Contraceptive Methods (CMPP)

Contraception

: deferral of pregnancy

Sterilization

permanent contraception

Contraception efficacy

the number of unplanned pregnancies that occur during a specified period of exposure and with use of a contraceptive method

What determines the lowest expected failure rate of contraceptives

Clinical trails

What are the failure rates for contraceptives

Lowest expected (Very best performance)

Usual experience (Typical rates)

What are the types of contraceptive methods

Fertiliy awareness-based

Barriers

IUDs

Chemical

Estrogen and Progestin Combinations

Progestin-only

Sterilization

Fertility awareness-based methods of pregnancy prevention (FAB) / Nature Family Planning

observation of naturally occurring signs and symptoms of fertile phase of the menstrual cycle

variability in the timing of ovulation is the reason why the period of abstinence must be relatively lengthy

How long is sperm viable in the female reproductive tract

2-7 days

What is the lifespan of the ovum

1-3 days

What is the period of maximal fertility for females

5 days before ovulation and ends on ovulation

On average, how long does ovulation take to occur after LH speak

16 hours

On average, how long does ovulation take to occur after estradiol peak

24 hours

On average, how long does ovulation take to occur after rise in progesterone

8 hours

What is the failure rate of FAB contraception

25%

What patients are good candidates for FAB contraception

Motivated patients

Motivated partners and willing to support partner

Patients with regular menses

Method chosen based on preferences of the patient/partner and number of days that abstinence is needed to avoid pregnancy

Calendar Method (FAB)

Record the length of 6 cycles

Estimate the beginning of the fertile period by subtracting 18 days from the length of the shortest cycle

Estimate the end of the fertile period by subtracting 11 days from the length of the longest cycle

average couple would practice periodic abstinence with this method for 16 days each month

Cervical Mucus Method / Billing’s / Creighton’s / TwoDay (FAB)

Method required sensing or observing the cervical mucus change over time

Estrogen-induced changes in cervical mucus, which occur at midcycle

An increase in the amount of clear, thin, stringy mucus

can be used with irregular cycles

Day of ovulation corresponds closely to the day of peak mucus

Abstinence on consecutive days during postmenstrual preovulatory period so that seminal fluid will not obscure observation of cervical mucus changes

Abstinence when the mucus become sticky and moist

Intercourse is permitted beginning on the 4th day after the last day of sticky, wet mucus

avoid unprotected intercourse for 14-17 days of each cycle

What are the methods used to calculate FAB abstience

Calendar Method

Cervical Mucus Method

Symptothermal method

Standard days method

Symptothermal method

Combining the cervical mucus method with basal body temperature (BBT)

BBT is recorded with a basal body thermometer 1st thing in AM

Temperature rises about 0.2-0.4º C or 0.4-0.8ºF in response to ovulation due to progesterone

Intercourse resumes night of either the 3rd day of a temperature shift or the 4th day after the last day of sticky, wet mucus, whichever is later

This method can be used with irregular cycles

Avoids unprotected intercourse for 12 to 17 days of each cycle

Standard days method

Identifies 8-19 of the cycle as fertile days and should avoid intercourse during those days

Women are provided with CycleBeads, a visual aid to help them identify their cycle length, the day of the cycle, and the fertile days of the cycle

What FAB methods are used for regular menesus

Calendar

Standard Days

What methods of FAB are used for irregular

Cervical Mucus

Symptothermal

How do methods for FAB vary in days of abstinence needed

Calendar = 16

Cervical Mucus = 14-17

Symptothermal = 12-17

Standard Days = 8-19

How does symptothermal compare to cervical mucus method

More complicated

Efficacy is better slighty

What do the color beads mean for CycleBeads

Red = 1st Day of the Cycle (Menses)

Brown = Pregnancy most unlikely

White = Fertile days

Combination OCPs

Contain estrogen and progestin

How are combination OCPs dosed

Fixed dosing

Phasic dosin g

Fixed Dosing (OCP)

A dosing for combination OCPs where the same dose is given every day of the cycle

Phasic Dosing (OCP)

A combination OCP dosing where dose of progestin gradually increases with doses

Inert Pills

Pills given at the time of desired/expected menses to stimulated natural progesterone withdrawl

MOA of Combination OCPs

Estrogen suppresses FSH and prevents follicular development

Progesterone suppresses midcycle GnRH surge, suppressing LH and preventing ovulation

Thickens cervical mucus

Decreases fallopian mobility

Thins endometrium

MOA of Progestin Only OCP

Progesterone suppresses midcycle GnRH surge, suppressing LH

Mature follicle is formed but usually does not release

Thickens cervical mucus and mostly become impermeble

Thins endometrium

How does Progestin OCPs compare to Combination

Higher failure rate

How often does ovaluation occur with Progestin only OCPs

40%

When is Progestin-only OCPs used

Lactating Women

Women who cannot estrogen for medical reasons

What occurs with Progestin OCP more than Combination

Spotting

How should Progestin OCPs be taken

Same time every day, starting with first day of menses

Why is Progestin OCPs used for lactation

Estrogen inhibits breast milk production

When is a dose considered “late” for Progestin OCPs

> 3 hours from normal dose time

If a woman misses a dose of Progestin OCP or is late, what is recommended

48 hours of backup method of contraception

Absolute Contraindications to OCPs

Venous Thrombosis

Hx of PE

CAD

Malignant tumor of breast, endometrium, or melanoma

Hepatic Tumors

Abnormal LFTs

Current Pregnancy

Hx of Stroke

Classic Migraines

Relative Contraindications to OCPs

Uterine Fibroids

Lactation

DM

Cigarette Smoking

Depression

Migraines

Dyslipidemia

Anti-epileptics

Abx Use

Why are fibroids a relative contraindication for OCPs

Can cause fibroids to grow (with estrogen)

When does DM cause contraindication to OCPs

Retinopathy

HTN

Nephropathy

Vascular Complications

When is smoking considered an absolute contraindication to OCPs

> 35 y/o

Why is depression a relative contraindication to OCPs

May worsen

Why are classic migraines a contraindication to OCPs

Risk of increased thrombotic stroke

When does dyslipidemia become a contraindication for OCPs

TG > 350 mg/dL

Why is dyslipidemia a contraindication to OCPs

Risk of Pancreatitis

Risk of CV Disease

What anti-epileptics increase breakdown of sex steroids, thus causes break through bleeding nad decreasing OCP effectiviness

Phenobarbital

Dilantin (Phenytoin)

What anti-epiletics do not effect OCPs

Valium (diazepam)

valproic acid (Depakene)

What is the only Abx proven to cause decreased effectiveness of OCPs

Rifampin

What are the components of the pretreatment eval for OCPs

Good personal and family history

Pretreatment Pap (unless < 21 y/o)

Ascertain contraindications

Instruct on use and side effects

Ask why doses are missed

What is the failure rate of OCPs

3% per year

What is the follow-up for OCP initation

3 months then annual for BP

What are come noncontrapcetive benefits of OCPs

Reduces dysmenorrhea

Reduces pelvic pain with endometriosis

Reduces menorrhagia

Reduces ectopic pregnancy risk

Redcues premenstrual syndrome / dysphoric disoder

Reduces risk of benign breast disease

Reduces ovarian cyst development

Reduces ovarian cancer

Reduces endometrial cnacer

Reduces colorectal cancer

Reduces moderate acne

Reduces hirsutism

More regular cycles

Common S/E to OCPs

Breakthrough bleeding

Weight gain

Headache

Mood change

Nausea and breast tenderness

Lipid/lipoprotein effects

Thrombotic effects

Breakthrough bleeding

unexpected vaginal bleeding or spotting that occurs between menstrual periods or during pregnancy

What is BTB associated with in OCPs

Dose

Potency

Individual Physiologic Response

How long is BTB caused normal for OCPs

First few cycles

If BTB persists with OCPs, what should be done"

Work up

What type of dosing has less risk of BTB

Fixed / Monophasic

What is the maximum weight gain after starting OCPs in one year

5 lbs

If headaches occur after starting an OCP but occur during the pill-free interval, what is the likely cause

Estrogen withdrawl

If headaches occur after starting an OCP but occur during the pill-free interval, what can prevent them

Continuous therapy

What hormone causes the nausea and breast tenderness?

Estrogen

What is the lipid effect of OCPs related to

Androgencitiy of progrestin

Estrogen : Progesterone Ration

What effect on lipids do combination OCPs have

Increases TG

What hormone is resposible for thrombotic effect of OCPs

Estrogen

Why does estrogen increase clotting

Increases Factor VII

Increases Factor X

Decreases ATIII

When is Postcoital contraception most effective

taken 72 hours of unprotected intercourse

When should postcoital contraception be considered

Sexual Assualt

Broken condoms

Dislodging of Diaphargms or Cervical Caps

Lapsed Use of Birth Control

Levonorgestrel (Plan B)

Postcoital contraception

What are the dosings for Levonorgestrel

2 tablets of 0.75 mg 12 hours apart

1.5 mg single dose

Failure Rate of Postcoital Contraception

25%

Ulipristal acetate (UPA)

Postcoital contraception

MOA of UPA

Antiprogestin

Delays ovaluation

Downside to Using UPA for Postcoital Contraception

Requires an Rx

medroxyprogesterone (DepoProvera)

Depot IM/SubQ injection contraceptive

When should DepoProvera be given

Within 5 days of current mensural cycle

Failure Rate of DepoProvera

0.3 %

MOA of DepoProvera

Blocks LH surge and ovulation

Decreases endometrial thickness

Increases cervical mucus

SUpression of FSH (Less than combination OCPs)

Follicular growth is maintained

Estrogen level = Early follicular levels

Benefits for DepoProvera

Not related to compliance or coital even

Benefits as progestins

3 month duration

Contraindications for DepoProvera

Pregnancy

Undiagnosed vaginal bleeding

Breast Cancer

Liver Disease

Side Effects of DepoProvera

Irregular menstural bleeding

Weight gain

Depression

Decreased HDL

Risk of neonatal / infant morality due to IUGR

BLACK BOX: Bone Loss / Significant loss of Bone Mineral Density

When does DepoProvera usually cause amenorrhia

After 1 year of use

What is the expected weight gain from DepoProvera

5 lbs

How long can weight from DepoProvera remain

6-8 months

How long can it take for ovulation to start after discontinuing DepoProvera

1 year

Who is at risk loss of bone due to DepoProvera

Age 18 to 54

What is the screening needed for patients on DepoProvera

DEXA scan after 2 years of use

Implanon (etonogestrel)

Implantable hormone

Single rod inserted under the skin of the upper arm

Side Effects of Implanon (EtonogesterL)

Irregular menstural bleeding

Weight gain

Depression

Failure Rate of Etonogesterl

0.2 %

Duration for Etonogesterl Implants

3 years

OrthoEvra

Weekly hormonal birth control patch that contains estrogen and progestin (norelgestromin/ethinyl estradiol)

MOA of OrthoEvra

Estrogen suppresses FSH and prevents follicular development

Progesterone suppresses midcycle GnRH surge, suppressing LH and preventing ovulation

Thickens cervical mucus

Decreases fallopian mobility

Thins endometrium

How is OrthoEvra used

Patch is worn for one week and replaced on the same day of the week for three consecutive weeks, the fourth week is “patch-free”

Patch placed on clean, dry skin located on the buttocks, upper outer arm, or lower abdomen

Benefits to OrthoEvra

Convenient, nothing to remember daily for birth control

Same benefits as oral contraceptives

Contraindication for OrthoEvera

Same as OCPs

Patient > 200 lbs