What’s New in Contraception?


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What's New in Contraception

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  • NuvaRing is a combined contraceptive vaginal ring developed by Organon. One ring provides contraceptive protection for 1 cycle by inhibiting ovulation. The ring can be easily inserted and removed by the woman herself. After insertion, the ring should remain inserted for 3 weeks followed by a ring-free interval. The ring should always be used on the same day of the week: if it was inserted on a Wednesday, it should be removed 3 weeks later, again on a Wednesday. After the ring-free interval, a new ring should be inserted, again on a Wednesday. Once inserted, each ring releases 15 μ g EE and 120 μ g ENG per day.
  • The ring is made of the plastic EVA. (Ethylene Venyl Acetate) with an outer diameter of 54 mm and a cross-sectional diameter of 4 mm. It contains ethinylestradiol (EE) and etonogestrel (ENG) uniformly dispersed in the E.V.A. core, that is surrounded by a thin outer layer that is 100% E.V.A.
  • To insert NuvaRing, the woman should find a position that allows her to insert the ring easily (for instance, standing with one leg raised, squatting or lying down). The ring is then compressed between the thumb and index finger and inserted into a comfortable position in the vagina.
  • For insertion, NuvaRing is compressed and inserted into the vagina. The ring should sit comfortably in the vagina; if it feels uncomfortable, it might be necessary to gently push it in a little further. The exact position of NuvaRing in the vagina is not critical for efficacy. The ring does not need to be placed around the neck of the cervix. The circular shape and flexibility of the ring allows a good fit, minimizing the risk of expulsion. The ring is easily removed by hooking the index finger around the ring or by grasping the ring between the index finger and the middle finger and just pulling it out. The used ring should be placed in the ring sachet.
  • In addition to once-a-month administration, these additional aspect offer benefits to women using NuvaRing
  • What’s New in Contraception?

    1. 1. What’s New in Contraception? Dr Harris N. Suharjono
    2. 2. Factors to consider: <ul><li>Innovative methods </li></ul><ul><li>Longer term </li></ul><ul><li>Reduced dosing </li></ul><ul><li>Reduced risks </li></ul><ul><li>Quick reversibility </li></ul><ul><li>Equally as effective as OCP </li></ul><ul><li>Less reliant on the user </li></ul>
    3. 3. What’s new? <ul><ul><li>Contraceptive patch ( Ortho Evra ) </li></ul></ul><ul><ul><li>Vaginal ring ( Nuvaring ) </li></ul></ul><ul><ul><li>Intrauterine system ( Mirena ) </li></ul></ul><ul><ul><li>Progestogen-only Implants ( Implanon ) </li></ul></ul><ul><ul><li>Transcervical sterilization methods </li></ul></ul><ul><ul><li>Yasmin </li></ul></ul><ul><ul><li>Seasonale </li></ul></ul><ul><ul><li>Emergency contraception (Plan B) </li></ul></ul><ul><ul><li>Male contraceptive method </li></ul></ul>
    4. 4. Ortho Evra : Contraceptive patch <ul><li>Is a thin, beige, plastic transdermal patch containing 6000 µg norelgestromin (NGMN) & 750 µg ethinyl estradiol (EE). ( 2002-Janssen- Cilag ) </li></ul><ul><li>Prevent ovulation & inhibition of sperm penetration by changes in the cervical mucus . </li></ul><ul><li>Weekly application for 3 weeks then 1 week break for withdrawal bleed. </li></ul>
    5. 6. Ortho Evra: Contraceptive patch <ul><li>Application: apply the patch to clean, dry, hairless skin on the buttock, abdomen, upper outer arm or upper back on day one of menses. </li></ul><ul><li>Failure rate: </li></ul><ul><ul><li>Perfect use: ≈1% </li></ul></ul><ul><ul><li>Typical use: ≈1-2% </li></ul></ul><ul><li>Benefits: less nausea and headache, weekly dosing reduces misuse, rapid return to fertility. </li></ul><ul><li>Disadvantages: oestrogen contraindications, may be less effective in women over 200 lbs. </li></ul><ul><li>Still pending approval in Malaysia. </li></ul>
    6. 7. Advantages and Disadvantages: Ortho Evra STD protection No Weight No proven effect Periods Regulated, may be lighter and less painful Benefits Compared to OCP, maybe less effected by oral antibiotics Risks DVTs rates similar to OCP
    7. 8. Reported Adverse Events: <ul><li>Breast discomfort, engorgement or pain (22%) </li></ul><ul><li>Headache (21%) </li></ul><ul><li>Application site reaction (17%) </li></ul><ul><li>Nausea and/or vomiting (17%) </li></ul><ul><li>Thromboembolic risks: </li></ul><ul><li>Studies showed risks to be equal or higher than </li></ul><ul><li>oral contraceptives containing 35 µg of ethinyl </li></ul><ul><li>estradiol and norgestimate </li></ul><ul><li>(S everal lawsuits have been instigated over these </li></ul><ul><li>issue in the US) </li></ul>
    8. 9. Vaginal ring ( NuvaRing ) <ul><li>A flexible ethylene-vinyl-acetate copolymer ring that releases a low dose of a progestin (etonogestrel) and estrogen (EE) over 3 weeks. </li></ul><ul><li>Approved for use in Europe then US since 2001 </li></ul>
    9. 10. NuvaRing Design, composition and use <ul><li>1 Ring per cycle </li></ul><ul><li>Regimen </li></ul><ul><ul><li>3 weeks of Ring-use </li></ul></ul><ul><ul><li>1 Ring-free week </li></ul></ul><ul><li>Daily release </li></ul><ul><ul><li>15 µg Ethinylestradiol </li></ul></ul><ul><ul><li>120 µg Etonogestrel </li></ul></ul>
    10. 11. NuvaRing Design & Composition
    11. 12. Insertion of NuvaRing
    12. 13. Insertion of NuvaRing
    13. 14. Vaginal ring ( Nuvaring ) <ul><li>Prevent ovulation & inhibition of sperm penetration by changes in the cervical mucus. </li></ul><ul><li>Failure rate: </li></ul><ul><ul><li>Perfect use: ≈1% </li></ul></ul><ul><ul><li>Typical use: ≈1-2% </li></ul></ul><ul><li>Vaginal muscle will keep the ring securely in place even during sex or exercise. If accidentally expelled, clinical efficacy is not reduced if out of the body for less than 3 hours. </li></ul>
    14. 15. Advantages and Disadvantages: Nuvaring STD protection No Weight No proven effect Periods Periods do not begin while ring is inserted (only 4.4% have irregular bleeding) Benefits Easy insertion and removal, only requires action every 1-3 weeks. Reversibility 0 to 4 weeks
    15. 16. Reported Adverse Events: <ul><li>Vaginitis (14.1%) </li></ul><ul><li>Headache (9.8%) </li></ul><ul><li>URTI (8%) </li></ul><ul><li>Leukorrhea (5.8%) </li></ul><ul><li>Nausea (5.2%) </li></ul><ul><li>Weight gain (4.9%) </li></ul><ul><li>Expulsion & Coital problems (2.6%) </li></ul>
    16. 17. Nuvaring: Ethinylestradiol dosing <ul><li>1 cycle of treatment </li></ul><ul><ul><li>NuvaRing (15 μ g EE / day) </li></ul></ul><ul><ul><li>Patch (20 μ g EE / day) </li></ul></ul><ul><ul><li>Oral contraceptive (30 μ g EE / day) </li></ul></ul><ul><li>Lower oestrogen dose, less nausea, breast tenderness and irregular bleeding.* </li></ul><ul><ul><li>*van den Heuvel MW, van Bragt AJ, Alnabawy AK, Kaptein MC (2005). Contraception 72 (3): 168–74. </li></ul></ul>
    17. 18. <ul><li>Once-a-month convenience </li></ul><ul><li>As reliable as the Pill </li></ul><ul><li>Easy to use </li></ul><ul><li>Low possibility to forget </li></ul><ul><li>Low dose </li></ul><ul><li>Neutral effect on body weight </li></ul><ul><li>Discreet </li></ul>NuvaRing Benefits for women
    18. 19. Implanon ® <ul><li>Implanon comprises a single subdermal rod and is licensed for 3 years ’ use.(Organon-1998) </li></ul><ul><li>Each implant contains 68 mg Etonogestrel (ENG) dispersed in a membrane of ethylene vinyl acetate. </li></ul>
    19. 20. Implanon ® <ul><li>Primary mode of action of the progestogen-only implant is the prevention of ovulation. </li></ul><ul><li>Insertion & removal are relatively easy to learn </li></ul>
    20. 21. Implanon ® <ul><li>Faculty of Sexual and Reproductive Healthcare(FSRH) Guidance (April 2008): Progestogen-only Implants </li></ul><ul><ul><li>Failure rate: <1 in 1000 over 3 years. </li></ul></ul><ul><ul><li>Excellent and relatively safe long term contraceptive method </li></ul></ul>
    21. 22. Advantages and Disadvantages: implanon STD protection No Weight No proven effect Periods 20% no periods, 50% with irregular periods. Benefits Rapid return to fertility, efficacy not affected by BMI, little or no risk of DVT, reduced risk of ectopic Disadvantages Menstrual irregularity, requires a minor surgical procedure, implant related problems (broken, migration, difficulty locating)
    22. 23. Mirena® Intrauterine System <ul><li>The Mirena IUS (LNG-IUS) has a T-shaped, plastic frame with a reservoir on the vertical stem containing 52 mg levonorgestrel mixed with polydimethylsiloxane. </li></ul><ul><li>A rate-limiting membrane allows LNG to be released into the uterine cavity at a constant dose of 20 μg/day. </li></ul><ul><li>Licensed for 5 years use. </li></ul>
    23. 24. Mirena® <ul><li>Mode of action: works primarily by its effect on the endometrium, thus preventing implantation. In addition, effects on cervical mucus prevent sperm penetration. Most women will continue to ovulate. </li></ul><ul><li>Failure rate: < 1 per 100 woman-years. </li></ul><ul><li>Other indications: menorrhagia, replacement for oral progestogen for ERT user.* </li></ul><ul><li>*FFPRHC Guidance (April 2004) </li></ul>
    24. 25. Advantages and Disadvantages: Mirena STD protection No Periods Irregularity, usually lighter. 60% have amenorrhoea by end of 1 st year Weight No proven effect Benefits Insert & forget! Excellent long term contraception plus other benefits Risks Uterine perforation (0.1%), small risk of PID and ovarian cyst (usually benign), expulsion risk(4%)
    25. 26. Transcervical Sterilization <ul><li>Description: Procedures that prevent pregnancy permanently by reaching and blocking the fallopian tubes through the vagina and uterus. </li></ul><ul><li>Stage of development: Some methods on the market and others in clinical trials. </li></ul><ul><li>Effectiveness: 0.2 to 2 pregnancies per 100 women in the first year of use. </li></ul><ul><li>How they work: Blocks the egg from descending a fallopian tube. </li></ul><ul><li>What’s new? Sterilization procedures for women that do not require surgery. </li></ul>
    26. 27. Transcervical Sterilization system: <ul><li>Essure PBC Device </li></ul><ul><li>‘ Adiana’ </li></ul><ul><li>Quinacrine – a chemical compound </li></ul>
    27. 28. Nonsurgical tubal sterilization ( Essure Permanent Birth Control- Essure PBC Device ) <ul><li>Appoved by FDA in Nov 2002. </li></ul><ul><li>A small metallic implant placed into the fallopian tubes through hysteroscopic guidance under LA. </li></ul><ul><li>The implant causes fibrosis and occlusion of the fallopian tubes (96% in 3/12 the rest in 6/12). </li></ul><ul><li>Non reversible </li></ul><ul><li>Additional contraception required for 3/12 until HSG confirms occlusion </li></ul>
    28. 29. Essure:
    29. 30. Adiana Sterilization System: <ul><li>A clinician delivers a catheter through a hysteroscope into the fallopian tube and uses the catheter to apply low level radiofrequency energy, followed by an insertion of a matrix (polymer implant, smaller than a grain of rice) </li></ul><ul><li>The matrix is left in the fallopian tube and the surrounding tissue will grow into it causing permanent blockage in 3/12 </li></ul><ul><li>Failure: 0.2 per 100 woman years </li></ul><ul><li>US FDA approval recently </li></ul>
    30. 31. Quinacrine: <ul><li>Quinacrine pellets introduced into the uterus causes blockage of the fallopian tube through scarring </li></ul><ul><li>Clinical trials approved by US FDA are underway </li></ul><ul><li>Serious complications fewer than surgical sterilization </li></ul><ul><li>Quinacrine is cheap and easily available </li></ul><ul><li>Does not require a doctor to insert </li></ul><ul><li>Failure:2 per 100 woman years </li></ul>
    31. 32. The New Pills: <ul><li>Yasmin® </li></ul><ul><li>Seasonale® </li></ul><ul><li>Plan B </li></ul>
    32. 33. Yasmin® <ul><li>Low-dose monophasic contraceptive. </li></ul><ul><li>30 mcg EE and 3mg drospirenone. </li></ul><ul><li>Drospirenone’s characteristic: </li></ul><ul><ul><li>Progestin </li></ul></ul><ul><ul><li>Spironolactone analogue ( ~ 25mg dose) </li></ul></ul><ul><ul><li>Antimineralocorticoid activity </li></ul></ul><ul><ul><li>Antiandrogenic activity (preclinical trial) </li></ul></ul>
    33. 35. Yasmin® <ul><li>With its activities similar to spironolactone it may lead to less water retention and breast tenderness while improving skin appearance (less acne). </li></ul><ul><li>Drospirenone is aslo part of the component in newer HRT  Angeliq ®. </li></ul><ul><li>Caution: can cause hyperkalaemia in high risk patient due to it’s spironolactone analogue property (ACEi, NSAIDs, renal insufficiency, adrenal insufficiency) </li></ul>
    34. 36. Seasonale® <ul><li>Is an extended-cycle oral contraceptive consisting of 84 pink active tablets each containing 0.15 mg of levonorgestrel and 0.03 mg of ethinyl estradiol, and 7 white inert tablets (91 days). </li></ul><ul><li>Taken continuously for 84 days, resulting in 4 menstrual period per year. </li></ul><ul><li>Higher incidence of irregular bleeding and reported cases of nasopharyngitis </li></ul>
    35. 37. Emergency contraception : <ul><li>Plan B : each dose contains 0.75 mg of levonorgestrel and can reduce risk of pregnancy by up to 89% </li></ul><ul><li>Take 1 white pill within 72 hours after unprotected sex and 1 more white pill 12 hours later </li></ul><ul><li>Recent research indicates that both doses can be taken at the same time up to 120 hours after unprotected sex </li></ul><ul><li>The pills are more effective the sooner they are taken, so take 2 Plan B pills at the same time as soon as possible after unprotected intercourse . </li></ul>
    36. 38. Female condom <ul><li>Benefits: protect againts STI and HIV infection, can be inserted up to 8 hours before sex, conducts heat well. </li></ul><ul><li>Disadvantages: application difficulty, higher failure rate, expensive and limited availability. </li></ul>
    37. 39. Male contraception: <ul><li>Beside condom & withdrawal, there are no other effective reversible male contraceptive method in the market </li></ul><ul><li>Male hormonal pills or injections </li></ul><ul><li>Anti-sperm vaccination: limited efficacy </li></ul><ul><li>Sub-dermal implants using 2 rods (synthetic GnRH & 1-alpha methyl-19-nortesterone) </li></ul><ul><li>Battery powered capsules inserted into each the vas deferens emit low-level electrical currents that immobilizes sperm as they flow </li></ul><ul><li>Experiments have also been done involving heating a man’s testicles to high temperature for a short period of time </li></ul>
    38. 40. Which is effective? <ul><li>“ The only effective contraceptive for </li></ul><ul><li>any woman is the one she is willing to </li></ul><ul><li>use consistently and correctly” </li></ul><ul><li>Thank you! </li></ul>