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Contraception

Contraception. Tracie Wilcox MD Assistant Professor of Medicine Resident Ambulatory Curriculum. Objectives. Review Different Methods of Contraception Review the advantages and disadvantages of each method Choose appropriate contraception based on different clinical situations

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Contraception

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  1. Contraception Tracie Wilcox MD Assistant Professor of Medicine Resident Ambulatory Curriculum

  2. 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

  3. 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 terminations

  4. Contraceptives • Hormonal Contraceptives: • oral, transdermal, intravaginal, IM, implanted • Barrier Devices • Diaphragm • Condoms: male and female • Cervical Caps

  5. Surgical: • Tubal Ligation, Vasectomy • Intrauterine Devices: • IUDs: copper or progesterone releasing

  6. 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

  7. Combination Pills • Synthetic estrogens • Ethinyl estradiol • Mestranol • Synthetic progestins • Many different progestins available

  8. 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

  9. Progesterone Component • Progestin doses range from 0.05mg – 1mg • Differ in their androgenic, estrogenic, and progestational activity

  10. First Generation Progestins • Norethindrone – ex: ortho-novum, necon • Norethindrone acetate – ex: junel, estrostep, loestrin • Ethynodiol diacetate – ex: zovia • Medium androgenic potency

  11. 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

  12. 3rd Generation Progestins • Norgestimate ( ortho-cyclen or tri-cyclen) • FDA approved to treat acne • desogestrel (desogen, ortho-cept) • Gestodene – not available in US

  13. 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

  14. 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

  15. 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

  16. 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

  17. Effectiveness • If taken correctly: 99.9% • In reality: 92.4% • Return to fertility: • Average 2 month delay in conception after OCP’s stopped

  18. Mechanism • Suppress ovulation • Suppress follicular development • Alter cervical mucous making sperm penetration more difficult • Alters endometrium making implantation less likely

  19. 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

  20. 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

  21. 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

  22. 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

  23. Risks Continued • Hepatic vein thrombosis • Portal vein thrombosis • Splenic artery thrombosis • Mesenteric artery thrombosis • Mesenteric vein thrombosis

  24. 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

  25. 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

  26. 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

  27. 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

  28. 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

  29. 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

  30. 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

  31. 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

  32. Combination Contraceptives • Side effects: • Breakthrough bleeding – most common reason for discontinuation • Nausea • Weight gain • Mood swings • Breast tenderness • Headaches • Acne, facial hair growth

  33. 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

  34. 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

  35. 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

  36. 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

  37. 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.

  38. 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

  39. 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

  40. 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

  41. 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

  42. 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%

  43. 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

  44. 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

  45. Depo-Provera • IM injection of 150 mg every 12 weeks • 99.7% success rate • medroxyprogesterone: • Thickens cervical mucous-less penetrable to sperm • Suppresses ovulation

  46. 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

  47. 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)

  48. 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

  49. 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

  50. 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

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