Contraception through the ages

Report
Contraception
Update
CONTRACEPTION THROUGH
THE AGES
Ulrike Sauer
Lead for Brent Contraceptive Services
Consultant in Sexual & Reproductive Health
Margaret Pyke Centre
May 2014
Objectives
Definition of Sexual health and rights
Choices of Contraception
• LARC
• What has remained the same?
• What is new?
• COC :Influences decision making
• Choices of Contraception in the different stages
of reproductive life
Definition of Sexual Health
…..” a state of physical, emotional, mental and social well-being in relation
to sexuality; it is not merely the absence of disease, dysfunction or
infirmity.
Sexual health requires a positive and respectful approach to sexuality and sexual
relationships, as well as the possibility of having pleasurable and safe sexual
experiences, free of coercion, discrimination and violence.
For sexual health to be attained and maintained, the sexual rights of all persons
must be respected, protected and fulfilled.”
WHO, 2006
Definition of Sexual Rights
“The fulfilment of sexual health is tied to the extent to which
human rights are respected, protected and fulfilled.
Sexual rights embrace certain human rights that are already
recognized in international and regional human rights
documents and other consensus documents and in national
laws.
….
includes
the right to decide the number and spacing of one's children
Choices of Contraception
in the different stages
of reproductive life
Puberty to first sexual intercourse
First sexual intercourse until childbirth
Perimenopausal
Spacing pregnancies after breast feeding
During breast feeding
Completed family
What has remained the same
 Contraception is one of the most liberating
interventions we have on offer for women.
 Contraception is good for women’s health
 Contraception is cost saving.
 For every £1 invested £11 are saved.
Long acting reversible
contraception
 Why LARC?
 Influences decision and update



IUD/IUS :New inserter for IUS and new
IUS
DMPA :late injections
Nexplanon
Why LARC ?
70
60
50
40
16-19
30
20-24
20
30-34
10
40-44
0
Contraception & Sexual Health, Office for National Statistics 2006-7
The pill is highly effective and with
perfect use has a failure rate of 0.3% in
the first year.1
But in practice failure is much higher—
closer to 8% or 9%.2
1 Trussell J. Contraceptive failure in the United States. Contraception 2004;70:89-96.
2 Kost K, Singh S, Vaughan B, Trussell J, Bankole A. Estimates of contraceptive failure from the 2002 national survey of family growth.
Contraception 2008;77:10-21.
Cost per year
Cost per month
CVR
Patch
COC
POP
Injectable
Implant
IUT
Nuvaring
£9.00
EVRA
£5.42
Cilest
< £1
Cerazette
£2.95
Depo
provera
£1.67
Implanon
£6.75
TT 380
Slimline
£0.98
Rigdevidon
< £ 1.00
Microgynon
£1.00
Femulen
£1.10
Micronor
£0.59
Yasmin
£4.90
Norgeston
£0.78
Mirena
£6.93
NICE guideline LARC
If 7% of women switched from the pill to
LARC methods
(doubling current usage to 15%)
the NHS could save approx. £100million
each year
by reducing unplanned pregnancies by 73,000
Accidental pregnancy in first year of use
%
LARC
Trussell J. Contraceptive efficacy. In: Hatcher RA, Trussell J, Stewart R. Contraceptive Technology, ed 17. NY: Ardent Media, 1998;800-801
Department of Health :
A Framework for Sexual Health Improvement in England
 Teenage pregnancy rates have fallen to their lowest
levels since record began
 The use of LARC has increased : 28% from
community contraception-service users in 2012/13
from 18% in 2003/2004
( Office for National statistics 2013)
( NHS Contraceptive services – England 2011-12, NHS Information Centre for
Health and Social Care )
but
 Up to 50% of pregnancies are still unplanned
 Condom and pill remain the most popular method of
contraception
Myth and Misconception
IUDs are not only for women who....
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
IUD/IUS can travel and reach the brain
IUDs are abortifacients
IUSs provide Relief for Women Suffering from Excessive
Bleeding
Breast cancer is a contraindication for IUD use
IUD/IUS increase the risk for pelvic inflammatory disease
(PID)
IUD/IUS increase the risk of sexually transmitted infections
(STIs)
IUD/IUS increase the risk of ectopic pregnancy
IUSs can’t be used as emergency contraception
IUD/IUS are only for women who have completed their
childbearing
Nulliparity is a contraindication for IUDso IUD /IUS use
Questions
1. No
2. No
3. Yes
4. No
5. No
6. No
7. No
8. Yes
9. No
10. No
yes or no
IUD/IUS Answers
 IUS/Mirena Provides Relief for Women Suffering from
Excessive Bleeding 7 In one study, only one out of 19 women
diagnosed with anemia at the insertion of Mirena still had this
condition after one year of use.9
 IUD Provide Viable Options for Women Whose Health
Conditions Limit Other Forms of Hormonal Contraceptives.
Some health conditions, including venous thromboembolism,
severe dyslipidemia, liver disease, estrogen-dependent tumors, or
poorly controlled hypertension prevent women from being able to
use other forms of contraceptives. IUDs provide a viable option for
these women.10
 Just IUDs but not IUS can be used as emergency contraception
IUD problems
 Perforation
 Expulsion
 Malposition
 Infection
IUD - Infection
 IUD/IUS do not cause pelvic infection
 Risk higher than background only in three weeks after
insertion (1:1000 with screening)
 Select women at low risk of STIs
 Take sexual history
 Screen for infection: chlamydia (+_ N gonorrhoea)
 Or consider prophylactic antibiotics
 If infection with IUD in situ, treat as PID, do not need
to remove IUD (NB Pregnancy risk)
Farley TM et al. Lancet 1992; 339: 785-88 FFPRHC Recommendations for Practice IUD 2004
IUD/IUS and Ectopic pregnancy
• Incidence of ectopic pregnancy 0.02 per 100 woman
years.
• This represents an 80-90% reduction
in risk compared with women not
using contraception.
• Between 5-50% of conceptions
with the LNG IUS are ectopic.
What is new?- EVOinserter
What is different about this inserter?
 The threads are now inside the inserter handle thereby eliminating
the handling of threads
 The diameter of the insertion tube has been
reduced from 4.8mm to 4.4mm
 There is now a centimetre scale on both sides
 The LNG-IUS cannot be reloaded into
the inserter if it is released prematurely
What is new – IUS Jaydess®
www.fsrh.org/pdfs/CEUProductReviewJaydess.pdf
What is new – IUS Jaydess®
Insertion tube
diameter
Duration of use
Dose
Indications
Jaydess®
Mirena®
3.80mm
4.40mm
3 years
13.5mg
Contraception
5 years
52mg
Contraception
Idiopathic
menorrhagia
Endometrial
protection in HRT
In theory Jaydess may be easier to insert and result in less pain at insertion than
Mirena but there have been no comparisons with the currently available Mirena
product
What is new – IUS Jaydess®
 Women using Jaydess are less likely to experience amenorrhoea
 Higher failure rates and ectopic pregnancy rates have been reported in
some trials of Jaydess but numbers are currently too small to confirm a
significant difference
 Jaydess contains a silver ring (table 1) which distinguishes it from other
intrauterine devices on ultrasound scan or x-ray
 The safety and efficacy of Jaydess have not been studied in women aged
below 18 years
 The Summary of Product Characteristics (SPC) for Jaydess states that it
is not first choice for contraception in nulliparous women as clinical
experience is limited
DMPA: nothing new just a
refresher of Late attenders
 No additional precautions if up to 14 weeks –
WHO & FRSH
 12 weeks plus 5 days – Manufacturers
 Over 14 weeks, consider giving DMPA at same time
as emergency contraception
 Long-term carbamazepine, phenytoin, primidone
& sodium valproate associated with loss of BMD &
fracture
Nexplanon
•Single
semi-rigid rod 40x2mm
•Releases
•No
30-40µg etonogestrel daily
skin incision required
•Lasts
3 years
•Radio-opaque
(Xray, CT as well as USS, MRI)
Acceptability and user perceptions
43% of women stop using the SDI within
three years;
33% because of irregular bleeding
UK Medical Eligibility Criteria (UKMEC)
UKMEC
Category
1
A condition for which there is no restriction for
the use of the method
2
A condition where the advantages of using the
method generally outweigh the theoretical
or proven risks
3
A condition where the theoretical or proven
risks usually outweigh the advantages
4
A condition which represents an unacceptable
health risk if the method is used
UKMEC guidance for LARC
use according to age
UKMEC guidance
 Depo – menarche to < 18 yrs = 2
18 to 45 yrs = 1
>45 yrs = 2
 Nexplanon - menarche to >45 yrs = 1
 IUD – menarche to < 20 yrs = 2
> 20 yrs = 1
 IUS ( Mirena) - menarche to < 20 yrs = 2
> 20 yrs = 1
Other reversible contraception
Influences decision


Combined hormonal contraception
Condoms
Acne , Hirsutism
The pill gives you
pimples, makes your
hair oily and makes you
hairy
 Young people may be advised that
combined oral contraception
(COC) use can improve acne.
 Young women whose acne fails to
improve with COC may wish to
consider switching to a COC
containing a less androgenic
progestogen or one with a higher
estrogen content.
 Young people should be advised
that the progestogen-only implant
may be associated with
improvement, worsening or onset
of acne.
WEIGHT
Taking the Pill
causes weight
gain”
“
 The limited data that exist
suggest no clear effect on weight
with COC use, and there is
currently insufficient evidence
to prove a clear causal
association between most other
hormonal contraceptives and
weight gain
 except depot
medroxyprogesterone acetate
(DMPA) use may be associated
with a gain of 2–3 kg in weight
over 1 year
Smoking
You can not take
hormones when
you are a smoker
“COC can be used by women aged <35
years who smoke.
Excess mortality in heavy smokers becomes
apparent from the age of 35 years,
accounting for 0.7 deaths per 1000 womanyears “.
“POC (progestogen-only contraception)
does not appear to
increase the risk of stroke or MI, and there
is little or no increase in venous
thromboembolism risk”
Vessey M, Painter R, Yeates D. Mortality in relation to oral
contraceptive use and cigarette smoking. Lancet 2003; 362: 185–191.
Faculty of Family Planning & Reproductive Health Care
Clinical Guidance Contraception for Women Aged Over 40 Years
Cancer
The pill can cause
cancer
 A large UK cohort study has shown that oral
contraception use is not associated with an
overall increased risk of cancer, and indeed
oral contraception may reduce overall
cancer risk.
 Research suggests that women taking the
combined contraceptive pill have a lower risk
of ovarian cancer than the general
population. ...The pill is also protective
against endometrial cancer, but can slightly
raise the short-term risk of breast cancer
and cervical cancer
BMJ. 2010;340:c927.
 The evidence with regard to cancer risk and
progestogen-only methods is more limited.
There are no consistent associations between
use of POP or injectable progestogens and
breast cancer incidence. No studies were
indentified in relation to use of the LNG-IUS or
progestogen-only implant and risk of breast
cancer in young women. As with other
progestogen-only methods, any attributable
risk is likely to be very small.
Hormone withdrawal symptoms
“The few studies that reported menstrual symptoms found that the
extended cycle group fared better in terms of headaches, genital
irritation, tiredness, bloating, and menstrual pain” 2
2.Edelman AB, Gallo MF, Jensen JT, Nichols MD, Schulz KF, Grimes DA. Continuous or
extended cycle versus cyclic use of combined oral contraceptives for contraception.
Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD004695.
DOI:10.1002/14651858.CD004695.pub2.
Drawbacks of the 21/7 regimen 1
 Hormone withdrawal symptoms
 Lack of pituitary–ovarian suppression
 Unnecessary withdrawal bleeding
1.Patricia J Sulak, Continuous oral contraception: changing times, Best
Practice & Research Clinical Obstetrics and Gynaecology (2007),
doi:10.1016/j.bpobgyn.2007.08.004
2.Edelman AB, Gallo MF, Jensen JT, Nichols MD, Schulz KF, Grimes DA. Continuous or
extended cycle versus cyclic use of combined
oral contraceptives for contraception. Cochrane Database of Systematic Reviews 2005,
Issue 3. Art. No.: CD004695. DOI:
10.1002/14651858.CD004695.pub2.
Modifying the 21/7 OC regimen
 Shortening the 7-day HFI 24/4
 Reducing the frequency of the 7-day HFI ( tricycle)
 Eliminating the 7-day HFI
 Adding oestrogen to the 7-day HFI
Take pill every day until you are
bleeding for 3 consecutive days
Than stop the pill for
Tailored regimens of
Combined hormonal
contraception
Condom myth
It's the man's
responsibility to
bring and wear a
condom
I can not use condoms
because I am too big /
I am allergic, etc
2 condoms
are better
than 1.
CONDOMS
PROTECT
AGAINST ALL
STIS
condoms
always break
and don’t
really work
Condoms have small
holes that allow
disease, infection, and
semen through.
Choices of Contraception
in the different stages
of reproductive life
Puberty to first sexual intercourse
• Contraception used for its non-contraceptive benefits
• Sex Education:
promoting the possibility of having pleasurable and safe
sexual experiences
Choices of Contraception
in the different stages
of reproductive life
Full choices
IUD/IUS can be fitted if nulliparous
Depo – fertility return time variable
If adolescent – remember Depo and bone
density
Remember safe sex message
Breastfeeding





All LARC methods could be used if no contraindications
Depo = UKMEC 2 if <6 weeks postpartum
IUD / IUS = UKMEC 3 if 48 hours – 4/52 postpartum
CHC contraindicated
Lactational amenorrhoea – if exclusively breast feeding
including night time feeds – 98% effective
Choices of Contraception
in the different stages
of reproductive life
•
•
•
•
•
•
Perimenopause
Still need for contraception
HRT is not contraceptive
IUS may be used as part of HRT regime –
endometrial protection, licensed for 4 years
use
Stop Depo at age 50 yrs – risk of osteoporosis
Nexplanon/IUS – use FSH to determine when
to stop contraception
Safer sex message – increase in incidence of
STI in divorced, newly single older people
http://www.fpa.org.uk/helpandadvice/mycont
raceptiontool
http://www.fpa.org.uk/helpandadvice/
mycontraceptiontool
let's put birth control back on the agenda transcript
….
But one of the simplest and most transformative
things we can do is to give everybody access to birth
control methods
http://www.gatesfoundation.org/media-center/speeches/2012/04/melinda-gates-tedxchange-the-big-picture
Melinda Gates
Contact details
[email protected]
m: 07525045391
Questions?
Thank you

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