Contraception IUS and Intradermal Implant

Transcription

1 Contraception IUS and Intradermal Implant David Glenn Weismiller, MD, ScM, FAAFP Department of Family and Community Medicine University of Nevada, Las Vegas School of Medicine

2 Disclosure Statement I have no relevant financial relationships to disclose that would in anyway create bias in the material I am presenting.

3 Learning Objectives Describe principles of patient selection regarding contraceptives Discuss the indications/contraindications for various contraceptive methods Appraise recommendations for use of longacting reversible contraceptives 3

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5 Helen tries out her new Not-Tonight-Honey nightgown 5

6 Why Contraception? Unintended pregnancies Families complete 40% of US pregnancies (>2M) are unintended In women 40y the rate is 51% About a third of unintended pregnancies occur in women who consider their families complete Health Benefits Risk(s) of Pregnancy

7 Contraceptive Options Irreversible Tubal ligation* Vasectomy Micro insert Abstinence Reasonable, acceptable option; particularly in younger patients l * Three most commonly used in US l Pregnancy poses a greater risk than any contraceptive method Reversible Oral contraceptives* Combined pills* Progestin-only pills Other hormonal options Implant Injections Vaginal ring Patch Intrauterine Devices Intratube Device Barrier methods Male condom* Natural Family Planning

8 Principles All methods can fail Two methods are better than one Methods used wrong fail more Always need a backup plan No plan offers an 85% chance of getting pregnant 8

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10 Contraceptive Counseling 1. What are your contraceptive goals? Do you ever plan to get pregnant? When? 2. Are you currently having sex with partner? 3. Have you tried any contraceptive methods? If so, which one(s)? 4. What did you like/dislike about the method(s)? 5. Are you a good pill taker? 10

11 Contraceptive Counseling 6. For user-controlled methods, how often did you forget to use the method? 7. Are there any methods you have heard about and would like to try? 8. How important is spontaneity of use? 9. Is protection from STIs important considering your life situation? 10. Is cost an issue? Does your health insurance plan cover any contraceptive method? 11

12 Benefits Risks Alternatives Inquiries Informed Consent BRAIDED Decision to change acceptable Explanation Documentation 12

13 The Current State of IUDS in the USA % of women using contraceptives (3,884,000 women) Used most by women Aged Married and cohabitating Covered by Medicaid No religious affiliation Foreign-born women are three times as likely as U.S.-born women to have ever used an IUD. Teenagers 3% Guttmacher Institute Data, October

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15 IUDs have been used in the U.S. for decades; safety controversy in the 1970s prompted the removal of all but one IUD from the U.S. market by First new generation IUD introduced to the U.S. market in 1988, following revised FDA safety and manufacturing requirements.

16 Types of IUDs IUD (Copper) Available Since Years Effective Use and FDA Approved Copper (Paragard) Approved only in parous women, but available to all women regardless of parity Can be used as Emergency Contraception when inserted within 5 days IUD (Hormonal) Mirena Approved only in parous women, but available to all women regardless of parity Skyla (slightly smaller than Mirena) Approved for women regardless of parity Liletta* Approved for women regardless of parity Kyleena (lower hormone levels than Mirena) Approved for women regardless of parity Possible side effects Abnormal menstrual bleeding Higher frequency or intensity of cramps/pain Inter-menstrual spotting in the early months Reduces menstrual blood loss significantly Hormone-related: headaches, nausea, breast tenderness, depression, cyst formation. *Actavis in conjunction with Medicines360, a non-profit women s pharmaceutical company, developed Liletta specifically to be low cost and available to public health clinics enrolled in the national 340B Drug Pricing Program, which provides reduced cost pharmaceuticals to providers that serve low-income populations.

17 Intrauterine Contraceptives Mechanisms of Action Levonorgestrel-Releasing Intrauterine System (LNG-IUS, Mirena and Skyla ) v Inhibits fertilization v Thickens cervical mucous v Inhibits sperm function v Thins and suppresses the endometrium v v v Source: Barr Pharmaceuticals, Inc. Copper-Releasing Intrauterine Contraceptive (ParaGard T380A) Inhibits fertilization Releases copper ions (Cu 2+ ) that reduce sperm motility May disrupt the normal division of oocytes and the formation of fertilizable ova Jonsson B, et al. Contraception. 1991;43: ; Videla-Rivero L, et al. Contraception. 1987;36: ; Kulier R, et al. Cochrane Database Syst Rev. 2006;3: CD

18 Considerations for IUDs IUD insertion, not IUD use, is associated with PID Cochrane Systematic Review (Grimes, Mohllajee) ACOG Practice Bulletin 2011 DO NOT cause future infertility Nulliparas can use an IUD Uterus sounds to depth of a minimum 6 cm The USMEC guidelines state that the advantages of using the IUD in adolescents generally outweigh the risks. Risk of uterine perforation 18

19 Candidates for IUD Use Multiparous and nulliparous women at low risk for STI Desire long-term reversible contraception Medical Conditions may be an optimal method Diabetes Thromboembolism AUB/dysmenorrhea Breastfeeding Breast cancer Liver disease 19

20 WHO Medical Eligibility Criteria for IUD Use in Women with Certain Medical Conditions TCu-380A LNG-IUS Medical Conditions WHO Risk Category* WHO Risk Category* Hypertension (controlled) 1 1 Multiple cardiovascular risk factors 1 2 History of DVT or pulmonary embolism 1 2 Stroke 1 2 Severe valvular heart disease (complicated) 2 2 HIV infection 2 2 AIDS (clinically well on antiretroviral therapy) 2 2 AIDS = acquired immunodeficiency syndrome; DVT = deep vein thrombosis; HIV = human immunodeficiency virus; IUD = intrauterine device; LNG-IUS = levonorgestrel-releasing IUD; TCu-380A = copper-releasing IUD; WHO = World Health Organization *Category 1= there are no restrictions for use of the contraceptive method; Category 2 = the benefits of using the contraceptive method generally outweigh the theoretical or proven risk WHO. Medical Eligibility Criteria for Contraceptive Use. 3rd ed Available at:

21 WHO Medical Eligibility Criteria for IUD Use in Women with Certain Medical Conditions (cont d) Medical Condition TCu-380A WHO Risk Category* LNG-IUS WHO Risk Category* Known thrombogenic mutations 1 2 Migraines with aura 1 2 Epilepsy 1 1 Diabetes 1 2 Obesity 1 1 Thyroid disorders 1 1 Viral hepatitis (active infection) 1 3 Viral Hepatitis (carrier) 1 1 IUD = intrauterine device; LNG-IUS = levonorgestrel-releasing IUD; TCu-380A = copper-releasing IUD; WHO = World Health Organization * Category 1= there are no restrictions for use of the contraceptive method; Category 2 = the benefits of using the contraceptive method generally outweigh the theoretical or proven risk; Category 3 = the risks of using the method usually outweigh the benefits WHO. Medical Eligibility Criteria for Contraceptive Use. 3rd ed Available at:

22 Medical Contraindications for Intrauterine Contraceptive Use Pregnancy Immediately after puerperal sepsis or a septic abortion Undiagnosed abnormal vaginal bleeding Malignancy of the genital tract Known anomalies or fibroids that significantly distort the uterine cavity in a way that is incompatible with IUD insertion Current pelvic inflammatory disease Current purulent cervicitis, chlamydial infection, or gonorrhea Allergy to any component of an IUD or Wilson's disease (for coppercontaining IUDs) Known pelvic tuberculosis WHO. Medical Eligibility Criteria for Contraceptive Use. 3rd ed. 2004; FFPRHC Guidance (April 2004). J Fam Plann Reprod Health Care. 2004;30:99-108; FFPRHC Guidance (January 2004). J Fam Plann Reprod Health Care. 2004;30:29-41; Angle MA, et al. Stud Fam Plann. 1993;24:

23 Patient Education and Consent Failure Rate (Effectiveness) ParaGard % Levonorgestrel 0.2% Reversibility (Median time to planned pregnancy) ParaGard 3 months Levonorgestrel 2-6 months Failure Rate Pregnancy Rate Method Typical use Perfect use 82% one year after device removal Combined OCP 9% 0.3% 89% two years after device removal Tubal Ligation 0.5% 0.15% Male condom 18% 2% Depo-Provera 6% 0.3% 23

24 Levonorgestrel-Releasing Intrauterine System: Different Patterns of Menstrual Bleeding* Type of Menstrual Bleeding Copper Intrauterine Device Levonorgestrel Intrauterine System Cycle 1 Cycle 4 Cycle 1 Cycle 4 Amenorrhea 0% 2% 0% 16% Infrequent bleeding 2% 2% 11% 57% Frequent bleeding 19% 0% 13% 1% Prolonged bleeding 24% 0% 22% 3% Irregular bleeding 17% 20% 67% 19% *Percentage of subjects meeting criteria for different patterns of bleeding during a specified 90-day cycle. Suvisaari J, Lahteenmaki P. Contraception. 1996;54: ; Luukkainen T, et al. Semin Reprod Med. 2001;19:

25 Intrauterine Contraceptives Do Not Increase the Risk of Ectopic Pregnancy A 2-year, 7-center, randomized trial (N=2,244) compared the levonorgestrelreleasing (LNg20) and the copper-releasing (Model TCu380Ag) intrauterine contraceptive devices (IUDs) No ectopic pregnancies were found A collaborative multicenter, case-controlled study compared women who had a history of ectopic pregnancy (n=615) with those who did not (n=3,453) Women who had never used an IUD were equally likely to have had an ectopic pregnancy as were IUD users IUD users were less likely to have had an ectopic pregnancy than were women who were not currently using contraceptives Sivin I, et al. Contraception. 1987;35: ; Ory HW. Obstet. Gynecol. 1981;57:

26 Intrauterine Contraceptives Noncontraceptive Benefits Intrauterine contraceptives decrease the risk for endometrial cancer The levonorgestrel-releasing intrauterine system (LNG-IUS) can be used as a first-line option to treat menorrhagia May be used in the presence of fibroids, unless they significantly distort or enlarge the uterine cavity Produces a 97% decrease in menstrual blood loss In a retrospective study, 80% of women who were prescribed the LNG-IUS for menorrhagia chose not to undergo a hysterectomy, as opposed to 9% of women who received normal care for the condition Hubacher D, Grimes DA. Obstet Gynecol Survey. 2002;57: ; Castellsague X, et al. Int J Cancer. 1993;54:

27 Some other recommendations IUD may be offered to women with a history of ectopic pregnancy Levonorgestrel system may be an acceptable alternative to hysterectomy in women with AUB-O FDA recommends that IUDs be removed from pregnant women when possible without an invasive procedure Remove in menopausal woman Counseling should include information about risk factors for STIs and PID -ACOG Practice Bulletin No. 59, IUD Obstet Gynecol 2005;105: Rauramo I.et al. Obstet Gynecol 2004; 104:

28 Intrauterine Contraceptives Management of Cramping and Bleeding If a patient has severe or prolonged cramping: Examine for partial IUD expulsion, uterine perforation, or pelvic inflammatory disease and treat if necessary Remove the IUD if the severe cramping is unrelated to menses or is unacceptable to the patient If symptoms are mild, they can be treated with nonsteroidal antiinflammatory drugs (NSAIDs) Heavy bleeding for more than 3 months: Examine the patient for infection, fibroids, or signs of anemia and treat if necessary Prescribe NSAIDs Remove the device if there is a medical contraindication or if the bleeding is unacceptable to the patient 28

29 Intrauterine Contraceptives Management of Infections Symptoms Fever, chills, unusual vaginal discharge Severe bleeding or abdominal cramping occurring 3 to 5 days after insertion Pain during intercourse If a sexually transmitted infection (STI) is diagnosed: Treat the infection Counsel the patient about how to prevent transmission of the STI Removal of intrauterine contraceptive (IUD) is not necessary If pelvic inflammatory disease is diagnosed: Treat the infection Remove the IUD only if symptoms fail to improve within 72 hours of after treatment begins Penney G, et al. J Fam Plann Reprod Health Care. 2004;30:29-41; WHO. Selected Practice Recommendations for Contraceptive Use. 2002; Grimes D. Lancet. 2000;356:

30 Intrauterine Contraceptives Management of Perforation during Insertion If uterine perforation occurs at the time of insertion: Remove the device Provide alternative contraception Monitor for excessive bleeding Follow up as appropriate Insert another device after next menses if desired by patient

31 Intrauterine Contraceptives Management of Missing Strings May be the result of partial or complete expulsion of the device or perforation of the uterus Rule out pregnancy Probe for strings in cervical canal Obtain ultrasound or x-ray, as needed Remove promptly if found outside the uterine cavity, and advise patient she is no longer protected Prescribe back-up contraceptive method, if necessary Speroff L, Darney PD. A clinical guide for contraception. 3rd ed. 2001; Ben-Rafael Z, Bider D. Obstet Gynecol. 1996;87:

32 Intrauterine Contraceptives ions Partial or unnoticed expulsion may present as irregular bleeding and/or pregnancy Risk of expulsion related to: Healthcare provider s skill at fundal placement Age and parity of woman Time since insertion Timing of insertion (e.g., expulsion risk is greater following a second-trimester abortion than a first-trimester abortion) WHO. In: Medical Eligibility Criteria for Contraceptive Use. 3 rd ed. Available at: 32

33 Contraception Code Cost of Device Mirena Skylar J7298 J7301 Billing and Coding Billing amount for Contraceptive Other Billing Requirements $ $ Bill w/ IUD insertion 58300/$ Paragard T380-A J7300 $ $ Bill w/ IUD insertion 58300/$ Billing Charge with Insertion or Administration Fee $1, $ ICD-10-CM Diagnostic Codes: Z Encounter for contraceptive management; insertion of intrauterine contraceptive device V30.43(_) Intrauterine contraceptive device; checking (1), reinsertion (3), or removal of intrauterine device(2) Z31.01 Screening pregnancy test (+) Z32.02 Screening pregnancy test (-) 33

34 Patient Education and Consent IUD Paragard T380-A Mirena (LNG-IUs) Advantages Long term, no patient compliance required; rapid return of fertility after removal FDA approved for up to10 years; (shown to be effective for up to 12 years) Decreased bleeding and dysmenorrhea; FDA approved for up to 5 years; (shown to be effective for up to 7 years) Adverse effects/disadvantages Rare uterine perforation; risk of infection with insertion Irregular/heavy bleeding and dysmenorrhea Irregular bleeding initially, followed by amenorrhea (reported in about 20% of users after 1 year of use); ovarian cysts 34

35 So how does choice impact lactation? nlam nabstinence/ Periodic Abstinence/ NFP Methods nbarrier Methods niud ncopper nsterilization nprogestin-only npills ninjectables nimplants nlevonorgestrel IUD ncombined pill npatch nring ninjectable No known impact on lactation Little to no known impact on lactation Some reports of negative impact on lactation Expected to have negative impact on lactation

36 Techniques for Insertion Copper T-380A Levonorgestrel (Mirena, Skylar) AHA Guidelines for Prophylaxis for Endocarditis 36

37 Insertion of an Intrauterine Contraceptive Device Use the proper insertion technique for each device to decrease the risk of uterine perforation and expulsion Use a sterile technique to reduce the risk of infection Antibiotic prophylaxis does not prevent infection at time of device insertion Johnson BA. Am Fam Physician. 2005;71: Oloto EJ, et al. Br J Fam Plann. 1997;22: ; Hubacher D, et al. Am J Obstet Gynecol Nov;195(5):

38 When to Insert an Intrauterine Contraceptive? Any time during menstrual cycle Any other time during a woman s cycle if: o She used appropriate contraception o She was not sexually active, or o Her pregnancy test was negative Any time after a pregnancy, a spontaneous abortion, a miscarriage, or an induced abortion if a woman has not engaged in unprotected intercourse WHO. Medical Eligibility Criteria for Contraceptive Use. 3rd ed. 2004; FFPRHC Guidance (April 2004). J Fam Plann Reprod Health Care. 2004;30:99-108; FFPRHC Guidance (January 2004). J Fam Plann Reprod Health Care. 2004;30:29-41.

39 Use of misoprostol before insertion? A 2007 study suggested that the use of misoprostol (Cytotec) before IUD insertion allowed for easier insertion. However, more recent studies show no benefit and increased side effects with misoprostol. The American College of Obstetricians and Gynecologists makes no recommendation regarding the use of misoprostol before IUD insertion. Edelman AB, Schaefer E, Olson A, et al. Effects of prophylactic misoprostol administration prior to intrauterine device insertion in nulliparous women. Contraception. 2011;84(3): Espey E, Singh RH, Leeman L, Ogburn T, Fowler K, Greene H. Misoprostol for intrauterine device insertion in nulliparous women: a randomized controlled trial [published ahead of print November 8, 2013]. Am J Obstet Gynecol. S

40 Guidelines for IUDs Organization ACOG 2007 ACOG 2007 Cochrane 2007 Recommendation Asymptomatic women may use an IUD within 3 months of treated pelvic infection or septic abortion. All adolescents should be screened for GC and chlamydia prior to insertion. No benefit from doxycycline or azithromycin prior to insertion. CDC 2010 Evidence is insufficient to recommend the removal of IUDs in women diagnosed with acute PID. However, caution should be exercised if the IUD remains in place, and close clinical follow-up is mandatory. The rate of treatment failure and recurrent PID in women continuing to use an IUD is unknown, and no data have been collected regarding treatment outcomes by type of IUD (eg, copper or levonorgestrel). 40

41 Key Recommendations for Practice Clinical Recommendation Nulliparous women and adolescents can be offered an IUD, although the 20-mcg per 24 hours levonorgestrel-releasing IUD (Mirena) is not approved by the U.S. Food and Drug Administration for use in nulliparous women Women who are at high risk of STIs but have no active signs or symptoms of genital tract STI should be tested for STIs at the time of IUD insertion. Insertion of the IUD may occur on the same day as STI testing, without waiting for test results. If results are subsequently found to be positive, treatment can be administered at that time and the IUD left in place. For women with a known STI that causes cervical infection, it is recommended that IUD insertion be delayed for at least three months after resolution of the infection. Prophylactic antibiotics should not routinely be administered before IUD insertion. Antibiotic prophylaxis does not have a major effect on reducing the risk of pelvic infection, and does not alter the need for IUD removal in the months after insertion. Misoprostol (Cytotec) should not be administered before IUD insertion. Although an earlier study showed easier insertion with misoprostol, subsequent studies showed no benefit and increased side effects. If a woman with an IUD becomes pregnant, the IUD should be removed. Evidence Rating C C C B B C 41

42 Intradermal Implant Hormonal (Progestin-only) Method Single-rod implant (4 cm in length and 2 mm in diameter) made of ethylene vinyl acetate and contains 68 mg of etonogestrel Duration of use: 3 years % (492,000 women) of contraceptive users* *

43 Implantable Hormonal Devices Single rod, subdermal implantation. 68 mg of etonogestrel period of up to three years Heavier women may need a new implant every two years Since 1998 > 3.5 million women (30 countries) Side Effects: Irregular bleeding HA, acne, dysmenorrhea, emotional lability NO significant side effect on BMD or lipid metabolism Merck

44 Contraceptive Implant Mechanisms of Action Suppresses ovulation Occurs within 1 day of insertion Ovulation in <5% of users after 30 months of use Increases viscosity of the cervical mucous Bennink, HJ. Eur J Contracept Reprod Health Care. 2000;5 Suppl 2:12-20; Le J, Tsourounis C. Ann Pharmacother. 2001;35: Slide Source: Contraception Online 44

45 Common Myths About Contraceptive Implants Among Clinicians Insertion and removal is time-consuming and difficult to learn Not true! Time to insert is 1.1 minutes Time to remove is 2.6 minutes Implants are associated with a higher risk of ectopic pregnancy Not true! No pregnancies were reported during 5,629 woman-years of use The baseline ectopic pregnancy rate in the United States is 1.97% Mascarenhas L. Eur J Contracept Reprod Health Care. 2000;5 Suppl 2:29-34; Glasier A. Contraception. 2002;65:29-37; Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 1995;44:

46 Contraceptive Implant: A 2-year study investigated the efficacy and tolerability of IMPLANON TM (N=330) Reasons for discontinuing participation in the study: Irregular bleeding: 13% Bleeding patterns were studied for reference periods of 90 days. The average number of bleeding or spotting days was 17.7 every 90 days. Bleeding patterns that occur with IMPLANON are unpredictable and may include changes in frequency or duration. Amenorrhea also occurs among some women. Change in the frequency or duration of bleeding is the most common reason women discontinue IMPLANON treatment. Other adverse events: 23% Emotional lability: 14.2% Headache: 12.7% Weight gain: 12.1% Dysmenorrhea: 9.7% Depression: 7.3% The IMPLANON US Study Group. Contraception. 2005;71:

47 Percentage change from baseline 70% 60% 50% 40% 30% 20% 10% 0% Decrease Changes in Acne (n=315) No Change Contraceptive Implant Increase Funk S, et al. Contraception. 2005;71: Noncontraceptive Benefits 50% 40% 30% 20% 10% 0% Changes in Dysmenorrhea (n=315) Decrease No Change Increase 47

48 Contraceptive Implantht Change In clinical trials, the mean cumulative weight gain was: End of first year: +2.8 lbs. End of second year: +3.7 lbs. Weight gain was the reason given for discontinuation of participation by 2.3% of subjects In one study, 12.7% of participants reported weight gain as an adverse event The majority of these adverse events were found to be related to the study medication The IMPLANON US Study Group. Contraception. 2005;71:

49 Contraceptive Implant Effect on Bone Mineral Density An open, prospective, comparative two-year study of a single-rod implant (n=44) vs. a nonhormonal intrauterine device (n=29) found: Essentially similar changes in bone mineral density from baseline No relationship between 17β-estradiol concentrations and changes in bone mineral density Beerthuizen R, et al. Hum Reprod. 2000;15:

50 Contraceptive Implant Administration If no hormonal contraceptive has been used in past month: Insert within 5 days of initiation of menses If switching from combination contraceptives, insert within 7 days of last active tablet, or during the ring-free or patchfree period If switching from a progestin-only method: Any day if using the progestin-only pill Same day as intrauterine device or implant removal On due date for next contraceptive injection IMPLANON [physician insert]

51 Contraceptive Implant Quick Start* If using Quick Start to insert the implant: It may be inserted any time during the menstrual cycle Determine risk for pregnancy Perform pregnancy test, if indicated Provide emergency contraception, if indicated Recommend nonhormonal contraception for 7 days *This method deviates from the manufacturers recommendations for timing of insertion and is considered a non-fda approved use. 51

52 Complications Insertion Discomfort at insertion site Bleeding Infection 52

53 Patient Education and Consent Cost $ per month over 3 years ($ 14.57) Failure Rate 0.05% Very convenient Adverse effects/disadvantages Irregular bleeding ( as with other progestin-based methods Removal issues Failure Rate Method Typical use Perfect use Combined OCP 9% 0.3% Tubal Ligation 0.5% 0.5% Male condom 18% 2% Depo-Provera 6% 0.3% 53

54 Risks to Lactation May decrease milk supply if initiated before milk supply is well established Anecdotal reports of immediate negative impact even when initiated after lactation is well established Progestin IUD typically has MINIMAL impact Potential to have the same impact as other progestin-only methods 54

55 So how does choice impact lactation? nlam niud nprogestin-only ncombined pill nabstinence/ Periodic Abstinence/NFP Methods nbarrier Methods ncopper nsterilization npills ninjectables nimplant nlevonorgestrel IUD npatch nring ninjectable No known impact on lactation Little to no known impact on lactation Some reports of negative impact on lactation Expected to have negative impact on lactation

56 Coding and Billing Contraception Code Cost of Device Billing amount for Contraceptive Other Billing Requirements Nexplanon J7307 $ $ Bill w/ Insertion Capsule 11981/$ Depo Injection (DMPA)* q 12 weeks J1055 $23.17 per dose; $92.68 per year $85.50 per dose; $ per year ICD-10-CM Diagnostic Codes: Z30.49 Nexplanon, unspecified birth control Z31.01 Screening pregnancy test (+) Z31.02 Screening pregnancy test (-) Bill w/ administration 90772/$43.00 Billing Charge with Insertion or Administration Fee $1, $ per dose; $ per year * DMPA for comparison 56

57 So what might we say about hormonal contraception Given the high level of anecdotal reports of the association of hormonal contraception (including progestin-only) with milk supply discourage where there is A young infant: < six weeks for progestin-only, < 6 months for combined Existing low milk supply or history of lactation failure History of breast surgery Multiple birth Preterm birth Compromised health of mother and/or baby 57

58 WHO Medical Eligibility Criteria 1 No restriction 2 Generally use 3 Not usually recommended 4 Not to be used Duration of BF method < 6 weeks PP Progestinonly pills Progestinonly depots Progestinonly implants/ IUD Combined injectable contraceptives Combined patch or ring Low dose combined > 6 w to < 6 m PP (primarily breastfeed) > 6 m PP

59 ACOG Breastfeeding: Maternal and Infant Aspects Committee Opinion All family planning choices are available to the postpartum lactating woman. Choice and clinical ramifications merit additional counseling. Support women in choosing breastfeeding Accurate information Problems arise Early discussion of contraception and follow-up Options to be explained in detail Nonhormonal methods Hormonal Methods Lactational Amenorrhea Method 59

60 Progestin vs. Combined OCP and Lactation Espey et al. Obstet Gynecol 2012;119(1):5-13 Objective: Estimate the effect of progestin-only compared with combined hormonal contraceptive pills on rates of breastfeeding continuation in postpartum women Results: No difference in breastfeeding continuation rates, contraceptive continuation, and infant growth parameters at 8 weeks Conclusion: Choice of combined hormonal or progestinonly contraceptive pills administered 2 weeks postpartum did not adversely affect breastfeeding continuation. 60

61 Contraceptive Implant Summary One option available in the United States Easy and quick to insert and remove Efficacy equivalent to sterilization Safe and rapidly reversible Irregular bleeding patterns may be a problem for some patients Majority of reproductive-age women are candidates, including adolescents Appropriate option for those preferring a long-term progestin-only method and do not want injections or an intrauterine device 61

62 Strategies to Reduce Barriers and Increase Use of Implants and IUDS Encourage implants and IUDS for all appropriate candidates including nulliparous women and adolescents Adopt same-day insertion protocols Screening for chlamydia, gonorrhea, and cervical dysplasia SHOULD NOT be required before implant or IUD insertion, but may be obtained on the day of insertion, if indicated ACOG Committee Opinion No Increasing use of Contraceptive Implants and Intrauterine Devices to Reduce Unintended Pregnancy. Obstet Gynecol. 2009;114(6):

63 Progestin-Only Methods More Appropriate Than Combined ACOG 2006 Smoking or obesity AND over age 35 [SOR B, A; respectively] Hypertension with vascular disease or > age 35 [SOR B] Lupus with vascular disease, nephritis [SOR A] Migraine with focal aura [SOR B] Current or personal history of VTE associated with pregnancy or estrogen unless on anticoagulation [SOR A] Coronary artery/cerebrovascular disease [SOR C]

64 Management of Unscheduled Bleeding in Women Using Contraception Contraceptive Preferred Treatment DMPA Expectant management 7-14 days oral estrogen (1.25 mg conjugated estrogen or 2 mg micronized estradiol Transdermal patch (0.1 mg estradiol/24 h) days of low-dose combined OCP Etonogestrel implant Expectant management Low-dose combined OCP for days (not studied) NSAID for 5-7 days Progestin pills Take at same time each day and minimize missed doses. Levonorgestrel IUD NSAID for 5-7 days (eg, ibuprofen 400 mg, naproxen 250 mg, or mefanamic acid 500 mg TID) Edelman A and Kaneshiro B. Management of unscheduled bleeding in women using contraception

65 Contraception and Adolescents Adolescents are capable of understanding complex messages that include support for abstinence, but also provide appropriate information about sexual activity and contraception It s a conversation at any age 65

66 Cavazos-Rehg PA, et. al. Age of sexual debut among US adolescents. doi: /j.contraception Age of Sexual Debut Kaplan Meier curves: probability of surviving free of sexual debut, according to race and gender.

67 Abstinence Convey to adolescents that this is expected, be realistic Abstinence teaching programs have some success Encouragement to practice abstinence can be a powerful tool to enhance empowerment for self care Advantages: no STDs, no cost, no pregnancy Disadvantages: difficult to maintain

68 Sexual Abstinence Educational programs that teach BOTH abstinence and contraception Delay onset of sexual activity and reduce number of sexual partners Ancheta et al. J Pediatr Adolesc Gynecol 2005;18. Pledge to remain abstinent: 50% honor pledge 12 months later STIs same whether pledgers or non-pledgers Rosenbaum et al. Am J Public Health. 2006;96

69 Best Practice Recommendations Clinicians should consider a tiered approach to contraceptive counseling, whereby the most effective and appropriate options are presented before less effective options. Requiring prerequisite preventive services, such as cervical cytology; breast examination; or evaluation for sexually transmitted infections, diabetes mellitus, dyslipidemia, liver disease, or thrombophilia, can introduce unnecessary barriers to contraceptive care. Family planning services should be offered to adolescents with assurances of confidentiality, in the context of relevant law. Intrauterine devices and contraceptive implants are safe and effective for postmenarchal adolescents and adults. The most common side effect of a progesterone only contaceptive (regardless of the the vehicle) is irregular bleeding, Evidence is insufficient to recommend the removal of IUDs in women diagnosed with acute PID.

70 70 Thank You

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72 References 1. ACOG Practice Bulletin 121. Long-Acting Reversible Contraception: Implants and Intrauterine Devices. Obstet Gynecol 2011;118: (Reaffirmed 2015) 2. ACOG Practice Bulletin 152. Emergency Contraception. Obstet Gynecol 2015;126:e Smoley BA, Robinson CM. Natural Family Planning. Am Fam Physician. 2012;86(10): Hardeman J and Weiss BD. Intrauterine Devices: An Update. Am Fam Physician 2014;89(6): Centers for Disease Control and Prevention. U.S. Medical eligibility criteria for contraceptive use, MMWR Recomm Rep. 2010;59(RR-4): Klein DA, Arnold JJ and Reese ES. Provision of Contraception: Key Recommendations from the CDC. Am Fam Physician. 2015;91(9): US Medical Eligibility Criteria (USMEC) for Contraceptive Use,