Contraception Basics for Health Educators Taylor Starr DO, MPH Assistant Professor Division of Adolescent Medicine Department of Pediatrics Golisano Children’s Hospital The University of Rochester School of Medicine and Dentistry June 2014

Learning Objectives •Review: • Relevant statistics in NY and the US • Female Reproductive Anatomy and Physiology • Confidentiality in NY State

•Categorize contraception methods based on efficacy •Explain: • Mechanism of action of each method • How each method is used • Duration of method • Common side effects of each method • Ways to improve contraception initiation and use 2

Comparing Student Sexual Activity in NY and the U.S.

YRBS Question

NY

US

% students ever had sex

37.9%

46.8%

% students who had sex with at least one person within past 3 months (currently active)

27.9%

34%

% currently sexually active students who used a condom at last sex

63.3%

59.1%

% who did use a method to prevent pregnancy during last sex

87.4%

86.3%

Youth Risk Behavior Survey, 2013 Source: Kann L, Kinchen S, et al. Youth Risk Behavior Surveillance--United States, 2013. Morbidity and Mortality Weekly Report. 2014, June 13;63(4):1-172. http://www.cdc.gov/mmwr/pdf/ss/ss6304.pdf.

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Comparing U.S. Teen Pregnancy Rates in Selected States (2010)

New Hampshire

28

50

Connecticut

44

39

Pennsylvania

49

34

New Jersey

51

32

New York

63

14

New Mexico

80

1

U.S.

57.4

Source:guttmacher.org/pubs/USTPtrends10.pdf

3. Kost (2012).

Causes of Recent Decline in Teen Pregnancy

Analysis concluded that for 15–19 year olds: 86% due to Increase in Contraceptive Use

14% due to Decrease in Sexual Activity

Teen Pregnancy Decline

Source: Santelli J, et al. Am J Public Health. 2007 Jan;97(1):150–6.

Common Misconceptions •If you don’t get periods, you can’t get pregnant •In order to get contraception, you must get a pelvic examination •You can’t get pregnant the first time you have sex •Contraception is dangerous or can make you infertile •Hormonal birth control provides protection against HIV/STIs •Emergency contraception and medical abortion are the same

Female Reproductive Anatomy

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Minors’ Rights to Confidential Reproductive Care in New York State A minor who understands the risks and benefits of proposed and alternative treatments can consent to reproductive health care including: • Pregnancy test • Contraception • Emergency contraception • Abortion • Pregnancy/prenatal care • Labor and delivery • STI testing and treatment 9. Guttmacher Institute (2012). 10. Mount Sinai Adolescent Health Center, NYCLU Reproductive Rights Project, & PRCH (2008).

Contraceptive Options

Duration

Type

Hormone

5/10 years

IUD

Y/N

Progestin/

3 Years

Implant

Y

Progestin only

3 Months

Injection

Y

Progestin only

Monthly

Ring

Y

Estrogen and progestin

Weekly

Patch

Y

Estrogen and progestin

Daily

Combined pills

Y

Estrogen and progestin

Daily

Progestin-only Pill

Y

Progestin only

Each sex

M/F condom

N

Each sex

Diaphragm

N

Each sex

Sponge

N

Each sex

Cervical Cap

N

Each sex

Spermicide

N

Each sex

Withdrawal

N

Each sex

Fertility awareness

N

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Contraceptive Options Extremely effective (prevents pregnancy >99%) • LARC (IUDs, Implant)

Very effective (prevents pregnancy 91-99%) • Injectable progesterone (Depo Provera) “the shot” • Combined hormonal methods (Ring, Patch, Pills)

Moderately effective (prevents pregnancy 81-90%) • Condom, Sponge, Diaphragm, Withdrawal

Effective (Prevents pregnancy up to 80%) • Fertility awareness, Cervical cap, Spermicide

Contraceptive Options Extremely effective

Very effective

Moderately effective

Effective

Effective >99% of the time

Effective >92% of the time

Effective ~80% of the time

Effective up to 75% of the time

Male/Female Sterilization

Injectable Patch

Male/Female Condom

Fertility Awareness

LARC: IUDs

Ring

Withdrawal

Cervical cap

Sponge

Spermicide

&

Implants Source:www.arhp.org

Pills

Diaphragm

Typical Effectiveness of Contraceptive Methods Most effective < 1 pregnancy/ 100 women in 1 year 6−12 pregnancies/ 100 women in 1 year Least effective >17 pregnancies/ 100 women in 1 year

Implant

Injectable

Male Condoms

Vasectomy

Pills

Female Condoms

Spermicides

Female Sterilization

Patch

Sponge

IUC

Ring

Diaphragm

Withdrawal

Fertility Awareness– Based Methods

Trussell J, et al. In: Hatcher RA, et al., eds. Contraceptive Technology. 2011. Chart adapted from WHO 2007.

Birth Control Effectiveness in 10,000 Women Extremely Effective Methods

Pregnancies per year

Nexplanon

5

Male Sterilization

15

Mirena IUD (Progestin)

20

Female Sterilization

50

Paragard (Copper IUD)

80

Methods with lower effectiveness

Pregnancies per Year

Depo-Provera

600

Minipill (progesterone only)

900

Combination Oral Contraceptive Pill

900

Condom

1800

Withdrawal

2200

No Method

8500

Source:www.reproductiveaccess.org

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Extremely Effective

LARC: Long Acting Reversible Contraception

•2 Methods: • IUD • Implant

•Safe, highly effective, long-acting •Cost effective •Rapid return of fertility •Increasing use among adolescents American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 121: Long-acting reversible contraception: Implants and intrauterine devices. Obstet Gynecol. 2011;118(1):184-196. Dean G, Schwarz EB. Intrauterine Contraceptives. In: Hatcher RA TJ, Cates, W., Kowal, D., Policar, M., ed. Contraceptive Technology. 20th ed. New York: Ardent Media; 2011:147-192

Extremely Effective

IUDs Long-acting, reversible, and user-independent

Mirena: progestin

Paragard: copper (no hormone)

• What: T-shaped plastic shaped rod

• What: T-shaped plastic rod

• How to use: Provider places in uterus

• How to use: Provider places in uterus

• Duration: 5 years

• Duration: 10 years

• Mechanism: Inhibits fertilization

• Mechanism: Inhibits fertilization

• Starts working: in 7 days

• Starts working: immediately

• Benefits: Reduced cramping and bleeding

• Benefits: no hormone

• Common Side effects: Amenorrhea

• Common Side effects: Increased

cramping and bleeding

IUD placement: basic steps

Exam: determine position of uterus

Place speculum, clean and stabilize cervix

Measure length of uterus

Adjust IUD insertion tube to measurement of the uterus

Place IUD using IUD insertion tube IUD strings are trimmed to 3 cm

Approximate length of insertion procedure: 5 minutes

18d

IUD Removal

Place the speculum

Visualize and grab the strings

Remove IUD

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Extremely Effective

Implant: NEXPLANON™ Long-acting, reversible, and user-independent

What: thin plastic rod; brand name: NEXPLANON How to Use: Inserted under the skin of upper arm by a healthcare provider Mechanism: Inhibits ovulation Duration: 3 years Starts working: Use back up method for 7 days after insertion Common side effects: change in bleeding pattern • irregular bleeding/nuisance bleeding • amenorrhea

)

Extremely Effective

Position the arm

NEXPLANON™ Insertion

Measure arm for insertion site

Open implant insertion device

Clean the insertion site

Place implant using insertion device

Approximate length of insertion procedure: 1 minute

Palpate implant

Numb the insertion site

Place pressure bandage

Extremely Effective

Nexplanon Removal

Satisfied: a new implant can be placed on day of removal Unsatisfied: provider will remove implant at any time; can start any other method the day of removal 22

Approximate length of removal procedure: 3 minutes

Contraceptive Options Extremely effective

Very effective

Moderately effective

Effective

Effective >99% of the time

Effective >92% of the time

Effective ~80% of the time

Effective up to 75% of the time

Male/Female Sterilization

Injectable Patch

Male/Female Condom

Fertility Awareness

LARC: IUDs

Ring

Withdrawal

Cervical cap

Sponge

Spermicide

&

Implants Source:www.arhp.org

Pills

Diaphragm

Very Effective

Injection: Depo-Provera Somewhat long-acting, reversible, and somewhat user dependent What: intramuscular injection of progestin How to use: provider gives injection in arm or buttock Duration: 3 months (12 weeks) Mechanism: inhibits ovulation Starts working: use condom for 7 days after initial injection Side Effects:

Bleeding: irregular menses 3-6 months then amenorrhea Other: hair loss, weight gain, reversible decreased bone density Depo

If more than 4 weeks late: • use condoms for next 7 days • Use EC within 5 days of unprotected sex

Very Effective

Vaginal Ring:

® NuvaRing

• What: small flexible unfitted ring with estrogen and progestin • How to use: user places in vagina once a month • Duration: 3 weeks • Mechanism: inhibits ovulation • Starts working: depends on cycle; use back up for 7 days • Benefits: more regular, lighter and shorter menses, lower risk of uterine and ovarian cancer • Common side effects: • Estrogen related: breast tenderness, nausea, headaches • Progestin related: bloating, spotting

SourceNuvaRing Prescribing Information. Organon. 2001: Timmer CJ. Clin Pharmacokinet. 2000. Herndon EJ. Am Fam Physician. 2004: Dieben TO. Obstet Gynecol. 2002: Linn ES. Int J Fertil. 2003. et al.

Very Effective

Placing and Removing Ring

Insertion

Removal

Use back-up method for 7 days if: • ring has been in >5 weeks Vaginal Ring • falls out and is not reinserted within 3 hours • ring has been out >7 days

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Very Effective

Transdermal Patch: OrthoEvra® What: beige-colored adhesive patch with estrogen and progestin How to use: user places a patch on clean dry skin weekly Duration: 1 week (9 days of hormone in each patch); change weekly Mechanism: inhibits ovulation Starts working: depends on cycle; use back up for 7 days Benefits: more regular, lighter and shorter menses, lower risk of uterine and ovarian cancer Common side effects: first 2-3 months: nausea, spotting between periods, breast tenderness Source: Abrams LS. Fertil Steril. 2002. Ortho Evra Prescribing Information. Archer DF. Fertil Steril. 2002. Zacur HA, et al. Fertil Steril. 2002. Zieman M. Fertil Steril. 2002. Archer DF. Contraception. 2004. Audet MC. JAMA. 2001.

Very Effective

Transdermal Patch

Placing the Patch

Use back-up method for 1 week if : • Patch falls off and is not reaffixed within 24 hours • patch has been on >9 days • off > 7 days

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Very Effective

Combined Oral Contraceptives

• What: small pill containing estrogen and progestin • How to use: take one pill at the same time daily • Duration: 1 day • Mechanism: inhibits ovulation • Starts working: depends on cycle; use back up for 7 days • Benefits: more regular, lighter and shorter menses, lower risk of uterine and ovarian cancer • Common side effects: first 2-3 months: nausea, spotting between periods, breast tenderness Source: russel J. Contraceptive Technology. 2011.

Very Effective

Combined Oral Contraceptive Pills

Oral Contraceptive Pills

Forgot 1 pill: take missed pill ASAP, continue pack as directed Forgot 2 or more pills: • take last missed pill ASAP, continue pack as directed • Use back up for 7 days 30

Very Effective

Progestin-Only Oral Contraceptives

• What: small pill containing progestin • How to use: take one pill at the same time daily; no placebo week • Duration: 1 day • Mechanism: inhibits ovulation • Starts working: depends on cycle; use back up for 7 days • Benefits: more regular, lighter and shorter menses, lower risk of uterine and ovarian cancer • Common side effects: first 2-3 months: nausea, spotting between periods, breast tenderness Progestin Only Pill

• • •

Forgot one pill: take ASAP If >3 hours late: use condoms for 7 days Forgot 2 pills: take ASAP, continue pack as directed and use condoms for 7 days

Source: Apgar BS. AFP. 2000. WHO MEC. 2004. Contraception Report. 1999. Apgar BS. AFP. 2000. et al.

Contraceptive Options Extremely effective

Very effective

Moderately effective

Effective

Effective >99% of the time

Effective >92% of the time

Effective ~80% of the time

Effective up to 75% of the time

Male/Female Sterilization

Injectable Patch

Male/Female Condom

Fertility Awareness

LARC: IUDs

Ring

Withdrawal

Cervical cap

Sponge

Spermicide

&

Implants Source:www.arhp.org

Pills

Diaphragm

Moderately Effective

Male Condom

•What: single-use protective sheath placed over the penis •Mechanism: barrier method; blocks sperm form reaching the egg •Benefits: one of 2 methods that protect against STIs

Source: Hatzell T. Sex Transm Dis. 2001. Trussel J. Fam Plann Perspect 1994. Trussel J. Contraceptive Technology. 2011.

Moderately Effective

Female Condom

•What: single use loose thin tube with: • closed end with inner ring that covers the cervix • open end with outer ring that stays outside the vagina

•Mechanism: barrier method; blocks sperm from reaching the egg •Benefits: one of 2 methods that protect against STIs

Source: Hatzell T. Sex Transm Dis. 2001. Trussel J. Fam Plann Perspect 1994. Trussel J. Contraceptive Technology. 2011.

Moderately Effective

Inserting and Removing Female Condom

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Moderately Effective

Sponge

• What: single use, small, circular sponge placed over the cervix for contraception • Mechanism: barrier method • How to use: • Sponge can be inserted up to 24 hours before intercourse • It must be left in place for at least six hours after the last sex • It should not be worn for more than 30 hours

in a row

Source: Engender Health. 2005. Trussel J. Contraceptive Technology. 2011.

Moderately Effective

Insertion and Removal of the sponge

INSERTION • Before inserting, wet the sponge with at least two tablespoons of clean water. • Squeeze the sponge to activate spermicide • Fold the sides of the sponge upward and away from the loop; make it look long and narrow • slide the sponge as far back into vagina as possible

REMOVAL • Put a finger inside the vagina and through the loop • Pull the sponge out slowly and gently

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Moderately Effective

Diaphragm

• What: reusable silicone cup that holds spermicide and covers the cervix • Mechanism: barrier method • How to use: • Healthcare provider prescribed the appropriate size • Insert the diaphragm into vagina up to six hours before sex • It must be left in place for at least six hours after the last sex • It should not be worn for more than 24 hours in a row

Source: Fihn SD. JAMA. 1985. D’Oro LC. Genitourin Med. 1994. Trussel J. Contraceptive Technology. 2011.

Moderately Effective

Inserting Diaphragm

39

Moderately Effective

Withdrawal Method

• What: when a man withdraws penis from vagina before ejaculation • Mechanism: prevents sperm form entering vagina

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Contraceptive Options Extremely effective

Very effective

Moderately effective

Effective

Effective >99% of the time

Effective >92% of the time

Effective ~80% of the time

Effective up to 75% of the time

Male/Female Sterilization

Injectable Patch

Male/Female Condom

Fertility Awareness

LARC: IUDs

Ring

Withdrawal

Cervical cap

Sponge

Spermicide

&

Implants Source:www.arhp.org

Pills

Diaphragm

Effective

Cervical Cap • What: reusable silicone cup that holds spermicide and covers the cervix • Mechanism: barrier method • How to use: • Healthcare provider prescribed the appropriate size • Insert the cap into vagina up to 6 hours before sex • It must be left in place for at least six hours after the last sex • It should not be worn for more than 48 hours in a row

Source: RHTP. 2006. FemCap.com. 2004.Trussell J. Contraceptive Technology. 2011.

Effective

Spermicide

•What: gel, cream, foam, film, or suppository placed inside the vagina •Mechanism: stop sperm from moving •How to use: • Used alone, with a barrier method, or other method

Roddy RE. N Engl J Med. 1998. Trussel J. Contraceptive Technology. 2011.

Effective

Fertility Awareness

What: ways to track ovulation to prevent pregnancy How to use: • Calendar Method: chart cycles on a calendar • Temperature Method: take your temperature in the morning daily • Cervical Mucus Method: check the changes in cervical mucus every day for the first part of your cycle until ovulation

Mechanism: keep sperm out of vagina in days near ovulation

Source: Arevalo M. Contraception. 2002. CycleBeads Product Information.

Emergency Contraception • What: used after unprotected sex to prevent pregnancy • How to use: • take medication within 3-5 days of unprotected sex, or • Have copper IUD placed within 5 days of unprotected sex

• Mechanism: • Levonorgestrel (LNG): high dose progestin that delays ovulation • Ulipristal Acetate: progesterone receptor modulator

• Common side effects: delayed menses, spotting

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Emergency Contraception

Trussell 2011; www.not-2-late.com; www.rhtp.org; Piaggio G. Lancet. 1999. Task Force on Postovulatory Methods. Lancet. 1998. Grimes DA. Ann Intern Med. 2002. Croxatto HB. Contraceptin 2001. Raine T. Obstet Gynecol. 2000. Gold MA. J Pediatr Adolesc Gynecol. 2004. Grimes DA. Ann Intern Med. 2002.

Emergency Contraception Pill Options Oral Progestin: • Plan B One-Step: 1 pill by mouth • Plan B: 2 pills by mouth • More effective the sooner it is taken (within 72 hours) • Over the counter or by prescription

Progesterone receptor antagonist: Ullipristal Acetate • Current brand name is Ella • Maintains efficacy over 120 hours • By prescription only • More effective for women 155-194 pounds

Emergency Contraception Website: www.not-2-late.com

Improving Contraceptive Management: Advanced EC Prescription Key Points: • Recommended for all sexually active females not on LARC • Does not increase risk taking behaviors • Increases EC use and decreases time to EC use after

unprotected sex • No limit to number of times a patient can use EC • Not as effective as preventive (before sex) contraception American College of Obstetricians and Gynecologists. Practice Bulletin No. 112: Emergency contraception. Obstet Gynecol. 2010;115(5):1100-1109. Gold MA, Wolford JE, Smith KA, Parker AM. The effects of advance provision of emergency contraception on adolescent women's sexual and contraceptive behaviors. J Pediatr Adolesc Gynecol. 2004;17(2):87-96. Polis CB, Schaffer K, Blanchard K, Glasier A, Harper CC, Grimes DA. Advance provision of emergency contraception for pregnancy prevention: a meta-analysis. Obstet Gynecol. 2007;110(6):1379-1388.

Improving Contraceptive Initiation: Quick start •Key Points: • Opportunity to provide contraception at times of high

motivation • No need to wait for menses to begin method • Initiate contraception immediately regardless of LMP or recent sex • Use back-up method for 7 days

Lara-Torre E. Contraception. 2002. Leeman L. Obstet Gynecol Clin N Am. 2007. Westoff C. Contraception. 2002.

Dual Method Use •What: Use of a condom plus another contraceptive •Goal: May dramatically reduce the risk of both pregnancy and STIs

40. Cates & Steiner (2002). 41. Warner & Steiner (2011).

Decreasing Barriers to Contraception Pregnancy test Pelvic exam Pap smear STI screening

Source: Leeman L. Obstet Gynecol Clin N Am. 2007

Start Birth Control Education With Highly Effective Methods Extremely effective

Very effective

Moderately effective

Effective

Effective >99% of the time

Effective >92% of the time

Effective ~80% of the time

Effective up to 75% of the time

Male/Female Sterilization

Injectable Patch

Male/Female Condom

Fertility Awareness

LARC: IUDs

Ring

Withdrawal

Cervical cap

Sponge

Spermicide

&

Implants Source:www.arhp.org

Pills

Diaphragm

Resources •www.reproductiveaccess.org •www.plannedparenthood.org •cdc.gov •youngwomenshealth.org •youngmenshealthsite.org

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