CONTRACEPTIONNancy Kang PGY2

OBJECTIVES

BARRIER METHOD

Latex condom most popular barrier method, also polyurethane, silicone and lambskin condoms available

Polyurethane condoms: more sensitivity, feel thinner, compatible with oil-based lubricants. $$$

Lambskin condoms: not recommended for protection against STI

BARRIER METHOD

Efficacy

Perfect use: 97% effective within first year

Typical use: 86% effective

Highest failure rate from age 20-24

STI rates in populations have been shown to decline when latex condoms are used. Decreases ADIS/HIV transmission by 85%

Polyurethane and other plastic condoms: Equivalent levels of contraceptive protection, may confer less protection from STI due to increased frequency of breakage and slippage

FEMALE CONDOM

Polyurethane sheath which acts as an intravaginal barrier

95% effective with perfect use. 80% effective with typical use

Women empowerment! Can be inserted up to 8hrs prior to intercourse

DIAPHRAGM

Intravaginal barrier used in conjunction with a spermicide

94% effective with perfect use and 80% effective with typical use

Potential protection from STIs by decreasing cervical exposure, but protection from HIV transmission is limited because of exposure to vaginal mucosa

Pelvic exam required for fitting diaphragms

DIAPHRAGM

Side effects

May increase risk of persistent/recurrent UTI

Increased risk of developing BV

Can be associated with toxic shock syndrome

CERVICAL CAP

Used intravaginally in conjunction with spermicide

Efficacy in nulliparous women: 92% effective with perfect use, 80% effective with typical use. In multiparous women: 74% effective with perfect use and 60% effective with typical use

Offers potential protection from cervical infections

Must be fitted

Should not be used in women with current vaginal/cervical infection, PID, cervical or uterine cancer or dysplasia. Can aggravate symptoms in women with STIs and vaginitis. Increased risk of toxic shock syndrome.

CONTRACEPTIVE SPONGE

Intravaginal one-size-fits-all barrier method, impregnated with spermicidal agents

Efficacy: theoretical efficacy rate of 90% in nulliparous women, but actual rates ~80% for nulliparous women typical use and 60% for multiparous women typical use

No STI protection!

Provides contraception for 12hours after insertion

Increased risk of TSS

NATURAL FAMILY PLANNING

Primary fertility signs: changes in cervical mucus, basal body temperature and cervical position

Efficacy estimates 20% failure rate for common use and 1-9% with perfect use

COMBINED OC

Of Canadian women who use contraception, 32% use combined OCP as their method

Monophasic (fixed amount of estrogen and progestin), biphasic (fixed amount of estrogen, amount of progestin increases in second half of cycle) or triphasic (estrogen may be fixed or variable, progestin increases in 3 equal phases)

EFFICACY

With perfect use, combined OCP is 99.9% effective

With typical use, failure rates range from 3-8%

Poor patient compliance major factor: 30% of women missed 3 or more pills in the first cycle. Another study found 47% miss 1 or more pills and 22% miss 2 or more pills per cycle.

? Effect of body weight. One retrospective study found women weighing >70kg had significantly increased risk of combined OCP failure

MOA

Main mechanism of action is to suppress gonadotropin secretion, thereby inhibiting ovulation

Development of atrophy, making endometrium unreceptive to implantation

Production of viscous mucus that impedes sperm transport

Possible effect on secretion and peristalsis within fallopian tube, which interferes with ovum and sperm transport

CONTRAINDICATIONS

<6 weeks postpartum if breastfeeding

smoker over the age of 35 (> 15cig/day)

HTN (> 160/100)

current or past history of VTE

Heart disease (ischemic or complicated valvular disease - PHTN, A Fib, history of bacterial endocarditis)

history of CVA

migraine headache with focal neurological symptoms

current breast ca

DM with retinopathy/nephropathy/neuropathy

severe cirrhosis, liver tumor (adenoma or hepatoma)

** undiagnosed vaginal bleeding

RELATIVE CI

smoker over the age of 35 (< 15cig/day)

adequately controlled HTN

HTN (140-159/90-99)

migraine headache over age of 35

symptomatic gallbladder disease

mild cirrhosis

use of medications that may interfere with combined OCP metabolism

RELATIVE CI

SIDE EFFECTS

Irregular bleeding: 10-30% in first month. Appears to improve with time

Breast tenderness: Usually decreases with time. May occur less often using OCs containing less estrogen. Decreasing caffeine intake may be helpful.

Nausea: Usually decreases with time. Decreasing estrogen content may be helpful or can try taking at hs or with food

Weight gain: Trials have failed to show any association

Mood changes: Trials have not demonstrated a significantly increased risk of mood changes

TROUBLESHOOTING

Breakthrough bleeding

Encourage users to continue with expectation that irregular bleeding will subside

If bleeding persists after third cycle or has a new onset, other causes must be ruled out - irregular pill taking, smoking, uterine or cervical pathology, pregnancy, use of concomitant medications and infection

Supplemental estrogen therapy (1.25mg conjugated estrogen PO for 7 days)

Therapeutic trial of another combined OC may be indicated - trial of OC containing a different type of progestin

RISKS

VTE: Rates 3-4x higher than non users. Absolute risk of VTE 1 to 1.5 per 10,000 users per year of use. Risk of VTE appears higher in first year of use

MI: Rates increase 3 fold in women taking combined OC containing more than 50mcg ethinyl estradiol

Stroke: Increased risk of stroke in users of combined OC containing more than 50mcg ethinyl estradiol. Some studies of low-dose OCs report no increased risk of stroke, others have reported an increased risk of up to 2-fold

Gallbladder disease: Increases secretion of chalk acid in bile, potentially leading to a higher incidence of gallstone formation; however, does not appear to be a significantly increased risk of gallstone formation

Breast cancer: Still controversial. More recent study of >9000 women, no significant association between use of combined OC and breast ca.

Cervical cancer: One study suggests long-term combined OC may increase risk of cervical ca in women who are HPV positive. Long-term study published in 2002 concluded that, in well-screened population of HPV-positive women, combined OC use did not increase risk of cervical ca

BENEFITS

cycle regulation

decreased flow

increased BMD

decreased dysmenorrhea and peri-menopausal symptoms

decreased acne, hirsutism

decreased endometrial and ovarian ca

INITIATION

Low dose preparation preferred (<35mcg ethinyl estradiol)

Conventionally, started during first 5 days of menstrual cycle, or the first Sunday after menses begin (to avoid weekend period). If starting within 5 days, no backup method needed. Alternative is “quick start” method. Backup method needed for first 7 days.

CONTINUOUS USE

Advantages: decreased incidence of pelvic pain, headaches, bloating/swelling and breast tenderness if experienced during pill-free interval. Improved over symptoms of endometriosis and PCOS

Disadvantages: little information on long-term safety (although long-term data for comparable total estrogen-progestin doses per month)

Take combined OC for 2-4 pill packages with hormone-free interval of 4-5 days. BTB common reason for returning to 21-day combined OC regimen. BTB will decrease over time. Use of monophonic pill regimen or a 21-day OC regimen has been shown to decrease incidence of BTB

TRANSDERMAL PATCH

Patch delivers 150mcg norelgestromin and 20mcg ethinyl estradiol systemically

One patch is applied weekly for 3 consecutive weeks, followed by 1 patch-free week

The patch is placed on 1 of 4 sites: the buttocks, upper outer arm, lower abdomen or upper torso (excluding the breast)

Efficacy: 0.3-0.7% failure rate with perfect use, up to 9% with typical use

Relative CI: women >90kg may find patch less effective

Local skin reaction in up to 20% of patients. Does not decrease over time. Only 2% of patch users discontinue it for this reason

VAGINAL RING

Ring releases 15mg of ethinyl estradiol and 120mcg of progestin etonogestrel per day

Each ring remains inserted for 3 consecutive weeks and then removed for a 1 week ring-free interval

Efficacy: 0.3-0.8% failure rate with perfect use, up to 9% with typical use

Relative CI: uterovaginal prolapse of vaginal stenosis if they prevent retention of ring

Side effects: irregular bleeding - less common, but does not decrease with time. Vaginal symptoms of discharge and irritation

INJECTABLE PROGESTIN

Depot medroxyprogesterone acetate injection q12 weeks

Highly effective: failure rate of less than 0.3%/year perfect use, typical use 3-6%

MOA: inhibits the secretion of pituitary gonadotropins, suppressing ovulation. Also increases viscosity of cervical mucus and induces endometrial atrophy

CI: pregnancy, unexplained vaginal bleeding and current diagnosis of breast ca. Relative CI: severe cirrhosis, active viral hepatitis and benign hepatic adenoma

SIDE EFFECTS

Menstrual cycle disturbance: irregular bleeding or unwanted amenorrhea. Unpredictable bleeding common in first few months, but decreased in amount and frequency with time. ~60% amenorrheic at 12 months, ~70% at 24 months

Hormonal side effects: headache, acne, decreased libido, nausea and breast tenderness

Weight gain: 2.5kg in first year, 3.7kg after 2nd year and 6.3kg after 4th year of use. One study found 56% of users reported increase in weight while 44% either lost weight or were weight neutral

Mood effects: Mood changes have been reported although prospective studies do not appear to demonstrate an increase in depressive symptoms

RISKS

Delayed return of fertility: average 9-month delay before restoration of full fertility after last injection

Reduction in BMD: Prospective studies have found a mean loss of FMD at the lumbar spine of between 0.87% and 3.52%. Does not appear to induce osteoporosis. Studies suggest improvement in BMD after it is discontinued

VTE, stroke, CVD: No apparent increase in risk at standard doses

TROUBLESHOOTING

Irregular bleeding: if persists beyond first 6 months of use

increase dose to 225 and 300mg IM for 2-3 injections

decreasing interval between doses

supplemental estrogen therapy (0.625mg conjugated equine estrogen PO for 28 days)

NSAIDs for 10 days

adding combined OCP for 1-3 months

Late injection: If <14 weeks, give next injection. If >14 weeks, check for pregnancy, give next injection and backup method x 2 weeks

PROGESTIN-ONLY PILL

Efficacy: with perfect use, failure rate of ~0.5%. With typical use, failure rate between 5 and 10%

MOA: through alterations in cervical mucus - reduce the volume of mucus, increase its viscosity and alter its molecular structure resulting in little or no sperm penetration. Ovulation may be suppressed or partially suppressed. POP must be taken at same time every day

CI: pregnancy and current breast cancer. Relative CI include active viral hepatitis and liver tumours

SIDE EFFECTS

Irregular bleeding: Spotting in ~12% of users in first month, decreases to <3% at 18 months.

Hormonal side effects: headache, bloating, acne and breast tenderness occur less commonly

INITIATION

Can be started at any time as long as pregnancy excluded

A pill containing active hormone taken every day, no pill-free interval!

Backup method should be used in first 7 days

Contraceptive reliability requires pill-taking at same time every day (within 3 hours)

IUD

Highly effective - failure rate of copper IUD was 1.26 per 100 women years and rate of ectopic pregnancy was 0.25 per 100 WY. Failure rate of Mirena was 0.09 per 100 WY and ectopic pregnancy rate was 0.02 per 100WY

MOA: Chief MIA appears to be prevention of fertilization.

Copper IUD: presence of a FB and copper in endometrial cavity causes biochemical and morphological changes that adversely affect sperm transport. Ovulation not affected.

Mirena: weak FB reaction and endometrial changes that include endometrial decidualization and glandular atrophy. Cervical mucus may become thickened. Ovulation may be inhibited in some women (not for the Jaydess).

IUD

CONTRAINDICATIONS

Pregnancy

current, recurrent or recent (within 3 months) PID or STI

Puerperal sepsis

Immediate post-septic abortion

Severely distorted uterine cavity

Unexplained vaginal bleeding

Cervical or endometrial cancer

Malignant trophoblastic disease

Copper allergy (for copper IUDs)

Breast ca (for mirena and Jaydess)

RELATIVE CI

Risk factors for STIs or HIV

Impaired response to infection (HIV positive women or women undergoing corticosteroid therapy)

From 48hours to 4 weeks postpartum

Ovarian cancer

Benign gestational trophoblastic disease

NON-CONTRACEPTIVE BENEFITS

Menorrhagia responds favourable to the use of Mirena

2 studies of women scheduled to undergo hysterectomy for menorrhagia: 64-80% subsequently cancelled hysterectomy, compared to 9-14% randomized to receive other medical treatments

SIDE EFFECTS

Bleeding

copper IUD: increase in menstrual blood loss by up to 65% over non-users. NSAIDs or tranexamic acid may help

Mirena: reduction in menstrual blood loss between 74 and 97%. Between 16 and 35% of users will become amenorrheic after 1 year of use

Pain or dysmenorrhea: up to 6% of users will have discontinued use at 5 years because of pain

Hormonal: depression, acne, headache and breast tenderness. Decrease over time. Weight neutral according to large trial over 5 years

Functional ovarian cysts: Reported in up to 30% of mirena users. Resolve spontaneously so should be managed expectantly

RISKS

Uterine perforation: Rate of 0.6 to 1.6 per 1000 insertions. Risk factors include postpartum insertion, inexperienced operator and a uterus that is immobile, extremely anteverted or retroverted

Infection: Relative risk of PID of 3.8 in first month after insertion, back to baseline risk after 4 months. Exposure to STIs and not the use of IUD itself is responsible for PID occurring

Expulsion: Most common in first year of use. Risk factors: immediately postpartum, nulliparity and previous IUD expulsion (30% chance if previous expulsion)

Failure: If a woman becomes pregnant with an IUD in situ, ectopic pregnancy must be excluded. Risk of SA increased in women who continue a pregnancy with an IUD in place

TROUBLESHOOTING

Lost strings: speculum exam to look for strings followed by U/S and then plain x-ray

Pregnancy with IUD in place: If wishes to terminate, keep in place until procedure. If wishes to continue with pregnancy, IUD should be removed if possible

Amenorrhea or delayed menses: exclude pregnancy, investigation should be as for a woman without an IUD. Up to 35% of mirena users may experience amenorrhea

Pain and abnormal bleeding: Rule out partial expulsion, perforation, pregnancy and infection. Treatment with NSAIDs may be helpful. Usually decreases over time.

TROUBLESHOOTING

Difficulty removing IUD: grasping string with ring forceps and exerting gentle traction can usually accomplish removal. Uterine sound can be used, cervical dilation may be required. Direct visualization of IUD with U/S or hysteroscopy may be required. Paracervical block and occasionally GA may be needed

STI with IUD in place: Treat STI. If suggestion of PID, device should be removed after pre-treating woman with abx

Actinomycosis on pap: up to 20% of copper IUD users, up to 3% of mirena users. If asymptomatic, reasonable to leave in place and follow with yearly pap and pelvic exams. If symptomatic, IUD should be removed after antibiotic preloading

PERIMENOPAUSE

Contraception should be recommended until menopause confirmed clinically

Combined OCs no longer CI in non-smoking women over age 35. May also help with menopausal symptoms

IUD

Progestin-only methods

Barrier methods

POSTPARTUM CONTRACEPTION

Combined OCs: may diminish quality and quantity of breast milk in postpartum period. Should not be used until lactation well established (usually 6 weeks pp)

Progestin-only pills: Provides a small increase in milk production. Progestins administered within first 72hrs pp may theoretically interfere with the fall in serum progesterone levels that triggers lactogensis, but prospective study did not detect any adverse effect on breastfeeding

Injectable progestin: Little or no effect on breast milk production or infant development. May be preferable to wait until breast milk established, otherwise first dose can be given immediately after birth

IUD: Usually wait until 4-6 weeks postpartum since higher risk of expulsion and uterine perforation

Lactational amenorrhea: Exclusively breastfeed at regular intervals (<4hrs during day), even during the night (<6hrs at night), have this contraception effect during first 6 months. Supplements increase the risk of ovulation in absence of menstruation.

EMERGENCY CONTRACEPTION

Emergency contraceptive pills

Plan B: 85% effective: 2 doses of 750mcg levonorgestrel 12 hours apart up to 72hrs after intercourse. May be preferred in women with significant CI to estrogen

Yuzpe method: 75% effective: 2 doses of 100mcg etinyl estradiol and 500mcg levonorgestrel 12 hours apart up to 72hours after intercourse

Side effects: Nausea, vomiting, dizziness and fatigue (Plan B better than Yuzpe). Antiemetic meclizine 50mg 1 hour before first dose

Insertion of copper IUD: approaches 100% effective. Can be inserted up to 7 days after unprotected intercourse

REFERENCES

Black A, Francoeur D, Rowe T et al. SOGC clinical practice guidelines: Canadian contraception consensus. J Obstet Gynaecol Can. 2004;26:219-96

www.rxfiles.ca

www.uptodate.com

www.jaydess.com