WHAT S NEW IN CONTRACEPTION? EVIDENCE-BASED CONTRACEPTIVE MANAGEMENT EVELYN KIELTYKA, MSN, MS, FNP

WHAT S NEW IN CONTRACEPTION? EVIDENCE-BASED CONTRACEPTIVE MANAGEMENT EVELYN KIELTYKA, MSN, MS, FNP

Most effective IMPLANT Brand name: Nexplanon Contains etonogestrel Effective for 3 years Implanon insert: Diaz S., Contraception, 2002: Trussel J, Contraceptive Technology, 2007 Croxatto HB, Contraception, 1998; Diaz S, Contraception, 2002; Funk S, Contraception, 2005. Implanon Prescribing Information. et al.

NEXPLANON (ETONOGESTREL) ENG IMPLANT Progestin only, implant effective for up to 3 years Studied in 17 countries, including US Marketed in 30 countries; >2.5 million insertions Inserted sub-dermally between biceps and triceps Must be inserted and removed only by clinicians that have completed training program

ENG IMPLANT: MECHANISM OF ACTION Inhibits ovulation none For 30 months Increases viscosity of cervical mucus 11 Clinical Trials evaluated 923 women 22,888 cycles in 3 years No pregnancies while implant was in place

Table 1. Bleeding patterns in etonogestrel-releasing subderma implant users during the first 2 years of use. Bleeding pattern Definition Percentage Amenorrhea Infrequent Prolonged No bleeding and/or spotting in 90 days Less than three bleeding and/or spotting episodes in 90 days (excluding amenorrhea) Any bleeding and/or spotting episode lasting more than 14 days in 90 days 22 34 18 Frequent More than five bleeding and/or spotting episodes in 90 days 7

LEVONORGESTREL INTRAUTERINE SYSTEM (LNG IUS) Brand name: Mirena 20 mcg levonorgestrel/day Approved for 5 years use Amenorrhea in ~20% of users by 1 year Mirena Prescribing Information. 2000.: Trussel J. Contraceptive Technology. 2007; Hidalgo M. Contraception. 2002.

Most effective Copper-T IUD Brand name: Paragard Copper ions Approved for 10 years use Can be used as emergency contraceptive Thonneau, PF. Am J Obstet Gynecol. 2008.: Forrtney JA. J Reprod Med. 1999.: Trussel J. Contraceptive Technology. 2007.

CHARACTERISTICS OF INTRAUTERINE CONTRACEPTION Highest patient satisfaction among methods Rapid return of fertility Safe Immediately effective Long-term protection Highly effective Belhadj H, et al. Contraception. 1986.; Skjeldestad F, et al. Advances in Contraception. 1988.; Arumugam K, et al. Med Sci Res. 1991.; Tadesse E. Easr Afr Med J. 1996.

Intrauterine Contraception in the U.S. Paragard Mirena Mechanism Copper ions Levonorgestrel Duration 10 years 5 years Efficacy (typ) 0.8 failures/hwy 0/1 failures/hwy Benefit No hormones Less bleeding Non contraceptive uses None Heavy periods Endometriosis Cost Less expensive More expensive

IUDs Safe and Effective for Teens American College of Obstetricians and Gynecologists said IUDs and contraceptive implants should now be considered one of the best birth control options for teens because they are reliable and reversible. Don t have to remember to take a pill at the same time daily Minimal if any complications Provide years of worry-free birth control Ensure higher levels of privacy as they don't require frequent follow-up appointments and can't be "discovered" in a teen's room (as pills might be) Cost effective, and in the long run, should cost less than other birth control methods Fewer menstrual cramps, lighter periods

Pre-IUD Insertion Screening Evidence supports no routine screening tests -Chlamydia, Gonorrhea: if high risk sexual behaviors or <26 yo and annual screening Chlamydia has not been done -Pregnancy test: only if pregnancy suspected -Pap smear: only if due for a routine Pap -Hematocrit: only if anemia suspected Any indicated screening test can be done on the day of IUC insertion

Combined Hormonal Contraceptives (Pills, Patches and Vaginal Ring) All three methods have similar -Contraceptive efficacy -Menstrual bleeding patterns -Side effects -Complications -Monthly cost Major difference: delivery system

Quick Start When prescribed in advance, why do some women fail to start OCs with the next menses? -Intervening pregnancy -Change in motivation to use OCs -Confusion regarding when to start OCs -Effort necessary to receive OCs from pharmacy -Fear of side effects What if -OCs routinely could be started at the moment that they are prescribed?

Clinical Uses: Extended CHC Regimens Convenience -Preference for long term light periods -Episodic delay in onset of menses -More consistent schedule of OC use -Fewer menstrual symptom episodes Prevents/ Minimizes Common Menstrual Symptoms -bloating, breast tenderness, mood swings -Monthly menstrual migraine or other headaches; menstrual seizures

Emergency Contraception Plan B available over-the-counter! No age restriction! over-the-counter cost = around $40-50 Family Planning $0-$43 based on sliding fee scale Can be taken up to 5 days after unprotected sex Will only prevent pregnancy will not stop a pregnancy if fertilization and implantation has already occurred. A partner or parent can buy EC.

Ulipristal Acetate (UPA): Ella Approved up to 5 days Mechanism of action -Inhibits implantation, but higher dose required -Delays or inhibits ovulation Failure rate vs. LNG (meta-analysis: 0-120 hr) -UPA 1.3% vs. LNG 2.2%

Ortho Evra (The Patch) Approved in 2002 Mimics 28 day birth control cycle Three 7 day patches for one week each Consistent and correct use Minimize failure rate

Ortho Evra (The Patch) Advantages Weekly Regime Forgiving Reversible Adherence Cycle Control No need for oral administration

Ortho Evra (The Patch) Side Effects Skin Reactions Breast Symptoms Headache Caution in women over 200 lbs.

Very effective Injectable Depo Medroxyprogesterone Acetate (DMPA) Brand name: Depo-Provera Intramuscular or subcutaneous injection every 3 months Trussel J. Contraceptive Technology. 2007. Cromer BA. Am J Obstet Gynecol. 2005. Trussel J. Contraception. 2004.; Westhoff C. Contraception. 2003. et al.

Body Weight and Contraception OC Patch DMPA Implant IUC Tubal Weight Gain No No Yes* No No No Increased failure rate in obese women Medical risk in obese women No Δ Yes # No Δ No Δ No Δ No Δ DVT No studies None None Difficult insertion Surgical complications WHO-MEC 2 2 1 1 1 Not rated *Mainly in obese adolescents and those who experience a 5% body weight increase within 6 months of DMPA initiation # In women who weigh 90 kg, increase of 2-4 failures/100 couples/year

Contact Information: Evelyn Kieltyka, MSN, MS, FNP 207-622-7524 ~~ Fax: 207-622-0836 ekieltyka@mainefamilyplanning.org Visit our website: www.mainefamilyplanning.org