Contraception

In the US in 2019, ___% of pregnancies were unintended

41.6%

What are 6 secondary health benefits of contraception?

1. Menstruation-related problems

2. Menstrual cycle irregularity

3. Acne

4. Pelvic pain in endometriosis

5. Androgen production in polycystic ovary syndrome

6. Risk of cancers

What forms of estrogen and progestin combo contraceptives are there?

- Pill

- Patch

- Ring

What forms of progestin only contraceptives are there?

- Pill

- Injectable

- Implants

- Intrauterine Device (IUD)

What is the MOA of combined hormonal contraception?

Blocks hypothalamic production of GnRH and suppress pituitary production/secretion of FSH and LH to inhibit follicular development and prevent ovulation, respectively.

What aspect of combined hormonal contraception drives contraceptive efficacy?

Progestins, estrogen adds to ovulation suppression, but its effects are not as prominent and it doesn't add to contraceptive efficacy

What is the purpose of estrogen in combined therapy?

To stabilize the endometrial lining and prevent irregular shedding

What is a secondary purpose of progestins in combined therapy?

Increases viscosity of the cervical mucus to inhibit sperm penetration

What are 4 examples of combined hormonal contraceptive transdermal patches?

1. Xulane

2. Zafemy

3. Twirla

4. Gwyn Lo

What are 5 examples of a combined hormonal contraceptive vaginal rings?

1. NuvaRing

2. EluRyng

3. Haloette

4. EnilloRing

5. Annovera

What are the 3 different kinds of estrogen found in oral pills?

1. Ethinyl estradiol

2. Estradiol valerate

3. Estetrol

What are the 8 different kinds of progestins found in oral pills?

1. Norethindrone

2. Ethynodiol diacetate

3. Norgestrel

4. Levonorgestrel

5. Norgestimate

6. Desogestrel

7. Drospirenone

8. Dienogest

What is the ONLY estrogen found in patches and rings?

Ethinyl estradiol

What are 2 forms of progestin found in transdermal patches?

1. Levonorgestrel

2. Norelgestromin

What are 2 forms of progestin found in vaginal rings?

1. Etonogestrel

2. Segesterone

Estradiol valerate is converted to estradiol __________

in vivo

What is estetrol?

E4, Native Estrogen with Selective actions in Tissues (NEST)

Which estrogen product is preferred?

Currently, there is no definitive data suggesting that one estrogen component should be selected over another

What is a proposed benefit of using estradiol valerate?

Cases less adverse effects due to conversion to naturally occuring estradiol in vivo

What is a proposed benefit of using Estetrol?

Activates nuclear estrogen receptor but antagonizes membrane estrogen receptor, proposed to antagonize estrogen receptors in breast tissue and the vascular system, may lead to decreased adverse drug events

Why are the different progestins so different?

They are metabolized to other substances that have varying estrogenic, antiestrogenic, and androgenic properties

_________________, __________________, and ________________ have moderate progestational and androgenic properties

- Norethindrone

- Norethindrone acetate

- Ethynodiol diacetate

What is special about norgestrel and levonorgestrel?

They are formulated to have increased affinity for progesterone receptors to decrease breakthrough bleeding, but also have increased androgenic activity

Which progestins were formulated to have decreased androgenic activity vs 2nd gen progestins?

Norgestimate and Desogestrel

Which progestins have very little affinity for any receptors other than progesterone?

Drospirenone and Dienogest

Which progestins ultimately have anti-androgenic effects?

Drospirenone and Dienogest

Too little estrogen in contraceptives can lead to what 2 symptoms?

- Vaginal dryness

- Early cycle spotting

Too much estrogen in contraceptives can lead to what 5 symptoms?

- Thrombotic + CV risk

- Increased BP

- Breast tenderness

- HA

- Nausea/bloating

Too little progestin in contraceptives can lead to what symptom?

Late cycle spotting

Too much progestin in contraceptives can lead to what 4 symptoms?

- Fatigue

- Breast tenderness

- HA

- Mood changes

To much androgens in the body can lead to what 4 symptoms?

- Acne

- Weight gain

- Hirsutism

- Increase in LDL, decrease in HDL

What are the 4th generation progestins?

- Drospirenone

- Dienogest

4th generation progestins have a similar structure to what drugs? What is the resulting effects?

Aldosterone antagonists, leads to antimineralocorticoid effects. Decreases Na/H2O retention, BP, and acne, BUT increased potassium and possible increase in VTE risk

In addition for contraception use, Yaz (EE/drospirinone) also has indications for...

- Acne

- Premenstrual dysphoric disorder (PMDD)

4th generation progestins may be beneficial for...

management of hyperandrogenism and irregular menstrual cycles in polycystic ovarian syndrome

What are the 4 categories of combined oral contraceptive options?

1. Monophasic

2. Biphasic

3. Triphasic

4. Quadriphasic

What is the difference between a monophasic and multiphasic combined oral contraceptive?

Monophasic = same amount of estrogen and progestin in all active tablets

Multiphasic = varying amounts of estrogen, progestin, or both. Attempt to minimize cumulative hormone dose and better mimic "natural" hormone levels throughout a cycle

What are 4 considerations when choosing an initial COC agent?

1. Choose monophasic first (easier to identify and manage side effects)

2. Choose a product with ≤35 mcg of EE + norethindrone ≤0.5 mg, levonorgestrel ≤0.15 mg, norgestimate ≤0.25 mg or equivalents

3. For women with oily skin, acne, or hirsutism, choose an agent with low androgenic or anti-androgenic activity

4. Consider patient preference for number of periods per year

Continue a COC product for _________ prior to changing products

2-3 months, unless a serious adverse event is present

What are transdermal patches contraindicated?

BMI ≥30

What colors are transdermal patches available in?

Only in beige

How are most transdermal patches used?

Change patch once a week for 3 weeks, then do not wear a patch for a week

Where can transdermal patches be worn?

Abdomen, buttock, back, or upper arm (minus Twirla)

Which patch has the highest amount of estrogen?

Xulane (Zafemy), 35 mcg/day

Which patch is the biggest?

Twirla, 28 cm^2

Which patch has demonstrated efficacy at BMI 25-30?

Gwyn Lo

Which patch has the lowest amount of estrogen?

Gwyn Lo, 20 mcg/day

A new vaginal ring should be inserted every _____ days

28 days

What are 3 unique ADEs with vaginal rings?

1. Foreign body sensation

2. Device expulsion - wash with cool/lukewarm water and reinsert

3. Vaginal symptoms

What are the storage considerations for vaginal rings?

Refrigerate until dispensing, after dispensing, can be at room temperature for 4 months

What is a potential con for vaginal rings?

Potential for increased risk of VTE vs lower generation progestins

Which ring is larger and can be used year-round?

Annovera (EE/Segesterone)

How is Annovera used?

Ring is left in place for 21 days, removed for 1 week, and then the same ring is replaced for another cycle (lasts 13 28-day cycles)

What are some specific storage counseling points for Annovera?

When removed, the ring should be cleaned with mild soap and warm water, patted dry with a clean cloth towel or paper towel, and placed in its case during the 1-week dose-free interval

Why are transdermal patches contraindicated in people with a BMI over 30?

Higher VTE risk compared to lower BMI

What BMI is contraindicated for Annovera?

BMI >29

What injectable progestin only option is there?

Medroxyprogesterone acetate (Depo-Provera)

What progestin only option is there for impants?

Etonogestrel (Nexplanon)

Which progestin in is hormonal IUDs?

Levonorgestrel

MOA of progestin only contraceptives depends on...

dose and method of administration

Describe the MOA of oral progestin contraceptives

- Inhibition of ovulation inconsistent 50% of the time

- Increases viscosity of cervical mucus

- Thins endometrial lining during anovulatory cycles only

Describe the MOA of injectable progestin contraceptives

- Complete inhibition of ovulation

- Increases viscosity of cervical mucus

- Thins endometrial lining

Describe the MOA of implantable progestin contraceptives

- Consistent inhibition of ovulation (97-99%)

- Increases viscosity of cervical mucus

- Thins endometrial lining

Describe the MOA of IUD progestin contraceptives

- Inhibition of ovulation inconsistent 50% of the time

- Increases viscosity of cervical mucus

- Locally alters endometrium

- Inhibits sperm survival and migration

What are some counseling points for taking progestin only pills (POP)?

- All 28 tablets are active, no week off

- Must be taken at the same time every day, if not, must use back up for 2 days (no more than 3 hours late)

What are some possible ADE with POP?

- Nearly 40-50% of women continue to ovulate as it mainly thickens cervical mucus, may increase risk for ectopic pregnancy

- Can have unpredictable/irregular bleeding

Describe Slynd (Drospirenone) and how its different

- 24 active tablets with 4 inactive/inert ones

- Claims efficacy up to 24 hours if a dose is delayed or missed

Where can Depo-Provera be injected?

Deltoid or gluteal muscle

Where can Depo-SubQ Provera be injected?

Abdomen or anterior thigh

How often is Depo-Provera given?

Every 3 months (13 weeks)

Why is the injectable progestin able to inhibit ovulation? What is a drawback

Progestin dose is sufficient enough, some increase in thrombosis risk

What are some unique ADEs for Depo-Provera?

- Menstrual irregularities

- Increased appetite can lead to weight gain

- Bone density loss (boxed warning)

- Prolonged return to fertility (10 months)

Depo-Provera should not be used for longer than _______ due to bone density loss

2 years

What is a unique newly discovered risk for using Depo-Provera?

Increased meningioma risk

Long-Acting Reversible Contraceptives (LARC) can be _____________ or _____________

Progestin-only or Non-hormonal

What is an example of a LARC?

Nexplanon implant (Etonogestrel)

How long can a nexplanon implant be left in?

5 years

Nexplanon implant was not studied in those _______% of IBW

>130%

What are some common ADEs of Nexplanon?

- Irregular bleeding (11% of d/c)

- Amenorrhea (22% with continued use)

- Continued prolonged bleeding/spotting (18-35%)

- Bruising at time of insertion or removal

What are 4 common IUD brands?

1. Mirena

2. Kyleena

3. Skyla

4. Liletta

Which IUDs last 8 years?

- Mirena

- Liletta

Which IUD lasts 5 years?

Kyleena

Which IUD lasts only 3 years?

Skyla

The shorter acting IUDs are good for which patients?

Those who have not had children, they are smaller and more comfortable

What is the MOA for an IUD?

- Thickening of cervical mucus

- Locally suppress endometrium

- Inhibits sperm survival and migration

Do women who have an IUD ovulate?

Most women do

What is a common ADE of IUDs?

Increased spotting in first 6 months, decreased with time, amenorrhea in 20% in first year, 60% in later years

Is there an increased risk of infertility with IUDs?

No

Can IUDs be used in nulliparous women?

Yes, but they are at greater risk for pain

What is considered first-line for heavy menstural bleeding?

Levonorgestrel IUD (CHC also beneficial like Natazia)

Heavy menstrual bleeding is defined as...

menstrual blood loss >80 mL per cycle lasting >7 days per cycle

What options are there for patients with heavy menstrual bleeding who do not want to use contraception?

- NSAIDs during menses (increased prostaglandin levels)

- Oral tranexamic acid (Lysteda, antifibrinolytic)

Name 2 non hormonal copper IUDs?

1. Paragard (old)

2. Miudella (new)

What is the MOA of copper IUDs?

Copper is continuously released into the uterine cavity, causing an inflammatory reaction within the endometrium that interferes with sperm motility/viability and fertilization

Can copper IUDs be used for emergency contraception?

Yes, it may prevent (but not disrupt) implantation. Must be used within the first 120 hours after unprotected sex. Only Paragard has been studied for this

What is a common side effect of the copper IUD?

May increase menstrual blood flow

How long does Paragard last?

10 years

Miudella is contraindicated in which patient populations?

Those who have a nickel allergy

How long does Miudella last?

3 years

What is Phexxi?

A vaginal gel that women can insert to maintain vaginal pH (lowers pH) and sperm are not as mobile (prescription-only item). Contains Lactic acid, citric acid, and potassium bicarbonate