Transcript Document

Choosing the best COC and
POP
Jill Zelin
POP
21/7 ED
Qlaira
Persona
21/7
Evra
triphasic
NuvaRing
NFP
levonelle
Spermicide
Depo-Provera
Silicone
diaphragm
ulipristal
Nexplanon
IUS
Cu IUDs
Latex
condom
non-latex
condoms
Mates Skyn
Avanti Ultima
Essure
Filshie clip
FemCap
Pasante
Unique
Femidon
% of women experiencing an unintended
pregnancy during the first year of use
Trussell J. In: Hatcher et al. (eds) Contraceptive Technology (20th Edition). New York, Ardent Media 2
www.fsrh.org
Key Benefits and Risks

BENEFITS









Contraceptive efficacy
Ovarian cancer
Endometrial cancer
Colorectal cancer
Menstrual problems
Ectopic pregnancy
Ovarian cysts
Benign breast disease
PID
Key Benefits and Risks


RISKS













Venous disease
Arterial disease
Breast cancer
Cervical cancer
COC progestogen ladder
cyproterone drospirenone
gestodene
desogestrel
norgestimate
levonorgestrel
norethisterone
More
oestrogenic
by DOSE
35mcg
Dianette
Cilest
30mcg
Yasmin
20mcg
Yaz
Femodene/ Marvelon
Katya
Femodette
Sunya
Prog-only
Microgynon
Loestrin 30
Loestrin 20
Mercilon
Cerazette
More oestrogenic by function
Norimin
Brevinor/Ovysmen
Norgeston
Femulen
Noriday/
Micronor
Less oestrogenic by function
Risk of venous thromboembolism (VTE) associated with non-use,
combined hormonal contraception (CHC) use over the course of 1
year
Risk of VTE per 10,000 healthy
women
Non contraceptive users and not
pregnant
2
CHC containing ethinylestradiol plus 5-7
levonorgestrel, norgestimate or
Norethisterone
CHC containing etonogestrel (ring)
and
norelgestromin (patch)
6-12
CHC containing ethinylestradiol plus 9-12
gestodene, desogestrel,
drospirenone
(adapted from http://www.ema.europa.eu/ema/index.jsp?curl=pages/news_and_events/news
/2013/11/news_detail_001969.jsp&mid=WC0b01ac058004d5c1)
Pharmacokinetics & dynamics
Based on data from various sources, no direct comparative data
VTE per 100,000 women/yr
having a baby (VTE)
DSG/GSD prog
LNG/NET prog
childbearing years (no COC)
0
10
20
1% mortality
30
40
50
60
70
VTE per 100,000 women/yr
Dinger JC et al. Contraception 2007; 75: 344
EURAS: effect of time on VTE risk
1st 3/12
2nd year
3rd Year
4th/5th year
0
50
100
150
incidence of VTE per 100,000 WY
Dinger JC et al. Contraception 2007; 75: 344
EURAS

BMI ≥30

3X VTE risk vs. normal weight
Dinger JC et al. Contraception 2007; 75: 344
Arterial Thromboembolism

MI


very small increase in risk in healthy users
vs. non users
Ischemic stroke

increased X2 in healthy users vs. non
users
Collaborative Group on Hormonal Factors
& Ca Breast 1996

Meta-analysis of 54 studies from 26
countries



53,297 women with Ca Breast
100,239 women without Ca Breast
Current COC users:RR=1.24[1.15-1.33]
i.e. 24% increased risk
Lancet 1996; 347: 1713-27
Women’s CARE Study 2002

Population-based case-control study in
US




4575 women with Ca breast
4682 controls
Current COC users: RR = 1.0 [0.8-1.3]
Past COC users: RR = 0.9 [0.8-1.0]
Marchbanks PA et al. NEJM 2002; 346: 2025-32
Why the differences?


Surveillance bias
Age of population



2002: restricted to women aged 35-64
1996: 9% of women with Ca Breast were
<35 years at the time of diagnosis
Are young women with BRCA1 and
BRCA2 mutations using COCs at
increased risk of Ca Breast?
Three-Nation Study 2005



Population-based case-control study
Is COC use a risk factor for early Ca
Breast in Caucasian carriers and noncarriers of BRCA1 and BRCA2
mutations?
Low-dose COCs are NOT associated
with increased risk of Ca Breast in
BRCA1 or BRCA2 carriers, or in noncarriers
Milne RL et al. Cancer Epidemiol Biomarkers Prev 2005; 14: 350-6
BRCA and Ovarian Cancer


BRCA mutations associated with increased
risk of Ca ovaries
Low-dose COCs may be associated with
reduced risk of Ca ovaries in BRCA1&2
carriers
Narod SA et al. NEJM 1998; 339: 424-8
Whittemore AS et al. Br J Cancer 2004; 91: 1911-15
FHx Ca Breast:
Practical Prescribing



Can use CHCs (UKMEC 1)
Counsel about inherent increased
background risk
Consider benefits


Reduced Ovarian, Endometrial, Colorectal Ca
Relief from period-related problems
Cervical cancer
Cervical cancer



COC use
Smoking
HPV
Risk of Cx cancer in women with Cx HPV
COC users vs. never users
Use of COCs
OR (95% CI)
<5 years
0.73 (0.52 to 1.03)
5-9 years
2.82 (1.46 to 5.42)
³10 years
4.03 (2.09 to 8.02)
Moreno et al. Lancet 2002; 359: 1085-192
Ca Cervix:
Practical Prescribing

Women using CHCs should be counselled:




Against smoking
Use condoms to protect against STIs
Take up the Cervical Screening Programme
Women with CIN can continue CHCs during
treatment
The pill is pretty safe
BUT
SOME WOMEN
ARE DANGEROUS!
Practical Prescribing


Who never?
Who maybe?

special advice/monitoring
Assessment

History
Assessment

Examination


Blood pressure
BMI (weight (kg/m2)/height(m)
UKMEC Eligibility
Because:
UKMEC 1: no restriction
No associated risks
UKMEC 2:
Benefits > risks
UKMEC 3:
Risks > benefits
UKMEC 4: unacceptable risk Risks >>> benefits
UKMEC 2009
Absolute contraindications







< 6 weeks postpartum if
breastfeeding
Smoker ≥ age 35 ≥15 cigs/day
BP systolic >160 or diastolic ≥95
Current or past Hx VTE
Known thrombogenic mutations
Major surgery with prolonged
immobilization
Systemic Lupus Erythematosus







Current or past Hx IHD/CVA
Diabetes > 20yrs OR with
“opathies”
Complicated valvular heart
disease
Migraine aura (“focal”)
Current breast cancer
Liver tumours
Liver disease: active
hepatitis/severe cirrhosis
Smokers:
Practical Prescribing

CHCs not recommended in smokers
>35 years



<15 cigs/day UKMEC 3
≥15 cigs/day UKMEC 4
Healthy, non-smoking women may
continue to use CHCs until menopause
‘Quick Start’ Method
•
•
•
Start at any time during
menstrual cycle
Use of back-up barrier
contraception for 7 days
If following emergency
contraception, do urine
pregnancy test in 3
weeks
Bridging
Oestrogenic and Progestogenic
effects
Oestrogenic
Progestogenic
Breast enlargement / tenderness
Acne
Bloating
Greasy hair
Weight gain (water retention)
Hirsutism
Nausea
Non-infective vaginal discharge
Weight gain
(increased appetite)
Some headaches
Depression
Chloasma
Loss of libido
Photosensitivity
Vaginal dryness
COC progestogen ladder
cyproterone drospirenone
gestodene
desogestrel
norgestimate
levonorgestrel
norethisterone
More
oestrogenic
by DOSE
35mcg
Dianette
Cilest
30mcg
Yasmin
20mcg
Yaz
Femodene/ Marvelon
Katya
Femodette
Sunya
Prog-only
Microgynon
Loestrin 30
Loestrin 20
Mercilon
Cerazette
More oestrogenic by function
Norimin
Brevinor/Ovysmen
Norgeston
Femulen
Noriday/
Micronor
Less oestrogenic by function
Drug interactions

Antibiotics

No concerns unless enzyme-inducing
Drug interactions

Enzyme-inducing agents




Antibiotics


Anti-epileptics
Anti-retrovirals
St John’s Wort
Rifampicin
Antifungals

Griseofulvin
FFPRHC guidance (April 2005) Drug interactions with hormonal contraception
Enzyme-inducing agents

CHCs

50 mcg monophasic
Norinyl-1 50 mcg mestranol
20 + 20 OR 20 + 30 standard COC (off-licence)


4 day PFI
tricycle/continuous
Progestogen-only pills currently available
in the UK
Brand name
Type of
progestogen
Dose
(µg)
Cerazette®
Desogestrel
75
Noriday®
Norethisterone
350
Micronor®
Norethisterone
350
Norgeston®
Levonorgestrel
30
POP

Femulen® - Etynodiol diacetate 500µg
no longer manufactured
UKMEC 3






Current ischaemic heart disease
Stroke while taking POP
Headaches migraine with aura, at any age
starting while taking POP
Gestational trophoblastic neoplasia with
abnormal hCG
Breast cancer in the past (5 years+)
Viral hepatitis active/Cirrhosis severe
(decompensated)/Liver tumours
UKMEC 4

Breast cancer current or within the last
5 years
Women over 40


Little benefit in using Cerazette –
traditional POPs as effective
Failure rates for traditional POPs vary
are lower for women aged over 40
compared to younger women
POP and weight


There is no evidence that the efficacy of
progestogen-only pills is reduced in
women weighing >70 kg and therefore
the licensed use of one pill per day is
recommended.
But I usually give 2!!