jenni keehbauch, mdhsc.ghs.org/wp-content/uploads/2016/03/contraception-greenville-2016.pdfjenni...

Jenni Keehbauch, MD

I wish to thank Ann Klega for her Contributions

After the mother leaves the room, she asks for a prescription for birth control.

Can you prescribe it without her mother’s knowledge?

Contraception can be given without parental consent if the minor is…

Married Ever been pregnant May suffer from probable health hazard if

contraception not given

Florida Statute 381.0051 Family Planning

Condoms: 2-12% COCs: 0.3-9%

Better compliance with patch or vaginal ring

Injections: .2-6% Female sterilization: 0.5% LNG-IUD: 0.2% Nexplanon: 0.2%

Used with permission from Dr. G. Lamvu

CDC US SPR, 2013

Hormones decrease production of testosterone

Stop sperm production through the pituitary and hypothalamus

No male hormonal contraceptive is ready for clinical use

The Cochrane Library 2010 Issue 1. Chichester, UK: John Wiley and Sons, Ltd

a. Ortho Novum 1/35, 4 tabs q 12 X 2

b. Levonorgestrel 0.75 mg, 2 tab x 1 (Plan B)

c. Alesse 5 pills PO q 12 hr x 2

d. All of the above

e. None, too late

Lancet. 2002;360(9348):1803-10

Next Choice - two levonorgestrel 0.75-mg tablets taken 12 hours apart or as a 1.5-mg

Plan B One Step - levonorgestrel 1.5mg tablet taken once

Ella - one ulipristal acetate 30-mg tab

Copper IUD – most effective

Use after implantation does not interrupt an established pregnancy

Contraceptive failure (condom broke/fell

off/never came out of wallet)

Missed doses of COC

3 doses of 30-35mcg, 2 doses of 20-25mcg

POP taken more than 3 hours late

More than 2 weeks late for depo

Sexual assault

What are her options?

Contraceptive Methods

Oral Contraceptives

Combined oral contraceptives

Extended use

Continuous

Progesterone only

Alternatives to Oral

NuvaRing

Ortho Evra

Depo-Provera

Implanon

Mirena

Ethinyl Estradiol (EE) Dose < 20 mcg Ultra Low 25 – 35 mcg Low 50 mcg High

Estrogen Dose

Minimizing

Estrogen

Side Effects

• Breast

Tenderness

•Nausea

•Vascular risk

Enhancing

Cycle

Control

•BTB/BTS

•Amenorrhea

1st Generation 2nd Generation 3rd Generation 4th Generation

Norethindrone Norgesterel

Levonorgesterel

Desogesterel,

Norgestimate

Drospirenone

More androgenic

More

progestational

More

progestational

Higher

thrombosis

Anti-mineral-

corticoid

Higher

thrombosis

Progesterone Dose

Minimizing

Progesterone

Side Effects

• Weight gain

•Fatigue

•Breast tenderness

•Mood changes

Enhancing

Cycle

Control

•Reduction in

bleeding

•Decreased

dysmenorrhea

0

2

4

6

8

10

12

Non U

sers

CO

C

Dro

sper

inone

Pre

gnan

cy

DVT Risk

Androgen Dose

Minimizing

Androgen

Side Effects

• Acne/Hirsutism

•Weight gain

•Lipid effects

More Estrogen

Improving

quality of

life

•Libido

More

Progestational

Menstrual benefits

Regulates cycles

Less blood loss

Less dysmenorrhea

Less PMS

Prevention of Ovarian and Endometrial Cancer

Decreased benign breast disease

Decreased ectopics Improved androgen

symptoms Increased bone mass

All COCs increase SHBG and decrease testosterone resulting in less acne and hirsutism

Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD004425

Decreased risk of endometrial cancer with as little as 3 months of use and decreased risk by 60% after 5 years

Decreased risk of ovarian cancer by 60% after 2 yrs

Protection remains for 15 years after cessation of OCP’s

Must be taken daily Does not protect from STD’s Increased Chlamydial infection Risk of arterial vascular disease/DVT

desogestrel or gestodene have a 2X greater risk Increased risk of breast and cervical cancer

Assuming 5 year usage of OCP’s in 100,000 women

20% increased risk for breast and cervical cancer (screened cancers)

50% decreased risk in ovarian and endometrial cancer (non-screened cancers)

There would be 44 fewer cancers diagnosed BMJ 2009;339:b2895

Category 1 - No restrictions in use Category 2 - Advantages generally outweigh concerns Category 3 - Exercise caution and monitor for adverse effects Category 4 - Refrain from using

Available online

http://www.cdc.gov/reproductivehealth/unintendedpregnancy/usmec.htm#a

http://www.who.int/reproductivehealth/publications/family_planning/mec_mobile_app/en/

App: (iphone) CDC US Medical Eligibility Criteria for

Contracpetive use 2010 Free http://www.cdc.gov/reproductivehealth/unintendedpregnancy/usmec.htm

http://www.cdc.gov/reproductivehealth/unintendedpregnancy/usmec.htm#a

History DVT/PE Hypercoaguable HTN> 160/100 Major surgery Breast Cancer CAD/CVD Postpartum <3wk

Migraines with aura Servere cirrhosis Diabetes w/

microvascular dz Over 35 and >15 cigs

Post-partum < 30 days if breastfeeding or risk for VTE

Undiagnosed abnormal uterine bleeding > 35 years old and light smoker Hypertension Gallbladder disease Migraine and age >35 Taking Meds that effect liver enzymes:

rifampin, griseofulvin, anti-convulsants,

St John’s Wort, barbituates...

Over 100 options Focus on a few that you know really well No clear rationale to use Biphasic or Triphasic

COC

Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD003553 Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD002032.

COMPARISON OF ORAL CONTRACEPTIVES Reference Drugs Estrogen Progestin Comments

ULTRA LOW-DOSE MONOPHASIC PILLS

Alesse

EE 20 mcg Levonorgestrel (LNG)

0.1 mg

Low estrogen, progesterone

Good choice to minimize risk of estrogen side effects like nausea, breast tenderness

headache, etc.

Decreased hormonal risk: CAD, CVA, etc

Loestrin 1/20 EE 20 mcg Norethindrone High progesterone, medium androgen

Minimize estrogen side-effects: nausea, bloating, nausea

Good for dysmenorrhea

LOW-DOSE MONOPHASIC PILLS <35 mcg

Ortho – Cept

Desogen

EE 30 mcg Desogestrel 0.15 mg Increased risk of DVT with desogestrel over other progestins.

Low androgen, high progesterone

Good for dysmenorrhea/acne

Yasmin EE 30 mcg Drospirenone 3 mg Antimineralocorticoid activity. May decrease cyclic fluid retention. Not high enough

levels of anti-mineralcorticoid for PCOS treatment

Can increase potassium.

Loestrin Fe 1.5/30 EE 30 mcg Norethindrone High Androgen/High progesterone;

May increase libido

Good for dysmenorrhea

Sprintec

Ortho-Cyclen

EE 35 mcg Norgestimate 0.25 mg CHEAP

Low progestin, low androgen

Good choice to minimize spotting and/or BTB and minimize androgenic effects.

Medium estrogen good for ovarian cyst suppression

Demulen 1/35 EE 35 mcg Ethynodiol diacetate High progesterone, low androgen

Ovcon-35 EE 35 mcg Norethindrone 0.4 Medium estrogen, low progesterone, low androgen

Better lipid profile with higher estrogen/progesterone ratio

Necon 0.5/35 EE 35 mcg Norethindrone 0.5 Medium estrogen, low progesterone, low androgen

Nordette EE 30 mcg LNG 0.15 mg High androgen, May increase libido

Quick Start •Start on day Rx given , regardless of where in cycle, if preg reasonably excluded •Increased compliance •Requires 7 days back up contraception if >5 days after menstruation begins

First Day Start •Start on first day of next menstruation •Maximum contraceptive effect •No back up needed

Traditional Start / Sunday Start •Start 1st Sunday after menstruation begins •Avoids withdraw bleeding on weekend •Requires 7 days back up contraception if >5 days after menstruation begins

No signs/symptoms of pregnancy and meets any of the following:

<8 days after start of nl menses

No intercourse since start of last menses

Correctly and consistently using reliable method of contraception

<8 days after induced or spontaneous abortion

Within 4 weeks postpartum

Fully or nearly fully (>85%) breastfeeding, amenorrheic,

and < 6 months post partum

US SPR, June 21,2013, Vol. 62, No. 5

Use an OCP with higher Progesterone to stabilize the endometrium

Loestrin 1.5/30

Desogen

Ortho-Cept

Demulen 1/35

Most ocps incresase SHBG thus

decrease circulating free testosterone.

Levonorgesterol and norgesterol due not

increase SHBG, and may be more

androgenic

Use an OCP with Low Estrogenic/Progesterone activity

Examples

Alesse

Try progestins with the most potent

androgenic activity

Desogestrel

Levonorgestrel

Any may provide a placebo effect

Change to contraceptive with Low estrogen/progesterone

Alesse Change to progesterone only contraceptive Avoid triphasics/biphasics Change to Extended or Continuous Cycle

Most studies suggest that use of extended-cycle contraceptives results in fewer menstrual symptoms such as headache, bloating and menstrual pain

Cochrane Database Syst Rev 2005; 20 (3):CD004695.

Avoid COC’s in patients with Aura or focal neurological signs (WHO 4)

Avoid starting in women with migraines >/= 35 (WHO 3)

20 mcg ethinyl estradiol/ 150 mcg norelgestromin per day

Transdermal: 3 wks on 1 off Failure rate: 1-2% perfect use Cost: $45 per month

Advantage

Ease of use

No daily management

Better adherence

Disadvantage

Site reaction (20%)

Increased DVT risk and hormonal side effects

Weight limit (<198#)

15 mcg ethinyl estradiol/ 120mcg etonorgestrel

Vaginal ring placed for 3 weeks removed for 1 Less side-effects than COCs Failure: 1-2% perfect use Cost: $25-35

Advantage Low dose estrogen

No sizing needed

Inserted and removed by user

Disadvantage May feel during

intercourse: remove and replace within 3 hours

May increase leukorrhea

Disadvantages

Not immediately reversible

Decrease in bone mineral density (LOE 3)

Weight gain, worsening depression, acne

No STI protection

Obstet Gynecol 2009;114:279-284.

Etonogestrel (progestin only) Subdermal rod 3 years Cost: $500 (prior approval with insurance

needed)

Advantages

Contraception within 24 hrs

Ovulation resumes within 3 weeks of discontinuing

Great for nulliparous

Disadvantages

Increased DVT risk

Irregular bleeding (20%)

Headache

Weight gain, acne

Norplant

6 capsule implanted in upper arm

Effective for 5yrs

Produced in US 1991-2002 (some availability until 2004)

Removal complication rate of 6-7%

Levonorgestrel (progesterone only) Primarily inhibits fertilization Also thickens mucus, slows transport,

inhibits capacitation and decreases ovulation

Failure: 0.1% Cost: $650

Longterm, but reversable Reduction in dysmenorrhea and menstrual

bleeding (70-90%) Can be used in treatment of endometrial

hyperplasia May avoid surgery1

May decrease the risk of PID

1. BJOG.2001;108(1):74-86

Spotting for up to 3-6 mos Expulsion (2-10%) Perforation 1:1000 PID risk immediately after insertion STI (trichomonas) Inflammatory paps

Uterine anomaly Active pelvic infection (PID) or STD in last 3 months Pregnancy Abnormal uterine bleeding that has not been

evaluated Current GYN cancer Gestational Trophoblastic Disease (GTD)

US Selected Practice Recommendations for Contraceptive Use, 2013

WHO Selected Practice Recommendations for Contraceptive Use, 2nd Ed.

US Medical Eligibility Criteria for Contraceptive Use, 2010