Contraception

Dr: Roaa Alsrory

 INTRODUCTION

• Contraception is the prevention of pregnancy by inhibiting sperm from reaching a mature ovum or by
preventing a fertilized ovum from implanting in the endometrium.

• Menstrual Cycle

– Follicular phase: GnRH stimulates the release of follicle-stimulating hormone (FSH) and luteinizing
hormone (LH); FSH stimulates estradiol secretion and stimulates follicles to develop; one in particular will
become the dominant follicle; occurs in first half of cycle; later in follicular phase; LH causes an increase in
androgen values.

– Ovulation: Typically occurs midcycle; mature follicle ruptures; a surge in LH occurs just before ovulation.

– Luteal phase: Progesterone is the more dominant hormone in the second half of cycle.

– Menses: Hormones have decreased, and withdrawal bleeding occurs if a woman does not become pregnant.
Methods of Birth Control

• Abstinence
• Male or female sterilization
• Natural family planning
• Spermicides
• Barrier methods
– Diaphragm or cervical cap
– Condom
– Female condom
– Sponge
Methods of Birth Control

• Hormonal contraception
– Combined contraceptives
• Combined oral contraceptive (COC) pills
• Transdermal patch
• Vaginal ring
– Progestin-only
• Progestin-only pill (POP or minipill)
• Progestin-only injectable
• Implanted rod
• Intrauterine device (IUD) or intrauterine system (IUS)
– Copper IUD
– Progestin-containing IUD or IUS
• Emergency contraception
Combined Hormonal Contraceptive (CHC)
• is the most commonly used form of oral contraception (OC) and contains a combination of
synthetic estrogen and synthetic progestin

• Estrogens suppress FSH release (which may contribute to blocking the LH surge) and also
stabilize the endometrial lining and provide cycle control.

– Ethinyl estradiol (EE) is the most common used synthetic estrogen.

• Progestins thicken cervical mucus, delay sperm transport, and induce endometrial atrophy.
They also block the LH surge and thus inhibit ovulation.
 Combined Hormonal Contraceptive (CHC)
• Adverse effects attributed to estrogen
– Nausea, vomiting , Bloating, edema, Irritability
– Cyclic weight gain , Cyclic headache , Hypertension , Breast fullness, tenderness

• Adverse effects caused by progestin

– Headaches , Increased appetite
– Increased weight gain , Depression, fatigue , Changes in libido
– Androgenic adverse effects
• Hair loss, hirsutism
• Acne, oily skin
Combined Hormonal Contraceptive (CHC)
• Types of progestins available in CHC

– Norethindrone , Norethindrone acetate , Ethynodiol diacetate, Norgestrel,

Levonorgestrel

– Desogestrel, Norgestimate, Drospirenone

• progestins with antiandrogenic properties

Combined Hormonal Contraceptive (CHC)
• CHCs are available in

– Monophasic: Same amount of hormone in pill every day except in placebo pills

– Biphasic: Amount of hormone may change halfway through cycle.

– Triphasic: Amount of hormone changes every week.

• Traditional: Progestin usually changes and estrogen stays the same.

• Estrophasic: Estrogen changes.

– Quadriphasic: Estrogen changes and progestin changes; four varying amounts throughout
monthly pack
Combined Hormonal Contraceptive (CHC)
• Start methods
– Same-day start: Start taking an active pill the first day of menses.
– Sunday start: Start taking an active pill the first Sunday after menses begins
(use a BUM for at least 7 days, most conservative for 1 month).
– Quick start: Start taking an active pill at the physician’s office or first day of
prescription, regardless of menstrual cycle day. Use a BUM for at least 7 days.
• Menses will not begin until all the active pills have been taken.
• Proper use: Take 1 tablet once daily at the same time every day.
Combined Hormonal Contraceptive (CHC)
• Missed doses: Missed COC pill means more than 24 hours between doses.
• Recommendations for missed combined oral contraceptives
• Missed 1 pill:
– Take missed dose as soon as possible, continue taking the remaining doses at the usual time
even if it means taking 2 tablets in one day, no BUM needed;
– generally EC is not necessary but may be considered (except ulipristal) if the patient
missed doses earlier in the cycle or in the last week of the previous pack.
Combined Hormonal Contraceptive (CHC)
• Missed 2 or more pills:
– If two or more doses are missed, more than 48 hours since scheduled administration time,
may recommend the following:
• Take most recent doses as soon as possible.
• Continue taking remaining doses at the usual time even if it means taking 2 tablets in one
day.
• Use a BUM or avoid intercourse until 7 active tablets have been taken for 7 consecutive
days.
• Use EC (except for ulipristal) if unprotected intercourse occurred in the previous 5 days.
 Combined Hormonal Contraceptive (CHC)
• Conditions that represent an unacceptable health risk with CHC use
– History of thromboembolic disease
– History of stroke (or current cerebrovascular disease)
– History of (or current) coronary artery disease, ischemic heart disease, or peripheral vascular disease
– History of carcinoma of the breast (known or suspected)
– History of any estrogen-dependent neoplasm (known or suspected)
– Undiagnosed abnormal uterine or vaginal bleeding
– Pregnancy (known or suspected)
– Breastfeeding < 21 days postpartum
– Heavy smoking (defined as 15 cigarettes or more per day) by women who are 35 years of age or older
– History of hepatic tumors (benign or malignant)
– Active liver disease
– Migraine headaches with focal neurologic symptoms (aura)
– Postpartum (during the first 21 days in women with additional risk factors for thromboembolism, including age
≥ 35 years, history of previous venous thromboembolism, preeclampsia, recent cesarean delivery, obesity, and
smoking)
Transdermal patch

• Patch placed on skin

• Proper use

– Place patch on a dry, hairless area of upper arm, shoulder, abdomen, or buttocks. Should
not be placed on the breast. Rotate site of patch each week.

– One patch per week for 3 weeks; week 4 is patch free (menses will occur then)

• Less effective in women weighing more than 198 lb (90 kg); should not be used
 Transdermal patch)

• Missed doses

– If patch is off for less than 24 hours, reapply patch; no BUM needed.

– If patch is off for more than 24 hours, open a new patch, new day 1; must use a BUM for first
week of the new cycle.

– EC is unnecessary but may be considered (except for ulipristal) if the patient missed doses
earlier in the cycle or in the last week of the cycle.
Vaginal rings

• NuvaRing; Product inserted vaginally; delivers 15 mcg ethinyl estradiol and 120 mcg
etonogestrel (active form of desogestrel) daily.
• Proper use
– Insert vaginal ring into vagina and leave for 3 weeks. Week 4, remove ring and menses will
occur.
– Should not be removed during intercourse.
• Missed doses: Inadvertent removal, expulsion, or prolonged ring-free interval
– If 3 hours or less, rinse with cool to lukewarm water and reinsert as soon as possible.
– If more than 3 hours, reinsert and use a BUM until ring has been used continuously for 7
days.
Vaginal rings
• Annovera
– Product inserted vaginally, delivers 0.15 mg/day of segesterone and 13 mcg/day of
ethinylnestradiol
• Proper use
– Insert vaginal ring into vagina and leave for 3 weeks. Week 4, remove ring and menses will
occur. Ring is stored and reinserted after 7 days.
– Should not be removed during intercourse
– The same vaginal ring is used for 13 cycles (1 year)
• Missed doses:
– If out 2 hours or less, rinse with warm water and reinsert as soon as possible
– If out 2 hours or more at one time or out for a time that adds up to more than 2 hours over the
21 days, a backup contraceptive method should be used until the ring has been in place
continuously for 7 days
 PROGESTIN-ONLY CONTRACEPTIVES
• Indications: Those who cannot use or tolerate combined hormonal contraceptives or those seeking
long-term contraception
• History of or current MI, stroke, DVT, CVD
• Atrial fibrillation
• Blood pressure 160/100 mm Hg
• Smoker age 35 or older
• Active, symptomatic liver disease
• Migraine headache with neurologic impairment or aura
• Breastfeeding (estrogen may decrease breastmilk production)
PROGESTIN-ONLY CONTRACEPTIVES
• Components: One of the following progestins
– Norethindrone 0.35 mg
– Drospirenone 4 mg
– Depot medroxyprogesterone acetate (DMPA)
• Mechanisms of Action
– Thickens cervical mucus, prevents sperm movement.
– Thins uterus lining.
– Suppresses midcycle peak of LH and FSH, inhibits ovulation (minimal with oral
progestin pills).
PROGESTIN-ONLY CONTRACEPTIVES
• Oral Norethindrone 0.35 mg (“mini-pill”)
• Start methods: May start on any day or on first day of period. There are no hormone-free days with the
POPs.
• Missed doses: Doses of POPs must be at the SAME time every day; a missed dose of POPs means more
than 3 hours late to take a dose. If a missed dose occurs, must use a BUM for 48 hours.
• Advantages
– Efficacy
– Decreased menstrual blood loss, cramps, pain
– Preferable in lactating women
• Disadvantages
– Progestin-related adverse effects (e.g., weight gain, acne)
– Irregular menses
– Adherence: Short time window for a missed pill
– Low-dose progestin; patient may ovulate
– Fewer noncontraceptive benefits
 PROGESTIN-ONLY CONTRACEPTIVES
• Oral Drospirenone 4 mg
• Start methods: Start active tablet on the first day of menses. There are 24 active tablets and 4
inactive tablets.
• Missed doses:
– If 1 active tablet is missed, take as soon as possible and finish the pill pack as instructed.
– If 2 active tablets are missed, take the last missed tablet as soon as possible.
– Continue taking 1 tablet a day as instructed. Use an additional BUM for 7 days.
• Advantages:
– Dosing is not as sensitive to timing as for traditional POPs.
• Disadvantages
– Progestin-related adverse effects
– Irregular menses
– Monitoring of thromboembolism, hyperkalemia, bone loss
 PROGESTIN-ONLY CONTRACEPTIVES
• Depot medroxyprogesterone acetate (DMPA) intramuscular (IM) injection
• A 1-mL crystalline suspension of 150 mg of DMPA injected intramuscularly every 11–13 weeks
• Start methods
– Preferred start: First 5 days of menses. No BUM needed.
– Alternative start: Any time in cycle if not pregnant. Use BUM for 7 days.
– Postpartum: May give injection before hospital discharge.
– Breastfeeding: May start immediately or wait 4–6 weeks.
• Boxed warning: Loss of bone; women who used DMPA for at least 5 years have significantly
reduced BMD of lumbar spine and femoral neck, particularly after 15 years of use and if initiated
before age 20.
– The effect is almost completely reversible, even after 4 years or more of DMPA use.
– All women placed on DMPA should be taking sufficient calcium and exercising regularly.
INTRAUTERINE DEVICES (IUDs) AND SYSTEMS (IUSs)

• Indications: To prevent pregnancy long term; levonorgestrel IUS is also indicated for heavy
menses in women who elect to use an IUD for contraception.

• Recommended for Women Who:

– Have no history of pelvic inflammatory disease (PID) or ectopic pregnancy

– Have heavy menses, cramps, anemia, or dysfunctional uterine bleeding

– Are seeking long-term (2 years or more) pregnancy protection

– Do not want to use estrogen-containing products

 INTRAUTERINE DEVICES (IUDs) AND SYSTEMS (IUSs)
• Copper
– Copper IUD inserted into the uterus by a health care professional
• Mechanism of action
– Primary action: Spermicidal
– Copper ions inhibit sperm motility and acrosomal enzyme activation so that sperm seldom reach fallopian
tube and are unable to fertilize the ovum.
– A sterile inflammatory reaction created in endometrium phagocytizes sperm.
• Does not interfere with ovulation and is not an abortifacient.
• Contraindications specific to copper IUD
– Pregnancy
– Uterus less than 6 cm or greater than 9 cm
– Undiagnosed abnormal vaginal bleeding
– Active cervicitis or active pelvic infection
– Recent endometritis (past 3 months)
– Allergy to copper; Wilson’s disease
INTRAUTERINE DEVICES (IUDs) AND SYSTEMS (IUSs)
• Progestin (levonorgestrel)

• Mechanism of action
– Foreign object in uterus, prevents implantation
– Progestin thickens cervical mucus, thins endometrium, and inhibits sperm motion.
IMPLANT (NEXPLANON)

• Indication: Long-term prevention of pregnancy

• Components: Etonogestrel, releases 60–70 mcg/day during weeks 5–6 and then decreases to 35–45
mcg/day by the end of the first year, 30–40 mcg/day after the second year, and 25–30 mcg/day at the end
of 3 years.

• Mechanism of Action:
– A rod inserted in upper arm, 99% effective for up to 3 years, releases progestin etonogestrel, which
acts similarly to other progestin-only contraceptives; not tested in women weighing more than 130% of
their ideal body weight; may be less effective in overweight women

• return to fertility within 1–3 months

• Nexplanon is radio-opaque so it is visible on radiograph.

EMERGENCY CONTRACEPTION

• A therapy used to prevent pregnancy after an unprotected or inadequately protected act of sexual
intercourse.

• Mechanism of Hormonal Methods

– Inhibits ovulation

– Prevents fertilization

– Increases thickness of cervical mucus

– Prevents implantation (controversial; most recent data suggest this does not occur)

– Not considered an abortifacient by medical standards; does not disrupt an implanted,

fertilized egg.
EMERGENCY CONTRACEPTION
• Indications
– Condom broke
– Misused contraceptive method (e.g., missed a pill, contraceptive patch fell off)
– Sexual assault
– Exposure to teratogen
– Unprotected vaginal intercourse

• Timing:
– Within 120 hours after unprotected intercourse; package insert for marketed products
(levonorgestrel products) states 72 hours, but studies show up to 120 hours may still prevent
pregnancy.
EMERGENCY CONTRACEPTION

• Progestin-only method

– Products: Levonorgestrel 1.5 mg (1 tablet)

– Available over the counter (OTC) for all ages; anyone may purchase.

• Ulipristal acetate

– Prescription only

– Progesterone receptor modulator: Binds to progesterone receptor

– Use BUM for 7 days after taking ulipristal if using hormonal contraception because
ulipristal blocks progesterone receptors.
EMERGENCY CONTRACEPTION