GU contraceptives

Hormone Cycle

Hypothalamus releases GnRH--> stimulates anterior pituitary which release LH and FSH

Normal menstrual cycle

begins at the end of the prior cycle. estrogen and progesterone levels decrease, turning on hormone cycle follicular phase, LH surge, ludeal phase

follicular phase

first half is follicular phase= several follicles are developing and one becomes dominant and follows through the rest of the cycle (increase in FSH)

LH surge

LH surge follows follicular phase which results in ovulation
after ovum becomes released the other follicles (corpus luedeum) increase progesterone

ludeal phase

second half is ludeal phase= progesterone increases, creating a favorable environment for implantation
day 6-8 peak in progesterone levels
estrogen and progesterone increasing negative feedback (shutting off hormone cycle)

end of cycle leading to beginning of menstrual cycle

no implantation leads to estrogen decreasing, progesterone decrease starting the next hormone cycle

MOA of Hormonal Contraceptives

inhibits LH surge- inhibit ovulation
thicken cervical mucous
alteration of endometrial lining

contraceptive pills hormonal efficacy

typical use 9%
perfect use 0.3%

transdermal patch efficacy

typical use 9%
perfect use 0.3%

vaginal ring efficacy

typical use 9%
perfect use 0.3%

depo provera injection efficacy

typical use 6%
perfect use 0.2%

progestin iuds efficacy

typical use 0.2%
perfect use 0.2%

progestin implant efficacy

typical use 0.05%
perfect use 0.05%

copper iud (paragard) efficacy non-hormonal

0.8% failure rate

natural cycles non-hormonal efficacy

7% failure rate

condoms/ withdrawal efficacy

22% failure rate

sponges efficacy

24% parous women
12% nulliparous women

fertility awareness based methods efficacy

24% failure rate

spermicides efficacy

28% failure rate

Advantages Combined oral contraceptives

• Return to fertility is 1-2 months after D/C
• Reduced risk of endometrial and ovarian cancer

Disadvantages for combined oral contraceptives

• Estrogen and progesterone side effects
• Estrogen: Nausea/bloating, breast tenderness, weight gain
• Progestin: Acne, weight gain
• ACHES
o Abdominal pain
o Chest pain
o Headache
o Eye problems
o Severe leg pain
• Daily use  adherence issues
• Potential risk for venous thromboembolism, stroke, or myocardial infarction

Combined oral contraceptive absolute contraindications

o Thromboembolic disease (VTE)
o Cerebrovascular or cardiovascular disease (CVD)
o Impaired liver function
o Breast or endometrial cancer or other suspected estrogen dependent cancer
o Pregnancy
o Smokers >35 yrs

Combined oral contraceptive relative contraindications

o Smokers < 35 yrs
o Migraines w/ aura (avoid COCs)
o Uncontrolled hypertension
o Gallbladder disease
o Hx of Gestational diabetes
o Hyperlipidemia
o Hx of jaundice with pregnancy
o Sickle cell anemia
o Postpartum/Lactation

Combined oral contraceptives drug interactions

• CYP-3A4 inducers ( decrease efficacy)
o Phenytoin
o Carbamazepine
o Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
o Rifampin

COC: If we have a short-term CYP-3A4 inducer:

Backup contraceptive during COC use and for an additional 7 days after discontinuation of 3A4-inducer

COC: If patient is using a short-term Rifampin-type medication

Backup during COC use and for an additional 28 days after

coc long term use with cypr 3a4 inducer

Switch to either depo or hormonal IUDs which can both bypass the interaction

coc cyp3a4 inhibitors

increase side effects
drug: ketoconazole

Interaction with Lamotrigine and COCs

decreases lamotrigine levels

If patient is using Lamotrigine and COC:

Switch to progestin only option, as the interaction is between estrogen and lamotrigine mainly OR switch contraceptive to extended-cycle option and remove the placebo period while increasing Lamotrigine dosing

seasonique/ lo-seasonique

 Levonorgestrel and ethinyl estradiol
 Tablets taken every day for 84 days with 7 days of low dose ethinyl estradiol or placebo

extended cycle option

Yaz

 -Drospirenone/ ethinyl estradiol
• Increased VTE risk with Drospirenone
24 day dosing Oral contraceptive

Minastrin 24

Fe-Norethindrone/ ethinyl estradiol
24 day dosing

amethyst

 Levonorgestrel 90 mcg and ethinyl estradiol 20 mcg
 Extended cycle OC for continuous use throughout entire year

xulane patch contraceptive type

• Combined hormonal contraceptive
• (Releases ethinyl estradiol 35 mcg and norelgestromin 150 mcg per day)

xulane patch aes

• Similar side effects compared to COCs
o Black Box Warning: VTE risk due to high level of estrogen absorption

xulane patch dosing/ administration

• Use weekly with one patch-free week
• Patch is smaller in size than Twirla

xulane counseling points

• Immediate return to fertility
• Need backup if removed for > 24 hours
• Reduced efficacy in individuals (> 90 kg)

twirla patch contraceptive type

• Combined hormonal contraceptive
• (Releases ethinyl estradiol 30 mcg and levonorgestrel 120 mcg per day)

twirla patch aes

• Similar side effects compared to COCs
• With lower dose, may offer lower risk of VTE compared to Xulane® patch

twirla dosing/ administration

• Use weekly with one patch-free week
• Twirla® patch is larger in size than the Xulane® patch

twirla patch counseling points

• Immediate return to fertility
• Need backup if removed for > 24 hours
• Reduced efficacy in individuals (> 92 kg)

nuva ring contraceptive type

• Combined hormonal contraceptive
• (120 mcg etonogestrel and 15 mcg ethinyl estradiol)

nuva ring aes

similar to cocs

nuva ring dosing/ admin

• 1 ring for 3 weeks with 1 ring-free week
• Use for 1 cycle

nuva ring counseling points

• Immediate return to fertility
• May be removed from the vagina for intercourse for up to 3 hours
• Potential for ring expulsion during intercourse

annovera contraceptive type

• Combined hormonal contraceptive
• (150 mcg/day segesterone acetate and 13 mcg ethinyl estradiol)

annovera aes

similar aes to cocs

annovera dosing/ admin

• 1 ring for 3 weeks with 1 ring-free week (store ring in compact case for the 7 days not in use)
• Use same ring for 1 year

annovera counseling points

• Immediate return to fertility
• May be removed from the vagina for intercourse for up to 2 hours
• Potential for ring expulsion during intercourse

depo provera contraceptive type

• Progestin-only hormonal contraceptive
• (150 mg/mL IM or 104mg/Ml SC medroxyprogesterone acetate)

depo provera aes

• Weight gain
• Black Box Warning: Bone mineral density changes
o FDA recommends time frame of usage be maxed out to 2 years due to BMD changes

depo provera dosing/ admin

• Given every 12 weeks either IM or SubQ (great for compliance)

counseling points

• Delay of fertility of approximately 10 months
• Office visit required every 12-14 weeks
• Effective option for individuals who are unable to use COCs

mirena iud contraceptive type

• Progestin-only IUD hormonal contraceptive
• 52 mg levonorgestrel (Releasing 20mcg/day)
• Also, for Menorrhagia (heavy menstrual bleed)

mirena aes

• Expulsion; Uterine perforation; Bleeding changes

mirena dosing/ admin

use for 5 years

mirena counseling points

compliance
immediate return to fertility

skyla contraceptive type

• Progestin-only IUD hormonal contraceptive
• 14 mg levonorgestrel (Releasing 14mcg/day after 24 days and 5mcg/day after 3 years)

skyla aes

• Expulsion; Uterine perforation; Bleeding changes

skyla dosing/ admin

use for 3 years

skyla counseling points

• Compliance
• Immediate return to fertility
• Smaller and tends to be more comfortable from an insertion perspective

liletta contraceptive type

• Progestin-only IUD hormonal contraceptive
• 52 mg levonorgestrel (18.6 mcg/day initially then 16.3 mcg/day at 1 year, 14.3 mcg/day at 2 years and 12.6 mcg/day at 3 years)

liletta aes

• Expulsion; Uterine perforation; Bleeding changes

liletta dosing/ admin

use 4 years

liletta counseling point

• Compliance
• Immediate return to fertility

kyleena contraceptive type

• Progestin-only IUD hormonal contraceptive
• 19.5 mg levonorgestrel (LNG) is 17.5 mcg/day after 24 days and declines to 7.4 mcg/day after 5 years

kyleena aes

• Expulsion; Uterine perforation; Bleeding changes

kyleena dosing/ admin

use for 5 years

kyleena counseling points

• Compliance
• Immediate return to fertility
• Smaller and tend to be more comfortable from an insertion perspective

paragard contraceptive type

non hormonal copper iud

paragard aes

• Expulsion; Uterine perforation; Heavier bleeding

paragard dosing/ admin

use for 10 years

paragard counseling points

• Compliance
• Immediate return to fertility

nexplanon contraceptive type

• Progestin-only Implant hormonal contraceptive
• (68 mg of etonogestrel (active metabolite of desogestrel)

nexplanon aes

irregular bleeding, headache

nexplanon dosing/ admin

use for 3 years

nexplanon counseling points

• Radiopaque Implant rod to assist with insertion and removal
• Immediate return to fertility

special considerations obese

o Increased VTE risk with CHC in obese patients,
o However, overall benefit outweighs risk (assuming there are no other VTE risk factors)

special considerations migraines

o Insane risk of stroke with CHC in aura migraine patients  DON’T USE

special considerations teens

o Consider high efficacy, safe options such as an IUD or implant (LARCS)

special considerations menstrual related s/s

o Consider extended cycle contraceptive options leads to decrease hormone-free period

special considerations smokers

o Do not use CHC for patients who smoke a lot and who are greater than or equal to 35 yo --> use progestin-only option or non-hormonal option (also do tobacco cessation)

post partum non breast feeding no VTE risk

o Post-partum, non-breast feeding, no VTE risk: Can start back on CHC after 3 week wait due to increased thrombosis risk

post partum non breastfeeding vte risk

o Post-partum, non-breast feeding, VTE risk (over 35 yo or BMI > 30): Can start back on CHC after 6 week wait

post partum breast feeding no vte risk

o Post-partum, breast feeding, no VTE risk: Wait at least 6 weeks for CHC (CDC) or Wait 6 months or until breast feeding is done, whichever comes first (WHO)CDC recommendation is most often used
o No wait time for patients who want to start on progestin-only contraception

post partum/ breast feeding

o No wait time for patients who want to start on progestin-only contraception

drospinerone containing oc pills and patch ___ vte risk

increase

depo provera key points

BMD changes
Cannot return to fertility right away --> wait at least 10 months

true or false: • Hormonal contraceptives do NOT provide STI protections

true

Patient is a 36 yof who presents to the clinic for an OB checkup. She is 38 weeks preg. Upon discussion with the patient, shes not interested in breastfeeding and wants to get back on the contraception she was on prior to preg after she delivers. Her previous contraception was Seasonique® (ethinyl estradiol 30 mcg and Levonorgestrel 0.15 mg/ethinyl estradiol 10mcg).
PMH/SH: Obese (Current BMI- 31 kg/m^2 non-smoke and no alcohol or rec sub use
Medications
– Acetaminophen 325mg occasionally for back pain
– Docusate sodium 100mg prn

What is the recommendation regarding restarting on Seasonique post delivery?

counsel patient that she needs to wait 6 weeks prior to starting back on her Seasonique
risk factors: obesity, age over 35
theoretically if patient was not obese and was over 35 y patient could start up after 3 weeks

Patient is a 22 yof who comes to pharmacy with new prescription for Lo/Ovral (ethinyl estradiol 30 mcg/ norgestrel 0.3 mg)
PMH/SH: bipolar disorder, no tobacco or rec substance abuse
meds
-lamotrigine 200 mg daily
- daily multi vit

Give current meds, what is an important counseling point?

Advise that her oral contraceptive can decrease effect of her lamotrigine in addition to the importance of sti protection

Patient is 29 yof who is one week post partum for incision check secondary to c section. currently breastfeeding and wants to know what contraceptive to use now. prior to pregnancy she used nuva ring (11.7 mg etonogestrel and 2.7 mg ethinyl estradiol)
PMH/SH: noncontributory
Meds
-acetaminophen 325 mg occasionally for headache
-docusate sodium 100 mg prn

what is an appropriate contraceptive option?

starting on a progestin only oral contraceptive

any estrogen containing products need to 6 weeks for this specific patient as they are breastfeeding

Patient is 35 yof went to clinic for annual exam. Is interested in another contraception. Tried nuva ring but is not comfortable using it. She is interested in regular birth control. Only using condoms now. She wants a baby in 3 years
PMH/SH: adult onset acne age 24; seasonal allergies; obesity BMI 34 kg/m^2; tobacco use (1/2 ppd for 5 years)
Meds
- flonase 2 sprays per nostril daily
-benzoyl peroxide 2.5% cream apply twice daily topically
ibuprofen 200-400 mg occasionally for headaches or menstrual cramps

Which is the most appropriate option for patient

nexplanon implant for 3 years

patient is Greater than 30 BMI
age 35 and smokes less than 15 cigs a day

xulane (no age, tobacco, obesity, thrombosis risk)
mirena is usually 5 year time frame; she wants to have a baby in 3 years
depo provera no because delay of fertility

Patient 26 yof emergency contraception. currently on depo provera but missed her last appointment due to hectic work schedule
pmh/sh: migraine with aura; tobacco use (1ppd for 7 years)
med: depo provera

which of the following would be appropriate to recommend as routine contraceptive option

Mirena (levonorgestrel) iud

headache with aura and tobacco user--> no chc (no safyral (ethinyl 30 mcg and drospinerone 3 mg) no nuva ring (ethinyl estradiol and etonogestrel))

micronor (norethindrone 0.15 mg) patient missed last appointment for depo so pill might not be best based on compliance

Patient is a 24 yof at follow up appointment. She has a 1.5 yo daughter and reports monogamous relationship. uses condoms but wants hormonal contraceptive as she is interested in having more kids
pmh/sh: bacterial vaginosis (2009), no tobacco, no alc, no rec sub use
meds: multi vit when she remembers

which of the following would be most appropriate

nexplanon implant and mirena iud
xulane patch- no because compliance may be challenging

patient is 45 yof picking up otc advil from pharm and wants contraception. reports she is done childbearing and is interested in seeking method until husband gets vasectomy.
pmh/sh: hx dvt. drinks alc socially, no tobacco or rec sub abuse
med: ibuprofen when needed migraines

depo provera

coc -dvt risk so no
nexplanon too long, patient needs short term doesn't need 3 years

patient 41 yof requesting hormonal contraception. she is 8 weeks postpartum and is not breastfeeding, she does report that she is interested in conceiving again in about a year
pmh/sh: htn, obesity (bmi 31) no alc, tobacco or rec sub use
meds
-lisinorpil 10 mg daily
-hctz 25 mg daily
prenatal vit daily

which of the following contraceptives is best

ortho micronor (norethindrone)

risk factors
obesity, htn, vte risk,age
progestin only options for this patient
combined contraceptives are a no due to risk factors
depo no because delay of fertility

patient 46 yof picking up refill of junel 21 1/20 (ethinyl estradiol 20 mcg and norethindrone 1 mg). she reports using this for contraception and reduction in menstrual symptoms
pmh: no sig, no alc, no tobacco &rec sub use
meds: multi vit daily and ca supplement daily

What is important to advise/ recommend

complete her refill and assess if she has any questions

patient is a 28 yof picking up her refill of Loestrin FE 1/20 (ethinyl estradiol 20 mcg, 1.0 mg norethindrone acetate) she reports spotting during beginning of cycle
phm/sh: occassional dysmenorrhea, no alc, tobacco or rec use
meds
- multivit, naproxen 220 mg 1-2 tabs po q 6-8h when needed for menstrual cramps

what is most appropriate to advise/ recommend to address the patients spotting?

advise to follow up with pcp (increasing hormone content will likely address spotting)

early to mid cycle spotting is due to estrogen deficiency
late cycle spotting--> progestin deficiency