Contraception Update 2021 - EMMA COFFEY MD CCFP SHE/HER - UBC CPD
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Contraception Update 2021 EMMA COFFEY MD CCFP SHE/HER EMMACOFFEYMD@GMAIL.COM
We would like to acknowledge that we are gathered today on the traditional territories of the Musqueam, Squamish and Tsleil-Waututh peoples.
I have no disclosures
Disclosures Off-label use will be indicated
Unless otherwise noted, data
presented is derived from SOGC
Contraceptive ConsensusObjectives Use a tiered effectiveness approach for your contraceptive counselling Incorporate the new contraceptive implant into your contraceptive counselling Recommend extended use of contraceptives in line with SOGC pandemic guidelines Enjoy my elder millennial cultural references
Objectives: the real world
u Give you a new framework for
approaching contraceptive discussion
u Convince you why it’s a good use of
your time
u Convince you you should be
recommending a LARC to most
patients
u (Hopefully) convince you to get
trained to insert LARCs if you do not
currently• What are you hoping to learn today?
Who inserts/removes
IUDs?
Help Me
Help You
Who inserts/removes
Nexplanon?What are your patients actually doing to prevent pregnancy? u LARC (IUD, implant) u SARC (pill, patch, ring, depo) u Condoms u Withdrawal u Nothing
What are your patients actually doing to prevent
pregnancy?
LARC 8.80%
Nothing 15.00%
Withdrawal 16.60%
SARC 37.50%
Condoms 48.40%
0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00%
Black A et al. CONTRACEPTIVE USE AND TEN-YEAR TRENDS IN CANADIAN
WOMEN OF REPRODUCTIVE AGE. J Obstet Gynecol 2019;41(5): 711–712.People at risk for pregnancy and not wanting to
What are your become pregnant
patients 15% never use contraception
actually
doing? 20% use inconsistently25-30% of your
patients who
So what? become pregnant
will have an
abortion“Well they knew
So what? how birth control
worked”People do not know how well most methods work (or don’t)
Stanback J, et al. WHO Tiered-Effectiveness Counseling Is Rights-Based Family
Planning. Global Health: Science and Practice September 2015, 3(3):352-357People do not know how well most methods work (or don’t) u Sterilization works u Nothing doesn’t work u Underestimate how well IUDs and implants work u Wildly overestimate efficacy of SARC, condoms, NFP
I’m not in the pocket of big LARC, but….
CHOICE study: most people choose LARC
u~70% of patients given adequate counselling where cost is not a factor will choose LARC
u45 % LNG-IUS
u13% subdermal implant
u10% copper
uLARC retention rates are 86 % at 1 year
u88% LNG-IUS
u 84% copper IUD
u83% subdermal implant Peipert JF, et al. Preventing unintended pregnancies by providing
no-cost contraception. Obstet and Gynecol 2012; 120(6):1291-97.
Peipert JF, et al. Continuation and Satisfaction of Reversible
Contraception. Obstet Gynecol 2011;117:1105–13.Barriers to effective contraception
Barriers to effective contraception
u Knowledge u Multiple appointments
u Cost u Covid
u Time off work u Fear of pain or trauma around pelvic
procedure
u Access to care
u Reproductive coercion (or fear of)Cash rules everything around me
Bayer.health-loyalty.com
ORGANON ASPIRETM Tel: 1-866-750-6048
Fax: 1-888-290-6061
Compassionate Program ENROLLMENT FORM Email: organonaspirecpsp@innomar-strategies.com
Monday to Friday, 8 a.m. to 8 p.m. EST
Objectives and Purpose of the Program
The ORGANON ASPIRETM Compassionate Program is pleased to offer you confidential patient-assistance services, free of charge, designed for patients who have been prescribed an Organon Product. Depending on
your eligibility or need, you will be offered these services which include the provision of compassionate product and clinic delivery.
Patient Information: To be completed by patient (Please print clearly. Patient signature required.)
First name: Last name:
Date of birth: (DD/MM/YYYY) Gender: ■ Male ■ Female ■ Other
Street address: City: Province: Postal code:
Preferred phone: Best time to reach you: ■ Morning ■ Afternoon ■ Evening
Alternate phone: Leave a message: ■ Yes ■ No
Email address: Preferred language: ■ English ■ French ■ Other
Do you have health insurance coverage? ■ Private ■ Public ■ Both Authorization to speak to patient’s caregiver: ■ Yes ■ No
Caregiver first name: Caregiver last name: Relationship:
If a legally authorized representative consents for the patient, complete the following:
First name: Last name:
Street address: City: Province: Postal code:
Permission to leave a message? ■ Yes ■ No
Email address: Relationship to patient:
SEE FULL PATIENT CONSENT TERMS ON REVERSE. PLEASE ENSURE YOU HAVE READ AND FULLY UNDERSTAND THE PATIENT CONSENT TERMS.
I, the undersigned, have read the above Program terms and conditions (the “Terms and Conditions”) found on the reverse side of this form and I agree to the collection, use and disclosure of my personal
information, including my sensitive personal health information, in accordance with the Terms and Conditions.
Patient’s Signature or Legally Authorized Representative’s Signature: Date: (DD/MM/YYYY)
Prescribing Information: To be completed by prescriber (Please print clearly. Prescriber signature required.)
Name of prescribed drug: Refills:
Diagnosis (required): Strength: Quantity:
Dosage and administration instructions Prescription information Special instructions
Prescriber Certification
I am requesting that the Organon product, described in the Prescribing Information section above, be supplied at no cost to my patient named above, in the event that the ORGANON ASPIRETM Compassionate
Program is unable to find reimbursement for this product. I understand that patient eligibility for provision of product at no cost to the patient is based on established financial needs.
Prescriber Information: To be completed by prescriber (Please print clearly. Prescriber signature required.)
Prescriber first name: Prescriber last name:
License number: Specialty:
Clinic name (if applicable):
Street address: City: Province: Postal code:
Phone number: Fax number:
Email address: Permission to leave a message at number provided: ■ Yes ■ No
Other Information / office stamp SEE FULL PRESCRIBER CONSENT TERMS ON REVERSE.
PLEASE ENSURE YOU HAVE READ AND FULLY
UNDERSTAND THE PRESCRIBER CONSENT TERMS.
Please read the information included on the reverse
side of this Patient Enrollment Form to obtain a full
description of the Program and, if you agree, sign below.
Prescriber Signature: Date: (DD/MM/YYYY)
Please fax this completed form to 1-888-290-6061 or email to organonaspirecpsp@innomar-strategies.comMany of your patients do not want to become pregnant right now
AND
Would have an abortion if they did become pregnant
BUT
TAKE HOME Are not consistently using effective contraception
POINT 1 AND/OR
Overestimate the efficacy of their contraception
AND
Would choose a long-acting reversible method if they couldTAKE HOME POINT 1b
TAKE HOME POINT 1c
Questions
Would you like to get pregnant in the next
few years, if ever?
Tiered
Effectiveness
Counselling How important is it that you not get
pregnant before you are ready?Gone in 60 seconds: Virtual Napkin Math u Implant: 1/2000 u LNG-IUS: 1/1000 u Copper IUD: 1/100 u Pill, patch, ring, depo: 1/10 u Condoms: 1/5 u Withdrawal: 1/5 u Fertility app: 1/5
Gone in 60 seconds: Which LARC?
Compassionate
IUD $45
Cost? Depends Cu IUD $75
Compassionate
implant free
Effectiveness? 1/100 Cu 1/1000 LNG IUD 1/2000 implantGone in 60 Seconds: Which LARC?
Bad – get copper
Hormones? IUD
Myth-bust first
Ick Factor? Not in my uterus - implant Not in my arm - IUD
Bad Yes - implant or Discourage
“I don’t want
hormones” –
Period? LNG-IUS copper IUD
KyleenaGone in 60 Seconds: Which LNG-IUS?
Would you be happy to Do you want to minimize
never get a period? hormone dose or IUD size?
YES YES
Mirena KyleenaTroubleshooting bleeding with iuds
• Wait it out
• Rule out infection, malposition, pregnancy
• NSAID
• Ibuprofen 800mg TID x 5 days
• Naproxen 500mg BID x 5 days
• Mefenamic acid 500mg BID x 5 days
• Estrogen
• OCP 1-3 cycles
• Estradiol (17B estradiol – Estrace) 2mg daily x 1-2 weeks
• CEE 1.25mg daily x 1-2 weeks
Zigler RE et al. Unscheduled vaginal bleeding with progestin-only
contraceptive use. American Journal of Obstetrics & Gynecology
2017 (May) 443-450.Subdermal etonogestrel implant (Nexplanon)
Inhibits ovulation
Benefits (off label)
Reduces menstrual bleeding
Reduces dysmenorrhea
Implant in 60 Risks
Seconds: The Minor insertion/removal related
(bruising, pain, scar, failed)
Basics
MigrationImplant in 60 Seconds: Side Effects
1/3 amenorrhea
Unpredictable bleeding: 1/3 infrequent bleeding
10% discontinuation 1/3 frequent or prolonged bleeding
Avg 6 days/month by 9 monthsImplant in 60 Seconds: Side Effects
Primarily acne and weight gain
Hormonal: 14% Often transient
discontinuation Serum levels peak at 2 weeks then fall
to steady state around 10% of OCPTroubleshooting bleeding with Implant
• Wait it out (6 days/month at 9 months)
• Rule out STI, pregnancy?
• NSAID
• Ibuprofen 800mg TID x 5 days
• Naproxen 500mg BID x 5 days
• Mefenamic acid 500mg BID x 5 days
• Estrogen
• OCP 1-3 cycles
• Estradiol 2mg daily x 1-2 weeks
• CEE 1.25mg daily x 1-2 weeks
Zigler RE et al. Unscheduled vaginal bleeding with progestin-only
contraceptive use. American Journal of Obstetrics & Gynecology
2017 (May) 443-450.Everyone!
Implant in 60
u
u People who don’t want a pelvic procedure
Seconds: (teenagers, trauma, abnormal uterus)
u IUD didn’t work for them
Who’s it for? u Long term depo usersInsertion location
Insertion Technique
Removal technique
UBC CPD (IUDs and Implants)
https://ubccpd.ca/course/iud2021
Implant
Training Manufacturer https://www.etonogestrel-
implant-training.ca/enu Implants are safe, effective and well tolerated
AND
TAKE HOME u
AND
WAY easier and faster to insert than an IUD
POINT #2 u You don’t need to buy any new tools
AND
u You should get trained in insertion and removal!Mirena: 7 years if >25 at insertion
(Most) 5 year copper IUDs: 7 years
LARC in the
10 year copper IUDs: 12 years
time of covid
Implant: 5 years
Evidence and SOGC supported (off-label), from pandemic contraception consensus:
https://sogc.org/common/Uploaded%20files/2020-04%20Contraception%20Consensus%20-%20Final%20Submitted.pdfRing: 28 days per ring
Patch: 10 days per patch
SARC in the
time of covid Depo: 14 weeks
Can initiate CHCs without a BP ifMirena for Emergency Contraception
Questions
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