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Contraceptive Choices 2008. debbie Robinson M.D. F.R.C.S.C. Objectives. Barrier methods Systemic Hormonal Contraception Pills/Patch/Ring Progesterone Only Options Intra-Uterine Devices Copper Mirena. Barrier Methods. Condoms Reliable contraception No protection from vulvar HPV or HSV

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contraceptive choices 2008

Contraceptive Choices 2008

debbie Robinson

M.D. F.R.C.S.C.

objectives
Objectives
  • Barrier methods
  • Systemic Hormonal Contraception
    • Pills/Patch/Ring
    • Progesterone Only Options
  • Intra-Uterine Devices
    • Copper
    • Mirena
barrier methods
Barrier Methods
  • Condoms
    • Reliable contraception
    • No protection from vulvar HPV or HSV
  • Female Condom
    • Similar to male condom but offers some vulvar protection against STI’s
  • Failure rate with perfect use = 2%
  • Failure rate with typical use = 12%
diaphragms
Diaphragms
  • Must be fitted
  • Must be used with spermicidal foams/gels, reapplied if more than one act of intercourse
  • Must be left in-situ for 6 hrs after intercourse
  • Reusable, wash with soap and water, good for about one year
  • Failure rate = 6-18%
sponge
Sponge
  • Sponge is impregnated with spermicidal foam and traps sperm within the sponge
  • Must use a new sponge for each act of intercourse
  • Must remove 1 hr after intercourse
  • Failure rate = 5-18%
systemic combined hormonal contraception
Systemic Combined Hormonal Contraception
  • Pill / Patch / Ring
  • All use combined E2 and a progestin
  • All inhibit ovulation reliably
  • Failure rate <1%
non contraceptive benefits of hormonal contraception
Non-Contraceptive Benefits of Hormonal Contraception
  • Regulation of menses
  • Decrease in dysmenorrhea
  • Decrease in menstrual flow
  • Decreases PMDD
non contraceptive benefits of hormonal contraception1
Non-Contraceptive Benefits of Hormonal Contraception
  • Decreases acne and hirsutism
  • Decrease in uterine CA
  • Decrease in ovarian CA
  • No increase in breast CA
contra indications
Contra-indications
  • Absolute:
    • Smoking >15cig/day over age 35
    • Liver disease
    • Undiagnosed vaginal bleeding
    • History of any E2 dependent tumor
    • Previous VTE
    • Hypertriglyceridemia
    • Migraine with neurological symptoms
special considerations
Special Considerations
  • Medications such as Dilantin, phenobarbital, carbamazepine, and rifampin increase liver enzyme activity and decrease effectiveness of the OCP
  • Medications such as fluconazole have the opposite effect and may increase estrogen side effects
mono phasic vs tri phasic
Mono-phasic vs Tri-phasic
  • Both give reliable contraception
  • Both have few side effects for most women
  • Slightly more BTB with tri-phasics
  • Some women will notice the changing progestin dose
    • Progestin side effects are breast tenderness, bloating, moodiness
  • Less flexibility with tri-cyclics
how long is too long
How Long is Too Long?
  • Using a monophasic preparation, women can use continuous hormonal contraception for as long as they are amenorrheic.
  • When BTB occurs, allow a withdrawal bleed and a hormone free week, then resume the hormones
  • Seasonale comes as 11 weeks of active pill and one week of placebo
estrogen dose
Estrogen Dose
  • Currently available are 20, 25, 30, 35, 50 mcg
  • Estrogen side effects are headache (either too much or from withdrawal), nausea
  • Estrogen adverse effects are VTE, increased lipids (esp TG’s), aggravated htn, increased activation of liver enzymes – may cause adenomas
estrogen dose1
Estrogen Dose
  • Most women will do fine on any dose
  • Women who are obese need a higher estrogen dose for contraception (but not for menorrhagia or irregular menses)
  • 50mcg pills are reserved for control of acute menorrhagia due to increased VTE risk
what progestin to choose
What Progestin To Choose
  • All formulations use “progestins”, not progesterone
  • 2nd generation progestins include levonorgestrel (Alesse, Tri-Phasil, Ovral, Seasonale) and norethindrone (Ortho7/7/7, Lo-Estrin, Min-Estrin)
  • Derived from testosterone and therefore have higher androgenic activity
what progestin to choose1
What Progestin To Choose
  • 3rd generation Progestins include Desogestrel (Marvelon, Linessa) and Norgestimate (Cyclen, Evra)
  • Also derived from testosterone, but modified to bind the androgen receptor less, and have less androgenic activity than 2nd generation progestins
progestational activity
Progestational Activity
  • Progestational activity refers to the degree that the progestin has progesterone-like effects:
    • Endometrial thinning
    • Side effects – breast tenderness, bloating, etc
  • P.A. in increasing order:
    • Norgestimate (Cyclen), levonorgestrel (Alesse), Norethindrone (Min-Estrin), Desogestrel (Marvelon)
androgenic activity
Androgenic Activity
  • Androgenic activity refers to:
    • the degree that the progestin can still bind the androgen receptor
    • Effects on SHBG
    • The degree to which it is bound to SHBG
what this means in real life
What This Means In Real Life
  • All OC’s are anti-androgenic overall
  • The estrogen component increases SHBG (antagonized to varying degrees by the progestin, but still lowered overall)
  • Increased SHBG decreases circulating free testosterone
what this means in real life1
What This Means In Real Life
  • The estrogen component also decreases gonadotropins which decrease ovarian production of testosterone
  • OC’s also suppress androgen production from the adrenal gland to a small degree
bottom line
Bottom Line

The Androgenic Activity of a Progestin is Irrelevant!!

Two progestins exist that are truly anti-androgenic and exert a greater effect than the usual OC’s – Cyproterone Acetate and Drosperinone

diane 35
Diane 35
  • Cyproterone Acetate – based on the progesterone molecule, is an anti-androgen
  • It blocks the binding of androgens to their receptors
  • It inhibits ovarian and adrenal testosterone production
  • It’s progesterone qualities protect the endometrium
yasmin
Yasmin
  • Drosperinone is based on the Spironolactone molecule, which competitively inhibits DHT at its receptor sites, and is therefore also an anti-androgen.
  • Yasmin has relatively high progestational activity and therefore is utero-protective, but b/c it is a mineralocorticoid, is does not cause bloating or weight gain
non oral preparations
Non-Oral Preparations
  • Evra – E2 (.6 mg) and norelgestromin
    • Apply to shoulder, lower abdomen, buttock
    • Change patch weekly
    • 3 weeks on, 1 week off
    • Has 2-3 day grace period
evra cont
Evra cont.
  • No effect on TG’s (no first pass liver effect)
  • Continuous, slow release dosing may reduce side effects such as BTB and headache
  • Lower peak levels of E2, with the total AUC equivalent to a 35mcg pill
  • NB: different than the US preparation, which has .75mg and an AUC equivalent to a 50mcg pill
  • Cannot use if >90 kg as the E2 will be absorbed and held in the adipose tissue
non oral preparations1
Non-Oral Preparations
  • Nuva-Ring E2 (15 mcg) and Etonogestrel
    • Placed in the posterior fornix and left in-situ for 3 weeks
    • Do not remove for intercourse
    • 1 week grace period
    • Also avoids first pass liver effect and gives advantage of continuous release
    • AUC equivalent to a 30 mcg pill
progesterone only options
Progesterone Only Options
  • Micronor and Depo-provera
  • Good for women who have a contra-indication to estrogen
  • Contraindicated in women with a significant history of depression
micronor
Micronor
  • “The mini-pill”
  • Contains norethindrone acetate only
  • Ultra low dose
  • No hormone-free period
  • Amenorrhea common
  • Must take at same time every day
  • Higher failure rate
  • Best for lactating or peri-menopausal women
depo provera
Depo-Provera
  • Three month depot of MPA
  • Reliable contraception
  • Amenorrhea common, but expect BTB first cycle
  • Slow return to fertility
  • Decreases bone density (reverses after cessation)
  • Causes weight gain (7-10 lbs average)
  • Breast tenderness common
intra uterine devices
Intra-Uterine Devices
  • Primary mechanism of action is a foreign body reaction
    • Inhibits retrograde contractions seen at time of ovulation
  • Secondary mechanism of action is at the level of the cervix
    • Copper – macrophages
    • Mirena – progesterone effect on mucus
intra uterine contraceptive devices
Intra-Uterine Contraceptive Devices
  • Tertiary mechanism of action is creating an endometrium unsuitable for implantation
    • Copper – local inflammatory response
    • Mirena – thin endometrium due to progesterone
  • Advantages – long term contraception with no action required by the woman
  • Does Not increase risk of PID
copper iucd s
Copper IUCD’s
  • Nova-T or Flexi-T
  • Contraception for a minimum of 10 years
  • No hormones so no hormonal contraindications
  • Does not inhibit ovulation
  • Does not modify menstrual cycle
  • May increase dysmenorrhea
iucd s mirena
IUCD’s - Mirena
  • Slightly larger than the copper IUCD
  • Good for 5 years of reliable contraception
  • May inhibit ovulation in first year, but not thereafter
  • Controls menorrhagia and dysmenorrhea
  • More expensive
  • Can be used in nullips, but may be more difficult to insert, and cause initial cramping