Contraception - Lebanese Society of Family Medicine

Contraception
Lebanese Society of Family Medicine
6th Annual Meeting
November 2007
Objectives
¾
List the most commonly utilized methods of
contraception in Lebanon
¾
Counsel patients about the appropriate use of
each of these methods
¾
Educate patients regarding the use of
emergency contraception
What is the most commonly
used
d method
th d off contraception
t
ti iin
Lebanon?
Natural
Sterilization
Intrauterine
Barrier
Hormonal
Prevalence of contraceptive method
currently used by ever
ever--married women
aged 15 - 49
________________________________________
Data Source
Beirut 84 Beirut 94 PAP Child 96 Bekaa 98
N = 1104 N = 626 N = 1730
N = 364
Method
%
%
%
%
_____________________________________________
OCP
26
19
16
19
IUD
20
26
28
29
FAM
24
22
16
4
Withdrawal
16
17
19
21
Other
15
17
20
27
Total
100
100
100
100
_______________________________________________
C. Myntti et al. Challenging the stereotypes: men, withdrawal, and reproductive health in Lebanon. Contraception 65
65((2002
2002):
):
165 – 170
170..
Current use of contraception
Any Method
¾
T
Tunisia
i i
62.6
62.
¾
Syria
46
46..6
¾
Algeria
57
57..0
¾
Djibouti
9.0
¾
Yemen
23
23..1
¾
L b
Lebanon
58.0
58.
¾
Morocco 63.
63.0
http://www.papfam.org/papfam/summery.htm
Modern Method
•Tunisia
T i i
53 1
53.1
•Syria
35.1
•Algeria
51.8
Djibouti
58
5.8
•Djibouti
•Yemen
13.4
•Lebanon
L b
34 0
34.0
•Morocco 54.8
Coitus interruptus
“Withdrawal”
¾
Perceived as natural, healthier and safer
¾
Dislike side effects of other methods
¾
Fear of future infertility
C Myntti et al
C.
al. Challenging the stereotypes: men
men, withdrawal
withdrawal, and reproductive health in Lebanon
Lebanon. Contraception
65(
65(2002
2002):
): 165 – 170
170..
Factors affecting choice of
contraception
M it l St
Marital
Status
t
Culture
Age
Components of contraceptive
success
Access
Compliance
Continuation
Counseling
Prevalence of contraceptive method
currently used by ever
ever--married women
aged 15 - 49
________________________________________
Data Source
Beirut 84 Beirut 94 PAP Child 96 Bekaa 98
N = 1104 N = 626 N = 1730
N = 364
Method
%
%
%
%
_____________________________________________
OCP
26
19
16
19
IUD
20
26
28
29
FAM
24
22
16
4
Withdrawal
16
17
19
21
Other
15
17
20
27
Total
100
100
100
100
_______________________________________________
C. Myntti et al. Challenging the stereotypes: men, withdrawal, and reproductive health in Lebanon. Contraception 65
65((2002
2002):
):
165 – 170
170..
Selected Practice Recommendations for Contraceptive Use; Second edition,World Health Organization, Geneva, 2004
Withdrawal
¾
¾
¾
¾
¾
Only 4% failure if practiced correctly
Must urinate first
Pre--ejaculate rarely has sperm and these are
Pre
usually dead
Cheap
Has worked for centuries
Rogow D, Horowitz S. Withdrawal: a review of the literature and an agenda for research. Stud Fam
Plan 1995;
1995;26:
26:140140-53
53..
Fertility Awareness Method
(FAM)
¾
Up to 98
98%
% effective
¾
Life of oocyte ((24
24 hours)
¾
Life of sperm ((2
2 - 5 days)
¾
Standard days method
¾
Two day method
Standard Days Method
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
plannedparenthood.org
Two Day Method
¾
“Did I notice any secretions today?”
¾
“Did I notice any secretions yesterday?”
¾
Must distinguish between cervical secretions
and
d semen
Selected Practice Recommendations for Contraceptive Use; Second edition,World Health Organization, Geneva, 2004
Emergency contraception
“Morning After Pill”
¾
¾
¾
Within 120 hours
COP ((75
75%)
%))
POP ((89
89%)
%)
z
¾
Norlevo (16
(16,
16,000 LL)
Copper IUD insertion
(94 - 99
99%
% effective)
Emergency Contraception
Mechanism of action
¾
¾
¾
¾
¾
¾
Blunt LH surge
I hibit ffollicle
Inhibit
lli l rupture
t
Interfere with corpus luteum function
Trap sperm in cervical mucus
Inhibit fertilization
Interfere with sperm, egg or embryo transport
Brunton J and Beal M. Current inssues in emergency contraception: an overview for providers. J
Midwifery Womens Health 2006;
2006;51
51((6):
):457
457--63
63..
Lactation
¾
¾
¾
¾
¾
¾
98
98--99
99%
% effective
breast--feeding
breast
g
exclusively
feedings no more than
4 hrs apart
baby < 6 months
No menses
25%
25
% ovulate before 1st
menses
OCPs
Mode of action
OC’s
OC’
Progest
g
Suppress LH
Decidualize End
Estrogen
g
Hostile Cx Mucus
Suppress FSH
OCPs
Potential side effects
Libido
Nausea
Headaches
Acne
Weight Gain
Depression
Mastalgia
Bleeding
Estrogen side effects
¾ Breast
tenderness
¾ Vaginal bleeding or spotting
¾ Enlarge fibroids
¾ Migraine headaches
¾ Abdominal bloating
¾ Nausea
¾ Skin rashes
Progestin side effects
¾ Acne
A
¾ Hair
growth
g
¾ Headache
¾ Mastalgia
¾ Nausea
¾ Dizziness
¾ Mood
¾ Libido
Progestin potency *
Progestin
Progestational Activity
(relative to 1 mg of
norethindrone)
Androgenic Activity
(relative to 1 mg of
norethindrone)
norethindrone 1 mg
1.0
1.0
norethrindrone
acetate 1 mg
1.2
1.6
ethynodiol
th
di l di
diacetate
t t
1 mg
1.4
0.6
levonorgestrel 1 mg
5.3
8.3
dl--norgestrel 1 mg
dl
2.6
4.2
norgestimate 1 mg
1.3
1.9
g
1 mg
g
norelgestromin
1.3
1.9
desogestrel 1 mg
9.0
3.4
drospirenone 1 mg
1.5
0.0
* - From Table 2 in Dickey RP: Individualizing oral contraceptive therapy. OBG Management Supplement October
2000, p 5.
Locally available OCPs
NAME (Price)
ESTROGEN
PROGESTIN
Marvelon (7
(7,000
000LL)
LL)
EE 30 mcg
Desogestrel 0.15 mg
Diane 35 (13,
13,000 LL)
EE 35 mcg
Cyproterone 2 mg
Femovan ((11
11,,000 LL)
EE 30 mcg
Gestodene 0.075 mg
Gracial (13
(13,,000 LL)
EE 40 mcg
Yasmin
Y
i (16
(16,
16,000 LL)
EE 30 mcg
Desogestrel 0.024
mg
Levonorgestrel 0.15
mg
D
Drospirenone
i
3 mg
Belara (8
(8,000 LL)
EE 30 mcg
Chlormadinone 2 mg
Microgynon (3000
(3000 LL) EE 30 mcg
Cerazette (9
(9,000 LL)
Desogestrel 75 mcg
Side Effect/Problem
Acne
Principal
higher estrogen, lower
androgen potency
Break-through bleeding higher estrogen, higher
progestin potency, lower
androgen potency
Pill Suggestions
Yasmin, Diane 35 ,Microgynon, Marvelon
Yasmin, Microgynon, Marvelon, Belara
Absent or too light
menstrual flow
higher estrogen, lower
progestin potency
Microgynon, Marvelo, Belara
Depression
lower progestin potency
Microgynon, Marvelon
Moodiness or irritability lower progestin potency
Microgynon, Marvelon
Headaches (not
menstruall migraines)
i i )
lower estrogen, lower progestin
potency
Microgynon
Breast soreness
lower estrogen, lower progestin
potency
Microgynon
Weight
g g
gain
lower estrogen,
g , lower pprogestin
g
potency
Yasmin,, Microgynon
gy
, Belara
Severe menstrual
cramps
higher progestin potency
Yasmin, Marvelon, Diane 35
Endometriosis or
endometriosis
prevention
lower
lo
er estrogen,
estrogen higher
progestin potency, higher
androgen potency
Yasmin Marvelon,
Yasmin,
Mar elon Diane 35,
35 Orgametril
Adapted from http://www.wdcyber.com/ncontr13.htm
Anticipatory Guidance
¾
¾
¾
¾
Individualize
counseling
Discuss changes
g in
bleeding, weight and
other expected side
effects
Stress that side effects
decrease over time
Mention possibility of
switching to another
brand in case of side
effects
ff t
¾
¾
¾
¾
¾
Emphasize non
non-contraceptive
benefits
Cue pill
pill--taking to
daily activity
Demonstrate how to
use the actual pill
pack
Discuss missed
pills
“Don’t stop
p taking
g
the pills before
calling me”
Return to fertility
“For women who
do not like to take
or
cannot take estrogens”
POP
•Less
ess effective
e ect e than
t a COCs
•Slowing down egg transportation
in the tubes
•Cervical mucus impenetrability to
sperm
•Effect maintained up to 27 h after
the tablet intake Æ “3 hours
missed-pill
p window”
•Ovulation inhibition incomplete:
approximately 50% of cycles
• Unpredictable bleeding pattern
•Slightly increased risk of ectopic
pregnancy
Cerazette
¾
Primary
Ovulation inhibition in up to 99
99%
% of cycles
¾
Secondary
Thickening of cervical mucus
Korver T et al. Contraception 2005
IUD
¾
¾
¾
¾
¾
¾
Copper T380
C
T380A
A
Mirena
(Levonorgestrel)
Mode of action
PID risk
Expulsion risk
Nulliparous women
Peterson and Curtis. LongLong-acting methods of contraception. N Engl J
Med 353 (2002
2002):
): 2169 – 75.
75.
ACOG Practice Bulletin: Clinical management guidelines for
obstetrician--gynecologists Number 59
obstetrician
59,, January
2005.Intrauterine
2005
.Intrauterine Device. Obstet Gynecol 2005
2005;;105
105::223223-232/
232/
Others
¾ Implanon
¾ Vaginal
ring
¾ Injectable
(Depo)
Progestin Implant
¾ Implanon
¾3
(Etonorgestrel)
years
¾ Cost 300
300,,000 LL ($200
($200))
Conclusions
¾
¾
¾
¾
Natural family planning is commonly practiced in
Lebanon and the region
Natural family planning can be effective
Primary care physicians should educate patients
about the availability of emergency
contraception
Counseling is essential to decrease
contraceptive failure