Preventing the Unintended: Contraception News

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Preventing the Unintended: Contraception News
4/18/2013
Preventing the Unintended:
Disclosures
Contraception News & Evidence
46th Annual Advances & Controversies
in Clinical Pediatrics
I
have nothing to disclose
May 17, 2013
Norma Jo Waxman MD
Department of Family and Community Medicine
Bixby Center for Global Reproductive Health
University of California San Francisco
Private Practice San Francisco
[email protected]
So, Why Don’t Teens Use
Contraception ?
NYC Subway Ads
Women Who Did Not Use Contraception Before
A Recent Unintended Birth In US, 2006-2008
Reason for not using contraception

Don’t think they can become pregnant or
ambivalent about becoming pregnant

Not aware of more highly efficacious methods

Irrational fear of hormones

Don’t expect to have sex or partner preference

Confidentiality

Access to care
Birth Control is NOT equally
effective
Percent
Did not expect to have sex ...................
Did not think you could get pregnant .............
Didn’t really mind if you got pregnant .............
Worried about side effects of birth control ..........
Male partner didn’t want you to use birth control ......
Male partner didn’t want to use birth control.........
14.1
43.9
22.8
16.2
7.3
9.6
Mosher WD, Jones J. Use of contraception in the United States: 1982–2008.
National Center for Health Statistics. Vital Health Stat 23(29). 2010.
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What are teens using?
 Current







use in women age 15-19:
OCP – 15.2%
Condoms – 6.4%
DMPA – 2.6%
Implant or patch – 1.5%
Withdrawal – 1.1%
Ring – 1.0%
IUD – 1.0%
4.6%
Mosher WD. Vital and Health Statistics 2010.
Finer LB, Jerman J, Kavanaugh MC. Changes in use of
long-acting contraceptive methods in the United States, 2007–2009. Fertil Steril 2012
http://www.fhi.org/nr/shared/enFHI/Resources/EffectivenessChart.pdf
First-tier methods
Second-tier methods
 Short-acting
reversible contraception: 9297% effective

Implanon
Copper T380A IUD
Depot medroxyprogesterone acetate (DMPA):
3 months

Vaginal ring (NuvaRing®): 3 weeks

Patch (Ortho Evra®): 1 week

Oral contraceptives pills (OCPs): 1 day
Mirena IUD
Third-tier methods
 Barrier



methods:68-85% effective

Male condoms: 85% effective

Diaphragm (w/spermicide): 84% effective
(spermicide alone: 71%)

Sponge:

• Parous women: 68%
• Nulliparous women: 84% effective
 Fertility

Maria
awareness-based methods:

16 yo
Sexually active for 3
years
Heavy cramps
G1P0
Declined birth control
after abortion because


“I’m never going to have
sex again”
“I hear hormones are
dangerous”
75% effective
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Medical Benefits of Hormonal
Contraception

Combined hormonal contraception (CHC) reduces:
Blood loss, PMS, dysmenorrhea, Ovarian cysts, acne,
perimenopausal sxs, DUB, PCOS, Endometriosis

OC users reduce risk of ovarian Ca by 40%1,
and by 80% after 10 yrs2

OC reduces risk of endometrial CA by up to 40%3

No increase risk of Breast CA in OC users4
1. Vessey et al Br J Cancer 1995. 2. Rosenberg et al Am J Epidmiol 1994
3. JAMA 1987:257(6) 4. Marchbanks et al NEJM 2002;346:2025-2032
Do women need a “break” or
“holiday” from contraception?
 NO!
they get pregnant
Risk Comparisons
(slide credit: Association of Reproductive Health Professionals)
Annual Risk of Death (per 100,000)
Skydiving
Driving
Pregnancy
Riding a bicycle
Airplane crash
Using OC*
*
100
20
11.5
0.8
0.4
0.06
Nonsmoker, under age 35
Trussell J, Jordan B. Contraception in press. Chang J, et al. MMWR 2003.
Harvard Center for Risk Analysis 2006. Bennett P. In: Risk Communication and Public Health 1999.
Alissa
16 years old
Afraid of pelvic exam
Interested in the pill
Is it safe to not have periods?
Dispel myths around “need to bleed”
 Teach our patients that amenorrhea on progestin
is safe vs. amenorrhea off hormones

What is required before starting
contraception?
1.
2.
3.
4.
5.
6.
Pelvic exam
Up to date Pap test
Breast Exam
STI testing
Pregnancy test
None of the above
Wants the one “with
no period”
What else does she
need today?
And the evidence says…
 Medical
 BP:
History:
Required
Helpful
 Pelvic
exam, Pap, Breast exam,
Hemoglobin, pregnancy test, STI
testing:
NOT REQUIRED!
Stewart F, et al. JAMA. 2001;285:2232-9. Tepper NK, et al. Contraception 2012
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Wait Until 21 To Start Pap Tests





ACOG 2009 & USPSTF 2012
screening women < 21 years of age may be
harmful and lacks benefit
Don’t start until 21, regardless of age of first
intercourse or number of partners
Over-screening & treatment of teens with CIN
 Double to triple rate preterm birth after LEEP
Why Wait Until 21 To Start Paps?

Spontaneous regression of CIN is common

65% regression of CIN 2 after 18 mo; 75%
after 36 mo

When CIN 3 persists, >10 years are required for
the lesion to acquire the capacity to become
invasive

UK starts pap screen at 25; some northern
European countries start at 30
Most HPV infections are low-grade, transient and
resolve completely without intervention
“Quick Start”
When can she start contraception?
“Quick Start” – start pill1,2 ( patch3, shot, ring4, ) on day of
visit - any time of the month.
•
The first day of her
period?
•
The first Sunday after
her period?
Back up method for 1 week (if not first week of cycle)
•
Anytime in her cycle,
including today?
Urine HCG if no withdrawal bleed at end of cycle, or
2 weeks after DMPA injection
•
All of the above?
Reassure - Exposure of embryo to OC not teratogenic
EC if unprotected sex in last 5 days
1. Westhoff et al Contraception 2002 2. Westhoff et al Fertil Steril 2003 3. Murthy AS,
et al. Contraception. 2005 4. Westhoff CW, et al. Obstet Gynecol. 2005
Dispensing 12 months of contraception
increases continuation & lowers costs
How many refills can I give her?
 One
month?
 3 months
 13 cycles
What if you have never seen her?
Can you refill a new patient’s contraception
until you could see her?
YES, it is safe to continue her medication
UCSF Bixby Center evaluated 2003 claims for 82,319
women dispensed OCPs via Fam PACT Outcomes:

Women who received 13 cycles more likely to be
receiving pills in 2004 than women who received 1 or 3
cycles.

Women dispensed 13 cycles more likely to receive Pap
& Chlamydia tests; less likely to have pregnancy test

Fam PACT saved $99/ year on women who received 13
cycles
Foster, D et al. Obstetrics & Gynecology 108(5):1107-1114, November 2006.
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Alissa
Increasing Teen OCP Adherence

Emphasize the noncontraceptive benefits of oral
contraceptives

Demonstrate concretely how to use pills.

Have teens explicitly discuss their concerns
about pill use so that they can be addressed

Help the teen plan for crucial logistics such as
pill storage and how to remember to take the
pills each day
16 years old
Afraid of pelvic exam
Interested in the pill
Wants the one “with
no period”
What else does she
need today?
Extended Cycle Dedicated Products
Extended/ Continuous Cycle Advantages

Traditional prescription flawed

May increase efficacy

2- 4 days of placebo rather than 7
Suppresses follicular growth seen during placebo week
Similar breakthrough bleeding
47% w/ follicle ready to ovulate by day 7 of placebo week!1

Loestrin 24 Fe ™






Symptoms w/ OC worse during withdrawal bleed
Cyclic vs. extended cycle: less headaches, tiredness,
bloating, menstrual pain 2
Treats anemia, dysmenorrhea, heavy bleeding, PMS,
menstrual migraines, endometriosis, PCOS

1. Baerwald, Contraception, 2004 2. Edelman et al Cochrane Review 2006 3.
Bachman, Contraception, 2004; Johnson, Contraception, 2007.
Continuous Cycle Dedicated Products

Lybrel ™



Seasonale ™ (generic version now available)





30 mcg EE/ 150 mcg LNG
84 active pills/ 7 placebo pills
Yaz ™

.
20 mcg EE/ 150 mcg DSG
21 days active, 2 days placebo, 5 days 10 mcg EE

20 mcg EE/ 3 mg DRSP
24 active pills/ 3 placebo pills
Alissa
16 years old
Afraid of pelvic exam
The condom broke 3
days ago
Interested in the pill
Seasonique ™



20 mcg EE/ 90 mcg LNG
Daily continuous use, no placebo, for a year
Mircette ™ (Kariva generic)

There is NO NEED TO BLEED3
20 mcg EE/ 1 mg NET
24 days active, 3 days of Fe
30 mcg EE/ 150 mcg LNG
84 active pills/ 7 pills 10mcg EE
LoSeasonique ™


20 mcg EE/ 100 mcg LNG
84 active pills/ 7pills 10mcg EE
Wants the one “with no
period”
What else does she
need today?
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EC Pills Available in the US:
ParaGard® (Copper-T IUD)
Dedicated products
 Off
label use
within 5 days after intercourse
 Effectiveness does not decline with delay
 Placed by a trained clinician
 Placed
Trussell J, Raymond EG. 2011.
Trussell J, Raymond EG. 2011.
Emergency Contraception
Plan B, Next Choice, Ella
Ulipristal Acetate versus
Levonorgestrel
 Ulipristal
acetate more effective than LNg
in postponing imminent ovulation
 In RCT, all 3 pregnancies with use from
73-120 h were in the LNg group
 Significantly more pregnancies prevented
in the UPA group (p=0.037)

Does not require an exam (or visit)

OTC for all ages as of April 2013

If you write a Rx, teens obtain confidentially and free

Advance Rx does not increase high risk behavior

Glasier AF et al. Lancet 2010; Schwarz and Trussell. Contraceptive Technology 2011.
Prescription ella
®
Does not interrupt or harm established pregnancy
 No
Evidenced Based Contraindication
Pregnancies per 1000 Women after
Unprotected Intercourse
Rx
required for all ages
May be ordered from online prescription
service - https://www.ella-kwikmed.com/

Pill mailed the next day
www.not-2-late.com.
ParaGard, ella, Plan B/Next Choice, Yuzpe, Nothing
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4/18/2013
Effectiveness: Obesity
ECP Failure among
obese versus non-obese women
• LNg:
OR = 4.41, 95%CI 2.05-9.44
• Ulipristal: OR = 2.62, 95%CI 0.89-7.00
ECP Mechanism of Action ?
 Strong
evidence suggests ECPs primarily
work by stopping or delaying ovulation
 Inhibits
ovulation & luteal function,
interferes with sperm migration
 The
best available evidence indicates that
ECPs have no effect post-fertilization
Glasier A et al. Contraception 2011.
Davidoff F, Trussell J. JAMA 2006; ICEC and FIGO statement. 2008; Novikova N, et al.
Contraception 2007; Brache V et al. Hum Reprod 2010; Stratton P et al. Fertil Steril 2010;
Gemzel-Danielsson K. Contraception 2010; Trussell J, Raymond E 2011.
What else is known about EC and teens

EC awareness is low: especially in immigrant
and low-income communities (Foster, Harper AJOG 2004)

Youth can be embarrassed to ask for EC (Free, BMJ
Emergency Contraception And Medical
Abortion: What’s The Difference?
Emergency
Contraception (EC or
Morning After Pill)
Medication Abortion
Mifepristone/RU486
2002)
What Does It
Do?
Prevents a pregnancy
after intercourse
Ends a pregnancy

Primary Care Providers do not routinely counsel
adolescents about EC (Chuang, Contraception 2004)
When is it
Used?
Works within 5 days of
unprotected sex
Ends pregnancies in
the first 9 weeks
Brand Names
Consider stocking EC in your office to dispense
directly or RX to all as advance prescription
Plan B or Next Choice
Ella
Levonorgestrel
Ulipristal
Mifeprex

What’s In The
Pills?
STI Screening in Teens
Alissa

16 years old
Afraid of pelvic exam
Interested in the pill
Wants the one “with
no period”
What else does she
need today?
mifepristone (taken
with misoprostol)



Chlamydia - annually and with each new partner

Sexually active women and MSM < 25 y.o.

Chlamydia most common reportable STI
• ¾ of infections asymptomatic
• Causes PID & tubal infertility in women.
Gonorrhea

Sexually active women < 25 years old and MSM

If practice-site prevalence >1% or diagnose with another STI
HIV

30% of new HIV infections occur in 13 to 25 years old
Any STI is an indication to screen for all other STIs.

I.E. if patient has trichomoniasis, screen for Chlamydia, GC,
Hepatitis, Syphilis and HIV.
7
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Urine Sampling for NAATs
Nucleic Acid Amplification Tests (NAATS)
 Collection


site
Male and female urine
Endocervical, vaginal, oral and anal swabs
 Sensitivity:

90-95%; specificity: 98-100%
Non-invasive urine specimens are acceptable
 Detects
tiny number of organisms
Guess What, NO PELVIC needed !
 At
least one hour since last void
 Do not cleanse perineum before sampling
 Collect first part of urinary stream

Collect only as much urine as required by test
 Draw
line on collection cup
 Sample for urinalysis and culture with
midstream sample, but no need to cleanse
perineum between first and second cup
Treatment and Testing Post-Treatment
Cheryl

Treatment
 Azithromycin 1gm p.o. x 1 for Chlamydia or
 Doxy 100mg BID for 7 days
 and Ceftriaxone 250 mg IM for GC
 Test of Cure
 Not necessary after high efficacy, single dose
treatment except in pregnancy
 Re-testing: women treated for Chlamydia or GC
should be re-tested in 3 months
 High likelihood of repeat infection
 Re-testing identifies highest risk patients
 Expedited Partner Treatment is legal in California
Weekly: Contraceptive Patch (Evra)

Apply weekly x 3, then 1 wk off
 Ethinyl Estradiol: 20 mcg/ day
 Norelgestromin (Norgestimate)




17yo G3P1
Forgets to take the pill
Recurrent cervicitis
from abusive
boyfriend
Really doesn’t want to
get pregnant again
EE Exposure with CHC
AUC (area under
curve) ng.h/mL

Place on arm, trunk, buttock

Same contraindications as OCs. Typical use efficacy may be
better than OCs1

Decreased efficacy, not contraindicated in women >198 lbs2

Breast discomfort and spotting > > than OC in cycles 1 & 23

Average levels of circulating estrogen 60% higher though
peak levels are lower compared to OCs
1. Sonnenberg et al, Am J Obstet Gynecol. 2005 , 2. Zieman M, Fertil & Steril, 2002
3. Audet, et al. JAMA. 2001;285:2347-2354.
Patch
OC*
Ring
37.7 + 5.6
22.7 + 2.8
11.2 + 2.7
* 30 mcg EE/150 mcg LNG
van den Heuvel,
Contraception 2005 72:168
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4/18/2013
Monthly: Vaginal Contraceptive
Ring
Ortho Evra and risk of Venous
Thromboembolism (VTE)
Retrospective case-control studies from claims data


Jick et al, 2006 Nested case-control design based on
information from PharMetrics; 59K patch, 147K OC users
• did not show increased risk of VTE : OR .9 (CI 0.5–1.6)
and OR 1.1 (CI 0.6–2.1) with 2006 data, when compared
to OCs containing 35mcg ethinylestradiol (EE) and
norgestimate





Cole et al, 2007. United Health Care claims data and chart
reviews; 99K patch 257K OC users
• did show odds ratio 2.4 (CI 1.1-5.5) for VTE among patch
users compared to OCs with 35 mcg EE and norgestimate

• Bias: new patch users vs. new and prior OC user

Jick SS et al. Contraception 2006;73:223-228 and Contraception 2007;76:4-7
Cole JA et al. Obstet Gynecol 2007;109:339-346
Vaginal Contraceptive Ring:
Nuva Ring
 Lowest
and constant serum
estrogen levels of all options
 Obesity doesn’t affect efficacy
microflora content1
 No GI interference with
absorption
 Avoids liver first-pass
metabolism
 Improves
1. Archer et al. Fertil Steril 2002
Tiffany




18 y/o G1P0
Has been using depoprovera successfully
since her abortion 3
years ago
Plans to start college
in the fall
Got headaches on
OC’s, and likes not
having a period. She
wants to stay on depo

One ring each month
Failure rate lower than pill
Easily placed and removed
Rarely noticed during sex
Continuation in teens > OCPs
Less spotting compared to pills
Lowest and constant serum
estrogen levels of all options
Avoids liver first-pass metabolism
Miller, Obstetrics and Gynecology, 2005
Vaginal Contraceptive Ring:
Off label, Alternative use regimens

The Ring is effective for up to 35
days1

Continuous cycling, increases
breakthrough bleeding2

“Calendar month” use 1-27th of
month, then off for rest of month
1. Mulders & Dieben, Fertil Steril 2001;75:865-70. 2. Miller, et al. 2005
Q 3 months: Progestin-Only Injection:
Depo Medroxyprogesterone Acetate (DMPA -IM 150mg q12wk)
•Irregular bleeding is expected
and Amenorrhea is normal:
50% at 1 year, 80% at 5 years
•Advantages for teens: privacy, adherence, efficacy,
decreased PID risk, decreased cramps & anemia
•May decrease seizure frequency and sickle crisis
•Part responsible for decrease in teen birth & abortion
•Calcium & Vit D, and weight bearing exercise
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4/18/2013
DMPA-IM 150 & Black Box Warning

Pregnancy & nursing cause similar or > bone loss than DMPA1

In teens, bone loss reversed w/in 12 months of discontinuation;
ultimate BMD may be higher in former DMPA users 2,6

No increased incidence of osteoporosis or fractures w/ DMPA
in >30yrs of worldwide use3

No role for BMD evaluation or treatment with bisphosphonates4

Experts feel “FDA's recent additional labeling for DMPA is
unnecessary and should be revised or rescinded” 4,5
1. Sowers Obstet Gynecol, 2000;96:189-93 2.Scholes Arch Pedatir Adol Med 2005;159:139-44
3. Westhoff C Contraception. 2003;68:75-87 4.ACOG Bulletin 2005 5. Kaunitz Contraception
2005;72:165-167 6. Harel et al Contraception, 2010;81: 281-291





 Teens
on DMPA gain more weight than
teens on COCs1
 Teens who gained > 5% of baseline
weight at 3 months were at high risk at
gaining even more weight at 12 months2
 Overweight teens may be more likely to
have significant weight gain on DMPA1,2
1. Mangan SA, et al. Overweight Teens at Increased Risk for Weight Gain While
Using Depot Medroxyprogesterone Acetate. J Pediatr Adolesc Gynecol 2002;15:79–
82. 2. Risser WL, Gefter LR, Barratt MS, Risser JM. Weight change in adolescents
who used hormonal contraception. J Adolesc Health 1999;24(6):433–436
Intrauterine Contraception (IUD) in Teens
Lawonda

DMPA and Weight Gain
16 yo nullip
Sexually active for 2
years
3 lifetime partners
partners
h/o Chlamydia
Plays basketball
Goes between 2
homes

Safe and effective in nulliparous women and women <20yrs old
CDC class 21-4

Higher continuation rates than with OCs in teens1

Progestin IUCs great choice for menorrhagia & dysmenorrhea

Does not affect future fertility

Lower PID risk b/c thicker cervical mucus & thinner
endometrium
1. Suhonen S. Contraception 2004 2. Nelson AL. Obstet Gynecol Clin North Am. 2000 3.Dardano KL, Burkman
RT. Am J Obstet Gynecol. 1999 4. Li C. Contraception 2004 5.Treiman K Population Reports. 1995.
Intrauterine Device and Adolescents. ACOG Committee Opinion December 2007
Do IUDs cause STIs and PID?
 Screen
for STI and insert IUD at same
visit1
 Transient
PID risk of 1/1000 likely due to
contamination at insertion 2,3
 Treat


STI and PID with IUD in place4,5,6
Do not remove unless treatment failure
Dose and duration does not change
1.Suffrin,C et al, Obstetrics & Gynecology. 120(6):1314-1321, December 2012 2. Grimes, D Lancet 2001;
7358:6-7, 3. Grimes, D Lancet 2000; 356:1013-9 4. CDC MEC 2010 5. Grimes Cochrane Database
2001, revised 2003 6. Tepper NK, et al. Contraception Oct 2012
What about the risk of Infertility?
 The
evidence shows:

IUDs DO NOT increase risk of infertility or STI1

PID risk with cervicitis similar with & w/o IUD1,2

Tubal infertility linked to presence of Chlamydia
antibodies, but NOT history of IUD3
1. Grimes, D. Lancet 2000; 356: 1013-19. 2. 1.Suffrin,C et al, Obstetrics & Gynecology.
2012 120(6):1314-1321 3. Hubacher D, et al. NEJM 2001; 345:561-7.
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4/18/2013
Benefits of LARC
 High



Benefits of LARC
 High
satisfaction rate:
4.6%

continuation/low pregnancy:
IUD (adolescents and young women):
• 75% continuation rate for LNG-IUD (vs. 45% for
Cu-IUD) at 6 mos1
70-90% young women satisfied with choosing
IUD (Godfrey 2010, Toma 2006, Suhonen
2004)

1 pregnancy (of 23 pts) after Cu-IUD removal
• 80% continuation rate for LNG-IUD (vs. 73% OCP)
at 1 yr2
Majority of postpartum teen Implanon users
did not identify anything they disliked (Lewis
2010)

No pregnancies reported in 200 women.
• Average time use 19.6 months in 21 adolescents3
1
Godfrey EM Contraception 2010.
2Suhonen
S. Contraception 2004.
3Toma
A. J Pediatr Adolesc Gynecol 2006.
LARC is safe when other hormonal methods
are contraindicated
Side effects & benefits LARC
Benefits of LARC
WHO Medical Eligibility for Initiating Contraception
Copper
IUD
LNGIUS
Implant
Breastfeeding (>6 weeks postpartum)
1
1
1
Smoking
1
1
1
<159 / <99
1
1
1
>160 / >100
1
2
2
+ Vascular
disease
1
2
2
Migraines
1
2
2
Diabetes mellitus
1
2
2
Liver disease
Cirrhosis
1
2/3
2/3
Tumors
1
3
3
1
3
3
 Decrease
in menorrhagia
 Decrease in dysmenorrhea
 Decrease in endometriosis pain

Condition
Hypertension
Implanon
• Average decrease in pain 63% with Implanon vs
53% with DMPA after 6 mos1

LNG-IUD
• 9 studies have shown improvement2
1
Walch K. Contraception 2009.
2Bahamondes
L. Contraception 2007.
WHO Medical Eligibility Criteria for Contraceptive Use. In Family Planning. 2007.
Active hepatitis
IUD Myths Debunked
Side Effects of LARC
 LNG-IUD:1



 Cu-IUD:2



 IUDs
during 1st 6 months
Abnormal bleeding in 50%
Abd/back pain or cramping in 27%
<15%: wt gain, mood changes, loss of libido,
acne
during 1st 9 weeks
Heavier menses: up to 68%
Pain/dysmenorrhea: up to 40%
Both decreased by 39 weeks
1
Wong RC. Contraception 2010.
2Hubacher


DO NOT cause Abortion:
LNG IUDs thicken cervical mucus, suppress
endometrium, & have some anovulatory effect
Copper IUDs act as a spermicide
 IUDs
DO NOT increase risk of ectopic
pregnancy

D. Contraception 2009.
64
recommended in women w/ H/O ectopicWHO Class 1
Hubacher NEJM 2001;108:784-90 , Grimes Cochrane Database 2004 .Andersson
Contraception 1994;49 4. Medical eligibility criteria for contraceptive use. 3nd edition,
Geneva: WHO, 2004
11
4/18/2013
Progesterone Implant:
Implanon™ & Nexplanon™
More IUD Myths Debunked

Insert at any point in the menstrual cycle1

Rapid return to fertility after removal

May insert both devices immediately post-1st
trimester abortion and 4 weeks post-partum

Safe in woman with HIV and AIDs stable on
ARVs- CDC class 2;

no increased risk of infection or viral shedding3,4,5

Highest Efficacy and continuance

Lasts 3 years & rapid return to fertility

Irregular bleeding primary side effect

Significant decrease in cramping and
overall bleeding

Must be trained by company to insert
Glasier A, Contraception 2002
Zheng SR, et al. Contraception. 1999;60:1-8.
Croxatto HB, et al. Hum Reprod. 1999;14:976-81.
1.Medical eligibility criteria for contraceptive use CDC, 2010. 2. Hubacher NEJM 2001
3 Sinei et al Lancet 1998 4 Morrison et al BJOG 2001 5 Richardson et al AIDS 1999
Implanon in teens
 High

continuation/low pregnancy:
Implanon for teenage mothers
• Implanon users pregnant later (23.8 mos) than
OCP/DMPA (18.1 mos) and barrier/none groups
(17.6 mos).
• Mean duration Implanon use 18.7 mos (compared
to 11.9 mos for OCP/DMPA).
• Implanon more likely to be continued at 2 yrs than
OCP/DMPA.
Lewis LN. Contraception 2010.
Helpful Resources
The Teen Contraception Visit

http://bedsider.org/

Non-judgmental, direct, open-ended ?s work best

Teens need concrete information- role play and
practice help (bananas, abstinence)

http://www.thenationalcampaign.org/

Your conversation and treatment is CONFIDENTIAL

EC info for providers& teens http://ec.princeton.edu/

RX (or give out) condoms and EC to all

Screen for Chlamydia annually and with each new
partner

www.reproductiveaccess.org


No Pelvic needed if asymptomatic!
Association of Reproductive Health Professionals
(ARHP) (www.arhp.org)

If you are really uncomfortable, or concerned about
confidentiality consider referring to colleague,
Planned Parenthood or Family Pact clinic

Guttmacher Institute (www.agi-usa.org)

http://www.plannedparenthood.org/info-for-teens/
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