1. Contraception: Old and New
Shellie Hawk, MSN, CNM

2. Barrier Methods

3. 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

4. Hormonal Contraceptives

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

6. 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

7. 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

8. 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

9. 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

10. 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

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

12. 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

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

14. 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

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

16. 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

17. 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

18. 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

19. 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?

20. 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?

21. 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?

22. 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?

23. 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?

24. 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?

25. 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