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  1. 1. Before you come to the Session <ul><li>Make a list of YOUR Contraception questions, concerns, frustrations that you encounter as you care for women. </li></ul><ul><li>1. </li></ul><ul><li>2. </li></ul><ul><li>3. </li></ul><ul><li>4. </li></ul><ul><li>5. </li></ul>
  3. 3. Your list… <ul><li>Needs </li></ul><ul><li>Issues </li></ul><ul><li>Requests </li></ul>
  4. 4. her list <ul><li>“ I’ve tried them all…nothing works for me, what should I do?” </li></ul><ul><li>“ ..the pill made me bleed, the shot made me gain weight, the patch irritated my skin, the ring fell out, the condom broke, I’m afraid of an IUD….I just had an abortion last month and don’t want another one……” </li></ul><ul><li>“ Don’t take my method away!!” </li></ul>
  5. 5. our path today <ul><li>Contraceptive overview </li></ul><ul><li>Complications </li></ul><ul><ul><li>Side effects </li></ul></ul><ul><ul><li>Misuse, misunderstandings </li></ul></ul><ul><ul><ul><li>Ours and Hers </li></ul></ul></ul><ul><ul><li>Underuse aka unintended pregnancy </li></ul></ul><ul><li>What’s coming down the road </li></ul>
  6. 6. risk <ul><li>Perceived </li></ul><ul><ul><li>Real </li></ul></ul><ul><ul><li>Myth </li></ul></ul><ul><li>Communicated </li></ul><ul><ul><li>How do you portray risk </li></ul></ul><ul><ul><li>How do you interpret/re-interpret the current evidence </li></ul></ul><ul><li>Experienced </li></ul><ul><ul><li>Side effect vs. complication </li></ul></ul>
  7. 7. method review <ul><li>Do it yourself </li></ul><ul><li>Barrier </li></ul><ul><li>Hormonal </li></ul><ul><li>Other </li></ul>
  8. 8. diy <ul><li>Abstinence </li></ul><ul><li>Counting the days/periodic abstinence </li></ul><ul><li>Withdrawal – Don’t underestimate it! </li></ul><ul><li>Breastfeeding </li></ul><ul><li>“ I can’t get pregnant if I ……” </li></ul>
  9. 9. barrier <ul><li>Male condom </li></ul><ul><li>Female condom </li></ul><ul><li>Sponge – it’s back!! </li></ul><ul><li>Caps – gone, but will return? </li></ul><ul><li>Diaphragm – out of fashion? </li></ul><ul><li>Spermicides </li></ul><ul><li>Microbicides – hopefully! </li></ul>
  10. 10. hormonal <ul><li>Pills </li></ul><ul><ul><li>COC </li></ul></ul><ul><ul><li>POP </li></ul></ul><ul><li>Patch </li></ul><ul><li>Ring </li></ul><ul><li>Injectables </li></ul><ul><li>IUC </li></ul><ul><ul><li>IUD, IUS </li></ul></ul><ul><li>Implants </li></ul>
  11. 11. pills <ul><li>Combined Oral Contraceptives </li></ul><ul><li>Withdrawal Bleeding/Hormone free Interval Trends </li></ul><ul><ul><li>Shortened </li></ul></ul><ul><ul><li>Absent </li></ul></ul><ul><ul><li>Is this safe? </li></ul></ul><ul><ul><li>Is this acceptable? </li></ul></ul><ul><ul><li>Is this beneficial? </li></ul></ul>
  12. 12. evra <ul><li>Extended/continuous use </li></ul><ul><li>I heard this is dangerous, will it kill me? </li></ul><ul><li>I can’t put it on my breasts because it causes breast cancer, right? Wrong! </li></ul>
  13. 13. nuva ring <ul><li>You want me to do what? Where? </li></ul><ul><li>Extended/continuous use </li></ul><ul><li>I love the Nuva Ring, but….I have this problem… </li></ul>
  14. 14. DMPA <ul><li>It won’t make me gain weight will it? </li></ul><ul><li>Last time I bled the whole time… </li></ul><ul><li>Sub Q/self administered </li></ul>
  15. 15. new and old barriers <ul><li>Stand alone </li></ul><ul><ul><li>Today sponge </li></ul></ul><ul><ul><li>Lea’s shield </li></ul></ul><ul><ul><li>Fem cap </li></ul></ul><ul><ul><li>Diaphragm </li></ul></ul><ul><ul><li>SILCS – one size flexible, silicone </li></ul></ul><ul><li>Impregnated with …. </li></ul>
  16. 16. female condom <ul><li>Current use </li></ul><ul><li>FC2 = second generation -- Less ‘noise’ </li></ul>
  17. 17. implanon <ul><li>Single rod system, 3 year efficacy </li></ul><ul><li>No reported pregnancies </li></ul><ul><li>Are you being trained? </li></ul><ul><li>Who is the perfect candidate? </li></ul><ul><li>What are the insertion criteria? </li></ul>
  18. 18. intrauterine contraception <ul><li>Why such low use of IUC in the US? </li></ul><ul><ul><li>2% in US compared to14% China & Africa, 28% E Europe </li></ul></ul><ul><li>Paraguard – ____ string color, good for ___ years </li></ul><ul><li>Mirena – _____ string color, good for ___ years </li></ul><ul><li>New shapes </li></ul><ul><ul><li>Conform to fundal shape </li></ul></ul><ul><li>New features </li></ul><ul><ul><li>‘ frameless’ </li></ul></ul><ul><ul><li>LNG </li></ul></ul>
  19. 19. post coital <ul><li>Hormonal/Plan B </li></ul><ul><li>Paraguard IUD </li></ul><ul><li>Pre and/or post coital </li></ul><ul><ul><li>In trials- Carraguard gel with LNG – (- efficacy as microbicide…but….) </li></ul></ul>
  20. 20. ..and now a word about us! <ul><li>Provider beliefs & behaviors </li></ul><ul><ul><li>About our clients </li></ul></ul><ul><ul><li>About the methods </li></ul></ul><ul><ul><li>‘ this is how we have always done it’ </li></ul></ul><ul><li>Use of the ‘evidence’ </li></ul><ul><li>Presentation of the evidence </li></ul><ul><li>Influence of policy </li></ul><ul><li>Institutional limitations </li></ul>
  21. 21. Use of the Evidence <ul><li>WHO Medical Eligibility Criteria </li></ul><ul><li>UK Medical Eligibility Criteria </li></ul><ul><li>CDC Medical Eligibility Criteria </li></ul><ul><ul><li>The Medical Eligibility Criteria for the United States were developed at the CDC in March, 2009. They will be disseminated widely through a CDC website, books such as Managing Contraception and Contraceptive Technology, and organizations such as Planned Parenthood, The California Family Health Council and Family Health International in Feb/March 2010 </li></ul></ul><ul><ul><li> </li></ul></ul>
  22. 22. preferences of the users <ul><li>Ideal method </li></ul><ul><ul><li>The one that works for her </li></ul></ul><ul><li>Most popular method </li></ul><ul><ul><li>In US ___________ </li></ul></ul><ul><ul><li>Worldwide______________ </li></ul></ul><ul><li>Trends in use </li></ul><ul><ul><li>IUC </li></ul></ul>
  23. 23. complications <ul><li>Medical Complications </li></ul><ul><li>Side effects </li></ul><ul><li>Misuse, Misunderstandings </li></ul><ul><li>Underuse </li></ul>
  24. 24. Medical Complications <ul><li>Vascular </li></ul><ul><ul><li>Stroke </li></ul></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>VTE </li></ul></ul><ul><li>Diabetes </li></ul><ul><li>Bone Mineral Density changes/loss </li></ul>
  25. 25. side effects <ul><li>Bleeding….and..Not bleeding </li></ul><ul><li>Headaches </li></ul><ul><li>Decreased libido </li></ul><ul><li>Decreased vaginal secretions </li></ul><ul><li>Monilia </li></ul><ul><li>Weight gain </li></ul><ul><li>I just ‘feel’ different </li></ul>
  26. 26. btb <ul><li>CHC </li></ul><ul><li>POP </li></ul><ul><li>DMPA </li></ul><ul><li>IUC </li></ul><ul><li>Norplant, Implanon </li></ul>
  27. 27. amenorrhea <ul><li>Desired </li></ul><ul><ul><li>Continuous use CHC </li></ul></ul><ul><ul><li>DMPA </li></ul></ul><ul><ul><li>Mirena </li></ul></ul><ul><ul><li>Norplant, Implanon </li></ul></ul><ul><li>Undesired </li></ul><ul><ul><li>COC </li></ul></ul>
  28. 28. Bone mineral density loss – the special case of DMPA <ul><li>Should we worry </li></ul><ul><li>How should we counsel </li></ul><ul><ul><li>Surveillance </li></ul></ul><ul><ul><li>Term limits </li></ul></ul><ul><ul><li>Calcium intake </li></ul></ul><ul><ul><li>Other risks for bone loss/osteopenia/osteoporosis </li></ul></ul><ul><ul><li>Kaunitz , Arias, McClung (2008) Bone Mineral Density Recovery After DMPA Injectable Contraception Use Contraception 77 67-76. </li></ul></ul>
  29. 29. headaches <ul><li>CHC </li></ul><ul><ul><li>New headache </li></ul></ul><ul><ul><li>MD diagnosed Migraine </li></ul></ul><ul><ul><li>Use of headache descriptor questionnaire </li></ul></ul><ul><ul><li>Use of headache diary </li></ul></ul><ul><li>DMPA </li></ul>
  30. 30. VTEs <ul><li>“ The general population risk is low—about 1 per 10,000 woman-years—and thus the incidence with COCs of 3.0 to 4.0 per 10,000 woman years is still low. </li></ul><ul><li>The risk is clearly lower than the incidence of 5.7 per 10,000 woman years estimated for pregnancy.” </li></ul><ul><li>Mishell (2000) Oral contraceptives and cardiovascular events: Summary and application of data. International Journal of Fertility 45:121 </li></ul>
  31. 31. VTEs and Evra <ul><li>Studies disagree on existence of increased risk for VTEs ONLY – no increased risk for stroke or MI </li></ul><ul><ul><li>The best studies we have: </li></ul></ul><ul><ul><li>One = no increased risk between COC and Evra </li></ul></ul><ul><ul><li>One = twofold increaseed risk for Evra users compared to COC users </li></ul></ul><ul><ul><ul><li>The FDA requested more research and data. </li></ul></ul></ul><ul><li>?Increased risk for women at risk? </li></ul>
  32. 32. Who are these ‘women at risk’ <ul><li>1. </li></ul><ul><li>2. </li></ul><ul><li>3. </li></ul><ul><li>4. </li></ul><ul><li>5. </li></ul><ul><li>6. </li></ul><ul><li>7. </li></ul><ul><li>8. </li></ul><ul><li>9. </li></ul><ul><li>10. </li></ul>
  33. 33. Migraines WITH Aura <ul><li>Women taking COS who have migraine headaches with aura have 2 – 4 times risk of strokes! </li></ul><ul><ul><li>May be dose related </li></ul></ul><ul><li>Your Neurology colleagues may disagree with you! Let them write the prescription! </li></ul><ul><li>Allais De Lorenzo Mana Benedetto (2004) Oral contraceptives in women with migraine: balancing risks and benefits Neurological Sciences 25:3 s211-214 </li></ul><ul><li>Curtis Chrisman Peterson (2002) Contraception for women in selected circumstances. Obstetrics & Gynecology 99:1100 </li></ul>
  34. 34. decreased libido <ul><li>Long term COC use </li></ul><ul><ul><li>‘ real’ change </li></ul></ul><ul><ul><li>Relationship change </li></ul></ul><ul><ul><li>?impact of age/perimenopause </li></ul></ul>
  35. 35. vaginal changes <ul><li>Increased secretions </li></ul><ul><li>Decreased secretions </li></ul><ul><li>Increased incidence monilia </li></ul><ul><li>‘ it just feels different’ </li></ul>
  36. 36. hypertension <ul><li>Per the evidence NOT an expected side effect of CHC use </li></ul><ul><li>Women well controlled on anti-hypertensives may use CHC – unless they are smokers! </li></ul><ul><li>Curtis Chrisman Peterson (2002) Contraception for women in selected circumstances. Obstetrics & Gynecology 99:1100 </li></ul>
  37. 37. weight gain <ul><li>Per the evidence NOT a side effect of hormonal contraceptive use… why do they tell us about weight gain patterns? </li></ul><ul><li>Gallo Grimes Schulz et al (2004) Combination estrogen-progestin contraceptives and body weight: Systematic review of randomized controlled trials. Obstetrics & Gynecology 103:359 </li></ul><ul><li>Gallo Lopez Grimes et al: (2006) Combination contraceptives: effects on weight. Cochrane Database Systematic Review 25:CD003987 </li></ul>
  38. 38. ‘ I don’t feel like myself’ <ul><li>Impact of fears - ?r/t fertility, medical harm </li></ul><ul><li>Impact of change in intimate relationships </li></ul><ul><li>Impact of actual chemical changes </li></ul><ul><li>Screen for depression, abuse, trauma, etc. </li></ul>
  39. 39. misuse, misunderstanding <ul><li>Fears </li></ul><ul><li>Missing dose/incorrect interval </li></ul><ul><ul><li>When does it matter </li></ul></ul><ul><ul><li>When would EC be appropriate </li></ul></ul><ul><ul><li>When to throw in the towel </li></ul></ul>
  40. 40. fears <ul><li>It will kill me </li></ul><ul><li>It won’t work </li></ul><ul><li>It will make me infertile </li></ul><ul><li>It will make me fat </li></ul><ul><li>My cousin didn’t like it </li></ul><ul><li>My mother got headaches </li></ul><ul><li>..the bleeding issue </li></ul><ul><li>My parents/bf/bff will find out </li></ul>
  41. 41. the schedule <ul><li>I didn’t start </li></ul><ul><li>When do I start </li></ul><ul><li>I forgot to </li></ul><ul><ul><li>Take it </li></ul></ul><ul><ul><li>Put it on </li></ul></ul><ul><ul><li>Put in in </li></ul></ul><ul><ul><li>Come for my shot </li></ul></ul><ul><li>I only use it when I have sex right? </li></ul>
  42. 42. quickstart <ul><li>Who needs an exam? </li></ul><ul><li>Quickstart with ec </li></ul><ul><li>Quickstart without ec </li></ul><ul><li>How to be reasonably sure she is not pregnant </li></ul><ul><li>Informed decision making </li></ul><ul><li>When is ‘quickstart’ not a good idea </li></ul>
  43. 43. mixing and matching <ul><li>Meds </li></ul><ul><li>Conditions </li></ul><ul><li>Post abortion </li></ul>
  44. 44. meds <ul><li>The truth about COCs and antibiotics </li></ul><ul><li>Anti seizure meds </li></ul><ul><li>Anti hypertensives </li></ul><ul><li>OTCs </li></ul><ul><li>Antiretrovirals </li></ul>
  45. 45. meds <ul><li>Don’t forget about OTCs </li></ul><ul><li>The Magic List – Good evidence that these DO decrease the absorption &/or efficacy of COCs: </li></ul><ul><li>Rifampin </li></ul><ul><li>Grisefulvin </li></ul><ul><li>COCs may change the absorption - + or – of these meds: </li></ul><ul><li>Tylenol, Morphine </li></ul><ul><li>Corticosteroids </li></ul><ul><li>Aminophylline, Theophylline </li></ul><ul><li>Could go either way : Anti seizure meds </li></ul>
  46. 46. co-existing conditions <ul><li>Diabetes </li></ul><ul><ul><li>Combined methods: </li></ul></ul><ul><ul><ul><li>?vigilence in first cycles re: glucose control, report changes </li></ul></ul></ul><ul><li>HIV +/AIDS </li></ul><ul><ul><li>Check interaction with Antiretrovirals as they VARY </li></ul></ul><ul><ul><li>IUC ok </li></ul></ul>
  47. 47. Co-existing conditions cont’d <ul><li>Seizure Disorder/Epilepsy </li></ul><ul><ul><li>CHM – little info re: Nuva Ring and Evra </li></ul></ul><ul><ul><li>Check interactions with specific med </li></ul></ul><ul><ul><li>DMPA best choice as may positively impact seizure threshhold </li></ul></ul><ul><li>Asthma </li></ul><ul><ul><li>CHM – no known adverse effect </li></ul></ul><ul><ul><li>May positively impact asthma attacks </li></ul></ul>
  48. 48. co-existing cont’d <ul><li>BMI </li></ul><ul><li>Obesity </li></ul><ul><ul><li>CHM - Decreased efficacy? (evidence uncertain) </li></ul></ul><ul><ul><ul><li>Evra - ?documented decreased efficacy > 198 lbs. </li></ul></ul></ul><ul><ul><ul><ul><li>Does this mean it is contraindicated? NO! </li></ul></ul></ul></ul><ul><li>Low BMI </li></ul><ul><ul><li>CHM – bone density protection? </li></ul></ul><ul><ul><li>DMPA – careful injection site choice </li></ul></ul>
  49. 49. initiation of contraceptives post abortion <ul><li>The PERFECT Quickstart moment! </li></ul><ul><li>CHC </li></ul><ul><li>DMPA </li></ul><ul><ul><li>Prolonged bleeding? </li></ul></ul><ul><li>Implant - Implanon </li></ul><ul><li>IUC </li></ul><ul><ul><li>?need to do GC/Chlamydia? </li></ul></ul><ul><ul><li>Risk of expulsion? </li></ul></ul><ul><li>EC for PRN use at the least! </li></ul>
  50. 50. underuse – unintended pregnancy <ul><li>Why can’t we reduce the unintended pregnancy rate in the US? </li></ul><ul><li>???% of women discontinue use of their method within the first year of use </li></ul><ul><li>What personal characteristics place women at risk for contraceptive failure? </li></ul>
  51. 51. So, how do YOU communicate risk? <ul><li>10% vs ‘1 in 10’ vs ‘low risk of ….’ </li></ul><ul><li>Risk of pregnancy vs Risk of method use </li></ul><ul><li>Address myth </li></ul>
  52. 52. Copyright ©2003 BMJ Publishing Group Ltd. Paling, J. BMJ 2003;327:745-748 Making risk communication more effective
  53. 54. The Seven Simple Strategies for Helping Patients Understand Risks J Paling 1. Prepare by first learning about the actual difficulties that patients experience in attempting to understand risks. 2. Accept the challenge that patients' emotions will invariably filter the facts and cannot be ignored. 3. Revise the way you explain probabilities to patients. The most commonly used methods can be greatly improved with small changes. 4. Try to avoid speaking to patients in terms of relative risks. Ensure you provide context so patients get “information” and not just “data.” 5. Never just give the negative perspective but, instead, make sure the positive perspective is always provided as well. 6. Explain the risk numbers by using visual aids. These give context as well as achieving understanding for the largest number of patients. 7. Realize that sharing visual aids with patients can serve to reinforce the health care provider–patient bond, enhance trust, and encourage acceptance of the health care provider's message.
  54. 55. so what do we do with… <ul><li>Nothing has worked in the past </li></ul><ul><li>I can’t do that </li></ul><ul><li>I’m afraid </li></ul><ul><li>I don’t believe you </li></ul>
  55. 56. ‘ Out the door’ Instructions <ul><li>When should I come back? </li></ul><ul><li>Why should I come back? </li></ul><ul><ul><li>Address ‘change of heart’ after she leaves your office </li></ul></ul><ul><li>PRN EC use ‘just in case’…. </li></ul><ul><li>Need for pregnancy test if Quickstarted? Opportunity to check in with her. </li></ul>
  56. 57. What’s coming on down the road? <ul><li>More COCs with shorter /no Hormone Free Interval </li></ul><ul><li>Continuous use research - Evra, Ring </li></ul><ul><li>More IUC choices </li></ul><ul><li>New Barriers </li></ul><ul><li>Microbicides?! </li></ul>
  57. 58. resources <ul><li>Online </li></ul><ul><ul><li>ARHP </li></ul></ul><ul><ul><li>Medscape </li></ul></ul><ul><ul><li>Dr.James Trussell </li></ul></ul><ul><li>Journals </li></ul><ul><ul><li>Contraception </li></ul></ul>