Professional Documents
Culture Documents
Objectives
Describe the pharmacologic differences in
oral contraceptives
Differentiate relative and absolute
contraindications to contraceptives
Review the wide range of contraceptive
choices
Identify patients who need emergency
contraception and describe the methods
of emergency contraception.
Outline
Oral contraceptives
Patch contraceptives
Injectable contraceptives
Ring contraceptives
Implantable contraceptives
Intrauterine devices
Emergency contraception
Disclaimer
I have nothing to disclose and have no
financial relationships with any
pharmaceutical or biotech company
I have used brand names in this
presentation to allow better understanding
and application to practice
SORT Taxonomy
A Consistent, good-quality patientoriented evidence
B Inconsistent or limited-quality patient
oriented evidence
C Consensus, disease-oriented
evidence, usual practice, expert opinion,
or case series for studies of diagnosis,
treatment, prevention, or screening
Important Dates
Egyptian women use a pessary made of crocodile
dung and lubricated with honey to prevent
pregnancy
1700s condoms made of animal intestine used
mainly for prevention of syphilis
1900 The first modern IUD is marketed
1960 FDA approves the first oral contraceptive
containing 150 g of mestranol
1974 Dalkon Shield is withdrawn from the market
2002 Norplant is removed from the U.S. market
Oral Contraceptive
Trends
Lower doses of estrogens
Newer progestins
Chewable tablets
Fewer hormone free days
Longer cycles (or no cycles)
Activity of OCPs
Contraceptive activity (efficacy)
Estrogenic activity
Progestational activity
Androgenic activity
Endometrial activity
Effect on serum lipoproteins
Managing Contraceptive Pill Patients, Twelfth Edition. Dickey R.
Estrogens in OCPs
Most pills use ethinyl estradiol (EE) as
their estrogen (50 g mestranol = 35 g
EE)
Doses range from 20 g 50 g, but most
are 20 g 35 g
Lower dose estrogens have the benefits of
less bloating and breast tenderness but
may increase the rate of breakthrough
bleeding especially in obese patients
Estrogens in OCPs
2004 Cochrane review
Low-dose estrogen OCPs resulted in
higher rates of bleeding pattern disruptions
Safety or effectiveness at preventing
pregnancy could not be assessed
Differences in progestin types not
accounted for
SORT A
Gallo MF, Nanda K, Grimes DA, Schulz KF. 20 mcg versus > 20 mcg Estrogen
Combined oral contraceptives for contraception. Cochrane Database
Newer Progestins
Minimal androgenic effects
Norgestimate
Desogestrel (etonogestrel)
Drospirenone
Antimineralocorticoid activity
Theoretically could cause hyperkalemia
Essentially no androgenic activity
Cochrane Database of Systematic Reviews 2007 Van Vliet HAAM, Grimes DA, Lopez LM, Schulz KF,
Helmerhorst FM. Triphasic versus monophasic oral contraceptives for contraception
Van Vliet HAAM, Grimes DA, Helmerhorst FM, Schulz KF. Biphasic versus monophasic oral contraceptives
for contraception
Gallo MF, Lopez LM, Grimes DA, Schulz KF, Helmerhorst FM. Combination
Contraceptives:effects on weight. Cochrane Database of Systematic Reviews 2007
Issue 2
Femcon Fe
The new name for Ovcon Fe chewable
Chewable spearmint flavored tablet
EE 35 g, norethindrone 0.4 mg (21 days)
Placebo contains 75 mg ferrous fumarate
ADVANTAGE: For those who cannot swallow
pills (and need fresh breath)
Yaz 24/4
Same ingredients as Yasmin but
EE 20 g (instead of 30 g)
3 mg of drospirenone
24 days of active medication and 4 days of placebo
(as compared to the usual 21/7)
ADVANTAGE:
Has an FDA indication for premenstrual dysphoric
disorder (the only hormonal contraceptive with this)
Shorter periods
Loestrin 24 Fe
24 days of hormones (similar to Yaz 24/4)
EE 20 g, Norethindrone 1 mg
Placebo pills contain iron
ADVANTAGE:
Periods last less than 3 days
More pronounced suppression of follicular
development
Seasonique
Like Seasonale:
EE 30 g, levonorgestrel 0.15 mg for 12 weeks
But
13th week contains EE 10 g (instead of placebo)
ADVANTAGES:
Low dose EE may reduce hormone withdrawal
symptoms (migraines and dysmenorrhea)
May cause less breakthrough bleeding then with
Seasonale (main reason women stop Seasonale)
Lybrel
Taken in a continuous 365-day regimen
EE 20 g and levonorgestrel 0.09 mg
28 pills in a pack
FDA approved and will be released July 2007
ADVANTAGE:
No menstrual bleeding
During the 13 pill pack:
59% of women achieve amenorrhea
20% of women have spotting only
21% of women required sanitary protection due to
breakthrough bleeding
http://www.drugs.com/newdrugs/fda-approves-lybrel-first-low-combination-oralcontraceptive-offering-women-opportunity-period-free-491.html?printable=1
Contraindications to Combined
Oral Contraceptives
Unexplained VTE or VTE associated with
pregnancy or exogenous estrogen use
(unless on anticoagulants)
Women age 35 and older who smoke
Poorly controlled diabetes or diabetes with
complications such retinopathy,
nephropathy, or other vascular
complications
Level A
Use of hormonal contraception in women with coexisting medical conditions. ACOG
Practice Bulletin No. 73. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2006: 107:1453-72.
Contraindications to Combined
Oral Contraceptives
OCPs should be stopped one week prior to
surgery or heparin prophylaxis should be
considered
Women with CAD, CHF, or cerebral vascular
disease
Use caution in obese women over the age of 35
Poorly controlled HTN (or complications)
Patients with Factor V Leiden gene mutation or
prothrombin gene mutations
Level B
Use of hormonal contraception in women with coexisting medical conditions. ACOG
Practice Bulletin No. 73. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2006: 107:1453-72.
Other Subgroups
BRCA1 and BRCA2 mutation carriers
No increased breast cancer risk before age
50 with at least one year of use
Possible increased risk in BRCA2 carriers
who have been on OCP's for at least 5 years
Injectable Contraceptives
Only one currently available is DepoProvera
Lunelle was withdrawn from the US due to
lack of demand and a recall (half-filled
syringes)
Depo-Provera
Medroxyprogesterone 150 mg given IM every 1113 weeks
New Depo-subQ Provera 104
Given every 12-14 weeks
Can be administered by the patient in the thigh or
abdomen
NuvaRing
EE 15 g/day and etonogestrel 0.12mg/day
Inserted into vagina and left in for three weeks
Removed for one week
Can be re-inserted if it has been out for less than
three hours (rinse with cold or warm water, not
hot)
8/10 partners do not feel the ring during
intercourse (can removed prior to intercourse)
http://www.nuvaring.com/HCP/PrescribingNuvaRing/StartingYourPatients/index.asp
Implantable Contraceptives
Norplant was on the US market from
1991-2002
Six rods containing levonorgestrel
Several class action law suits over:
Failure to disclose side effects (irregular
bleeding)
Difficulty removing rods
Implantable Contraceptives
IMPLANON released August 2006
One rod containing etonogestrel
Can be left in for up to three years
Only providers who have completed a
comprehensive practical training session
can insert IMPLANON (sponsored by
Organon)
www.implanon-usa.com
IMPLANON
Mean insertion time 1.3 minutes (range 115 minutes)
Mean removal time 3.8 minutes (range 160 minutes)
4 cm long and 2 mm in diameter
IUDs
Fell out of favor in the 70s and 80s
There are two on the market today
Paragard
Lasts 10 years
Copper (non-hormonal)
Increase bleeding with menses
Mirena
Lasts 5 years
Contains levonorgestrel
Bleeding will decrease or even become absent!
IUDs - Contraindications
ACTIVE pelvic inflammatory disease
Pregnancy
Current sexual behavior suggesting a high risk
for PID
Post-pregnancy or post-abortion uterine infection
in the past three months
Cancer of the uterus or cervix
Infection of the cervix
Vaginal bleeding of unknown cause
http://www.paragard.com/hcp/custom_images/ParaGard_HCP_Safety_Info.pdf
IUDs - Complications
PID/endometritis
Very rare use of prophylactic antibiotics
confer little benefit prior to insertion
(Grimes DA, Schulz FK. The Cochrane
Database of Systematic Reviews SORT A)
Uterine perforation
Expulsion of IUD
Emergency Contraception
Emergency Contraception
Levonorgestrel (LNG) emergency
contraception (EC):
Has little or no effect on post-ovulation events
(i.e. fertilization, implantation)
In rare circumstances EC may prevent
implantation but by a similar mechanism as
OCP's
Does not increase risk to an established
pregnancy or developing embryo
Novikova N et al. Effectiveness of levonorgestrel emergency contraception given
before or after ovulation a pilot study. Contraception 2007:75:112-18.
Emergency Contraception
Treatment with EC should be initiated as
soon as possible after unprotected
intercourse
EC should be made available to patients
who request it up to 120 hours after
intercourse
No clinician examination or pregnancy
testing is necessary before EC is given
Emergency Contraception
FDA approved over the counter sales of
LNG-EC (Plan B) August 2006
Patient must be 18 or older and present
an ID to the pharmacist
Insurance may not pay without a
prescription
Average cost is $42 per pack
Emergency Contraception
LNG-EC is more effective and is
associated with less nausea and vomiting
than estrogen-progestin regimens (1.1%
vs 3.2%)
LNG-EC can be taken as a single dose
The two doses of LNG-EC are equally
effective if taken 12-24 hours apart
Level A
Emergency contraception. ACOG Practice Bulletin No. 69. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2005: 106:1443-52.
Emergency Contraception
Preven (combined EC) no longer available
in the US
OCP's can be used
Regimens can be complicated
Combined OCPs associated with nausea and
vomiting
Summary
Newer progestins and lower dose estrogens
have greatly improved combined oral
contraceptive choices
Venous thromboembolism remains the greatest
risk to all combined oral contraceptive users
(especially those who smoke and are over age
35)
Extended cycle contraceptives are excellent
choices but have increased risk of breakthrough
bleeding
Summary
Ortho Evra and Depo-Provera remain
good options in the right patients
Dont forget about IUDs and NuvaRing for
those patients who cannot remember to
take pills
Emergency contraception is contraception
References
Ebell MH, Siwek J, Weiss BD, Woolf SH, Susman J,
Ewigman B, Bowman M. Strength of Recommendation
Taxonomy (SORT): A patient-centered approach to grading
evidence in the medical literature. Am Fam Physician
2004;69:549-57
Masimasi, N, et. al. Update on hormonal contraception.
Cleveland Clinic Journal of Medicine 2007:74(3):186-98.
The Practice Committee of the American Society for
Reproductive Medicine. Hormonal contraception: recent
advances and controversies. Fertility and Sterility
2006:86(suppl 4):s229-35.
New Contraceptive Choices. Population Reports April 2005.
David P et al. Hormonal contraception update. Mayo Clinic
Proceedings 2006:81(7):949-55.
References
Gallo MF, Nanda K, Grimes DA, Schulz KF. 20 mcg versus >
20 mcg Estrogen combined oral contraceptives for
contraception. Cochrane Database of Systematic Reviews
2007 Issue 2
Van Vilet HAAM, Grimes DA, Helmerhorst FM, Schulz KF.
Biphasic versus monophasic oral contraceptives for
contraception. Cochrane Database of Systematic Reviews
2007 Issue 2.
Van Vliet HAAM, Grimes DA, Lopez LM, Schulz KF,
Helmerhorst FM. Triphasic versus monophasic oral
contraceptives for contraception. Cochrane Database for
Systematic Reviews 2007 Issue 2.
Gallo MF, Lopez LM, Grimes DA, Schulz KF, Helmerhorst
FM. Combination Contraceptives: effects on weight.
Cochrane Database of Systematic Reviews 2007 Issue 2.
References
Edelman AB, Gallo MF, Jense JT, Nichols MD, Schulz
KF, Grimes DA. Continuous or extended cycle versus
cyclic use of combined oral contraceptives for
contraception. The Cochrane Database of Systematic
Reviews 2007 Issue 2.
FDA approves Lybrel, first low dose combination oral
contraceptive offering women the opportunity to be
period-free over time.
http://www.drugs.com/newdrugs/fda-approves-lybrel-first
-low-combination-oral-contraceptive-offering-women-oppo
rtunity-period-free-491.html?printable=1
Archer D et al. Evaluation of a continuous regimen of
levonorgestrel/ethinyl estradiol: phase 3 study results.
Contraception 2006:74:439-45
References
Use of hormonal contraception in women with coexisting
medical conditions. ACOG Practice Bulletin No. 73.
American College of Obstetricians and Gynecologists.
Obstet Gynecol 2006: 107:1453-72.
Cole J, Norman H, Doherty M, Walker A. Venous
thromboembolism, myocardial infarction, and stroke
among transdermal contraceptive system users. Obstet
Gynecol 2007: 109(2):339-46.
Thacker H, Falcone T, Atreja A, Jain A, Harris CM. How
should we advise patients about the contraceptive patch
given the FDA warning? Cleveland Clinic Journal of
Medicine 2006: 73(1): 45-47.
Courtney K. The contraceptive patch: latest
developments. AWHONN 2006:10(3):250-54
References
Rager K. No bones about it depot
medroxyprogesterone acetate remains an excellent
contraceptive option for adolescents. Journal of Pediatric
and Adolescent Gynecology 2005:4(5):187-88.
Depot medroxyprogesterone acetate and bone mineral
density in adolescents the black box warning: a
position paper of the Society for Adolescent Medicine
2006:39:296-301.
Sidney S et al. Venous thromboembolic disease in users
of low-estrogen combined estrogen-progestin oral
contraceptives. Contraception 2004:70:3-10.
References
Jick S, Kaye JA, Russman S, Jick H. Risk of nonfatal
venous thromboembolism with oral contraceptives
containing norgestimate or desogestrel compared with
oral contraceptives containing levonorgestrel.
Contraception 2006:73:566-70.
Jick S, Jick H. The contraceptive patch in relation to
ischemic stroke and acute myocardial infarction.
Pharmacotherapy 2007:27(2):218-20.
Haile R et al. BRCA1 and BRCA2 mutation carriers, oral
contraceptive use, and breast cancer before age 50.
Cancer Epidemiol Biomarkers Prev 2006:15(10):186370.
References
Lin J, Zhang S, Cook N, Manson J, Buring J, Lee I. Oral
contraceptives, reproductive factors, and risk of
colorectal cancer among women in a prospective cohort
study. American Journal of Epidemiology 2007:advanced
publication.
Grimes DA, Schulz FK. Antibiotic prophylaxis for
intrauterine contraceptive device insertion. The Cochrane
Database of Systematic Reviews 2007 Issue 2.
Emergency contraception. ACOG Practice Bulletin No.
69. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2005: 106:1443-52.
Raymond EG, Trussell J, Polis C. Population effect of
increased access to emergency contraceptive pills.
Obstetrics & Gynecology 2007:109(1):181-88
References
Glasier A. Emergency postcoital contraception. NEJM
1997:337(15):1058-64.
Morning After Pill is Cleared for Wider Sales. Harris G.
The New York Times August 24, 2006.
Novikova N et al. Effectiveness of levonorgestrel
emergency contraception given before or after ovulation
a pilot study. Contraception 2007:75:112-18.
Raine T et al. Direct Access to emergency contraception
through pharmacies and effect on unintended pregnancy
and STIs. JAMA 2005:293(1):54-62.
Gainer E et al. Menstrual bleeding patterns following
levonorgestrel emergency contraception. Contraception
2006:74:118-24.