17.1.2 - Progestogen-Based, Iud & Vaginal Ring Contraception

Front 1

Progestogen-only contraceptives
- MOA

Back 1

1. thicken cervical mucous, impeding passage of sperm
2. change endometrium, reducing potential for implantation
3. Act on hypothalamus to reduce gonadotropin release, which inhibits ovulation in <50% of women (minipill), or all women (implant/depot)

Front 2

Progestogen only contraceptives
- indications

Back 2

1. contraception
2. emergency contraception
3. menstrual disorders
4. endometriosis
5. HRT (with oestrogen)

Front 3

Progestogen only contraceptives - name them

Back 3

1. etonorgestrel (Implanon, Nuva-Ring with ethinyoestradiol)

2. levonorgestrel (Microlut, Microval (disc) Levonelle-2, Norlevo, Postinor-2)

3. MDPA (Depo-provera, Depo-ralovera, Provera, Ralovera)

4. norethisterone (Micronor, Noriday-28, Locilan-28, Primolut N)

Front 4

Progestogen only contraceptives
- CI
- Cautions
- surgery?
- RF/LF

Back 4

CI
- Pregnancy
- Breast ca (current)
- Liver ca (current), cirrhosis, acute viral hepatitis
Cautions:
- Postpartum: heavy vag bleeding if <3/52
- Abnormal vag bleeding
- current VTE (ok if historical)
- Enzyme-inducers: ok with Mirena, Cu IUD, MDPA but not Implanon or tablets
- Surgery: OK to use
- RF ok, not ok in severe LF

Front 5

Progestogen only contraceptives
- BF
- Preg

Back 5

BF: ok, preferred
Preg:
1. Implanon, NuvaRing: B3, remove
2. Mirena (B3) and Cu IUD: increased risk of miscarriage, ectopic pregnancy, preterm delivery, infection; remove device ASAP if can be taken out safely
3. Norethisterone: when used for contraception B3: no assoc with defects but more ectopy, when used at higher doses D: can cause virilisation of femal fetus if taken from 8 weeks after conception
4. Levonorgestrel: B3 when for contraception (risk of ectopy), D when for ECP (no effect on established pregnancy but increased ectopy)
5. MDPA: IM category A!, oral daily doses >30mg cat D: theoretical & unlikely risk of virilisation of femal fetus after 8/52

Front 6

Progestogen only contraceptives
Adverse Effects

Back 6

Common
1. menstrual irregulatrity/amenorrhoea
2. breast tenderness
3. acne
4. weight change
5. depression

Infrequent
- lethargy, headache, dizziness

Rare
- jaundice, decreased libido, androgenisation (hirsutism, greasy hair), anaphylaxis

Front 7

Implanon
1. in fat people?

Back 7

Theoretical risk of decreased efficacy in third year; consider earlier replacement

Front 8

Implanon
1. How is it inserted
2. When is it inserted

Back 8

1. Subdermally into inner, upper, non-dominant arm. After the procedure, feel the site to confirm that the rod is in place
2. If inserted on days 1-5 it is effective immediately. On any other day, it will take 7 days.
- If taking a COC, insert on the day after the last active tablet in the pack or at the latest when the first active tablet is due, for immediate effect
- If changing from another progestogen only method, insert at any time for immediate effect (or when next injection due)
- If post partum, insert 21-28 days post-partum, 4 I.E.

Front 9

Implanon
1. when does fertility return
2. what dose form

Back 9

Soon after removal, within 1-2 months
2. 68mg implant

Front 10

Microlut
1. Cautions
2. When can it be started?

Back 10

1. Malabsorption
2. Weight >70kg; consider doubling the dose if contraception is not reduced by e.g. BF, >45 years

2. Start
- 21/7 post partum or after last active COC pill in pack, on first day of menses: effective immediately
- At any time; effectiveafter 2 days.

Front 11

Microlut
- How do you take it for ECP
- what if taking enzyme inducers?

Back 11

1.5mg stat (preferred)or 750mg q12h x2

1.5mg = 50x30mcg (approx 2 strips)
750mg = 25x30mcg (approx 1 strip)

If using enzyme inducers, 2.24mg as a single dose has been suggested (=3 tablets) but evidence is lacking

Front 12

Microlut counselling points

Back 12

1. there is no pill free period
2. if pill is >3hr late (or you vomit/diarrhoea), you are not protected for 48hrs (still take it)
3. if you miss a pill and intercourse has occurred recently, get ECP

Front 13

MDPA depot
- specific considerations
- dose & starter dose
- specific adverse effects (4)

Back 13

- LOSS OF BMD: BMD decreases for the first few years of use; this loss may not be completely reversible and the long term consequences are not yet known. Re-evaluate BMD after 2 years from stopping, and avoid use in adolescents as reduction in BMD may be more significant than in adults
- 150mg deep IM q12/52
- no need for test dose with 50mg injection
- 50% become amenorrhoeic after 12/12 (irregular bleeding occurs initially); delayed return to fertility, weight gain; & decreased BMD

Front 14

Depo-Ralovera
- what time frame can be used for giving repeat injections
- When should first injection be given if
(a) all natural
(b) post-partum
(c) post-partum and BF
(d) on COC

Back 14

- 12 weeks; can give up to 2/52 early or late
- Days 1-5 of cycle
- 6 weeks post partum if BF
(use extra contraception until then); otherwise 3 weeks post partum
- if on COC, give on the day after last active tablet

Front 15

Depo-Provera
**Counselling points

Back 15

1. irregular bleeds, amenorrhoea
2. decreased BMD: ensure adequate Ca, vit D, and weight bearing exercise, AND SMOKING CESSATION
3. delayed return of fertility up to 1 year?, but presume fertile after 2 weeks after injection due date

Front 16

Provera
(a) dose forms

Back 16

(a) 2.5mg.56, 5mg.56 tablets (Provera)
* 10mg.30/100 tab (Ralovera, Provera, Medroxyhexal)
*100mg.100, 200mg.60, 250mg.60, 500mg.30 tabs (Provera)
* 50mg/mL suspension for injection (Depo-Provera)
*150mg/mL suspension for injection (Depo-provera, Depo-ralovera)

Front 17

Provera
(b) dosing when not for contraception

Back 17

Endometriosis
IM : 50mg weekly, 100mg 2-weekly for at least 6/12
Oral: 10mg tds

5-10mg for 10-14 days of 2nd half of cycle:
1. Dysfunctional uterine bleeding (anovulatory) during assumed 2nd half of cycle
2. Secondara amenorrhoea
3. Cyclical HRT (with continuous estrogen)

Continuous HRT: 1.25-5mg d, (with oestrogen)

Front 18

Micronor
(a) dose forms
(b) dosage

Back 18

(a)
350mcg tab (Micronor, Noriday-28, Locilan-28)
5mg.30 tab (Primolut N)

(b)
1. 350-700mcg d, beginning on day 1 of cycle, or after last active COC tablet in pack, or 21 days post partum (OR whenever-wait 2/7)
2. Dysfunctional uterine bleeding: 5mg (or higher) tds for 10 days to stop bleeding; or 5mg d-bd for days 16-25 of cycle to regulate bleeding
4. endometriosis: 5-10mg d for 4-6 months
5. HRT: 1.25mg d for 10-14 days of each month

Front 19

Micronor
(A) extra considerations
(b) what about PMS?

Back 19

(a) >70kg and no reduced fertility: consider taking 700mcg d for contraception
- malabsorption syndrome
(b) There is no evidence

Front 20

IUD
(a) CI
(b) considerations
(c) BF/Preg

Back 20

(a)
1. Pregnancy
2. PID or STI
3. Anatomically distorted uterus
4. Endometrial or cervical cancer (current)
(b) Nulliparity - difficult to insert, higher risk of expulsion
2. Test for and manage before insertion: STI, abnormal papsmear, abnormal bleeding
3. Postpartum - wait at least 6 weeks because of increased risk of uterine perforation
(c) Preg: remove asap if possible: increased risk of miscarriage, preterm delivery and infection, ectopic pregnancy
BF: safe: theoretically increased risk of uterine perforation

Front 21

IUD
Adverse Effects

Back 21

Common: light bleeding, period pain, or increased menstrual bleeding with possible menorrhagia for Cu
*Irregular bleeding usually settles within 3-6 months (and then lighter bleeding or amenorrhoea may occur) with the Mirena but not the Cu.
Mirena is used for menorrhagia

**In first three weeks there is an increased risk of PID - report fever, discharge, lower abdominal pain
* Post insertion pain/cramps (give NSAID 1 hr prior)

Front 22

IUD
Counselling

Back 22

1. about bleeding
2. about PID
3. about checking for strings each month after the period! contact doctor if strings cannot be felt

Front 23

Mirena
(a) dose
(b) indications
(c) when do you put it in?
(d) when do you replace it?

Back 23

(a) 52mg every 5 years
(b) contraception, HRT adjunct to oestrogen, menorrhagia!!
(c) contraception immediate if inserted in days 1-7 of cycle or 6 weeks after delivery
(d) replace at any time in cycle

Front 24

Copper IUD
(a) products

Back 24

Copper T 380A
Multiload-Cu375 radiopaque

The Copper T 380A has a lower pregnancy rate and lasts 8 years, but isn't in MIMS online

The Multiload lasts 5 years

Front 25

IUDs
(A) delay in fertility?
(b) post-insertion antibiotics?
(c) MRI

Back 25

(a) no evidence
(b) NO; but endocarditis prophylaxis is required inthose at risk
(c) not a problem

Front 26

Copper IUD
when to insert for contraception and
for emergency contraception?

Back 26

- insert in first 12 days of cycle or 6 weeks after delivery
- up to 5 days after intercourse. Can be inserted after 5 days if the time of ovulation can be estimated and is not more than 5 days ago.

Front 27

NuvaRing
(a) dose forms
(b) dosing
(c) storage

Back 27

(a) 1&3x etonogestrel and ethinyoestradiol rings
(b) insert 1 ring for 3 weeks every 4 weeks
(c) 3 years at 2-8 degrees; after dispensing: 4 months (the date of dispensing should be written on the box)

Front 28

NuvaRing
(a) what if the ring will expire during insertion
(b) when do i start?

Back 28

(a) it's ok, as long as it hasn't expired before insertion
(b) days 1-5 of cycle; if on COCs within 7 days of last active tablet in pack; minipill: same day as last pill; IUD/implant/depot: when removed/due

Front 29

NuvaRing
(a) What if the ring comes out? (What to do and safety period)
(b) What might cause the ring to be come out

Back 29

(a) rinse in luke warm water and re-insert as soon as possible; if lost insert a new ring (may continue new ring for another full 3 weeks)
If the ring was out for >3hr, you may not be protected for 7 active days
(b) if it was not inserted properly, it may come out on removal of a tampon, on bowel motions, or if constipated and straining

Do not use a cervial cap or diaphragm, as this may interfere with positioning of ring

Front 30

NuvaRing
(a) what if I forget to change the NuvaRing or if I forget to insert a new NuvaRing

Back 30

(a) If 4/52 or less, insert a new ring after a 1 week ring-free period. If more than 4/52, insert a new ring ASAP and use alt contraception fot 7 days. Consider possibility of preg (Cat B3)
Ditto if leave out for more than 7 days.

Front 31

Progestogens - Drug Interactions (3)

Back 31

1. Enzyme inducers: only effect Implanon and the minipills and ECP (increase dose to 2.25mg)
2. ABX: not significant except rifamycins
3. There was 1 case of significantly increased INR with ECP: monitor

Front 32

COCs - Drug Interactions (6 types)

Back 32

N.B. Interactions are with ethinyloestradiol (CYP3A4) not progesterone unless an enzyme inducer is involved

1. COCs can increase BGLs
2. Rifamycins: Short course (~2/7) of rifampicin or any course of rifabutin: use alternative during and for 7 days after; long courses: use alternative during and for 4/52 after
3. griseofulvin and aprepitant - use alternative during and for 4/52 after
4. other inducers: bosentan (CI in preg), some antivirals, CBZ, phenobarbitone, phenytoin, St John's Wort, TOPIRAMATE
4.5 Orlistat induced diarrhoea may reduce COC BA
5. Thyroid hormone binding may be altered, measure after 3/12 and then may increase thyroid dose
7. Lamotrigine conc may be reduced
6. COCs may increase selegeline

Front 33

COCs - what about ABX?

Back 33

“there is no evidence to support the belief that anti-infectives (other than rifampicin, rifabutin, griseofulvin and some antiretrovirals) alter the effectiveness of COCs” (AMH, 2008)
Women using long-term, low-dose tetracyclines for acne or malarial prophylaxis only require additional cover for the first 2 weeks of antibiotic use. (TG)
Theoretical basis for interaction: Inactive metabolites of oestrogen are regenerated by gut bacteria, prolonging activity. Wide-spectrum ABX reduce regeneration, causing contraceptive failure.

Front 34

COCs - what about enzyme inhibitors?

Back 34

May increase concentrations of oestrogens, leading to increased side effects, such as breast tenderness, bloating or nausea. In practice, this rarely occurs because of the low dose formulations used.
Example drugs: fluconazole, diltiazem and verapamil, cimetidine, gemfibrozil.