Teaching Contraception:

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1 Slide 1 Teaching Contraception: An Interactive Lecture Using Managing Contraception edition Carrie Cwiak MD, MPH Alison Edelman MD, MPH Robert A. Hatcher, MD, MPH Miriam Zieman,, MD Mark Nichols, MD Jeffrey Jensen, MD, MPH Slide 2 Combined Oral Contraceptives 8% failure with typical use/ 0.3% with perfect use Estrogen/Progestin Inhibit ovulation Health benefits decreased menstrual flow decreased menstrual pain less acne & hirsutism cancer protection Predictable cycle control Warner Chilcott

2 Slide 3 Combined Oral Contraceptives 1. Give 3 examples of how to start taking combined oral contraceptives. - First day of menses or Sunday after menses - Immediately - QUICKSTART - Immediately after abortion or miscarriage - Immediately after emergency contraception - 3 weeks postpartum Warner Chilcott Slide 4 Combined Oral Contraceptives (OCs( OCs) 2. How do you choose the right pill? Can any woman take combined OCs? Pill Type: Monophasic vs. Multiphasic Prescribing Precautions: - Smoker over age 35 - CAD or heart disease - H/O or risk of blood clot - HTN, DM with vascular changes - Migraines with neurological symptoms - Active liver/gallbladder problems Ortho-McNeil

3 Slide 6 Emergency Contraception (EC) 4. Your patient has just had unprotected sex. How she can use her Alesse TM for Emergency Contraception? Combined oral contraceptive - Use within 120 hours of sex - Take anti-emetic 1 hour before - Take 5 pink/active tablets - Repeat dose 12 hours later - Plan B TM, IUD more effective Wyeth-Ayerst Slide 7 Combined Transdermal Patch Transdermal patch Ethinyl estradiol + norelgestromin Change once a week for 3 weeks, 1 week off for menses Ortho-McNeil Worn on trunk (except breasts), arm, buttock

4 Slide 8 Combined Patch 5. Your patient left her Ortho Evra TM patch on for 10 days. What is the first year effectiveness? Is it still effective now? - Use a back-up method! -Patch can remain on for 9 days Ortho-McNeil -<1% failure in women weighing 90 kilograms or less Slide 9 Combined Vaginal Ring Flexible vaginal ring Ethinyl estradiol + etonogestrel 0.3% perfect use failure rate Organon USA, Inc.

5 Slide 10 Combined Vaginal Ring 6. Your patient wants to try the Nuva Ring. TM Instruct her in its use and what to do during sexual intercourse. -Active for at least 3 weeks, 1 week off for menses - For sex: leave it in, or take it out for no longer than 3 hours Organon USA, Inc. Slide 11 Postpartum Contraception 7. What options does your postpartum patient have for contraception before her postpartum visit? Postpartum sterilization - Sterilization - Progestin-only methods - Condoms - Copper IUD - Lactational amenorrhea - Estrogen contraception (only after 3 weeks)

6 Slide 12 Hormonal Contraceptive Methods 8. Your patient has a blood pressure of 165/105 and needs a method of contraception. Which methods should be used with caution? - Estrogen - Depo-Provera Slide 13 Emergency Contraception: Plan B TM 9. A woman had unprotected sex and wants emergency contraception. How do the pills work? When should she take them? - Mechanisms of Action: Not an abortifacient, disrupts follicular development, blocks LH surge, inhibits ovulation, disrupts luteal phase. - Take within 120 hours, 2 pills at the same time. - Start contraception immediately Women s Capital Corporation, Plan B (levonorgestrel)

7 Slide 14 Progestin-Only Injection 10. A 19 year-old recently received Depo-Provera TM and is concerned about bleeding. Is this normal? What if she is amenorrheic? - Irregular bleeding is common initially - Amenorrhea is normal: 50% at 1 year, 80% at 5 years Family Health International Slide 15 Progestin-Only Injection 11. Your patient reports a 25-pound weight gain in the last 18 months. She blames the Depo-Provera TM what do you tell her? -Average weight gain: 5.4 pounds in 1 year -Need to discuss weight loss strategies -Consider other methods Courtesy: Ortho-McNeil

8 Slide 16 Levonorgestrel Intrauterine System 12. What are the non-contraceptive benefits of the Mirena TM IUS? What is a disadvantage? - Improved dysmenorrhea - Decreased menstrual flow - Decreased menorrhagia - Decreased bleeding from fibroids - Protection from uterine cancer Berlex Laboratories, Inc. Disadvantage initial menstrual irregularity Slide 17 Progestin-Only Pills 13. What advice do you give your patient who is taking carbamazepine for seizures and progestin- only pills for contraception? Change her method Are there other medications to ask about? Is there a better method for her? Consider Depo-Provera TM

9 Slide 18 Progestin-Only Pills 14. A 40 year-old smoker wants to use OCs.. What kind of OCs should she use? What are the disadvantages? Progestin-only pills - Irregular bleeding - Less forgiving if taken late - Possible effects on mood & ovarian follicles Ortho-McNeil Slide 19 Progestin Implants 15. Your patient is worried about finding a qualified provider for her Norplant TM removal and about the cost. Where can she get information? Population Council or the manufacturer How many years is Norplant TM effective? How many capsules should be removed? Five Six

10 Slide 20 Implanon Slide 21 IMPLANON A single rod, progestin-only only subdermal implant effective for up to 3 years Clinical trials in over 17 countries, including the US Supplied in a sterile and disposable preloaded applicator Inserted subdermally in the groove between the biceps and triceps muscles IMPLANON [package insert]. Roseland, NJ: Organon USA Inc; 2006.

11 Slide 22 Hormonal Contraception 16. A teenager has been using Depo-Provera TM for 2 years and now has pelvic inflammatory disease (PID). How does this affect her fertility? Decreases it What is her risk now of bilateral tubal occlusion? 8% How can you help her use condoms? Slide 23 Copper IUD Courtesy: Durex condoms 17. How does this IUD work? Does it cause abortion? No For how long does it work? 12 years Does it affect fertility or ectopic pregnancies? Courtesy: Not-2-late.com No effect on fertility, and decreases ectopics

12 Slide 24 Male Condoms 18. A woman s s boyfriend refuses to wear condoms because he is allergic to latex. What is your advice? Try another type What types of condoms are there? Latex, polyurethane, and natural membrane Courtesy: Durex condoms Slide 25 Female Sterilization 19. What issues should you counsel patients on before tubal sterilization? How effective are the different methods? Filshie clips 10-year failure rates: Postpartum 0.8% Filshie clip 0.9% Silastic bands 1.8% Courtesy: Albert Yuzpe, MD Interval partial salpingectomy 2.0% Bipolar cautery 2.5%

13 Slide 26 Male Sterilization 20. A 34 year-old man has just had a vasectomy. When can his partner stop her birth control? When two consecutive sperm counts are zero (usually after 12 weeks) Courtesy: T. Clenney MD, MPH and J. Higgins, MD Slide 27 Spermicides 21. A 19 year-old is only using spermicides for birth control. How effective are these? Do they affect her risk of HIV or sexually transmitted infections (STIs( STIs)? 29% failure with typical use/ 15% with perfect use May increase risk of HIV

14 Slide 28 Female Condom 22. What are some advantages and disadvantages of the Reality TM female condom when compared to the male condom? Advantages: - Can be inserted 8 hrs before sex - Female-controlled method - Non-latex Slide 29 Withdrawal 23. A 16 year-old girl was told by her boyfriend that withdrawal has the same efficacy as abstinence. How would you advise her? Failure rate is 27% with typical use It may expose her to HIV and other STIs

15 Slide 30 Diaphragm 24. What lubricants can you use with a diaphragm? Water-based or silicone Are certain lubricants a problem with other methods? Oil-based products will affect condoms & caps made of latex Slide 31 Cervical Cap 25. Similarities and differences between the cervical cap and diaphragm? - Both can be placed 6 hours before sex -Both need to stay in place 6 hours after sex - The diaphragm can stay in place 24 hours - The cap can stay in place 48 hours The FemCap TM Vaginal view with groove for spermicide shown

16 Slide 32 Abortion 26. Your patient has an unplanned pregnancy and desires termination. What are her two options? - Medical - Surgical What are the relative advantages to each? Slide 33 Fertility Awareness Methods 27. How effective are the fertility awareness methods? 12-25% failure with typical use, 1 9% with perfect use FIGO, Parthenon Publishing

17 Slide 34 Abstinence 28. A 14 year-old plans to abstain from sex. What instructions would you give? What can you give her before she leaves the office? Condoms and EC pills Family Health International Slide 35 Lactational Amenorrhea Method 29. Name three conditions for lactational amenorrhea (LAM) to be effective. - A woman who is breastfeeding exclusively - A postpartum woman who is amenorrheic - A woman whose infant is less than 6 months old Family Health International

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