Contraception

1. Contraception Elizabeth Dehmer Special Month Presentation Aug. 20, 2008

2. Introduction We routinely prescribe teratogenic medications to women of childbearing age. Examples: statins, ace inhibitors, coumadin, tetracycline, doxycycline, streptomycin, phenytoin, valproic acid, carbamazepine, lithium.

3. Question What are the advantages, disadvantages, side effects and contraindications of the following contraceptive methods? Barrier Methods Oral Contraceptive Pills Injectable Contraceptives Contraceptive Patch Vaginal Ring Intrauterine Devices

4. Barrier Methods Condoms Female Condoms Cervical Cap Diaphragm

5. Condoms Acts as barrier against passage of semen into vagina Good for individuals who have multiple partners, and individuals who do not want medical intervention for contraception.

6. Condoms Advantages: Protects against STDs Readily available Inexpensive Allows male partner to be involved in contraception Disadvantages Failure rate: 2% for perfect use? 15% with typical use Requires responsible attitude on the part of the male May decrease enjoyment of sex Lots of ways to have errors with condoms that can lead to failure: failure to use with every act of intercourse, improper lubricant use with latex condoms (oil-based lubricants), incorrect placement of condom, poor w/drawal technique (without securing condom), opening condom packet carelessly with fingernails, teeth, or sharp objects, not checking expiration date, unrolling condom before putting it on can increase chance of tearing, using wrong size of condom, using too little or too much lubricant. Lots of ways to have errors with condoms that can lead to failure: failure to use with every act of intercourse, improper lubricant use with latex condoms (oil-based lubricants), incorrect placement of condom, poor w/drawal technique (without securing condom), opening condom packet carelessly with fingernails, teeth, or sharp objects, not checking expiration date, unrolling condom before putting it on can increase chance of tearing, using wrong size of condom, using too little or too much lubricant.

7. Female Condoms Polyurethane sheath intended for one-time use with two flexible rings. Acts as a barrier to passage of semen into vagina Ring at closed end of sheath serves as insertion mechanism and internal anchor placed inside the vagina. Second ring remains outside of the canal after insertion.Ring at closed end of sheath serves as insertion mechanism and internal anchor placed inside the vagina. Second ring remains outside of the canal after insertion.

8. Female Condoms Advantages Protects against STDs Can be inserted up to 8 hrs before intercourse Sheath coated on inside with silicone based lubricant Disadvantages More expensive than condoms Awkward, difficult to place May cause UTI Failure rate: 5% perfect use?21% typical use $2-2.50 compared to 25-50 cents for condoms Can cause UTI if left in for a prolonged period$2-2.50 compared to 25-50 cents for condoms Can cause UTI if left in for a prolonged period

9. Cervical Cap Cup-shaped latex device fits over the base of the cervix Spermicide required May be inserted up to 8 hrs prior to intercourse and left in place for 48 hrs. Spermicide to fill 1/3 of the way fullSpermicide to fill 1/3 of the way full

10. Cervical Cap Advantages Provides continuous protection for duration of use regardless of number of intercourse acts, and does not require additional spermicide Non-hormonal Disadvantages Requires professional fitting and training Can lead to cervical erosions Obesity can make placement difficult High failure rate (In nulliparous women 6% with perfect use, 16% with typical. In parous women, 26% with perfect use, 32% typical use) Risk of toxic shock syndrome of left in place longer than prescribed period Requires h/o normal pap smears

11. Diaphragms Shallow cap with spring mechanism in rim to hold in place in vagina Spermicide required Must be left in place 6hrs following intercourse

12. Diaphragms Advantages Non-hormonal contraception controlled by woman Disadvantages High failure rate: perfect use 6%, typical use 16% Prolonged use can increase risk of UTIs Requires professional fitting and training Can develop odor if not properly cleaned Can cause vaginal erosions Requires additional spermicide for repeated use

13. Oral Contraceptive Pills Combined Oral Contraceptive Pills Extended-cycle/continuous Oral Contraceptive Pills Progestin-Only Contraceptive Pills Emergency Contraception

14. Combined Oral Contraceptive Pills Contain estrogen and progestin Monophasic Multiphasic Block ovulation, alter cervical mucus, stimulate atrophic change in endometrium 21 days of hormone followed by 7 days of placebo to allow withdrawal bleeding Monophasic: equal quantity of hormone in each tablet Multiphasic: contain varying amounts of estrogen and progestin in active pills in an attempt to mimic natural hormone fluctuations and provide lowest effective dose of hormone. Monophasic: equal quantity of hormone in each tablet Multiphasic: contain varying amounts of estrogen and progestin in active pills in an attempt to mimic natural hormone fluctuations and provide lowest effective dose of hormone.

15. Combined Oral Contraceptive Pills Advantages: Failure rate less than 0.3% with perfect use (8% typical use) Fertility returns rapidly Bleeding is decreased Greater cycle predictability Decreased risk of benign breast disease, PID, ovarian and endometrial cancers Disadvantages: Increased risk of stroke, acute MI, venous thromboembolic disease Increased risk of hepatic adenoma, cervical cancer, breast cancer Do not protect against STDs When used with antibiotics or anticonvulsants, efficacy may be decreased **Patients at higher risk of thromboembolism are sedentary, overweight, smokers, hypertensive, diabetic, hypercholesterolemic**Patients at higher risk of thromboembolism are sedentary, overweight, smokers, hypertensive, diabetic, hypercholesterolemic

16. Combined OCPs: Side effects Nausea Headache Weight gain Vomiting Dizziness Mastalgia Melasma Hypertension Mood changes Decreased libido Increased triglycerides Severe depression Spotting, breakthrough bleeding Side effects usually subside within first few months of initiation Melasma-skin condition: brown patches on the face Side effects usually subside within first few months of initiation Melasma-skin condition: brown patches on the face

17. Combined OCPs: Contraindications Smoker of age > 35 Encourage smoking cessation in patients younger than 35 History of breast cancer Abnormal vaginal bleeding of unknown etiology Cerebrovascular disease Congenital hyperlipidemia Ischemic heart disease Migraine Active viral hepatitis Diabetes >20 years OR with severe vascular disease, nephropathy, retinopathy, neuropathy Major surgery with prolonged immobilization Severe hypertension Hepatic neoplasm Impaired liver function Thrombophlebitis, thromboembolic disease, known thrombogenic mutations

18. Combined OCPs: Examples Monophasic: Ortho-cyclen OrthoNovum Lo/Ovral Low-Ogestrel Nordette Loestrin 1.5/30 and 1/20 Alesse Yasmin Multiphasic: Ortho Tri-Cyclen Cyclessa Ortho-Novum 777 TriNorinyl Triphasil Tri-Levlen Trivora Estrostep Start date varies: on day 1 of menstruation, first Sunday after menstruation, day 5 of cycle Yasmin: contains synthetic progestin chemically related to spironolactone (with anti-androgen and anti-mineralocorticoid activity). Causes less weight gain and water retention, greater reduction in acne, hirsutism and PCOS. Can reduce blood pressure. Side effects include K retention. No evidence of improved cycle control with multiphasic preparations, and they cannot be taken continuously in order to skip bleeds.Start date varies: on day 1 of menstruation, first Sunday after menstruation, day 5 of cycle Yasmin: contains synthetic progestin chemically related to spironolactone (with anti-androgen and anti-mineralocorticoid activity). Causes less weight gain and water retention, greater reduction in acne, hirsutism and PCOS. Can reduce blood pressure. Side effects include K retention. No evidence of improved cycle control with multiphasic preparations, and they cannot be taken continuously in order to skip bleeds.

19. Extended-cycle/continuous OCPs Increase the time between hormone-free intervals or decrease the number of hormone-free days in each cycle Effective at reducing or eliminating scheduled withdrawal bleeding Associated with more frequent unscheduled bleeding or spotting

20. Extended-cycle/continuous OCPs Advantages when compared to usual combined OCPs include reduction in: Hormone withdrawal symptoms PMS and PMDD Irregular bleeding Headaches Side effects and contraindications are similar to combined OCPs. It is unknown whether extra weeks of hormone exposure increase risk of thromboembolism.

21. Extended Cycle/Continuous OCPs 84/7 regimens: Seasonale and Seasonique 24/4 regimens: Yaz and Loestrin 24 Fe Lybrel: No placebo or pill-free interval. No head to head trials between Seasonal and Seasonique but Seasonique seems to have less bleeding. Same hormones but seasonique has ethinyl estradiol in the 7 pills Yaz, like Yasmin, contains synthetic progestin drospirenone with anti-androgen and anti-mineralocorticoid activity, and therefore causes less weight gain and water retention, has greater reduction in acne, PMDD, hirsutism, PCOS, and BPNo head to head trials between Seasonal and Seasonique but Seasonique seems to have less bleeding. Same hormones but seasonique has ethinyl estradiol in the 7 pills Yaz, like Yasmin, contains synthetic progestin drospirenone with anti-androgen and anti-mineralocorticoid activity, and therefore causes less weight gain and water retention, has greater reduction in acne, PMDD, hirsutism, PCOS, and BP

22. Progestin-Only OCPs Suppresses ovulation, has variable dampening effect on midcycle peaks of LH and FSH, increases cervical mucus viscosity, leads to atrophic endometrium, reduces cilia motility in the fallopian tube **MUST BE TAKEN AT THE SAME TIME EVERY DAY** If a pill is delayed by three hours it is considered missed and extra precautions must be taken for 7-14 daysIf a pill is delayed by three hours it is considered missed and extra precautions must be taken for 7-14 days

23. Progestin-Only OCP Advantages: Risk of serious complications to which estrogen contributes is greatly reduced Decreased dysmenorrhea, menstrual blood loss, PMS symptoms Fertility returns immediately after cessation Disadvantages: **requires compliance** Does not protect against STDs Therefore can be use in women unable to take estrogen due to breastfeeding, cardiovascular disease including diabetes, breast cancer, migraine, in women with h/o DVTTherefore can be use in women unable to take estrogen due to breastfeeding, cardiovascular disease including diabetes, breast cancer, migraine, in women with h/o DVT

24. Progestin-Only OCP: Side effects Menstrual irregularities Spotting, breakthrough bleeding Amenorrhea Weight gain Headache Adverse impact on lipids Mood changes Severe depression Acne Hypoestrogenism Hair loss

25. Progestin-Only OCPs Contraindications: pregnancy, current breast cancer, vaginal bleeding Caution: breastfeeding < 6 weeks postpartum, active viral hepatitis, hypertension >160/100, current ischemic heart disease, h/o stroke, current DVT or pulmonary embolism, diabetes w/ vascular disease, severe decompensated cirrhosis

26. Progestin-Only OCPs: Examples Ovrette (0.075 mg Norgestrel) Micronor or Nor-QD (0.35 mg norethindrone) First pill is taken on day 1 of menstruation

27. Emergency Contraception Progestin-only: Plan B (levonorgestrel 0.75 mg) Norgestrel 1.5 mg Combined: Norgestrel 100 mg, ethinyl estradiol 100 mcg Levonorgestrel 50 mg, ethinyl estradiol 100 mcg First dose < 72 hours after unprotected intercourse, second dose 12 hours later

28. Injectable Contraceptives Depo-Provera

29. Injectable Contraceptives (Depo-Provera) Progestin-only: Depo-medroxyprogesterone acetate (DMPA) 150 mg IM every 12 weeks Alters endometrial lining, thickens cervical mucus and blocks LH surge preventing ovulation

30. Depo-Provera Advantages Extremely effective. Failure rate 0.3% with perfect use, 3% with typical use. Efficacy is not altered by varying weight nor use of concurrent medications nor sickness/diarrhea Decreased anemia, dysmenorrhea Decreased risk of endometrial and ovarian ca, PID, ectopics Safe for use in breast-feeding mothers Does not produce serious side effects of estrogen: OK to use in patients with diabetes, lipid disorders, complicated migraines, h/o CVA/CAD/CHF, SLE, peripheral vascular disease Disadvantages Involves injections and remembering to visit MD every 3 months Persistent irregular bleeding Delayed return to fertility Weight gain-about 5 lbs in first year. Depression Consider in patients on anti-convulsants!Consider in patients on anti-convulsants!

31. Side effects of Depo-Provera Edema, thromboembolic disorders Nausea, vomiting, diarrhea, abdominal pain Hot flashes, decreased libido, menstrual changes, breast tenderness, galactorrhea Weight gain Headache, insomnia, dizziness, depression, fatigue, nervousness Rashes, alopecia, acne, urticaria, pruritus Injection site reactions Can cause decreased bone mineral density, but this is not associated with increased fracture risk, is transient and reversible upon discontinuation.

32. Contraindications to Depo-Provera Known or suspected pregnancy Undiagnosed vaginal bleeding or missed abortion Known or suspected malignancy of the breast Active thrombophlebitis, current thromboembolic disease, or cerebral vascular disease Liver dysfunction or disease

33. Contraceptive Patch Ortho Evra

34. Ortho Evra Apply once weekly for 3 weeks. Placebo is one patch-free week during which withdrawal bleeding occurs Blocks LH surge (preventing ovulation), thickens cervical mucus, alters endometrial lining Apply to abdomen, buttock, upper arm or outer torsoApply to abdomen, buttock, upper arm or outer torso

35. Ortho Evra Efficacy similar to OCPs: 0.3% failure rate with perfect use, 8% with typical use. Once a week regimen may be easier for some patients to follow compared to daily pill Less effective in women who weigh > 90 kg Side effects, contraindications, cardiovascular risk similar to combined OCPs May also have application site reactions, 1-2 patches per year per user may fall off, and there is likely increased risk of VTE compared to combined OCPs

36. Vaginal Ring NuvaRing

37. NuvaRing Ethylvinyl acetate ring Ethinyl estradiol 0.015 mg/day +etonogestrel 0.12 mg/day Inserted intravaginally for three weeks Thickens cervical mucus, alters endometrial lining, blocks LH surge preventing ovulation

38. NuvaRing Side effects, contraindications similar to combined OCPs. Ring specific: 2.5% of women will have 1 event/year where ring falls out Leukorrhea/vaginitis Leukorrhea-thick white vaginal dischargeLeukorrhea-thick white vaginal discharge

39. Intrauterine Devices Copper T 380A Mirena

40. IUDs Copper T IUD Causes migration of WBCs into the uterine cavity resulting in phagocytosis of spermatozoa Copper ions seem to have direct toxic effect on spermatozoa Can be left in place for 10 yrs Bleeding: Increases flow 50%, regular periods, 7-12% remove for bleeding and/or pain at 1 year Mirena Releases 20 mcg LNG per day into uterine cavity for 5 years Inhibits fertilization: anovulation, thickens cervical mucus, inhibits sperm and ovum motility and function Can be left in place for 5 years Bleeding: Decreases flow 90%, irregular periods w/ spotting, 20% amenorrheic at 1 year, 7% remove for bleeding within 1 year

41. IUDs Advantages: Efficacy. Failure rate w/ perfect use 0.1-0.6%, typical use 0.1-0.8% Long-term Reversible Most cost-effective No systemic side effects Mirena only: decreased menorrhagia, dysmenorrhea, anemia Decreased rate of ectopic pregnancies overall* Disadvantages Increased risk of PID (only at insertion) Risk of perforation with insertion Cramping and pain at insertion May be expelled unnoticed No STD protection REQUIRES COUNSELING, HISTORY, PELVIC EXAM, SCREEN FOR GONORRHEA/CHLAMYDIA and PAP SMEAR** *but ratio of extrauterine to intrauterine pregnancy is increased if conception does occur. **This is not felt to be the case for hormonal contraception?only necessary screening prior to prescribing is complete medical history and BP check. Women who are older and therefore at greater risk for breast ca and cervical ca should be advised strongly about importance of pap smears and clinical breast exam for detecting these conditions. *but ratio of extrauterine to intrauterine pregnancy is increased if conception does occur. **This is not felt to be the case for hormonal contraception?only necessary screening prior to prescribing is complete medical history and BP check. Women who are older and therefore at greater risk for breast ca and cervical ca should be advised strongly about importance of pap smears and clinical breast exam for detecting these conditions.

42. Contraindications to IUDs High risk for STDs Current cervicitis or PID Known or suspected pregnancy Uterine anatomy interfering w/ placement AIDS, not doing well on ARV therapy Mirena only: Current DVT Copper only: Allergy to copper or Wilson�s dz Gynecologic or breast malignancy Unexplained vaginal bleeding

43. References Himmerick, Kirstine A. Enhancing contraception: A comprehensive review. JAAPA 2005;18:26-33. Nelson, Anita. Communicating with Patients about Extended-Cycle and Continuous Use of Oral Contraceptives. Journal of Women�s Health 2007;16:463-470. Scott, Alison and Anna Glasier. Evidence based contraceptive choices. Best Practice and Research Clinic Obstetrics and Gynaecology 2006;20:665-680.

44. References Contraception. First Consult. Online. 30 July 2008. Spencer, Abby, Rachel Bonnema, Megan Cunnane, Alda-Maria Gonzaga, and Mindy Sobota. Contraception: What Every Internist Should Know. SGIM Annual Meeting. Sheraton Center Toronto Hotel, Toronto. 27 April 2007. Stewart FH, Harper CC, Ellertson CE, Grimes DA, Sawaya GF, Trussell J. Clinical breast and pelvic examination requirements for hormonal contraception: current practice vs. evidence. JAMA 2001;285:2232-9.

45. Acknowledgements Amy Weil, MD