3:45 4:30 pm Beyond the Pill: Long Acting Contraceptives and IUDs Presenter Disclosure Information The following relationships exist related to this presentation: Christine L. Curry, MD, PhD: No financial relationships to disclose. SPEAKER Christine L. Curry, MD, PhD Off-Label/Investigational Discussion In accordance with pmicme policy, faculty have been asked to disclose discussion of unlabeled or unapproved use(s) of drugs or devices during the course of their presentations. LEARNING OBJECTIVES Identify available options for long acting reversible contraception (LARC) Discuss the indications and contraindications for LARC Explain the non contraceptive benefits of each LARC method Illustrate effective processes for counseling patients on LARC and making appropriate referrals Unintended Pregnancy is Common in the US 6.6 million pregnancies Intended Unintended 49% 40%* 51% 60% Abortion Birth http://www.guttmacher.org/pubs/fb Unintended Pregnancy US.html#11 *excludes miscarriages Distribution Of Contraception Use By Women In The Us Unintended Pregnancy And Contraceptive Use % of US women 15 44 years 38% of women 15 44 do not use a contraceptive method Mosher, et al. Vital Health Stat. 2010. http://www.guttmacher.org/pubs/fb_contr_use.html#table1l. In Brief. 2008.
Appropriate Patient Counseling Effectiveness Failure rate: # of women per 100 who become pregnant after 1 yr. when using a b.c. consistently & correctly Typical use failure rate takes into account improper or inconsistent use Medical Eligibility Cost Ease of use Side effects Identifying and correcting misinformation/myths Current Contraceptive Methods Available In The US Most effective pregnancy >99% of the time Male/Female Sterilization IUD/IUS Implants Very effective pregnancy ~91 99% of the time Pills Injectables Patch Ring Moderately effective pregnancy ~81 90% of the time Male/Female Condom Sponge Diaphragm Effective pregnancy up to 80% of the time Fertility awareness Cervical cap Spermicide Hormonal Vs. Non Hormonal Direct Counseling To Focus On Effectiveness Hormonal 1. Oral contraceptives (pills) 2. Vaginal ring 3. Transdermal patch 4. Injected hormones 5. Hormonal implant 6. Hormonal IUDs Non Hormonal 1. Abstinence 2. Copper IUD 3. Condom 4. Sponge 5. Diaphragm 6. Fertility Awareness 7. Spermicide http://www.contraceptivetechnology.org/the book/take a peek/contraceptive efficacy/ Resources for Effectiveness Counseling Resources for Effectiveness Counseling http://www.nytimes.com/interactive/2014/09/14/sunday-review/unplanned-pregnancies.html?_r=0 http://bedsider.org/methods/matrix
CDC Medical Eligibility Criteria COST Category 1 2 3 4 Definition http://www.cdc.gov/mmwr/pdf/rr/rr59e0528.pdf A condition for which there is no restriction for the use of the contraceptive method A condition for which there is no restriction for the use of the contraceptive method A condition for which the theoretical or proven risks usually outweigh the advantages of using the method A condition for which the theoretical or proven risks usually outweigh the advantages of using the method Phone application available 16 https://www.americanprogress.org/issues/women/news/2012/02/15/11054/the-high-costs-of-birth-control/ 17 Identify available options for long acting reversible contraception (LARC) Guidelines on Use of LARC Copper Intrauterine Device Levonorgestrel Intrauterine Device Etonogestrel Implant Pediatricians should be able to educate adolescent patients about LARC methods, including the progestin implant and IUDs. Given the efficacy, safety, and ease of use, LARC methods should be considered first line contraceptive choices for adolescents American Academy of Pediatrics, 2014 Policy Statement, Contraception for Adolescents, American Academy of Pediatrics, 2014 Guidelines on Use of LARC Guidelines on Use of LARC Long acting reversibly contraceptive methods have few contraindications, and almost all women are eligible for implants and IUDs American Congress of Obstetricians and Gynecologists, 2011 Encouraging appropriate patients to use LARCs may help lower the rate of unintended pregnancies in the United States, especially in high risk women. There are few contraindications for the use of LARCs, even in nulliparous women and adolescents 2012 American Academy of Family Physicians, ACOG Practice Bulletin Number 121, 2011 American Academy of Family Physicians, Guidelines for the Use of Long Acting Reversible Contraception, 2012
Intrauterine Contraception Intrauterine Devices Copper IUD Paragard Use up to 10 years Heavier periods No hormonal side effects Levonorgestrel releasing IUDs Mirena, Skyla and Liletta Local progestin effect Use up to 5 (Mirena) and 3 (Skyla, Liletta) years Lighter menstruation Some systemic effects Small T shaped device inserted into uterus Fine plastic threads hang slightly out of cervix into vagina for removal Copper IUD Mass effect Alters uterine and cervical mucus Impairs spermatozoa function/motility Inhibits fertilization Can be used as emergency contraception Inhibits implantation IUDs: Mechanism of Action Levonorgestrel releasing IUD Mass effect Releases ~15 20 mcg per day of Levonorgestrel progestin reduces LH surge Thickens cervical mucus Impairs spermatozoa motility/function Inhibits fertilization Atrophy of endometrium Impairs tubal motility >50% of women are anovulatory Pregnancy Test Bimanual exam Insert speculum and cleanse cervix Stabilize cervix with tenaculum Measure uterine length Prepare the IUD for insertion Insert IUD Trim strings IUDs: Insertion Patient may experience dizziness, pain, cramping and bleeding throughout procedure ACOG Practice Bulletin Number 121, 2011 Patient is a 37 year old G2P2 who states she has completed child bearing. She does not want permanent sterilization but desires LARC. Her priority is to avoid exposure to hormones at any cost. After counseling, she selects a Copper IUD for contraception. Which of the following is a normal and expected change in her menstrual bleeding pattern? May worsen pre existing dysmenorrhea, pelvic pain, or heavy menstruation Expect increased flow and duration of menstruation Expectant management with use of NSAIDs
Copper IUD Increased menstrual flow Increased amount and duration Usually no change in hemoglobin Increased dysmenorrhea Management Patience and reassurance NSAIDS around clock, start 1 day before menses IUDs: Side Effects Levonorgestrel releasing IUD Decreased menstrual bleeding in 80% of users at 1 year 20% with amenorrhea 40 50% decrease in blood loss Rare: Headache, nausea, emesis, breast tenderness Management: conservative Copper T IUD Risks and Contraindications Contraindications Active cervical or reproductive organ infection Undiagnosed abnormal uterine bleeding Abnormal uterine anatomy Copper IUD May worsen pre existing dysmenorrhea, pelvic pain, or heavy menstruation ACOG Practice Bulletin Number 121, 2011 Levonorgestrel Releasing IUD Risks and Contraindications Contraindications Active cervical or reproductive organ infection Undiagnosed abnormal uterine bleeding Abnormal uterine anatomy CDC Medical eligibility criteria PROS & CONS OF IUDS Advantages Disadvantages Very effective (essentially no user error ) Irregular bleeding may occur for 3 6 months Long term protection No STI protection No interruption of sexual activity Risk of PID (usually within first 1 2 months Don t have to remember to use following insertion) Expulsion up to 5% in the first year Can be used during breast feeding 1/1000 risk of perforation of uterine wall at time of insertion Rare occurrence of embedding into uterine lining Common IUD Misinformation More than 50% believed IUDs are likely to cause an infection and this will make them less likely to use method Almost 50% believed IUDs can move around in a woman s body 40% believed women must undergo surgery for an IUD 25% young adults believed that an IUD can t be stopped early Kaye, Kelleen et al.the Fog Zone. The National Campaign to Prevent Teen and Unplanned Pregnancy 2009 Intrauterine contraception (IUC) Busting myths and misconceptions Can be used in nulliparous women Insertion may be more challenging Can be used in adolescents Emphasize understanding of changes in menstruation being expected May have higher expulsion rates Can be placed before you have GC/CT screening results Can be kept in place while you treat for PID or other pelvic infections Does not increase overall risk of ectopic pregnancy Deans et al. Contraception 2009 Behringer et al. Contraception 2011 Hubacher D. Contraception 2007
Intrauterine contraception (IUC) Busting myths and misconceptions Can be used in women with a history of pelvic infections, must be three months from last GC/CT or PID infection No antibiotics needed at time of placement No association with infertility A 24 year-old G0 presents to your office. She desires intrauterine contraception but is concerned she is not a candidate for this method due to a past infection with Chlamydia, treated 9 months ago. Her last period was 2 weeks ago and she has not had intercourse since this time. IUDS and STIs Past TREATED infection is not a contraindication Recommend follow up screening Reinforce need for condoms for STI prevention Subdermal Implant Thin rod placed in subdermal tissue Brand name: Nexplanon Mechanism: releases ~60 mcg etonogestrel per day, inhibits ovulation and thickens cervical mucus Effective for 3 years Failure rate is 0.05% ETONOGESTREL IMPLANT INSERTION AND REMOVAL Inserted as outpatient average time 0.5 minutes mandatory training by manufacturer timing of insertion Insert any time in cycle; rule out pregnancy Back up method if not within the 1 st 5 days of menses Average removal time 3.5 minutes Etonogestrel Implant Bleeding Patterns Menstrual changes: Irregularity and unpredictability Spotting (50% declining to 30% after 6 months) Amenorrhea (20%) Prolonged bleeding (20% declining to 10% after 3 months) Frequent irregular bleeding (<10%) Other: Acne (17% reported, 1.3% discontinued) Weight gain (12.7% reported, 3.3% discontinued) Overall increase in BMI 0.7kg/m 2 (not a significant increase) Funk et al. Contraception 2005;71:319. Mansour et al. Eur J Contr Reprod Health Care 2008;13S1:13 Funk et al. Contraception 2005;71:319. Choosing a Birth Control Method. Association of Reproductive Health Professionals. 2011.
Subdermal Implant Benefits and Risks No maintenance, highly effective, confidential Rapidly reversible upon removal Menstrual bleeding is highly variable Most common reason for discontinuation Can manage with oral contraceptives for first few months Continuation rate > 75% Option for women Cannot tolerate estrogen Are tolerant of unpredictable bleeding Hesitant to use intrauterine contraception Subdermal Implant Contraindications Current breast cancer Some antiepileptic drugs Inability to manage irregular and unpredictable menses SLE with anti phospholipid antibodies Hepatocellular adenoma Unexplained vaginal bleeding suspicious for serious condition, before evaluation Patient is a 19 year old G0 who presents to clinic seeking contraception. She is sexually active with two male partners. Her medical history is notable only for a BMI of 32. She has irregular menstruation that she feels is too heavy. She would like lighter menstruation and is comfortable with the idea of amenorrhea. Multiple sex partners is not a contraindication to IUD use Heavy menstruation is a reason to discourage Copper IUD use (patient satisfaction) Levonorgestrel releasing IUDs associated with lighter menstruation LARC not contraindicated in setting of obesity Of the LARC options, which would you recommend as the best choice for this patient? Summary Long acting reversible contraception (LARC) is the first line contraception for most patients There are many non contraceptive benefits of each LARC method Counseling can influence patient selection of LARC