 mcg/d Levo 17.5 mcg/d 14 mcg/d years 5-7 years 3-5 years 5 years Only 3 years Periods stay No periods Periods unlikely Periods likely Periods likely No hormones Inexpensive, generic, Medicaid covered Smaller size for Nulliparous LARC Injections Same side effect profile as IM medroxyprogesterone Subcutaneous use (medroxyprogesterone acetate injectable suspension 104 mg/0.65 ml) More comfortable than IM injections, small quantity injected Dosage q 14 weeks. Bone mineral density concern for over 2 years of use same as regular IM medroxyprogesterone More expensive than generic Depo-Provera Generic Depo-Provera: $50-$100/dose Sub Q Depo-Provera: up to $225/dose 5

7 LARC Nearly 100% effective Injectable a single rod insert Into the upper arm Can be inserted in 15 seconds Effective for 3 years Side effects weight gain, hair loss, bleeding Better tolerated than older products with multiple rods Requires physician training to insert Can cost up to $800 Gaining popularity in the US 2 brands available newer one is radio-opaque. Single rod implant 4 cm in length 2 mm in diameter 68 mg of etonogestrel Duration of use: 3 years Pearl Index: with typical use A flexible plastic ring left in place for 3 weeks 91% effective at preventing pregnancy with usual use Uses similar hormones to OCP Suppresses ovulation just like the pill It has same risks as associated with birth control pills Releases on average mg/day of etonogestrel and mg/day of ethinyl estradiol over a three-week period of use. Cost: About $130 a month (Houston GoodRx) 6

8 Stays in place for three weeks NOT A LARC When 21 days are completed, remove ring to allow a menstrual cycle. After a seven-day break, insert a new ring. Take a break for 1 week As with a Diaphragm, must be willing and able to insert the device Some women are unwilling to perform this insertion Difficult and unpleasant for some women Targets women who forget to take pills daily Has a convenient timer with alarms at 3 weeks and 7 days later to reinsert In studies, sexual partners did not care about the presence of the ring Can take out for intercourse (if desired) for 3 hours only Not a LARC as patients are required to rely on the calendar and alarms to remember to insert and take out. Insertion similar to that of a diaphragm Days after insertion Pros Ease of use Discrete Low dose estrogen Effective Cons Not all insurance covers, expensive $$$ Yuk factor for insertion Spotting More leukorrhea and vaginal discharge Insert the ring on the first day of the menstrual period no later than the fifth day. Use a backup contraceptive method first month Begin using the vaginal ring 4 weeks after delivering a baby if not breastfeeding 7

9 If ring slips out of the vagina Ok if less than 3 hours Reinsert If patient has lost the ring (if it slipped out unnoticed), insert a new ring and continue original schedule If out for >3 hours Rinse the ring with cool water and reinsert it as soon as possible Use a backup method of contraception, such as a male condom or spermicide, for 7 days Do not use a diaphragm or female condom as a backup method Can cause the ring to dislodge If forgotten ring for an extra week (4 weeks) Remove it, have one ring-free week, and then insert a new ring. Ring left in for >4 weeks: Not protected from pregnancy Use a backup method, such as a male condom or spermicide, until a new ring has been in place for seven days in a row. 91% effective This is a weekly hormonal contraceptive. The small square, which contains estrogen and progestin, in a patch, enabling the hormones to be absorbed into the body. How does it work? Same as the OCP Prevents pregnancy by: Stopping the ovaries from releasing egg Thickening the cervical mucus, making it difficult for sperm to enter the uterus Changing the lining of the uterus It is now GENERIC (name brand removed from US market) Releases150 mcg of norelgestromin and 35 mcg of ethinyl estradiol per day Convenient for patients who cannot remember contraception Does not require daily attention Requires weekly attention May cause a predictable menstrual bleeding pattern Does not interrupt sexual activity Should not be used by women who are breastfeeding or who smoke Pros Compliance much greater than with the OCP Ease of use Accessible Generic: Cost: $94-$115 per month Cons Application site problems Application reactions Patch falls off Doesn t work as well in obese women over 198 lbs. Poor pharmacokinetics increase the failure rate Spotting in first 2 months more common than with OCP Breast tenderness more than with OCPs (first 2 months) 8

10 Apply to clean, dry skin only on abdomen, arms or buttocks. Apply the patch on the first day of the menstrual cycle or, start on a Sunday. Wear a new patch each week for three weeks, then off for 1 week Week off = menses After the "patch-free" week, apply a new patch and continue the cycle, wearing the patch for three weeks followed by one patch-free week. Don t cut them Don t put them on with powder or lotion DURING Week 1: Start a new patch change day Use backup method for 7 days DURING Week 2 or 3: Forget for 1-2 days: Remove the old patch as soon as remembered, and apply a new patch. Apply next patch on normal "patch change day." Forget for >2 days: Start a new four-week cycle Use a backup method for 7 days During Week 4: Remove it as soon noticed Start new cycle of patches on your normal "patch change day." No backup method necessary. If less than 24 hours after it was applied, try to reapply it, or apply a new patch immediately. No backup method will be needed, and your "patch change day" will remain the same. Do not reapply the patch if it is no longer sticky or if it is stuck to itself or another surface. In studies 2.8% of patches partially detached, 1.8% completely detached. You will be exposed to about 60% more estrogen if you use *THE PATCH* than if you use a typical birth control pill containing 35 micrograms of estrogen. In general, increased estrogen may increase the risk of side effects, including blood clots. 3 month OCP Levonorgestrel/Ethinyl estradiol tablets 0.15 mg / 0.03 mg for 84 days PLUS Ethinyl estradiol tablets 0.01 mg for 7 days Reduces bleeding 84 days of active pills, then 7 days non-hormonal or estrogen only pills Advantage: ONLY 4 MENSES PER YEAR Great for menorrhagia or dysmenorrhea 9

11 Much less expensive ($) Generic equivalents are Ashlyna, Amethia and Camrese, Quasense, Jolessa, and Intravale In Houston market, as low as $47 per 3 months compared to as high as $327 for brand name. (GoodRx source) Can use regular OCP for 3 months in a row No need to use name brand product Still must pay 3 copays for 1 Rx - (3 mos) Currently, most birth control pills are taken for 21-days followed by a seven-day break. In 2003, the 3 month pill was introduced to the American market. Taking this concept one step further, ALL YEAR PILL users take a hormone pill 365 days a year. There are no placebo pills; and patients do not experience a menstrual period. Suppresses the menstrual period for a full year. Low dose, combination pill Continuous LNG 90 mcg/ee 20 mcg Advantages and Benefits of all year pill 59% of women stopped bleeding after six months of use. One study reported that after 7 to 13 pill packs, women on all year pill reported less nausea and breast pain than those on a 21-day birth control pill. Other research showed that 114 women who used the all year pill for 3 months reported less PMS and period-related pain. Similar in chemistry to generic Microgestin or Junel 1/20 Continuous, daily levonorgestrel/ethinyl estradiol vs. 21-day, cyclic levonorgestrel/ethinyl estradiol: Efficacy, safety and bleeding in a randomized, open-label trial. CONCLUSIONS: Continuous LNG 90 mcg/ee 20 mcg was shown to be a safe and effective OC in this direct comparison to a cyclic OC. Suppression of menses and the potential for no bleeding requiring sanitary protection Contraception Dec;80(6): Epub 2009 Aug 6.Teichmann A, Apter D, Emerich J, Greven K, Klasa-Mazurkiewicz D, Melis GB, Spaczynski M, Grubb GS, Constantine GD, Spielmann D. Effective? In Actual use Efficacy is 92% Effectiveness lowered by: Antibiotics Anti-seizure medications St. John's Wort Erratic use of pills Any healthy woman who wishes to guard against unplanned pregnancies or who wants to suppress her period. Particularly suited to women suffering from: PMS Dysmenorrhea Endometriosis Uterine Fibroids May also be preferred by women with extremely busy or erratic schedules (such as doctors!) 10

12 Same risks as OCPs Every type of female OCP does slightly increases risk of blood clots and breast cancer, particularly if you are over 35 and a smoker. No clinical studies have yet been completed studying the long-term effects of the all year pill. Main side effect: Irregular Spotting However, after taking for seven months, less than 30% of patients continued to experience this side effect. One concern for women is that suppression of menstruation for such a long period may result in an irreversible loss of bone density, Noted after 2 years of continuous use Irreversible Office procedure, 99.8 % effective Permanent sterilization Requires hysterosalpingography Minimally invasive A microinsert placed trans-cervically through fallopian tubes to cause scarring Requires back up method for 3 months Side effects cramping, pain, nausea, vomiting, dizziness, bleeding New Fertility Awareness Methods From Sweden in 2014 Certified as a Birth Control Method by the E.U. It relies on a woman's recorded daily temperature and details about menstruation to determine fertility. On days where the risk of pregnancy is high, a red light indicates you should avoid intercourse or use protection to prevent pregnancy. A Green Light means the risk of pregnancy is low. Red Light Use Protection that day 11

13 Used perfectly, the pill has an effectiveness rate of 99.7 % In actual use, the effectiveness rate drops to 92 percent. That's compared to 93 percent for the Natural Cycles app. $10/month subscription fee Today, women can choose from multiple methods. Hormonal Methods and Surgical Methods remain the most effective. Convenience and ease of use are the most important considerations for most women. LARCs have become more popular in the USA. Emergency contraception is used when a woman who does not wish to become pregnant has unprotected intercourse. There are two main forms of emergency contraception Emergency contraceptive pills (ECPs) Copper-releasing IUDs Emergency Contraceptive Pills (ECPs) Available over the Counter When taken in elevated doses within 72 hours of unprotected intercourse, ECPs can reduce the risk of pregnancy by 75%. Taking them as soon as possible after sex increases their effectiveness. ECPs do not provide ongoing pregnancy protection throughout the cycle. Side Effects Nausea Progestin-only pill cause less nausea Who can use emergency OCPs? Patients who can tolerate OCPs Contraindications: Pregnancy Breast cancer Clotting disorders 12

14 Indications An emergency contraceptive that can be used to prevent pregnancy following unprotected intercourse or a known or suspected contraceptive failure (i.e., a broken condom). Dosage and administration Each Brand Name packet includes a single course of treatment which consists of one tablet; each tablet contains 1.5 mg levonorgestrel. The tablet should be taken orally as soon as possible within 72 hours (three days) of unprotected intercourse. Effectiveness Effectiveness declines as the interval between intercourse and the start of treatment increases. Safe for most women There have been no serious complications Side effects include Nausea, abdominal pain Fatigue, headache Menstrual changes Mechanism of Action Preventing ovulation or fertilization by altering tubal transport of sperm and/or ova. In addition, it may inhibit implantation by altering the endometrium. LNG EC is not effective after fertilization has occurred, a finding that is important to explain to prospective EC users who consider a fertilized ovum a potential life not to be interfered with. Will it harm an unborn fetus? NO. There is no evidence that Emergency Contraception Pills would harm a pregnant woman or a developing fetus if the product were accidentally taken during early pregnancy. Many studies have found no effects on fetal development associated with long-term use of contraceptive doses of oral progestins. (Remember progestins support pregnancy.). Judge, D, Levonorgestrel Emergency Contraception Works Before and Not After Fertilization Contraception 2010 May. Many common oral contraceptive pills can be used as ECPs, off label. "Off-label" use of approved medications is legal and commonplace in the US. Further, in February 1997, the FDA declared Emergency Contraceptive use of birth control pills to be safe and effective. See next slide for Brand Name equivalents that can be used as Emergency Contraception Currently, the following brands of pills can be used as Emergency Contraception Pills in the U.S.A: Pill Brand Manufacturer Pills per Dose Alesse Wyeth 5 pink pills Aviane Duramed 5 orange pills Cryselle Duramed 4 white pills Enpres Duramed 4 orange pills Lessina Barr 5 pink pills Levlen Berlex 4 light orange pills Levlite Berlex 5 pink pills Levora Mayne 4 white pills Lo/Ovral Cadence 4 white pills Low-Ogestrel Mayne 4 white pills Ogestrel Watson 2 white pills Portia Barr 4 pink pills Seasonale Teva 4 pink pills Tri-Levlen Berlex 4 yellow pills Trivora Mayne 4 pink pills BRAND NAME EMERGENCY CONTRACEPTION: Plan B Levonorgestrel 1.5mg 1 pill My Way Levonorgestrel 1.5mg 1 pill Take Action Levonorgestrel 1.5mg 1 pill Next Choice Levonorgestrel 0.75mg. 2 pills Aftera, Ella, EContra Ez, After Pill are other brands Emergency IUD: Effective for up to five days after unprotected intercourse Can reduce the risk of pregnancy by 99.9 percent The Copper T380-A IUD can be left in place for up to 10 years for regular contraception, or it can be removed after the next menstrual period 13

15 A17 y.o. nulliparous teen is sexually active and has trouble remembering contraception. Pregnancy would be a major problem. Wants efficacy and convenience. HER BEST OPTIONS ARE HORMONAL: Ring Patch IM Medroxyprogesterone 35 year old obese female Trouble remembering her pills Has Heavy periods HER BEST OPTIONS ARE: Progestogen IUD Vaginal Ring Injectable progestin AVOID The Patch and the Implant in obese females efficacy decreased. 20 year old female with recent DVT after an MVA Factor V Leiden positive hypercoagulable OCP s discontinued in ER Would be ok getting pregnant as has been married 5 years Options non hormonal: Condoms IUD Copper Barrier Methods AVOID Estrogen Sexually active teen with acne First time to use pill OCP? Which ones are best for this indication? Progestins Desogestrel Norgestimate OCPs use quick start method Preg test and start method in the office What percentage of unintended pregnancies occur in women who use contraception? 1. 24% 2. 32% 3. 41% 4. 76% 14

16 What do modern women want from contraceptives? 1. Safety 2. High Efficacy 3. Ease of Use 4. Consistent with her values 5. Not dependent on memory or time 6. All of the above Choose the correct statement about the transdermal contraceptive patch: 1. May be less effective in women over 198 lbs. 2. Does not increase cervical mucosa 3. Skin should be prepared with lotion before applying patch 4. Harder to remember than daily oral contraceptive pills Which of the following is the most common reason for failure of the vaginal ring? 1. Forgetting to insert new ring 2. Breakage 3. Unnoticed expulsion 4. Incorrect placement Choose the correct statement about the Levonorgestrel Intrauterine System: 1. Releases 40 micrograms of Levonorgestrel daily 2. Effective for 10 years 3. Contraindicated in women with uterine anomalies 4. High failure rate A pap test is required before prescribing contraception. 1. True 2. False Placement of the IUS is contraindicated in nulliparous women. 1. True 2. False 15

17 The Essure Procedure 1. Inhibits sperm migration 2. Requires hysterosalpingography and hysteroscopy 3. Not recommended for women over All of the above Which of the following is a LARC? 1. Emergency Contraceptive Pill 2. The Essure Procedure 3. Etonogestral Implant 4. The Contraceptive Patch Paragard Copper IUD Mirena Levonorgestrel IUD Liletta Levonorgestrel IUD Kyleena Levonorgestrel IUD Skyla Levonorgestrel IUD NuvaRing Vaginal Ring Xulane The Patch (generic) Ortho Evra Patch Discontinued Nexplanon The Implant (Radio-opaque) Implanon The Implant Seasonale 3 month pill $262 for 3 month supply Quasense, Jolessa, Intravale generic for Seasonale $48 for 3 month supply Seasonique 3 month pill with extra Estrogen $ for 3 month supply Ashlyna, Camrese, Daysee, Amethia generic for Seasonique - $75 for 3 month supply Amethyst All year OCP (Lybrel discontinued) Yaz and Yasmin Drosperinone containing OCPs Micronor, Nora-BE, Nor-QD, Ovrette and Errin Progestin only pills American College of Obstetrics and Gynecologists. (July 2011, Reaffirmed 2015). Clinical Practice Bulletin: Long-Acting Reversible Contraception: Implants and Intrauterine Devices. Morbidity and Mortality Weekly Report Recommendations and Reports / Vol. 65 / No. 3 July 29, 2016, U.S. Medical Eligibility Criteria for Contraceptive Use, 2016 Dean G, Goldberg AB. (2017). Intrauterine contraception: Devices, candidates, and selection. In: UpToDate, Schreiber CA, Eckler K (Eds), UpToDate, Waltham, MA. Bowers R. FDA approves smaller levonorgestrel intrauterine system A Mini Mirena Contraceptive Technology Update March; 34(3): Gemzell-Danielsson K, Schellschmidt I, Apter D. A randomized, phase II study describing efficacy, bleeding profile and safety of 2 lowdose levonorgestrel-releasing intrauterine contraceptive systems and Mirena. Fertility and Sterility. 2012; 96(3): Hardeman J. Intrauterine devices: An update. Am Fam Physician Mar 15;89(6): Heath, CB and Sulik, SM, Audio Digest Family Practice, Contraceptive Methods. 54:02 Levonorgestrel-releasing intrauterine systems (Mirena) compared with other methods of reversible contraceptives, French 2000, BJOG. 107: Robinson, J and Burke, A, Obesity and Hormonal Contraceptive Efficacy, Womens Health, 2013 Spe: 9(5): Judge, D, Levonorgestrel Emergency Contraception Works Before and Not After Fertilization. Contraception May. Guttmacher Institute. Contraceptive use in the USA (2012). (Accessed 31 March 2013). Edelman AB, Cherala G, Stanczyk FZ. Metabolism and pharmacokinetics of contraceptive steroids in obese women: a review. Contraception. 82, (2010). Medline Trussell J, Guthrie KA. Choosing a contraceptive: efficacy, safety, and personal considerations. In: Contraceptive Technology (20th Revised Edition). Hatcher RA,Trussell J, Nelson AL, Cates W, Kowal D, Policar MS (Eds). Ardent Media, NY, USA, (2011). Xu H,Wade JA, Peipert JF, Zhao Q, Madden T, Secura GM. Contraceptive failure rates of etonogestrel subdermal implants in overweight and obese women. Obstet. Gynecol. 120, (2012). Medline Teichmann A, Apter D, Emerich J, Greven K, Klasa-Mazurkiewicz D, Melis GB, Spaczynski M, Grubb GS, Constantine GD, Spielmann D. Contraception Dec;80(6): Epub 2009 Aug Aiken AR, Dillaway C, Mevs-Korff N, 2015 May;132: doi: /j.socscimed Epub 2015 Mar 19. A blessing I can't afford: factors underlying the paradox of happiness about unintended pregnancy. 16

18 Finer LB and Zolna MR, Declines in unintended pregnancy in the United States, , New England Journal of Medicine, 2016, 374(9):852,852, Herndon, EJ, Zieman, M., New Contraceptive Options, American Family Physician, 69:4 Feb 2004, pp Weismiller, DG, Emergency Contraception, American Family Physician, 70:4 pp Weiss, D, Does emergency contraception promote teen sex? Contemporary Ob/Gyn, Sept 1, Trussell, J., Contraceptive failure in the United States. Contraception May;83(5): Guttmacher Institute Fact Sheet, Unintended Pregnancy in the United States, September 2016 Family Planning, A Global Handbook for Providers, WHO 2007, 2011 update types of Birth Control, Health.com Frost JJ et al., Return on investment: a fuller assessment of the benefits and cost savings of the US publicly funded family planning program, Milbank Quarterly, 2014, Sonfield A, Hasstedt K and Gold RB, Moving Forward: Family Planning in the Era of Health Reform, New York: Guttmacher Institute, Sonfield A et al., The Social and Economic Benefits of Women s Ability To Determine Whether and When to Have Children, New York: Guttmacher Institute, Kavanaugh ML and Anderson R, Contraception and Beyond: The Health Benefits of Services Provided at Family Planning Centers, New York: Guttmacher Institute, HealthyPeople.gov, Healthy People 2020, Family planning objectives, 2011, Finer LB and Zolna MR, Declines in unintended pregnancy in the United States, , New England Journal of Medicine, 2016, 374(9): , Singh S, Sedgh G and Hussain R, Unintended pregnancy: worldwide levels, trends and outcomes, Studies in Family Planning, 2010, 41(4): Kost K, Unintended Pregnancy Rates at the State Level: Estimates for 2010 and Trends Since 2002, New York: Guttmacher Institute, 2015, Finer LB and Zolna MR, Shifts in intended and unintended pregnancies in the United States, , American Journal of Public Health, 2014, 104(S1):S44 S48. Lindberg LD and Kost K, Exploring U.S. men s birth intentions, Maternal and Child Health Journal, 2013, Frost JJ, Frohwirth L and Zolna MR, Contraceptive Needs and Services, 2014 Update, New York: Guttmacher Institute, 2016, Figure Sources: State Unintended Pregnancy Rates Source: Kost K, Unintended Pregnancy Rates at the State Level: Estimates for 2010 and Trends Since 2002, New York: Guttmacher Institute, 2015, Pregnancies by Intention Status Source: Special tabulations of data from Finer LB and Zolna MR, Declines in unintended pregnancy in the United States, , New England Journal of Medicine, 2016, 374(9): , Unintended Pregnancy Rates Source: Finer LB and Zolna MR, Declines in unintended pregnancy in the United States, , New England Journal of Medicine, 2016, 374(9): , Modern Contraception Works Source: Sonfield A, Hasstedt K and Gold RB, Moving Forward: Family Planning in the Era of Health Reform, New York: Guttmacher Institute,

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