Contraception: Old and New Shellie Hawk, MSN, CNM

Barrier Methods

Barrier Methods: Failure rate 10-21% Advantages Disadvantages Safe and Easy Found OTC Immediate Protection Some protect against STI’s Need to insert prior to sex Allergy and Irritation Unpleasant taste

Hormonal Contraceptives

Combined Oral Contraceptives: Failure rate 3% Estrogen: Ethinyl estradiol Mestranol Progestins: Norethindrone Norethindrone acetate Ethanediol diacetate Norethynodrel Norgestrel Levonorgestel Desogestrel Norgestimate Driospirenone

Combined Oral Contraceptives : Monophasic/Triphasic Estrogenic Effects Progestational Effects Inhibits ovulation Alteration of the endometrium Accelerated ovum transport Luteolysis Thickens cervical mucous Inhibits capacitation Slows ovum transport Suppresses endometrium Ovulation inhibited by HPO disturbances

Combined Oral Contraceptives Disadvantages Advantages Excellent protection Safe for most women Noncontraceptive benefits Woman in control Easy to use and reverse Protective benefits May cause mood changes No protection against STI’s Cost Possible side effects Must be taken every day Rare risks/complications

Combined Oral Contraceptives Absolute Contraindications History of thromboembolic disorders CVA CAD Known or suspected breast carcinoma Known or suspected estrogen dependent neoplasia Pregnancy Benign or malignant liver tumor/impaired liver function Previous cholelithiasis of pregnancy Undiagnosed abnormal uterine bleeding

Ortho Evra Patch: Failure rate < 1-2% Transdermal patch Ethinyl estradiol/norelgestromin Easy delivery/bypasses GI tract Contraindications are essentially the same as for COC 60% more estrogen released than OCP’s Increased risk for blood clots

NuvaRing: Failure rate 1-2 % Contains estrogen and progestin Releases ethinyl estradiol/etonogestrel daily for 21 days Contraindications are essentially the same as for COC Easy Works like a COC but don’t have to remember to take a pill daily

IUD: Failure rate 1-3% Immobilize sperm Speed transport of the ovum thru the tube Inhibit fertilization

IUD’s Hormone releasing Mirena Skyla Releases progestin continuously ( 52 mg levonorgestrel) Thins the endometrium making periods light and for some none Can cause irregular bleeding Good for 5 years Only IUD approved for alternate uses Releases progestin continuously ( 13.5 mg levonorgestrel) Smaller so is better for women/teens who have never been pregnant Thins the endometrium making periods light and for some none Can cause irregular bleeding (more then Mirena ) Good for 3years

IUD’s ParaGard - Copper Contains copper Has no hormones so maintain regular periods Periods maybe heavier and crampier Good for 10 years

New IUD’s Two new hormone releasing IUD’s are coming on the market Kyleena – 19.5 mg levonorgestrel – 5 years Liletta – Levonorgestel releasing 52 mg – 3 years Slightly smaller and narrower then the Mirena Has more progestin then the Skyla

Absolute Contraindications to IUD’s Cervical cancer Distorted uterine cavity Endometrial cancer Gestational trophoblastic disease Post septic abortion PID STI Mirena – Hx breat CA

Progestin Only Contraceptives Depoprovera Nexplanon Failure rate < 1% Injection 150 mg IM or 104 mg SQ every 3 months Good for those who can not take estrogen Suppresses FSH/LH so no ovulation Can cause irregular bleeding Takes time for cycles to return after discontinued Failure rate 0.01% Implanted and removed during an office visit May cause irregular bleeding Good for 3 years

Progestin Only Pills: Less effective when not breastfeeding Used when estrogen contraindicated Breastfeeding Increased break through bleeding Increase in progestin related side effects Breast tenderness Headaches Depression Fatigue Decreased libido

Emergency Contraception Most common is Plan B Contains 0.75 mg levonorgestrel in 2 doses taken 12 hours apart Or Plan B One-Step Contains 1.5 mg levonorgestrel in 1 dose Must be used within 72 hours of unprotected intercourse Available over the counter

Cases 1: LM is a 26 yo G0 P0 who presents to your office with C/O no periods for 7 months. She states that she got her first period at age 14 and they were always irregular. She was on OCP’s from age 16 until about 1 ½ years ago. When she stopped her periods were regular for about the first 6 to 8 months but then nothing for the last 7. She and her husband want kids but not for a few years. What do you suspect? What is your concern about the amenorrhea? How might you manage this patient?

Case 2 GB is an 18 yo G0 P0 who presents with C/O severe cramps with her periods. She gets a period every month but she feels they are not regular. They are so bad that she has missed 1-2 days of school every month. What is the cause? How might you help GB?

Case 3 MM is a 45 yo G2 P2002 who presents with C/O extremely heavy periods. She states the until the last 6-8 months they were fine but now they are so heavy that she is afraid to leave the house because she bleeds right thru her tampon. What are you concerned about? How might you manage her?

Case 4 NC is an 18 yo G0 P0 who is not sexually active. She is leaving for college in the fall and wants some birth control but wants to be sure that it will not make her acne worse. Her friend told her that she is on some OCP that really helped her skin. What OCP might you suggest and why?

Case 5 SF is a 32 yo G3 P2012 who presents to your office with C/O menstrual migraines. She states that she does get an aura with her migraines. How might you help her?

Case 6 AJ is a 24 yo G0 P0 who was recently diagnosed with endometriosis. She is getting married and needs birth control as she is not ready to start a family. What might you suggest and why?

Emerging contraceptive options: New IUD’s New OCP’s containing estradiol/dienogestrel New OCP’s with estrogen, progestin, androgen (support sexual arousal) New Patch –Twirla –EE/levonorgestrel with a lower dose the Ortho Evra New vaginal rings – all progesterone that can stay in for 3 months New injectable with 50 mg levonorgestrel butanoate that can suppress for 6 months with less progesterone side effects then Depoprovera Barrier methods – one size diaphragm, new female condom more like a tampon, new spermicides that are microbial as well as spermicidal to decrease transmission of STI’s