Hormonal Contraception

Ahmad Sameer Tanbouz

5th Year Medical Student - JU

Combined [Estrogen & Progestin] Methods

OCPs

Transdermal Patches (Ortho Evra)

Vaginal Ring (NuvaRing)

Progesterone-Only Methods

The Minipills (POPs)

Injections

Implants

Outline

OCPs

Estradiol which is a natural Estrogen is NOT Orally Effective

Ethinyl Estradiol = synthetic Estrogen – Orally Effective –

Most contain Low dose Ethinyl Estradiol (20-35µg) plus

Progestin (Norethindrone, Norgestrel, Levonorgestrel,

Despgestrel, Norgestimate, Drospirenome)

Failure rate (0.3% to 8%)

OCPs

Place the body in a Pseudo-Pregnancy state by interfering

with the release of FSH & LH from the anterior pituitary

The Pseudo-Pregnancy state suppresses ovulation &

prevents pregnancy from occurring

Because the FSH & LH surges do not occur, follicle growth,

recruitment & ovulation do not occur

It causes Thickening of the cervical mucus to render it less

penetrable by sperm & changes the endometrium to make it

unsuitable for implantation

Monophasic Combination Pills

Contains a fixed dose of Estrogen & Progestin in each tablet

It is taken for the 1st 21 days out of 28-day monthly cycle. During the last 7 days of each cycle, a placebo pill or no pill is taken (21/7 regimens). Other Regimen (24/4)

Bleeding should begin within 3 to 5 days of completion of the 21 days of hormones

Monophasic Combination Pills

Women with menstrual-related disorders (such as endometriosis, menorrhagia, anemia, dysmenorrhea, menstrual irregularity, menstrual migraines, PMS, PCOS or ovarian cysts) may benefit from extending the number of consecutive days of hormonal pills thus increasing the length of continuous hormonal suppression & decreasing the number of withdrawal bleeds

Seasonale contains 84 consecutive hormonal pills followed by 7 placebo pills, or 7 low-estrogen pills

Lybrel – a 365-day OCP regimen – provides a combination of Estrogen & Progestin pill each day, 365 days of the year

Multiphasic Combination Pills

Vary the dosage of Estrogen and/or Progestin in the active hormone pills in an effort to mimic the menstrual cycle

It may provide a lower level of Estrogen & Progestin overall but it is highly effective at preventing pregnancy

Non-contraceptive health benefits of OCPs

Decrease risk of serious diseases Ovarian CA Endometrial CA Ectopic pregnancy Severe anemia PID – thickens cervical mucus – Salpingitis

Improve quality of life problems IDA [Iron Deficiency Anemia] Dysmenorrhea – suppression of PG release – Functional ovarian cysts Benign breast disease Osteoporosis

Non-contraceptive health benefits of OCPs

Treat / manage many disorders DUB – stabilizes endometrium & shedding – Dysmenorrhea Endometriosis Acne/ Hirsutism

Side Effects

Estrogen-related: Nausea Breast changes (tenderness, enlargement) Fluid retention/bloating/edema Weight gain (rare) Migraine, headaches Thromboembolic events Liver adenoma (rare)

Side Effects

Progestin-related: Amenorrhea Headaches Breast tenderness Increased appetite Decreased libido Mood changes Hypertension Oily skin Hirsutism

Complications

Cardiovascular – DVT, PE, CVA, MI, HTN

Cholelithiasis

Cholecystitis

Benign liver adenoma

Cervical adenocarcinoma

Retinal thrombosis

OCPs with Estrogen >50mg can increase coagulability, leading to higher rates of MI, stroke, thromboembolism and PE particularly in women who smoke. At a lower doses of estrogen (35 µg or less) women over 35 who smoke more than one pack of cigarettes per day are still at increased risk of heart attack, stroke, DVT & PE if they use OCPs

The Progestin in OCPs have been found to raise LDL while lowering HDL in pill users smoking more than 1 pack per day

OCPs are contraindicated in women over age 35 who smokes 15 or more cigarettes a day. These women often benefit from Progesterone-only IUDs or permanent female or male sterilization

Contraindications

Absolute Thromboembolism PE CAD CVA Smokers over the age of 35 Breast / Endometrial CA Unexplained vaginal bleeding Abnormal liver function Known or suspected pregnancy Severe hypercholesterolemia Severe triglyceridemia

Contraindications

Relative Uterine fibroids Lactation DM Sickle-cell disease Hepatic disease HTN SLE Migraine headaches Seizure disorders Elective surgery

Medications that reduces the efficacy of OCPs

Barbiturates

Carbamazepine (Tegretol)

Phenytoin (Dilantin)

Rifampicin

Topiramate (Topamax)

Medications whose efficacies are changed by OCPs

Diazepam (Valium)

Methyldopa

Phenothiazides

Theophylline

TCAs

Missed Combined OCPs Miss 1 pill during first 2 weeks of the cycle:

Take 1 pill as soon as patient remembers & the next pill at the usual time.

Miss 2 pills in a row during first 2 weeks of the cycle: Take 1 pill the day patient remembers & the next pill at the usual time. Back-up method of birth control & Emergency Contraceptive method

is required during next 7 days

Missed 2 pills in a row during third week of the cycle OR miss 3 in a row at any time: Throw out pack & start a new pack immediately Back-up method of birth control required during next 7 days

Transdermal Patches – Ortho Evra

Continuous release of 6mg Norelegestromin & 0.60mg Ethinyl

Estradiol into bloodstream

Applied to lower abdomen, buttocks, shoulder, upper arm

As effective as OCP in preventing pregnancy (>99% with

perfect use)

Transdermal Patches – Ortho Evra

Women apply one patch each week for 3 weeks followed by

1 week patch-free during which they will have a withdrawal

bleed.

It has been found that effectiveness is decreased in markedly

overweight women (greater than 90 kg)

The patch can cause skin irritation in some users

Vaginal Ring - NuvaRing

It releases a daily dose 15µg of Ethinyl Estradiol &120µg of

Etonogestrel

The ring is placed in the vagina for 3 weeks and is removed for

1 week to allow for a withdrawal bleed.

As effective as OCP in preventing pregnancy (98%)

Vaginal Ring - NuvaRing

Because one size of vaginal ring fits all women, the vaginal ring

does not need to be fitted by a clinician

The use of Antifungal Agents & Spermicides is permitted

Disadvantages: Discomfort Headache Vaginal Discharge Recurrent Vaginitis

The Minipill (POPs) Deliver a small daily dose of Progestin (0.35 mg

Norethindrone) without any Estrogen

POPs have lower Progestin levels than combination pills, thus

the nickname Minipills

Higher failure rate (1.1 – 13% with typical use, 0.51% with

perfect use) than other hormonal methods

They are taken Every Day of the cycle with NO hormone-free

days

The Minipill (POPs) They are not as effective as the combination pills since failure

rate increases if punctual dosing is not achieved

It thicken the cervical mucus making it less permeable to sperm

It causes endometrial atrophy & ovulation suppression

Because they contain no estrogen, POPs are ideal for

nursing mothers & women for whom estrogens are

contraindicated including women over 35 who smoke & women

with HTN, CAD, CVD, SLE, Migraines & Thromboembolism

The Minipill (POPs)

Disadvantages: Irregular menses ranging from amenorrhea to irregular

spotting POPs must be taken at the same time each day

(a delay of more than 3 hours is similar to a missed pill!!!) Acne formation Breast tenderness & Irritability

Missed progestin-only pills:• If a pill is missed, it should be taken as soon as possible;

the next pill should be taken at the scheduled time. Backup contraception should be used for the next 48 hours

Injections Depo-Medroxy-Progesterone Acetate (DMPA)

It is injected IM every 3 months in a vehicle that allows the slow

release of Progestin over a 3-month period

It acts by suppressing ovulation, thickening the cervical

mucus & making the endometrium unsuitable for

implantation

Injections It is one of the most effective contraceptive methods available

This formulation carries the benefit of lower Progestin levels but

the same efficacy rates

50% of DMPA users will have amenorrhea after 1 year of

use and 80% after 5 years of DMPA use! This makes it a

good option for women with bleeding disorders, or on

anticoagulation, or who are in military or who are mentally &

physically disabled

Injections Advantages:

Highly effective Acts independent of intercourse Only requires injections every 3 months Reduces the risk of Endometrial CA & PID Reduces the amount of menstrual bleeding Useful in treatment of menorrhagia, dysmenorrhea,

endometriosis, menstrual related anemia & endometrial hyperplasia

Injections Disadvantages:

Decreased Bone Density (Reversible) Irregular bleeding Weight gain Mood changes Hair loss Headache

After discontinuation of injections, some women may experience a

significant delay in the return of regular ovulation (6 to 18

months)

Implants It is a single-rod, Progestin implant that provides 3 years of

uninterrupted contraceptive coverage

The Progestin used in Implanon is Etonogestrel – the same

Progestin used in NuvaRing –

The device provides slow release of 68mg of Etonogestrel over

3 years

It is the size of a matchstick & is placed in the subdermal skin of

a woman’s upper arm

Implants When appropriate timing of placement is utilized, Implanon is

effective 24 hours after placement & has quick return to fertility

once the device is removed by a clinician

Advantages: Implantable Provides 3 uninterrupted years of contraceptive coverage

Disadvantages: The need for a clinician to insert & remove the device Unpredictable bleeding profile