3/22/2011
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Guidelines for Long‐Acting, Reversible Contraception
in Adolescents and Young Women
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Patty Cason RN, MS, FNP‐BC
Assistant Clinical Professor & Lecturer
UCLA School of Nursing
Clinical Trainer California Office of Family Planning
Planned Parenthood Los Angeles
Private Practice
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A Few Notes Before we Begin
• Moderating: Elizabeth Locke
•
All phones are muted
•
Questions can be asked via the Q & A box throughout the session or raising your hand
throughout the session or raising your hand in WebEx
•
Lines will be opened at the end for additional questions
2/15/2011
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2/15/2011
– lockee@cfhc.org
• Handouts
• Follow‐Up Survey
– Zoomerang survey in 6 weeks (Look for that in your e‐mail the week of May 3rd.)
• CEUs
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3/22/2011
Disclosures
Learning Objectives
• Implanon trainer
• Describe three category 4 conditions listed in the 2010 CDC Medical Eligibility Criteria regarding use of IUCs
• List 3 national organizations that support use of List 3 national organizations that support use of
IUCs in adolescents and young women
• Discuss recommended content for policies and protocols for successfully providing IUCs and Implants
Facts on American Teens’
Sexual and Reproductive Health
• By age 15 , 13% of teens have ever had sex
• By age 19, 70% have had sexual intercourse
• Most young people have sex for the first time at about age 17, but marry in their middle or late 20s
• At most recent sex, 83% of teen females and 91% of teen A
83% f
f
l
d 91% f
males used contraceptives
• 61.5% of sexually active students reported that either they or their partner had used a condom during last intercourse
Why teens need good contraception
Facts on American Teens’ Sexual and Reproductive Health Guttmacher Institute January 2010
9
Facts on American Teens’
Sexual and Reproductive Health
• Eighty‐two percent of teen pregnancies are unplanned; they account for about one fifth of all unintended pregnancies annually.
• Seven percent of teen mothers receive late or no prenatal care Babies born to teens are more likely to be low‐
care. Babies born to teens are more likely to be low
birthweight than are those born to women in their 20s and 30s.
• Teen mothers are now more likely than in the past to complete high school or obtain a GED, but they are still less likely than women who delay childbearing to go on to college.
Facts on American Teens’ Sexual and Reproductive Health Guttmacher Institute January 2010
Disparities in Rates of Unintended Pregnancy • The rate of unintended pregnancy in 2001 was substantially above average among women aged 18‐24
– unmarried (particularly cohabiting) women
– low‐income women
– women who had not completed high school – minority women. • Forty‐eight percent of unintended conceptions in 2001 occurred during a month when contraceptives were used
• The findings may reflect a need for increased and more effective contraceptive use, particularly among high‐risk groups.
Finer LB, Henshaw SK. 2006. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health. Jun;38(2):90‐6.
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American College of Obstetricians and Gynecologists (ACOG)
excepts from:
Primary and Preventive Health Care for Female Adolescents • The primary health risks to adolescents are behavioral, such as a sedentary lifestyle, poor diet, smoking, alcohol and drug d
lif
l
di
ki
l h l dd
use, driving under the influence of drugs or alcohol, early initiation of sexual activity, and poor use of contraception.
• 2001 Youth Risk Behavior Surveillance Report indicates that many will begin exhibiting one of these risky behaviors* by age 13 years
• adolescent behaviors tend to reflect an assumption of invulnerability
Guidelines, position statements and recommendations on use of LARC methods for teens *early initiation of sexual activity and poor use of contraception
14
ACOG
“Expanding access to LARC for young women has been declared a national priority.”
ACOG
From:
ACOG Practice bulletin Number 450 December 2009
December 2009 Increasing Use of Contraceptive Implants and Intrauterine Devices To Reduce Unintended Pregnancy Institute of Medicine (US). Initial national priorities for comparative effectiveness research. Washington, DC: National Academies Press; 2009
ACOG
ACOG
“High US unintended pregnancy rates may in part be the result of relatively low use of the contraceptive implant and intrauterine devices”
“These top‐tier methods share the highest continuation rates of all contraceptive methods, one of the most important factors in contraceptive success ”
contraceptive success .
Trussell J, Schwarz EB, Guthrie K, Raymond E. No such thing as an easy (or EC) fix. Contraception 2008;78:351–4
Chandra A, Martinez GM, Mosher WD, Abma JC, Jones J. Fertility, family planning, and reproductive health of U.S. women: data from the 2002 National Survey of Family Growth. Vital Health Stat 23 2005;(25):1–160
Whitaker AK, Johnson LM, Harwood B, Chiappetta L, Creinin MD, Gold MA. Adolescent and young adult women's knowledge of and attitudes toward the intrauterine device. Contraception 2008;78:211–7. Stanwood NL, Bradley KA. Young pregnant women's knowledge of modern intrauterine devices. Obstet Gynecol 2006;108:1417–22
Hatcher RA, Trussell J, Nelson AL, Cates W Jr, Stewart F, Kowal D, editors. Contraceptive technology. 19th rev. ed. New York (NY): Ardent Media, Inc.; 2007
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ACOG
“Increasing the use of contraceptive implants and IUDs also could reduce repeat pregnancy among adolescent mothers and repeat abortions among women seeking induced
abortions among women seeking induced abortion.”
Stevens‐Simon C, Kelly L, Kulick R. A village would be nice but...it takes a long‐acting contraceptive to prevent repeat adolescent pregnancies. Am J Prev Med 2001;21:60–5. Goodman S, Hendlish SK, Reeves MF, Foster‐Rosales A. Impact of immediate postabortal
insertion of intrauterine contraception on repeat abortion. Contraception 2008;78: 143–8. Heikinheimo O, Gissler M, Suhonen S. Age, parity, history of abortion and contraceptive choices affect the risk of repeat abortion. Contraception 2008;78:149–54
ACOG
“IUDs may be safely used by nulliparous women and by adolescents.” Adolescent Health Care Committee of ACOG
• In 2007 advocated for increased use of IUCs in adolescents
– regardless of their gravidity and parity status
– should be considered as part of the available armamentarium for contraception. • “With a three‐year contraceptive duration, and easy insertion and removal, the etonogestrel implant will open new alternatives for adolescents looking for long‐term contraception…”
Society of Family Planning SFP
• “Use of the Mirena™ LNG‐IUS and Paragard™ CuT380A intrauterine devices in nulliparous women” – SFP Guideline 2009
– Release date 15 December 2009
Intrauterine device and adolescents. ACOG Committee Opinion No. 392. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:1493–5. Intrauterine device. ACOG Practice Bulletin No. 59. American College of Obstetricians and Gynecologists. Obstet Gynecol 2005;105:223–32. SFP Conclusion and Recommendations
SFP Conclusion and Recommendations
The following recommendations are based on good and consistent scientific evidence (Level A):
• The Mirena™ LNG‐IUS and the Paragard™ T380A are effective and safe contraceptive devices for
are effective and safe contraceptive devices for nulliparous women.
• When compared to other methods of contraception, IUDs have comparable or higher continuation rates of use in nulliparous women.
The following recommendation is based primarily on consensus or expert opinion (Level C):
Adolescent women should be considered
Adolescent women should be considered candidates for IUDs.
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Association of Reproductive Health Professionals (ARHP)
• No position statement or clinical guideline…BUT • Very strong support of increased use of LARC and decreased barriers to use of LARC
– Several slide decks in their CORE series
– Heavy emphasis at annual meetings
Advantages of IUC for Adolescents
– Long‐term, highly effective method
– No action required at time of intercourse or
time of intercourse or on a daily basis
– Well tolerated by appropriately selected and counseled patients
Slide courtesy of ARHP
Deans EI, Grimes DA. Contraception. 2009; Suhonen S et al. Contraception. 2004; Toma A, Jamieson MA. J Pediatr Adolesc Gynecol. 2006. Nulligravid Adolescent Case: Nulligravid Adolescent Case: Clinical Considerations
Practice Tips (continued)
• Insertion difficulty (smaller os and uterus than in parous woman)
• Insertion pain
• Possible increased risk of STIs (chlamydia) and PID (because of age <25 years)
• Conduct chlamydia testing on the same‐day(with normal clinical exam)
• Use an Os finder to locate cervical opening
• Uterine dilators to enlarge cervical opening prior to insertion
• Take the timing of insertion into account
more…
Deans EI, Grimes DA Contraception. 2009; Grimes DA. Lancet. 2000.
Slide courtesy of ARHP
Nulligravid Adolescent Case: Counseling Points
• Follow‐up and side‐effect monitoring important
• Counsel regarding signs of expulsion
• Encourage use of condoms with new g
partners
Hubacher D. Contraception. 2007; Tomas A et al. J Pediatr Adolesc Gynecol. 2006.
Goodman S et al. Contraception 2008
Slide courtesy of ARHP
ACOG‐ Recommendations
The following strategies can reduce barriers and increase use of implants and IUDs: • Provide counseling on all contraceptive options, including implants and IUDs, even if the patient initially states a if th
ti t i iti ll t t
preference for a specific contraceptive method. • Encourage implants and IUDs for all appropriate candidates, including nulliparous women and adolescents. Slide courtesy of ARHP
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Medical Eligibility Criteria
ACOG
Category
“Young women were likely to report a positive attitude about intrauterine contraception after a brief, 3‐minute educational intervention.” Definition
Recommendation
1
No restriction for the use of the contraceptive method
2
The advantages of using the method More than
generally outweigh the theoretical usual follow-up
needed
or proven risks
or proven risks
3
Clinical
The theoretical or proven risks usually outweigh the advantages of judgment that
this patient can
using the method
Use the method
safely use
4
Whitaker AK, Johnson LM, Harwood B, Chiappetta L, Creinin MD, Gold MA. Adolescent and young adult women's knowledge of and attitudes toward the intrauterine device. Contraception 2008;78:211–7
2010 CDC Medical Eligibility Criteria LNG‐IUD
Category 3
•Pregnancy
•Puerperal sepsis
•Post-septic abortion
•Unexplained vaginal bleeding
(initiation only)
•Malignant GTD ↑ hCG
•Cervical/endometrial cancer*
•Uterine anomaly/fibroids**
•Current GC/CT/purulent
cervicitis/PID/pelvic TB
•Benign GTD with ↓ hCG
•Increased risk of STIs (initiation
only continuation is a 2 )***
• AIDS ((nott clinically
li i ll well)
ll)
*Implant 2/1
**with distortion of cavity
*** very high individual risk of
exposure to GC or Ct
Category 4
• Current breast cancer
Category 3
• Positive (or unknown)
antiphospholipid antibodies
• Migraine
g
with aura 2/3
•Past breast cancer (5yrs
NED)
•Severe cirrhosis
•Liver tumors
•IHD 2/3
33
2010 CDC Medical Eligibility Criteria Cu‐IUD
Category 4
Do not use the
method
32
2010 CDC Medical Eligibility Criteria Both IUC Products
Category 4
An unacceptable health risk if the
contraceptive method is used
34
2010 CDC Medical Eligibility Criteria contraceptive etonogestrel implant
Category 3
Severe thrombocytopenia
(initiation only, continuation is
a 2)
35
Category 4
• Current breast cancer
Category 3
• Positive (or unknown)
antiphospholipid antibodies
• Migraine with aura 2/3
•Past breast cancer (5yrs NED)
•Severe cirrhosis
•Liver tumors
•IHD hx and current 2/3
•Stroke 2/3
•Unexplained vaginal bleeding
(before evaluation)
36
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Summary of LARC recommendations for medical conditions U.S. Medical Eligibility Criteria for Contraceptive Use
Summary of LARC recommendations for medical conditions U.S. Medical Eligibility Criteria Condition
LNG‐IUD
Cu‐IUD
Implant
Condition
LNG‐IUD
Cu‐IUD
Implant
1
Menarche to age 20 2
2
1
Headache non‐migraine
1
1
Age 20 and older 1
1
1
Headache migraine without aura
2/2
1
2/2
Nulliparity
2
2
1
Multiple risk factors for CVD
2
1
2
Past ectopic
1
1
1
2
PID (Current)
4/2
4/2
1
Past PID with subsequent pregnancy
1/1
1/1
1
Past PID without subsequent pregnancy
2/2
2/2
1
STIs GC and CT
4/2 4/2
1
Trichomonas and BV
2/2
2/2
1
Hypertension >160/100 or with vascular disease
2
1
Obesity
1
1
1
Smoking (any age)
1
1
1
Breastfeeding < 1 month postpartum
2
Breastfeeding > 1 month postpartum
1
Known thrombogenic mutations
Summary of LARC recommendations for medical conditions added to the U.S. Medical Eligibility Criteria
Condition
LNG‐IUD
Cu‐IUD
Implant
1
History of bariatric surgery
1
1
Peripartum cardiomyopathy
2
2
Rheumatoid arthritis On immunosuppressive therapy
On immunosuppressive therapy
2/1
2/1
1
Rheumatoid arthritis Not on immunosuppressive therapy
1
1
1
Endometrial hyperplasia
1
1
1
Inflammatory bowel disease (IBD) 1
1
1
Solid organ transplantation Complicated
3/2
3/2
2
Solid organ transplantation
Uncomplicated
2
2
2
2
1
2
Summary of other changes in classifications for LARC use from WHO Medical Eligibility Criteria for Contraceptive Use, 4th edition
Condition
LNG‐IUD
Cu‐IUD
Implant
Acute DVT/PE
2 {3}
2 {1}
2
History DVT No change
2 {2}
1 {1}
2
History DVT
Hi
DVT
*Higher risk for recurrent DVT/PE (≥1 risk factors)
2
1
1 2
History DVT
*Lower risk for recurrent DVT/PE (no risk factors) 2
1 2
*New categories
Summary of other changes in classifications for LARC use from WHO Medical Eligibility Criteria for Contraceptive Use, 4th edition
Condition
LNG‐IUD
Cu‐IUD
Implant
Valvular heart disease*
1 {2}
1 {2}
1
Ovarian cancer
1 {3/2}
1 {3/2}
1
Uterine fibroids
Uterine fibroids
2 {1 if no terine
2 {1 if no uterine distortion and 4 if uterine distortion is present}
2 {1 if no terine
2 {1 if no uterine 1
distortion and 4 if uterine distortion is present}
*Complicated (pulmonary hypertension, risk for atrial fibrillation, history of subacute bacterial endocarditis)
Immediate Post Partum IUC Insertion
42
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2010 US MEC: Postpartum IUC Insertion
Summary of other changes in classifications for LARC use from WHO Medical Eligibility Criteria for Contraceptive Use, 4th edition
Condition
LNG‐IUD
Cu‐IUD
Implant
Postpartum < 48 hours
2 {1} (No difference for BF or not)
1{1}
1
2 {3}
2{3}
Postpartum > 48 hours<4 weeks
Cu- T LNG-IUC Comment
<10 minutes 1
after delivery of the placenta
1
2
10 minutes after delivery of the placenta to <4 wks
2
2
≥4 wks 1
1
Evidence:Immediate postpartum Cu‐IUD insertion, particularly when insertion occurs immediately after delivery of the placenta, is associated with lower expulsion rates than is delayed postpartum insertion up to 72 hours postpartum; no data exist that examine times >72 hours postpartum. In addition, postplacental
placement at the time of Cesarean section has lower expulsion rates than does postplacental
vaginal insertions. Insertion complications of perforation and infection are not increased by Cu‐IUD placement at any time during the postpartum period (10–23). No evidence is available that compares different insertion times for the LNG‐IUD. 44
2010 US MEC: Postpartum IUC Insertion


Insert IUC <10 minutes of placental delivery
– Use sponge forceps on cervical lip; 2nd sponge
forceps to insert
– Cut stringg flush with external cervical os
Can insert at time of caesarean section
3/22/2011
Immediate Post abortion IUC Insertion
45
Summary of other changes in classifications for LARC use from WHO Medical Eligibility Criteria for Contraceptive Use, 4th edition
Condition
LNG‐IUD
Cu‐IUD
Implant
Post 1st trimester abortion
1
1
1
Post 2nd trimester abortion
2
2
1
46
Post Abortion IUC Insertion
(WHO & CDC MEC, Cochrane Review)
• No difference in complications for immediate versus delayed insertion of an IUC after abortion • There were no differences in safety or expulsions after There were no differences in safety or expulsions after
insertion of an LNG‐IUC compared to Cu‐IUC
• Expulsion greater when an IUC was inserted following a 2nd
trimester vs. a 1st trimester abortion
48
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ACOG
“Immediate postpartum and postabortal
insertion of an IUD is safe and effective.”
Avoid unnecessary delays, such as waiting to initiate a method until after a postabortion or initiate a method until after a postabortion
or
miscarriage follow‐up visit or to time insertion with menses. Grimes DA, Lopez LM, Schulz KF, Stanwood NL. Immediate postabortal insertion of intrauterine devices. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD001777. DOI: 10.1002/14651858.CD001777. pub2. Grimes DA, Schulz KF, Van Vliet HH, Stanwood NL, Lopez LM. Immediate postpartum insertion of intrauterine devices. Cochrane Database of Systematic Reviews 2001, Issue 2. Art. No.: CD003036. DOI: 10.1002/14651858. CD003036
Given a choice, what methods do h
h d d
women choose?
50
The Contraceptive CHOICE Project
In the United States, currently less than 3% of women use a LARC method. In this initial planned analysis of CHOICE, 56% chose IUC and 11% chose a subdermal
implant Thus two‐thirds
implant. Thus, two
thirds of participants who were not of participants who were not
using a contraceptive method or were willing to switch to a new method chose LARC. The Contraceptive CHOICE Project: g
g
g
reducing barriers to long‐acting reversible contraception
3/22/2011
51
The Contraceptive CHOICE Project
The overwhelming selection of LARC methods among the first 2500 women enrolled in CHOICE is evidence of a greater than expected interest in the use of the most effective, reversible methods of contraception to prevent pregnancy. Secura G, Allsworth J, Madden T, Mullersman JL, Piepert J. The Contraceptive CHOICE Project: reducing barriers to long‐acting reversible contraception Am J
Obstet Gynecol 2010;203:115.e1‐7.
Secura G, Allsworth J, Madden T, Mullersman JL, Piepert J. The Contraceptive CHOICE Project: reducing barriers to long‐acting reversible contraception Am J
Obstet Gynecol 2010;203:115.e1‐7.
The Contraceptive CHOICE Project
• Our project demonstrates the potential for much greater use of LARC methods that are “forgettable” and therefore effectiveness is not dependent on patient adherence. We attribute the high LARC rates to several factors: (1) providing a brief, standardized script explaining LARC to all women screened; (2) removing financial barriers; and (3) offering and providing IUCs to all eligible women, Secura G, Allsworth J, Madden T, Mullersman JL, Piepert J. The Contraceptive CHOICE Project: reducing barriers to long‐acting reversible contraception Am J
Obstet Gynecol 2010;203:115.e1‐7.
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The Contraceptive CHOICE Project
AGE
n
% of total
LARC %
Other %
<18
99
4
3.5
4.9
18‐20
426
17
14.4
22.4
21‐25
1053
42.1
39.8
46.8
>25
922
36.9
42.3
25.9
Secura G, Allsworth J, Madden T, Mullersman JL, Piepert J. The Contraceptive CHOICE Project: reducing barriers to long‐acting reversible contraception Am J
Obstet Gynecol 2010;203:115.e1‐7.
The Contraceptive CHOICE Project
Our ultimate goal is to evaluate whether widespread use of LARC methods will result in a decrease in unintended pregnancies. We will
decrease in unintended pregnancies. We will assess this outcome by determining whether rates of teen pregnancy and repeat abortions (proxy measures for unintended pregnancy) decrease in our region.
Secura G, Allsworth J, Madden T, Mullersman JL, Piepert J. The Contraceptive CHOICE Project: reducing barriers to long‐acting reversible contraception Am J
Obstet Gynecol 2010;203:115.e1‐7.
The Contraceptive CHOICE Project
The Contraceptive CHOICE Project
In conclusion, by removing the financial barrier to all contraceptive methods, introducing LARC methods as a first‐line contraceptive option, and addressing misperceptions regarding LARC dd
i
i
ti
di LARC
methods, CHOICE has provided almost 1700 of the first 2500 participants with a long‐acting reversible method of contraception. Our multivariable analysis suggests that although we found statistically significant demographic and behavioral predictors of LARC acceptance, the associations are small and unlikely to be clinically
associations are small and unlikely to be clinically meaningful. We believe these initial results suggest there is not a particular type of woman who selects LARC; rather LARC methods are acceptable and wanted by a diverse group of women who are considering a new method of contraception.
Secura G, Allsworth J, Madden T, Mullersman JL, Piepert J. The Contraceptive CHOICE Project: reducing barriers to long‐acting reversible contraception Am J
Obstet Gynecol 2010;203:115.e1‐7.
ACOG
Advantages
Disadvantages
• Are independent from coitus • up‐front costs and user motivation and • the need for office visits for adherence insertion and removal
• Have the highest effectiveness, continuation rates, and user ti
ti
t
d
satisfaction • Do not require frequent visits for resupply • Require no additional funding for consistent use once they have been placed • Are highly cost‐effective • Are reversible, with a rapid return to fertility after removal Secura G, Allsworth J, Madden T, Mullersman JL, Piepert J. The Contraceptive CHOICE Project: reducing barriers to long‐acting reversible contraception Am J
Obstet Gynecol 2010;203:115.e1‐7.
ACOG
“Because of these advantages and the potential to reduce unintended pregnancy rates, LARC methods should be offered as first‐line contraceptive methods and encouraged as contraceptive methods
and encouraged as
options for most women.”
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ACOG
“Although there is a slight increased risk of infection in the first 20 days after IUD insertion, evidence indicates there is no increased risk of pelvic inflammatory disease or infertility in IUD
pelvic inflammatory disease or infertility in IUD users.”
Association between IUC use and PID
61
Intrauterine device. ACOG Practice Bulletin No. 59. American College of Obstetricians and Gynecologists. Obstet Gynecol 2005;105:223–32. SFP Conclusion and Recommendations
The following recommendations are based on good and consistent scientific evidence (Level A):
• IUDs do not increase the risk of pelvic infection or infertility
or infertility. • Levonorgestrel‐based devices reduce users‘ risk of pelvic infection.
Pre‐screening for STD b f
STDs before
IUC Insertion
64
ACOG‐ Recommendations
The following strategies can reduce barriers and increase use of implants and IUDs: • Adopt same‐day insertion protocols. Screening for chlamydia, gonorrhea, and cervical cancer should not be required before implant or IUD insertion but may be obtained on the day of insertion, if indicated. The Contraceptive CHOICE Project
Access to contraceptive methods is improved by immediate start of OCPs, vaginal ring, transdermal patch, DMPA, and .
Secura G, Allsworth J, Madden T, Mullersman JL, Piepert J. The Contraceptive CHOICE Project: reducing barriers to long‐acting reversible contraception Am J
Obstet Gynecol 2010;203:115.e1‐7.
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Comparison of the Incidence of PID in IUD users by GC & CT screening stategies
• Kaiser Permanente Northern California
• 55,250 women
• 26,411 (47.8%) unscreened
• 5354 (9.7%) screened same day
• 10,442 (18.9%) screened within 8 weeks prior
Conclusions: “No difference in PID rates between screened and unscreened women or by time screened.”
Sufrin C, Postlewaite D, Armstrong MA, Merchant M, Steinhauer Comparison of the Incidence of PID in IUD users by GC & CT screening stategies. Oral Abstract Contraception 2010;82:186
Planned Parenthood
MEDICAL SCREENING AND EVALUATION
History — Targeted medical and sexual history must be completed within the past year and annually thereafter. It must include, but is not limited to • contraindications, special conditions, and other circumstances for consideration (as listed above)
• history and risk of sexually transmitted infections
• possible pregnancy
• history of breast mass (LNG IUC)
• post delivery and breastfeeding status (LNG IUC)
Physical exam requirement immediately prior to insertion —
• Pelvic — including speculum and bimanual exams to determine uterine size and position.
• Limited ultrasound may be useful when palpation/confirmation of uterine position is difficult on bimanual exam.
The following tests should be performed, if indicated
• hematocrit or hemoglobin
• tests for cervical infection — gonorrhea and chlamydia
• wet prep and tests for other STIs
2010 Planned Parenthood Federation of America Manual of Medical Standards and Guidelines
ACOG
Planned Parenthood
From:
ACOG Practice bulletin Number 112, May 2010 IUD insertion as emergency contraception • A Cu IUC may be effective in preventing pregnancy when inserted within five days following unprotected mid cycle coitus
following unprotected, mid cycle coitus.
• If not otherwise contraindicated, a Cu IUC may be inserted for the purpose of both emergency and long‐term contraception.
Emergency Contraception
“The copper IUD is appropriate for use as emergency contraception for women who desire long‐acting contraception.”
2010 Planned Parenthood Federation of America Manual of Medical Standards and Guidelines
Pilot project shows
women will choose Cu IUD for EC
• Prospective observational study offering emergency contraception with either the copper intrauterine device or oral levonorgestrel
• 60% chose oral LNG
• 40% chose the copper IUD
Turok DK, Gurtcheff SE, Handley E, Simonsen SE, Sok C, Murphy P. 2010. A pilot study of the Copper T380A IUD and oral levonorgestrel for emergency contraception. Contraception. 82(6):520‐5. Epub 2010 Jul 15
Planned Parenthood
CLIENT SELECTION
Indications —An IUC may be provided to clients who do not have any contraindications as listed below. below
• In addition to its use as a contraceptive, the Mirena may be considered for a woman who has moderate or severe dysmenorrhea, menorrhagia, or anemia.
2010 Planned Parenthood Federation of America Manual of Medical Standards and Guidelines
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Planned Parenthood
Contraindications —
• Personal Characteristics and Reproductive History
–
–
–
•
Reproductive Tract Infections and Disorders
–
–
–
–
–
–
•
•
•
pregnancy or suspicion of pregnancy (USMEC, 4)
postabortal or postpartum endometritis or septic abortion in past three months (USMEC, 4) known or suspected allergy to copper or history of Wilson's disease (for Cu IUC only, i.e., do not use Cu IUC)
undiagnosed abnormal vaginal bleeding (USMEC, 4)
history of gestational trophoblastic disease with persistently elevated β‐hCG levels or malignant disease (USMEC, 4)
known cervical cancer that has yet to be treated (USMEC, 4)
known or suspected breast cancer (LNG IUC only, i.e., do not use LNG IUC) (USMEC, 4)
known endometrial cancer (USMEC 4)
known endometrial cancer (USMEC, 4)
abnormalities of the uterus resulting in distortion of the uterine cavity such that proper placement is prevented (USMEC, 4)
congenital uterine anomalies (bicornuate, septate, etc.)
large or obstructive myomata
NOTE: LNG IUC may be used as treatment to control bleeding in women with these conditions. It can be used for contraception if correct placement is possible. There is no published data on the rate of expulsion or pregnancy in IUC users with myomata.
–
–
–
–
–
–
Planned Parenthood
CLIENT SELECTION
Indications —Implant placement may occur if
• contraindications do not exist
• a long‐term, high‐efficacy, not‐coitus‐dependent, a long term high efficacy not coitus dependent
private method is desired
Contraindications —
• Reproductive Tracts Infections and Disorders
– Breast cancer —current (USMEC, 4), suspected, and past (USMEC, 3)
Current PID (USMEC, 4) known or suspected untreated chlamydia, gonorrhea, mucopurulent cervicitis (USMEC, 4) known pelvic tuberculosis (USMEC, 4)
history of symptomatic pelvic actinomycosis confirmed by a culture (not asymptomatic colonization, see below) or current evidence of colonization in a woman without an IUC in place
small uterine cavity with sounding less than 6.0 cm
suspected or known uterine perforation occurring with the placement of a uterine sound during the current insertion procedure 2010 Planned Parenthood Federation of America Manual of Medical Standards and Guidelines
2010 Planned Parenthood Federation of America Manual of Medical Standards and Guidelines
ACOG
ACOG
“Both the implant and IUDs are highly cost‐
effective even with relatively short‐term (12–24 months) use.”
“To increase use of LARC methods, barriers such as lack of health care provider knowledge or skills, low patient awareness, and high upfront costs must be addressed ”
costs must be addressed.
Trussell J, Lalla AM, Doan QV, Reyes E, Pinto L, Gricar J. Cost effectiveness of contraceptives in the United States. Contraception 2009;79:5–14. Foster DG, Rostovtseva DP, Brindis CD, Biggs MA, Hulett D, Darney PD. Cost savings from the provision of specific methods of contraception in a publicly funded program. Am J Public Health 2009;99:446–51. Chiou CF, Trussell J, Reyes E, Knight K, Wallace J, Udani J, et al. Economic analysis of contraceptives for women. Contraception 2003;68:3–10. ACOG‐ Recommendations
The following strategies can reduce barriers and increase use of implants and IUDs: • Support efforts to lower the up‐front costs of LARC methods. • Advocate for coverage of all contraceptive Advocate for coverage of all contraceptive
methods by all insurance plans, both private and public. • Become familiar with and support local, state, federal (including Medicaid), and private programs that improve affordability of all contraceptive methods, including implants and IUDs. ACOG‐references
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Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy In the United States, 1994 and 2001. Perspect Sex Reprod Health 2006;38(2):90–
6. Kissin DM, Anderson JE, Kraft JM, Warner L, Jamieson DJ. Is there a trend of increased unwanted childbearing among young women in the United States? J Adolesc Health 2008; 43:364–71. Hatcher RA, Trussell J, Nelson AL, Cates W Jr, Stewart F, Kowal D, editors. Contraceptive technology. 19th rev. ed. New York (NY): Ardent Media, Inc.; 2007. Halpern V, Grimes DA, Lopez LM, Gallo MF. Strategies to improve adherence and acceptability of hormonal methods of contraception. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD004317. DOI: 10.1002/14651858. CD004317.pub2. Moos MK, Bartholomew NE, Lohr KN. Counseling in the clinical setting to prevent unintended pregnancy: an evidence‐based research agenda. Contraception 2003;67: 115–32. Lopez LM, Newmann SJ, Grimes DA, Nanda K, Schulz KF. Immediate start of hormonal contraceptives for contraception. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD006260. DOI: 10.1002/14651858.CD006260. pub2. Trussell J, Schwarz EB, Guthrie K, Raymond E. No such thing as an easy (or EC) fix. Contraception 2008;78:351–4. Trussell J, Wynn LL. Reducing unintended pregnancy in the United States. Contraception 2008;77:1–5. Chandra A, Martinez GM, Mosher WD, Abma JC, Jones J. Fertility, family planning, and reproductive health of U.S. women: data from the 2002 National Survey of Family Growth. Vital Health Stat 23 2005;(25):1–160. Institute of Medicine (US). Initial national priorities for comparative effectiveness research. Washington, DC: National Academies Press; 2009. Stevens‐Simon C, Kelly L, Kulick R. A village would be nice but...it takes a long‐acting contraceptive to prevent repeat adolescent pregnancies. Am J Prev Med 2001;21:60–5. Goodman S, Hendlish SK, Reeves MF, Foster‐Rosales A. Impact of immediate postabortal insertion of intrauterine contraception on repeat abortion. Contraception 2008;78: 143–8. Heikinheimo O, Gissler M, Suhonen S. Age, parity, history of abortion and contraceptive choices affect the risk of repeat abortion. Contraception 2008;78:149–54. World Health Organization. Medical eligibility criteria for contraceptive use. 3rd ed. Geneva: WHO; 2004. Available at: http://whqlibdoc.who.int/publications/2004/9241562668.pdf. Retrieved August 13, 2009. World Health Organization. Medical eligibility criteria for contraceptive use: 2008 update. Geneva: WHO; 2008. Available at: http://whqlibdoc.who.int/hq/2008/WHO_ RHR_08.19_eng.pdf. Retrieved August 13, 2009. Harper CC, Blum M, de Bocanegra HT, Darney PD, Speidel JJ, Policar M, et al. Challenges in translating evidence to practice: the provision of intrauterine contraception. Obstet Gynecol 2008;111:1359–69. Intrauterine device and adolescents. ACOG Committee Opinion No. 392. American College of Obstetricians and Gynecologists. Obstet Gynecol
2007;110:1493–5. 13
3/22/2011
SFP References
SFP References
[1] Hatcher RA, Trussell J, Nelson A, Cates W, Stewart F, Kowal D. Contraceptive technology 19th edition; 2008.
[2] ACOG Practice Bulletin #59. Obstet Gynecol 2005;105:223.
[3] The Guttmacher Institute. Facts on contraceptive use. Jan 2008. Available at: http://www.guttmacher.org/pubs/fb_contr_use.pdf(Accessed March 2009).
[4] National Survey of Family Growth 2002, Centers for disease control and prevention.
[5] Stanwood NL, Garrett JM, Konrad TR. Obstetrician–gynecologists and the intrauterine device: a survey of attitudes and practice. Obstet Gynecol 2002;99:275–80 [Evidence grade: II‐2].
[6] Stubbs E Schamp A. The evidence is in. Why are IUDs still out? Family physicians
[6] Stubbs E, Schamp
A The evidence is in Why are IUDs still out? Family physicians' perceptions of risk perceptions of risk
and indications. Can Fam Physician 2008;54:560–6 [Evidence grade: II‐2].
[7] Wellings K, Zhihong Z, Krentel A, Barretta G, Glasier A. Attitudes towards long‐acting reversible methods of contraception in general practice in the UK. Contraception 2007;76(3):208–14 [Evidence grade: II‐2].
[8] Stanwood NL, Bradley KA. Young women's knowledge of modern intrauterine devices. Obstet
Gynecol 2006;108(6):1417–22 [Evidence grade: II‐2].
[9] Asker C, Stokes‐Lampard H, Beavan J, Wilson S. What is it about intrauterine devices that women find unacceptable? Factors that make
women non‐users: a qualitative study. J Fam Plan Reprod Health Care 2006;32(2):89–94 [Evidence grade: II‐2].
[10] Available online at: http://www.paragard.com/health_care_professional/global/pdf/Prescribing‐
Info.pdf (Accessed March 2009)
[11] Available online at: http://berlex.bayerhealthcare.com/html/products/pi/Mirena_PI.pdf (Accessed March 2009)
[12] World Health Organization. Medical eligibility criteria for contraceptiveuse; 2004. updated 2008. Available online at:http://www.who.int/reproductive‐health/publications/mec/mec.pdf.
[13] Suhonen S, Haukkamaa M, Jakobsson T, Rauramo I. Clinical performance of a levonorgestrel‐releasing intrauterine system and oral contraceptives in young nulliparous women: a comparative study. Contraception 2004;69(5):407–
12 [Evidence grade: I].
[14] Brockmeyer A, Kishen M, Webb A. Experience of IUD/IUS insertions and clinical performance in nulliparous
women—a pilot study. Eur J Contracept Reprod Health Care 2008;13(3):248–54 [Evidence grade:II‐2].
[15] Wildemeersch D, Janssens D, Vrijens M, Weyers S. Ease of insertion, contraceptive efficacy and safety of new T‐
shaped levonorgestrel‐releasing intrauterine systems. Contraception 2005;71(6):465–9 [Evidence grade: III].
[16] Wildemeersch D, Janssens D, Andrade A. The Femilis LNG‐IUS:contraceptive performance — an interim analysis. Eur J Contracept Reprod Health Care 2009;14(2):103–10 [Evidence grade: III].
[17] Prager S, Darney PD. The levonorgestrel intrauterine system in nulliparous women. Contraception 2007;75(Suppl):S12‐5.
[18] Sivin I, Stern J, Coutinho E, et al. Prolonged intrauterine contraception:a seven year randomized study of the levonorgestrel 20 mcg/day (LNg20) and the Copper T380 Ag IUDs. Contraception 1991;44:473–80 Evidence grade: I]. 20) and the Copper T380 Ag IUDs. Contraception 1991;44:473–80
Evidence grade: I].
[19] Veldhuis H, Vos A, Lagro‐Janssen A. Complications of the intrauterine device in nulliparous and parous women. Eur
J Gen Pract 2004;10(3):82–7 [Evidence grade: III].
[20] Dueñas JL, Albert A, Carrasco F. Intrauterine contraception in nulligravid vs parous women. Contraception 1996;53(1):23–4 [Evidence grade: II‐3].
SFP References
SFP References
[21] Hubacher D. Copper intrauterine device use by nulliparous women: review of side effects. Contraception 2007;75(Suppl):S8–11 [Evidence grade: I].
[22] Rivera R, Chen‐Mok M, McMullen S. Analysis of client characteristics that may affect early discontinuation of the TCu‐380A IUD. Contraception 1999 Sep;60(3):155–60 [Evidence grade: III].
[23] Caliskan E, Oztürk N, Dilbaz BO, Dilbaz S. Analysis of risk factors associated with uterine perforation by intrauterine devices. Eur J Contracept Reprod Health Care 2003;8(3):150–5 [Evidence grade:III].
[24] Tatum HJ, Schmidt FH, Phillips D, McCarty M, O'Leary WM. The Dalkon Shield controversy. Structural and bacteriological studies of IUD tails. JAMA 1975;231(7):711–7 [Evidence grade: III].
[25] Ebi KL, Piziali RL, Rosenberg M, et al. Evidence against tailstrings increasing the rate of pelvic inflammatory disease among IUD users. Contraception 1996;53:25 [Evidence grade: III].
[26] Lee NC, Rubin GL, Ory HW, Burkman RT. Type of intrauterine device and the risk of pelvic inflammatory disease. Obstet Gynecol 1983;62:1–6 [Evidence grade: III].
[27] Lee NC, Rubin GL, Borucki R. The intrauterine device and pelvic inflammatory disease revisited: new results from the Women's Health Study. Obstet Gynecol 1988;72:1–6 [Evidence grade: II‐2].
[28] Farley TM, Rosenberg MJ, Rowe PJ, Chen JH, Meirik O. Intrauterine devices and pelvic inflammatory disease: an international perspective. Lancet 1992;339(8796):785–8 [Evidence grade: II‐3].
[29] Toivonen J, Luukkainen T, Allonen H. Protective effect of intrauterine release of levonorgestrel on pelvic infection: three years' comparative experience of levonorgestrel‐ and copperreleasing intrauterine devices. Obstet Gynecol
1991;77(2):261–4 [Evidence grade: I].
[30] Randic L, Vlasic S, Matrljan I, Waszak CS. Return to fertility after IUD removal for planned pregnancy. Contraception 1985;32(3):253–9 [Evidence grade: III].
[31] Hubacher D, Lara‐Ricalde R, Taylor DJ, Guerra‐Infante F, Guzman‐Rodriguez R. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. N Engl J Med 2001;345:561 [Evidence grade: II‐1].
[31] Hubacher D, Lara‐Ricalde R, Taylor DJ, Guerra‐Infante F, Guzman‐Rodriguez R. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. N Engl J Med 2001;345:561 [Evidence grade: II‐1].
[32] Farmer M, Webb A. Intrauterine device insertion‐related complications:can they be predicted? J Fam Plann Reprod
Health Care 2003;29:227–31 [Evidence grade: III].
[33] Hubacher D. Pain from copper intrauterine device insertion randomized trial of prophylactic ibuprofen. Am J Obstet
Gynecol 2006;195:1272–7 [Evidence grade: I].
[34] Fiala C, Gemzell‐Danielsson K, Tang OS, von Hertzen H. Cervical priming with misoprostol prior to transcervical
procedures. Int J Gynaecol Obstet 2007;99(Suppl 2):68–71 [Evidence grade: II‐2].
[35] Sääv I, Aronsson A, Marions L, Stephansson O, Gemzell‐Danielsson K. Cervical priming with sublingual misoprostol
prior to insertion of an intrauterine device in nulliparous women: a randomized controlled trial. Hum Reprod
2007 22(10) 2647 52 [E id
2007;22(10):2647–52 [Evidence grade: I].
d I]
[36] Allen RH, Bartz D, Grimes DA, Hubacher D, O'Brien P. Interventions for pain with intrauterine device insertion. Cochrane Database Syst Rev 2009(3), doi:10.1002/14651858.CD007373.pub2. Art. No.: CD007373 [Evidence grade: I].
[37] ACOG Committee Opinion No. 392. Intrauterine device and adolescents Obstet Gynecol. 2007; 110(6):1493–5 [Evidence grade:III].
[38] Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health 2006;38 (2):90–6 [Evidence grade: II‐2].
[39] Gold MA, Johnson LM. Intrauterine devices and adolescents. Curr Opin Obstet Gynecol 2008;20(5):464–9 [Evidence grade: III].
[40] Otero‐Flores JB, Guerrero‐Carreño FJ, Vázquez‐Estrada LA. A comparative randomized study of three different IUDs in nulliparous Mexican women. Contraception 2003;67(4):273–6 [Evidence grade:II‐2].
[41] Sivin I. Problems in the conduct and analysis of “a comparative randomized study of three different IUDs in nulliparous Mexican women”. Contraception 2004;69(3):259–60 [Evidence grade: III].
[42] O'Brien PA, Kulier R, Helmerhorst FM, Usher‐Patel M, d'Arcangues C. Copper‐containing, framed intrauterine devices for contraception: a systematic review of randomized controlled trials. Contraception 2008;77(5):318–27 [Evidence grade: I].
Reminders
• Moderating: Elizabeth Locke
– lockee@cfhc.org
• Handouts
• Follow‐Up Survey
– Zoomerang survey in 6 weeks (Look for that in your e‐mail the week of May 3rd.)
• CEUs
2/15/2011
83
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