All types of Contraceptives

Explain the full mensural cycle (w/ hormones)

1. The low estrogen and progesterone at the end of the previous cycle triggers the hormnoal cycle to inc LH and FSH
- Hormonal cycle = hypothalamus secrege GnRH, trigger anterior pit to make LH and FSH, they trigger more estrogen and progesterone

Folicular phase
2. Lots of follicles dev and one dominant one actually matures

Ovulation
3. LH Surge = ovulation (egg/ovum releases)

Leutial Phase
4. Rest of the follicle (corpus luteum) primary job is to release progesterone
- Goal: favorable env to implant egg
5. Progesterone rise, peak 6-8 days
- Estrogen and progesterone inc and negative feedback on hormone cycle

No implant:
6. estrogen and progesterone decrease and restart to step 1

what is one counseling point that you have to tell everyone who is using contraceptives (what are you not protected from and still need protection for)

STI PROTECTION! CONTRACEPTIVES DONT PROVIDE THAT

MOA of Hormonal Contraceptives

MAIN: Inhibit LH Surge which inhibits ovulation
Also (not as important here)
- thickening of cervical mucous (dec implant/fertilize)
- Alteration of endometrial lining (dec implant)

Typical use efficacy for combined or progestin only contraceptive pills, transdermal patch and vaginal rings

9%

Typical use efficacy for Depo Provera

Hint: (progestin only depot Injection)

6%

Typical use efficacy for Progestin IUDs (LARCs) and list of IUDs

0.2%
Mirena
Skyla
Liletta
Kyleena

Typical use efficacy for Nexplanon

(Hint: Progestin implants)

0.05%

Typical use efficacy for Paragaurd

Hint: Copper IUDs (LARC)

0.8%

Typical use efficacy for natural cycles contraceptive app

7% typical use efficacy

Indications/non contraceptive benefits of combined oral contraceptives

- Contraception
- emergency contraception
- Acne
- Endometreosis
- Cyclic bleeding withdrawl
- PMDD

Non contraceptive benefits
- dismenorrhea (painful bleeding)
- PCOS
- Menorragia (heavy peroid bleeding)

Difference btwn combined oral contraceptives and progestin only contraceptives

- COCs have estrogen and progesterone

Monophasic combined oral contraceptives definition

- Same dose of E2 and P4 in all four weeks/throughout cycle

Multiphasic combined oral contraceptives definition

- different doses of E2 and P4 between weeks or in different points of the cycle
- do this to better mimic natural changes in hormones in the cycle, BUT may cause more SE

Regular cycle combined oral contraceptives def

- active pill for 21 days then 7 days of placebo

what is extended cycle combined oral contraceptives def and why would a pt want that

- getting hormones for more than 21 days aka dec placebo timeframe
- some people get menstral sx on the placebo days so this could mitigate that

how long is immediate return to fertility?

- re establish normal cycle within next month or 2 aka next cycle or two
- once that cycle is finished next one should be normal

Pros with Combined Oral Contraceptives

- 9% typicla failure rate
- immediate return to fertility
- Reduction of dysmernorrheal sx
- reduced risk of endometrial and ovarian cancer

Cons with Combined oral contraceptives

- Estrogen and Progesterone SEs
- Has to be taken daily (within 24 hrs) so compliance problem
- Potential risk for VTE, stroke or MI
- Group of patients are CI for this drug bc of estrogen componenet

*Absolute CIs with Combined oral contraceptives* and probably combined contraceptive patches (Xulane and Twirla)

- Thromboembolic disease
- Cerebrovascular or Cardiovascular disease
- Impaired liver function
- Personal hx breast or endometraial cancer or other suspected estrogen dependent cancer
- pregnanc
- SMOKERS at least 35 Y/o
- Migraines w/ aura??? (almost Absolute CI)

*Relative CIs with Combined oral contraceptives* and probably combined contraceptive patches (Xulane and Twirla)

- Smokers under 35 yo
- Migraines w/o aura (AVOID COCs)
- uncontrolled HTN
- Galbladder disease
- Hx Gestational DM
- Hyperlipidemia
- Hx jaundice w/ pregnancy
- Sickle cell anemia
- Pregnancy/lactation

COCs, combined contraceptive patches (Xulane and Twirla) and combined vaginal rings (Nuva Ring and Annovera) Estrogen Excess SEs

- Nausea/bloating
- breast tenderness
- weight gain

COCs, combined contraceptive patches (Xulane and Twirla), and combined vaginal rings (Nuva Ring and Annovera) progesterone excess SEs

- weight gain
- acne

COCs, combined contraceptive patches (Xulane and Twirla), and combined vaginal rings (Nuva Ring and Annovera)

estrogen/progesterone deficency SEs

- spotting
- Amenorrhea (breakthrough spotting)

If the spotting is early to mid cycle cycle, which hormone is low/need to be increased?

Estrogen needs to be increased

If the spotting is late cycle, which hormone is low/need to be increased?

progesterone needs to be increased

Serious SEs w/ COCs and probably combined contraceptive patches (Xulane and Twirla)/combined vaginal rings (Nuva Ring and Annovera)
(hint: ACHES acronym, DVT and MI stuff)

Abdominal pain
Chest pain
Headache
Eye problems
Severe leg pain

see these most often when starting for first time or switching products

What drugs/DDI will Decrease COC levels and efficacy

3A4 INDUCERS
- Phenytoin
- Carbamazepine
- NNRTIs Non nucleoside reverse transcriptase inhibitors
- Rifampin

What is the DDI risk w/ antibiotics and COCs?

- its a low risk but some doctors say that COCs should be held bc will dec antibiotic levels

What drugs/DDI will Increase COC levels and SEs

3A4 INHIBITORS
- ketoconazole

what drug levels are Decreases when taken with COCs

- Lamotrigine!

How to ensure contraception when taking short term use of most 3A4 inducers

- use backup/additional contraceptives during 3A4 inducer use
and
- 7 days after stop the inducer!

How to ensure contraception when taking short term use of RIFAMPIN

- use backup/additional contraceptives during RIFAMPIN use
and
- *28 days* after finish the induer

How to ensure contraception when taking LONG term use of Any 3A4 inducer

swithc COC to another type such as depot or hormonal IUDs to avoid DDI

which componenet of the COCs is causing the lanotrigine, 3A4 induer and 3A4 inhibitor DDI?

Estrogen
- thats why we can switch to a progesterone only one and be fine/avoid DDI

Two options to mitigate the Lamotrigine and COC DDi

A. change COC: use progesterone only product instead (remove estrogen)

B. change lamotrigine dosing and COC dosing:
- switch to extended cycle and or remove placebo period
and
- increase lamotrigine dose
(do this so dont have to change lamotrigine dose when on placebo and can have constant dose!)

For ref: ex of extended cycle COCs

- Seasonique or Lo Seasonique: estrogen + levonorgestrel 84 days and 7 day placebo or low dose estrogen only

24 day cycles
- Yaz
- Minastrin 24 Fe

- Amethyst: continuous active pill cycle/no placebo

List of Combined (estrogen and progesterone) Contraceptive patches

- Xulane
- Twirla

what type of contraceptive is Xulane

Combined (estrogen and progesterone) contraceptive patch

what type of contraceptive is Twirla

Combined (estrogen and progesterone) contraceptive patch

Estrogen and progesterone dose for Xulane

Combined hormonal contraceptive (dose released per day)
- Ethinyl estradiol 35 mcg
- Norelgestromin 150 mcg

Estrogen and progesterone dose for Twirla

Combined hormonal contraceptive (dose released per day)
- Ethinyl estradiol 30 mcg
- legonorgestrel 120 mcg

similarities btwn Xulane and Twirla's SE, efficacy and Safety profile

similar SEs to COCs
same efficacy of 9% typical failure rate

How does Xulane's risk profile compare to Twirla

twirla might have lower risk of VTE bc lower dose

BBW w/ Xulane

inc risk VTE

Xulane and Twirla administration

use patch weekly with one patch free week
- can shower and swim i htink with the patch on

How does Twirla's patch size compare to Xulane?

twirla is a bigger patch than xulane

List of immediate return to fertility

Estrogen and Progesterone products:
- Combined oral contraceptives
- Combined contraceptive patches (Xulane and Twirla)
- Combined vaginal rings (Nuva ring and Annovera)

When do you need a backup contraceptive if Xulane or Twirla is removed? (what timeframe)

if removed for over 24 hrs then need a backup contraceptive

what population is there reduced efficacy of Xulane?

if pt over 90 kg

what population is there reduced efficacy of Twirla?

if pt over 92 kg

List of the combined contraceptive Vaginal rings

- Nuva ring (120 mcg etonogestrel and 15 mcg ethinyl estradiol)
- Annovera (50 mcg segessterone acetate and 13 mcg ethinyl estradiol)

What type of contraceptive is Nuva ring

Combined (estrogen and progesterone) vaginal ring

What type of contraceptive is Annovera

Combined (estrogen and progesterone) vaginal ring

administration/dosing for Nuva ring (combined vaginal ring)

- use 1 ring for 3 weeks with 1 free ring week then throw that ring out
- use a new ring each cycle (1 ring per cycle)

administration/dosing for Annovera (combined vaginal ring)

- use ring for 3 weeks then ring free week
- use the same ring for A WHOLE YEAR
- wash ring in btwn cycles

How long can Nuva ring be removed from the vagina for intercourse b4 you need alternative protection?

up to 3 hours

How long can Annovera be removed from the vagina for intercourse b4 you need alternative protection?

up to 2 hours

Counseling points for nuva ring and annovera

- dont have to remove before intercourse
- potential ring expulsion during intercourse
- immediate return to fertility after stopping it
- still has patient administration factors to it

List of progestin only products

Oral daily pill:
- Micronor
- Camila

Injection:
- Devo Provera

LARCs (long acting reversible contraceptives)
IUDs:
- Mirena
- Skyla
- Liletta
- Kyleena
Contraceptive Implant:
- Nexplanon

Pros of progestin only products

- patients that cant take COCs can use these products aka minimize estrogen related risks/effects
- immediate return to fertility for most of them

Cons of progestin only products and why

- NEED COMPLIANCE they MUST take the drug within 3 hours at the same time every day for efficacy
- this is bc of MOA: relys on changing mucus and changing lining thickness for contraception no change in LH at all here

What type of contraceptive is micronor?

Oral progestin only daily pill

What type of contraceptive is Camila?

Oral progestin only daily pill

what is a major counseling point with Micronor and Camila contraceptives?

MUST take oral pill at the same time, within 3 hrs, every day!!

What type of contraceptive is Depo Provera?

Contraceptive injection (progesterone only)

List of Progestin only injections

Depo-Provera

Route of administration/dose for Depo Provera

- 150 mg/mL IM injection medroxyprogesterone acetate OR
- 104 mg/MI Sub Q "

AEs with Depo Provera

- Weight gain (few lbs)

Black Box warning and duration with Depo Provera

- Bone mineral density issues
- FDA restricts usage timeframe to 2 years total
- ACOGA says no timeframe, has risks but still use it if best/preferred option

Efficacy of Depo Provera (DELETE?)

- 6% standard failure rate

how often dose/administer Depo Provera

- Injection every 12 weeks (3 months)
- can be 12 to 14 weeks

Is there a delay of fertility with Depo Provera? and if so how long

YES there is!
- 10 months is the average delay of fertility, can be longer or shorter

List of LARCs (Long acting reversible contraceptives)

Intrauterine Devices (W/ Estrogen):
- Miren
- Skyla
- Liletta
- Kyleena

Copper IUD
- Paragaurt

Contraceptive implant
- Nexplanon

Pros of Long acting reversible contraceptives (LARCs)

- more effective and less dependent on user
- non hormonal or progestin only are safer bc no estrogen
- More convenient/less opportunity for user error

List of hormonal IUDs (LARCs, progestin only)

- Mirena (50 mg levonorgesterel)
- Skyla (14 mg levonorgesterel)
- Liletta (52 mg levonorgesterel)
- Kyleena (19.5 mg levonorgesterel)

what kind of contraceptive is Mirena

IUD (intrauterine device)
and LARC (long acting reversible contraceptive)

what kind of contraceptive is Skyla

IUD (intrauterine device)
and LARC (long acting reversible contraceptive)

what kind of contraceptive is Liletta

IUD (intrauterine device)
and LARC (long acting reversible contraceptive)

what kind of contraceptive is Kyleena

IUD (intrauterine device)
and LARC (long acting reversible contraceptive)

What extra indication does Mirena (IUD, LARC) have?

- also for menorrhagia (heavy bleeding)

What contraceptives are also for emergency contraception

- Combined oral hormonal contraceptives (estrogen and progesterone)
- Copper IUD (Paragaurd)

What is the most efficacious emergency contraceptive? (make stikey note into flashcard)

which IUDs are smaller and might be more comfortable for insertion

- Skyla
- Kyleena

AEs for IUDs

Very low possibility:
- expulsion
- uterine perforation
- bleeding changes

How long can Mirena and Kyleena (seperate?) (IUD, LARC) be effective for (in years)?

efficacious for up to 5 years but can replace earlier

How long can Skyla (IUD, LARC) be effective for (in years)?

efficacious for up to 3 years but can replace earlier

How long can Liletta (IUD, LARC) be effective for (in years)?

efficacious for up to 4 years but can replace earlier

Which hormonal IUDs are effective for the longest timeframe?

- Mirena
- Kyleena

Which IUDs are effective for the shortest timeframe?

Skyla

Which IUDs are effective for a moderate timeframe (not too long or short)?

Liletta

What is the return to fertility like with IUDs?

Immediate return to fertility

What type of contraceptive is Paragaurd?

Non hormonal Copper IUD
and also a LARC (long acting reversible contraceptive)

AEs with Paragaurd (copper IUD/LARC)

- Expulsion
- Urine perforation
- Heavier bleeding

What is a unique and important counseling point that patients can expect with Paragaurd (copper IUD, LARC)?

- can cause heavier bleeding

How long is Paragaurd (copper IUD, LARC) effective for (in years)?

- up to 10 years but can be replaced sooner

What is the return to fertility like with Paragaurd (Copper IUD, LARC)?

immediate return to fertility

List of Contraceptive Implants (LARC)

- Nextplanon

what type of contraceptive is Nexplanon?

Contraceptive implant (progestin only, 68 mg ethonogesterel)
and a LARC (long acting reversible contraceptive)

AEs with Nexplanon (contraceptive implant/LARC)

- Irregular bleeding
- HA

How long can Nexplanon (contraceptive implant, LARC) be effective for (in years)?

up to 3 years but can replace before then