R7 - Contraception

Question 1

What is a contraceptive?

Answer 1

• “Prevention of conception prior to
  implantation”
• Acts prior to pregnancy
  -prior to measurable serum hCG
• No contraceptives are abortifacient!

Question 2

Progestin (primary)

Answer 2

Combined Hormonal Contraceptives (Pill, Patch, Ring)

Suppresses ovulation
Inhibits (LH)
*Thickens cervical mucus
*Thins endometrium

Question 3

Ethinyl Estradiol

Answer 3

Combined Hormonal Contraceptives (Pill, Patch, Ring)

Inhibits FSH
*No follicle growth
*Stabilizes endometrium

Question 4

Non‐contraceptive Benefits CHC

Answer 4

– decreased menstrual flow (and anemia)
– decreased menstrual pain
– decreased acne & hirsutism
– cancer protection
* ovarian
* endometrial

Question 5

CHC Absolute Contraindications

Answer 5

-Hx of venous thromboembolism (risk of recurrence)
-Migraines with aura
-Hypertension if poorly controlled (over 160 or 100)
-Smoker > 35 yo > 15 cigs/day
-Under 21 days postpartum

Question 6

Combined oral contraceptives (COCs) “The Pill”

Answer 6

21 days active pill, 7 days placebo

Most common side effects
-break through bleeding
-nausea
-breast tenderness

Continuous use
-increase efficacy
-increased breakthrough bleeding

Question 7

20 mcg vs 30/35 mcg EE

Answer 7

increased spotting with <= 20 mcg pill

Question 8

Monophasic, bi- or tri-phasic

Answer 8

Tri phasic not necessary

Question 9

Drospirenone (Antiandrogenic Progestin)

Answer 9

-VTE: +/- increased risk
-PMDD: fewer sys at 3-6 mo but equiv at 2 yr
-Acne: all CHC pills treat, +/- greater benefit

Question 10

Weekly: Transdermal Contraception “Patch”

Answer 10

3 weeks on 1 week off
- 35 and 150 mcg EE, 30 and 120 mcg EE and levo
- Improve compliance
- On trunk, arms, lower back or buttock
- FEWER AE: especially GI, 20% skin irriation
- May be less effective if under 90 kg

Question 11

Monthly: Vaginal Ring

Answer 11

15mcg EE and120 mcg etonogestrel
- Ring in vagina 3 wks, removed for 1 wk
- Constant, low hormone levels

• Easily placed and removed
• Most people with a vagina and penis don’t notice during intercourse
• High acceptability and compliance
• FEW AE — comparable to pills
  — Less spotting 5%
  — 1% stop method because of discharge
  (physiologic, NOT pathologic)
  — 2.5% stop method because of discomfort

Question 12

Every 12 months: contraceptive ring (annovera)

Answer 12

• 17.4mg Ethinylestradiol and 103 mcg segesterone acetate
• One ring every 12months
  – Ring placed in vagina x 3 wks, removed x 1 week
  – Continuous use
• Efficacy, risks and side effects similar to the EE/ENG ring

Question 13

Summary: Pills/Patches/rings

Answer 13

• All include combo of estradiol and progestin
• MOA for all is suppression of ovulation through inhibiting LH and FSH
• Similar efficacy: 9% failure, <1% perfect use
• Patches/rings = less frequent dosing, less GI side effects (but higher risk of VTE)

Question 14

Every 3 months: Injection (DMPA)

Answer 14

• DMPA 150 mg IM every 12-14 weeks
• Very effective
• MOA: inhibits ovulation
• Side effects: delayed return to fertility, irregular bleeding, amenorrhea, increase seizure threshold, weight gain

Question 15

DMPA & BMD

Answer 15

BMD decreases by 1-2% per year

FDA: limit to 2 yrs in young women

WHO and ACOG don’t agree with this
- no evidence of increased fractures
- reverses by 12 months after d/c

No indication for DEXA or Ca supp

Weigh risks against risk of preg

Question 16

Every 3-5 years: Single-Rod Implant (Nexplanon)
-MOA AND AE

Answer 16

Etonogestrel 60 mcg/day

MOST effective > 99%

MOA: suppress ovulation and thicken mucous

Very easy and well tolerated

AE: bleeding, amenorrhea, slight weight gain (SWAGB)

Question 17

Copper IUD: 10-12 years

Answer 17

-Prevent fertilization, decrease motility/viability of sperm
-Inhibition of implantation

Question 18

Every 3-8 Years:
Levonorgestrel Intrauterine Systems

Answer 18

MOA:
Fertilization inhibition
-thickens mucus
-inhibit sperm motility/function
-endometrium suppressed
-ovulation inhibited

Question 19

IUD:
Dispelling Common Myths

Answer 19

• IUDs :
  DO NOT cause pelvic infection
  DO NOT impair future fertility
  CAN be used for nulligravidas

Question 20

Emergency Contraception

Answer 20

Oral LNG available over the counter, UA is not

• LNG EC = 89% reduction of pregnancy risk
• LNG EC has minimal to no efficacy in women who are overweight or obese
• UA more effective for BMI >25

Question 21

Copper T IUD (em. contra)

Answer 21

10x more effective than Plan B

spermicidal prevents fertilization, ? Endometrial effects