Using the Best Evidence to
Select the Best Contraceptive
Jody Steinauer, MD, MAS
Dept. Ob/Gyn & Reproductive Sciences
University of California, San Francisco
Disclosure Statement
I have nothing to disclose.
Do you place intrauterine contraception in your
clinical practice?
a. Yes
b. No
How comfortable would you be offering a
woman an IUD if she had a history of
Chlamydia and no current infection?
a. Very comfortable
b. Somewhat comfortable
c. Uncomfortable
Would you offer a 20 year-old woman with
migraine the combined oral contraceptive?
a. Yes
b. It depends
c. No
Objectives
Remember contraception in your clinical practice.
Find evidence about contraception for women with
possible contraindications.
Encourage women to use longer acting methods.
Address recent controversies and myths.
Review extremely recent & important information.
Jane is a 27 year-old woman taking combined
oral contraceptive pills, who presents to your
clinic for an annual examination. She reports
having missed two periods. Her urine
pregnancy test is positive.
6.4 Million US Pregnancies Annually
52 %
Intended
48 %
Unintended
Jones PSRH 2008
6.4 Million U.S. Pregnancies Annually
25 % Unintended
Despite method use
52 %
Intended
23 % Unintended
No method used
Henshaw Family Planning Perspectives, 1998
Why did Jane get pregnant?
Jane ran out of pills last month. She tried to
schedule an appointment, but because she
was overdue for a pap smear the clinic staff
couldn’t call in refills. Today was the first day
she could get an appointment.
Provider Barriers to Contraception
• Clinical Visit
– BP check to initiate estrogen-containing methods
– No pap smear or other examination
– Refill methods without seeing patient
• Remember birth control
– 48% using D or X rx counseled on contraception1
• Knowledge about contraindications
– US guidelines
Schwarz Ann Intern Med, 2007.
Case: Counseling Issues
After Jane has completed her pregnancy she
returns to you for contraceptive counseling.
Jane has had migraine headaches since she
was a teen. She has no aura and they have
not changed with the combined pill.
Can she use the pill again?
Can my patient use this method?
WHO Medical Eligibility Criteria (MEC)
www.reproductiveaccess.org
www.who.int
1
2
Can use the method
Can use the method
3
Should not use method
unless no other method
is appropriate
Should not use method
4
No restrictions
Advantages generally
outweigh theoretical or
proven risks.
Theoretical or proven risks
generally outweigh
advantages
Unacceptable health risk
Birth control
methods
Medical
conditions
MEC Category
US MEC: 2010
• Current WHO MEC contains > 1800
recommendations
• No need to adapt most recommendations
– Science is the same
– Recommendations are used around the world
• CDC accepted majority of WHO recommendations
– Adapted a few for the US context
Cervical
ectropion
Cervical
intraepithelial
neoplasia (CIN)
Cirrhosis
(DVT)
/Pulmonary
embolism (PE)
1
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
1
a) Undiagnosed mass
b) Benign breast disease
c) Family history of cancer
i) current
ii) past and no evidence of
current disease for 5 years
2
1
1
4
3
2
1
1
4
3
2
1
1
4
3
2
1
1
4
3
2
1
1
4
3
1
1
1
1
1
1
1
1
1
1
1
2
1
2
2
2
1
1
4
4
1
3
2
1
3
2
1
3
2
1
3
2
1
1
1
3
2
2
2
2
1
4
4*
2
2
2
2
2
2
2
2
2
2
3*
2
2
2
2
2
2
1
1
1
1
1
4
2
2
2
2
1
2
1
1
1
1
1
1
1
1
1
1
1
a) Mild (compensated)
b) Severe‡ (decompensated)
i) higher risk for recurrent
DVT/PE
ii) lower risk for recurrent
DVT/PE
b) Acute DVT/PE
i) higher risk for recurrent
DVT/PE
ii) lower risk for recurrent
DVT/PE
d) Family history (first-degree
relatives)
(i) with prolonged
immobilization
(ii) without prolonged
immobilization
f) Minor surgery without
immobilization
Implant
LNG--IUD
Copper-IUD
a) Thalassemia
b) Sickle cell disease‡
c) Iron-deficiency anemia
(including cysts)
Injection
Progestin-only pill
Benign ovarian
tumors
Breast disease
Combined pill,
patch, ring
Anemias
Sub-condition
Condition
U.S. Medical Eligibility Criteria for
Contraceptive Use (USMEC)
United States Medical Eligibility Criteria for Contraceptive Use
http://www.cdc.gov/reproductivehealth/unintendedpregnancy/USMEC.htm
US MEC: 2010
Existing WHO guidance
New medical conditions
• Breastfeeding and CHC
• Breastfeeding and
progestin-only methods
• Postpartum IUDs
• Ovarian cancer and IUDs
• Fibroids and IUDs
• DVT/PE and hormonal
contraception
• Valvular heart disease and
IUDs
• Rheumatoid arthritis
• Endometrial hyperplasia
• Inflammatory bowel
disease
• Bariatric surgery
• Solid organ
transplantation
• Peripartum
cardiomyopathy
Migraine and Combined Hormonal
Contraception (CHC)
Migraine, COC*, and Stroke
Synergistic effect of Migraine and COC
OR 8.7 (95% CI 5.0-15.0)
1
OR 13.9 (95% CI 5.5-35.1) 2
*COC= combined oral contraceptive pills
Etminan BMJ, 2005.
Tzourio BMJ, 1995.
WHO/US: Headaches and CHC*
Non-migrainous
Migraine
(i) w/o focal neurologic symptoms
Age < 35
Age > 35
(ii) w/ focal neurologic symptoms
(at any age)
1
2
3
4
Focal symptoms = AURA = vision changes, numbness, parasthesias
Non-focal = Prodrome, photo/phonophobia, N/V
WHO/US: Headaches and CHC*
Initiate
Non-migrainous
Migraine
(i) w/o focal neurologic symptoms
Age < 35
Age > 35
(ii) w/ focal neurologic symptoms
(at any age)
Continue
1
2
2
3
4
3
4
4
Focal symptoms = AURA = vision changes, numbness, parasthesias
Non-focal = Prodrome, photo/phonophobia, N/V
Absolute Risk of Stroke
No COC
COC
Healthy
6 per 100,000 ♀ /yr
12 per 100,000 ♀ /yr
Migraine
12 per 100,000 ♀ /yr 19 per 100,000 ♀ /yr
Migraine + aura 18 per 100,000 ♀ /yr 30 per 100,000 ♀ /yr
Stroke in pregnancy: 34 per 100,000 ♀ / year
Speroff & Darney Clinical Guide for Contraception 2005
Case: Counseling Issues
After reviewing the US and WHO MEC you
decide Jane could use the pill again.
But is it the best method for her?
How effective is the combined oral
contraceptive for prevention of pregnancy?
Typical use ≠ Perfect use
Natural Family Planning
Failure Rate
Perfect Use Typical Use
Contraceptive Method
No Method
Periodic Abstinence
Standard Days Method®*
Ovulation Method
Symptothermal
Two-Day Method®
85%
85%
5%
3%
2%
3%
12%
22%
13-20%
14%
* Including Cycle Beads
National Center Health Statistics; Contraceptive Technology
Barrier Methods
Failure Rate
Contraceptive Method
Perfect Use Typical Use
Withdrawal
4%
18 %
Condoms
2%
17 %
Cervical Cap (parous/nullip)
26%/9%
32%/16%
Sponge (parous/nulliparous) 20%/9%
32%/16%
Female Condoms
5%
27 %
Diaphragm
6%
16 %
National Center Health Statistics; Contraceptive Technology
Hormonal Methods
Contraceptive Method
Combined Hormonal Pills
Progestin Only Pills
Transdermal Patch
Vaginal Ring
3-Month Injection
Implants
Copper IUD/LNG IUS
Failure Rate
Perfect Use Typical Use
<1 %
8%
<1 %
8%
<1 %
8%
<1 %
8%
<1 %
3%
<1 %
<1 %
<1 %
<1 %
National Center Health Statistics; Contraceptive Technology
Realities of Pill Use
There are many barriers such as limitations on number
of pill packs dispensed.
Percent of Women (%)
Realities of Pill Use 1996
Diary
Electronic Device
70
60
Cycle 1
Cycle 2
Cycle 3
50
40
30
20
10
0
0
1
2
3
0
1
2
3
0
1
2
3
Active Pills Missed
Active Pills Missed
Potter Fam Plann Perspect, 1996
Mean Pills Missed
Realities of Pill Use 2010
Cycle
Hout et al ACOG, September 2010
% women using contraception
Contraceptive Method Use in US,
2006-2008
40
35
30
25
20
15
10
5
0
28%
5.5%
Sterilization
(male and
female)
Pill
Condom
IUD
Withdrawal
Method
DMPA
Natural
Family
Planning
Implant/
Patch
Other *
*Other includes cervical cap, foam, female condom, and EC
Alan Guttmacher Institute, Facts In Brief, 2010.
% women using contraception
Contraceptive Method Use in US,
2006-2008
40
35
30
25
20
15
10
5
0
10 million women
Sterilization
(male and
female)
Pill
Condom
IUD
Withdrawal
Method
DMPA
Natural
Family
Planning
Implant/
Patch
Other *
*Other includes cervical cap, foam, female condom, and EC
Alan Guttmacher Institute, Facts In Brief, 2010.
Contraceptive Methods:
Old Approach to Counseling
• Natural Family Planning
• Barrier Methods
• Hormonal Methods
Contraceptive Methods:
Old Approach to Counseling
• Natural Family Planning
• Barrier Methods
• Hormonal Methods
• New: Focus on highest efficacy
http://www.fhi.org/nr/shared/enFHI/Resources/EffectivenessChart.pdf
Counseling: Frequency of Intervention
•
•
•
•
•
•
•
•
•
Permanent: sterilization
Every 10 years: IUD
Every 5 years: IUD
Every 3 years: implant
Every 3 Months: injection
Monthly: vaginal ring
Weekly: patch
Daily: pill, NFP
Episodic: barrier methods, NFP
Increasing efficacy
Daily: Natural Family Planning
• Help women identify fertile days
– Fertility window 6-8 days
– Failure rate 12-22%
• Two-day method®
– Simple, accurate method – quicker to learn
– Two questions
• Did I note secretions today?
• Did I note secretions yesterday?
• If yes to either, consider fertile
Natural Family Planning: Two-day Method®
• Study of 450 women – 3,928 cycles
• Failure rates:
– 14% typical use
– 3% perfect use (no intercourse)
– 6% semi-perfect (barriers or withdrawal)
– Half of pregnancies in first 3 months
• Mean fertile window 12 days
• High acceptability
Arevalo, Fertil Steril, 2004.
Daily: Combined Oral Contraceptives
• Traditional prescription flawed
• Extended cycle may ↑efficacy
– 47% - follicle > 10 mm at day 7 of
placebo week!
– If delay in new pack may ovulate!
Baerwald, Contraception, 2004.
Extended Cycle:
Shortened hormone-free week
• 23, 24 or 26 days hormones + 2-5 d placebo
– Decreased ovarian activity at end of placebo
– Shorter withdrawal bleeds
– Similar breakthrough bleeding
– 3 FDA-approved products in US
• New quadriphasic pill – 2 d E, 22 d E+P, 2d E
– Start on cycle d 1; backup x 9 d
Spona Contraception, 1996
Bachman Contraception, 2004
Endrikat Contraception, 2001.
Extended Cycle:
Fewer hormone-free weeks
• 12 wks hormone/1 wk off
• Ethinyl estradiol and levonorgestrel
– 84 days LNG 150 µg/EE 30 µg; 7 days placebo
– Decreased breakthrough bleeding over time
Anderson Contraception, 2003
Median Number of BTB/Spotting
Days/Cycle
Tricycle Breakthrough
Bleeding/Spotting
20
15
12
10
6
6
2 (93-175)
3 (183-266)
5
4
0
1 (1-84)
4 (274-357)
Cycle (days)
Anderson FD, et al., Contraception, 2003.
Extended Cycle:
Continuous Use
• Continuous for one year
– Increased spotting in first six months
– Median 1.5 days spotting in last trimester
• FDA-approved: ethinyl estradiol and levonorgestrel
– 90 mcg levonorgestrel + 20 mcg EE
Miller Obstetrics and Gynecology, 2003.
Kwiecen, Contraception, 2003.
Foidart, Contraception, 2006.
Choosing a COC
• Estrogen dose
– Low dose = < 50 mcg
• Progestin type
– 1st-generation: norethindrone
– Second-generation: levonorgestrel
– Third-generation: desogestrel
– Drospirenone: spironolactone derivative
• VTE risk
– Increased risk with 3rd generation progestin
• OR= 1.7 (1.4-2.0)
– Increased risk with drospirenone
• OR = 1.64 (1.27 to 2.10)
Kemmeren BMJ 2001; Lidegaard BMJ 2009
Choosing a COC
• Careful with very low-dose estrogen – ↑ bleeding
• Monophasic fine
• No drospirenone
– Increased risk VTE
– PMDD: fewer sxs 6 months – equivalent at 2 yr
– Acne: Equivalent to other pills
30 or 35 mcg EE + 2nd generation progestin
Shortened or erased placebo week if possible
Monophasic
VanViet Cochrane 2006
LaGuardia Contraception, 2003
Freeman Womens Health 2001
van Vloten Cutis 2002
Jane no longer wants to take a pill every day.
She asks you about other birth control
methods which she doesn’t have to think
about as often.
What can you offer her?
Weekly
5-10 years
3 months
Monthly
3 years
Daily:
Progestin-only Pills (POPs)
• 35 mcg norethindrone DAILY
– No hormone free interval!!
• Primary mechanism = cervical mucus thickening
• Requires very punctual dosing
– If > 3 hours late, need back up x 48 hours
Weekly:
Transdermal Contraception “Patch”
• Norelgestromin and EE
– 20mcg EE & 150mcg norelgestromin
• One patch each week for 3 weeks,
then week off
• Better compliance than with pill
(88% v. 78%)
Audet JAMA, 2001
Weekly: Patch
• Few side effects – comparable to pills except:
– 20% skin irritation – 2% stopped method
– More breast discomfort in first 2 cycles (19%) than
pills (6%)
– More spotting (20%) than pills in first 2 cycles
– 3% detached – recent RCT 46% experience at least
one detachment in one cycle
• Prescribe replacement patch
Creinin Obstet Gynecol 2008
Patch and VTE*
2 studies, 2 results
Case control studies from insurance claims. Patch vs. 35mcgEE/norgestimate
No association:1,2
Association:3
59K patch & 147K OC users
99K patch & 257K OC users
Risk of non-fatal VTE:
OR=0.9 (CI 0.5–1.6) 1
OR=1.1 (CI 0.6–2.1) 2
Risk of non-fatal VTE:
OR=2.4 (CI 1.1-5.5)3
• New users:
• All were new users
• No chart review
OR=2.2 (0.8-6.1)
• Charts reviewed
Better study supports increased risk.
1.Jick SS Contraception 2006;
2. Jick SS Contraception 2007
3. Cole JA Obstet Gynecol 2007
EE Exposure with
combined hormonal contraception
AUC (pg/ml):
Patch = 37.7 + 5.6
COC = 22.7 + 2.8
Ring = 11.2 + 2.7
van den Heuvel, Contraception 2005
(*30 mcg EE COC)
Patch & Body Weight
• 3,319 patch users, 22,160 cycles
• 15 failures overall 0.8% failure
– 7 of them wt>80Kg
– 5 of them wt >90kg (<3% of total study population)
• Did not present BMI
• Conclusion: less effective if wt>90kg (198 lbs)
Zieman M, Fertil & Steril, 2002
Monthly:
Contraceptive Vaginal Ring
• Ethinyl estradiol and
etonogestrel
– 15 mcg EE & 120 mcg desogestrel
• One ring each month:
– Ring in vagina x 3 wks
– Ring removed x 1 week
• Constant, low hormone levels
Miller Obstet and Gynecol, 2005.
Monthly: Ring
• Few side effects – comparable to pills except
– Spotting: only 5% (significantly less in first month)
– Discharge: 1% stop method
– Discomfort: 2.5% stop method
– Expulsion: recent RCT: 20% expelled at least once
during 3-week period
Dieben Obstet Gynecol, 2002
Creinin Obstet Gynecol, 2008
Monthly:
Extended Cycle Ring
• RCT of 561♀: 4wk, 8 wk, 12 wk, continuous:
– All regimens well-tolerated
– Extended: ↓ bleeding days,  spotting days
• Potential for use on a monthly basis
– Serum levels for 35 days
I instruct patients to remove ring the last 3-4 days
of the month if they want withdrawal bleed.
Miller Obstet Gynecol, 2005
Every 3 months:
Progestin Injection
• Medroxyprogesterone acetate 150 mg IM
– One injection every 12-13 weeks
• Very effective
– Typical use failure = 3%
• Side effects:
– Delayed return to fertility (9-10 months)
– Irregular bleeding, amenorrhea (50% at 1 yr)
– Weight gain (5 lbs at 1 year, 16 lbs at 5 yrs)
• SQ low-dose (104 mg) version now available
Progestin Injection & BMD
• BMD decreases by 1-2% per year
• FDA: limit to 2 yrs. in young women
– WHO & ACOG do not agree
– Bone loss reverses by 1 year after discontinuation.
• No indication for DEXA
• Weigh risks against risk of pregnancy
• New evidence of increased fractures (OR 1.4, CI1.2-1.6)
• Overall risk is VERY low and returns to baseline 2yrs after d/c.
Meier, J Clin Endocrin Metab, 2010.
Scholes Arch Pediatr Adolesc Med, 2005.; Scholes, Epidemiology, 2002; ACOG 2008 Com Opin 415.
Progestin Injection: Delay
• Traditionally recommend caution after > 14
weeks from last DMPA injection
• WHO recommends 4-week grace period
– Repeat up to 16 weeks
Missed Hormonal Contraceptives:
New Recommendations
• Guidelines for CHC and DMPA
• For CHC:
– The hormone free interval (HFI) not > 7 days
– In the 1st week
• Back-up should be used after >1 missed dose until 7 days of
use occur. Consider EC.
– In the 2nd and 3rd week
• If < 3 days are missed, eliminate the next HFI
• If > 3 days are missed, back-up contraception and
consideration of EC should be added
Soc Ob GYN of Canada, JOGC 2008; 219:1050-62
Every 3 years:
Single-Rod Implant
•
•
•
•
Etonogestrel 60mcg/day
Efficacy > 99%
Very easy & well tolerated to insert
1 year continuation: 75%-90%
– Reasons for discontinuation:
Bleeding (11-40%)
Mood swings (10%)
Weight gain (10%)
Blumenthal Eur J Contracept Reprod Health
Care, 2008
Progestin Implant: Side Effects
• Bleeding: “Irregularly irregular” (40%)
– Amenorrhea: 22%
– 7% frequent: > 5 B-S episodes in 90-day period
– 18% prolonged: at least 1 B-S episode > 14 days
– 20% have B-S for >50 days in first 90-day period
– Generally NOT heavy
• Weight: minor changes (2.3%)
– Mean weight gain = 3.7 lbs at year 2
Blumenthal Eur J Contracept Reprod Health Care, 2008
Mansour Eur J Contracept Reprod Health Care 2008.
Implant: Bleeding Treatment
• Estrogen reduces number of bleeding days
with 6-rod implant (and DMPA)
– 50 mcg Ethinyl Estradiol x 14-21 d
• Mifepristone reduces number of days
– Plus 20 mcg EE
• NSAIDS – mixed results
– Ibuprofen 800mg po TID x 5 d
– Mefenemic acid 500 mg po BID x 5 d
– Aspirin 80 mg po qd x 10 d
I recommend 1) Ibuprofen 2) 30 mcg COC or higher dose ERT
Every 5-10 Years:
Intrauterine Devices
(IUD, IUC, IUD, IUS)
Copper T 380A IUD
0.8% failure (1 yr) 1.2% failure (7 yr)
Levonorgestrel Intrauterine
System (LNG-IUS)
• Levonorgestrel 20 mcg/day
• 0.1% failure (1 yr) 1.1% (7 yr)
10 years
5 years
Comparable to BTL failure rate of 1.8% /10 yrs
Lockhat Fertil Steril, 2005
Worldwide Use of IUD
50
40
30
%
Using
20
IUD
10
0
Asia
Europe
Latin America
& Caribbean
Africa
Oceania
North
America
Population Reference Bureau, 2002.
IUD Review
• Current IUDs do NOT cause PID!!!
– Transient increased risk at time of insertion
– STI at time of insertion increases risk
– GC/CT screening can follow CDC guidelines
– Okay to screen on insertion day – treat if +
• Beyond time of insertion
• Overall decreased risk with LNG IUS
• No increased risk with Copper IUD
• Okay to treat for PID with IUD in place
Svensson L, et al. JAMA. 1984; Sivin I, et al. Contraception. 1991.
Farley T, et al. Lancet. 1992; Hubacher, NEJM, 2003.
Rate of PID by Duration of Use
10
n=20,000 women.
8
Rate per
1000
WomanYears
6
Baseline PID risk:
1-2 cases /TWY
4
2
0
20 days
21 days - 8 years
Duration
Adapted from Farley T, et al. Lancet. 1992;339:785-788.
IUDs in Nulliparous Women
• Use by nulliparous women is safe and effective1-4
• LNG-IUS is appropriate for nulliparous women
with menorrhagia and/or dysmenorrhea
• IUD expulsion, bleeding, and pain are slightly
more likely among nulliparous women2-5
Suhonen S. Contraception 2004;69:507-512
Nelson AL. Obstet Gynecol Clin North Am. 2000;27:723-740
Dardano KL, Burkman RT. Am J Obstet Gynecol. 1999;181:1-5
Li C. Contraception 2004;69:247-250
Treiman K, et al. Population Reports. 1995
IUD & Vaginal Bleeding
Study Group
Control
Paragard
Mirena
Mean Blood Loss (mL)
35
50-80
5
– After 12 mos: average 90% decrease blood
– Increased spotting common in first 3-6 months
– 50% have amenorrhea by 1 year
Speroff & Darney Clinical Guide for Contraception 2005
Is Jane a candidate for an IUD?
Women of any reproductive age seeking
long-term, highly effective contraception
Postpartum Intrauterine Contraception
2010 US MEC:
Postpartum IUD Insertion
Postpartum (BF or non-BF
women) including postcaesarean section
LNG-IUD
Cu-IUD
<10 min after delivery of
placenta
2
1
10 min after delivery of
placenta to <4 wks
2
2
>4 wks
1
1
Puerperal sepsis
4
4
Why 10 minutes?
Postpartum IUD Insertion
37.3%
Adjusted Cumulative
Expulsion Rates
40%
31.5%
35%
28.8%
30%
25%
20%
15%
9.5%
10%
5%
0%
p<0.001 (≤10 minutes compared to all other groups)
Chi Contraception 1985
How do you do it?
Post-placental IUD Insertion
2
1
2010 US Medical Eligibility Criteria
Post-abortion
OC/P/R POP
DMPA
Implant
1st trimester
1
1
1
1
2nd trimester
1
1
1
1
Immediate
post-septic
abortion
1
1
1
1
Permanent: Tubal Sterilization
• Postpartum
salpingectomy
• Silicone Band
(Yoon, Fallope)
• Filshie Clip
• Electrosurgical
dessication
Failure risk 0.5-1.8%
Increases over time
Hysteroscopic Transcervical
Tubal Sterilization
Tubal sterilization:
Transcervical
• Coils inserted into proximal tubes via
hysteroscopy
– Induces scarring reaction in tubes
• Back-up method x 3 mo, confirm w/ HSG
• Low failure rate (0.26% at 5 yrs)
• Non-invasive
Post-exposure:
Emergency Contraception
• ↓ risk of pregnancy by 89% after unprotected sex
• Essentially no contraindications
• Does not harm an established pregnancy
• Available behind the counter if >= 17 years
• Can be effective up to 5 days after unprotected sex
• No exam or pregnancy test required
Emergency Contraception
• Levonorgestrel 1.5 mg
– Single-dose tablet
• Labeled for 72 hours from last intercourse
– Two tablet dose – new name
• Same as old Plan B
• Labeling: 1 tab Q12 hours; off label: 2 tablets at once
• Ulipristal Acetate (UPA): 30 mg
– Selective progesterone receptor modulator
– Taken orally in single 30 mg dose
– Approved in Europe(2009) for up to 5 days
Jane
• You counsel Jane about the other options
available, emphasizing those with high
efficacy that require less intervention. She
ends up choosing a highly effective IUD which
you place that same day.
Summary
• Unintended pregnancy remains a common
problem in the US
• Many effective methods available
– Minimize barriers to contraception
• Provider, systemic, and patient
– Encourage more effective methods
– Use USMEC guidelines
Resources
• WHO and US Medical Eligibility Criteria for
Contraceptive Use
– www.who.int
– www.cdc.gov
– www.reproductiveaccess.org
• A Pocket Guide to Managing Contraception
• UCSF Family Planning Consult Service
– (415) 443-6318
Acknowledgments
• Thanks to all who have shared slides
– Carolyn Sufrin
– Mike Policar
– Phil Darney
– Sarah Prager