Part 3 - Hormonal Contraceptives_2024
Hormonal Contraceptives Overview
1. Introduction
Instructor: Sarah E. Kubes, PharmD, BCPPS.
Updated By: Melanie Sokol, PharmD Candidate 2023.
Affiliations:
Clinical Assistant Professor, College of Pharmacy, The University of Texas at Austin.
Adjoint Assistant Professor, School of Medicine, University of Texas Health Science Center at San Antonio.
Pediatric Clinical Specialist Pharmacist, University Health System.
2. Objectives
Understand the intricate role of sex hormones such as estrogen and progesterone in regulating the female reproductive cycle, including the follicular and luteal phases.
Evaluate a variety of non-hormonal contraception methods and articulate their effectiveness and application.
Compare different hormonal contraceptives based on their mechanisms, delivery methods, and patient outcomes.
Explain contraindications specific to various contraceptive methods, focusing on individual patient health profiles.
Design a personalized contraceptive plan considering age, medical history, lifestyle, and reproductive goals.
3. Key Terminology
Assigned Sex at Birth: The sex assigned by medical personnel at birth based on physical anatomy, often categorized as male or female.
Cisgender: An individual whose gender identity aligns with the sex they were assigned at birth.
Transgender: An individual whose gender identity differs from the sex assigned at birth, encompassing a wide range of identities.
Biological Definitions:
Female: Generally characterized by the capacity to produce ova (eggs) in reproductive systems.
Male: Typically associated with the production of motile gametes (spermatozoa).
Gender: A complex social construct that encompasses societal expectations, roles, and traits traditionally attributed to being male or female.
4. Outline of Topics
Part 1: Hormones and the Menstrual Cycle o Importance of hormone fluctuations and their physiological impacts.
Part 2: Non-hormonal Contraceptives
Efficacy, mechanisms, and suitability for different populations.
Part 3: Hormonal Contraceptives
In-depth examination of various hormonal contraceptives, including prevailing theories on their effectiveness.
Part 4: Patient-Specific Contraceptive Selection
Tailoring approaches based on patient history, preferences, and lifestyle.
5. Types of Contraceptives
Non-Hormonal:
Fertility awareness method: Tracking ovulation cycles to avoid pregnancy.
Withdrawal method: The male partner withdraws before ejaculation.
Spermicides: Chemicals that immobilize sperm.
Barriers (includes condoms, sponge, cervical cap, diaphragm): Physical blockades to sperm entry.
Copper IUD: A non-hormonal device that releases copper to prevent sperm from fertilizing an egg.
Sterilization/Vasectomy: Permanent methods for those who do not wish to conceive.
Hormonal:
Pills (combined and progestin-only): Daily oral pills containing hormones.
Patch: A transdermal system releasing hormones through the skin.
Vaginal Ring: A flexible ring inserted into the vagina, releasing hormones locally.
Injectable: Often administered quarterly or biannually.
Implants: Subdermal implants offering long-term hormone release.
Hormonal IUD: Releases hormones locally within the uterus.
Emergency contraception: Pills taken after unprotected intercourse to prevent ovulation or fertilization.
6. Efficacy of Contraceptives
Higher Efficacy:
Implant systems, injections, and hormonal IUDs have efficacy rates exceeding 99%.
Appropriate Use Effectiveness:
Birth control pills and patches can be 91-99% effective with proper adherence and management.
Barriers:
Typical use shows effectiveness ranging between 79-88%, dependent on proper application and consistency.
7. General Information
No method except abstinence guarantees 100% pregnancy prevention.
Utilizing dual methods (e.g., condoms with hormonal methods) substantially increases efficacy.
Comprehensive education regarding contraceptive risks, benefits, potential side effects, and sexually transmitted infections (STIs) is crucial for informed decision-making.
Emergency contraception options must be readily available and understood by women.
8. Key Takeaways from Practice Data
As of 2017-2019, 65% of women aged 15-49 utilized some form of contraception.
Common methods noted included: Female sterilization, oral contraceptive pills, male condoms, and Long-Acting Reversible Contraceptives (LARCs).
Contraceptive adoption varies widely by factors such as age, educational background, and racial/ethnic demographics.
9. Types of Hormonal Contraceptives
Oral:
Combined Oral Contraceptive Pills (OCPs): Contain both estrogen and progesterone.
Progestin-only pills: Suitable for various situations, particularly for breastfeeding women or those with certain contraindications to estrogen.
Injectable: Depo-Provera®; administered every three months.
Vaginal Ring: NuvaRing®; replaced monthly, releasing hormones directly in the vaginal canal.
Transdermal Patch: OrthoEvra®; provides consistent hormone exposure throughout the week.
IUDs:
Mirena, Skyla: Intrauterine devices releasing levonorgestrel for long-term contraception.
Implant: Nexplanon™; a small rod implanted under the skin for long-term hormone release.
Emergency Contraception: Plan B®; utilized post-unprotected intercourse to prevent pregnancy.
10. Mechanism of Action for Combined OCPs
Prevent ovulation by suppressing the release of Luteinizing Hormone (LH) and Follicle-Stimulating Hormone (FSH) through a mix of estrogen and progestin.
Secondary mechanisms include:
Thickening of cervical mucus, creating a barrier to sperm passage.
Alteration of the endometrial lining to prevent implantation of a fertilized egg.
11. Pros & Cons of Combined OCPs
Pros:
High effectiveness in preventing pregnancy; potential reduction in ovarian/endometrial cancer risk; may decrease the incidence of ovarian cysts and pelvic inflammatory disease (PID).
Cons:
Associated risks include thrombosis, stroke, as well as side effects such as headache, nausea, and mood changes (abbreviated as ACHES: Abdominal pain, Chest pain, Headaches, Eye problems, Severe leg pain).
12. Contraindications for Combined OCPs
Absolute Contraindications:
Thromboembolic disorders (such as deep vein thrombosis), diagnosed estrogen-dependent cancers (like certain breast cancers), and active liver disease.
Relative Contraindications:
Include but are not limited to: uterine abnormalities, multiple sexual partners increasing STI risk, and women over 35 years with risk factors such as smoking.
13. Handling Missed Doses
Guidelines for handling missed doses vary between combined OCPs and progestin-only pills. The appropriate course of action depends on how many doses were missed and the specific timing of the missed doses.
14. Special Population Considerations
Women/Age > 40: Despite the increased risk of infertility, many can still conceive; personalized counseling and options recommended.
Post-Partum Women: Initiation of combined OCPs is typically recommended 3-4 weeks post-delivery to reduce risks related to clotting.
Breastfeeding Women: Progestin-only methods are preferred to avoid potential risks associated with estrogen's impact on milk supply.
15. Newer Contraceptives
Innovations include Opill (the first over-the-counter birth control pill), Phexxi® (a non-hormonal vaginal gel), Ovaprene (a hormonal vaginal ring), and additional methods under research that aim to enhance efficacy and safety.
16. Patient Education Points
Essential to discuss contraceptive methods, initiation schemes, what to expect regarding side effects and efficacy, and potential drug interactions that may influence contraceptive effectiveness.
17. Case Studies & Practical Application
Employ practice scenarios designed to assist in recommending appropriate contraceptive methods tailored to individual patient information and unique health needs.