Contraception - christianacare.org · • Take two pills daily for next two days then resume schedule – (Monday and Tuesday) remembers Wednesday ... –Pregnancy rates similar to

Contraception

Xandie Gold, MD

Objectives

• Review Different Methods of

Contraception

• Review the advantages and

disadvantages of each method

• Choose appropriate contraception

based on different clinical situations

• Review how to prescribe contraceptives

Unintended Pregnancies

• 49% of pregnancies in US are

unintended

• Rates: 82% in teenagers and 38% in

perimenopausal women

• Half of unintended pregnancies end in

terminations

Contraceptives

• Hormonal Contraceptives:

– oral, transdermal, intravaginal, IM,

implanted

• Barrier Devices

– Diaphragm

– Condoms: male and female

– Cervical Caps

• Surgical:

– Tubal Ligation, Vasectomy

• Intrauterine Devices:

– IUDs: copper or progesterone

releasing

Contraceptives

Oral Contraceptives

• Introduced in early 1960s

• Most widely used form of reversible birth control

• Have contraceptive and noncontraceptive benefits

• 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 treatment

• Higher doses increase incidence of VTE

• Lower doses may result in significant breakthrough bleeding or spotting

• 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

Progesterone Component

• Progestin doses range from 0.05mg –

1mg

• Differ in their androgenic, estrogenic,

and progestational activity

First Generation Progestins

• Norethindrone – ex: ortho-novum,

necon

• Norethindrone acetate – ex: junel,

estrostep, loestrin

• Ethynodiol diacetate – ex: zovia

• Medium androgenic potency

2nd

Generation Progestins

• High progestational and androgenic activity

• Levonorgestrel • Most widely prescribed progestin

– Ex: Levlen, Alesse, Tri-Leven, Triphasil

• Approved for emergency contraception

• Approved for extended cycle use –ex: seasonal

• Norgestrel

– Ex: cryselle, lo-ovral

3rd

Generation Progestins

• Norgestimate ( ortho-cyclen or tri-

cyclen) • FDA approved to treat acne

• desogestrel (desogen, ortho-cept)

• Gestodene – not available in US

3rd

Generation Progestins

• 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

– Yaz:

– Useful in women with excess water retention, acne, hirsutism

– Watch for hyperkalemia

Variety of Combination Pills:

• Monophasic

• Multiphasic - 2 or 3 different progestin

doses

• 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

Effectiveness

• If taken correctly: 99.9%

• In reality: 92.4%

• Return to fertility:

– Average 2 month delay in conception after

OCP’s stopped

Mechanism

• Suppress ovulation

• Suppress follicular development

• Alter cervical mucous making sperm

penetration more difficult

• Alters endometrium making implantation

less likely

Noncontraceptive Benefits

• Definite • 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

Noncontraceptive Benefits

Possible:

• 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 OCP

• 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

• Stroke

– 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

smokers

– OC are contraindicated if age>=35 and smoke >15

cig/day

• HTN

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

Contraindications

• 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, endometrium

• Uncontrolled HTN, unexplained vaginal bleeding

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 DVT

• 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

month

• 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

exam

• 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

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

Missed Pill

– Miss two in third week • Take two pills daily until all active pills

completed

• 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

Combination Contraceptives

• Side effects:

– Breakthrough bleeding – most common reason for

discontinuation

– Nausea

– Weight gain

– Mood swings

– Breast tenderness

– Headaches

– Acne, facial hair growth

Breakthrough Bleeding

• Most common in low dose combination

pills

• 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

• Bleeding early in cycle or no withdrawal bleeding

• Ex: ortho tri cyclen lo (25 mcg) to orth-tri cyclen ( 35 mcg)

– Increase progestin dose • Bleeding after day 14 in cycle

– Change to more androgenic progestin • Decreases bleeding at any time during cycle

• Ex: levlen ( LNG progesterone)

– Switch from extended cycle to 28 day cycle regimen

Nausea

• Related to estrogen dose

• Usually most severe in first 1 – 3 cycles

of OC use

• Management:

– Take with food or bedtime

– Change to OC with lower estrogen dose

Headaches

• 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 Risk

• 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

• Treatment:

– d/c in women with new migraine

headaches or worsening of pre-existing

headaches

– Switch to OC with lower estrogenic activity

– Switch to progestin only contraceptive

– Try extended cycle OCP to decrease pill

free intervals

Libido Changes

• Decreased: – Direct action on brain from progestin

– Increase in sex hormone-binding gonadotropin induced by estrogen

• Treatment: – OCP with less estrogenic or progestational

properties

– Higher androgenic properties • Progesteron component: levonorgestrel,dl-norgestrel,

desogestrel

• Ex: alesse, lo-ovral, levlen

Thyroid

• The estrogen component of OC pills

raises serum concentrations of

thyroxine-binding globulin (TBG)

– Increased levels of total thyroxine & total

triiodothyronine

– No change in levels of free thyroxine and

free triiodothyronine

– T3 resin uptake will be low

Liver

• Hepatic adenoma

• Correlates with dose and duration of OCP use

• 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 bleeding

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

– Breastfeeding

– Contraindication to estrogen containing pills

– Estrogen related side effects on combination pill

– Heavy smokers over age 35

Depo-Provera

• IM injection of 150 mg every 12 weeks

• 99.7% success rate

• medroxyprogesterone:

– Thickens cervical mucous-less penetrable

to sperm

– Suppresses ovulation

Depo-Provera

• First dose given within 5 days of LMP

• If given >=7th day of LMP, another form

of contraceptive should be used for 7

days

• 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 Depoprovera

• Accelerated rate of bone loss – Increases with increasing duration

– No data on fracture risk

– Majority will be reversible within 1-2 years of discontinuation

– 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 intake

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 organs

• Undiagnosed vaginal bleeding

• Pregnancy

Implantable Progestins

• Nexplanon/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

• Norplant

– 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

users

Side Effects

• Breast tenderness

• Headache

• Application site irritation

• Nausea

• Breakthrough bleeding

Efficacy

• < 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

weeks

• Insert on or before

day 5 of LMP-use

backup for 7 days

Side Effects NuvaRing

• Vaginitis

• Leukorrhea

• Weight gain

• Nausea

• Headache

• Breakthrough bleeding

Efficacy

• Similar to OCP use

• Slightly higher rates of discontinuation

due to local side effects

Emergency Contraception

• Administer within 72 or 120 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

Regimens

• Yuzpe Regimen:

– 100mcg of ethinyl estradiol and 0.5 mg of levonorgestrel. E.g. Ovral, Preven (50mcg/0.25mg)

• Take 2 pills within 72 hours and 2 pills 12 hours later

– Has a 75-80% efficacy rate

– Usually requires antimetic

Regimens

• Levonorgestrel: Progesterone only, Plan B/NextChoice

– 1.5 mg once

– Prevents 85%

– Less nausea and vomiting

– Available over the counter for women above age 17, with rx for under age 17

Regimens

• ella (ulipristal acetate)

– Selective progesterone receptor modulator

– Single dose of 30mg

– Requires rx

• Paragard

– Effective if inserted up to 120 hours after

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

common

IUD Advantages

• Highly effective

• Convenient

• 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 IUD’s

• Wilson’s disease or copper allergy - copper based IUD’s

Other Methods

• Lactation:

– Most useful in first three months

– Effective if woman is breast feeding full

time and is amenorrheic

• Tubal Ligation

• Vasectomy

Summary

• Many different methods

– Pills (combined and progesterone-only),

patch, ring, injection, implant, IUD, tubal

ligation

• The best contraceptive is the one the

patient uses!

THANK YOU!

Contact: agold11@jhmi.edu, agold@christianacare.org