Hormonal Contraception – Lecture Notes

Overview & Context

Lecture focus: hormonal (pharmacologic) contraception; non-pharm methods previously covered and remain examinable for counseling scenarios.
Case-based exam (K-Sim) will require BRAND + GENERIC memorization of the products listed in the instructor’s drug tables.
Pharmacists in many U.S. states can now PRESCRIBE certain contraceptives (MA: pill + patch; NH: pill, patch, ring, shot)⟶ real-life relevance.
Paradigm shift: move from effectiveness-only, clinician-driven recommendations toward SHARED DECISION-MAKING that centers patient autonomy and avoids reproductive coercion (historical IUD & sterilization abuses cited).

Hormonal Components & Mechanisms

All prescription contraceptives contain a SYNTHETIC PROGESTERONE ("progestin").
• Blocks LH surge ⟶ ↓ ovulation.
• Thickens cervical mucus ⟶ ↓ sperm penetration.
• Induces endometrial ATROPHY ⟶ ↓ implantation + lighter periods.
Optional ESTROGEN (almost always Ethinyl Estradiol – “EE”; abbreviation acceptable on K-Sim).
• Suppresses FSH, stabilises endometrium ⟶ predictable, cyclic bleeding.
• Adds NO essential contraceptive efficacy; purpose is cycle control and some symptom relief.

Product Categories

COMBINED HORMONAL CONTRACEPTIVES (CHCs = EE + progestin)
• Oral pill (CHC pill/COC)
• Transdermal patch
• Vaginal ring
PROGESTIN-ONLY METHODS (no estrogen)
• POP = “mini-pill”
• Depot shot (q3-month injection)
• Subdermal implant
• Hormonal IUDs
• Oral & non-oral emergency contraception
Non-hormonal (copper IUD, condoms, etc.)—discussed previously.

Efficacy & Adherence Reality Check

With PERFECT use every method ≈ $99\%$ effective.
Real-world ("typical") failure rates track with adherence demands:
• LARC (IUD, implant) >99\%—user independent.
• Depot shot $94\%$ (requires clinic q3 mo).
• CHC pill/patch/ring $91\%$ .
• POP lowest—very tight dosing window.
Key counseling pearl: discuss the behavioral element rather than the product “strength.”

Safety Screening (7 MUST-KNOW Contra-indications)

Color coding on instructor’s table: CHCs = RED across all; progestin-only = predominantly GREEN.

Current OR history of BREAST CANCER – avoid ANY estrogen or progestin.
Post-partum < $6$ weeks OR breastfeeding < $30$ days (hyper-coagulable state).
MIGRAINE WITH AURA (visual/auditory/neuronal prodrome).
Personal history of VTE / DVT / PE / MI / STROKE (“blood-clotty things”).
HYPERTENSION (controlled or uncontrolled) in contraception context.
Age ≥ $35$ and SMOKING/VAPING (any quantity).
Severe hepatic disease† (implied on CDC chart) – instructor groups under clot categories.
†Family history of breast cancer = category 1 (still OK).

The CHC Pill, Patch & Ring – Core Facts

Contain both EE + progestin ⟶ regular withdrawal bleed each cycle.
Daily (pill) / weekly (patch) / q4-wk (ring) dosing; $24$ -hour grace window for missed CHC pill.
Return-to-fertility: IMMEDIATE (within < $24$ h of last dose) – dispels infertility myth.
Common hormonal adverse effects: breast tenderness, nausea, headaches, spotting—usually self-limit by month 3.
SERIOUS adverse mnemonic ACHES (emergent stop + ED):
• Abdominal pain
• Chest pain/SOB
• Headache “worst ever”
• Eye/vision changes
• Severe leg pain (calf/thigh)

Choosing a CHC Pill – Stepwise

Pick ESTROGEN DOSE (dose = risk)
• Very-low <15 µg (special situations).
• Low $15–30$ µg – DEFAULT for exams.
• Moderate $30–35$ µg – consider in known poor adherers for "forgiveness."
• High $50$ µg – never first-line in contraception questions.
Pick PROGESTIN GENERATION (bold = exam list)
• 1st gen – norethindrone, etynodiol; well-studied, neutral.
• 2nd gen – levonorgestrel, norgestrel; lowest VTE risk but more ANDROGENIC (acne, hirsutism, lipids).
• 3rd gen – desogestrel, norgestimate; middle-ground.
• 4th gen – drospirenone, dienogest; anti-androgenic (great for adolescent acne) but HIGHEST VTE risk & causes hyper-K⁺ (spironolactone-like).
• Age-based example: 16-y/o with cystic acne ⟶ 4th gen; 38-y/o smoker ⟶ 2nd gen.
Screen for DRUG INTERACTIONS
• Proven antibiotic interaction: $\text{rifampin / rifabutin}$ (TB tx).
• ANTICONVULSANTS (carbamazepine, phenytoin, topiramate, oxcarbazepine, phenobarbital, primidone) – induce enzymes, ↓ CHC & POP pill efficacy.
• Drospirenone + K⁺-sparing or ACE/ARB, NSAID, heparin ⟶ monitor $\text{K}^+$ .
• Certain PI/NNRTI HIV drugs (check app).
• St John’s Wort (CYP induction).
• Tirzepatide (Mounjaro) – slows GI motility → switch to NON-oral method; other GLP-1s okay.
Choose PACK TYPE
• Monophasic (21/7) – same dose x3 weeks + 7 placebo; simple titration; lighter bleed.
• Multiphasic – varying doses; NO proven side-benefit; harder for clinicians.
• Extended cycle / Continuous
– 24/4 packs (e.g., "Loestrin 24 \textit{Fe}"): extra EE days + iron placebo for IDA pts.
– 84/7 packs ("Seasonique"): period every $3$ months ("seasonal").
– 365/0 continuous (e.g., Amethyst): amenorrhoea.
Decide START PROTOCOL
• Day-1 (menses day 1) – $0$ backup days; may delay initiation.
• Sunday start – first Sunday after onset; $7$ -day backup; goal weekend-free menses.
• Quick start (preferred) – start today; $7$ -day backup; use sticker strip to reset weekday labels.

Drug Interaction Deep Dive (high-yield list)

Avoid CHC & POP pill with:
$\boxed{\text{Rifampin/Rifabutin}}$
$\boxed{\text{Inducing anticonvulsants (list above)}}$
Drospirenone – check $\text{K}^+$ with ACEI/ARB, spironolactone, eplerenone, NSAIDs.
HIV meds – ritonavir, efavirenz, etravirine may ↓ EE levels.
Herbal – St John’s Wort category 2 (avoidable).
Tirzepatide – switch to non-oral form during therapy.

Return to Fertility & Special Concerns

CHC, POP, implant, IUD: fertility returns within <1 cycle.
Depot shot (covered in later lecture) – median $\approx 9$ months delay, up to $18$ mo.
Myth-buster: OCs do not cause long-term infertility; missed pill >24 h can allow ovulation.

Patient Counseling & Practical Pearls

Perform reasonable-sure-not-pregnant screen (pregnancy test only positive wk 4–5).
Reinforce 3-month "stick-with-it" trial for minor hormone side effects.
Teach ACHES warning signs & emergency protocol.
Supply sticker strip, missed-dose instructions, and backup-method timeframes.
Discuss period management options (skip placebo; schedule around wedding, travel, athletics).
Emphasise STI protection still requires barrier methods.

Ethical, Social & Regulatory Notes

CDC “U.S. MEC” app (logo "Contraception") gives colour-coded 1–4 safety categories; pharmacists rely on it instead of memorizing 6-page contras.
Federal guideline websites have faced political takedown (HIV guidelines already removed)—possibility of contraception guidance removal mentioned.
Historical coercion examples (provider refusal to remove IUD, pressuring high-efficacy methods) underline importance of patient choice.

Key Numbers & Formulas to Memorize

Pregnancy test positive ≈ wk $4\text{–}5$ gestation.
CHC typical failure $91\%$ , shot $94\%$ , LARC >99\%.
Post-partum CHC delay: $\le 42\text{ days}=6\text{ weeks}$ .
Backup after quick/Sunday start: $7\text{ days}$ barrier.
Depot shot re-dose every $\approx 90$ days (content teased for next lecture).

(End of detailed bullet-point study notes. All elements correspond to the transcript; mathematical figures rendered in LaTeX syntax where required.)

The professor mentioned and emphasized the following progestin components of CHCs (Combined Hormonal Contraceptives) to know, noting they are on the "exam list":

Levonorgestrel (2nd generation)
Norgestrel (2nd generation)
*

The professor emphasized several key aspects regarding oral combined hormonal contraceptives (CHCs):

Core Facts: CHC pills contain both Ethinyl Estradiol (EE) and a progestin, leading to regular withdrawal bleeding. They are typically dosed daily, with a 24-hour grace window for a missed pill. Fertility returns immediately after cessation.
Common Adverse Effects: Patients should be counseled on typical side effects like breast tenderness, nausea, headaches, and spotting, which usually self-limit by the third month.
Serious Adverse Effects (ACHES): Patients must be educated on the ACHES mnemonic which indicates emergent situations requiring immediate medical attention: Abdominal pain, Chest pain/SOB, Headache “worst ever”, Eye/vision changes, and Severe leg pain.
Choosing a CHC Pill Stepwise Process: This involves selecting:
- Estrogen Dose: Low dose (15–30 µg) is the default for exams.
- Progestin Generation: Specifically, the professor emphasized knowing levonorgestrel and norgestrel (both 2nd generation) as they are on the exam list. These have the lowest VTE risk, though they can be more androgenic. Fourth-generation progestins like drospirenone were also highlighted for their anti-androgenic properties (useful for acne) but also for their highest VTE risk and potential for hyperkalemia.
- Drug Interactions: High-yield interactions to avoid with CHC pills include $rifampin/rifabutin$ and inducing anticonvulsants. For drospirenone, monitoring $K^+$ with ACEI/ARB, spironolactone, eplerenone, or NSAIDs was stressed. Caution with HIV medications, St. John's Wort, and Tirzepatide (requiring a switch to non-oral methods) was also noted.
- Pack Type: Monophasic (21/7) packs are simple, while extended-cycle or continuous regimens can lead to fewer periods or amenorrhea.
- Start Protocol: The