11/08/2015

Synopsis

CONTRACEPTION: CHOICES & OPTIONS By

Dr Uche A Menakaya JUNIC Specialist Imaging & Women's Center Canberra, Australia

Unintended Pregnancy In Australia 51% of women responding to an Australian online survey indicated they had experienced an unplanned pregnancy At the time of their unplanned pregnancy 63% were aged 24 years or younger

Approximately unplanned in Australia each year 60% were 200,000 using at least one formpregnancies of contraception

21% of those were using more than one contraception method

Unintended Pregnancy & Motherhood Interrupts education and uptake of work opportunities Unexpected financial burden on the woman and her partner

Overview of unintended pregnancies/abortion Communicating contraception Contraceptive options Evidence for LARC in Young Women

Acknowledge The Contributions Of Lynda Olive (MSD) And Jenny Leung In The Preparation of this Presentation

Outcomes Of Unintended Pregnancies OUTCOME

PERCENTAGE

MOTHERHOOD

56%

TERMINATIONS

29%

MISCARRIAGE

13%

ADOPTION

2%

Termination In Australia 1 in 4 pregnancies in Australia, Mostly first Trimester Abortion rate in 2003 was 19.7 per 1,000 women ( 15 - 44 yrs) statistics provide conservative estimate of There Medicare are approximately 75,000aabortions annually in Australia elective terminations of pregnancy

Unplanned babies are at greater risk of adverse health outcomes Higher risk of falling into or remaining in poverty

Medicare statistics do not include abortions performed in

The third highest in the developed world public hospitals

In 2012, there were 61,593 rebates claimed for abortions performed

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Contraception: Sub optimal Uptake? Didn’t think they would get pregnant

Side effects and contraindications Lack of partner support for contraception

EFFECTIVE COMMUNICATION /COUNSELLING

Embarrassed to ask Judgment affected by alcohol/drugs Abuse/assault Cost

Applying ESP in Contraception

Effective Communication Explore / Share / Promote positive behaviours Motivational Interviewing developed in 1970s by William Miller to address problem drinking

Essentials Empathy and Reflective listening Identifying discrepancies between behaviours and broader goals Avoidance of confrontation/ argumentation Roll with resistance Support self-confidence by increasing perceptions of ability to change 1. Petersen R et al. Contraception 2004;69(3): 213-217.

Explore any discrepancies between pregnancy intentions and contraceptive use Desire to achieve or avoid pregnancy Perceived risk of STIs Contraceptive likes/dislikes Consistency of use What are some of the things that make it hard for you to use contraception?

Share information on physiology and contraceptive method use Promote behaviours that reduce risk of unintended pregnancy/STIs 1. Petersen R et al. Contraception 2004;69(3): 213-217.

Steps for Effective Contraceptive Counselling Tailor the counselling to the age and previous experiences Education on transmission of STD Anticipatory counselling in reference to side effects Cover non-contraceptive benefits of hormonal contraception Counter prevailing myths 1. Fraser I S and Kovacs GT. MJA 2003; 178 (12): 621-623.

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Importance Of Informed Choice

Medical Eligibility Criteria for the safe provision of contraception

Every patient has the right to receive accurate, balanced and comprehensive information

MEC 1: No restriction on use of the method

The increasing number of options increases the difficulty and responsibility for practitioners to provide full information

MEC 2: Advantages generally outweigh the theoretical or proven risks

Contraceptive misuse is often a consequence of a lack of information and support Contraception will be discontinued if women feel their opinions have not been heard

Case study 1: Saida

Hypothetical patient

Saida is a 23 year old woman requesting a repeat prescription of her combined contraceptive pill

MEC 3: Theoretical or proven risks generally outweigh the advantages. Requires expert clinical judgement MEC 4: Unacceptable risk if the method is used

Medical Eligibility Criteria (1)

On further questioning she tells you she is 1 week post partum and not keen to breast feed. She used the COCP previously and is happy to get back on it as soon as possible. She is a non-smoker, has no significant medical or surgical history and takes no regular medications. Her BMI is normal.

How would you manage this consultation?

Medical Eligibility Criteria (2)

Medical Eligibility Criteria (3)

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Case study 2: Leonie Leonie is 18 year old presents wanting to discuss her contraceptive options.

Contraceptive options: Advantages & Disadvantages

Which method do you feel most comfortable prescribing/recommending as the sole method of contraception?      

Combined hormonal contraceptive (pill or ring) Progestogen only pill Contraceptive implant IUD Contraceptive injection Non hormonal barrier options – condoms diaphragms

What factors would influence your decision?

Condoms are the best protection against STIs but have a typical ‘contraceptive’ failure rate of 18% in the first year of use The failure rate includes failure to use them for every episode of intercourse1

Use Of Condoms/Contraception At First Intercourse

16.7% males, 15.1% females for those born 1940-1950 used a condom1

Safer sex option

EMERGENCY CONTRACEPTION Case study 3: Jane Jane is a 22 year old student who presents to her pharmacist for emergency contraception. She now presents to you. She is in a long-term relationship but ran out of condoms and had unprotected sex two days ago. She has a past history of two terminations.

First intercourse/Use of Contraception 100 90 80 70 60 50 40 30 20 10 0 18-29

Doubling up with another effective contraceptive method can reduce the risk of both pregnancy and STIs – this is known as dual protection Chlamydia World wide 2008 106 million new cases:15 – 49yrs Direct lifetime cost 2013 >$500 million USD

Adapted from Boyle FM et al. 20031

70.5% males, 73.5% females for those born 1970-1981 used a condom1 % of Respondents

Doubling Up With Condoms And An Effective Contraceptive Method

30-39 40-49 Age in the year 2000

50-59

Males - Condom Used

Males - Contraception Used

Females - Condom Used

Females - Contraception Used

Adolescents who use condoms at their sexual debut are more likely to use condoms in later sexual encounters and experience fewer STIs than those who don’t.

Emergency Contraception With Levonorgestrel • Easy dosage schedule • No prescription required

Candelays be used ovulation any time in the Levonorgestrel prevents• or bycycle interfering with Advantages tolerated with low incidence of side effects follicular development •• Well Can be supplied in advance by a pharmacist or with a script from a doctor

• Estimated percentage of pregnancies prevented – 85% • Costotherwise may be prohibitive some women (pregnancies that would haveforoccurred if no method • Effectiveness decreases with time (proven effectiveness used) to 96 hours)

STAT DOSE

DIVIDED DOSE Disadvantages

• Does not provide ongoing contraception

1.5mgof tablet • Affected byNorLevo®, liver enzymePostinor®-2) drugs 21 xdoses 0.75mg  Approved for use (Levonelle®-2, for up to 72 hours after inducing unprotected sex • Non-menstrual bleed may be mistaken for menses

(Levonelle®-1, Postinor®-1) taken 12 hours NorLevo®-1, apart or Each dose made up of a single 0.75mg tablet or 25 Microlut® (Levonelle®-2, NorLevo®, Postinor®-2) progestogen only pills)

 No2 Xlimit to the number of times it can be taken in a cycle 0.75mg tablets

What information would be useful for Jane?

1. Family Planning NSW, QLD and VIC. 2012. Contraception: an Australian Clinical Practice Handbook. 3rd Edition. Sexual Health and Family Planning Australia.

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Emergency Contraception with a Copper IUD • Highly effective up to 120 hours following Insertion of a Copper IUD interferes with sperm movement, inhibits intercourse Advantages fertilization by direct•toxicity and mayforalso prevent implantation of a fertilised May used ongoing If Insert reasonably up to Day certain 12 ofbe about the cycle the timing or within ofcontraception ovulation, 5 days of insert the first up to ovum. • earliest Not affected by drug interactions or GI is problems 5episode days after of unprotected the sex predicted for theovulation cycle, whichever or within 5 later. days of • Inserted removed so the first unprotected sexand episode for by thetrained whichever isthat Estimated percentage of pregnancies prevented –cycle, (99%practitioner pregnancies access to this method wouldlater otherwise have significant occurred iflimitations no methodtoused) • Contraindications as for Copper IUDs Disadvantages • Cost may be prohibitive some women To completely exclude the possibility of existingforimplantation, instructions for timing of insertion are based on very conservative estimates.

Day 7 of the cycle is used as the earliest day of fertile ovulation and 5 days are allowed for implantation 1. Family Planning NSW, QLD and VIC. 2012. Contraception: an Australian Clinical Practice Handbook. 3rd Edition. Sexual Health and Family Planning Australia.

Vaginal Ring Contraceptive Advantages vs vs. COCs Disadvantages COCs •• • • • ••

Women unablecombined to obtain hormonal a supply ofcontraceptive more than 4 months a time1 An alternative deliveryatsystem May cause local device related symptoms eg. increased 1 physiological vaginal or discomfort Non-daily action may discharge improve compliance Occasionally accidently expelled May bewomen useful dislike for women with IBD of or vaginal other malabsorption conditions1 Some self-insertion ring

• Requires user to remember to insert a new ring after the ring-free 1 • Extra precautions not needed if there is vomiting or severe diarrhoea break (Can sign into SMS Mobile phone reminder system) Not available the PBS bleeding compared to 30µg •• May have lessonbreakthrough ethinyloestradiol/150µg levonorgestrel COC2

Combined Oral Contraceptives Disadvantages Advantages •• Higher typical-use failure ratesuse Very effective with correct • Readily available • Are relatively expensive in some formulations (Some are not PBS • Easily reversible listed) • Predictable withdrawal bleeds / ability to manipulate cyclesrare, but serious risks, including venous thromboembolism • Have • (VTE) Can be to disease, manageasmenstrual andused arterial a result of problems containing oestrogen • Most improve acne • Personal and family history are particularly important

• Have limited use with some common conditions e.g. migraine with aura (MEC4) and body mass index (BMI) ≥ 35kg/m2 (MEC 3) 1. Family Planning NSW, QLD and VIC. 2012. Contraception: an Australian Clinical Practice Handbook. 3rd Edition. Sexual Health and Family Planning Australia.

Progestogen-only Pills Advantages Disadvantages • Few contraindications / Readily accessible / Easily

Must be taken at the same time each day to maintain effectiveness reversible

• Oral option for women May be less appropriate for women who find it difficult to adhere to • with medicalpillcontraindications to oestrogen containing precise scheduled taking contraceptives • who experience oestrogen side effects

May unpredictable bleeding patterns • cause who are breastfeeding

Provide no protection from STIs but cantobeother used with condoms • Shorter time to onset compared hormonal

methods

• Available on the PBS

IUDs (1)

Contraceptive implant Advantages Disadvantages • Highly effective with minimal action required by the woman • Require procedure for insertion/removal • Long duration of action - up to 3 years / cost effective over time Optioninforbleeding women… • • Changes patters in all users • with medical contraindications to oestrogen • Specific complications associated with procedure • who experience oestrogen-related side-effects with IBDfrom or other malabsorptive conditions • No• protection STIs but can be combined with condoms as required • Results in amenorrhoea in around 20% - may be seen as an advantage • Initial costs can reduce access for some women • May be useful for women with dysmenorrhoea Available on implant the PBS • • Small risk of the moving a short distance from original position • May be difficult to removal, particularly if initially inserted deeply

Disadvantages Advantages •• Procedure required forlong-acting insertion/removal Highly effective, very with minimal action required by user •• Specific associated the procedure Rapidly complications reversible once device is with removed •• • • •

Relativelymay inexpensive over time because offor long duration of use Insertion be moderately uncomfortable some women Good alternative to sterilization Expulsion may occur - sometimes unrecognized May be useful for women with IBD, or other malabsorption conditions

•• Requires medical intervention discontinue Can be used in women takingtoliver enzyme inducing drugs •• • •

An alternative to contraceptives containing oestrogen Provides no protection against STIs Can be used during breastfeeding without effect on breast milk or infant May have upfront costs that reduces access for some women development

1. Family Planning NSW, QLD and VIC. 2012. Contraception: an Australian Clinical Practice Handbook. 3rd Edition. Sexual Health and Family Planning Australia.

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IUDs (2)

Contraceptive Injection

Advantages Cu-IUD/LNG-IUD Only Cu-IUD only • Good choice for women where hormonal methods are contraindicated or for women looking for a non-hormonal method • Can be used as EC if inserted within 120 hours after UPSI • Is immediately effective in action Levonorgestrel-IUD only • Delivers reduction in menstrual bleeding over time • Particularly suited for women requiring management of heavy menstrual bleeding or for those who find increased bleeding to be a problem with Copper IUDs

Advantages Disadvantages • Highly effective LARC /Undetectable by other people •• Cannot be reversed withdrawn once givenenzyme inducing drugs No increased risk of or failure with use of liver

cause amenorrhoea - may be a desirable •• Commonly May delay the return to fertility after cessation of use outcome for some • Can be used to manage appropriately investigated menstrual problems •• May produce unacceptable vaginal bleeding patterns An option for women medical contraindications to oestrogen • •Maywith cause a decrease in bone density that is likely to be reversible • who experience oestrogen related side-effects e.g. nausea/breast tenderness Provides no protection from STIs canother be combined with condoms •• May be useful for women with IBD- or malabsorptive conditions • Available on the PBS 1. Family Planning NSW, QLD and VIC. 2012. Contraception: an Australian Clinical Practice Handbook. 3rd Edition. Sexual Health and Family Planning Australia.

Why LARC In Young People?

LONG ACTING REVERSIBLE CONTRACEPTION FOR YOUNG PATIENT

The Contraceptive Method Used Influences The Unintended Pregnancy Rate Women who experience pregnancy during the first year of use: Data are estimations for first year of typical use of the method. Based on US Survey Data1. Not head-to-head studies

Emergency contraception used Higher background fertilityrarely in young women An average of 18 acts of unprotected intercourse leading up conception in a study of US women seeking an abortion3 Pill tocompliance 47% of pillforusers in a study reported missing one or more pills Reasons unprotected intercourse: per cycle thinking one could not get pregnant (42%) procuring a contraceptive method (40%) Condom difficulties failures a typical ‘contraceptive’ failure rate of 18% in the first year of not planning to have sex (38%) use

The Contraceptive Method Used Influences The Continuation Rates Estimates of continuation rates at one year with typical use Based on US Survey Data1. Not head-to-head studies

Women, %

Male condom 100 90 80 70 60 50 40 30 20 10 0

85%

43%

Combined pill and progestogen only pill

67%

Levonorgestrel IUS

80%

Depot medroxyprogesterone 18% 0.05%

0.2%

0.8%

Implant

IUS- LNG

IUD -Copper

6%

56%

Implant

9%

84% 0

Injectable

OC

Male Condoms

No Contraception

Adapted from Trussell J. 20111 These estimates were derived from the experience of women in the 1995 National Survey of Family Growth (NSFG) or the 1995 and 2002 NSFGs Estimates of first-year continuation rates for methods of contraception available in the United States.

OC = oral contraceptive (progestogen-only and combined pills); IUD = intrauterine device. IUS-LNG = intrauterine system-levonorgestrel

10

20

30

40

50

60

70

80

90

% of women continuing use

Adapted from Trussell J. 20111 These estimates were derived from the experience of women in the 1995 National Survey of Family Growth (NSFG) or the 1995 and 2002 NSFGs Estimates of first-year continuation rates for methods of contraception available in the United States.

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1999 Teenage Pregnancy Strategy

The UK Policy Initiative: Teenage Pregnancy Strategy

Conception rates/abortion rates and LARC usage in the UK Conception Rate/Crude Abortion Rate/LARC Usage in girls under 18 Crude Abortion Rate/ 1,000 girls

LARC Usage in thousand cycles sold

50

2000

45

1800

40

1600

35

1400

30

1200

25

1000

20

800

15

600

10

400

5

200

0

LARC Usage in thousand cycles sold

Conception Rate/Crude Abortion Rate

Conception Rate/ 1,000 girls

0 1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

The Contraceptive Choice Project  Over 9,000 women aged 14-45 who wished to avoid  Young women under the age of 21 were also pregnancy were counselled regarding all reversible interested inmethods the IUD available and implant. contraceptive and then offered any method they wanted, at no cost 75% chose  >40% of young women 14-17LARC years chose the implant.  Women who chose short acting methods were 20 times more likely to experience an unplanned pregnancy than those using LARC  >40% of young women 18-20 years chose an IUD.  Under 20s using short acting methods were twice as likely to experience failure as older women

The Contraceptive Choice Project 2007 - 2011 To Remove The Financial Barriers To Contraception, Promote The Most Effective Methods Of Birth Control Reduce Unintended Pregnancy

The Contraceptive Choice Project  Unplanned Pregnancy rate12 months: Continuation rate at Choice Participants 35/1000  LARC = 86% Background rate 52/1000  Short acting methods = 55%  Abortion rate

 Continuation rateParticipants at 24 months: Choice 6/1000

 LARC = 77% Background rate 20/1000  Short acting methods = 41%

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The Contraceptive Choice Project Teen Pregnancy rate:  Choice participants 34/1000 Teen Background 158/1000 birthraterate:

Choice Participants 19.4/1000 Background rate rate: 94/1000 Teen Abortion Choice Participants 9.7/1000 Background rate 41.5/1000

1.

Family Planning Alliance Australia. Long acting reversible contraception (LARC): Position statement. Available from: http://www.fpv.org.au/assets/FPAA-LARC-Position-Statement-FINALOctober-2014.pdf Accessed on: 3.12.14

LARC Use In Australia  Less than 10% of Australian women use long acting methods  Less than 1/6 contraceptive consultations involved LARC “Multiple factors influence a woman’s decision to use contraceptive LARC, including accessinvolve lack ofthe awareness  7/10 consults combined and contraceptive information aspill well as misconceptions about oral their safety and side effects”

THANK YOU

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