Birth Control Pill Alternatives

1. Birth Control Pill Alternatives Julaine Stiers, MD, FACP March 2013

2. Resource • Contraceptive Technology, Robert Hatcher, MD, MPH, 20th edition, revised 2011.

3. Transdermal Patch • Ortho Evra- brand name. Has generic. • 20 mcg ethinylestradiol and 150 mcg norelgestromin are released into the circulation per day. • Thin square patch. • Beige color. • Medicated adhesive layer. Latex free. • Apply to upper outer arm, abdomen, buttock, or upper torso. *But not the breasts.

5. Transdermal Patch • Each patch lasts 7 days. • Change weekly for 3 weeks. • Then have a 4th patch-free week, when menses will occur. • Prevents ovulation by suppressing LH and FSH, prevents sperm penetration by thickening cervical mucus, and prevents implantation by thinning the endometrium.

6. Transdermal Patch • Effectiveness: • Equivalent to BCPs in clinical trials. • Perfect use=0.3% pregnancies in one year. • Typical use=0.8%. • Correct use rates are higher than BCPs. • Patch=93%. • Pill=80%.

7. Transdermal Patch • Precautions: • Less effective in women weighing more than 198 lbs. *Need back-up contraception. • Medical contraindications same as for BCP. • Serum levels of estrogen are higher and may lead to more side effects.

8. Transdermal Patch • Advantages: • Safe, effective, and rapidly reversible. • Once-a-week dosing leads to successful use. • Can be used by healthy women throughout the reproductive years. • Less menstrual cramps and bleeding. • No significant weight gain.

9. Transdermal Patch • Disadvantages: • Weekly change. • Difficult to conceal on skin. • Have to buy from a pharmacy. • Private storage needed. • Higher cost. • No STI protection.

10. Transdermal Patch • Same health complications as BCP: • MI • Stroke • VTE-may be slightly higher since more estrogen. • HTN • DM • GB disease • Liver disease

11. Transdermal Patch • Side effects similar to BCP, but some more likely: • Breast tenderness. • Headaches. • Nausea. • Spotting. • All improved over 3 cycles.

12. Transdermal Patch • Unique side effects: • Skin irritation-red, itchy rash-occurs in 3%. • Not for use in women with psoriasis or eczema. • Detachment of patch-occurs about 5 %. • Check daily that patch is adhered. • Avoid any lotions near the site. • If partially or completely detached, try to reapply. If sticks well, use for the 7 days. If not, replace patch. If patch has been loose for more than 24 hrs, use EC if needed, and then use back-up method for 7 days.

13. Transdermal Patch • Start methods: • Any day, if she is reasonably certain she is not pregnant. Needs 7 days of back-up. • First day of menses. • Sunday start-needs 7 days of back-up. • If switching from BCP, follow the same guideline. *Takes 48 hours for therapeutic level of hormones. • If switching from Depo-Provera, apply patch when next injection is due.

14. Transdermal Patch • Start methods: • After 1st or 2nd trimester abortion or miscarriage, start the patch immediately. If not started within 5 days, then an additional method of contraception is needed for 7 days. • After pregnancy, may start the patch 3 weeks after delivery and use back-up method for 7 days. If breastfeeding, wait 4 weeks.

15. Vaginal Ring • NuvaRing-brand name, no generic. • Supplies 15 mcg of ethinylestradiol and 120 mcg etonogestrel daily. • Flexible, soft, transparent plastic ring. • Diameter of 54 mm( 2 inches). • Placed in the vaginal canal. • Releases hormones in steady low doses, so serum levels are lower than BCP or the patch.

17. Vaginal Ring • Leave ring in vagina for 21 days. Remove for 7 days for withdrawal menses. • Hormone levels are achieved on the first day of ring use. • Suppresses ovulation, thins the endometrium, and thickens cervical mucus. • Effectiveness 99%. • Can be used with tampons and spermicide gel.

18. Vaginal Ring • Advantages: • Private. • Easy to use. • Reliable-Ring effective up to 35 days if patient forgets to remove on schedule. • Alternative for women who cannot swallow pills or have intestinal absorption problems. • Cycle control-Spotting in < 10%. • No weight gain. • Safe in women with latex allergy.

19. Vaginal Ring • Disadvantages: • Hesitation to touch genitals. • For storage longer than 4 months, refrigeration recommended. • Vaginal discharge. • Vaginal discomfort during intercourse-Ring may be removed for 3 hours without decreasing effectiveness. • Accidental expulsion.

20. Vaginal Ring • Medical complications same as for BCP. • Side effects same as BCP: • Nausea • Headache • Breast tenderness • Local side effects: • Vaginitis-Toxic shock syndrome. • Leukorrhea • Discomfort

21. Vaginal Ring • Start methods: • First day of menstrual bleeding. No back-up contraception needed. • Days 2-7 of menstrual bleeding. Use back-up contraception for 7 days. • Quick start any other day of cycle if she is reasonable certain she is not pregnant. Use back-up for 7 days. • If she is switching from BCP, she inserts the ring on the day she would start a new pack of pills. • If switching from Depo-Provera, insert ring on the day her injection would be due.

22. Vaginal Ring • Start methods: • After a 1st or 2nd trimester abortion or miscarriage, a ring may be inserted within 5 days. No back-up contraception needed. If inserted later than 5 days, use back-up contraception for 7 days. • After pregnancy, the ring may be started 3 weeks after delivery and use back-up contraception for 7 days. If breastfeeding, wait 1 month.

23. Vaginal Ring • Problems: • If a new ring is inserted late, use EC if unprotected intercourse, and a back-up method for 7 days. • If ring is removed or expelled, rinse with cool or lukewarm water and reinsert. • If the ring is out for more than 3 hours, use EC if indicated, and a back-up method of contraception for 7 days. • If the ring is lost, use a new ring for 21 days.

24. DMPA Injection • Contains depot medroxyprogesterone acetate(DMPA). Brand name Depo-Provera. • 150 mg given deep IM q 12 weeks(11 to 13 weeks). Alternative formula of 104 mg SC. • Inhibits ovulation by suppressing FSH and LH. • Thickens cervical mucus which prevents sperm penetration. • Causes atrophy of endometrium.

25. DMPA Injection • Failure rate in perfect use is 0.2% and in typical use is 6%. • Cost may be higher or lower than BCP depending on insurance coverage. • Generic now available.

26. DMPA Injection • Advantages: • No estrogen. Decreases risk for blood clots and nausea. Indicated for women over 35 and those with migraines, HTN, and smokers. • Fewer, lighter, or no menses. Decreases PMS, cramps, and blood loss. Indicated for women with dysmenorrhea and anemia. 50% of users are amenorrheic by the end of the 1st year. 70% by the end of the 2nd year. • Suppresses endometriosis.

27. DMPA Injection • Advantages: • Long-term effectiveness. • Reversible, but some delay. • May be used without partner or others knowing. • Rare drug interactions. • Lower risk for seizure in epileptics and seizure medicines do not decrease effectiveness. • Fewer sickle cell crises.

28. DMPA Injection • Advantages: • Decreased risk for PID and endometrial or ovarian cancer. • No increased risk for breast cancer. • May be used during lactation, but must wait 6 weeks and until milk production is well established.

29. DMPA Injection • Disadvantages: • No protection against STIs. • Menstrual irregularity. Bleeding is unpredictable. • Rarely will have heavy prolonged bleeding requiring estrogen therapy. • Weight gain due to increased appetite. About 5 lbs in first year and up to 10 lbs after 5 years. • Breast tenderness.

30. DMPA Injection • Disadvantages: • Depression. Caution in women with history of postpartum depression. • Not possible to discontinue immediately. Takes 6 to 8 months after the last injection for progesterone to clear. May take up to 12 months for ovulation to occur. • Requires visit q 3 months for injection.

31. DMPA Injection • Disadvantages: • Decreased spinal bone mineral density in 18 to 54 year olds was 7%. Higher in those starting DMPA prior to age 21 and in those using for longer than 15 years. Most loss is in the first 2 years and then slows. Density rapidly returns after stopping DMPA. • Allergic reactions-rare. • Headaches. • Decreased libido.

32. Intrauterine Device(IUD) • Most common reversible method of birth control worldwide. 50% of contraceptive users in Asia. 5% in USA. • Copper T 380A(ParaGard)-polyethylene with copper wire. Lasts 10 years. • Levonorgestrel(LNg, Mirena)-polyethylene with progestin. Lasts 5 years. • Both are latex free. • Contain barium sulfate for visibility on Xray. Also visible on US and MRI.

33. IUD

34. IUD • Mechanism of action: • The foreign body effect causes a sterile inflammatory reaction in the uterus which is toxic to sperm and eggs and prevents fertilization and impairs implantation. • Copper increases this effect. • Progestin thickens the cervical mucus and suppresses the endometrium and prevents ovulation with systemic absorption. • Are not abortifacients.

35. IUD • Effectiveness: • Copper T pregnancy rate is 0.5% in the first year. Cumulative rate is 2.2% at 10 years. • LNg pregnancy rate is 0.1% in the first year. Cumulative rate is 1.0% at 5 years. • Continuation rate at 1 year is 90%.

36. IUD • Advantages: • Highly effective. • Safe. • Long-term. • Convenient. • Rapidly reversible. • Cost effective. • Easy placement and removal. • High user satisfaction.

37. IUD • Advantages: • Few contraindications. • Not estrogenic. • Copper T for emergency contraception. • Immediate placement after delivery, miscarriage, or abortion. • Protection against ectopic pregnancy. • Reduced endometrial cancer. • LNg decreases menstrual bleeding and cramps.

38. IUD • Disadvantages: • Requires a procedure. • Uterine cramping with insertion. May last 30 minutes. May have nausea or feel faint. • Menstrual disturbances with LNg. By 2 years, 50% have amenorrhea. • Copper T causes increased menstrual bleeding and cramps. • Expulsion of the IUD. • PID-0.1% after insertion, then back to ave.

39. IUD • Disadvantages: • Uterine perforation-usually happens at time of insertion. Incidence is 0.1%. • Pregnancy complications. • Actinomyces-like organisms seen on Pap-usually benign. • LNg may interfere with breastfeeding, so delay insertion 6 to 8 weeks postpartum.

40. IUD • Management: • May insert at any time of the menstrual cycle if pregnancy is excluded. • Appt one month after insertion to check placement and evaluate for infection. • Pt to check threads monthly and RTC if threads not palpable or feel too long, or IUD is palpable. Use condoms for backup. • Use ultrasound to check if IUD is in uterine cavity. If absent, use abdominal Xray to see if it is in abdominal cavity.

41. IUD • Management: • Patient to return for pelvic pain, vaginal discharge, or change in bleeding pattern. • NSAIDs for menstrual pain and excessive flow. • Do not remove if treating cervicitis or PID, unless the bacteria is Actinomyces. • Do not remove when doing endometrial biopsy. • Remove if accidental pregnancy.

42. Implant • Brand names: • Norplant-6 rods-no longer marketed since 2002. • Implanon or Nexplanon-one rod 4 cm long and 2 mm wide. On market since 2010. Contains the progesterone etonogestrel. Lasts 3 years. • Inhibits ovulation, thins endometrial lining, and thickens cervical mucus. • Pregnancy rate 0.1%.

44. Implant • Advantages: • Highly effective. • Easy to use. • Private. • Decrease acne. • Decrease dysmenorrhea and endometriosis pain. • No metabolic effects. • Decrease risk of ectopic pregnancy.

45. Implant • Advantages: • No estrogen. • Reversible. • High acceptability and continuation rate. • Cost effective if left in place for 3 years.

46. Implant • Disadvantages: • Changes in menstrual bleeding-may increase or decrease. Often amenorrhea. • Requires a procedure for insertion and removal. • Pain, bruising, skin irritation, or infection. • Breakage of the implant. • Ulnar nerve damage. • Expulsion.

47. Implant • Disadvantages: • Hormone side effects: • HA • Moodiness • Breast pain • Abd pain • Nausea • Loss of libido • Vaginal dryness

48. Implant • Disadvantages: • Ovarian cysts. • No STI protection. • Weight gain-about 5 lbs over 3 years. • Decreased efficacy with some medications: • Warfarin • HIV antivirals • Epilepsy meds • Rifampin • May decrease bone density.

49. Implant • Timing of insertion: • Days 1-5 of menstrual period. • If on BCP, while taking active pills or during placebo week. • If on DMPA, the day next injection is due. • If has IUD, same day IUD is removed. • If abortion or miscarriage, 5 days after. • 3-4 weeks postpartum or 6 weeks if breastfeeding.