Contraception and HRT

Types of Contraception

Barrier methods, Hormonal contraceptives, Intrauterine devices (IUDs), Emergency contraception

Barrier Methods

Male condoms, female condoms, diaphragm, cervical cap, vaginal sponge, spermicides

Male Condoms

Latex, polyurethane, or lambskin (no STI protection)

Female Condoms

Polyurethane (higher failure rate)

Counseling point with condoms

1. Don’t combine male and female condoms

2. Avoid use with spermicides

Spermicide

Contains nonoxynol-9 which is toxic to sperm. 15% failure rate. DOES NOT protect against STIs

Diaphragm

Reusable, dome-shaped rubber cap providing mechanical barrier. Must be placed on cervical side using contraceptive jelly before insertion. Can insert up to 6 hour before intercourse and can be left in place for up to 6-24 hours (diaphragm)

Cervical Cap

Slightly smaller than diaphragm. Similar to diaphragm. Can insert up to 6 hour before intercourse and can be left in place for up to 8-48 hours (cervical cap)

Contraceptive Sponge

OTC disposable polyurethane foam with nonoxynol-9. Insert 6 hrs before intercourse and can be left in for 6-30 hours. Protection for repeated intercourse. Avoid use if history of toxic shock syndrome.

Combined Hormonal Contraceptives (CHCs)

Contain estrogen and progestin. Suppresses ovulation, thicken cervical mucus, and thin the endometrial lining.

COC dosing regiment

Monophasic: same strength estrogen and progestin. 24 active, 4 inactive

Multiphasic: Estrogen and progestin strength changes, mimics intrinsic hormone levels

Extended: 91 day or 365 day. Fewer menstrual periods and symptoms

Progestin Generations

1st: Ethynodiol, Norethindrone, Norethindrone Acetate, Norgestrel

Progestin-Only Pills (POPs)

Also known as "mini-pill". Indicated for those who can’t take estrogen.

28 day active dose regimen

! Must take the same time every day! If >3 hours late, use a backup method for the next 48 hours.

Can cause breakthrough bleeding and increased risk of ectopic pregnancy

COC AE

Estrogen dose too high: Breast tenderness, heavy menses, mood changes, N/V/B, weight gain

Estrogen dose too low: Amenorrhea, breakthrough bleeding, spotting, vaginal dryness

Progestin: Acne, depression/fatigue, hirsutism, weight gain

CHC Cardiovascular Warnings

Dyslipidemia, increased risk of coronary artery disease, increased risk of VTE, 6-8 mmHg increase in blood pressure

CHC Cancer Risks

Increased risk: Breast, Cervical

Signs to Stop Hormonal Contraceptives

ACHES: Abdominal pain (liver/gallbladder issues), Chest pain (MI/PE), Headaches (stroke), Eye problems (stroke), Severe leg pain/swelling (DVT)

Relative Contraindications to CHCs

Epilepsy, Diabetes, Hypertension, Lactation/Breastfeeding, Migraines, Smoking

Absolute Contraindications to CHCs

≥35 y/o + >1 pack per day smoker, Breast/genital tract cancer, History of VTE and/or stroke, Ischemic heart disease, Liver disease, Migraines with aura

Choosing OCP Dose

Low dose (20-25 mcg EE): Healthy ≥35 years, adolescents, underweight, no drug interactions

OCP based on AE

• Frequent BTB/spotting: Early/mid-cycle higher → estrogen; Late cycle higher progestin.

• Migraines: Use OCP with lower estrogen content or progestin-only.

• Acne: Use OCP with less androgenic activity (e.g., 3rd or 4th gen progestins).

Transdermal Patch

Xulane: 35mcg EE + 0.15mg norelgestromin. New patch every 7 days for 21 days. Not effective in patients >90kg

NuvaRing

15mcg ethinyl estradiol + 0.12mg etonogestrel. Keep in for 21 days and take out for 7 days

Annovera

13mcg ethinyl estradiol + 0.15mg segesterone acetate. One ring provides contraception for 13 cycles (1 year)

Depo-Provera

150mg IM injection every 3 months

Black box warning: Short term bone los in younger women of reproductive age

Average of 10 months to return to fertility

Etonogestrel Implant (Nexplanon)

68mg etonogestrel rod providing protection for 3 years. Inserted in upper arm

IUD Contraindications

Severe distortion of uterine cavity, Known/suspected pregnancy, Wilson's disease or copper allergy (for copper IUD), Unexplained abnormal uterine bleeding, Current or history of breast cancer

Levonorgestrel IUDs

T-shaped flexible devices. Common SE is breakthrough bleeding and spotting for 6 months.

Progestin Containing (Mirena, Liletta, Skyla)

• Mirena®: 20 mcg/day levonorgestrel, replace every 8

years. Also indicated for menorrhagia (heavy menstrual

bleeding).

• Liletta®: 19 mcg/day levonorgestrel, replace every 8

years.

• Skyla®: ~14 mcg/day levonorgestrel, replace every 3

years.

Less cramps and ligher/no periods after initial 6 months

Copper IUD (ParaGard)

Non-hormonal and approved for 10 years. Causes heavier periods/worsened cramps.

Emergency Contraception Types

Levonorgestrel (Plan B), Ulipristal Acetate (Ella), Copper IUD

Levonorgestrel EC

Take within 72 hours of intercourse. Decreased efficacy in patients with >25 BMI

Ulipristal Acetate EC

Single dose in 120 hours of intercourse. More effective than levonorgestrel. Reduced efficacy in patient with BMI > 25. MUST wait 5 days to resume hormonal contraception.

Copper IUD as EC

EC Key Counseling Points

NOT for routine contraception and does not protect against STI. If period does not return within 3 weeks, take a pregnancy test

Physical Changes in Menopause - VVA

Vaginal epithelial atrophy (increased pH, infection risk), cervical atrophy (dryness, dyspareunia), reduction in size of uterus/ovaries, urinary tract changes (UTIs, incontinence), regression of breast size

Physical Changes in Menopause - Vasomotor

Hot flashes (~75% of menopausal women), persist >1 year in 85% of patients and >5 years in 25-50%

HRT Benefits

Helps manage vasomotor symptoms and urogenital atrophy

HRT Risks

CVD, breast cancer, endometrial cancer, VTE, gallbladder disease

HRT Eligibility Criteria

Symptomatic and otherwise healthy

HRT Contraindications

Cancer (breast or endometrial), stroke (esp. within 12 months), MI (esp. within 12 months), DVT/PE, active liver or gallbladder disease

HRT Treatment Approach - Vaginal Symptoms

Topical HRT (vaginal creams, tablets, non-systemic vaginal ring) or personal lubricants

HRT Treatment Approach - Vasomotor

Systemic HRT, SSRIs/SNRIs, clonidine, gabapentin, pregabalin

HRT with Intact Uterus

Estrogen + Progestin (to prevent endometrial cancer) or Bazedoxifene + CEE

HRT without Uterus

Estrogen ALONE (oral, transdermal, or systemic)

Combined Estrogen + Progestin Products

Premphase, Prempro, Activella, FemHRT, Angeliq (oral)

Estrogen-Only Products

Premarin, Estrace (oral)

Progestin-Only Products

Provera (medroxyprogesterone acetate), Aygestin (norethindrone acetate)

Ospemifene (Osphena)

Estrogen agonist in vaginal mucosa

Brisdelle (Paroxetine)

SSRI for vasomotor symptoms (hot flashes)

Phytoestrogens

Weak estrogen-like properties

Black Cohosh

Does not appear to have estrogenic activity

St. John's Wort

May modulate 5HT, NE, and dopamine levels