Contraception Xandie Gold, MD 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 Unintended Pregnancies • 49% of pregnancies in US are unintended • Rates: 82% in teenagers and 38% in perimenopausal women • Half of unintended pregnancies end in terminations Contraceptives • Hormonal Contraceptives: – oral, transdermal, intravaginal, IM, implanted • Barrier Devices – Diaphragm – Condoms: male and female – Cervical Caps Contraceptives • Surgical: – Tubal Ligation, Vasectomy • Intrauterine Devices: – IUDs: copper or progesterone releasing 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 Combination Pills • Synthetic estrogens – Ethinyl estradiol – Mestranol • Synthetic progestins – Many different progestins available 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 Progesterone Component • Progestin doses range from 0.05mg – 1mg • Differ in their androgenic, estrogenic, and progestational activity First Generation Progestins • Norethindrone – ex: ortho-novum, necon • Norethindrone acetate – ex: junel, estrostep, loestrin • Ethynodiol diacetate – ex: zovia • Medium androgenic potency 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 3rd Generation Progestins • Norgestimate ( ortho-cyclen or tri- cyclen) • FDA approved to treat acne • desogestrel (desogen, ortho-cept) • Gestodene – not available in US 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 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 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 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 Effectiveness • If taken correctly: 99.9% • In reality: 92.4% • Return to fertility: – Average 2 month delay in conception after OCP’s stopped Mechanism • Suppress ovulation • Suppress follicular development • Alter cervical mucous making sperm penetration more difficult • Alters endometrium making implantation less likely 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 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 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 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 Risks Continued • Hepatic vein thrombosis • Portal vein thrombosis • Splenic artery thrombosis • Mesenteric artery thrombosis • Mesenteric vein thrombosis 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 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 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 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 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 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 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 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 Combination Contraceptives • Side effects: – Breakthrough bleeding – most common reason for discontinuation – Nausea – Weight gain – Mood swings – Breast tenderness – Headaches – Acne, facial hair growth 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 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 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 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 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. 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 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