Q&A: Important messages for PCPs on World Contraception Day
Each year, World Contraception Day is recognized on September 26 to raise awareness of all available contraceptive methods and to encourage women to make informed decisions on their sexual and reproductive health, according to WHO.
“Nearly half of all pregnancies in the United States are unplanned, with significant consequences for a woman and her family,” Maria Rodriguez, MD, MPH, assistant professor of obstetrics and gynecology in the Oregon Health and Science University School of Medicine, told Healio Internal Medicine. “Providers should talk to all women of reproductive age about their reproductive life plan and provide counseling on the many different methods of contraception available to help women meet their goals.”
“Each method of contraception has different pros and cons that need to be individualized to the woman’s medical history and preferences,” she added.
Contraceptive failure or incorrect use results in approximately 33 million of the unplanned pregnancies, according to the World Contraception Day Coalition. The coalition noted that each year contraception can help prevent 188 million unintended pregnancies, 112 million abortions, 1.1 million newborn deaths and 150,000 maternal deaths.
To mark World Contraception Day, Healio Internal Medicine spoke with Rachel Peragallo Urrutia, MD, MSCR, assistant professor of general obstetrics and gynecology at the University of North Carolina at Chapel Hill School of Medicine, about how primary care physicians should discuss birth control with patients, the benefits and risks of short- and long-term use of hormone and hormone-free contraception, new products for contraception and what affects the efficacy of birth control. – by Alaina Tedesco
Question: What are your recommendations for discussing birth control with patients?
Answer: My recommendation is to keep the conversation patient-centered and to use a shared decision-making approach. I usually begin with questions about their current partner/sexual orientation, current sexual activity and plans on having children.
One key question for PCPs is: “Would you like to become pregnant in the next year?” If patients indicate that they are interested in either avoiding pregnancy for a time or indefinitely, I start asking them their ideas for how they would like to do so. I like to get a feel for which methods they may have used in the past and what they liked or did not like about those methods.
We then narrow it down to methods that may be a good fit for the particular situation and we can have a more detailed conversation about pros and cons of those methods. There are a couple of great tools available such as the bedside method explorer and the CDC effectiveness table.
Q: What are the risks and benefits, both short- and long-term, of hormone-free contraception?
A: There are currently only a handful of hormone-free contraceptive options.
One is the Copper IUD (eg, Paragard), which has high effectiveness for both typical and perfect use (<1% chance of pregnancy over 1 year of use). It can be used for up to 10 years. Many patients who use a copper IUD complain of heavier and more painful periods, but others like the idea of having regular periods with this device.
There are other small but important risks of using a device, including migration or perforation of the uterus and need for surgery to remove the device. Though women are very unlikely to get pregnant while using this device, if they do, there is a higher risk that the pregnancy could be ectopic.
Another important group of nonhormonal methods is barrier methods. Male and female condoms have the additional benefit of being able to reduce the risk for contracting sexually transmitted infections. As a group, these methods are less effective during typical use as they require users to take steps to use them correctly at each act of intercourse.
Pregnancy occurs among 13% of typical male condom users, 21% of typical female condom users and 17% of typical diaphragm users and contraceptive sponge users during 1 year of use. Barrier methods may decrease sexual pleasure and can cause rare allergic reactions. Latex-free condoms and diaphragms are available. Traditionally, diaphragms have required a fitting, but there is a new one size fits most diaphragm, Caya, that can be prescribed to a patient’s pharmacy.
Fertility awareness-based methods are another option for women who want to avoid hormones. Women who use these methods track one or more signs of fertility to determine days of high fertility and avoid unprotected intercourse on those days. There are a variety of fertility awareness-based methods available.
We recently published a systematic review on the effectiveness of these methods. The typical use pregnancy rates range from 2% to 33% over 1 year of use. Two methods, Sensiplan and the Marquette Method, may be the most effective, but also require more time and expense. A new Internet app, Natural Cycles, has been approved by the FDA for pregnancy prevention and has a typical use pregnancy rate of around 10% during the first year of use.
Spermicides is another group of methods, which is where Amphora would fit in. Currently, Amphora is being tested as a contraceptive method, so I would not recommend using it outside the context of the clinical trial. However, for tested spermicides, about 21% of typical users become pregnant during 1 year of use. Spermicides can cause vaginal irritation in some users.
Finally, male and female sterilization are options for patients who want to avoid hormones, but obviously these methods are only appropriate for users who desire no future childbearing. Vasectomy may be slightly more effective than tubal occlusion, but both have pregnancy rates of less than 1% per year.
Q: What are the risks and benefits, both short- and long-term, of hormonal birth control options?
A: Combined oral contraceptive, rings and patches contain estradiol and various progestin compounds. For some users, these methods can improve cyclic bleeding patterns, mood changes, pain and headaches. For other users, these methods can make some of these symptoms worse. Combined pills may also reduce libido. Pills must be taken every day, but patches only have to be changed every week and vaginal rings every month.
A new combined hormonal 1-year vaginal ring was just approved by the FDA. Typical use pregnancies for combined hormonal methods happen in about 7% of women during 1 year of use. Women who use these methods have an increased risk for blood clots, strokes and heart attacks. These risks are usually quite low for most users, but would be higher in women who smoke, are older than 35 years or have a strong family history. Long time users may have a higher risk for breast cancer and cervical cancer but have a lower risk for uterine and ovarian cancer.
Depo Provera does not contain estrogen, so it has a lower risk for blood clots and strokes but can cause weight gain. Depo Provera can also help reduce heavy and irregular bleeding in some women. About 4% of typical users become pregnant during 1 year of use.
The etonorgestrel implant is a highly effective method that may reduce menstrual bleeding. The most common adverse side effect is frequent and irregular bleeding. In rare cases, it can migrate and be difficult to remove.
The levonorgestrel IUDs, such as Mirena, Skyla, Kyleena and Liletta, are highly effective methods that can cause significant improvement in heavy bleeding and dysmenorrhea. The bleeding with a levonorgestrel IUD can be irregular and unpredictable especially during the first few months of use; however, bleeding overall is usually light.
More than 70% of women who use these devices stop having a period at some point. The devices do decrease the risk for endometrial cancer. Although pregnancy is very rare, pregnancies that do occur are more likely to be ectopic pregnancies.
Q: Are there any emerging products for pregnancy prevention that PCPs should be aware of?
A: There are many emerging internet applications for fertility awareness, but few of these have undergone or are undergoing effectiveness testing. There are some wearable devices that are being developed for fertility awareness such as wrist and vaginal sensors for temperature and heart rate. However, none of these have undergone effectiveness testing.
It is important for primary care physicians to be aware of these, however, because there is a great deal of direct to consumer advertising for these products. PCPs should also be aware of the Liletta levonorgestrel IUD given that this device is generic and lower cost than the brand name options.
Q: Is there anything that may affect the efficacy of contraception?
A: The most important thing that can affect the efficacy of contraceptive methods is failing to use a chosen method correctly and consistently. This is the most common cause of unplanned pregnancy for any method.
However, there are certain medications such as some antibiotics that can reduce the effectiveness of hormonal methods including pills, patches, rings, Depo Provera and the implant. Women who are being prescribed new medications should be sure to discuss how this might impact the effectiveness of their contraceptive.
Disclosures: Rodriguez reports being a trainer for Merck for Nexplanons and a member of the advisory boards for Cooper Surgical and Bayer. Urrutia reports that part of her salary is paid to the University of North Carolina for clinical work at Reply OB/GYN & Fertility. The mission of Reply is to provide access to and education for fertility awareness-based methods.