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Patient-centered Contraception

Patient-centered Contraception. Nearly half of pregnancies in the United States are unintended. Approximately 6.4 million pregnancies per year. Outcomes of Unintended Pregnancies Approximately 3.0 Million Annually.

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Patient-centered Contraception

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  1. Patient-centered Contraception

  2. Nearly half of pregnancies in the United States are unintended. Approximately 6.4 million pregnancies per year

  3. Outcomes of Unintended PregnanciesApproximately 3.0 Million Annually

  4. Most unintended pregnancies occur when women fail to use contraceptives or use their method inconsistently.

  5. Half of women at risk are not fully protected from unintended pregnancy. 28 million U.S. women at risk for unintended pregnancy

  6. Unintended pregnancy rate by race/ethnicity/income Unintended pregnancies per 1,000 women

  7. Why do women experience unintended pregnancies?

  8. Effectiveness Group Family Planning Method Typical-Use Rate of Pregnancy Perfect-Use Rate of Pregnancy Efficacy: Numbers & Categories Table“Less Effective Methods” No Method No method 85% 85% Less effective Male latex condoms 14% 3% Diaphragm 20% 6 Cervical cap 20%-40% 9%-26% Female condoms 21% 5% Spermicide 26% 6% Withdrawal 19% 4% Fertility Awareness 20% 1%-9%

  9. Yolanda 17 year-old high school senior Requests pregnancy test, birth control pill Had unprotected sex 4 days ago Urine pregnancy test is negative. What do you do next?

  10. Emergency Contraception:Levonorgestrel (Plan B) Take at once, up to 5 days after unprotected sex. Lowers risk of pregnancy by 58-89%

  11. Levonorgestrel EC:Mechanism of Action Inhibits ovulation Does NOT cause abortion

  12. Ulipristal acetate: a new emergency contraceptive option Decreases risk of unintended pregnancy by about 90% Maintains nearly full efficacy up to 5 days after unprotected intercourse

  13. Hormonal Contraceptives What is needed before prescribing? Medical history REQUIRED Pap smear Pelvic/breast exam STI testing Hemoglobin NOT REQUIRED Blood pressure RECOMMENDED

  14. Hormonal ContraceptivesWhich women/teens can’t use estrogen? Estrogen contraindications: Migraine with aura Uncontrolled hypertension Postpartum < 6 weeks History of DVT Smoking: NOT a contraindication in women/teens under age 35

  15. Yolanda is eligible for the pill.When should she start?

  16. Advance EC prescrbing Should Yolanda get a prescription for EC, too? .

  17. 21 year old waitress Had a medication abortion 1 week ago in your office Has severe PMS symptoms OCs helped just a bit Jessyka

  18. Extended Cycle Regimens

  19. Liz 21-year-old healthy college student Takes oral contraceptive, but forgets pills often Has trouble getting refills while at college, and now the pills are too expensive

  20. Percent of Women (%) Adherence with OCs:What Women Do! Number of pills missed Potter L et al. 1996.

  21. What are the common reasons for missing pills?

  22. Back to Liz… She would like to try something easier to remember. What information do you need?

  23. Efficacy: Numbers & Categories Table“Effective Methods” Effectiveness Group Family Planning Method Typical-Use Rate of Pregnancy Perfect-Use Rate of Pregnancy Effective Birth control pills 8% 0.1%-0.5% Transdermal patch Unknown (8%) 0.3%-0.8% Vaginal ring Unknown (8%) 0.1%-0.5%

  24. Estrogen/progestin vaginal ring Active for at least 3 weeks Lowest estrogen dose: 15 mcg / day Same efficacy and contraindications as OCs May remove for up to 3 hours QuickStart same as with OCs

  25. Estrogen / Progestin Patch 1 patch weekly for 3 weeks, then one week off Same efficacy & contraindications as OCs OK to shower, swim, exercise with patch on Failures in trials were in women over 198 pounds, but still rare Higher risk of clots? Conflicting studies… Gallo MF, et al. Cochrane Reviews. 2003, Issue 1. Art. No. CD003552. Jick S, et al. Contraception 73 (2006)

  26. How many refills should we give Liz?

  27. Resa 16 years old Doesn’t want to get pregnant until she finishes school Wants contraception that she can hide from her mom What are her choices?

  28. Highly Effective MethodsNOT USER DEPENDENT Effectiveness Group Family Planning Method Typical-Use Rate of Pregnancy Perfect-Use Rate of Pregnancy Highly Effective (for all users) Male and female sterilization 0.2%-0.5% 0.1%-0.5% Implants 0.1% 0.1% Hormone shot 0.3% 0.3% Intrauterine devices 0.8%-2% 0.6%-1.5%

  29. Progestin-Only Injection Hatcher, R et al. A Pocket Guide to Managing Contraception, 2007-2008

  30. Depo Provera & Bone Density Weighing risks and benefits: No need to restrict Depo Provera use

  31. Amy 21-year-old G4P2 New boyfriend wants her to get pregnant, but she doesn’t want a child now.

  32. Intrauterine Devices

  33. IUD Myths Debunked IUDs can be used safely by nulligravid women and teens! IUDs DO NOT raise risk of PID. IUDs DO NOT raise risk of infertility. IUDs DO NOT raise risk of ectopic pregnancy.

  34. IUD Myths Debunked IUDs DO NOT cause abortion. OK to insert IUD at any point in the menstrual cycle. OK to insert immediately post-partum or following surgical abortion OK to test for STIs at time of insertion (& treat infections with IUD in place)

  35. Blanca 36-year-old G6P4 Has fibroids and anemia

  36. Progestin IUD (MIRENA)

  37. Progestin Implant Highly effective and rapidly reversible Discreet Not user-dependent Contain no estrogen Can be used during lactation Active hormone: etonogestrel (68 mg) Reinprayoon. Contraception 2000Diaz. Contraception 2000

  38. Features of Progestin Implants Causes spotting Requires certified clinician visits for insertion and removal

  39. Counseling to Enhance Adherence • LISTEN to her ideas about the best method. • EXPLORE lifestyle issues that may impact adherence. • ENCOURAGE her to call you with problems/concerns.

  40. % of Women Continuing Contraceptive Use at 1 Year Impact of Choice Pariani. Stud Fam Plann, 1991 1991

  41. Inconsistent pill use is linked to:low level of satisfaction with provider & low continuity of care. Percent of pill users who missed one or more pills during the past three months

  42. Office barriers to adherence

  43. Feeling unable to call a provider with questions is linked to contraceptive non-use. % of at-risk women experiencing contraceptive non-use in the past year

  44. Electronic Health Records

  45. DE-LINK pap smears from birth control prescriptions. • ROUTINELY prescribe 1-year supply with 3 packs at a time. • Use Quickstart. • Ask about contraceptive needs at all types of visits. • Emphasize high-efficacy methods, but honor women’s choice whenever possible. Take-home message:Be pro-active with contraception!

  46. References and Resources Hatcher et al, Contraceptive Technology 2007 Managing Contraception – book online @ www.managingcontraception.org Medical Eligibility Criteria for Contraceptive Use 2010 by WHO www.who.int/reproductive-health Association of Reproductive Health Professionals www.arhp.org Alan Guttmacher Institute www.agi-usa.org Planned Parenthood www.plannedparenthood.org The Cochrane Collaboration www.cochrane.org www.Not-2-Late.com Reproductive Health Access Project www.reproductiveaccess.org

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