Contraceptive Toolbag

1. ContraceptiveToolbag Diana Koster, M.D. Planned Parenthood of New Mexico April 14, 2010

2. Goals Provide: • Contextual information about U.S. teen pregnancy rates • Updated medical information • reproductive healthcare needs • contraception • LARC (long-acting reversible contraception) • Emergency contraception • Comfort in role as educators and counselors of teens

3. Unintended Pregnancy in U.S.(per 1000)

4. U.S. Compared to Europe • Sexual debut is equivalent. • Pregnancy and STIs are more frequent among US teens than among (most) European teens. (New Mexico #1 in teen pregnancy.) • US teens have more partners. • Use of birth control is less in U.S. than in other developed nations. • US teens less likely to use medical (i.e., most effective) contraceptives.

5. Births in Women Under 20(per 1000)

6. Teens in U.S. and Europe

7. No Contraception at Last Intercourse(per 1000)

8. MissedPills

9. Obstaclesto Healthy Sexuality • Ignorance • Parental discomfort • Teacher/counselor discomfort • Lack of clarity about how best to deliver messages • Lack of access to confidential services • Incomplete brain maturation • Abstinence-only education (as opposed to abstinence-based education)

10. Abstinence-based Abstinence as preferred for teens Accurate contraceptive information for future Proven successful Abstinence-only Abstinence until marriage No contraceptive education Inaccurate Unsuccessful Refusal skills Abstinence Education

11. Myth # 1 Abstinence and contraception cannot both be taught successfully. Teaching our youth about contraception will make them become sexually active.

12. American Academy of Pediatrics “Reduction of unintended pregnancy is best achieved by strategies that include…effective programs to delay and reduce sexual activity….Strategies to reduce unplanned pregnancies should include improving the knowledge, accessibility, and availability of contraception services, including emergency contraception.” Policy Statement in Pediatrics, Vol. 116 No. 4 Oct 2005

13. Support for Comprehensive Sexuality Education • National Institutes of Health • Institute of Medicine • Centers for Disease Control • American Medical Association • American College of Obstetrics and Gynecology • Society for Adolescent Medicine

14. Goals of Sexuality Education • Promote good decision-making • feelings of comfort • appropriate outcomes • Pregnancy prevention/delay • Prevention of STDs/STIs

15. Myth # 2 Minors must have parental consent/permission to obtain birth control.

16. New Mexico Law (condensed) • Minors of any age may get reproductive healthcare without parental permission. • Such care includes birth control as well as testing and treatment for sexually transmitted infections. • Sexual activity under age 13 must be reported to CYFD.

17. Myth # 3 There are 100% effective birth control methods. Anyone who gets pregnant using birth control “screwed up.”

18. Contraceptive Effectiveness(expressed as failures per 100 women years of use)

19. Contraceptive Continuation(at one year)

20. Myth #4 Birth control is dangerous.

21. Safety of Contraception Use of a properly selected contraceptive method is always safer for a woman than pregnancy.

22. Myth #5 Making emergency contraception (easily) available will increase irresponsible behavior.

23. Emergency Contraception(“morning-after-pill”) • Provides chance to prevent unplanned pregnancy and to start regular contraceptive care • Is not the “abortion pill” – (ovulation disrupted or delayed) • Is medically safe for all • Can be used in addition to “regular” method • Is available “behind-the-counter” for > 17, by prescription for < 16 (not science-based) • Does not increase risk-taking • Forms include • Plan B/Plan B 1-Step • Next Choice • Birth control pills in special doses

24. Emergency Contraception • “The sooner, the better” • Advance provision ideal – cf. fire extinguisher • Available at: • Planned Parenthood • Public Health Department • School-based health centers (?) • Pharmacies • www.not-2-late.com

25. Myth #6 To use (hormonal) birth control safely, a woman must first have a complete physical exam and lab testing including a Pap smear and STD testing.

26. Complete history Testing – Pap, STDs Complete exam Pelvic Breast check Thyroid exam Heart and lungs Blood pressure, weight Targeted history Testing – variable, age-specific Exam – variable, age-specific, usually,none needed for teen beginning birth control “Annual Exam”Then Now

27. Advantages to New Approach • Provides opportunity to educate patients/students concerning individual healthcare needs • Avoids fear of pelvic as barrier to initiation of contraception • Makes contraception more affordable • Allows contraception to be started quickly • Spends healthcare dollars more appropriately :

28. Starting the Pill(and other hormonal contraception) It is good medical practice to make decisions concerning prescription of birth control pills to women based solely on a careful health history and a blood pressure measurement. - World Health Organization

29. Myth #7 A birth control method can only be started when a woman is having her period.

30. Beginning Birth Control Any contraceptive method may be started at anytime in a woman’s cycle as long as it is reasonably certain that she is not pregnant.

31. Myths #7-9 Teens cannot use IUDs. Women who have not had babies cannot use IUDs. Unmarried women cannot use IUDs.

32. Ideal Contraceptive • Easy – little/no attention needed • Highly effective • Few/no side effects • No medical risks • Effective for years • Rapidly reversible • STD/STI prevention • Private • ONE WITH WHICH USER IS COMFORTABLE!!

33. LARC (long-acting reversible contraceptive) • Intrauterine contraception • IUD – Paragard • IUS – Mirena • Implant – Implanon

34. Tiers of Contraceptive Effectiveness • IUDs, implant, sterilization • DMPA (“shot”) • Pills, patches, rings • Everything else - David Grimes (modified)

35. IUC/IUD/IUS (Intrauterine Contraceptive/Device/System) • Effective for 5 or 10 years • Private • Convenient • Cost effective • Paragard: ~$500 for 10 years or ~$50 per year • Mirena: ~$600 for 5 years or ~$120 per year • Generally considered inappropriate for teens. Why? • Old data from previous devices

36. IUD/IUS/IUC • As effective as sterilization • Minimal user effort • Makes sperm unable to fertilize egg (Paragard), thickens mucus and suppresses ovulation (Mirena) • Appropriate method for teens • Five (Mirena) or ten-twelve (Paragard) years of protection • No STD/STI protection but does not cause PID(pelvic inflammatory disease)

37. Implanon • As effective as sterilization • Minimal user effort • Progestin-only implant similar to Norplant • Thickens mucus and suppresses ovulation • Continuous low levels of hormone • Three years of protection

38. Other Hormonal Contraception • Pills – multiple brands with varying doses • Combined = estrogen + progestin • Mini-pill = progestin only • Patch = OrthoEvra • Ring = NuvaRing • Shot = DepoProvera (DMPA) * * * * * * • Emergency contraception (Plan B/Next Choice)

39. Oral Contraceptive Discontinuation • 28% discontinue by 6 months • 33-50% discontinue by 1 year • Reasons for discontinuation range from break-up with partner to fear of medical risks to uncomfortable side effects and include inability to afford birth control

40. HormonalContraception • SAME (or very similar): • mechanisms of action • risks (no estrogen risks with minipill and DMPA) • benefits • effectiveness • DIFFERENT: • delivery system • real world effectiveness (?)

41. Noncontraceptive Benefitsof hormonal contraceptives • Reduces: • pain with periods • Irregularity of periods • amount of blood loss and therefore anemia • Decreased risk of cancer of • uterus • ovary • Lessens risk of • benign breast disease • rheumatoid arthritis

42. Oral Contraceptive“The Pill” • Estrogen and progestin taken in low doses daily for three weeks with one hormone-free week each cycle • Suppresses ovulation and thickens cervical mucus • Modern low doses - fewer side effects, theoretical efficacy = 99+% • Increased failure with late or missed pills

43. Myths # 10-16 The Pill causes: • acne • weight gain • cancer • sterility • heart disease • birth defects • stunted growth in a teen

44. Myths # 17-19 A woman should go off contraception periodically to “give her body a rest.” There is a limit to how long it is safe for a woman to use contraception. A woman should not be on a contraceptive unless she is sexually active.

45. Fears about Hormonal Contraception • Inappropriate, based on old data or observations. • Estrogen use in smoking woman > 35 year old is the true danger for hormonal contraception • Hormonal contraception is extremely safe for most healthy women • 20 times safer than pregnancy and childbirth • 33 times safer that driving an automobile • Decreases the risk of several serious diseases and the severity of several others

46. Ortho Evra(Contraceptive Patch) • Skin patch with the same type of hormones as in the birth control pill • Requires weekly, not daily attention • May have higher “real world” effectiveness because easier to use than pills • Less nausea than pill, rare skin irritation

47. Myth # 20 Ortho Evra is a dangerous birth control method; it causes strokes in many women.

48. NuvaRing • Vaginal ring containing same type of hormones as birth control pills • Lowerlevels of systemic hormones • Requires monthly, not daily or weekly attention • May have higher “real world” effectiveness because easier to use than pills

49. Myths #21 & 22 Not having a period every month is unhealthy: the blood needs to “come down.” DepoProvera (DMPA) causes significant weight gain and osteoporosis

50. DepoProvera • Failure rate = 3/1000 • Private • Progestin-only - no estrogen side effects • Easier adherence: every twelve week injection • Absence of periods probable • Bone changes reversible • Weight change generally not significant