Case Studies in
Family Planning
Jennifer McCaul MD
Family Medicine Refresher
Course
March 6, 2015
Unintended Pregnancy
Of 3.2million pregnancies
per year in US- 49% are
unintended.
› 43% of unintended
pregnancies end in
termination.
› Highest rate in teens and
young adults.- almost
10% 18-24 year olds
yearly.
› Obese women are at
higher risk of unintended
pregnancy.
› Women > 40 have the
second highest rate of
unintended pregnancy.
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Patient Driven
Contraception Selection
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Selection of best family planning
method for your patient requires
working together.
Questions to ask:
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pMHx?
Smoker?
Male or female partners?
FHx stroke or blood clots?
Age?
Frequency of intercourse?
Need for STD protection?
Are you good at taking meds?
Need for non-contraceptive benefits?
Cost?
Desired degree of permanence?
Comfort with insertion/vaginal?
Tolerance of irregular bleeding?
Weight?
Breastfeeding?
Baseline menstrual characteristics?
What has worked/not worked in past?
What are the options?
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Combined oral
contraceptives (COCs)
Natural family
planning/fertility
awareness
Withdrawal
Progestin-only pill
Depo-Provera
Copper IUD (Paragard)
Levonorgestrel IUD
(Mirena, Skyla)
Emergency
contraception
Spermicides
Progestin Implant
(Nexplanon)
› Nuva Ring
› Evra Patch
› Diaphragm
› Male Condoms
› Female condoms
› Tubal ligation
› Essure
› Lactational
Amenorrhea
› Vasectomy
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Effectiveness of Family
Planning Methods
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Effectiveness ranges
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Most effective with <1 pregnancy/100
women/ 1year
› Implant,
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More effective
› Depo,
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IUD, vasectomy, Tubal, essure
LAM, pills, patch, ring
Less effective
› Condoms,
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diaphragm, FAM
Least effective with approx 30
pregnancies/100 women/1year
› Withdrawal,
spermicides
Choosing the right method
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If difficulties arise:
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WHO and CDC both have published, easily
accessible guidelines regarding elegibility
for contraception and recommended
methods for comorbid diseases.
Nexplanon
Etonorgestrel implant
Good for 3 years
0.05% failure rate
Implanted into biceps groove in
office visit
Removed through sm incision
Manufacturer training mandatory
Menstrual irregularities common
Acne/wt gain less common
Likely less effect on BMD then depo
Paragard
Copper IUD
Effective for 10 years
Menses are heavier
NSAIDs effective to decrease
No hormone side effects
>99% Effective – typical use
Mirena
Levonorgestrel releasing IUS
Local progestin
Effective for 5 years
Menses Lighten- approved for
treatment of menorrhagia
Hormone side effects are rare
>99% effective -typical use
Skyla
Low dose LNG-IUS
Good for 3 years
Less progestin side effect
Radio-opaque ring to allow
x-ray visualization
Depot
Medroxyprogesterone
Acetate
Every 3 mo intramuscular inj
Can initiate any time if preg (-)
Back up for 7 days if not within 5
days of start of menses
Highly effective 96%
Wt gain- worse in obese women
Bleeding irregularly
Decrease BMD-returns after stopping
DEXA not recommended
Delayed fertility return
Combined Oral
Contraceptive
Pills (COCs)
Safe for most young women
Typical use effectiveness 92%
Benefit – acne treatment and
regulated cycles
Many contraindicationsparticularly in older women
with comorbid conditions
May be less effective in obese
women
Also 3 mo- Seasonale,
Seasonique
12 mo- lybrel
Contraceptive
Patch (Evra)
Weekly transdermal patch
Estrogen and progesterone
Continuous delivery
Less effective in wt > 90 kg
Higher risk of VTE
Vaginal
Contraceptive
Ring (Nuva)
3 wks in, 1 wk out
Lowest estrogen dose- continuous
Use back up if out > 3 hrs
And now for the Cases….
Mary is a 46 year old who has been on the pill for
many years and still does not want to become
pregnant. She is a non-smoker, nl BMI and otherwise
healthy. Which of the following could be a good
option for her?
› A. Continue the OCP
› B. Place a paragard
› C. Refer for Tubal
› D. Place a Nexplanon
› E. Tell her to stop pill
and not to worry, she
probably can’t get
pregnant
› F. All of the above
› G. A, B, C and D
When to stop the Pill?
In a non-smoker, in absence of other adverse
clinical conditions, the pill can generally be
safely continued to menopause.
› Check FSH annually on day 6-7 of the
placebo pills to decide if the pill can be
discontinued.
› There may be a small increased risk of breast
cancer in pill users.
› There is probably a decreased risk of ovarian
and endometrial cancer with pill usage.
› There is an increased incidence of VTE and
risk factors should be re-evaluated often.
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How to start the Pills…..
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If a new start or has been off pill for a
while
Quick start- if pregnancy test negative and
> 5 days since LMP then barrier for 5-7 days
› BP should always be checked
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Jill is a 25 yo G1P1, in a monogamous
relationship, wishes to space her
pregnancies. She is 64”, 225 lbs. and still
trying to lose her baby weight. She
wonders what the best method for her is.
Which is the least appropriate method for
her?
A. LNG-IUS
› B. Depo
› C. OCP
› D. Copper IUD
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Best options for the Obese
patient
Depo-provera causes up to 20 lb wt gain
› OCP associated VTE risk increases in obese
patients, use particular care in smokers
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WHO identifies BMI >25 as an independent risk
factor for VTE with OCP use.
Obese OCP users are 2X as likely to have arterial
embolic disease or MI as non-obese
› Contraceptive patches are less effective in
obese women and recommended to be used
only with caution in women >90kg.
› Vaginal ring contraception is not thought to be
affected by weight.
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Kari is a 16 yo G0P0 who presents for
her initial gyn visit and asks for
contraception, she has recently
become sexually active with her first
partner. Non-smoker. Regular menses.
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You first appropriately
recommend:
A. A pap smear
› B. A complete gyn exam
› C. Screening for Chlamydia
› D. Telling her mother
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You ask Kari a number of questions and
find out she has a hard time keeping to
a regular schedule and does not think
she will remember pills.
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Turns out she is not
alone:
OCP Adherence in
Adolescents
45% at 3 mos
33% at 12 mos
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Options you offer
her include:
Patch
› Ring
› IUD
› Implant
› Condoms (for STD
protection alone)
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Which of the following is true
about intrauterine contraceptive
use in adolescents?
A. If the patient is found to have STD at the
time of insertion, the IUD should be removed
› B. IUDs are no more likely to be expelled when
inserted in nulliparous patients than in their
parous counterparts.
› C. Unintended pregnancy is up to 22X more
frequent in short acting contraceptive users
than in adolescents using LARC.
› D. Adolescents who use LARC are more likely
to be infertile later in life.
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The “Active” Adolescent
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42 percent of US teens aged 15-19 have had
sexual intercourse.
82 percent of adolescent pregnancies are
unplanned.
Short acting methods have higher discontinuation
rates and higher pregnancy rates than LARCsand are chosen by a majority of teens.
Intrauterine device usage is safe in adolescents,
does not increase infertility, does not increase risk
of PID after 20 days after insertion.
If STD+ at time of insertion, leave in place and
treat.
Although IUDs can be inserted relatively easily in
nulliparous patients there may be a higher risk of
expulsion in these patients. No benefit from
misoprostol.
Be sure to counsel about cost, confidentiality and
expected changes in menstrual cycle.
Tina is a 20 year old university student
who presents to your clinic 8 hours after
an episode of intercourse with her
boyfriend during which they noticed
that the condom “broke.” She is
worried about preventing pregnancy.
With perfect use of
condoms the
failure rate is 14%
at one year.
› FYI…..NO ONE has
perfect use of
condoms
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Tina has never used another method of
contraception. After counseling Tina
about her options at this stage, she
opts for emergency contraception.
Which of the following is true?
A. She should not have any side effects at all
from use of emergency contraception.
› B. Emergency contraception requires a
prescription.
› C. Patients taking emergency contraception
may not get their next menses for months.
› D. It may be worthwhile to give a second
dose on the prescription in case of vomiting
within ½ hr of use.
› E. EC must be taken within 12 hours of
unprotected intercourse.
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Emergency Contraception
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Options include:
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High dose Levonorgestrel (plan B, next
choice)
High dose COC (Yuzpe method- two-six
tabs taken twice, 12 hr apart)
Ullipristal (Ella)
Copper IUD Placement
All should be done within 5 days of
intercourse
Next menses generally within 1 wk of nl
schedule.
Progestin only typically more effective
and with less side effects but all should
be given with anti-emetics.
Janet is a 36 year old G3P3 whose history includes a
DVT in her last pregnancy. She has stopped her
coumadin and is worried about unintended
pregnancy, she asks you what she can do to
prevent it, knowing hormones are risky. Your advice
would be:
A. Tubal ligation
› B. Copper IUD
› C. Natural family planning
› D. Essure
› E. Barrier methods
› F. All of the above
› G. None of the above
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The patient who cannot
tolerate hormones….
There are multiple non-hormonal methods
available to this patient population.
› Important questions to ask:
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When (if ever) do you want to become pregnant?
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IUD (probably both fine), NFP, barrier methods
› >5y- copper iud
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How imperative is it that you avoid pregnancy?
› Very-
IUD
› Not- NFP, barrier, withdrawal
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Are you done with your childbearing?
› Yes-Essure,
tubal, vasectomy
The patient with prior VTE
The mechanism of increased risk of VTE is
increased liver production of clotting
factors.
› In theory progestin only contraceptives
(implant, IUD, Depo, mini-pill) should not
increase risk of VTE.
› Remember to inquire about menorrhagiacopper IUD can worsen this.
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NFP/Fertility
Awareness/Withdrawal
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Effectiveness ranging from 3% annual pregnancy
rate to 27%.
Best for couples that are monogamous, mutually
dedicated to avoiding contraception and for
whom unplanned pregnancy is acceptable due
to high failure rate.
For more information including provider education
courses http://www.usccb.org/issues-andaction/marriage-and-family/natural-familyplanning/what-is-nfp/science/nfp-education-forhealthcare-professionals.cfm
Essure- An alternative to BTL
Permanent
› Non-hormonal
› Office-Based
hysteroscopy
› Well-tolerated
› Needs test for
confirmation
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Gwen is a 28 year old presenting to your
office requesting contraception. PMHx of
SLE and depression.
Smokes 1ppd. BMI 32. BP 138/72. Which of
the following is a contraindication to
COCs?
A. Borderline BP
› B. SLE
› C. Depression
› D. Smoker
› E. Obesity
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Contraindications to COCs
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Absolute
VTE hx
› SLE
› Smoker >35
› Liver disease
› Estrogen
responsive tumor
› Uncontrolled HTN
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Relative
Smoker <35
› Depression
› Migraine
› Obesity
› Family/personal
history of Breast
Cancer
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Non-contraceptive benefits to
OCPs
Cycle regulation
› Treatment dysmenorrhea/menorrhagia
› Treatment of acne
› Hormonal HA may improve with extended
cycle
› Decreased risk of endometrial and
ovarian cancer.
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Cindy is 22, nulliparous, has been on depo for
2 cycles. She is having irregular bleeding and
is frustrated. She wants to know how long
should she try to wait it out?
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Amenorrhea with Depo
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Month 1
› 50%
have < 8 days monthly
› 40% have 11-30 days
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Month 3
› 30%
amenorrhea
› 35% 11-30 days
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Month 12
› 60%
amenorrhea
› 80% 1-7 days spotting
Treatment of Progestin only
bleeding
Can occur with mini-pill, IUD, implant and
Depo
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Estrogen alone- 21 days then 7 days break
› COC- 21 days then 7 day break
› NSAIDS- 5-7 days
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Levonorgestrel IUS- Average at 1year
10% bleed monthly
› 20% amenorrhea
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Sarah is a 31yo G4P4 who has had a Paragard
IUD in for the last 4 years. She is generally
happy with it but she could not feel the strings
on her check this month. On exam you can
not feel the strings. What is your next step?
A. Quantitative HCG
› B. Ultrasound
› C. add COCs
› D. reassure her- its probably still in there…
› E. A and B
› F. all of the above
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Management of Missing
IUD strings- Is it in the
Abdomen, Uterus or Sewer?
Managing Missing IUD strings
You must find the IUD- Can’t assume it fell out, you
must check KUB (if pregnancy is negative).
› If b-HCG >1500- IUP should be visible- if not r/o
ectopic
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IUDs reduce total risk and number of ectopic and
intrauterine pregnancies.
However, the ratio of ectopic/intrauterine
pregnancies is increased when an IUD is in place.
If pregnancy on US, and the IUD is below it,
pregnancy outcomes improve with removal.
› If in place on TVUS and strings are not visible can
leave in place until removal necessary, remove
with removal device, remove with hysteroscopy.
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Amy is a 24 yo G1P1 who is 3 months
postpartum. She inquires about
breastfeeding safe contraception that won’t
affect her milk supply. Which of the following
options is the least appropriate?
A. Mirena IUD
› B. COCs
› C. Skyla IUD
› D. Progestin only pill
› E. Paragard IUD
› F. Nexplanon implant
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The Breastfeeding Mom
Lactational amenorrhea method is a highly effective
temporary method of contraception.
› Another method of contraception must be used as
soon as any of the following occurs:
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menstruation resumes
the frequency or duration of breastfeeding is reduced
bottle feeds are introduced
the baby reaches 6 months of age.
Progestin only, copper IUD, and barrier contraceptive
methods are all safe in the breastfeeding mom and
will not affect her milk supply.
› Progestin only minipill may be less effective at
prevention of pregnancy than other methods.
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Conclusion
Successful initiation and maintenance of
effective family planning requires
collaboration between physician and
patient and may prevent millions of
unintended pregnancies yearly.
› Talk with your patients and take time to
explain side effects. It will result in better
continuation rates and longer term
success.
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Questions?????
Thank you
References available on request.