Contraception – SOGC 2004 + Rx Files 9th edition

1 With all patients, especially adolescents, young men, postpartum women, and perimenopausal women, advise about adequate contraception when opportunities arise.

2 In patients using specific contraceptives, advise of specific factors that may reduce efficacy (e.g., delayed initiation of method, illness, medications, specific lubricants).

Hx & Physical:

  1. BP & STI screen
  2. condom use (to protect against STIs)
  3. Contraindications (see below – different between combined vs progestin only)
    • Liver, breast, HTN, H/A, smoking hx

3 In aiding decision-making to ensure adequate contraception:
a) Look for and identify risks (relative and absolute contraindications).
b) Assess (look for) sexually transmitted infection exposure.
c) Identify barriers to specific methods (e.g., cost, cultural concerns).
d) Advise of efficacy and side effects, especially short-term side effects that may result in discontinuation.

4 In patients using hormonal contraceptives, manage side effects appropriately (i.e., recommend an appropriate length of trial, discuss estrogens in medroxyprogesterone acetate [Depo– Provera]).

Combined OC’s

Absolute C/I (combined):
  1. < 6week postpartum if still BF
  2. Smoker (>15cig/day) >35yo
  3. HTN (≥ 160/100)
  4. Current or Hx of VTE
  5. Hx of CVA
  6. Complicated valvular disease: A Fib, endocarditis, pulm HTN
  7. Ischemic heart disease
  8. DM with retinopathy/neuropathy/nephropathy
  9. Current Breast Ca
  10. Severe Cirrhosis, liver tumor (adenoma, hepatoma)
  11. Migraine H/A with focal neurological symptoms
Relative C/I (combined):
  1. Smoker (<15cig/day) >35yo
  2. Controlled HTN (<160/100)
  3. Migraine > 35yo
  4. Symptomatic gallbladder dz or Hx of combined OCP related cholestasis
  5. Mild cirrhosis
  6. >35yo with BMI >30
Non-Contraceptive Benefits:
  1. Cycle regulation, ↓menstrual flow, ↓dysmenorrhea, ↓peri-menopausal symptoms, ↓moliminal symptoms
  2. ↑BMD, ↓acne, ↓hirsutism, ↓
  3. ↓endometrial & ovarian ca,  ↓ risk of fibroids,  ↓salpingitis
S/E:
  1. Irregular Bleeding – common in the first 3 months and tend to improve with time
    • Encourage to continue OCP for 3mo rather than switching
    • if bleeding after 3 cycles, new onset, then r/o other causes:
      1. smoking
      2. noncompliance: pill use, timing, missed pills
      3. uterine/cervical pathology: vag bleed after intercourse, Pap & STI testing,
      4. malabsorption: diarrhea, vomiting in the last cycle
      5. pregnancy: do preg test, inquiresymptoms of pregnancy:
        • if confirmed, stop the pill. No ↑ birth defects
      6. med (anticonvulsans, rifampin, herbal med)
    •  Amenorrhea -r/o pregnancy, ensure pt that it’s not dangerous, add estrogen if not acceptable
  2. Breast Tenderness and nausea – generally improve with time (↓ with less estrogen)
    • Mastalgia often resolves after few cycles & ↓ caffeine / estrogen content may help
    • Galactorrhea – rare and need to r/o prolactinoma
    • Nausea – r/o pregnancy, Take pill with food, at bedtime, or ↓ estrogen often control the nausea.
  3. Wt Gain – no strong correlation
  4. Mood Changes

Risks:

  1. VTE – 3-4x ↑ (higher in the first yr of use)
  2. MI (if >50ug ethinyl estradiol, 3x ↑)
  3. Stroke (↑ if >50ug ethinyl estradiol & in HTN pt)
  4. Gallbaldder dz – ↑ cholic acid in bile
  5. Breast Cancer – controversial
  6. Cervical Cancer – uncertain

Fertility is restored within 1-3 mo after stopping combined OC.


Rx:

A low-dose preparation is preferred. The one that provides effective contraceptioin, acceptable cycle control, and the least s/e for that pt.

Combined OCP
  1. Alesse – EE 20ug + Levonorgestrel 0.1mg
  2. Marvelon – EE 30ug + Desogestrel 0.15mg
  3. Yaz – EE 20ug + Drospirenone 3mg
  • Start 1st Sunday of period (old school teaching, pt can actually start any time), if started >5d from LMP, use backup x 7 days
  • Never exceed 7 day pill-free interval between packs
Continuous combined OCP use:
  • Continue until breakthrough bleed or 4 packs.
  • Break through decreases over time
  • Any Contraceptive with
  • reasonable approach to Tx severe dysmenorrhea, menorrhagia, menstrual migraine, or postpone withdrawal bleeding

Counselling:

  • Inform possible s/e, benefits, common myths, warning signs
  • Condon use for protection against STIs and HIV
  • emphasize dual protection & emergency contraception in the event of missed pills

Missed pills

  • If 1 pill delayed <24hr, take ASAP
  • Week1: >1pill missed, take 1 ASAP, continue till end of pack
  • Week2/3: 1 pill ASAP, daily till end of pack and start new cycle without HFI (Hormone Free)
  • >= 3pills – 7 days of backup method

Combined Patch – EVRA (1 patch weekly x 3-12, off one week)

Same C/I as combined OC escept less effective for Wt >90kg (relative c/i)

S/E:
  1. irregular bleeding/spotting – similar to combined OC
  2. Breast symptoms & H/A – more common with the patch in the first 2 cycles
  3. Local Skin reaction – don’t increase over time – 20% of pt

EE 35ug + norelgestromin 200ug – buttocks/deltoid/ torso (no breast)

  • Missed dose – 48hr window of forgiveness (patch effective up to 9d)
  • If comes off, reapply ASAP
    • Off >24hr in week 1 – 7d back up method
    • Off >24hr in week2/3 – finish cycle and start new without HFI
  • Excellent adhesive that stays on while swimming, shower, exercise, in hot, humid weather
  • need to apply to clean dry area: buttocks, upper outer arm, lower abdomen, upper torso, excluding breast
  • Back up method x 7 days if started after the first day of withdrawal bleeding
  • Patch free period < 7 days
  • Assume same drug interaction as combined OC

Vaginal Ring – NUVARING (3 week in, 1 week off)

  • Same absolute c/i as combined OC
  • Relative C/I: uterovaginal prolapse, vaginal stenosis
  • EE15ug + Progestin etonogestrel 120ug – keep in fridge (stable 4mo at room temp)

S/E:

  • Irregular bleeding – doesn’t seem to be higher in the first cycle for the ring
  • H/A (11.8%), nausea (4.5%), breast tenderness (2.8%)
  • Additional Vaginal s/e:
    1. ↓ irregular bleeding, leucorrhea
    2. 1% FB sensation/coitus issues /expulsion


Progestin Only- norethindrone

  1. Micronor – Norethindrone 0.35mg Po x 28 days – Take same time daily (within 3hr)
    • if irregular bleeding and no other cause:
      • add NSAID
      • change to combined OCP
      • or supplement estrogen
    • if started >7d after LMP or take > 3hr apart, use backup x 7d
  2. DMPA – Depo Provera – 150mg progestin IM deltoid Q12weeks during the 1st 5 days of period
  1. Indications:
    • Known c/i or sensitivity to estrogen
    • >35yo smoker
    • pt with migraine h/a, sickle cell dz, endometriosis
    • Breastfeeding – no effect on breast milk production or infant development
    • taking anti-convulsant medications
    • Poor compliance to daily meds
    • appropriate choice for pt with hx of VTE, but use with caution for pt with thrombophilia
  2. Absolute C/I:
    • Pregnancy,
    • unexplained vaginal bleed (depo provera only)
    • current breast Ca
  3. Relative C/I:
    • Severe cirrhosis, active viral hepatitis, benign hepatic adenoma
  4. Risk:
    • Delayed return of fertility (9mo),
    • dec BMD – reversible and no evidence DMPA causes osteoporosis
      • dietary & lifestyle modifications to improve peak bone mass eg. exercise, calcium intake, & smoking cessation
    • VTE, CV dz, stroke – no ↑ risk but limited data
  5. Non-contraceptive Benefits:
    • ↓ risk of endometrial ca
    • Amenorrhea with subsequent reduction in dysmenorrhea and anemia
    • ↓ endometriosis symptoms, PMS, chronic pelvic pain, menstrual cramping, PID
    • ↓Seizure and sickle cell crisis
  6. S/E:
    • menstrual cycle disturbance
    • Hormonal s/e: H/A – most common, acne, decreased libido, nausea, breast tenderness
    • wt gain (4kg) – small proportion only; dietary counselling is advised
    • Mood: controversial
    • if irregular bleeding
      1. r/o pregnancy, infection, genital pathology
      2. inc to 225-300mg for 2-3 injections (IM only)
      3. dec interval (IM only)
      4. ibuprofen400-800mg bid x 10d
      5. or add OCP for 1-3 mo / supplement estrogen

IUD

  1. Copper IUDs: Nova-T / Flexi-T 300 – Q5yr
  2. Levonorgestrel-releasing IUD: Mirena – Q5yr (not for post-coital contraception)
  3. Can be inserted and removed in any time of the cycle
Absolute C/I
  1. Pregnancy
  2. Current, recurrent, or recent (3mo) PID or STI
  3. Puerperal sepsis, immediate post-septic abortion
  4. Severely distorted uterine cavity
  5. Unexplained vaginal bleeding
  6. Cervical or endometrial cancer;
  7. malignant trophoblastic dz
  8. Copper allergy – copper IUD
  9. breast cancer – Mirena
Relative C/I
  1. Risk factor for STI / HIV or HIV-positive
  2. Immunocompromised – corticosteroid Tx
  3. 48hr to 4 weeks postpartum – IUD must insert immediate 10-15min after delivery of the placenta (↑ risk of explusion and perforation)
  4. Ovarian Ca, bening gestational trophoblastic dz
Nulliparous is not a C/I
Non-contraceptive benefits
  1. ↓ endometrial ca
  2. ↓menstrual flow and cramping – for menorrhagia and dysmenorrhea (Mirena)
S/E:
  1. Increased or irregular menstrual bleeding – most common in the first month; ↑ with Copper IUD but ↓ with Mirena
  2. Pain / dysmenorrhea – exclude infection, malposition, and pregnancy; ↓ menstrual pain with Mirena
  3. Hormonal (Mirena): depression, acne, H/A, breast tenderness – max at 3 mo then ↓ – no sig wt gain
  4. Functional Ovarian cyst  ↑ with Mirena – expectant Tx
Risks:
  1. Uterine Perforation
  2. Infection (STI exposure but not IUD use itself increase PID) – PID relates to insertion process if + STI
    • Cervix carefully inspected prior to insertion & if there is any mucopurulent d/c or pelvic tenderness, cervical swabs should be performed & insertion delayed until the results are known
    • Abx prior to IUD insertion is not necessary but required if presence of STI prior to the removal of an IUD
    • F/u visit post-insertion to exclude infection, assess bleeding pattern, assess satisfaction.
  3. Expulsion
    • If the strings can not be found, u/s to identify location. If not identified within the uterus / pelvis, plain x-ray of the abdomen to r/o uterine perforation. Both Mirena & copper IUD are radio-opaque

IUD does not ↑ risk of ectopic; but exclude ectopic in women conceived with an IUD in place

  • once r/o ectopic, leave the device in place if wishes to terminate the pregnancy
  • Remove IUD if wishes to continue with the pregnancy

Reference:

http://sogc.org/wp-content/uploads/2013/01/143E-CPG2-March2004.pdf


Product Selection guided by S/Sx of

1) Estrogen Deficiency:

  1. early bleeding & spotting days 1-9 or Continuous bleeding or spotting
  2. Dec in flow or Absence of withdrawal bleeding
  3. Nervousness or vasomotor symptoms
  4. Atrophic vaginitis or Hx pelvic relaxation surgery

2) Progestin Deficiency:

  1. Late bleeding and spotting days 10-21
  2. Delayed withdrawal bleeding

3) Estrogen excess and/or progestin deficiency

  1. PMS -bloating and edema, irritability,
  2. nausea, vomiting, leg cramps
  3. hypermenorrhea, menorrhagia, dysmenorrhea
  4. Cyclic weight gain, headache, visual changes

4) Excess Estrogen

  1. Hypermenorrhea, menorrhagia, dysmenorrhea, mucorrhea
  2. Thromboembolism, clotting
  3. Inc breast size or cystic change
  4. Cervical extrophy, inc uterine or fibroid growth
  5. HTN, vascular h/a
  6. UTI, chloasma

5) Excess Progestin

  1. Depression, fatigue
  2. weight gain, increase appetite
  3. Breast tenderness
  4. Libido decrease
  5. HTN, Hypoglycemia – dizzy
  6. Cervicitis, yeast infection
  7. Leg vein dilation

6) Excess Androgen

  1. Libido increase
  2. Oily skin / scalp, acne, rash & pruritus
  3. Hirsutism – OC, Spironolactone 25-100mg bid, drospirenone,
  4. Cholestatic jaundice

 7) Acne – All helps, official Acne indication:

  1. Tri-cyclen
  2. Yasmin, Yaz
  3. Diane 35 (not for contraception)

Efficacy is measured by the pearl index

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Posted in 16 Contraception, 99 Priority Topics, FM 99 priority topics, Gyne

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