Contraceptive Choices 2008

1. Contraceptive Choices 2008 debbie Robinson M.D. F.R.C.S.C.

2. Objectives • Barrier methods • Systemic Hormonal Contraception • Pills/Patch/Ring • Progesterone Only Options • Intra-Uterine Devices • Copper • Mirena

3. Barrier Methods • Condoms • Reliable contraception • No protection from vulvar HPV or HSV • Female Condom • Similar to male condom but offers some vulvar protection against STI’s • Failure rate with perfect use = 2% • Failure rate with typical use = 12%

4. Diaphragms • Must be fitted • Must be used with spermicidal foams/gels, reapplied if more than one act of intercourse • Must be left in-situ for 6 hrs after intercourse • Reusable, wash with soap and water, good for about one year • Failure rate = 6-18%

5. Sponge • Sponge is impregnated with spermicidal foam and traps sperm within the sponge • Must use a new sponge for each act of intercourse • Must remove 1 hr after intercourse • Failure rate = 5-18%

6. Systemic Combined Hormonal Contraception • Pill / Patch / Ring • All use combined E2 and a progestin • All inhibit ovulation reliably • Failure rate <1%

7. Non-Contraceptive Benefits of Hormonal Contraception • Regulation of menses • Decrease in dysmenorrhea • Decrease in menstrual flow • Decreases PMDD

8. Non-Contraceptive Benefits of Hormonal Contraception • Decreases acne and hirsutism • Decrease in uterine CA • Decrease in ovarian CA • No increase in breast CA

9. Contra-indications • Absolute: • Smoking >15cig/day over age 35 • Liver disease • Undiagnosed vaginal bleeding • History of any E2 dependent tumor • Previous VTE • Hypertriglyceridemia • Migraine with neurological symptoms

10. Special Considerations • Medications such as Dilantin, phenobarbital, carbamazepine, and rifampin increase liver enzyme activity and decrease effectiveness of the OCP • Medications such as fluconazole have the opposite effect and may increase estrogen side effects

11. Mono-phasic vs Tri-phasic • Both give reliable contraception • Both have few side effects for most women • Slightly more BTB with tri-phasics • Some women will notice the changing progestin dose • Progestin side effects are breast tenderness, bloating, moodiness • Less flexibility with tri-cyclics

12. How Long is Too Long? • Using a monophasic preparation, women can use continuous hormonal contraception for as long as they are amenorrheic. • When BTB occurs, allow a withdrawal bleed and a hormone free week, then resume the hormones • Seasonale comes as 11 weeks of active pill and one week of placebo

13. Estrogen Dose • Currently available are 20, 25, 30, 35, 50 mcg • Estrogen side effects are headache (either too much or from withdrawal), nausea • Estrogen adverse effects are VTE, increased lipids (esp TG’s), aggravated htn, increased activation of liver enzymes – may cause adenomas

14. Estrogen Dose • Most women will do fine on any dose • Women who are obese need a higher estrogen dose for contraception (but not for menorrhagia or irregular menses) • 50mcg pills are reserved for control of acute menorrhagia due to increased VTE risk

15. What Progestin To Choose • All formulations use “progestins”, not progesterone • 2nd generation progestins include levonorgestrel (Alesse, Tri-Phasil, Ovral, Seasonale) and norethindrone (Ortho7/7/7, Lo-Estrin, Min-Estrin) • Derived from testosterone and therefore have higher androgenic activity

16. What Progestin To Choose • 3rd generation Progestins include Desogestrel (Marvelon, Linessa) and Norgestimate (Cyclen, Evra) • Also derived from testosterone, but modified to bind the androgen receptor less, and have less androgenic activity than 2nd generation progestins

17. Progestational Activity • Progestational activity refers to the degree that the progestin has progesterone-like effects: • Endometrial thinning • Side effects – breast tenderness, bloating, etc • P.A. in increasing order: • Norgestimate (Cyclen), levonorgestrel (Alesse), Norethindrone (Min-Estrin), Desogestrel (Marvelon)

18. Androgenic Activity • Androgenic activity refers to: • the degree that the progestin can still bind the androgen receptor • Effects on SHBG • The degree to which it is bound to SHBG

19. What This Means In Real Life • All OC’s are anti-androgenic overall • The estrogen component increases SHBG (antagonized to varying degrees by the progestin, but still lowered overall) • Increased SHBG decreases circulating free testosterone

20. What This Means In Real Life • The estrogen component also decreases gonadotropins which decrease ovarian production of testosterone • OC’s also suppress androgen production from the adrenal gland to a small degree

21. Bottom Line The Androgenic Activity of a Progestin is Irrelevant!! Two progestins exist that are truly anti-androgenic and exert a greater effect than the usual OC’s – Cyproterone Acetate and Drosperinone

22. Diane 35 • Cyproterone Acetate – based on the progesterone molecule, is an anti-androgen • It blocks the binding of androgens to their receptors • It inhibits ovarian and adrenal testosterone production • It’s progesterone qualities protect the endometrium

23. Yasmin • Drosperinone is based on the Spironolactone molecule, which competitively inhibits DHT at its receptor sites, and is therefore also an anti-androgen. • Yasmin has relatively high progestational activity and therefore is utero-protective, but b/c it is a mineralocorticoid, is does not cause bloating or weight gain

24. Non-Oral Preparations • Evra – E2 (.6 mg) and norelgestromin • Apply to shoulder, lower abdomen, buttock • Change patch weekly • 3 weeks on, 1 week off • Has 2-3 day grace period

25. Evra cont. • No effect on TG’s (no first pass liver effect) • Continuous, slow release dosing may reduce side effects such as BTB and headache • Lower peak levels of E2, with the total AUC equivalent to a 35mcg pill • NB: different than the US preparation, which has .75mg and an AUC equivalent to a 50mcg pill • Cannot use if >90 kg as the E2 will be absorbed and held in the adipose tissue

26. Non-Oral Preparations • Nuva-Ring E2 (15 mcg) and Etonogestrel • Placed in the posterior fornix and left in-situ for 3 weeks • Do not remove for intercourse • 1 week grace period • Also avoids first pass liver effect and gives advantage of continuous release • AUC equivalent to a 30 mcg pill

27. Progesterone Only Options • Micronor and Depo-provera • Good for women who have a contra-indication to estrogen • Contraindicated in women with a significant history of depression

28. Micronor • “The mini-pill” • Contains norethindrone acetate only • Ultra low dose • No hormone-free period • Amenorrhea common • Must take at same time every day • Higher failure rate • Best for lactating or peri-menopausal women

29. Depo-Provera • Three month depot of MPA • Reliable contraception • Amenorrhea common, but expect BTB first cycle • Slow return to fertility • Decreases bone density (reverses after cessation) • Causes weight gain (7-10 lbs average) • Breast tenderness common

30. Intra-Uterine Devices • Primary mechanism of action is a foreign body reaction • Inhibits retrograde contractions seen at time of ovulation • Secondary mechanism of action is at the level of the cervix • Copper – macrophages • Mirena – progesterone effect on mucus

31. Intra-Uterine Contraceptive Devices • Tertiary mechanism of action is creating an endometrium unsuitable for implantation • Copper – local inflammatory response • Mirena – thin endometrium due to progesterone • Advantages – long term contraception with no action required by the woman • Does Not increase risk of PID

32. Copper IUCD’s • Nova-T or Flexi-T • Contraception for a minimum of 10 years • No hormones so no hormonal contraindications • Does not inhibit ovulation • Does not modify menstrual cycle • May increase dysmenorrhea

33. IUCD’s - Mirena • Slightly larger than the copper IUCD • Good for 5 years of reliable contraception • May inhibit ovulation in first year, but not thereafter • Controls menorrhagia and dysmenorrhea • More expensive • Can be used in nullips, but may be more difficult to insert, and cause initial cramping