hormonal contraception

types of hormonal contraception

implant
LNG IUD
shot
pill
vaginal ring
patch
emergency contraceptive

purpose of estrogen in contraceptives

suppress fsh
increase sex-hormone binding globulin

suppress fsh → ________________________
increase sex-hormone binding globulin → ____________________

prevent dominant follicle
increase binding of free androgens

purpose of progestin in contraceptives

prevent LH surge

thicken cervical mucus

change motility of fallopian tubes

atrophy of endometrium

prevent LH surge → _____________________

thicken cervical mucus → _____________________

change motility of fallopian tubes → _____________________________

atrophy of endometrium → ______________________

inhibit ovulation

inhibit sperm penetration / transport

impair transport of sperm / ova

impair implantation

estrogen dosing

v low dose = <20 mcg
low dose = 20-35 mcg
high dose = 50 mcg

symptoms of too much estrogen

bloating
fibroid growth
melasma
vision changes
cyclic weight gain
mood changes
heavy menses

symptoms of not enough estrogen

light menses
vaginal dryness
spotting
no withdrawal bleeding

progestin component progestational

prevent ovulation
lessen bleeding
desire high selectivity

progestin component androgenic

acne
hirsutism
desire lower activity

progestin component antiestrogenic

androgenic side effects
desire lower activity

symptoms of too much progestin

acne
hirsutism
increased/decreased sex drive
jaundice
hair loss
swelling

symptoms of not enough progestin

bleeding late in cycle
heavy menses

potential health benefits beyond pregnancy prevention

decreased risk of:

endometrial cancer
menstrual-related headaches
ovarian cancer
improvement in perimenopausal symptoms

implant - nexplanon

serious side effects: mood changes, acne

pain with insertion
irregular bleeding for first 6-12 months

long term protection up to 3 years

fertility my be delayed or rapid

LNG IUD

serious side effects: uterine perforation, infection, expulsion

common: cramping, spotting for 3-6 months, less frequent periods

amenorrhea, safe to breastfeed, lower risk of uterine cancer, long term

immediate return of fertility

copper iud

serious: uterine perforation, infection, expulsion

common: cramping, spotting for 3-6 months, heavier periods

lower risk of uterine cancer, long term, breastfeed

immediate return of fertility

nonhormonal iuds

paragard

hormonal iuds

mirena (52 mg)
skyla (13.5 mg)
liletta (52 mg)
kyleena (19.5 mg)

shot - depot medroxyprogesterone acetate

150 mg IM or 104 subq

serious: low bmd, heavy bleeding

common: weight gain, change in acne and mood, spotting, no period

lower risk of uterine cancer, breastfeed, amenorrhea

possible delay in return of ferility

pill - combined (coc)

serious: stroke, blood clots (estrogen related)

common: nausea, spotting, changes in mood, headaches

improved acne, lower risk of ovarian/uterine cancer, regular periods

immediate return of ferility

pop- norethindrone and norgestrel

daily within 3 hours
no placebo

serious: headaches, heavy bleeding, ectopic

common: spotting and menstrual changes

safe to breast feed, lack of estrogen related effects

immediate return of fertility

pop- drosperinone 2 mg (slynd

daily
no placebo

serious: headaches, hyperkalemia

common: spotting and menstrual changes

safe to breastfeed, lack of estrogen related effects

immediate return of fertility

monthly vaginal ring

left in for 3 weeks, removed for 1 ring
new inserted after 7 days

serious: blood clots, stroke

common, nausea, spotting, breast discomfort, changes in mood

improved acne, regular and less painful periods

immediate return of fertility

annual vaginal ring - segesterone and ee

left in for 3 weeks, removed for 1 week
wash with mild soap/warm water
reinsert

serious: blood clots, stroke

common: headache, nausea, vulvovaginal infection

improved acne, lower risk of ovarian cancer, lighter periods, can use 1 up to 13 times

immediate return of fertility

patch - norelgestromin and ee

transdermal patch
new patch every week for 3 weeks, free for 7 days

serious: blood clots

common: nausea, spotting, breast discomfort, skin irritation, change in mood

improved acne, lower risk of ovarian cancer, lighter periods

immediate return of fertility

patch- levonorgestrel and ee

transdermal patch
new patch every week for 3 weeks, free for 7 days

serious: blood clots

common: nausea, spotting, breast discomfort, skin irritation, change in mood

improved acne, lower risk of ovarian cancer, lighter periods

immediate return of fertility

general approaches to starting contraception

quick start

next period start

sunday start

quick start

anytime certain is not pregnant

if more than 1-6 days after period start, use 2-7 day backup

next period start

start within 1-6 days of period

no backup

sunday start

start on sunday after period starts

if more than 1-6 days, use 2-7 day backup

restarting after emergency contraception

levonorgestrel and ulipristal acetate

start/resume method immediately; back up method for 7 days

actions after late or missed combined oral contraceptives

1 pill <24 hours / 24-<48 hours late

take missing dose as soon as possible

take normal dose at normal time

no additional contraceptive

emergency contraceptive considered

actions after late or missed combined oral contraceptives

≥2 pills missed ≥48 hours

take most recent missing dose asap

continue taking dose at normal time

use back up

last week of hormonal pills: omit hormone free interval, start new pack

emergency contraceptive considered

actions after delayed application with combined hormonal patch

<48 hours

apply new patch asap

keep same patch change day

no contraceptive needed

actions after delayed application with combined hormonal patch

≥48 hours

apply new patch asap

keep same patch change day

use back up

delayed in third patch week: omit hormone-free week

emergency contraception considered

actions after delayed insertion with combined vaginal ring

<48 hours

insert ring asap

keep ring in until removal day

no contraception needed

actions after delayed insertion with combined vaginal ring

≥48 hours

insert ring asap

keep ring in until removal day

use back up

if occurred in their week: omit hormone free ring, start new immediately

emergency contraception considered

how to handle late/missed doses of:

norethindrone or norgestrel oral pill

>3 hrs late: take missed pill asap

continue daily pills

backup for 2 days

how to handle late/missed doses of:

progestin-only injection

within 15 weeks: receive injection, no backup

>15 weeks: receive injection, backup for 7 days if not pregnant

how to address irregular bleeding

take pills at same time

ibuprofen 800 TID x5 days

how to address headaches

discontinue if worsens

otc pain relievers

continue product if placebo

how to address nausea

take pills with food / at bedtime

continue if at start of cycle

how to address breast tenderness

supportive bra

otc pain relievers

less estrogen products

how to address acne

topical

different fill

combined product

serious side effects of combined methods

ACHES

abdominal, chest, head, eye, severe leg pain

chc and migraines

migraines w/o aura → steady level, potential benefits

migraines w/ aura → higher risk for stroke

chc ≥50 mcg ee has highest risk

progestin only recommended

progestin only contraindications

current breast cancer

progestin only cautions

hx breast cancer

cirrhosis

bariatric

liver tumors

sle

haart

anticonvulsants

rifampin/rifabutin