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Transcript Contraception

Review Different Methods of
Review the advantages and
disadvantages of each method
Choose appropriate contraception
based on different clinical situations
Review how to prescribe contraceptives
Unintended Pregnancies
Survey from 2001 revealed 49% of
pregnancies in US were unintended
Rates 82% in teenagers and 38% in
perimenopausal women
Half of unintended pregnancies end in
Hormonal Contraceptives:
 oral, transdermal, intravaginal, IM,
Barrier Devices
 Diaphragm
 Condoms: male and female
 Cervical Caps
 Tubal Ligation, Vasectomy
Intrauterine Devices:
 IUDs: copper or progesterone
Oral Contraceptives
Introduced in early
Most widely used form
of reversible birth
Have contraceptive and
Estrogen + progestin
combination or
progestin alone
Combination Pills
Synthetic estrogens
Ethinyl estradiol
 Mestranol
Synthetic progestins
Many different progestins available
Estrogen Component
Ethinyl estradiol doses range from 20 -150 mcg
Doses > 50mcg no longer available in US
Low dose estrogen (35 mcg or less) recommended as initial
Higher doses increase incidence of VTE
Lower doses may result in significant breakthrough bleeding or
20 mcg dose helpful in premenopausal women or those with
significant estrogen side effects
50mcg dose needed in women on certain anticonvulsants
Ex: Genora 1/50; Nelova 1/50, Ortho-Novum 1/50, Demulen 1/50
Progestin doses range from 0.05mg –
Differ in their androgenic, estrogenic,
and progestational activity
First Generation
Norethindrone – ex: ortho-novum,
Norethindrone acetate – ex: junel,
estrostep, loestrin
Ethynodiol diacetate – ex: zovia
Medium androgenic potency
2nd Generation
High progestational and androgenic activity
Most widely prescribed progestin
Ex: Levlen, Alesse, Tri-Leven, Triphasil
Approved for emergency contraception
Approved for extended cycle use –ex: seasonal
Ex: cryselle, lo-ovral
3rd Generation
Norgestimate ( ortho-cyclen or tricyclen)
FDA approved to treat acne
desogestrel (desogen, ortho-cept)
Gestodene – not available in US
3rd Generation
Lower androgenic activity
Less acne, hirsutism, weight gain
Less effect on carbohydrate metabolism
and lipid profile
Similar contraceptive effectiveness as
older formulations
Higher rates of DVT
4th Generation Progestin
Drosperinone – new progestin derived from
17-alpha spironolactone
Progestogenic, antiandrogenic, and
antimineralcorticoid activity
Ex: Yasmin: 30 mcg of ethinyl estradiol and 3 mg
of drospirenone
Useful in women with excess water retention,
acne, hirsutism
Watch for hyperkalemia
Variety of Combination
Multiphasic - 2 or 3 different progestin
21 day regimen
28 day regimen
21 active pills + 7 inert pills
24 active pills + 4 inert pills
Ex: YAZ and Lo-estrin
Continuous OCP
Extended cycle
Seasonale – 91 days total – 84 days active + 7
days inactive
Seasonique – 91 days total - 84 days active + 7
days 5mcg ethinyl.estradiol
Useful for endometriosis, premenstrual
dysphoric disorder, or lifestyle reasons
Efficacy unchanged
Breakthrough bleeding common
No risk of endometrial hyperplasia
If taken correctly: 99.9%
In reality: 92.4%
Return to fertility:
Average 2 month delay in conception after
OCP’s stopped
Suppress ovulation
Suppress follicular development
Alter cervical mucous making sperm
penetration more difficult
Alters endometrium making implantation
less likely
Decreases DUB by 81-87% and menstruation
related anemia
 Decreases dysmenorrhea
 Decreased risk of ovarian cancer
 Decreased risk of endometrial cancer by 50%
 Decreased risk of PID (50-80%)
 Decreased risk of ectopic pregnancy
 Treatment of Acne
Reduced risk of Colorectal Cancer
Reduction of Uterine Leiomyomas
Decrease in benign breast disease
Reduces Ovarian Cyst formation
clear benefit at 50mcg estrogen dose
Decreased hip fracture risk
Risks of Combination
DVT: risk 3-6 fold
Absolute risk is 3-4 per 10,000
Risk increased in third generation progestins:
Compared to nonusers, risk of DVT increased 6-9 fold
Presence of hypercoagulable state increases risk
even further
Risks Continued
Ischemic: increased risk by 2 ½ times
Increased risk with age, HTN, Migraine headaches
Myocardial Infarction:
80% of cases of MI among OC users are in
OC are contraindicated if age>=35 and smoke >15
Risks Continued
Hepatic vein thrombosis
Portal vein thrombosis
Splenic artery thrombosis
Mesenteric artery thrombosis
Mesenteric vein thrombosis
Risks Continued
Breast cancer – results conflicting
large meta-analysis 1996:
Slightly increased risk of breast cancer during use and
for first ten years after use – RR 1.24
No increased risk of diagnosis after 10 years off OCP
Cancers usually less clinically advanced if diagnosed
while on OCP or up to 20 years after OCP use
Epidemiologic studies have generally not
demonstrated an association between OC use
and the risk of breast cancer later in life
Pregnant or breastfeeding
History of DVT, PE, MI, Stroke,
Hypercoagulable state
Liver disease
Smoker >15 cig/day age> 35
Complicated Migraine Headaches or
migraines in women > age 35
Estrogen dependent tumor –breast,
Uncontrolled HTN, unexplained vaginal
Choosing OCP’s
No benefit of triphasics over monophasics
Estrogen content 35 mcg or less
Consider OCP w/ lower androgenic
properties but weigh against increased risk of
Common starting regimens:
2nd gen: Levlen, Alesse, lo-ovral
3rd gen: Ortho – cyclen, desogen
Higher estrogen doses needed initially in
women with heavy flow and cramps
Ex: ovral (50 mcg), ogestrel
Choosing OCP’s
Become familiar with 1 or 2 brands with
varying estrogen and progesterone
levels in case need to adjust based
upon side effect profile
Starting OCP’s
Sunday start
First Sunday of LMP
 Use a backup method for 7 days for first
Quick start
 Start
first pill at time of office visit
 Increases compliance
 Back up method for 7 days
Monitoring on OCP’s
No lab studies mandatory at starting or
for monitoring
Can be started prior to breast or pelvic
BP check at f/u
Missed Pill
Miss one pill anytime in cycle
Take missed pill immediately and next pill at regular time
Miss two pills on First or Second Week of Pack
Take two pills daily for next two days then resume
(Monday and Tuesday) remembers Wednesday
On Wednesday take Monday and Tuesdays pills
On Thursday take Wednesday and Thursday’s pills
Use backup for 7 days
Missed Pill
Miss two in third week
Take two pills daily until all active pills
 Restart cycle with one pill daily within 7 days
 Use backup method until new pack restarted
and for first 7 days of new pack
Miss 3 more during any week
Throw the pack away and start a new pack within
7 days
Use backup method of birth control for first 7
days of new pack
Side effects:
Breakthrough bleeding – most common reason for
Weight gain
Mood swings
Breast tenderness
Acne, facial hair growth
Breakthrough Bleeding
Most common in low dose combination
Most frequent in the first three months
as endometrium adjusts to lower
hormone levels
Increased rate if miss a pill
Increased rates in extended use cycles
Breakthrough Bleeding
Treatment options
Increase estrogen dose
Increase progestin dose
Bleeding after day 14 in cycle
Change to more androgenic progestin
Bleeding early in cycle or no withdrawal bleeding
Ex: ortho tri cyclen lo (25 mcg) to orth-tri cyclen ( 35 mcg)
Decreases bleeding at any time during cycle
Ex: levlen ( LNG progesterone)
Switch from extended cycle to 28 day cycle
Related to estrogen dose
Usually most severe in first 1 – 3 cycles
of OC use
Take with food or bedtime
 Change to OC with lower estrogen dose
Related to high estrogen content
Usually concentrated in pill-free days and first
days of cycle
Ischemic stroke risk increased in patients with
hx of migraines
Do not give to women with aura or focal symptoms
Do not give to women with migraine over age 35
Do not give if frequent or severe migraine hx
Migraines and Stroke
Meta-analysis - relative risk of ischemic
stroke among women with migraine
taking oral contraceptives, from the
pooled data of three studies, was 8.72
(95% CI 5.05-15.05)
Risk of ischaemic stroke in people with migraine: systematic review and meta-analysis of
observational studies. AUEtminan M; Takkouche B; Isorna FC; Samii A SOBMJ 2005 Jan
8;330(7482):63. Epub 2004.
Headaches Continued
d/c in women with new migraine
headaches or worsening of pre-existing
 Switch to OC with lower estrogenic activity
 Switch to progestin only contraceptive
 Try extended cycle OCP to decrease pill
free intervals
Libido Changes
Direct action on brain from progestin
Increase in sex hormone-binding gonadotropin
induced by estrogen
OCP with less estrogenic or progestational
Higher androgenic properties
Progesteron component: levonorgestrel,dl-norgestrel,
Ex: alesse, lo-ovral, levlen
The estrogen component of OC pills
raises serum concentrations of
thyroxine-binding globulin (TBG)
Increased levels of total thyroxine & total
 No change in levels of free thyroxine and
free triiodothyronine
 T3 resin uptake will be low
Hepatic adenoma
Correlates with dose and duration of OCP
Incidence 30-40 / 1 million in OCP users
1 / 1 million women in non users
Increased number, size, and risk of bleeding
in OCP users
s/s: abdominal pain, incidental, rupture / abd
Progesterone Only Pill
• Micronor / Nor-QD / Camila / Erin / Jolivette /
Nora-B / Ovrette •
0.35 mg norethindrone
Lower than doses in combination pills
Marketed in US
28 days of active pills
• Success rates: typical failure rate thought to
be > 8%
Progesterone Only Pills
Mechanism of action
Thickens cervical mucous, thins endometrium,
inconsistent ovulation suppression
Start first pill on first day of LMP
Pills MUST be taken at the same time every
day to ensure effectiveness
Missed pill defined as taken more than 3 hours
later than usual
If taken later women should take immediately +
next pill on time + added precautions x 2 days
Progesterone Only Pills
Side effects:
Irregular bleeding
Ovarian cysts
Breast tenderness
Clinical uses
Contraindication to estrogen containing pills
Estrogen related side effects on combination pill
Heavy smokers over age 35
IM injection of 150 mg every 12 weeks
99.7% success rate
Thickens cervical mucous-less penetrable
to sperm
 Suppresses ovulation
First dose given within 5 days of LMP
If given >=7th day of LMP, another form
of contraceptive should be used for 7
Efficacy is up to 14 weeks
Clinical Uses
Can’t or won’t take daily OC
Migraine headaches
Breast feeding
Can start after 6 weeks
Efficacy: 99.7% ( theoretical and actual)
Depo-side effects
Irregular bleeding
Persistent bleeding can be treated with 50
mcg of ethinly estradiol for 14 days
Other: weight gain, headaches, dizzy,
injection site reactions
Takes about 6-9 months after last
injection for return of fertility but may be
as long as 18 months
Bone Density in
Accelerated rate of bone loss
Increases with increasing duration
No data on fracture risk
Majority will be reversible within 1-2 years of
Black box warning by FDA in 2006 limits use to 2
years except in those patients in which other
forms of birth control methods are inadequate
September 8th 2008 ACOG opinion statement disagrees
Not recommended to have routine BMD
Ensure adequate exercise, vitamin D, and calcium
Contraindications to
Progestin only regimens
* Hx of or current thromboembolic
disorders or Cerebral vascular disease
Severe hepatic dysfunction or disease
Carcinoma of the breast or genital
Undiagnosed vaginal bleeding
Implantable Progestins
Implanon (etonogestrel)
progesterone releasing contraceptive implant
approved for 3 years
Single plastic rod about length of toothpick
Implant day 1-5 of cycle
Pregnancy rates similar to IUD and sterilization
No longer available due to limited supplies and
problems with removal
Estrogen Patch
Ortho Evra:
Releases 20 mcg ethinyl estradiol and 150
mcg of norelgestromin per day
Each patch worn for 1 week for cycle of
3 weeks then withdrawal bleed during
week 4
Caution for women with weights over
90kg as may be less clinically effective
Estrogen Patch
DVT risk:
Steady state levels of estrogen much
higher with patch users then OCP users
 One study showed 2.4 OR increased risk
of VTE for patch users compared to OCP
Side Effects
Breast tenderness
Application site irritation
Breakthrough bleeding
< 1 pregnancy / 100 users
Higher compliance rates than OCP
users and higher “perfect use” rates
Contracetive Vaginal
Ring: Nuvaring
Delivers 15 mcg of
ethinly estradiol and
120 mcg of
etonogestrel per day
Intravaginal for three
Insert on or before
day 5 of LMP-use
backup for 7 days
Side Effects NuvaRing
Weight gain
Breakthrough bleeding
Similar to OCP use
Slightly higher rates of discontinuation
due to local side effects
Administer within 72 hours of
unprotected intercourse
most effective if taken within 12 hours
Mechanism of action
Inhibits ovulation, prevents implantation, or
may cause regression of corpus luteum
Yuzpe Regimen:
100mcg of ethinyl estradiol and 0.5 mg of
levonorgestrel. E.g. Ovral, Preven
Take 2 pills within 72 hours and 2 pills 12 hours
Has a 75-80% efficacy rate
 Usually requires antimetic
Levonorgestrel: Progesterone only, Plan
0.75 mg Q 12 hrs for total of two doses
 Prevents 85%
 Less nausea and vomiting
Copper IUD inserted within 5 days is
also effective
Barrier Methods
Male condom; efficacy 14/100
Diaphragm: 20/100
Cervical Cap:
Never pregnant: 20/100
 Ever Pregnant: 40/100
Today Sponge: barrier plus spermicide. Effective for
24 hours. Estimated efficacy of 89-91%
No special fitting required
IUD Options
Levonorgestrel (Lng IUC)
Mirena = trademark
 Progesterone secreting
 Can be left in place for 5 years
 First yr pregnancy rate 0.1-0.2%
 Irregular bleeding common early followed
by development of amenorrhea in 20%
IUD Options
Copper T (Tcu380A IUD)
Paragard = trademark
 Copper releasing
 Approved to remain in place for 10 years
 First yr pregnancy rate 0.6-0.8%
 Heavy menses and dysmenorrhea
IUD Advantages
Highly effective
High patient satisfaction
Inexpensive over time
No effect on fertility after removal
Decreases risk of ectopic pregnancy compared to
no contraception
LNg IUD can decrease risk of PID from newly
acquired STD’s once IUD in place
Progestin thickens cervical mucous which acts as barrier
to ascending infection
IUD Concerns
High initial cost
No protection against STD’s
Small increase risk of PID in first 20 days
after placement
Related to contamination during insertion process
and presence of pre-existent STD’s
If pregnancy occurs while IUD in place then
more likely to be ectopic
CI to IUD Placement
Pregnancy or suspicion of pregnancy
Congenital or acquired uterine anomaly
Active pelvic infection or high risk of pelvic infection
Known or suspected uterine or cervical neoplasia, or unresolved
abnormal Pap smear
Unexplained abnormal uterine bleeding
Increased susceptibility to infections with microorganisms
Genital actinomycosis
Known or suspected carcinoma of the breast - progestin based
Wilson’s disease or copper allergy - copper based IUD’s
Other Methods
Most useful in first three months
 Effective if woman is breast feeding full
time and is amenorrheic
Tubal Ligation
Question # 1
To which of the following patients would you
prescribe combination OCP’s?
A) 30 y.o. female who smokes?
B) 29 y.o. female with migraine headaches
preceded by an aura?
C) 29 y.o female who is 2 weeks postpartum?
D) 19 y.o. female homozygous for factor V
Leiden and hx of DVT?
Answer # 1
Case 1
18 year old female presents to your clinic to
discuss contraceptive options. She has
become sexually active within the past 6
months and so far has been using condoms.
She is interested in going on oral
contraceptives and wants your advice.
Her medical history is significant for seizure
She takes Phenobarbitol
How do you advise her?
Case 1 Answer
Choose OCP with higher estrogen dose
Ex: Genora 1/50; Nelova 1/50, Ortho-Novum
1/50, Demulen 1/50
Choose non estrogen containing OCP
Case 2
You recently started your 25 year old
patient on loestrin (1/20 mcg) She has
been noticing breakthrough bleeding
early in the menstrual cycle. This is her
first month on the pill. How would you
counsel this patient and what are your
options for treatment?
Case 2 Answer
Re-evaluate after 1-2 more months
 Increase estrogen dose
Ex: orth-tri cyclen ( 35 mcg)
Change to more androgenic progestin
Decreases bleeding at any time during cycle
 Ex: levlen ( LNG progesterone)
Case 3
Your patient calls in a panic because she
has missed two doses of the pill and
this is her second week of the pack.
What do you tell her?
Case 3 Answer
Miss two pills on First or Second Week of
Take two pills daily for next two days then
resume schedule
(Monday and Tuesday) remembers Wednesday
On Wednesday take Monday and Tuesdays pills
On Thursday take Wednesday and Thursday’s pills
Use backup for 7 days
Case 4
You see a 28 year old women for
contraceptive counseling. She has a
history of migraine headaches.
Can she go on the pill?
What factors do you need to
Case 4 Answer
No if age over 35, migraine with aura or
focal neurologic deficit, severe and
frequent migraines
Case 5
A 25 y o female on ortho tri cyclen ( 35
mcg estrogen) for the past 3 months
complains of nausea and headaches (
not described as migraines) since
starting the pill. How would you adjust
her birth control regimen?
Case 5 Answer
Change to OCP with lower estrogen
dose - ex: ortho-tri cyclen low (25mcg)
Case 6
Which of the following is true regarding BMD
and depo-provera injections
BMD should be monitored on a yearly basis
All patients on depo-provera should be started on
anti-resorptive agents
Use of depo-provera should be limited to 2 yrs at a
time if possible according to packaging
Fracture risk is increased 5 fold in depo-provera
Case 6 Answer
Case 7
Progesterone only pills are useful in
which one of the following clinical
A: Post partum with breastfeeding
B: Smokers > 35
C: Women on seizure medications
D: All of the above
Case 7 Answer
D: All of the above