Contraception in the Community
| Adapted by Jill Gallin, CPNP | |
| Assistant Professor of Clinical Nursing |
U.S. Pregnancies:
Unintended vs. Intended
Adolescents Who Have Had Intercourse
The Need for
Contraception
Unintended Pregnancies (%) by Age
The Need for
Contraception
Pregnancies Ending in Abortion by Age
Adolescent Pregnancy
An International Perspective—Developed Countries
Adolescents Delay Seeking Medical Contraceptive Services
FDA Advisory Committee’s Recommendation on Delay of Pelvic Exam
Adolescents’ Contraception at First Intercourse
Method Use, Last
Intercourse
Young Women, 14 to 22 years old
Properties of
Contraceptives
Desired by Women
| Highly effective | |
| Prolonged duration of action | |
| Rapidly reversible | |
| Privacy of use | |
| Protection against STD | |
| Easily accessible |
| Effectiveness | ||
| Theoretical | ||
| Actual | ||
| Importance of not being pregnant | ||
| Likelihood and ability to comply | ||
| Frequency of intercourse | ||
| Age | ||
| Oral contraceptives: combined, progestin-only | ||
| Long-acting | ||
| Injectable | ||
| Implant | ||
| IUD: copper T, progestin-only | ||
| Barrier contraceptives | ||
| Spermicides | ||
| Natural family planning | ||
| Emergency contraceptives | ||
| Female/male sterilization | ||
Current Trends in Contraception
| Developing new delivery systems | |
| Increasing access to a full range of options | |
| Emphasizing better compliance | |
| Widening use of emergency contraception |
| Dosing: every day same time | |
| Rx refill | |
| Cost | |
| Not so private | |
| Side Effects | |
| Contraindications | |
| See handout | |
| Combined | |
| Progesterone only |
Levonorgestrel and
Norethindrone
Plasma Levels After Single Oral Dose
Drugs That Decrease the Effectiveness of OCs
| Anticonvulsants | ||
| Barbituates (including phenobarbital and primidone) | ||
| Phenytoin | ||
| Carbamazepine | ||
| Toprimate | ||
| Vigabatin | ||
| Anti-infectives | ||
| Rifampin | ||
| Griseofulvin | ||
Drugs That Do Not Decrease the Effectiveness of OCs
| Anti-infectives | ||
| Tetracycline | ||
| Doxycycline | ||
| Ampicillin | ||
| Metrondiazole | ||
| Quinolone antibiotics | ||
Noncontraceptive Benefits of OCs
| Cycle-related: | ||
| Irregular cycles | ||
| Dysmenorrhea | ||
| Menorrhagia | ||
| Anemia | ||
| Functional ovarian cysts | ||
| Cancer reduction: | ||
| Ovarian | ||
| Endometrial | ||
| Colorectal | ||
Noncontraceptive Benefits of OCs
| Prevention of: | ||
| Bone loss | ||
| Fibrocystic/benign breast disease | ||
| Pelvic inflammatory disease (PID) | ||
| Ectopic pregnancy | ||
| Treatment of: | ||
| Acne | ||
| Hirsutism | ||
| Perimenopausal symptoms | ||
Studies Show OCs Reduce Risk of Ovarian Cancer
Ovarian Cancer and
OCs
Risk Reduction by Years of Use
OCs Protect Against Ovarian Cancer After Discontinuation
OCs Reduce Risk of Ovarian Cancer in High-Risk Women
| BRCA1 and BRCA2 mutations increase ovarian cancer risk | ||
| 45% increased risk in carriers of BRCA 1 | ||
| 25% increased risk in carriers of BRCA 2 | ||
| OCs reduce ovarian cancer risk in
carriers of BRCA1 or BRCA2 |
||
| 20% reduction with short-term OC use (Ł3 y) | ||
| 60% reduction with long-term OC use (ł6 y) | ||
Studies Show OCs Reduce
Risk
of Endometrial Cancer
OCs Reduce Risk of Endometrial Cancer By Years of Use
OCs Protect Against Endometrial Cancer After Discontinuation
Ovarian and Endometrial Cancers and Low-Dose OCs
| Ovarian cancer | ||
| If protective effect is due to prevention of “incessant ovulation,” low-dose OCs are likely protective | ||
| Endometrial cancer | ||
| Data on protective effect indicate no significant difference between 35 µg and >50 µg EE OCs | ||
Bone Mass and OC Use
Studies Examining Association
| 9/13 studies show positive effects | ||
| Up to 12% increase in BMD vs. control subjects | ||
| Greatest protection with OC use of ł10 y | ||
| Primarily an estrogen effect;
progestins may be important |
||
| 4 studies show neutral effect | ||
| No studies show decreased BMD with OC use | ||
Higher Bone Density
More Likely in OC Users
Higher Bone Density
Association With Longer OC Use
Do 20 µg EE OCs Increase Bone Mineral Density?
| 20 µg EE OCs: significant increases in vertebral bone density (oligomenorrheic, perimenopausal women) | |
| 0.625 mg conjugated equine estrogens (HRT) = ~ 5 µg EE | |
| 5 µg EE doses: demonstrate bone-sparing properties | |
| 20 µg EE OCs: protective benefits
are maintained in perimenopausal women |
|
| Androgen-stimulated disorder | ||
| All OCs: | ||
| Are antiandrogenic | ||
| Reduce free testosterone | ||
| Improve acne for most women | ||
Reductions in Inflammatory
Lesion Counts at Cycle 6*
EE 35 µg/NGM (Ortho Tri-Cyclen) vs.
Placebo
Reductions in Total Lesion
Counts at Cycle 6*
EE 35 µg/NGM (Ortho Tri-Cyclen) vs.
Placebo
Reductions in Inflammatory
Lesion Counts at Cycle 6
EE 20 µg/LNG 100 µg (Alesse) vs. Placebo
Reductions in Total Lesion
Counts at Cycle 6
EE 20 µg/LNG 100 µg (Alesse) vs. Placebo
| Ż Ovarian and adrenal androgen secretion |
|
| SHBG to bind androgens | |
| Ż 5a-reductase activity |
Primary Dysmenorrhea
Incidence
OC Use in Adolescents
Decreased Dysmenorrhea and Compliance
| Reduction of dysmenorrhea was the most statistically and clinically significant predictor of consistent OC use | |
| Adolescents with severe dysmenorrhea who experienced positive effects (decreased cramping or flow) were 8 times more likely to be consistent pill users (missed Ł3 pills per month) than others |
| 50% of women and 80% of adolescents report pain with menses | |
| OCs reduce menstrual fluid volume and prostaglandin levels | |
| OCs provide marked improvement of symptoms | |
| NSAIDs complement OC use |
How OCs Improve Primary Dysmenorrhea
| By ovulation inhibition, progesterone-stimulated endometrial prostaglandin production is reduced | |
| By reducing menstrual flow, which contains prostaglandins |
OC Compliance
A Real Concern with Adolescents
| Daily pill taking habit difficult | |
| Cost considerations | |
| Obtaining refills | |
| Misinformation about the pill |
Reported Pill Use vs. Actual Pill Use
OC Continuation Rates
All Ages
Reasons for OC
Discontinuation
All Ages
What Happens When
Women Discontinue OCs
| 42% discontinue without consulting their health-care provider | |
| 19% discontinue without selecting another contraceptive method | |
| 69% choose a less-effective contraceptive method |
| First-time users | |
| Inconsistent users | |
| Users at risk for chlamydial cervicitis and endometritis | |
| Smokers |
Breakthrough Bleeding in OC
New Starts
35 µg EE OC vs. Two 20 µg EE OCs
Breakthrough Bleeding in OC
Switchers
35 µg EE OC vs. Two 20 µg EE OCs
| Rates reported for different OCs are highly variable depending on study design and other factors | |
| Few randomized, prospective studies directly compare BTB between OCs | |
| Data do not support perception that 20 µg EE OCs generally have more BTB than 30–35 µg EE OCs |
| Chlamydial infections are common in women of childbearing age — detected in 9.2% of female military recruits | ||
| BTB in women previously well regulated on OCs is an added marker for chlamydial infection | ||
| 29% of OC users with BTB tested positive for Chlamydia trachomatis vs. 11% without BTB but at high risk | ||
Adolescents’ Anticipated
vs. Reported Side Effects
EE 20 µg/LNG 100 µg Formulation
Relative Risk of
Estrogen-Related Side Effects
35 µg EE OC vs. Two 20 µg EE OCs
| Relative Risk of | |
| 35 vs. 20 mg EE OCs | |
| (Ortho Tri-Cyclen vs. | |
| Side Effect Alesse and Mircette) | |
| Breast tenderness 1.5* | |
| Nausea 1.6* | |
| Bloating 1.4* | |
| *P<.05. | |
Side Effects of EE 20 µg/LNG 100 µg (Alesse) vs. Placebo: No Significant Difference
Weight Gain Is Not A Trivial Concern for OC Users
| Adolescents | ||
| Major fear leading to discontinuation | ||
| 85% of suburban teens cited weight gain as an important concern | ||
| Adult women | ||
| Common reason for self-initiated discontinuation | ||
Women’s Perceptions About Weight Gain and OCs
| In a survey of 704 women aged 18-45 years: | |
| 20% report fear of weight gain is a reason they would not take or stop taking OCs | |
| 27% of those who had never taken OCs say, among other reasons, this was because of fear of weight gain | |
| 17% of current or previous OC users cite fear of gaining weight as a reason for discontinuation |
Controlled Studies Fail to Show Weight Gain Linked to OC Use
The Press Underreports Studies of OC Benefits
| 1986-1997: 9 studies on OC health effects published in N Engl J Med and JAMA |
||
| All studies showed positive health effects |
||
| 8 out of 9 studies ignored by major newspapers |
||
Management of Side Effects
Preventive/Anticipatory Guidance
| Acknowledge that side effects can be bothersome and uncomfortable | ||
| Discuss breakthrough bleeding, nausea, weight gain at initial visit | ||
| Set realistic expectations and counsel | ||
| Most side effects improve over time | ||
| Acne improvement is not immediate | ||
How to Improve Successful Use of OCs
| Emphasize the many noncontraceptive benefits | |
| Cue pill-taking to daily activity | |
| Provide spare pack; advise to keep as emergency backup | |
| Provide written instructions | |
| Train office contact person to respond to calls |
Improving Successful OC Use
Anticipatory Guidance
| Individualize counseling to patient’s concerns and history | |
| Breakthrough bleeding | |
| Amenorrhea | |
| Side effects decrease over time | |
| Demonstrate how to use the actual pill pack | |
| Missed pills | |
| “Don’t stop taking the pills before calling me” |
| Caution that OCs do not prevent STDs | |
| Discuss condom use: “How are you protecting yourself from AIDS?” | |
| Ask how she plans to discuss condom use with her partner | |
| Discuss emergency contraception |
| Synthetic progesterone | ||
| Private | ||
| Requires clinic visit Q 3 months | ||
| Effective in 24 hours | ||
| Side Effects | ||
| Contraindications | ||
| Unexplained vaginal bleeding | ||
| pregnancy | ||
Comparison of New
Contraceptive Methods
Contraceptive Implant: Implanon
| Single implant rod (4 cm in length and 2 mm in diameter) made of ethylene vinyl acetate | |
| Contains 68 mg of etonogestrel (3-keto-desogestrel), the active metabolite of desogestrel |
|
| Effective for 3 years | |
| Inhibits ovulation during the entire treatment period |
Implanon Efficacy, Safety and Tolerability
| No pregnancies in 1,200 women-years of exposure | |
| Good safety profile | |
| Irregular bleeding is most common adverse effect | |
| Requires clinician visit for initiation and discontinuation | |
| Single implant systems using newer progestins may solve some of the adverse effects and problems presented by earlier implants |
Levonorgestrel Intrauterine System: Mirena
| Releases 20 mg of levonorgestrel per 24 hrs | ||
| Duration: 5 years | ||
| Packaged with sterile inserter | ||
| High efficacy | ||
| Pearl Index of 0.1 | ||
Mirena Cycle Control,
Safety, and Tolerability
| Requires clinician visit for initiation and discontinuation | |
| Early spotting | |
| Significant reduction in menstrual blood loss and high rate of amenorrhea | |
| High rates of continuation | |
NuvaRing Cycle Control and Tolerability
| Good cycle control | ||
| Irregular bleeding was rare (2.6% - 6.4% of evaluable cycles) |
||
| Withdrawal bleeding occurred (97.9% - 99.4% of evaluable cycles) |
||
| Well tolerated and well accepted by users and their partners (only 5% of partners objected to use) | ||
NuvaRing Compared to
OC:
Irregular Bleeding
Contraceptive Patch: Ortho Evra
| Patch contains 6 mg norelgestromin and 0.75 mg ethinyl estradiol | ||
| Delivers continuous systemic doses of hormones | ||
| 150 µg norelgestromin (NGMN) | ||
| 20 µg ethinyl estradiol (EE) | ||
| Direct comparisons to oral contraceptive delivery doses cannot be made | ||
Ortho Evra Efficacy and Compliance
| High Efficacy | ||
| Overall Pearl Index of 0.88 | ||
| After 6 cycles, overall pregnancy possibility is half that of OC users | ||
| May be less efficacious in women ł198 lb (90 kg) | ||
| NIH study in progress | ||
| Compliance is superior with Ortho Evra compared to OC | ||
| Ortho Evra compliance unaffected by age | ||
| Lower compliance with OC in younger compared with older subjects | ||
Ortho Evra Compared to OC:
Breakthrough Bleeding*
Ortho Evra Compared to OC: Adverse Events
| Clinicians should not assume they know what a woman’s contraceptive needs are | ||
| After listening to a woman’s concerns, counseling should be non-directive and informative | ||
| A menu of contraceptive options should be presented to all reproductive-aged women | ||
| Consider using computer-based instruction or videos before the clinician consult to optimize education | ||
| With good counseling, women will select a contraceptive method that best suits their needs | ||