Family Planning

Family Planning

1. What every clinician should know

All reproductive aged women should be counseled regarding their pregnancy risk. All contraceptive options should be reviewed, and recommendations made based on a woman’s medical history and her desired timing for a subsequent pregnancy. Contraceptive options include, in order of relative effectiveness, contraceptive implant, surgical sterilization, intrauterine devices, progestin-only injectable, oral contraceptive pills, contraceptive patch, contraceptive vaginal ring, barrier methods, and fertility awareness-based methods.

Women who engage in unprotected sex and are not currently using contraception may use emergency contraception.

If unintended pregnancy occurs, women should be counseled regarding all pregnancy options including continuing a pregnancy, adoption, and abortion. Methods of abortion include medical and surgical options.

Combined hormone contraceptives

Combined hormone contraceptives (CHC) include: Combined oral contraceptive pills (COC) / Contraceptive patch / Contraceptive vaginal ring

Combined hormonal contraception, containing both estrogen and progestin hormones, prevent pregnancy mainly by suppressing ovulation via negative feedback to the hypothalamic-pituitary-ovarian axis, thickening the cervical mucus thereby preventing sperm entry and inducing endometrial changes that may prevent implantation. These methods are associated with a typical failure rate of 8% within the first year of use. Drug interactions with certain anticonvulsant therapy, protease inhibitors, and rifampicin may decrease the effectiveness of combined hormonal contraceptives (CHCs). Most broad-spectrum antibiotics do not affect the effectiveness of COCs.

COCs require daily administration. The contraceptive patch requires weekly administration for 3 weeks with a patch-free interval during the 4th week. The contraceptive vaginal ring requires 21 days of use followed by a 7-day ring-free interval.

Advantages

• Advantages of CHC use include relative ease of initiation, rapid reversibility, decreased dysmenorrhea, decreased menstrual blood loss, regulation of menses, and reduced premenstrual symptoms.

• General health benefits include reduction in the risk of ovarian and endometrial cancer and decreased acne and hirsutism.

• Due to these effects, non-contraceptive uses for CHCs include management of irregular menstrual bleeding, menorrhagia, dysmenorrhea, and premenstrual symptoms.

Side effects

• Common side effects associated with CHCs include irregular bleeding, absence of withdrawal bleeding, headache, decreased libido, mood symptoms, mastalgia, skin changes such as acne and hirsutism, and nausea and vomiting.

• Skin irritations such as redness or rash are specific to the contraceptive patch. An increase in vaginal secretions is commonly associated with contraceptive ring use.

• Ring expulsion also occurs, increasing pregnancy risk if the ring has been expelled for greater than 3 hours in a 24-hour period.

Contraindications

Contraindications to CHCs are limited by the thrombotic effects of estrogen, oral absorption of COCs, and drug metabolism. Based on the U.S. Medical Eligibility Criteria (MEC) for Contraceptive Use, unacceptable health risk is associated with CHC use among women with the following conditions:

• immediately postpartum (< 21 days among healthy women, or less than or equal to 42 days among women with high risk factors for venous thromboembolism (VTE) such as smoking, deep venous thromboembolism (DVT) or pulmonary embolism (PE), known thrombogenic mutations, and peripartum cardiomyopathy);

• greater than or equal to 35 years of age who smoke 15 or more cigarettes per day;

• multiple risk factors for arterial cardiovascular disease such as older age, smoking, diabetes, and hypertension;

• severe hypertension (systolic blood pressure greater than or equal to 160mm Hg or diastolic blood pressure greater than or equal to 100 mm Hg)

• vascular disease;

• history of DVT/PE, not on anticoagulant therapy with higher risk for recurrent DVT/PE (at least one risk factor such as history of estrogen-associated DVT/PE, pregnancy-associated DVT/PE, idiopathic DVT/PE, known thrombophilia including antiphospholipid syndrome, active cancer, history of recurrent DVT/PE);

• acute DVT/PE;

• DVT/PE and established on anticoagulant therapy for at least 3 months (at least one risk factor such as known thrombophilia, active cancer, and history of recurrent DVT/PE);

• known thrombogenic mutations;

• ischemic heart disease;

• stroke;

• complicated valvular heart disease (e.g., pulmonary hypertension, risk for atrial fibrillation, history of subacute bacterial endocarditis);

• peripartum cardiomyopathy with moderately or severely impaired cardiac function, or women with normal or mildly impaired cardiac function who are within 6 months of diagnosis

• systemic lupus erythematosus with positive or unknown antiphospholipid antibodies;

• migraine headache with aura at any age or migraine headache without aura among older women (greater than or equal to 35 years);

• current or recent (within 5 years) breast cancer

• diabetes mellitus with nephropathy, retinopathy, neuropathy, vascular disease or prolonged duration (> 20 years);

• acute viral hepatitis;

• hepatocellular adenoma;

• malignant liver tumor;

• complicated solid organ transplantation (e.g., graft failure, rejection, cardiac allograft vasculopathy);

Progestin-only contraceptives

Progestin-only contraceptives (POC) include progestin-only pills, injectable, and contraceptive implants. Their effectiveness varies greatly but they all work through a similiar mechanism. Progestin-only contraceptives (POCs) prevent pregnancy primarily by suppressing ovulation.

Side effects: With regard to side effects, menstrual irregularities and formation of functional ovarian cysts are more common among POC users compared to CHC users. However, POCs serve as excellent alternatives to estrogen-containing contraception with regard to their acceptability profile.

Only contraindication: The only condition associated with unacceptable health risk among POC users, according to the U.S. MEC, is current or recent (within 5 years) breast cancer.

Progestin-only pills (POPs) are similar to COCs with regard to their effectiveness.

• This contraceptive method requires daily administration without a hormone-free interval, unlike COCs. Since progestin levels decline to nearly undetectable levels at 24 hours after ingestion, health care providers must emphasize the importance of daily POP ingestion at the same time each day.

• The side effect profile is similar to combined hormonal contraception.

Depot medroxyprogesterone acetate (DMPA) is an injectable that requires intramuscular administration at 3-month intervals (between 11-14 weeks), though a subcutaneous formulation is also available. It is associated with a 3% typical failure rate within 1 year of use.

• DMPA is associated with decreased premenstrual symptoms and commonly induces amenorrhea, generally a desirable effect for many women.

• Common side effects include menstrual irregularities, weight gain, and delayed return to fertility up to 12 months. DMPA use is also associated with a temporary and usually reversible decrease in bone mineral density. However, it has not been associated with an increase in fragility fracture. The American College of Obstetricians and Gynecologists (ACOG) does not endorse specific recommendations regarding calcium, vitamin D, or estrogen supplementation.

The contraceptive implant is a single-rod subdermally-implantable device that remains effective up to 3 years of use. Based on regulations enforced by the Food and Drug Administration, the device must be inserted by a health care provider after undergoing a specific training program sponsored by the drug manufacturer. It is associated with a typical failure rate of 0.05% within 1 year of use, the highest relative effectiveness among all contraceptive methods.

• It is rapidly reversible and causes reduction in dysmenorrhea.

• While women usually report infrequent bleeding or amenorrhea, approximately 10% of implant users discontinue use due to frequent bleeding or prolonged bleeding.

Intrauterine contraception

Intrauterine devices (IUDs) offer rapidly reversible long-term contraception with high effectiveness rates; the typical failure rate is 0.2-0.8% within 1 year of use.

• Insertion-related problems may include uterine cramping, uterine perforation, and upper genital tract infection related to transient introduction of endocervical bacteria into the endometrial cavity.

• Disadvantages associated with IUD use include altered bleeding pattern (irregular bleeding or amenorrhea among levonorgestrel IUD users, or prolonged or heavy bleeding among copper IUD users), spontaneous expulsion, and pregnancy complications if the device fails.

• Due to the high efficacy associated with IUDs, the absolute risk of ectopic pregnancy among IUD users is low even though the proportion of ectopic pregnancies may be greater among women who become pregnant with an IUD in place.

• Contraindications to IUD use include puerperal or post-abortion sepsis and malignant gestational trophoblastic disease.

While IUD continuation may considered, initiation of IUD use poses unacceptable health risk among women with the following conditions:

• unexplained vaginal bleeding that has not been evaluated

• cervical cancer

• current or recent breast cancer (for levonorgestrel IUD use)

• current cervicitis or pelvic inflammatory disease, including pelvic tuberculosis

The levonorgestrel IUD has several contraceptive effects including thickening of the cervical mucus, endometrial suppression, inhibition of sperm capacitation and survival, and suppressed ovulation in some women. It is highly efficacious up to 5 years of use and can be used to treat heavy menstrual bleeding. Irregular light bleeding or spotting is common within the first few months of use.

The copper IUD impairs sperm function, preventing fertilization. It is highly efficacious up to 10 years of use and serves as a great option for women who desire a non-hormonal contraceptive method. Heavy and prolonged menstrual bleeding can occur, although these symptoms may be managed with use of non-steroidal anti-inflammatory drugs.

Surgical sterilization

Both male and female surgical sterilization offer highly effective contraception to individuals who do not desire future fertility. Female surgical options include postpartum sterilization, interval sterilization via laparoscopy or mini-laparotomy, or hysteroscopic tubal occlusion. The overall typical failure rate for these methods is 0.5% within 1 year.

Other Methods

Contraceptive barrier methods include cervical cap, diaphragm and male and female condoms. These methods require insertion for each encounter and are associated with a 15-20% typical failure rate. Similarly, withdrawal and fertility-awareness methods, such as calendar-based and symptoms-based methods, are associated with an approximately 25% typical failure rate.

Emergency contraception (EC) may be used to reduce pregnancy risk when other forms of contraception are not used or improperly used (e.g., missed pills). Single-dose levonorgestrel 1.5 mg, ulipristal 30 mg, and the copper IUD may be used within 5 days of unprotected or under-protected sex. Specific dose formulation of COCs may also be used as EC.

2. Management

Contraceptive initiation should primarily be prescribed based on assessment of pregnancy risk.

• Non-hormonal contraceptive methods are immediately effective upon initiation of use, with the exception of hysteroscopic sterilization which requires a confirmatory imaging study in 3 months to verify tubal occlusion.

• Hormonal contraceptives are immediately effective when initiated within 5 days of the beginning of menses among women with regular menstrual cycles. Outside this time period, health care providers may consider initiating hormonal contraception if the patient reports abstinence, consistent condom use, or copper IUD use. Further, abstinence or back-up contraception for an additional 7 days is necessary when initiating contraceptive pills, patch, vaginal ring, and the levonorgestrel IUD; 4 days for the contraceptive implant. Similarly, switching different types of hormonal contraceptives requires overlapping use up to 7 days, with the exception of COCs and POPs.

Screening for cervical cancer and/or sexually transmitted infections should not be required prior to contraceptive initiation. Instead, they should be performed based on respective cancer screening guidelines and risk assessment guidelines of infection risk.

Follow-up visits may be prescribed to assess compliance, review side effects, and assess possible expulsion among IUD users.

• While most side effects are transient, some problems may necessitate intervention.

• Changes in pill formulation, shortened pill-free interval or extended use may minimize pill-related side effects.

• A short course of COC, exogenous estrogen or non-steroidal anti-inflammatory drugs may decrease the irregular bleeding that is common among POC users.

3. Complications

In cases of contraceptive failure, women should be counseled regarding pregnancy options including continuing a pregnancy, adoption, or abortion.

An early ultrasound is indicated to establish gestational age.

An intrauterine device should be removed to prevent spontaneous abortion or septic abortion, or other pregnancy complications such as preterm labor, premature rupture of membranes, or placental abruption.

Women who choose pregnancy termination may undergo medical or surgical methods depending on gestational age, medical history, state-defined legal restrictions, and availability of trained providers.

Medical abortion can be performed using a combination of mifepristone and misoprostol. Other evidence-based regimens include a combination of methotrexate and misoprostol or misoprostol alone.

Surgical abortion can be performed by suction curettage using electric or manual vacuum aspiration.

Second trimester pregnancy termination require labor induction or dilation and evacuation.

Cervical priming with misoprostol or osmotic dilators is indicated.

4. Prognosis and outcome

Contraceptive compliance is highly dependent on individual-based counseling with a focus on limiting barriers to contraceptive initiation. Management of side effects or switching methods may improve compliance.

Return to fertility is rapid upon discontinuation of non-permanent contraceptive methods, with the exception of DMPA which may delay fertility for an average of 10 months.

5. What is the evidence for specific management and treatment recommendations

“Centers for Disease Control and Prevention.U.S. medical eligibility criteria for contraceptive use, 2010: adapted from the World Health Organization medical eligibility criteria for contraceptive use, 4th edition”. MMWR. vol. 59. 2010. (This publication identifies eligibility of use of available contraceptive options based on common medical conditions, highlighting acceptable methods and contraindications.)

Hatcher, RA, Trussell, J, Nelson, AL, Cates, WC, Stewart, FH, Kowal , D. “Contraceptive technology”. 2007. (This textbook provides comprehensive information regarding contraceptive options and their associated physiologic effects, advantages, side effects, contraindications, and management of common problems.)

Lesnewski, R, Prine, L, Ginzburg, R. “Preventing gaps when switching contraceptives”. Am Fam Physician.. vol. 83. 2011. pp. 567-70. (This article focuses on practical management of patients who choose to switch contraceptives, eliminating a fertile interval.)

“Long-acting reversible contraception: implants and intrauterine devices. Practice Bulletin No. 121. American College of Obstetricians and Gynecologists”. Obstet Gynecol. vol. 118. 2011. pp. 184-96. (This guideline focuses on IUDs and the contraceptive implant with regard to medical eligibility, insertion guidelines, follow-up, and management of common problems.)

“Medical management of abortion. ACOG Practice Bulletin No. 67. American College of Obstetricians and Gynecologists”. Obstet Gynecol. vol. 106. 2005. pp. 871-82. (This guideline provides information on first trimester medical abortion with respect to evidence-based regimens, their associated risks, and follow-up.)

Shoupe, D. “Contraception”. 2011. (This textbook provides practical guidance on use of contraceptive methods, with an emphasis on counseling, non-contraceptive benefits, disadvantages and contraindications, follow-up, and management of common problems.)

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