contraception - christianacare.org · • take two pills daily for next two days then resume...
TRANSCRIPT
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
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: [email protected], [email protected]