OB- Contraception and Hormonal Management

Clinical Introduction and Patient Selection Considerations

• Taking contraception seriously is paramount; non-adherence or contraindication risks are significant, with some risks being $10\%$ higher compared to patients who do not have specific risk factors.

• The primary goal of a clinical encounter is to match the right method to the right patient to avoid wasting time for both the provider and the patient.

• Crucial questions to ask during a patient history intake include:

  • Have you used anything before?

  • Did that method work for you?

  • What did you like about the method?

  • What did you not like or what didn't work?

  • Do you want to get pregnant in the future? (Crucial for determining the timeline of fertility return).

• Consider practical limitations such as the ability to swallow pills. There are patients who physically cannot swallow pills due to medical history, such as an esophageal injury from a suicide attempt via overdose.

• Lifestyle and memory must be assessed: Some patients find it easier to remember a daily task, while others prefer weekly or even less frequent intervals.

• Discuss side effect preferences: Modern medicine allows for the near-complete removal of the menstrual cycle, which some patients view as a significant benefit, while others may find it concerning or undesirable.

Contraception Efficacy and Failure Rates

• In a healthy couple consisting of one man and one woman using no prevention, the likelihood of conception within a year is approximately $85\%$.

• The goal of contraception is to reduce that rate to as close to $0\%$ as possible.

• Perfect Use: This represents the statistics when a patient uses the method exactly as prescribed without any errors.

• Typical Use: This represents how people actually use methods in the real world, accounting for human error, which significantly increases failure rates for certain methods.

• Comparing methods:

  • Long-Acting Reversible Contraception (LARC) and sterilization occupy the highest tier of efficacy where perfect use and typical use circles overlap almost exactly on reliability graphs.

  • As methods move toward barrier or behavioral options, the gap between typical and perfect use widens significantly, making them less reliable.

Long-Acting Reversible Contraception (LARC)

• LARC is the recommended option for patients who want highly reliable protection but want the option to become pregnant again in the future.

• Subdermal Insert: An implant that is placed under the skin of the upper arm.

• Intrauterine Devices (IUDs): All forms of IUDs fall under the LARC category.

• These methods are considered "top-tier" because they remove the element of daily or weekly user error.

Contraindications and Safety for Estrogen-Based Methods

• Combined hormonal contraceptives containing estrogen are contraindicated in several specific populations:

  • Patients with liver disease (severe).

  • Current smokers who are $35$ years of age or older and smoke more than half a pack of cigarettes per day.

  • Patients with a history of Migraine with Aura (due to increased stroke risk).

  • Patients with suspected or confirmed breast cancer.

  • Patients with certain cardiovascular diseases.

• Blood Pressure Limitations:

  • Preferably, blood pressure should be less than $140/90$\n - Within the range of $140/90$ to $160/110$, combination methods might be used if they are the only option, but it is not preferred.

  • Combination estrogen methods should not be used if blood pressure is $160/110\,\text{mmHg}$ or higher (severe features).

• Progesterone Alternatives: Progesterone-only methods (Progestin) can be used safely in almost all cases where estrogen is contraindicated, including for patients with migraine with aura or obesity.

• Obesity: It is safer for an obese patient to be on contraception than it is for them to become pregnant, despite common misconceptions regarding weight and hormonal safety.

• Anti-seizure Medications: Providers must be careful as certain seizure medications can reduce the efficacy of hormonal contraception.

• Anticoagulants: Modern anticoagulants are much more compatible with contraceptive methods than older versions.

Impact on Cancer Risks

• Breast Cancer: The relative risk of breast cancer increases with duration of use. Using hormonal contraception for more than $10$ years is associated with a relative risk of $1.3$.

• Ovarian Cancer: There is a significant reduction in ovarian cancer risk, estimated at a $40\%$ to $50\%$ reduction.

  • Clinical Note: While breast cancer is serious, the $5$-year survival rate is over $90\%$. Conversely, the $5$-year survival rate for ovarian cancer is only $20\%$ to $30\%$. Therefore, the protective benefit against ovarian cancer is a critical clinical consideration.

• Other Cancers: Hormonal contraceptives also appear to reduce the risk of colorectal and endometrial cancers.

Hormonal Pill Administration and Variations

• Monophasic Pills: These contain the same amount of hormone in every active pill. In a pack, active pills (often colored) can be swapped (e.g., pill $4$ and pill $13$) without affecting efficacy.

• Biphasic and Triphasic Pills: These change the hormone dosage weekly to mimic a more physiological cycle. Examples include Trilevulin and Ortho-Tri-Cyclen.

• Extended Cycle/Continuous Use: Some pills are designed to limit menstruation to four times a year (90-day cycles).

  • Patients can skip the "fake week" (placebo pills) to avoid having a period entirely.

  • There is no physiological necessity to have a monthly withdrawal bleed.

  • Insurance companies may sometimes resist covering this if the prescription is not written specifically for continuous use, as the patient will cycle through packs $25\%$ faster.

Initiation Protocols

• First Day Start: Starting the pill on the first day of the menstrual period.

• Sunday Start: Starting on the first Sunday after the period begins. This was traditionally used so the withdrawal bleed would not occur on a weekend.

• Quick Start Method: The preferred clinical method. If the patient's pregnancy test is negative in the office, they start the method immediately regardless of where they are in their cycle.

  • Requirement: Use a backup method (condoms or abstinence) for $7$ days after starting.

  • If the patient has had unprotected intercourse in the last $5$ days, the protocol may vary regarding the pregnancy test timing.

Injectable and Invisible Methods

• Depo Provera (The Shot):

  • Administered every three months.

  • Side effects often include irregular bleeding initially, followed by amenorrhea (cessation of periods).

  • Crucial Caveat: Fertility may not return to normal for up to $10$ months after the first injection. This is not the right method for a patient who wants to be pregnant within a few months (e.g., wanting to be pregnant by January when it is currently July).

• Visibility Concerns: The injection is the only truly "invisible" method. This is important for patients in situations of reproductive coercion where a partner or parent might discard pills or try to remove an IUD.

Vaginal Rings

• NuvaRing:

  • A disposable ring used for one cycle and then thrown out.

  • It can be placed anywhere in the vagina; it does not need to be in a specific spot to be effective.

  • Historically used for $3$ weeks on and $1$ week off, but can be left in for up to $5$ weeks.

  • Patients can use these back-to-back to skip periods.

  • It can remain in the vagina during sexual intercourse.

• Annovera:

  • A newer reusable ring (released approximately $6$ years ago).

  • One ring lasts for an entire year ($13$ cycles).

  • It can be used for $3$, $4$, or $5$ weeks at a time, or left in continuously. It eliminates the need for monthly pharmacy visits.

Questions & Discussion

• Question: Is the estrogen contraindication specifically if they have visual aura?

• Response: Correct. If the patient has migraine with visual aura, estrogen should be avoided, and progesterone/progestin should be used instead.