female contraception-latest development-pansy lam
TRANSCRIPT
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
1/55
THE LATEST DEVELOPMENTON FEMALE CONTRACEPTION
Dr Pansy W.Y. Lam
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
2/55
Definitions:
Pearl Index number of pregnancy in 100 women
in 1 year Cumulative pregnancy rate in number of years
Failure rate~ Pregnancy rate
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
3/55
Various methods of contraception
Combined Pills (COC)
Contraceptive Injection
Contraceptive implant
Transdermal Patch
Progestogen only pills
Intra-uterine Systems (LNG-IUD)
Condoms
Spermicides
Diaphragms
Intra-uterine Devices (IUD)
Sterilization - male and
female
Natural family planning
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
4/55
Efficacy of various contraceptive methods commonly used in US &
Western Europe
*The total number of unplanned pregnancies which occur per 100 womanyears of use
1. The Gallup Organization Inc. 2004; 2. Skouby 2004; 3. Leidenberger 1998; 4. Baltzer et al. 1985;
5. Ortho-McNeil Pharmaceutical Inc. 2001; 6. Ortho-McNeil Pharmaceutical Inc. 2002
Reliability Contraception type Pearl Index*
Very high Combined oral contraceptives 0.032.36
Very high Transdermal patch ~1.0
Highvery high Mini-pill (progesterone only) 0.44.3
Reasonable Male condom 714
Unreliable Coitus interruptus (Withdrawal) 1040
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
5/55
Combined OC pills
Actions
Pearl index of 0.1
Inhibit FSH and LH secretions thus preventingovulation
Thicken cervical mucus to prevent sperm penetrating
uterus
Endometrial thinning to prevent fertilized egg
implantation
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
6/55
Combined OC pills
Other uses
Good cycle regulator
Menorrhagia - reduce mean menstrual blood loss
Dysmenorrhoea
Endometriosis Premenstrual syndrome
PCOS
Acne
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
7/55
Categorization of Combined OC pills
Categories Estrogen dose/day Progestogen
1st generation 50ug/day levonorgestrel
2nd generation 20 - 35ug/day levonorgestrel
or norgestrel
3rd generation 20 - 30ug/day desogestreland gestodene
New generation 20 - 30ug/day Drospirenone(DRSP)
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
8/55
Combined OC pills
Preparation
Monophasic 21, 21/7, 22/6, 24/4, 84/7
Biphasic 2 types of combined E+P
Triphasic 3 types of combined E+P
No advantage in biphasic and triphasic preparations
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
9/55
Estrogens
Side effects dose dependent
Coagulation- stroke, DVT ( especially in smoker)
Lipid problem ( inc HDL and lower LDL) Breast tenderness
Water retention and weight gain
Depression-serotonin reduction
GIT condition- nausea and vomiting
Photosensitive
Breast cancer?
Liver tumour risk?
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
10/55
Progestogenic
activity
Antiandrogenic
activity
Antimineralo-
corticord activity
Glucocorticord
activity
Progesterone + (+) + -Drospirenone + + + -
Cyproterone acetate + + - (+)
Desogestrel + - - -
Dienogest + + - -
Gestodene + - (+) -
Levonorgestrel + - - -
Norgestimate + - - -
+ effect, (+) negligible at therapeutic dosages, - no effect
Pharmacological Profile of Progestogens
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
11/55
Risks of Oral Contraceptives:
Nonfatal Venous Thromboembolism
Food and Drug Administration. FDA Talk Paper. Nov. 24, 1995.
EstimatedAverageRisk/
100,0
00Women/Year
Healthy Non-OCUsers
Users of OCs Pregnant Women0
20
40
60
80
100
515 (2
nd
generation)
25 (3rd
generation)
60
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
12/55
Cardiovascular Mortality Risk with Smoking and Age in
COC Users
Oral contraceptive user
Oral contraceptive nonuser
SmokerNonsmoker SmokerNonsmoker
< 35 years of age 35 years of age
Casesper100
,000Woman-Years
AttributableRisk/100,000
User-Years
0.06 1.73 3.03 19.4
Sherif K.Sherif K.Am J Obstet Gynecol.Am J Obstet Gynecol. 1999;180(Pt 2):S3431999;180(Pt 2):S343--S348.S348.
0
5
10
15
20
25
30
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
13/55
Cardiovascular Risk On the basis of a large EU surveillance study in > 58,600 women followed-up
for over 142,400 women years, the European Agency for the Evaluation of
Medicinal Products has concluded COCs are safe and highly effective atpreventing pregnancy, and that there is no reason for women currently using
any brand of a COC to stop taking the medication - 2007
Source: Dinger JC., et al. The safety of a drospirenoneSource: Dinger JC., et al. The safety of a drospirenone --containing OC. Contraception 2007;75:344containing OC. Contraception 2007;75:344--354354
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
14/55
Combined OC pills
Contraindications
Hypertension, DM, Hyperlipidaemia
Potential high risk age >35
Venous Thrombotic Embolism
Stroke
Breast cancer risk controversial
Liver tumour risk- controversial
Varicose Precaution in smoker
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
15/55
New preparation with low estrogen
pills (20mcg daily)
low estrogen pills
Increase problems of BTB and spotting
Risk of failure with missed pills increased
Alternative contraception if in doubt recommended
e.g. take other drugs, missed pills frequently
New regimes of 24/4 and 84/7 regimes
Side effects varies due to different types ofprogestogen (Drosperinone, Dienogest)
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
16/55
New 24/4 regime with Drospirenone
Contraindications and precautions ?Increase non-fatal venous thromboembolism actively being investigated
the same as those for other low-dose combined oral contraceptives In addition, should not be used in women with conditions that predispose to
hyperkalemia, e.g. renal insufficiency, hepatic dysfunction and adrenal
insufficiency
Women who are taking daily long-term medications that may increase
serum potassium levels
Such agents include angiotensin converting enzyme (ACE) inhibitors, angiotensin-
II receptor antagonists, potassium-sparing diuretics, potassium supplementation,
heparin, aldosterone antagonists and non-steroidal anti-inflammatory drugs
(NSAIDs)
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
17/55
Other new preparation Seasonale:
Levonorgestrel-015mg + ethinylestradiol-30mcg Extended cycle regime- 84 days with 7 pill-free
days
Pearl Index- 1.0 HWY Less PMS
Precaution with estrogen related condition
attention with smoker / DM/ hypertension More spotting can occur
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
18/55
Other new prepapration Dienogest (DNG) with estradiol valerate (E2V)
Dynamic-estrogen step down and progestogen stepup sequence good cycle control
DNG- strong progestogenic and low androgenic
effect
Highly endometrial selective
Low estrogenic and androgenic
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
19/55
Dienogest (DNG)
with Estradiol Valerate (E2V)
Reliable contraception- Pearl Index- 0.42
Shorter withdrawal bleeding duration Less irregular spotting
Lighter period - useful for abnormal menstrual
bleeding Well tolerated -Satisfactory rate- 79.5%
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
20/55
DNG/E2
V preparation Less metabolic effect including haemostatic parameters- Prothrombin and
D-Dimer
Inc HDL and lower LDL
No change to CHO metabolism
Less acne
Better vaginal surface cell maturation
Same endometrial stimulation and FSH suppression effects (as other lowdose OCP)
Well tolerated -Satisfactory rate- 79.5%
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
21/55
OC Discontinuation:
Impact of Side Effects In a study of 1657 women not desiring pregnancy, 32% new
starters and 16% switchers discontinued OCs due to side effects
within 6 months*.
Most common side effects leading to OC discontinuation (n=293):
Bleeding irregularities 12%
Nausea 7%
Weight gain 5% Mood change 5%
Breast tenderness 4%
Headache 4%
*Excluding women who discontinued to pursue pregnancy or were no longer in a sexual relationship
Rosenberg J, Waugh MS. Am J Obstet Gynecol. 1998;179:577-582.
Managing expectations
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
22/55
Progestogen only pills (Mini-pill)
Mechanism
Progestogen effect
Thinning of endometrium
Thicken cervical mucus
?may prevent ovulation for some pills
Take it same time each day even when menstruating
Loss the contraceptive effect if 3 hours late, ?longer in
newer drugs (Cerazette)
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
23/55
Progestogen only pills (mini-pills)
Applications
breastfeeding
diabetics
women who smoke
Women who could not use combined OC pills e.g.
blood pressure has gone up on the Pill
older women.
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
24/55
Side effects Irregular period
Secondary amenorrhoea sometimes
May be ectopic if get pregnant (ectopics are said
to be rarer with Cerazette)
May increase pigmentation
Breast pain
Sometimes nausea, headache, dizziness, depressionand weight change.
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
25/55
Transdermal Patch Ethinyl estradiol 20mcg + norelgestromin 150mcg
daily release One patch per week for 3 weeks, one patch-free
week per cycle
Apply to body including abdomen, buttock, outerarm, upper torso, exclude breast
Failure rate 0.3% perfect user and 0.9% typical
user
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
26/55
Transdermal patch
Side effects and disadvantage
All the side effects of COC pills
Slightly increased risk of VTE Vs COC pills Skin irritation
May come out and loss adhesiveness
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
27/55
Contraceptive injections Progestogens only
Combined estrogen + Progestogen
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
28/55
Contraceptive Injections
(Progestogens only)
12-wk injection: Depo-Provera (DMPA)
8-wk injection: Noristerat or NET-EN (norethisterone) Intramuscular injections
Cumulative pregnancy rate: 0.1-0.7 % in first year,
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
29/55
Actions of Contraceptive Injections Prevents ovulation
Thickens cervical mucus to prevent spermpenetration
Endometrial thinning to prevent implantation
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
30/55
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
31/55
Progestogen only injections
Disadvantages Once given, cannot be removed and side effects may
last >3 months
Irregular bleeding in first few months, may be heavyand prolonged
Weight gain, fluid retention, increase in acne and
breast discomfort Long-acting drug may not ovulate after 6-8 months or
rarely 2 yr, not related to the length of time used
After the first few months, periods become lighter than
usual or even no periods at all (7 in 10 women afterthe injection for a year).
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
32/55
Pregestogen only injection
Side effects
Stopped due to menstrual disturbance, fluid
retention, weight gain, acne, breast discomfort Late return of fertility
Reduced BMD slightly (no evidence of increased
osteoporotic fracture risk) recovery afterstopping, reassessed every 2 year
C/I :no period for six months, risk of osteoporosis,
heavy drinker, anorexia nervosa
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
33/55
Combined monthly injectables
(Cyclofem)
Cyclofem, Mesigyna, Lunelle, Chinese injectable No. 1
Monthly injection of every 30 days Effectiveness (Cyclofem)
Correctly used - 1% in one year
Typically used (missed or delayed injeiton) 3% in one
year
Action: prevents ovulation + thicken cervical mucous
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
34/55
Combined monthly injectables
(Cyclofem)
Mechanism: combine E+P
Contraceptive effects of estrogen + progestogen Side effects of risks of OC pills
Medroxyprogesterone 50mg micmic effects of
Depo-provera
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
35/55
Side effects and disadvantages Hypertension
Smoker >35 Severe headache or migraine
Breast tenderness, dizziness, weight gain
Bleeding disorders scanty, irregular, prolonged or
no period at all
1-3 months to have period return to normal status
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
36/55
Contraceptive implants A tube of 40mm long and 2mm wide
Progestogen
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
37/55
Contraceptive implants
Advantages 3 years
Can breast feed Reduce
dysmenorrhoea
No missed pills
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
38/55
Contraceptive implants
DisadvantagesInsert under LA
Wound site problem such as infection
Removed under LA, not immediately reversibleSide effects of progestogen
Menstrual problems: Prolonged heavy flow in the beginning
Irregular flow Secondary amenorrhoea
Fluid retention, weight gain
Breast pain
Other problems
Injection time might be forgotten
Difficult to locate after years, new type has barium filled more easilylocated
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
39/55
Intrauterine device Intrauterine device Copper IUCD
Intrauterine system Hormonal IUCD
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
40/55
Copper IUDs
Action
Copper IUDs prevent fertilization by immobilizing
sperms and prevent implantation by changingendometrial lining
Does not affect ovulation or the menstrual cycle.
C IUD
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
41/55
Copper IUDs
Advantages and disadvantages No side effects of hormones
May increase mean menstrual blood loss May increase ascending infection, vaginal fungal
infection
Failure may result in ectopic pregnancy
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
42/55
Intrauterine systems / Hormonal IUCDs
Intrauterine device
Hormonal effect of progestogen Endometrial thinning
Thicken cervical mucus
I t t i t
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
43/55
Intrauterine systems
Advantages and disadvantages Originally designed for treating menorrhagia,
menstrual blood loss could be reduced dramatically Prolonged spotting in first 3-6 months after insertion
can be troublesome
Risk of ectopic pregnancy if failure still present Prolonged secondary amenorhoea can be worrying
Reversal of fertility difficult to predict
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
44/55
Female Barrier Methods
Female condom
Diaphragm Cervical cap
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
45/55
Female condom
5% pregnancy rate
Advantages
Prevents the spread of STD, including
HIV and AIDS. No hormonal side effects.
Can be used by people with latexsensitivities.
It can be pre-lubricated and it can be
used with oil and water-based lubricants.Disadvantages:
Sometimes difficult to insert or use.
Does not contain spermicide.
Can break or leak.
More expensive than male condoms.
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
46/55
Cervical cap
The cervical cap is a rubber capshaped like a thimble, which fitsover the cervix
Advantages:
Placed days or hours before sex
The cap also uses less spermicidethan the diaphragm
Disadvantages: No means of protecting from STD
Left for a few days withspermicide may cause odour
Occasionally the cap canbecome dislodged duringintercourse rendering itineffective
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
47/55
Diaphragm
A rubber cap that looks like acervical cap inserted in the
vagina and placed over thecervix with spermicide
Advantages:
5 % pregnancy if usedprobably
Disadvantages:
Does not stop the spread ofSTDs
Slight risk of Toxic Shock
Syndrome May experience difficulty
with urinating.
Safety Period / Natural Family
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
48/55
Safety Period / Natural Family
Planning2-20% failure rate
Calender charting
Mucus monitoring Dry day, ~5 days after
period
Wet day (thick sticky
discharge) cervicalopening
Basal bodytemperature increased
only 1F during ovulation
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
49/55
Current Prevalence of Contraception
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
50/55
0
10
20
30
40
50
60
70
Male condom
Female sterilization
Intra-uterine Device (IUD)
Oral contraceptive
Rhythm
1987
1992
1997
2002
2007
Male condom
Female
sterilization
Intra-uterine
Device (IUD)
Oral
contraceptive Rhythm
1987 32.2 16.8 5.6 20.3 6.7
1992 40.0 21.9 5.9 19.8 5.9
1997 44.4 22.9 5.9 16.3 3.5
2002 54.3 16.8 10.4 9.4 3.4
2007 63.1 8.9 11.7 8.4 2.9
in Hong Kong
* Sources: KAP Survey conducted by FPA in 1987-2007
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
51/55
Comparison of Contraceptive Methods
Failur
e
Rate
Efficac
y
Reversible Convenienc
e
Weight Gain
Combined Oral
Contraceptive
0.2
3
DRSP causes
no signif
weight gain
Intra-uterine
System (IUS)
0 0.2
Need to beremoved byphysician
X X
Sterilization 0 1 X X X
Contraceptive
Injection
0 1 Waiting periodof 6 to 12months
X
Intra-uterine
Device (IUD)
0.3 2
Need to beremoved byphysician
X X
Condom 2 - 15 X
Natural Family
Planning
2 - 20 X X
Source: Guillebaud J. Contraception Today 1997, 3rd Edition
Efficacy of various contraceptive methods commonly used in US &
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
52/55
Efficacy of various contraceptive methods commonly used in US &
Western Europe
*The total number of unplanned pregnancies which occur per 100 womanyears of use
1. The Gallup Organization Inc. 2004; 2. Skouby 2004; 3. Leidenberger 1998; 4. Baltzer et al. 1985;
5. Ortho-McNeil Pharmaceutical Inc. 2001; 6. Ortho-McNeil Pharmaceutical Inc. 2002
Reliability Contraception type Pearl Index*
Very high Combined oral contraceptives 0.032.36
Very high Transdermal patch ~1.0
Highvery high Mini-pill (progesterone only) 0.44.3
Reasonable Male condom 714
Unreliable Coitus interruptus (Withdrawal) 1040
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
53/55
Conclusion
All E+P preparations have similar risks and side
effects COC still the best drug if hormones are not
contraindicated
Progestogens only pills have their advantages butbleeding problems
IU devices can be very useful and long term
Barrier method, if probably used, effective and less
side effects with some protection of STD
S
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
54/55
Suggestion
Individualize recommendation
Know your client Discuss
Make agreements
-
8/3/2019 Female Contraception-Latest Development-Pansy Lam
55/55
Thank You!!Thank You!!