Reproductive Health Update: Reproductive Health Update: Encouraging Students to Use Encouraging Students to Use

ContraceptivesContraceptives

John Kulig, MD, MPHJohn Kulig, MD, MPH

Lead Medical SpecialistLead Medical Specialist

Sara Mackenzie, MDSara Mackenzie, MD

Regional Medical SpecialistRegional Medical Specialist

March 28, 2013March 28, 2013

OverviewGoals:Goals:

This webinar will provide an update on contraceptive methods, This webinar will provide an update on contraceptive methods, including long-acting reversible methods. Additionally, including long-acting reversible methods. Additionally, presenters will provide strategies to promote consistent use of presenters will provide strategies to promote consistent use of contraceptives by students.contraceptives by students.

Objectives:Objectives:

After this presentation, participants will be able to:After this presentation, participants will be able to:

Implement a comprehensive family planning program for female Implement a comprehensive family planning program for female and male students on center.and male students on center.

Counsel students about delaying pregnancy and parenting in Counsel students about delaying pregnancy and parenting in support of employability.support of employability.

Counsel students about current contraceptive options and Counsel students about current contraceptive options and provide access to all methods.provide access to all methods.

Family Planning ProgramPRH 6.11 R4

A family planning program shall be A family planning program shall be provided to all students on a voluntary provided to all students on a voluntary basis. At a minimum, this program shall basis. At a minimum, this program shall include counseling, health promotion include counseling, health promotion activities and medical services. The activities and medical services. The Center Director shall appoint a staff Center Director shall appoint a staff member to implement and monitor this member to implement and monitor this program.program.

Sexual Health MisinformationOne in five adolescents believe that birth control pills offer protection from STDsOne in five adolescents believe that condoms are “not effective” in preventing STD transmissionOne in six adolescents believe that sex without a condom once in awhile is “no big deal”One in ten adolescents believe that “you do not need to use condoms unless you have a lot of sexual partners.”Half of adolescents believe that raising the subject of condoms raises suspicions about both partners’ sexual history

Ref: Kaiser Family Foundation National SurveyRef: Kaiser Family Foundation National Survey

http://nahic.ucsf.edu//downloads/ReproHlth2007.pdf

Unintended pregnancy in U.S. Unintended pregnancy in U.S. (all age groups)(all age groups)

82% of teen pregnancies unintended82% of teen pregnancies unintended

49% of 49% of allall pregnancies unintended pregnancies unintended 29% mistimed29% mistimed 19% unwanted19% unwanted 43% end in abortion43% end in abortion

Teen child bearing associated with:Teen child bearing associated with:

School dropoutSchool dropout

Infants of teens more likely to have low Infants of teens more likely to have low birth weight, lower academic achievement, birth weight, lower academic achievement, and increased likelihood of becoming teen and increased likelihood of becoming teen parentparent

Case 1:Case 1:

Student presents to wellness center Student presents to wellness center requesting pregnancy test – worried she requesting pregnancy test – worried she might be pregnant. You review chart and might be pregnant. You review chart and see prescribed oral contraceptives at see prescribed oral contraceptives at entrance. She says: “I started it but my entrance. She says: “I started it but my period started after a couple of weeks, so I period started after a couple of weeks, so I stopped for a week, then started the next stopped for a week, then started the next package but had bleeding again, so I package but had bleeding again, so I stopped.”stopped.”

Of teens with live birth:Of teens with live birth:

50% not using contraception at time 50% not using contraception at time pregnancy – of these 1/3 thought could not pregnancy – of these 1/3 thought could not get pregnant at that timeget pregnant at that time

21% using highly effective contraceptive 21% using highly effective contraceptive (although only 1% with IUD)(although only 1% with IUD)

24% moderately effective contraceptive24% moderately effective contraceptive

5% rhythm or withdrawal method5% rhythm or withdrawal method

REF: Prepregnancy contraceptive use among teens with unintended pregnancies REF: Prepregnancy contraceptive use among teens with unintended pregnancies resulting in live births 2004-2008 MMWR v61/No.2 January 20, 2012resulting in live births 2004-2008 MMWR v61/No.2 January 20, 2012

To decrease teen pregnancy:To decrease teen pregnancy:

Reduce or delay onset of sexual activityReduce or delay onset of sexual activity

Provide factual information about Provide factual information about conditions in which pregnancy occursconditions in which pregnancy occurs

Increase motivation and negotiation skills Increase motivation and negotiation skills for preventionfor prevention

Increase access to contraceptives Increase access to contraceptives

Increase use of most effective Increase use of most effective contraceptivescontraceptives

REF: Prepregnancy contraceptive use among teens with unintended pregnancies REF: Prepregnancy contraceptive use among teens with unintended pregnancies resulting in live births 2004-2008 MMWR v61/No.2 January 20, 2012resulting in live births 2004-2008 MMWR v61/No.2 January 20, 2012

AbstinenceAbstinence

Teenage Births

teenage birth rate had fallen “below any teenage birth rate had fallen “below any level previously recorded in the US” as of level previously recorded in the US” as of 2005, 2005, butbut increased 3.4% in 2006 and 1.4% increased 3.4% in 2006 and 1.4% in 2007 (15-19 year-olds), then lower in 2008in 2007 (15-19 year-olds), then lower in 200830% overall decline in the past decade30% overall decline in the past decade40% decline among African American 40% decline among African American teenagers since 1991teenagers since 1991abortion rate among women 15-19 declined abortion rate among women 15-19 declined from 40 per 1,000 in 1990 to 24 per 1,000 in from 40 per 1,000 in 1990 to 24 per 1,000 in 20002000attributed to less sexual activity and more attributed to less sexual activity and more effective use of contraceptioneffective use of contraception

Changes in marriage

The proportion of 25-year-olds who have never been married has

increased steadily since the 1970s. Source: The Brookings Institution, 2007

Oral Oral Contraceptive Contraceptive PillsPills

Noncontraceptive Benefits of OCs

decrease menstrual flow (lighter, shorter periods)decrease menstrual flow (lighter, shorter periods)

decrease menstrual cramps (no ovulation)decrease menstrual cramps (no ovulation)

improve anemia (lighter, shorter periods)improve anemia (lighter, shorter periods)

improve acne (estrogen effect)improve acne (estrogen effect)

protect against ovarian and endometrial cancerprotect against ovarian and endometrial cancer

decrease benign breast disease decrease benign breast disease

decrease ovarian cyst formationdecrease ovarian cyst formation

prevent ectopic pregnancyprevent ectopic pregnancy

protect against some causes of PIDprotect against some causes of PID

protect against osteoporosisprotect against osteoporosis

Contraindications to Use of OCs

deep vein thrombosisdeep vein thrombosis

pulmonary embolismpulmonary embolism

cerebrovascular disease cerebrovascular disease

coronary artery diseasecoronary artery disease

factor V Lyden mutation or other known thrombophiliafactor V Lyden mutation or other known thrombophilia

migraine headache with aura or neurologic changesmigraine headache with aura or neurologic changes

estrogen-dependent cancerestrogen-dependent cancer

active liver diseaseactive liver disease

major surgery or immobilizationmajor surgery or immobilization

pregnancy or breastfeedingpregnancy or breastfeeding

Drug Interactions with OCs

carbamazepine (Tegretol)carbamazepine (Tegretol)

griseofulvin (Grifulvin)griseofulvin (Grifulvin)

phenobarbital (Luminal)phenobarbital (Luminal)

phenytoin (Dilantin)phenytoin (Dilantin)

primidone (Mysoline)primidone (Mysoline)

rifampin (Rifadin)rifampin (Rifadin)

rifabutin (Mycobutin)rifabutin (Mycobutin)

ritonavir (Norvir)ritonavir (Norvir)

St. John’s wort St. John’s wort

Extended Cycling

fewer and shorter menstrual periods – fewer and shorter menstrual periods – one or four per yearone or four per year

shorter hormone-free intervalsshorter hormone-free intervals

better ovarian suppression (PCOS)better ovarian suppression (PCOS)

decreased premenstrual dysphoric decreased premenstrual dysphoric disorder (PMDD), premenstrual syndrome disorder (PMDD), premenstrual syndrome (PMS), acne vulgaris, endometriosis, (PMS), acne vulgaris, endometriosis, menstrual migrainemenstrual migraine

preferred by athletespreferred by athletes

Seasonale®

Seasonique®

Seasonale®

extended regimen combined oral extended regimen combined oral contraceptive pills with ethinyl contraceptive pills with ethinyl estradiol 0.03 mg and levonorgestrel estradiol 0.03 mg and levonorgestrel 0.15 mg0.15 mg

91 day cycles - 84 days on – 7 days off91 day cycles - 84 days on – 7 days off

4 menstrual cycles per year - one each 4 menstrual cycles per year - one each seasonseason

Seasonique®

extended regimen combined oral extended regimen combined oral contraceptive pills with ethinyl estradiol contraceptive pills with ethinyl estradiol 0.03 mg and levonorgestrel 0.15 mg0.03 mg and levonorgestrel 0.15 mg

91 day cycles - 84 days on both – 91 day cycles - 84 days on both –

7 days on ethinyl estradiol 0.01 mg7 days on ethinyl estradiol 0.01 mg

4 menstrual cycles per year - one each 4 menstrual cycles per year - one each seasonseason

Oral Contraception: Red Flags

Mnemonic: ACHES

Abdominal pain (severe)

Chest pain (severe), cough, shortness of breath

Headache (severe), dizziness, weakness, or numbness

Eye problems (vision loss or blurring), speech problems

Severe leg pain (calf or thigh)

Emergency Emergency ContraceptionContraception

Plan B

Does knowledge of EC alter adolescent sexual behavior?

study of 916 male and 852 female students age study of 916 male and 852 female students age 14-15 in 12 schools in UK14-15 in 12 schools in UK

single lesson on emergency contraceptionsingle lesson on emergency contraception

improved knowledge persisted six months improved knowledge persisted six months later in comparison with controlslater in comparison with controls

no difference in sexual activity, intent to use no difference in sexual activity, intent to use EC or use of EC EC or use of EC

Ref: Ref: BMJBMJ 2002:324:1179-1183 2002:324:1179-1183

Contraceptive Contraceptive PatchPatch

Ortho Evra

Ortho Evra

seven day contraceptive patchseven day contraceptive patch

113/4 3/4 inch three-layer adhesive patchinch three-layer adhesive patch

releases ethinyl estradiol 20 µg and releases ethinyl estradiol 20 µg and norelgestromin 150 µg dailynorelgestromin 150 µg daily

applied to the buttocks, lower abdomen or applied to the buttocks, lower abdomen or upper body – not breastsupper body – not breasts

newly applied weekly for three weeks, then newly applied weekly for three weeks, then one week off for mensesone week off for menses

less effective in women over 198 poundsless effective in women over 198 pounds

Ortho Evra

The pharmacokinetic profile for the ORTHO EVRA The pharmacokinetic profile for the ORTHO EVRA patch is different from oral contraceptives in that it patch is different from oral contraceptives in that it has higher steady state concentrations (60% higher) has higher steady state concentrations (60% higher) and lower peak concentrations (25% lower) of and lower peak concentrations (25% lower) of ethinyl estradiol (EE) compared with an oral ethinyl estradiol (EE) compared with an oral contraceptive containing 35 mcg EE. contraceptive containing 35 mcg EE.

Increased estrogen exposure may increase the risk Increased estrogen exposure may increase the risk of adverse events, including venous of adverse events, including venous thromboembolism. thromboembolism.

Safety information added 2007

Ortho Evra

The results of epidemiologic studies evaluating the The results of epidemiologic studies evaluating the risk of venous thromboembolism (VTE) among risk of venous thromboembolism (VTE) among women using ORTHO EVRA compared to those women using ORTHO EVRA compared to those using oral contraceptives containing 30-35 mcg EE using oral contraceptives containing 30-35 mcg EE and either levonorgestrel or norgestimate reported and either levonorgestrel or norgestimate reported odds ratios ranging from 0.9 (no increase in risk) to odds ratios ranging from 0.9 (no increase in risk) to 2.4 (approximate doubling of risk). 2.4 (approximate doubling of risk).

Safety information added 2007

Ortho Evra

Side effects leading to discontinuation:Side effects leading to discontinuation:nausea (2%)nausea (2%)moodiness (1.5%)moodiness (1.5%)headache (1.1%)headache (1.1%)breast discomfort (1%)breast discomfort (1%)irritation at application site (1.9%)irritation at application site (1.9%)

Inadvertent detachment uncommon (1.9%), Inadvertent detachment uncommon (1.9%), even with exercise, humid climates, saunas, even with exercise, humid climates, saunas, hot tubs.hot tubs.

Contraceptive Contraceptive Vaginal Vaginal RingRing

NuvaRing

NuvaRing

contraceptive vaginal ring - 2 inch diametercontraceptive vaginal ring - 2 inch diameter

worn for 21 days => removed for 7 days to allow worn for 21 days => removed for 7 days to allow menses => replaced with new ringmenses => replaced with new ring

releases 120 mcg of etonogestrel and 15 mcg of releases 120 mcg of etonogestrel and 15 mcg of ethinyl estradiol dailyethinyl estradiol daily

one size only - does not require fitting one size only - does not require fitting

cannot be inserted incorrectlycannot be inserted incorrectly

no increase in vaginal infections/dischargeno increase in vaginal infections/discharge

3 hour window for reinsertion after inadvertent 3 hour window for reinsertion after inadvertent removalremoval

Long acting reversible Long acting reversible contraceptives (LARCs)contraceptives (LARCs)

IUDs and contraceptive implantsIUDs and contraceptive implants

Highly effective and safeHighly effective and safe

High satisfaction and continuation ratesHigh satisfaction and continuation rates

Underutilized in U.S.Underutilized in U.S.

Recent study noted significant reduction in Recent study noted significant reduction in abortions, repeat abortions, teen birth abortions, repeat abortions, teen birth rates with use of LARCsrates with use of LARCs

Preventing Unintended Pregnancies by Providing No-cost contraception; Preventing Unintended Pregnancies by Providing No-cost contraception; Obstetrics and Gynecology vol 120, no 6, 1291-1297 December 2012Obstetrics and Gynecology vol 120, no 6, 1291-1297 December 2012

Progestin-only Progestin-only Injectable Injectable ContraceptionContraception

Depo Provera

depot medroxyprogesterone depot medroxyprogesterone

acetate 150 mg IM once every acetate 150 mg IM once every

12 weeks – highly effective12 weeks – highly effective

inhibits ovulation, thickens cervical mucus, inhibits ovulation, thickens cervical mucus, thins the endometriumthins the endometrium

irregular bleeding/spotting => irregular bleeding/spotting =>

amenorrhea within 2 years (70%)amenorrhea within 2 years (70%)

concerns:concerns:– weight gain (54%)weight gain (54%)– osteoporosis risk, reversibleosteoporosis risk, reversible

Contraceptive Contraceptive ImplantImplant

Implanon => Nexplanon

progestin-only contraceptive implant progestin-only contraceptive implant

single flexible 4 cm rod inserted under the single flexible 4 cm rod inserted under the skin of the upper arm skin of the upper arm

contains 68 mg etonogestrel – releases 40 contains 68 mg etonogestrel – releases 40 mcg daily - 3 year efficacy mcg daily - 3 year efficacy

no pregnancies in 73,000 monthly cyclesno pregnancies in 73,000 monthly cycles

irregular menstrual bleeding common irregular menstrual bleeding common

clinician visit required for insertion and clinician visit required for insertion and removal – new insertion device for Nexplanonremoval – new insertion device for Nexplanon

Nexplanon is radiopaqueNexplanon is radiopaque

Implanon

Nexplanon

Intrauterine Intrauterine Contraceptive Contraceptive SystemSystem

Mirena

levonorgestrel-releasing intrauterine levonorgestrel-releasing intrauterine system - 20 mcg daily - 5 year efficacysystem - 20 mcg daily - 5 year efficacy

highest risk of PID within 20 days of highest risk of PID within 20 days of insertioninsertion

irregular menstrual bleeding common irregular menstrual bleeding common in first 3-6 monthsin first 3-6 months

clinician visit required for insertion and clinician visit required for insertion and removalremoval

Mirena

ParaGardParaGard®® T 380A T 380A

copper-releasing IUDcopper-releasing IUD

believed to work primarily by believed to work primarily by preventing sperm from reaching and preventing sperm from reaching and fertilizing the eggfertilizing the egg

10 year efficacy10 year efficacy

irregular menstrual bleeding common irregular menstrual bleeding common in first 3-6 monthsin first 3-6 months

clinician visit required for insertion clinician visit required for insertion and removaland removal

ParaGard® T 380A

Barrier Barrier MethodsMethods

Vaginal spermicides

FC2 Female Condom

Male latex condoms

Male polyurethane

condoms

Factors influencing condom useavailabilityavailabilitypartner negotiationpartner negotiationlow “cost” - reduction in pleasurelow “cost” - reduction in pleasurehigh benefit - partner’s appreciation, belief high benefit - partner’s appreciation, belief that condoms prevent STDsthat condoms prevent STDsfavorable male attitude toward responsibilityfavorable male attitude toward responsibilitycondom use condom use declinesdeclines with age and length of with age and length of the relationshipthe relationship23% of young men (17-22 yr) using condoms 23% of young men (17-22 yr) using condoms report at least one condom break during the report at least one condom break during the previous year => emergency contraceptionprevious year => emergency contraception

Condom use and hormonal contraception

Consistent condom useConsistent condom use

OCsOCs 21%21%

DMPADMPA 18%18%

NorplantNorplant 9% 9%

Condom use at last intercourseCondom use at last intercourse

hormonal contraception - 52%hormonal contraception - 52%

no hormonal contraception - 69%no hormonal contraception - 69%

Adherence

assure privacy and confidentialityassure privacy and confidentiality

discuss options and personal discuss options and personal preferencespreferences

connect to education and employmentconnect to education and employment

counsel about side effectscounsel about side effects

schedule monthly recall visitsschedule monthly recall visits

continue condom use!continue condom use!