Contraception Part 3

•Serious (uncommon) -Expulsion: may be increased with younger age (<25 years old) -PID -Contraceptive failure which increases risk of ectopic pregnancy -Perforation •Less serious: -Irregular bleeding -Pelvic pain •Risk for ADR: -Young age -Postpartum/postabortion -Breastfeeding -Distorted uterine cavity

ADRs for IUDs

•Unscheduled bleeding is most common ADR •Other relatively common: -Headache -Weight gain -Acne -Breast tenderness -Emotional lability

ADRs of contraceptive implant (Etonogestrel).

•Weight changes: variable •HA: possible increase in migraines (if susceptible) •Mood disorders: variable but some evidence to increase depression •Endo: increased baseline diabetes risk -No need to increase usual screening -Caution patients with diabetes to monitor glucose closely

ADRs of injectables

-Limit use less than 2 years -Loss of bone mineral density •UpToDate, ACOG, CDC, WHO, SOGC, SAHM all state available evidence does NOT justify limiting duration (may be continued for decades) •Counsel on: calcium, vitamin D, exercise, avoid smoking, screening for bone mineral density

BBW (controversy) with injectables

•Severe distortion of uterine cavity •Uterine or cervical neoplasia •Active pelvic infection •Known or suspected pregnancy Wilson's disease or copper allergy •Unexplained abnormal uterine bleeding •Breast cancer (only applies to LNg IUD) •Other medical issues: for LNg IUDs in patients with active liver disease •Dysmenorrhea or menorrhagia (only applies to copper IUD)

CI for IUDs

•Same as combined oral contraceptives •Additional CIs: -BMI ≥30 kg/m2 •EE/N (Xulane) due to increased risk for thromboembolism •EE/LNG (Twirla) due to lower efficacy (and possibly increased VTE) AVOID TRANSDERMAL PATCHES HERE •Additional ADRs: application site irritation

CI, warnings, and ADRs associated with transdermal patches

•Same OCP •Additional ADRs: -Vaginitis, vaginal wetness, leukorrhea -Rare toxic shock (only reported for EE/ENG)

CI, warnings, and ADRs of intravaginal ring

1)IUDs cause infection: (-Routine antibiotic prophylaxis to prevent pelvic infection is not recommended before IUD insertion**) 2)Increase risk of ectopic pregnancy: (-Overall risk is lower than general population because pregnancy rates are lower. but if pregnancy occurs, IUD users are at higher risk of pregnancy being ectopic) 3) IUDs cause infertility 4) danger in nulliparous women

IUD myths and misperceptions

postcoidal IUD

Insertion of _____ is the most effective method of postcoital contraception when inserted up to 5 days after unprotected intercourse

•Liletta, Mirena: 6 years max •Kyleena: 5 years max •Skyla: 3 years max

Levonorgestrel IUD products

multifactorial: 1)Chronic inflammatory changes of the endometrium and fallopian tubes, which have spermicidal effects and inhibit fertilization and implantation 2)Changes in cervical mucus that inhibit sperm transport (e.g., increased copper concentration, thickening, glandular atrophy or decidualization) 3)Thinning and glandular atrophy of the endometrium, which inhibits implantation 4) Direct ovicidal effects 5) pregnancy is prevented by foreign body effect of IUD frame (prevents sperm getting to egg) 6) No evidence that IUDs disrupt an implanted pregnancy (no abortion)

MOA of IUD

-Avoidance of exogenous hormones -Continuation of endogenous menstrual cycle -Desire for long-term contraception -Need for emergency contraception

Reasons to choose copper IUD vs LNg IUD

•Ethinyl estradiol and norelgestromin (EE/N) (Xulane) •Ethinyl estradiol and levonorgestrel (EE/LNG) (Twirla)

Transdermal patch products. Overall, each product delivers much more estrogen v. pills •Peak concentrations are lower however •Unsure of clinical significance

•Reversible •Private •Lasts 12 weeks •Effective in obese women •Reduces the risk of ectopic pregnancy •Periods become light and may cease •Reduces dysmenorrhea and other menstrual symptoms •Few drug interactions •Fewer seizures in women with epilepsy •Fewer sickle cell crises in women with sickle cell disease •Reduces pelvic pain in women with endometriosis •Reduces uterine bleeding in women with heavy bleeding due to uterine fibroids •May reduce risk of pelvic inflammatory disease

advantages of injectable products

postcoital contraception

aka emergency contraception. Products that prevent pregnancy from occurring after an episode of unprotected intercourse (UPI). Does not interrupt an existing pregnancy so does NOT cause abortion MOA: Disrupts the timing of ovulation or prevents fertilization of an ovulated egg. EC is not an abortifacient

•Efficacy •Ease-of-use (i.e., "forgettable") •Safety (most women, including teens and nulliparous women) •Cost (consider long-term) •"Private" and does not interfere with the spontaneity of sex •Long-acting •Rapidly reversible •Few ADRs or CIs •Avoidance of exogenous estrogen

benefits of IUD

•LARCs (along with implants) are recommended as first-line for most women and adolescents •Consider plans for pregnancy within next 1 to 2 years -If so, probably not cost-effective •Review risk/benefits of estrogen exposure -Great option when wanting to avoid estrogen -Not good for patients who need estrogen •Consider other medical issues that may be treated by the noncontraceptive benefits of other methods •Those at low risk of acquiring sexually transmitted infections, since such infections increase the risk of developing pelvic inflammatory disease (PID) •Want or need to avoid estrogen exposure (all IUDs) or hormone exposure (copper IUDs)

candidates for IUDs

•Potential benefits of contraceptive patches: -Weekly rather than daily dosing, which appears to result in improved compliance -Non-oral route of administration is useful for patients who have difficulty swallowing pills -Therapeutic effects are achieved at lower peak doses since first-pass hepatic metabolism and enzymatic degradation in the gastrointestinal tract are avoided -Sustained drug delivery results in relatively constant plasma hormone levels while the patch is worn (i.e., peaks and troughs do not occur) •Potential benefits of oral estrogen-progestin contraceptive pills: -More private than a visible patch -Pills do not detach -Possibly lower risk of VTE

comparisons of patch vs pill

spermicide

contains spermicide (Nonoxynol-9) •Products available OTC (gel, foam, cream, film, suppository, tablet) •One of the least effective forms of contraception when used alone •Timing issues •Local irritation •Messy

•Etonogestrel (Nexplanon)

contraceptive implant product. it is a plastic rod inserted on inner side of upper, nondominant arm. Max time is 3 years

Paragard Intrauterine copper

copper IUD product. Releases copper continuously into the uterine cavity. Can worsen uterine bleeding and dysmenorrhea. Effective for 10 years (LONGEST PRODUCT)

•Increase in unscheduled bleeding •Possible increased weight gain •Possible increase in depressed mood •Decrease in bone density that is usually reversible •Small risk of severe allergic reaction •Return to fertility is not immediate •Return clinic visits needed every 12 weeks

disadvantages of injectable product

•Apply 1 patch weekly x 3 weeks -Avoid areas rubbed by tight clothing •Followed by 1 patch-free week •Theoretically could be used in extended regimen •UpToDate experts counsel against this due to potential increased VTE risk

dosing for transdermal patch

male hormonal contraceptives

had to stop research d/t severe mood swing and severe ADRs.

•When no contraceptive was used or with contraceptive failure within the previous 5 days (best within 3 days): -2 doses missed (OCs) -POP dose later than 3 hours -2 weeks late of DMPA -Dislodging, delay in placing, or early removal of patch/ring -Other (e.g. diaphragm/IUD expulsion, condom breakage) •New contraceptive start with UPI and pregnancy can't be ruled out •Sexual assault

indications of postcoital contraception

1)Copper IUD: initiation: anytime addition Contraception: none exam or tests needed: Bimanual examination and cervical inspection 2)Levonorgestrel IUD initiation: anytime addition Contraception: If >7 days after menses started, use back-up method or abstain for 7 days exam or tests needed: Bimanual examination and cervical inspection 3)Implant initiation: anytime addition Contraception: If >5 days after menses started, use back-up method or abstain for 7 days exam or tests needed: none 4)Injectable: initiation: anytime addition Contraception: If >7 days after menses started, use back-up method or abstain for 7 days exam or tests needed: none

initiation strategies and additional tests for IUD, implantables, and injectables

DMPA (depot medroxyprogesterone acetate) types: •Medroxyprogesterone (Depot-Provera): IM injxn q 3 mos •Medroxyprogesterone (Depo-SubQ Provera 104): subQ injxn q 3 mos (provides slower/more sustained absorption; lower dose needed)

injectable contraceptive product. •Highly effective, reversible (within limits of up to 18 months), and reduced compliance burden •MOA: -Inhibits gonadotropin secretion --> inhibit follicular maturation and ovulation. Results in hypoestrogenic state --> inhibits endometrial proliferation -Transforms endometrium from proliferative into secretory -Change cervical mucous to be less permeable to sperm

•Ethinyl estradiol and etonogestrel (EE/ENG) (NuvaRing, EluRyng)

intravaginal ring and left in place for 3 wks and then removed and discarded. New ring inserted after 7 days. can be used in continuous fashion as well.

•Ethinyl estradiol and etonogestrel (EE/ENG) (NuvaRing, EluRyng) •Ethinyl estradiol and segesterone acetate (EE/SA) (Annovera)

intravaginal ring products

•Ethinyl estradiol and segesterone acetate (EE/SA) (Annovera)

intravaginal ring that you leave in place for 3 wks, remove, wash with mild soap/water, and reused 1 wk later after free week. provides contraception for 13 cycles (1 yr)

•Latex: 80%+ in US -Less expensive -Can't use in latex allergy -Can't be used with oil-based lubricants (breaks down latex) •Synthetic: ~15% -Generally non-allergenic -Compatible with any lubricant -Longer shelf-life -Not sure about disease prevention so typically reserved for latex allergies •Natural membranes: <5% in US -Made of intestinal cecum of lambs -Any lubricant is ok -Small pores may permit virus passage (Hep B, HSV, HIV)

male condom types ingredient

•Obesity increases: -Metabolic rate -Clearance of hepatically metabolized drugs -Circulating blood volume -Absorption of contraceptive steroids by adipose tissue •Results: takes twice as long to achieve therapeutic steady-state levels of contraceptive hormones •Healthy obese women can use any method •IUDs and implants are the most effective •Other methods like OC and POP have conflicting data regarding efficacy •If using OC, best to start with estrogen of 20-30 mcg

obesity and contraception topics/issues

•Fertility awareness based methods (using basal body temp/menstrual cycle to predict ovulation) •Withdrawal •Lactation

other non-drug device types

1.5 mg single-dose forms available OTC with no age restrictions (Plan B One Step, My Way, Next Choice One Dose, etc.)

postcoital Levonorgestrel product. Suggest giving women a home supply or encouraging them to buy in advance ADR: Acute N/V most common. antiemetics can be given prophylactically. If vomiting within 2 hours, give antiemetic and re-dose levonorgestrel. Irregular bleeding can occur for a few weeks

-diaphragm/cervical cap -sponge -spermicides -vaginal pH regulator gel

precoital contraception products

-Reduction of menstrual bleeding and anemia -Possible amenorrhea -Reduction in dysmenorrhea -Treatment of endometriosis-related pelvic pain

reasons to choose LNg vs. copper IUD

•Can be given early if necessary •Can be given up to 14 days late without need for additional contraceptive protection -Don't tell patients! •If >14 days, exclude pregnancy and advise to abstain or use backup contraception for 7 days

timing of injectable products

•IUD -Pro: most effective of all types, provides ongoing highly effective contraception -Con: initial cost, requires procedure •Levonorgestrel PO -Pro: available OTC, relative cost -Con: not as effective as other options •Ulipristal (Ella) progesterone receptor modulator that prevents binding of progestin (postpones follicular rupture) and alters endometrium (impairs implantation) -Pro: most effective PO option -Con: requires prescription, not all pharmacies stock product •Ethinyl estradiol plus levonorgestrel (Yuzpe regimen) -Pro: may be more accessible and more private -Con: not as effective and poorly tolerated

types of Postcoital contraception

condoms

•Barrier that prevents direct contact with semen, genital lesions, and sub-clinical viral shedding •Primary noncontraceptive benefit is protection offered against STI •Variety of shapes, sizes, colors, thicknesses, with/without lubricants/spermicides, with/without reservoir-tip

sponge

•Contains 1000 mg of nonoxynol-9 (spermicide) •Can be left in place and used repeatedly for up to 24 hours •Less effective and higher discontinuation rate v. diaphragm

Vaginal pH regulator gel

•Lactic acid + citric acid + potassium bitartrate (Phexxi) •Maintains lower pH even in presence of alkaline semen -Immobilizes sperm •New 2020 •Supposed less irritation to both partners v. nonoxynol-9 •Estimated pregnancy rate 20-30 per 100 women years

intrauterine devices (IUD)

•Most commonly used method of long-acting reversible contraception (LARC) worldwide. made of plastic and release copper or progestin to enhance contraceptive action. •Benefits: high efficacy and safety, ease of use, and low cost •Provides a nonsurgical option for pregnancy prevention that is as effective as surgical sterilization

diaphragm/cervical cap

•Reusable female contraceptive device •Typically silicone in the US but latex in other countries •Partially filled with spermicide prior to coitus (sex) and placed to cover the cervix

female condoms

•single-use internal condom" (class II medical device) •Many insurance companies cover cost if prescribed •Most common product is FC2® •Hormone-free, latex-free