Methods of Contraception & Contraindications Sheila Flaum DO Clinical Lecturer University of Michigan Disclosures

 I have no disclosures Contraception is Common

99% of women aged 15-44 who have ever had sexual intercourse have used at least one contraceptive method 60% of all women of reproductive age are currently using a contraceptive method Contraceptive use is common among women of all religious denominations Guttmacher Institute:https://www.guttmacher.org/fact-sheet/contraceptive-use-united-states Most Common Methods Effectiveness of Contraception

Bedsider.org Satisfaction of Reversible Methods Categories of Contraception

Estrogen + Progesterone Only Non-Hormonal Progesterone COPs LNG-IUDs Sterilization NuvaRing Nexplanon Copper IUD Patch Depo Diaphragm POPs Condom Cervical Cap Sponge Spermicide Withdrawal Fertility Awareness US MEC

1- No restriction (method can be used) 2- Advantages generally outweigh theoretical or proven risks 3- Theoretical or proven risks usually outweigh the advantages 4- Unacceptable health risk (method not to be used) Estrogen+Progesterone Methods

 MOA: affects HPA axis to prevent LH surge, preventing ovulation  Include COPs, NuvaRing, Patch Combined Oral Contraceptive Pills

 Contain estrogen & progestin  Most newer formulations contain:  10 – 50 mcg of ethinyl estradiol  1 of 8 available progestins

Estrogen-Related Progestin-Related

• Breast tenderness • Bloating • Nausea • Anxiety • Vomiting • Irritability • Headaches • Depression • Menstrual irregularities • Reduced libido Contraceptive Patch

• Brand name: Xulane® • Beige-colored patch applied once/week • 3 weeks on, 1 week off • 9 days of medication in each patch • Serum levels of EE ~ 35 mcg + norelgestromin NuvaRing

 Flexible, unfitted ring placed in vagina  In 3 weeks/out 1 week (*Can be removed for up to 3h)  4 weeks of medication in ring  Continuous use: change once every 4 weeks  Serum levels ~15 mcg EE + etonogestrel Contraindications to Estrogen- Progesterone Methods

MEC 3 Past h/o Breast Cancer w/o evidence of dz for 5 yrs Breastfeeding 21-30 days PP or 30-42 days PP w/ risk factors for VTE Bariatric Surgery (COPs only) History of cholestasis related to CHC use Controlled HTN Inflammatory Bowel Disease Multiple risks factors for atherosclerotic CV dz MS with prolonged immobilization Peripartum Cardiomyopathy > 6 months Age 35 w/<15 cig/day Superficial venous thrombosis Medications: Fosamprenavir, anticonvulsants, lamotrigine, rifampin Contraindications to Estrogen+ Progestone Methods MEC 4 Age 35 > 15 cig/day Ischemic Heart Disease/Peripartum Cardiomyopathy < 6 months Uncontrolled HTN SLE w/ + APA Migraines with Aura Complicated Valvular Disease Personal History of VTE/ CVA Complicated Solid Organ Transplant Major Surgery with Acute Viral Hepatitis Prolonged Immobilization Pregnancy Severe Cirrhosis <21 Days Postpartum Malignant Liver Tumors Diabetes with neuropathy, nephropathy, vascular dz, retinopathy or > 20 years Current Breast Cancer Progesterone Only Methods

 MOA: LNG IUD: thickens cervical mucus Implant: inhibits ovulation at HPA axis Depo: Inhibits ovulation at HPA axis POPs: inhibit ovulation at HPA axis LNG IUDs  Brand name: Mirena®  20 mcg levonorgestrel/day  Approved for 5 years of use, can be used for 7 years  Amenorrhea in ~20% of users by 1 year

 Brand name: Liletta®  18.6 mcg levonorgestrel/day  Approved for 3 years, anticipate extension 5-7 years LNG IUDs  Brand name: Skyla® • 14 mcg levonorgestrel/day Approved for 3 years of use Amenorrhea in ~6% of users by 1 year

 Brand name: Kyleena® 19.5 mcg levonorgestrel/day Approved for 5 years of use Amenorrhea in ~ 12% of users by 1 year Contraindications to LNG IUDs MEC 3 MEC 4 Past h/o Breast Cancer w/o Distorted Uterine Cavity evidence of dz for 5 yrs

Severe Cirrhosis Current Breast Cancer Malignant Liver Tumors Cervical Cancer Complicated Solid Organ Endometrial Cancer Transplant SLE w/ + APA GTN with persistently elevated BHCGs with evidence or suspicion for intrauterine dz Pregnancy Initiation with Current PID Postabortal or Postpartum Sepsis Pelvic TB Initiation with unexplained vaginal bleeding Implant

Brand name: Nexplanon® Contains etonogestrel Effective for 4 years Contraindications to Implant

MEC 3 MEC 4 Past h/o Breast Cancer w/o Current Breast Cancer evidence of dz for 5 yrs

Severe Cirrhosis Continuation with Ischemic Heart Disease Malignant Liver Tumors Continuation after CVA SLE w/ + APA Unexplained Vaginal Bleeding Injectable

 Depot Medroxyprogesterone Acetate (DMPA)  Brand name: Depo-Provera®  IM or SQ injection every 3 months Key Points About DMPA due to Black Box Warning: No evidence it causes increase in fractures Bone mineral density returns to baseline after cessation of DMPA Bone health largely dependent on nutrition and exercise ACOG and WHO support long term use Contraindications to Injectable

MEC 3 Past h/o Breast Cancer w/o RA on immunosuppressive evidence of dz for 5 yrs therapy

Severe Cirrhosis H/o CVA Diabetes with retinopathy, SLE w/ +APA nephropathy, neuropathy, vascular dz or > 20 years Uncontrolled HTN SLE with severe thrombocytopenia Ischemic Heart Disease Unexplained Vaginal Bleeding Malignant Liver Tumors H/O CVA Multiple Risk Factors for *** MEC 4 **** Atherosclerotic Current Breast CA Cardiovascular Disease POPs

 Called the “mini-pill”  Two formulations: norethindrone & norgestrel  No placebo week  Timing of pill-taking is crucial Contraindications for POPs

MEC 3 MEC 4 Past h/o Breast Cancer w/o Current Breast Cancer evidence of dz for 5 yrs

Severe Cirrhosis Malabsorptive Bariatric Surgery Continuation with Ischemic Heart Disease Malignant Liver Tumors Continuation with CVA SLE w/+ APA Anticonvulsants: phenytoin, carbamazepine, barbiturates, topiramate, oxcarbazepine Rifampin Non-Hormonal Methods

 MOA:  Copper IUD: reduces sperm motility and viability  Sterilization: prevents fertilization  Diaphragm, cervical cap, sponge, condoms: barrier  Spermicide: reduces sperm motility  Withdrawal: prevents fertilization  Fertility Awareness: prevents fertilization Copper IUD

 Brand name: ParaGard®  Copper ions  Approved for 10 years of use and can be used up to 12 years  Can be used as emergency contraceptive Contraindications to Copper IUD MEC 3 MEC 4 SLE with severe Distorted Uterine Cavity thrombocytopenia Complicated Solid Organ Initiation with Cervical Transplant Cancer Continuation with Pelvic TB Initiation with Endometrial Cancer Initiation with GTD and high BHCG levels with intrauterine disease Pregnancy Pelvic TB Unexplained Vaginal Bleeding Initiation with PID Post abortion or postpartum sepsis Male Sterilization

 Standard of care = no- scalpel vasectomy (NSV) Small (few mms) opening is made in the scrotal sac skin to deliver vas deferens Ligate/cauterize No sutures Contraindications to Male Sterilization

 Desires Reversible Contraception  Coagulopathy  Undescended Testes  Testicular Tumor Female Sterilization

• Ligating • Blocking (clips or rings) • Cauterizing • Salpingectomy Contraindications to Female Sterilization

 Desires Reversible Contraception  Contraindications to Anesthesia  Contraindications to Abdominal Surgery Barrier Methods

 Diaphragm  Sponge  Condom  Cervical Cap Contraindications to Other Non-Hormonal Methods

 Unable to place Barrier Method, either due to discomfort or anatomy  Within 6 weeks postpartum for cervical barriers  Spermicide: allergy to nonoxynol-9  Fertility Awareness: Unpredictable menstrual cycles  Lactational Amenorrhea: > 6 months postpartum Emergency Contraception Emergency Contraception- Yuzpe Method Contraindications to Emergency Contraception:

 Plan B, Ella or Yuzpe Methods: None  WHO discusses frequent or repeated ECP may be harmful for women with conditions classified as MEC 2,3 or 4  Copper IUD: Thank you!