Hormonal Contraception Ahmad Sameer Tanbouz 5 th 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 1 st 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