Contraception for the Next Generation

Jenni Keehbauch, MD
I wish to thank Ann Klega for her
Contributions
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After the mother leaves
the room, she asks for a
prescription for birth
control.
Can you prescribe it
without her mother’s
knowledge?
Contraception can be given without parental
consent if the minor is…
 Married
 Ever been pregnant
 May suffer from probable health hazard if
contraception not given
Florida Statute 381.0051 Family Planning
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Condoms: 2-12%
COCs: 0.3-9%
 Better compliance with patch
or vaginal ring
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Injections: .2-6%
Female sterilization: 0.5%
LNG-IUD: 0.2%
Nexplanon: 0.2%
Used with permission from Dr. G. Lamvu
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Hormones decrease
production of testosterone
Stop sperm production
through the pituitary and
hypothalamus
No male hormonal
contraceptive is ready for
clinical use
The Cochrane Library 2010 Issue 1.
Chichester, UK: John Wiley and Sons, Ltd
a. Ortho Novum 1/35, 4 tabs q 12 X 2
b. Levonorgestrel 0.75 mg, 2 tab x 1 (Plan B)
c. Alesse 5 pills PO q 12 hr x 2
d. All of the above
e. None, too late
Lancet. 2002;360(9348):1803-10
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Use after implantation does not interrupt an
established pregnancy
 Next Choice - two levonorgestrel 0.75-mg tablets
taken 12 hours apart or as a 1.5-mg
 Plan B One Step - levonorgestrel 1.5mg tablet
taken once
 Ella - one ulipristal acetate 30-mg tab
 Copper IUD – most effective
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Contraceptive failure (condom broke/fell
off/never came out of wallet)
Missed doses of COC
 3 doses of 30-35mcg, 2 doses of 20-25mcg
POP taken more than 3 hours late
 More than 2 weeks late for depo
 Sexual assault

What are her options?
Contraceptive
Methods
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Oral Contraceptives
 Combined oral
contraceptives
 Extended use
 Continuous
 Progesterone only
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Alternatives to Oral
 NuvaRing
 Ortho Evra
 Depo-Provera
 Implanon
 Mirena
Ethinyl Estradiol (EE) Dose
< 20 mcg
25 – 35 mcg
50 mcg
Ultra Low
Low
High
Minimizing
Estrogen
Side Effects
Enhancing
Cycle
Control
• Breast
Tenderness
•Nausea
•Vascular risk
•BTB/BTS
•Amenorrhea
Estrogen Dose
1st Generation
Norethindrone
2nd Generation
Norgesterel
Levonorgesterel
3rd Generation
4th Generation
Desogesterel,
Norgestimate
Drospirenone
More androgenic More
progestational
More
progestational
Higher
thrombosis
Anti-mineralcorticoid
Higher
thrombosis
Minimizing
Progesterone
Side Effects
Enhancing
Cycle
Control
• Weight gain
•Fatigue
•Breast tenderness
•Mood changes
•Reduction in
bleeding
•Decreased
dysmenorrhea
Progesterone Dose
Pr
eg
na
nc
y
e
C
se
rs
C
O
U
D
ro
sp
er
in
on
N
on
12
10
8
6
4
2
0
DVT Risk
Minimizing
Androgen
Side Effects
Improving
quality of
life
• Acne/Hirsutism
•Weight gain
•Lipid effects
•Libido
More
Progestational
More Estrogen
Androgen Dose
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Prevention of Ovarian
and Endometrial Cancer
Decreased benign
breast disease
Decreased ectopics
Improved androgen
symptoms
Increased bone mass
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Menstrual benefits
 Regulates cycles
 Less blood loss
 Less dysmenorrhea
 Less PMS
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All COCs increase SHBG and decrease
testosterone resulting in less acne and
hirsutism
Cochrane Database of Systematic Reviews 2009,
Issue 3. Art. No.: CD004425
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Decreased risk of endometrial cancer with as
little as 3 months of use and decreased risk by
60% after 5 years
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Decreased risk of ovarian cancer by 60% after
2 yrs
Protection remains for 15 years
after cessation of OCP’s
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Must be taken daily
Does not protect from STD’s
Increased Chlamydial infection
Risk of arterial vascular disease/DVT
 desogestrel or gestodene have a 2X greater risk
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Increased risk of breast and cervical cancer
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Assuming 5 year usage of OCP’s in 100,000
women
 20% increased risk for breast and cervical cancer
(screened cancers)
 50% decreased risk in ovarian and endometrial
cancer (non-screened cancers)
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There would be 44 fewer cancers
diagnosed
BMJ 2009;339:b2895
Category 1 - No restrictions in use
Category 2 - Advantages generally
outweigh concerns
Category 3 - Exercise caution and monitor
for adverse effects
Category 4 - Refrain from using
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Available online
 http://www.cdc.gov/reproductivehealth/unintendedpr
egnancy/usmec.htm#a
 http://www.who.int/reproductivehealth/publications/f
amily_planning/mec_mobile_app/en/
App: (iphone) CDC US Medical Eligibility Criteria for
Contracpetive use 2010 Free
http://www.cdc.gov/reproductivehealth/unintendedpregna
ncy/usmec.htm
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http://www.cdc.gov/reproductivehealth/unintendedpregnancy/usmec.htm#a
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History DVT/PE
Hypercoaguable
HTN> 160/100
Major surgery
Breast Cancer
CAD/CVD
Postpartum <3wk
Migraines with aura
Servere cirrhosis
Diabetes w/
microvascular dz
 Over 35 and >15 cigs
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Post-partum < 30 days if breastfeeding or risk for
VTE
Undiagnosed abnormal uterine bleeding
> 35 years old and light smoker
Hypertension
Gallbladder disease
Migraine and age >35
Taking Meds that effect liver enzymes:
 rifampin, griseofulvin, anti-convulsants,
St John’s Wort, barbituates...
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Over 100 options
Focus on a few that you know really well
No clear rationale to use Biphasic or Triphasic
COC
Cochrane Database of Systematic Reviews 2006,
Issue 3. Art. No.: CD003553
Cochrane Database of Systematic Reviews 2006,
Issue 3. Art. No.: CD002032.
COMPARISON OF ORAL CONTRACEPTIVES
Reference Drugs
Estrogen
ULTRA LOW-DOSE MONOPHASIC PILLS
EE 20 mcg
Alesse
Loestrin 1/20
EE 20 mcg
Progestin
Levonorgestrel (LNG)
0.1 mg
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High progesterone, medium androgen
Minimize estrogen side-effects: nausea, bloating, nausea
Good for dysmenorrhea
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Increased risk of DVT with desogestrel over other progestins.
Low androgen, high progesterone
Good for dysmenorrhea/acne
Drospirenone 3 mg
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Antimineralocorticoid activity. May decrease cyclic fluid retention. Not high enough
levels of anti-mineralcorticoid for PCOS treatment
Can increase potassium.
High Androgen/High progesterone;
May increase libido
Good for dysmenorrhea
Norethindrone
Desogen
EE 30 mcg
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Low estrogen, progesterone
Good choice to minimize risk of estrogen side effects like nausea, breast tenderness
headache, etc.
Decreased hormonal risk: CAD, CVA, etc
LOW-DOSE MONOPHASIC PILLS <35 mcg
EE 30 mcg
Desogestrel 0.15 mg
Ortho – Cept
Yasmin
Comments
Loestrin Fe 1.5/30
EE 30 mcg
Norethindrone
Sprintec
EE 35 mcg
Norgestimate 0.25 mg
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CHEAP
Low progestin, low androgen
Good choice to minimize spotting and/or BTB and minimize androgenic effects.
Medium estrogen good for ovarian cyst suppression
Demulen 1/35
EE 35 mcg
Ethynodiol diacetate
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High progesterone, low androgen
Ovcon-35
EE 35 mcg
Norethindrone 0.4
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Medium estrogen, low progesterone, low androgen
Better lipid profile with higher estrogen/progesterone ratio
Necon 0.5/35
EE 35 mcg
Norethindrone 0.5
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Medium estrogen, low progesterone, low androgen
Nordette
EE 30 mcg
LNG 0.15 mg
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High androgen, May increase libido
Ortho-Cyclen
Traditional Start /
Sunday Start
Quick Start
First Day Start
•Start 1st Sunday after
menstruation begins
•Start on day Rx given ,
regardless of where in
cycle, if preg reasonably
excluded
•Start on first day
of next
menstruation
•Avoids withdraw
bleeding on weekend
•Requires 7 days back
up contraception if >5
days after menstruation
begins
•Increased compliance
•Maximum
contraceptive
effect
•Requires 7 days back up
contraception if >5 days
after menstruation
begins
•No back up
needed
No signs/symptoms of pregnancy and meets any of the following:
 <8 days after start of nl menses
 No intercourse since start of last menses
 Correctly and consistently using reliable method of
contraception
 <8 days after induced or spontaneous abortion
 Within 4 weeks postpartum
 Fully or nearly fully (>85%) breastfeeding, amenorrheic,
and < 6 months post partum
US SPR, June 21,2013, Vol. 62, No. 5
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Use an OCP with higher Progesterone to
stabilize the endometrium
 Loestrin 1.5/30
 Desogen
 Ortho-Cept
 Demulen 1/35
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Most ocps incresase SHBG thus
decrease circulating free testosterone.
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Levonorgesterol and norgesterol due not
increase SHBG, and may be more
androgenic
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Use an OCP with Low
Estrogenic/Progesterone activity
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Examples
 Alesse
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Try progestins with the most potent
androgenic activity
 Desogestrel
 Levonorgestrel
Any may provide a placebo effect
Change to contraceptive with
 Low estrogen/progesterone
 Alesse
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Change to progesterone only contraceptive
Avoid triphasics/biphasics
Change to Extended or Continuous Cycle
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Most studies suggest that use of extendedcycle contraceptives results in fewer
menstrual symptoms such as headache,
bloating and menstrual pain
Cochrane Database Syst Rev 2005; 20 (3):CD004695.
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Avoid COC’s in patients with Aura or
focal neurological signs (WHO 4)
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Avoid starting in women with migraines
>/= 35 (WHO 3)
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20 mcg ethinyl estradiol/ 150 mcg
norelgestromin per day
Transdermal: 3 wks on 1 off
Failure rate: 1-2% perfect use
Cost: $45 per month
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Advantage
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Disadvantage
 Ease of use
 Site reaction (20%)
 No daily
 Increased DVT risk and
management
 Better adherence
hormonal side effects
 Weight limit (<198#)
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15 mcg ethinyl estradiol/ 120mcg
etonorgestrel
Vaginal ring placed for 3 weeks removed for 1
Less side-effects than COCs
Failure: 1-2% perfect use
Cost: $25-35
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Advantage
 Low dose estrogen
 No sizing needed
 Inserted and removed
by user
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Disadvantage
 May feel during
intercourse: remove
and replace within 3
hours
 May increase
leukorrhea
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Disadvantages
 Not immediately reversible
 Decrease in bone mineral density (LOE 3)
 Weight gain, worsening depression, acne
 No STI protection
Obstet Gynecol 2009;114:279-284.
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Etonogestrel (progestin only)
Subdermal rod
3 years
Cost: $500 (prior approval with insurance
needed)
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Advantages
 Contraception
within 24 hrs
 Ovulation resumes
within 3 weeks of
discontinuing
 Great for
nulliparous
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Disadvantages
 Increased DVT risk
 Irregular bleeding (20%)
 Headache
 Weight gain, acne
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Norplant
 6 capsule implanted in upper arm
 Effective for 5yrs
 Produced in US 1991-2002 (some availability until
2004)
 Removal complication rate of 6-7%
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Levonorgestrel (progesterone only)
Primarily inhibits fertilization
Also thickens mucus, slows transport,
inhibits capacitation and decreases
ovulation
Failure: 0.1%
Cost: $650
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Longterm, but reversable
Reduction in dysmenorrhea and menstrual
bleeding (70-90%)
Can be used in treatment of endometrial
hyperplasia
May avoid surgery1
May decrease the risk of PID
1. BJOG.2001;108(1):74-86
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Spotting for up to 3-6 mos
Expulsion (2-10%)
Perforation 1:1000
PID risk immediately after insertion
STI (trichomonas)
Inflammatory paps
Uterine anomaly
Active pelvic infection (PID) or STD in last 3 months
Pregnancy
Abnormal uterine bleeding that has not been
evaluated
 Current GYN cancer
 Gestational Trophoblastic Disease (GTD)
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US Selected Practice Recommendations for
Contraceptive Use, 2013
WHO Selected Practice Recommendations
for Contraceptive Use, 2nd Ed.
US Medical Eligibility Criteria for
Contraceptive Use, 2010