KontraceptionU-kursus 2014

Kresten R. Petersenoverlæge, dr.med

Gynækologisk-obstetrisk afd. Odense Universitetshospital

Disposition

• Kontraception i forskellige aldersgrupper med særlig vægt på de unge og de ”gamle”.

• Medicinske fordele ved kontraception

Legal abortions/1000 w. in Denmark 1975-2012

1975

1980

1985

1990

1995

1999

2003

2006

2010

0

5

10

15

20

25

30All Ages

Teenagers

•Statens Seruminstitut 2014

Antal tilfælde af Klamydia T. i Danmark 1994-2011

0

5000

10000

15000

20000

25000

30000

35000

1994 1996 1998 2000 2002 2004 2006 2008 2009 2011

Statens Seruminstitut

Use of contraception in women seeking legal abortion - 00

Abortion – Danish (n=1028)

Abortion – Non-Danish(n=214)

Contraceptive use (%) 44,7 36,0

No contraceptive use (%) 55,0 60,7

Condom (%) 25,2 21,5

OC (%) 15,0 9,3

Other (%) 3,8 4,2

None (%) 55,0 60,7

Rasch et al: Human Reprod 2007;22:1320-6

Teoretisk effektivitet Faktisk effektivitet

Ingen kontraception 85 85

Afbrudt samleje 4 27Kondom 2 15Pessar 6 16Kombinations p-piller 0,3 8P-plaster og P-ring 0,3 8Gestagen stav 0,5 0,5Kobberspiral 0,6 0,8Gestagenspiral 0,2 0,2Kvindelig sterilisation 0,5 0,5Mandlig sterilisation 0,1 0,15

Contraceptive efficacy - % women pregnant during first year

Hatcher RA, et al Contraceptive Technology: Nineteenth Revised Edition. New York NY: Ardent Media, 2007

De unge

• Ca 50 % bruger p-piller

• Dårlig compliance

• Glemmer tabletterne

• Generet af bivirkninger

Discontinuation of OCs

0

25

50

75

100

0 2 4 6

Months of use

Perc

ent

Rosenberg, Am J Obstet Gynecol 1998;179:577

Discontinuation of OCEuropean study

Side effectsWeight gainHealth problems/riskNot naturalForgot to takeNo need for contr.

24 %8 %

16 %5 %5 %

30 %

Skouby. Eur J Contracep Reprod Health 2004;9:57

Discontinuation of OC during first 6 months – American study

Bleeding irreg.NauseaWeight gainMood changesBreast tendernessHeadachesMethod relatedNo need for contr.

12 %7 %5 %5 %4 %4 %14%23 %

Rosenberg, Am J Obstet Gynecol 1998;179:577

Alternatives to OC’s

Ring and patches

Patches:20 mcg EE + 150 NGT3 x1 w.patch 1 w withoutPearls index < 1.5Continous use

Rings15 mcg EE + 120 ETO3 w.ring 1 w withoutPearls index < 1Can be removed for 3 h

Same contraindications as OCs

NuvaRing

Common questions.Can the ring be felt ??

• 87 % of the women never/seldomly felt the ring during intercourse

• 74% of the partners never/seldomly felt the ring during intercourse

• 5% considered it a problem

Dieben et al. Obstet Gynecol 2002;100:585-93

Implant – Implanon NXT

Etonorgestrel implantContraceptive effect - 3 y

• At registration• 73429 cykles• No pregnancies

• Latest post marketing report*:• 218 pregnancies in 205.000 insertions• 13 directly method related

Harrison. Contraception 2005;71:306

Progestogen DepotDepo-Provera

Depo Provera

• 150 mg MPA given i.m. every 3 months

• Pearls index far below 1

• Well suited for women with questionable compliance

What about Cupper IUDs ????

Mode of action:Foreing body reaction in endometriumCu ions are toxic to spermatozooesReduced fertilisation

Main concerns:Decreased fertility due to PIDIncreased menstrual flow and pain

Proportion of women with tubal infertility, non-tubal infertility and fertile women who had used IUDs

0102030405060708090

100

Tubal infert(n=357)

Non-tubalinfet (n=948)

Fertile (n=583)

IUD use

No IUD use

Hubacher. N Engl J Med 2004;345:561-67

IUDs in nulliparous women Wiener 1978

(n=226, 6 months) Skouby 1981

(n=120, 12 month) Petersen 1991

(n=236, 12 month) Termination (%)

Expulsion 12 7 10

Bleeding/pain 5 14 13

Pregnancy 2 2 0

PID 2 6 9

Personal 0 6 3

Continuation 79 66 65

1 year clinical performance of OCs and LNG-IUDs in nullips – a randomized study

OC (n=99) LNG-IUD (n=94)Pain 0 6,7*

Hormonal 9,8 4,9

Bleeding/spotting 1,3 2,5

Expulsion NA 1,2

Other medical 1,1 2,1

Pl. pregnancy 2,6 0

Personal 15,4 4,6*

Cont. rate 72,7 79,8

Suhonen. Contraception 2004:69:407-12

Hvad så med de ældre kvinder ??

Særlige hensyn

• Konkurerende medicinske sygdomme (adipositas, DM, hypertension,cancer)

• Gynækologiske tilstande (fibromer, blødningsforstyrrelser)

WHO – medical eligibility for contraceptive use 2004

The eligibility was graded in four categories:

1: OCs can be used in any circumstances2: OCs can generally be used3: OCs not usually recommended unless other more appropriate methods are not available or not acceptable4: OCs should not be used

WHO – medical eligibility for oral contraceptive use - Smoking:

Age < 35 y

Age > 35 y.

LightHeavy (>20 cig/day

2

34

WHO – medical eligibility for oral contraceptive use - Headache

• Mild• Severe (recurrent incl.

Migraene without focal neurological sympt).

• With focal neurological sympt

1

2

4

Only one risk factor allowed

• Age > 35• Smoking• Obesity• Varicose veins• Mild hypertension• DM without complications• Migraine

Non contraceptive effects of EE+Progestogen methods

Positive: Bleeding disturbances, endometriosis, dysmenore,

hirsutism, ovarian cysts, endometrial- and ovarian cancer

Negative: Vascular disease

OCs and reprod. cancerRCGP: 46.000 w recr. from 1968-69 1.083.000 w. years

Never users (31%) Ever users (69%)

Breast 1 (448) 0.98 (891)

Cervix 1 (36) 1.33 (118)

Endometrial 1 (75) 0.58* (81)

Ovary 1 (93) 0.54* (96)

Gyn.Combined 1 0.71*

Hannaford.BMJ 2007:335:651-9

Ovarian cancer and oral contraceptives Collaborative Group on Epidemiological Studies of Ovarian Cancer

Lancet 2008;371:303-14

• 45 epidemiological studies from21 countries• 23257 women with ovarian cancer.• 87303 controls without ovarian cancer• Median age of cancer diagnosis: 56 y.• Median year of diagnosis: 1993• Average duration of use: 4.4 y (cancer) 5.0 y

(controls)

Relative risk of ovarian cancer in ever users. Effect of duration of use

Never users =1

0

0,2

0,4

0,6

0,8

1

1,2

Less than 1y 1-4 y. 5-9 y. 10-14 y > 15 y