POP and Non-Hormonal Contraception

What is the MOA of POPs, DMPA, and progestin implant?

Thickens cervical mucus, thins uterine lining, prevents ovulation

What is the MOA of progestin IUDs?

Copper and hormonal = decrease sperm motility

Hormonal ONLY = thins uterine lining, thickens cervical mucus

What is the typical drug and dose of a progestin only pill (POP, Minipill)?

Norethindrone 350 mcg

1 tablet at the same time each day

What is important to note when taking POPs?

1 tablet at the same time each day and it MUST BE WITHIN THE SAME 3 HOUR WINDOW

What risk is higher with POP?

Risk of ectopic pregnancy is higher with POPs than with other HCs

Is a back-up method required when starting POP within first 5 days of LMP starting?

No

Is a back-up method required when starting POP > 5 days since last LMP started?

Yes, for 2 days

How should a late dose of POP be managed?

Take immediately

No back up

How should a missed dose of POP be managed?

Take one pill immediately and continue taking pills daily

Use back up for 48 hours

EC recommended if intercourse within the past 5 days

What are advantages/benefits of POP?

No estrogenic side effects

Good choice when estrogen is CI

Does not disrupt breast milk production

Decreased menstrual pain

Reversible

What are disadvantages/risks of POP?

Less efficacy than combined pills

MUST be taken at same time every day

Benefits of COCs may not apply to mini-pill

BTB = most common complaint and reason for discontinuing

What is an alternative POP?

Drospirenone 4 mg

What are benefits to a drospirenone-based POP?

24 hour missed dose window

No evidence of cardiothrombolic events in trials = no BBW like drospirenone COCs have

What are warnings/precautions of drospirenone POPs?

Hyperkalemia, renal impairment, thrombotic risk, bone loss

What drug is a progestin injection?

Depot medroxyprogesterone acetate (DMPA) (Depo-Provera)

How often is DMPA dosed?

Inject every 12 weeks

Where should DMPA be injected depending on the route of administration?

IM = gluteal or deltoid muscle

SQ = abdomen or thigh

When should the first dose of DMPA be taken?

Within 5 days of onset or menstrual bleeding

How should missed doses of DMPA be managed?

> 1 week late, IM version = exclude pregnancy before next dose

> 2 weeks late, SQ version = exclude pregnancy before next dose

What are common ADE of DMPA?

Spotting/bleeding irregularity, prolonged bleeding, amenorrhea, weight gain

What is a BBW of DMPA?

BMD

Describe bone loss and DMPA

DMPA use is associated with short term bone loss

Majority of cases it IS reversible after discontinuation

BMD loss seems greater with increased duration of use and may not be reversible

How long should DMPA be continued?

Ideally, no longer than 2 years

Only continue for more than 2 years if other contraception is inadequate and if benefit > risk

What are advantages to DMPA?

VERY effective, may be used immediately after birth when NOT breastfeeding, reduces sickle-cell crises, fewer seizures in seizure disorders

What are disadvantages to DMPA?

Slow return to fertility (~10 months), BMD concerns

What drug is a progestin only IUD?

Levonorgestrel (Mirena, Skyla, Liletta)

What is the duration of action of progestin only IUDs?

Mirena = up to 8 years

Skyla, Liletta = up to 3 years

What is a common adverse event of progestin only IUDs?

Irregular bleeding

How long is a copper IUD (Paraguard) effective for?

Up to 10 years

What drug is a progestin only implant?

Etonorgestrel (Nexplanon)

What is the duration of action of progestin only implants?

Up to 3 years

What is a common adverse event of progestin only implants?

Irregular bleeding

Amenorrhea is common as well!

How long does it take for fertility to return following progestin only implant use?

Within 30 days

What is in vaginal pH modulators (Phexxi)?

Lactic acid, citric acid, potassium bitartrate vaginal gel

What are the directions for Phexxi?

Insert one prefilled applicator PRIOR to intercourse (up to one hour)

MUST be reduced for each act of intercourse

May be used with condoms and diaphragms

When should the use of Phexxi be avoided?

With vaginal rings

In those with recurrent UTIs

What are ADRs of Phexxi?

Vaginal discomfort

What is Natural Cycles?

Technologically advanced fertility app that helps to prevent or plan pregnancy without hormones

Clinically-validated algorithm that uses body temperature, menstruation data, and optional LH test results to determine fertile window