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Long acting

Contraception

Jamiyah Hassan
Senior Consultant OBGYN, UMMC
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Woman of today

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21st Century Woman

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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
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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


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

Planned birth

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Contraceptive options

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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

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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

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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

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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

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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

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Thai fishermen IUD


made from fishing line

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Intrauterine Devices (IUDs)


Intrauterine devices History:

Variety
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Intrauterine Devices (IUDs)


Intrauterine devices - Insertion:

Grasping forceps

sounding

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Intrauterine Devices (IUDs)


Intrauterine devices - Insertion

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Intrauterine Devices (IUDs)


Intrauterine devices - Insertion

IUD thread reaching


out of the cervical os
2 cm.

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Intrauterine Devices (IUDs)


Lost intrauterine device after perforation of uterine wall:

Lost IUDs

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Intrauterine Devices (IUDs)


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).
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Intrauterine Devices (IUDs)


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

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Depot-Injections

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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)

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Hormonal Contraception Depot Injections


Injectables Pharmacokinetics:
Action

MPA

Ovulation inhibition
(inhibition of preovulatory
LH-peak)
Cervical mucus thickening
Endometrial transformation
Endometrial atrophy
Pearl index

++

+
++
++
0.1 - 0.6

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Norethisterone
++

++
+
(+)
0.1 - 0.6

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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

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Hormonal Contraception Depot Injections


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
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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
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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

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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
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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

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Blumenthal et al, European Journal of Contraception and Reproductive Health Care 2008

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

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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%

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Blumenthal et al, European Journal of Contraception and Reproductive Health Care 2008

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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

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Impact on pre-existing
dysmenorrhea

n=187

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

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Impact on endometriosis
Pain intensity
scores by VAS

Implanon n = 21
DMPA
n = 20

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

37

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Estradiol levels
Estradiol (pmol/L)
1200

Implanon
IUD

1000
800
600

400
200
0
baseline

12
months

24
months

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Beerthuizen et al. Human Reproduction 15, 2000: 118-122

last measurement
38

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BMD at the lumbar spine


z-Score
for BMD

Implanon

IUD

1
0
-1

-2
baseline

6
months

12
months

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Beerthuizen et al. Human Reproduction 15, 2000: 118-122

24
months
39

last measurement
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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

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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
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Insertion

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Implanon NXT: Implant

3% of EVA in implant
core is replaced by
bariumsulfate
Bioequivalent to current
implant

X-ray visible
MRP approval in
Europe
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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
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Hormone-Releasing IUD
Levonorgestrel containing intrauterine system
(Mirena):

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Hormone
release fromTemplates
Mirena intrauterine system

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Hormone-Releasing IUD
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)
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thickening of cervical
mucus (impairing sperm
motility)

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Hormone-Releasing IUD
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)

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days

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Hormone-Releasing IUD
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

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about
20% of women
may have no bleeding after 1
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year

Hormone-Releasing IUD
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)

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Hormone-Releasing IUD
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)

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Hormone-Releasing IUD
Noncontraceptive benefits:

(Hubacher D, Grimes DA, Obstet Gynecol Survey 2002,57:120-128)

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Hormone-Releasing IUD
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.

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Surgical Methods of Contraception

Tubal sterilization by mini-laparotomy:

Pomeroy method

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Surgical Methods of Contraception


Laparoscopic tubal sterilisation:

Application of Yoon-Silastic-Fallopian Ring

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Surgical Methods of Contraception

Male sterilization vasectomy:


Scalpel vasectomy. The vas deferens can be palpated as a wire-like
structure. Dissection and ligation with non-resorbable material.

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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
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Thank You

Stay healthy..and sexy


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