Prescribing Contraception Pills, Implants, Intrauterine Devices and Emergency Contraception Max Brinsmead MB BS PhD February 2015

Method %Pregnant 1st Year Use % Still Using Typical Use Perfect Use After 12m None 85 Spermicides 30 15 40 Withdrawal 4 Periodic Abstinence 25 1-3 50 Female Barriers 20 5 Male Condoms The Pill 8 0.3 66 Injection Depot 3 56 Implanon 0.1 75 Copper IUD 1 0.6 80 Mirena IUS Female Sterilisation 0.5 100 (99) Male Sterilisation 0.15 100 (95)

Australian Contraceptive Use In a 2003 survey of women aged 25 – 30 yrs: 72% were using “effective contraception” Of these 70% were using a COC Of these 20% were also using condoms 20-25% were using condoms only Fewer than 5% were using other methods From the 2001 census women aged 18 - 40 Withdrawal was a common method used 3% using “natural family planning”

Combined Oral Contraceptive Mode of Action Primarily by inhibition of folliculogenesis Suppression of FSH (and LH) Secondarily by thickening cervical mucous Also affects endometrium Advantages Simple Reversible Effective Unrelated to coitus

Combined Oral Contraceptive Health Benefits Reduces menstrual loss Reduces menstrual pain Reduces pre menstrual symptoms (for most women) Regulates menstrual bleeding Fewer functional ovarian cysts Some protection from Pelvic Inflammatory Disease Less benign breast diseases Reduced risk of symptomatic fibroids Can reduce hirsutism and acne Reduces risk of endometriosis Reduces risk of rheumatoid arthritis Reduces risk of ovarian, endometrial & colon cancer

Combined Oral Contraceptive Disadvantages & Unwanted Effects Nausea Intermenstrual (breakthrough) bleeding (BTB in this talk) Weight gain Chloasma (pigmentation on the face) Acne Candidiasis Dysphoria i.e. Feel lousy, depressed & uninterested in sex “Sexually available” “Not natural” “Sinful”

Major Risks from the Combined Oral Contraceptive Thromboembolism Increases risk 2-fold Absolute risk is low (2 per million per year) One month of the pill = driving a car for one hour Maybe only in genetically at risk women Breast Cancer Increases risk 1.24x Absolute risk low (1 per 1000 women to age 45) Unrelated to duration of use or other risk factors Disappears 10 years after use Cancers are clinically less advanced Cervical Cancer Some data suggests increased risk of progression of CIN Cardiovascular Disease Data incomplete Benign Liver Tumours 1:100,000 users

Major Risks from the Combined Oral Contraceptive When considering the major risks of any method of contraception… It is important to also consider the risks and problems that can occur from unwanted pregnancy

Contraindications to the Combined Oral Contraceptive (COC) History of arterial or venous thrombosis Known Thrombophilia Ischaemic heart disease or Severe Dyslipidaemia Active liver disease Cyanotic heart disease or pulmonary hypertension Migraine with aura or CNS signs Transient ischaemic cerebral attack Age >35 years AND smoking Or BP >160/110 Or migraine Gallstones Diabetes with retinopathy or nephropathy Pancreatitis Hepatic porphyria Breast cancer Within 21 days of childbirth Liver tumour COC – induced hypertension SLE Pemphigoid gestionis

Relative Contraindications to COC Pregnancy Undiagnosed genital bleeding Hypertension Cholestasis of pregnancy Obesity Smoking Varicose veins Family history of thrombosis or thrombophilia Immobility Major surgery Inflammatory bowel disease e.g Crohns Hyperprolactinaemia On drugs that increase metabolism of oestrogens Heterozygous sickle cell anaemia Age >40 Breast feeding History of hypertension in pregnancy Valvular heart disease Anti retroviral therapy

Pill Formulations 4 types of Oestrogen There is a confusingly wide range of COCs available… 4 types of Oestrogen Mestranol - converts to EE in the body (present in Norinyl) Ethinyl oestradiol (EE) in doses of 20, 30 and 50 ug Oestradiol valerate (present in Olaira) 17ß Oestradiol (present in Zoely) 3 (or 4) generations of oral Progestins First generation (no longer in use) Second generation d-Norgestrel and Norethisterone Third generation Cyproterone acetate (present in Diane, Brenda, Estelle & Juilet) Desogestrel (present in Marvelon) Gestodene (present in Femoden & Minulet) Drosperinone (present in Yasmin and Angeliq) Nomegestrol acetate (present in Zoely)

Pill Packs 21 and 28-day packs 3-Month cycle packs The latter are called ED = Every day Contain 7 placebo or “sugar tablets” Are popular in Australia 3-Month cycle packs Yaz Flex September 2012 Triphasic formulations With 3-steps of Progestin dosage Reduce overall dose of Progestin Reversed sequential Used only for the anti-androgen Cyproteron acetate Be aware that most companies have two names for the same formulation

Pill Prescribing 1 In general I recommend a monophasic 30 ug EE pill with a 2nd generation progestin i.e. Levonorgestrel or Norethisterone For example: Microgynon 30 or Levulen Nordette 30 or Monofeme Warn the patient that breakthrough bleeding is common in the first 3 months of use Then modify according to symptoms/problems Don’t change too quickly or too many times “There is no ideal contraceptive”

Pill Prescribing 2 Whilst tricyclic preparations reduce overall dose of ingested drug they: Have a greater rate of breakthrough bleeding Are not suitable for deferring menstruation May have a greater risk of failure Third generation pills i.e. those that contain the newer progestins should be used only in low risk women who have unacceptable progestogenic side effects And The patient must be warned that they have a greater risk of thromboembolism But there may be less risk of arterial disease

Pill Prescribing 3 Choose COC’s with cyproterone acetate e.g. Diane 35 for patients with acne, hirsutism or polycystic ovarian disorder For patients with persistent BTB try Norethisterone-type progestin e.g. Brevinor Before… Increasing the oestrogen e.g. Microgynon 50 A few patients may require Microgynon 20 or 30 BD Then try to reduce of the oestrogen after several months with no BTB

Pills for Difficult Patients For nausea… Take pill at night and try an anti emetic e.g. Maxolon For patients who conceive on the pill… Omit 1-2 tablets of placebo and go for longer cycles For dysphoria… Try Pyridoxine 25 mg TDS or Multi B vitamins Or a 3rd generation COC For PMT or weight problems Try Yasmin – the 4th generation pill For patients on anticonvulsants Use 50 ug pill or 30 ug BD and omit 1-2 placebo tablets For most other problems switch to POP or Mirena Antibiotics rarely cause problems for patient on COC

The Progestin only Pill (POP) Act by: Inhibition of ovulation Reduce sperm penetration of cervical mucous Some endometrial effects Useful for: Lactating women Many others for whom COC is contraindicated Beware – Big women may require 2/day > 100 Kg

The Progestin only Pill Disadvantages: Must be taken at the same time each day (or within 3 hours of the same time each day) Irregular PV bleeding Mastalgia Functional ovarian cysts can occur Some women develop amenorrhoea and low E2 May not protect so well from ectopic pregnancy Not suitable for women at risk of arterial disease

Injection (Depot Provera) “The POP for patients who can’t remember to take a tablet every day” (But patients need to attend every 12 weeks) Cheap and very effective Problems: Irregular bleeding (15 – 50%) Settles over time in most But may last up to 18months after a single shot in a few Uncertain return to fertility Acne, headaches, mastalgia & dysphoria Functional ovarian cysts can occur Amenorrhoea & hypo oestrinism & maybe osteoporosis Some question the risk of breast cancer but there is NO evidence for increased risk

Implanon Matchstick-sized subdermal implant containing 68 mg Etonorgestrel Releases 40 ug daily for at least 3 years Rapid return to fertility after removal Problems: Only 35% patients have “regular” periods Amenorrhoea in 20% over time But 15 – 20% experience frequent, irregular bledding Headaches, mastalgia and dysphoria Functional ovarian cysts can occur Requires expert insertion (training) A few nerve injuries from inappropriate deep insertion

Copper Intrauterine Device Safe and effective Daily compliance not required Effective for up to 10 years Rapidly reversible Can be inserted up to 5 days post ovulation for emergency contraception Problems: Pain Increased menstrual bleeding Expulsion (1:20 insertions) Perforation (1:500 insertions with experienced operator) Infection (conflicting data but WHO says only for 1st 21 days) Pregnancy with IUD is high risk (remove IUD asap) Ectopic pregnancy not more common but less protection from extrauterine than from intrauterine pregnancy

Mirena Intrauterine System Highly effective because daily compliance not required Lasts 5 years Blood concentrations of d-Norgestrel 1/10th less than POP Reduces menstrual bleeding by 85 - 90% after 6m “The nearly ideal contraceptive” Has reduced the hysterectomy rate in the UK by 30% Problems: Frequent bleeding in the first 3 months of use Acne, mastalgia, weight gain & dysphoria in a few (≈1%) Insertion expertise required (Nulliparas difficult) A few expulsions occur Infection in a few patients (conflicting data) WHO says that there is a spike lasting only 3 weeks after insertion Thereafter associated only with risk of STD

Max’s Maxim Number 3 Nature did not intend that a woman should have too many menstrual periods She is supposed to be pregnant, breast- feeding, postmenopausal or dead And the next best alternative is being on the Pill Or putting the Pill into her uterus (Mirena)

The woman who is breastfeeding Conception will not occur for at least six months in a woman who is breastfeeding Exclusively i.e. no missed feeds, comp feeds or solids Suckles regularly day and night Has amenorrhoea

Emergency Contraception Postinor 2: Levonorgestrel 750 ug – two tablets Administer ASAP and repeat 12 hours 95 - 98% effective if used with 24h 60% effective if used within 48-72h Multiple mechanisms of action Side effects few – repeat if vomited Contraindications – very few This method supersedes the Yuzpe regimen of 2x50 ug COC repeated after 12 hours Copper IUD very effective for up to 5 days after coitus or ovulation

For other special cases and difficult patients The WHO website has comprehensive guidelines for all contraceptive methods Includes relative and absolute contraindications with many rare medical conditions

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