Women's Health: Contraception 560

Front 1

Spermicides: how to use

Front 2

Spermicide Risks

Back 2

Spermicide Risks:
• Epithelial breakdown of vaginal & cervical mucosa
• Increases vulnerability for HIV penetration
• Increases risk of bacteria penetration
o Vaginal infections
o STD’s
• Allergies to spermicide

Front 3

Menstrual Cycle per Terri’s Contraception Slides

Back 3

Menstrual Cycle
• Brain triggers Hypothalamus to secrete GnRH →
• Pituitary Gland secretes LH & FSH →
• Ovaries secrete 3 steroids →
1. Progesterone
2. Androgen
3. Estrogen
• Which inhibit LH & FSH & GnRH (Neuroendocrine feedback axis)

Front 4

Comb Hormonal Contraception

Back 4

Combined Hormonal Methods:

1) COC’s (Combined Oral Contraceptives)
2) Transdermal Patch
3) Contraceptive Ring

Front 5

Progestin Only Contraceptives

Back 5

Progestin Only:

1) Injectable- Depo Provera
2) Mini Pill
3) Mirena IUD
4) Implanon

Front 6

Benefits of Combined Hormonal Contraception

Back 6

Benefits of Combined Hormonal Contraception
• Highly effective
• Regulates menstrual flow- (anemia, Factor VIII)
• Prevents ovarian & endometrial cancer- benefits 15+yrs.
• Prevents ectopic pregnancy
• Increase bone density
• Protects from PID/salpingitis
• No significant change in insulin/glucose
• Lipid sparing- new progestins
• Decreased Clotting risk- 20 mcg pills & 15 mcg NuvaRing

Front 7

Combined Hormonal Contraception Reduces Risk of -

Back 7

Combined Hormonal Contraception reduces risk of:
• Dysmenorrhea
• Ovarian cysts
• Fibroids
• Endometriosis
• Benign breast disease

Front 8

Disadvantages of Combined Hormonal Contraception

Back 8

Disadvantages of Combined Hormonal Contraception

Front 9

Side Effects Combined Hormonal Contraception

Front 10

Comb Hormonal Contraceptives: Who Should Not Use

Front 11

Types of Combined Oral Contraceptives (COCs)

Back 11

Combined Oral Contraceptives (COCs)
1. Monophasic: 21 or 24 active pills contain same amount of Estrogen/Progestin (E/P)
2. Monophasic: Extended use 91 or 28 day active pills containing the same amount of
Estrogen/Progestin (E/P)
3. Continuous dosing: Take active hormone pill daily up to 3, 6 or 12 months (skip & discard sugar pills)
4. Multiphasic: 21 active pills contain 3 different E/P combinations (e.g., 6/5/10)

Front 12

COCs: When to Start

Back 12

COCs: When to Start
o Anytime you can be sure pt is not pregnant
o Days 1-7 of the menstrual cycle -1st day start is preferred
o Sunday start
o Postpartum: after 3 weeks if not breastfeeding
o Postabortion (immediately or within 5-7 days)

Front 13

COC’s Androgenic Side Effects

Back 13

o Increased appetite & weight gain
o Depression, fatigue, tiredness
o Altered libido (decrease or increase)
o Acne, oily skin, hirsutism, pilonidal cysts
o Increased breast size (alveolar tissue)
o Increased LDL
o Decreased HDL
o Pruritis
o Decreased carbohydrate tolerance

Front 14

Excess androgen can -

Back 14

Excess androgen can inhibit ovulation
o Irregular menstrual cycles
o Secondary amenorrhea
o PCOS
o Insulin resistance
o Metabolic syndrome

Front 15

With young age safest choice is -

Back 15

With young age (21yo) safest choice is:

A low estrogen dose pill- 20- 25 mcg E

Front 16

COC & depression

Back 16

COC’s & Depression
o OCP Modification= switch to lower progestin dose
o Assess need for depression med
o Lifestyle modifications as indicated

Front 17

COC & Mood Swings

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COC & Mood Swings
o Multiphasic pills can trigger mood swings 2° varying hormonal levels each week of cycle
o Switch to monophasic pills
o Lower progestin dose if possible

Front 18

COC & ↓ Libido

Back 18

o Change to lower estrogen & progestin activity
o Change to monophasic pill with lower estrogen activity and greater androgen
o Increase androgen activity
o Testosterone Cream applied daily to arm or thigh- increases sexual desire
o Consider Libido cream (compounded) if needed or “KY Intense” applied to labial mucosa & clitoris before sex- increases sensation

Front 19

Estrogen AE

Front 20

COC’s Estrogenic Activity

Back 20

COC Estrogenic Activity:
o Provides stability of endometrial lining
o Potentiates progestational activity
o Suppresses FSH (estradiol level up already)
o Prevents selection and emergence of follicle
o Ovary is not stimulated
o Leuteolysis- degeneration of corpus luteum

Front 21

COC & Nausea

Back 21

If does not go away after 3 cycles:

o Lower dose estrogen pill
o Pill with lower progestational activity
o Take pill with food & at bedtime

Front 22

COC & Headache

Back 22

COC & Headache etiology:

o Fluid retention & vascular
o Tension headaches are NOT 2° COCs
o If menstrual migraines, withdrawal of estrogen may be the trigger

Front 23

COC & Headache: Tx

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If fluid related H/A:
Lower the estrogenic activity

If menstrual migraines:
1) Skipping bleed by continuous dosing may help
2) Change to Depo-Provera (continuous & non-estrogen)

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Sx of excess Progestin (OCP)

Back 24

• Hypertension
• Leg vein dilation
• Increased appetite
• Depression
• Fatigue
• Hypoglycemic SX’s
• Decreased Libido
• Shorter Menses

Front 25

Sx of Progestin Deficiency (OCP)

Back 25

• Spotting days 10-21 cycle
• Heavy menstrual flow & clots
• Delayed withdrawal bleed
• Bloating, dizziness, syncope
• Edema, Irritability
• Headache (cyclical)
• Leg cramps, N/V
• Cyclic weight gain
• Cyclic visual changes

Front 26

Cause of COC Spotting/BTB

Front 27

COC BTB Tx

Back 27

 Keep menstrual chart for 2-3 months
 Back-up contraceptive (may indicate inadequate efficacy)
 Reassure patient that spotting frequently resolves spontaneously
 Expect spotting the first 2-4 cycles
 Pregnancy testing
 Assess for PID/ or vaginal infection

Front 28

If BTB days 1-10

Back 28

If BTB days 1-10:

o Estrogen Deficiency
o Increase estrogenic activity starting with low dose
o Avoid the 50 mcg pills if possible

Front 29

If BTB days 10-21

Back 29

If BTB days 10-21
o Progestin deficiency (not sloughing adequately)
o Change to multiphasic pill (progestin dose rises 3rd week)
o ↑ progestational activity
o ↑ endometrial activity

Front 30

COC BTB General Idea

Back 30

COC BTB General Idea is to ↑ endometrial activity:
o ↑ estrogen dose
o ↑ progestin dose
o ↑ androgenic progestins
o Changing estrogen/progestin ratio
o If on POP- switch to COC

Front 31

Transdermal Patch

Back 31

Transdermal Patch = Ortho EVRA

Front 32

Vaginal Ring (NuvaRing)

Back 32

Vaginal ring NuvaRing (Organon)
o Sits in vaginal vault
o Insert monthly (leave in for 3 weeks)
o Continuous low dose of hormones through vaginal mucosa (etonogestrel & ethinyl estrodial)
o If out for >3 hrs, use back up contraception until ring is in place for 7 days.
o Beneficial for vaginal dryness and atrophy

Front 33

Emergency Contraception

Back 33

• All methods are very effective
• IUDs also provide long-term contraception
• Can dose regular COC to continue for contraception
o Rx 1-3 cycles of pills
o Take ECP dose as prescribed from 1 cycle
o Take 1 pill daily after completing ECP until pack is empty
o Then start new cycle 1 daily

Front 34

Emergency Contraception (High-Dose)

Back 34

PLAN B- Preferred Method:
1. Take 1 tablet (750 mcg of LNG) orally within 72 hours of unprotected intercourse.
2. Take 1 more tablet in 12 hours. Total = 2 tablets
3. If no menses within 3 weeks, r/o pregnancy.
4. Less nausea compared to COC dosing choices

Front 35

COCs: Instructions for Use as Emergency Contraception (Low-Dose)

Back 35

Emergency Contraception (Low-Dose)
1. Take 4 tablets of a low-dose COC PO within 72 hours of unprotected intercourse.
2. Take 4 more tablets in 12 hours. Total = 8 tablets
3. If no menses (vaginal bleeding) within 3 weeks, r/o pregnancy

Front 36

Progestin-Only Contraceptives
(POC)

Front 37

POC Adverse Effects

Back 37

o Amenorrhea (Irregular bleeding/spotting initially in most women)
o Weight gain ( 2 kg/10 lbs) is common
o Depression and fatigue
o Although pregnancy is unlikely, if pregnancy occurs, it is more likely to be ectopic
o Bone density loss, maybe
o Possible ↓ effectiveness for Epilepsy Rx(phenytoin and barbiturates) and TB (rifampin)
oHeadache/n/v/dizziness
o Lower abdominal/pelvic pain (with or without SX’s of pregnancy)
o Vaginal Dryness or Atrophy

Front 38

Progestin-Only Injectable Contraceptives (PICs)
Depo-Provera (DMPA)

Back 38

PICs: Timing of 1st Injection
o Days 1 to 7 of the menstrual cycle, or anytime during the menstrual cycle when you can be reasonably sure she is not pregnant
o Postpartum: Immediately or 6 wks postpartum visit if breastfeeding
o Postabortion: immediately or within first 7 days
o Reinjection every 10-13 weeks

Front 39

Mirena

Back 39

Mirena:
o Progestin-releasing IUD
o Thickens mucous plug
o Interferes with reproduction before ova reaches uterine cavity
o Interferes with sperm motility
o Thins uterine lining
o Decreases menstrual flow by 40 ml monthly

Front 40

Mirena Insertion & Retention

Back 40

o Inserted by trained PA, NP or MD
o Multiparous preferred (safety & ease of insertion)
o Must use sterile technique
o Insert days 1-7 of menstrual cycle
 Dilated cervical os eases insertion
o Remains in place x 5 years
o May expel spontaneously- check for strings after menses

Front 41

Implanon (Organon)
Rod Implanted in Upper Arm

Back 41

o Progestin + active metabolite of desogestrel
o Rod- 40 mm length, 2 mm diameter
o Implanted in upper arm
o Sterile procedure- quick insertion (1.1 minutes)
o Quick removal (2.6 minutes)
o Slow release of hormone over 3 years
o Inhibits ovulation- highly effective
o Rapid return to fertility upon removal

Front 42

Implanon (Organon)
Rod Implanted in Upper Arm

Back 42

Implanon (Organon):
Bleeding patterns are irregular & unpredictable
– Average over 90 days:

Front 43

When to Insert Implants

Back 43

o Anytime patient is not pregnant
o Days 1-5 of the menstrual cycle
o Within 7 days of last combined contraceptive dose
o The due date of next Depo
o The day of IUD removal
o Any day when taking POP
o Postpartum:
o after 4-6 weeks if breastfeeding
o 3-4 weeks postpartum if not breastfeeding
o Postabortion (immediately or in first 5 days s/p)

Front 44

Types of Non-Medicated IUDs

Back 44

Non-medicated IUDs:

Copper-releasing:
– Copper T 380A Paraguard
– Nova T
– Multiload 375

Front 45

IUDs: Contraceptive Benefits

Back 45

IUD Benefits:
o Highly effective
o Effective immediately
o Long-term method (up to 10 y with Copper T 380A)
o Do not interfere with intercourse
o Immediate return to fertility upon removal
o Do not affect breastfeeding
o Inexpensive (Copper T 380A)

Front 46

Copper IUD Limitations

Back 46

o Increases menstrual bleeding and cramping approx. 20 ml. (copper-releasing only)
o Menses can be irregular, heavy & prolonged
o IUD may be spontaneously expelled
o Rarely (< 1/1000 cases), perforation of the uterus may occur during insertion
o Does not prevent ectopic pregnancies
o May increase risk of PID and subsequent infertility in women at risk for STDs