Which progestin has anti-androgenic SEs?
Drospirenone (4th gen)
Benefits of Drospirenone (4th gen)?
ADEs? (3)
Anti-mineralocorticoid and anti-androgenic.
Causes less water retention and less acne, oily skin and hirsutism (androgenic SEs)
ADEs: hyperkalemia, thromboembolism, bone loss
3 main ADEs of COCs?
- Breast CA
- VTE
- Ischemic stroke, MI
Contraindications for COCs with regards to breast CA? (3)
- Age > 40 y/o
- Family history/ risk factors of breast CA
- Current/ recent hx of breast CA within 5 years
Contraindications for COCs with regards to VTE? (6)
- Hx of DVT/ PE, acute DVT/ PE, and pts with DVT/ PE and on anticoagulant therapy
- Major surgery with prolonged immobilization
- < 21 days postpartum + other risk factors
- < 6 weeks postpartum if breastfeeding
- Thrombogenic mutations
- SLE with APLA (antiphospholipid antibody syndrome)
Explain the role of estrogens and progestins in causing the SE of VTE
Estrogens ↑ hepatic production of factor VII, factor X and fibrinogen of coagulation cascade
New generation progestins (Drosperinone, Cyproterone, Desogestrel) ↑ protein C resistance
For a pt at risk of VTE, what contraceptive methods do we suggest?
- Low dose EE + older progestins
- Progestin-only pill
- Barrier methods
Explain the role of COCs in causing ischemic stroke/ MI- does it happen more with estrogen or progestin?
What are the risk factors?
More with estrogen
Risk factors:
- Age
- HTN
- *Migraine headache with aura
- Obesity
- Dyslipidemia
- Smoking
- Prothrombic mutations
Contraindications for use of COCs with regards to ischemic stroke/ MI? (8) (MSHCCSHD)
- Migraine with aura ⚠️ (AVOID estrogen completely, use progestin-only or barrier methods)
- SBP > 160 mmHg / DBP > 100 mmHg
- HTN with vascular disease
- Current/ hx of ischemic heart disease
- Cardiomyopathy
- Smoking ≥ 15 sticks/day AND age ≥ 35 y/o
- Hx of cerebrovascular disease
- Diabetes > 20 yrs or with complications
For a pt at risk of ischemic stroke/ MI, what contraceptive methods do we suggest?
- Low dose estrogen
- Progestin-only pill
- Barrier methods
We can initiate a COC on 3 different dates:
1) First day of menstrual cycle
2) First sunday after menstrual cycle begins
3) Quick start- NOW
Elaborate on the need for backup contraceptives for each of the options + advantage of the 2nd option
1) First day of menstrual cycle: no backup contraceptive required
2) First sunday after menstrual cycle begins: backup contraceptive required for at least 7 days.
Advantage: May provide weekends free of menstrual periods
3) Quick start- NOW: backup contraceptive required for at least 7 days and potentially until next cycle begins
What is the suggested action for ADEs:
1) Breakthrough bleeding
2) Acne
3) Bloating
1) Breakthrough bleeding:
if early-mid phase: ↑ estrogen
if late phase: ↑ progestin
2) Acne
switch to less androgenic progestin
if on POP, consider switching to COC
can ↑ estrogen
3) Bloating
↓ estrogen
change to progestin with mild diuretic effect (Drospirenone)
What is the suggested action for ADEs:
4) N/V
5) Headache
6) Menstrual cramps
7) Breast tenderness/ weight gain
4) N/V
↓ estrogen
take pills at night/ change to POP
5) Headache
Exclude migraine with aura first
Usually occurs in pill-free week → switch to extended cycle/ continuous/ shorter pill-free interval
6) Menstrual cramps
↑ progestin/ switch to extended cycle or continuous
7) Breast tenderness
Keep both estrogen/ progestin as low as possible
What medications have DDI with COCs? (3) (HAR)
How do they affect COCs?
- HIV antiretrovirals
- ↓ effectiveness of COC and antiretrovirals - Anticonvulsants
- ↓ serum free conc of estrogen and progestin - Rifampicin
- Alters gut flora → alters metabolism of COC → less active drug
- Use additional contraception until Rifampicin discontinued for at least 7 days
What are the actions to take when one dose of COC is missed (<48h)?
Take missed dose immediately
Continue rest as usual
What are the actions to take when 2 or more consecutive doses of COC missed (>48h)?
Is backup contraceptive required?
Take missed dose immediately, discard the rest of the missed doses
Continue rest as usual
Backup contraceptive for at least 1 week
What are the actions to take when COC doses are missed during the last week (day 15-21)?
Is backup contraceptive required?
- Finish remaining active pills in current pack
- Skip hormone-free interval
- Start new pack next day
Backup contraceptive for at least 1 week
What are the 2 types of POP?
- Continuous POP: norethinedrone/ levonorgestrel → 28 active pills
- Drospirenone → 24 active, 4 inactive
What are the instructions for starting a POP, any backup contraceptive required?
- Start within 5 days of menstrual cycle: no backup contraceptive required
- Any other day: backup contraceptive required for 2 days (7 days for drospirenone)
What do we do if we:
1) Late dose of N/L by >3h
2) Miss dose of Drospirenone by <24h
3) Miss dose of Drospirenone by ≥ 48h (≥ 2 pills missed)
1) Take missed dose and continue, backup for 2 days
2) Take missed dose and continue
3) Backup needed for 7 days
What can you say about hormonal transdermal patches and vaginal rings?
Continuous, higher exposure to estrogen ↑ risk of VTE
How often do we given progestin injections?
Every 12w, do not use for longer than 2y
SEs of progestin injections? (3)
What is one disadvantage?
- Variable breakthrough bleeding in first 9 months (MOST COMMON)
- Weight gain
- Short term bone loss (bone mineral density ↓)
Disadvantage:
Return to fertility might be delayed
Contraindications of progestin injections? (2)
- Older women
- Other osteoporosis risk factors (eg long term steroids)
