Long Acting Contraception

Long acting
Contraception
Jamiyah Hassan
Senior Consultant OBGYN, UMMC
Powerpoint Templates
Page 1
Woman of today
Page 2
21st Century Woman
Page 3
Attitudes and roles have changed for

the modern woman
Lifestyles of women have changed dramatically in recent
years:
Education and career goals
Relationship status/family planning
Access to information
Changing needs from healthcare provider relationship
partnership
Empowerment drives active involvement in individualized
contraceptive choices
Page 4
Challenges: Changes in Womens Lifestyle

1965
Menarche
1st
child
2nd child
3rd
child
Menopause
Contraception
12
15
22
28
2000
1st
child
Menarch
e
12
51 yrs
2nd
child
Menopause
Contraception
15
30
51 yrs
30 years of fertility control

30 years of conscious family planning
Different needs in different phases of a womans fertile years

Page 5
Page 6
Page 7
Page 8
Unintended pregnancies remain

an issue
Number of yearly pregnancies
worldwide (millions)
20
0
Planning status
Outcome
150
Abortion
Unplanned
Unplanned birth
100
50
Planned
All pregnancies
Bongaarts J & Westoff CF. Studies in Family Planning 2000;31:193202
Planned birth
Page 9
Page 10
Contraceptive options
Page 11
Options for Long Acting

Reversible Contraception
Ideal for women who want or need:
Prevention of pregnancy over a long-term period

Freedom from daily pill taking
Effectiveness and reversibility
Hormonal contraception without estrogen
Post partum contraception while breastfeeding
Contraception immediately after abortion and
miscarriage
Discrete method with minimal follow-up
Page 12
Contraceptive options
Longterm
Injection, effective up to
12 weeks
Copper intrauterine device (IUD),

effective for up to 10 years
Levonorgestrel (LNG) intrauterine

system, effective for up to 5 years
Implants, effective for up to 3

years
Page 13
Possible non-contraceptive
benefits
Reduced menstrual blood
loss/amenorrhea
Can be used in smokers

>35 years
Improved dysmenorrhea/
endometriosis symptoms
Suitable for estrogenintolerant women
Reduces cyclical
hormone symptoms
Can be used in breastfeeding women
Page 14
Efficacy of contraceptive methods

% women experiencing unintended pregnancy during first year of use 1, non-comparative U.S. data
Method
Typical use
% of women
Perfect use
% of women
Chance
85
85
Condom
14
Pill
0.1 (COC)
Continuation rate
% of women
61
71
0.5 (POP)
Copper IUD
0.8
0.6
78
DMPA
0.3
0.3
70
LNG IUS
0.1
0.1
81
Implants
0.05
0.05
82
Page 15
Intrauterine Devices (IUDs)

Intrauterine devices History:
Since hundreds of years, owners of camels
achieve contraception with intrauterine placed
pebbles
- 1909 Richter describes thread-like pessary
- 1928 Grfenberg uses ring made of silver
wire
Thai fishermen IUD

made from fishing line
Page 16

Intrauterine devices History:
Variety
Page 17

Intrauterine devices - Insertion:
Grasping forceps
sounding
Page 18

Intrauterine devices - Insertion
Page 19

Intrauterine devices - Insertion
IUD thread reaching

out of the cervical os
2 cm.
Page 20

Lost intrauterine device after perforation of uterine wall:
Lost IUDs
Page 21

Intrauterine devices - most commonly used brands:
Mirena
1st (plastic), 2nd (copper) and 3rd (hormone-releasing) generation IUDs

(Nova-T contains a silver core in order to prevent fragmentation of copper
wire).
Page 22

Characteristics of intrauterine devices:
Contraindications for IUDs
Prerequisites for IUD insertion
- Negative Pregnancy Test

- Normal PAP Smear
Antibiotic Prophlaxis for IUD

insertion
Local Inflammation/Infection
Uterine Anomalies
Unclear Genital Bleeding
Use of Anticoagulants
Copper Allergy
Not Necessary
PEARL Index
- 0.53.0 (2nd Generation IUDs)

- 0.050.1 (3rd Generation IUDs)
Side Effects
- Expulsion of the IUD (18%)

- Uterus Perforation (0.120.68/1000)
- Local Inflammation (1.49.6/1000)
- Ectopic Pregnancy (6.88.9/1000/10
years)
- Menstrual Irregularities (25%)
- Spotting, Dysmenorrhea (44-59%)
Follow-Up
- Vaginal Ultrasound Immediately After

Insertion
- Vaginal Ultrasound After 6 Weeks
- Yearly Gynecologic Exam
Page 23
Depot-Injections
Page 24
Hormonal Contraception Depot Injections

Depot contraceptives = Long-term
contraceptives
Injectable depot drugs:
Implantable depot drugs:
- Three-months injection = depot

medroxyprogesteron acetate
- Levonorgestrel-containing IUD
(Mirena)
(DMPH = Depot Provera,

Depot-Clinovir)
- Monthly injection:
- Etonogestrel-containing implants,
or vaginal ring (Implanon, NuvaRing).
norethisterone acetate
(Noristerate)
Page 25

Injectables Pharmacokinetics:
Action
MPA
Ovulation inhibition
(inhibition of preovulatory
LH-peak)
Cervical mucus thickening
Endometrial transformation
Endometrial atrophy
Pearl index
++
+
++
++
0.1 - 0.6
Norethisterone
++
++
+
(+)
0.1 - 0.6
Page 26
Hormonal Contraception - Depot

Injections
Advantages of progestin depot injections
- Patient cannot forget the pill.

- Endometriosis
- Uterine fibroids
- Dysmenorrhea
Disadvantages
- Bleeding disturbances in first six months (later atrophy)

- Long-term use may contribute to osteoporosis (?)
Fertility after discontinuation:
- Average latency until next pregnancy after IUD four months vs. depot
progestins 10 months
- Cumulative pregnancy rate after two years, however no difference
between depot progestins and other contraceptive methods
Page 27

Monthly injection:
Advantages
Pearl index 0 - 0.2

They contain no ethinyl estradiol (less side effects)
Administration only once a month
Good cycle control due to estradiol
Fertility returns immediately after discontinuation
Disadvantages
- Monthly visit to the family planning clinic
Page 28
Implanon: ENG release and

MOA
4 cm
2 mm
Core: ethylene vinyl acetate (EVA)
etonogestrel (68 mg)
Rate-controlling membrane (0.06 mm):
EVA
Release rate: 6070 g/day initially, decreasing

to 2530 g/day by end of third year,
sufficiently
high to suppress ovulation
Page 29
ENG plasma levels, return of

ovulation
Mean serum concentration-time profile of ENG during 2 years of Implanon use and after removal in 20 women
Post-insertion
Months 1-24
Post-removal
>90% women
ovulate within
4 weeks of
discontinuation1
1. Bennink HJ, et al. Eur J Contracept 2000;5:1220
Page 30
Efficacy
No pregnancies in clinical trials: PI 0 (0 0.2)
In nine years clinical use overall reported
pregnancy rate of 0.049 per 100 implants
used
50% related to non-insertion, untimely insertion or
existing pregnancy before insertion
Method failure rate of 0.010 per 100 implants,
25% related to
Cy-P450 enzyme inducing concomitant
medication
Page 31
Adverse Events
thought to be related to Implanon in >5% of women
WHO preferred
term
AE %
Discontinuation
%
Headache
15.3
1.6
Weight increase
11.8
2.3
Acne
11.4
1.3
Breast pain
10.2
<1
Emotional lability
5.7
2.3
Abdominal pain
5.2
<1
Blumenthal et al, European Journal of Contraception and Reproductive Health Care 2008
Page 32
Bleeding pattern changes

Bleeding patterns will alter
Most women experience
infrequent bleeding or
amenorrhea
In up to 75% of reporting
periods, number of
bleeding/spotting days was
less than that seen in natural
cycle
11.3% of patients discontinued

due to bleeding irregularities
Mainly prolonged flow and/or
frequent bleeding episodes
Bleeding pattern during initial

phase predicted future patterns
(and discontinuation) for most
users
Counseling on progestogen only bleeding

pattern is essential for compliance
Mansour D, et al. Eur J Contracept Reprod Health Care 2008;13:1328
Page 33
Cumulative discontinuation rates
Cumulative probability
of discontinuation:
End
of year 1: 18%
End of year 2: 30%
End of year 3: 36%
3 year cumulative
discontinuation due
to bleeding = 11%
Blumenthal et al, European Journal of Contraception and Reproductive Health Care 2008
Page 34
Impact on acne
The majority of women without acne
at baseline experienced no change
Funk S, et al. Contraception 2005;71:319326
60% of women with acne at baseline

experienced an improvement
Page 35
Impact on pre-existing
dysmenorrhea
n=187
Funk S, et al. Contraception 2005;71:319326
Page 36
Impact on endometriosis
Pain intensity
scores by VAS
Implanon n = 21
DMPA
n = 20
Walch K, et al. Contraception 2009;79:29-34
37
Page 37
Estradiol levels
Estradiol (pmol/L)
1200
Implanon
IUD
1000
800
600
400
200
0
baseline
12
months
24
months
Beerthuizen et al. Human Reproduction 15, 2000: 118-122
last measurement
38
Page 38
BMD at the lumbar spine

z-Score
for BMD
Implanon
IUD
1
0
-1
-2
baseline
6
months
12
months
Beerthuizen et al. Human Reproduction 15, 2000: 118-122
24
months
39
last measurement
Page 39
Summary of the etonogestrel

implant
>99% effective in real use
Effective for up to 3 years
Well tolerated, with mostly no
change in acne or an
improvement
No impact on BMD
Rapid return to fertility
Positive effects on
dysmenorrhoea and
endometriosis
Can be used while
breastfeeding
Expectations and acceptability
of bleeding changes can be
managed with pre-insertion
counseling
Page 40
Implanon NXT: Applicator

Applicator design elements:
Preloaded for single use
Implant is retained in needle before insertion
Single-handed movement with slider
Needle visible
from aside,
retracts in
applicator
with slider
Distance
needle
applicator
= 4mm
Page 41
Insertion
Page 42
Implanon NXT: Implant
3% of EVA in implant
core is replaced by
bariumsulfate
Bioequivalent to current
implant
X-ray visible
MRP approval in
Europe
Page 43
Hormone-Releasing IUD
Progestin-containing intrauterine system (Mirena):
Properties:
-
T-shaped polyethylene body

Release of levonorgestrel 20 g/d
Contraceptive protection 5 years
Pearl index 0.1 - 0.2
Atrophic endometrial changes
Strong reduction of menstrual bleeding
duration and volume
- 25% amenorrhea (year 1-5)
- 60% amenorrhea (year 6-10)
- Mirena introduced in Germany 1997
> 500,000 women use Mirena
Page 44
Levonorgestrel containing intrauterine system
(Mirena):
Powerpoint
Hormone
release fromTemplates
Mirena intrauterine system
Page 45
Levonorgestrel containing IUD
(Mirena):
Mode of action:
change in the uterotubal environment
(impairing sperm motility)
change in the decidua of
the endometrial stroma,
reduced proliferation
(Inhibition of implantation)
thickening of cervical
mucus (impairing sperm
motility)
Page 46
Levonorgestrel containing IUD
(Mirena):
pg/ml
Comparison of Levonorgestrel-plasma concentration of various
contraceptives
8000
6000
Combined OC
progestogenonly-pill
4000
Norplant
2000
Mirena
0
adapted from Diaz et al. (1987), Kuhnz et al. (1992), Nilson et al. (1986), Weiner et al. (1976)
days
Page 47
Bleeding patterns of LNG-containing
intrauterine systems (Mirena):
-3
-2
-1
10
11
In the first 3-6 months irregular bleeding and

spotting
shorter, lighter and less painful periods
Powerpoint
Templates
about
20% of women
may have no bleeding after 1
Page 48
year
Bleeding pattern of LNG-containing intrauterine
systems:
Length of period
Volume of menstrual blood
days
increase in ml
40
copper IUD
copper IUD
20
4
0
2
Mirena
20
Mirena
0
0 2 4 6 8 10 12 14 16 18 20 22 24 months
40
decrease in ml
adapted from Luukkainen et al. (1992)
adapted from Scholten et al. (1989)
Page 49
Levonorgestrel containing IUD:
Cons
Pros
very high contraceptive efficacy

(PI 0.1)
intermenstrual bleeding and

spotting in the first 3-6 months
local delivery to the target organ

low systemic effect
needs to be inserted
(poss. local anaesthesia and
not dependent on compliance
long-acting: up to 5 years
shorter, lighter and less painful

periods
hormonal side effects in a few

women
Price
can be used while

breastfeeding
endometrial protection during

estrogen replacement therapy
dilatation up to Hegar 4)
Page 50
Noncontraceptive benefits:
(Hubacher D, Grimes DA, Obstet Gynecol Survey 2002,57:120-128)
Page 51
LNG-releasing intrauterine system:
Use in perimenopause
- Reliable contraception when women have ended their family planning,
and pregnancy would be extremely unwanted
- Pregnancies in this age group are associated with risk of complications
Use in postmenopause
- With increased risk of breast cancer diagnosis after hormone replacement
therapy > 50 years, new ways of progestin application are searched for.
- Estrogen application via skin patch, avoiding first liver passage and
topical progestin application through intrauterine system. With respect to
the fact that contraception is no longer needed, intrauterine postmenopausal
systems can be smaller with reduced LNG-release.
Page 52
Surgical Methods of Contraception
Tubal sterilization by mini-laparotomy:
Pomeroy method
Page 53

Laparoscopic tubal sterilisation:
Application of Yoon-Silastic-Fallopian Ring
Page 54
Male sterilization vasectomy:

Scalpel vasectomy. The vas deferens can be palpated as a wire-like
structure. Dissection and ligation with non-resorbable material.
Page 55
Conclusions
Women of today
Value independence and individually defined lifestyles
Empowered through increased information access
Have multiple factors influencing contraceptive needs
Long acting contraception is useful for women who do
not want daily or weekly use
Important for clinician to listen to womans individual
needs and consider them as active partner in decisionmaking process
Important to consider women on individual level
Page 56
Thank You
Stay healthy..and sexy

Page 57

Long Acting Contraception

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Long acting

21st Century Woman

Attitudes and roles have changed for

Challenges: Changes in Womens Lifestyle

30 years of fertility control

Different needs in different phases of a womans fertile years

Unintended pregnancies remain

Bongaarts J & Westoff CF. Studies in Family Planning 2000;31:193202

Options for Long Acting

Prevention of pregnancy over a long-term period

Copper intrauterine device (IUD),

Levonorgestrel (LNG) intrauterine

Implants, effective for up to 3

Can be used in smokers

Suitable for estrogenintolerant women

Can be used in breastfeeding women

Efficacy of contraceptive methods

Intrauterine Devices (IUDs)

Thai fishermen IUD

Intrauterine Devices (IUDs)

Intrauterine Devices (IUDs)

Intrauterine Devices (IUDs)

Intrauterine Devices (IUDs)

IUD thread reaching

Intrauterine Devices (IUDs)

Intrauterine Devices (IUDs)

1st (plastic), 2nd (copper) and 3rd (hormone-releasing) generation IUDs

Intrauterine Devices (IUDs)

Prerequisites for IUD insertion

- Negative Pregnancy Test

Antibiotic Prophlaxis for IUD

- 0.53.0 (2nd Generation IUDs)

- Expulsion of the IUD (18%)

- Vaginal Ultrasound Immediately After

Hormonal Contraception Depot Injections

Implantable depot drugs:

- Three-months injection = depot

(DMPH = Depot Provera,

Hormonal Contraception Depot Injections

Hormonal Contraception - Depot

- Patient cannot forget the pill.

- Bleeding disturbances in first six months (later atrophy)

Fertility after discontinuation:

Hormonal Contraception Depot Injections

Pearl index 0 - 0.2

Implanon: ENG release and

Release rate: 6070 g/day initially, decreasing

ENG plasma levels, return of

1. Bennink HJ, et al. Eur J Contracept 2000;5:1220

Bleeding pattern changes

11.3% of patients discontinued

Bleeding pattern during initial

Counseling on progestogen only bleeding

Mansour D, et al. Eur J Contracept Reprod Health Care 2008;13:1328

Cumulative discontinuation rates

Funk S, et al. Contraception 2005;71:319326

60% of women with acne at baseline

Funk S, et al. Contraception 2005;71:319326

Walch K, et al. Contraception 2009;79:29-34

BMD at the lumbar spine

Summary of the etonogestrel

Implanon NXT: Applicator

Preloaded for single use

Implant is retained in needle before insertion