birth control made simple 2013 university of arizona

7/29/2019 Birth Control Made Simple 2013 University of Arizona

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BIRTH CONTROL MADE SIMPLE Richard Wahl, M.D.Department of PediatricsUniversity of [email protected] 18, 2013

Too Much Estrogen:Nausea, bloating, breast tenderness,hypertension, melasma, headache.

Too Little Estrogen:Break-through bleeding (early or mid-cycle),spotting, hypomenorrhea, osteopenia.

Too Much Progestin:Breast tenderness, headache, fatigue, mood swings.

Too Little Progestin:Break-through bleeding (late cycle).

Too Much Androgen:

Increased appetite, weight gain, acne, oily skin, hirsutism, decreased libido, increased breast size, breast tenderness,Lipids: increased LDL, decreased HDL.

Progestin Activity: (Desogestrel Norgestrel Levo-norgestrel) > Norethenidrone

Androgenic Potency: Medroxyprogesterone acetate > (Norgestrel Levo-norgestrel) > (Norethindrone Ethynodiol) >(Desogestrel Norgestimate = non-androgenic) > (Drospirenone = anti-androgenic)

Low Dose Monophasic OCPs

Brand Names Ethinyl

estradiol

Progestin Estrogen

potency

Progestin

potency

Androgen

potency

Comments

Alesse AvianeLevlite Lutera

20 mcg Levo-norgestrel0.1 mg

+ ++ ++ Spotting more likely.Missed pills problematic.Osteopenia? (20 mcg EE relative hypoestrogenemia)

Loestrin 1/20Microgestin 1/20

20 mcg Norethindrone 1 mg + ++ ++

Levlen Levora

Nordette Portia30 mcg Levo-norgestrel

0.15 mg+ +++ ++/+++ Minimize spotting or break-

through bleeding.

Lo/Ovral Cryselle 30 mcg Norgestrel 0.3mg + +++ ++/+++

Loestrin 1.5/30Microgestin 1.5/30

30 mcg Norethindrone acetate1.5 mg

+ ++ ++

Desogen ApriOrtho-Cept

30 mcg Desogestrel 0.15 mg + +++ 0 Non-androgenic.2x risk DVT vs. LNG3

YasminOcella Zarah

30 mcg Drospirenone 3 mg + ?? - Anti-androgenic. PCOS Tx.Spironolactone analog. New

> 2x risk DVT vs. LNG10Demulen 1/35Zovia 1/35

35 mcg Ethynodiol diacetate1 mg

++ ++ ++

Ortho-Cyclen

MonoNessa

35 mcg Norgestimate 0.25 mg ++ + 0 Low androgen activity.No reports of incr. DVT risk

Ovcon-35 35 mcg Norethindrone 0.4mg ++ + + Femcon Fe Chewable

ModiconBrevicon

35 mcg Norethindrone 0.5 mg ++ + +

Orho-Novum 1/35 35 mcg Norethindrone 1 mg ++ ++/+++ ++

(50 mcg Mestranol = 35 mcg Ethinyl Estradiol)


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Birth Control Made Simple 2013 Page - 2

Biphasic OCPs

Brand Names Ethinyl

estradiol

Progestin Estrogen

potency

Progestin

potency

Androgen

potency

Comments

MircetteAzurette

Kariva

20 mcg x21 days,0 x 2 days,10 x5 days

Desogestrel 0.15 mgx 21 days

+ +++ 0 Non-androgenic.Less break-through bleeding.2x increased DVT risk.

Triphasic OCPs

Estrostep Fe

Tilia

20 mcg x5

30 mcg x735 mcg x9

Norethindrone 1 mg

x 21 days

+ ++/+++ ++ FDA Acne indication

Ortho Tri-

Cyclen Lo

Generic in 2016?

25 mcg x21 days

Norgestimate 0.18 mgx7, 0.215 x 7, 0.25 x7

+ + 0 Low androgen activity.No reports of incr. DVT risk.

Cyclessa 25 mcg x21 days

Desogestrel 0.1 mg x70.125 x7, 0.15 mg x 7

+ +++ 0 2x increased DVT risk3

Triphasil

Tri-Levlen

30 mcg x7

40 mcg x530 mcg x10

Levo-norgestrel 0.05

mg x6, 0.075 mg x 5,0.125 mg x 10 days

++ + +/++ Good for mid-cycle spotting.

Higher estrogen dose pre-ovulation.

Ortho Tri-

Cyclen

TriNessa

Tri-Spintec

35 mcg x21 days

Norgestimate 0.18 mgx7, 0.215 x 7, 0.25 x7

++ + 0 FDA Acne indicationNo reports of incr. DVT risk.

Tri-Norinyl 35 mcg x21 days

Norethindrone 0.5 mgx7, 1mg x9, 0.5 x 5

++ +/++ +/++

Ortho-Novum7/7/7

35 mcg x21 days

Norethindrone 0.5 mgx7, 0.75 x7, 1 mg x7

++ +/++ +/++

Extended Cycle OCP

Seasonale

Jolessa

30 mcg Levo-norgestrel

0.15 mg

+ ++ ++/+++ Continuous 84-day cycle,

then 7 days off. Increasedspotting or cyclic bleeding.

Seasonique 30mcg x84 days10mcg x 7 days

Levo-norgestrel0.15 mg

+ ++ ++/+++ No hormone-free days.Less spotting than above?

Yaz 20 mcg x 24days

Drospirenone 3 mg + ?? - Similar to Yazmin. LowerEstrogen, 24/4 day cycle.> 2x risk DVT vs. LNG10

Lybrel 20 mcg Levo-norgestrel0.09 mg

+ + +/++ Continuous OCP. Earlyspotting/BTB, then improves

Natazia

(New July 2010)

Estradiol(3mg 1mg)

Dienogest (new)( Drospirenone)

(2mg 3mg)

? +++ - Estradiol instead of EE.Dienogest: anti-androgenic

4-phase pill, with 2 dayhormone-free breakPossible increased DVT risk.

Progestin-Only Pills

MicronorNor-QD

--- Norethindrone0.35 mg

0 + + Irregular menses, butreduced overall blood loss.OK for breastfeeding.


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Other Hormonal ContraceptivesDepo-Provera --- Medroxy-progesterone

acetate 150 mg IM0 +++ ++++ Q 12 weeks. Irregular menses

amenorrhea. Osteopenia.Delayed return of fertility.Improves epilepsy, sickle cell.

Depo-SubQ --- Medroxy-progesteroneacetate 104 mg SQ

0 +++ ++++

Mirena IUD (or IUS) Levo-norgestrel

20 mcg/day x 5 years

0 +++ ++/+++ IUD cost: $500

Insertion:

$300See reference 11.ParaGard (Copper T 380A)

IUD

No Hormone, x 10 years 0 0 0

Norplant rods --- Levo-norgestrel 36mg x 6 rods = 216 mg;

0 ++ ++ No longer available in U.S.

Implanonimplant

--- Etonogestrel 0.06mg/day x 3 years

0 ++/+++ 0 Active form of desogestrel.Possible increased DVTrisk.

Nexplanon --- Identical to Implanon Radiopaque on X-ray

NuvaRingVaginal insert

EE 15mcg/day

Etonogestrel 0.12mg/day x 3 weeks

++? +++ 0 Vaginal ring x 3 weeks.Increased vaginal discharge

Possible increased DVTrisk.

Ortho EvraPatch

EE 20mcg/day

Norelgestromin(Norgestimate)150 mcg/day

+++ + 0 1 patch weekly x 3 weeks.Poor cycle control.Increased DVT risk

Emergency ContraceptionPlan BNext Choice

--- Levo-norgestrel0.75 mg each tablet

- +++ +++ Initial dose < 72 120 Hrs. Maytake both tabs together. Check HCG

Plan B One Step Levo-norgestrel1.5 mg

- +++ +++ Take pill < 72 120 Hr ofunprotected sex. Check HCG

ellaOne or ella Ulipristal acetate30 mg

Selective progesterone receptor modulator. 1 dose given < 72 120 Hr ofunprotected sex. (cf. RU-486/mifepristone). More effective than Plan B.8,9

Evital Levo-norgestrel

1.5 mg ??

Fake emergency contraception, not FDA approved. Contents uncertain.

FDA Press Release 7/28/2011. Manufactured in Dominican Republic?

Missed Contraceptive Doses7

1. Combined OCP (Monophasic, Triphasic, etc.)a. Missed 1 active pill < 24 hr late: Take missed pill ASAP. May take 2 pills same day.b. Missed 1 or more active pills, > 24 hr late:

i. During week 1: Take pill ASAP, use back-up x 1 week, consider EC if unprotected sex past 5 days.ii. During week 2 3 and < 3 missed pills: Take 1 pill ASAP, continue active pills until pack finished, then

discard inactive pills and start new pack.iii. During week 2 3 and > 3 missed pills: Take 1 pill ASAP, continue active pills until pack finished, then

discard inactive pills and start new pack. Back-up method x 1 week, consider EC for unprotected sexduring missed pills until 7 active pills have been taken.

c. Continuous/Extended OCP: missed pill after 21 days of continuous OCP use:i. < 7 days missed: Re-start OCP; no special precautions.

ii. > 7 days missed: Take pill ASAP, use back-up x 1 week, consider EC if unprotected sex past 5 days.2. Contraceptive Patch (Ortho-Evra)

a. Patch detached < 24 hr: Reapply or replace ASAP, patch change day stays the same, complete usual cycle of 3patches.

b. Patch delayed or detached > 24 hr:i. During week 1 and detached > 24 hr (or uncertain): Apply new patch ASAP, patch change day stays the

same, complete usual cycle of 3 patches. Back-up protection x 1 week and consider EC if sex past 5 days.ii. During week 2 3 and detached < 72 hr: Apply new patch ASAP, patch change day stays the same. Finish

course of 3 patches and immediately start new patch cycle with no off-week.


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iii. During week 2 3 and detached > 72 hr: Apply new patch ASAP, patch change day stays the same. Finishcourse of 3 patches and immediately start new patch cycle with no off-week. Back-up protection x 1 week,consider EC for prolonged omission.

c. Extended wear (> 9 days):i. Patch 1 or 2 left on for 9 to 11 days: Apply new patch, change day stays the same. Finish course of 3

patches and immediately start new patch cycle with no off-week.ii. Patch 1 or 2 left on for > 12 days: Same as above plus back-up protection x 7 days and consider EC if sex

past 5 days.iii. Extended wear of Patch 3: No concern unless left on past scheduled start of new patch cycle.

3. Contraceptive Ring (NuvaRing)a. Removal for < 3 hr: Reinsert ASAP. Removal day (day 21 after taking ring out of foil) unchanged.b. Insertion delayed > 24 hr or removal for > 3 hr:

i. Week 1 and removal > 3 hr (or uncertain): Reinsert ASAP. Removal day (day 21 after taking ring out offoil) unchanged. Back-up x 7 days and consider EC if sex past 5 days.

ii. Week 2 3 and removal < 72 hr: Reinsert ASAP. Removal day (day 21 after taking ring out of foil)unchanged. Then start new cycle with new ring and no ring-free period.

iii. Week 2 3 and removal > 72 hr: Reinsert ASAP. Removal day (day 21 after taking ring out of foil)unchanged. Then start new cycle with new ring and no ring-free period. Back-up protection x 7 days andconsider EC if repeated or prolonged omission.

c. Ring left in for > 28 days:i. For 28 35 days: Insert new ring with no ring-free period. Keep until scheduled removal day (day 21 after

taking ring out of foil).

ii. For > 35 days: Same as above plus back-up protection x 7 days and consider EC if sex past 5 days.4. Progestin-Only Pills (Micronor, Nor-QD)

a. Delayed > 3 hr or missed > 1 pill:i. If unprotected sex past 5 days: EC recommended. Continue pill next day, taking same hour daily. Back-up

protection x 48 hr.ii. No unprotected sex past 5 days: Take pill ASAP, continue one pill daily, taking same hour each day. Back-

up protection x 48 hr.5. Depot Medroxyprogesterone Acetate Injections (Depo-Provera)

a. Last injection < 14 weeks ago: give next injection ASAP.b. Last injection > 14 weeks ago:

i. If unprotected sex < past 5 days and urine HCG negative: Provide EC, give next injection ASAP, back-up protection x 1 week. Repeat HCG in 3 weeks.

ii. If unprotected sex > past 5 days and urine HCG negative: Give next injection ASAP, back-up protection x1 week. Repeat HCG in 3 weeks.

iii. No unprotected sex past 14 days and urine HCG negative: Give next injection ASAP, back-up protection x1 week.References:

1. Gupta N, Corrado S, Goldstein M: Hormonal contraception for the adolescent. Pediatr Rev 2008, 29(11):386-3962. Hatcher RA. Contraceptive Technology, 19th edition. 2008, Thomson Reuters, New York3. Petitti DB. Clinical practice. Combination estrogen-progestin oral contraceptives.N Engl J Med 2003;349(15):1443-1450.4. Comparison of oral contraceptives: a summary. Prescriber's Letter 2010;26(7):231207 (Updated June 2010)5. Natazia (Estradiol Valerate and Dienogest). Prescriber's Letter 2010;26(7):2607066. Missed doses of hormonal contraceptives. Prescribers Letter 2009;25(1):2501207. Guilbert, E, et al. Missed hormonal contraceptives: new recommendations.J Obst Gyn Can 2008;30(11): 1050-62.8. Fine P, Mathe H, et al. Ulipristal acetate taken 48-120 hours after intercourse for emergency contraception. Obstet Gynecol.

2010;115(2 Pt 1):257-263.

9. Glasier AF, Cameron ST, Fine PM, et al. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomisednon-inferiority trial and meta-analysis.Lancet. 2010;375(9714):555-562.

10. Jick SS, Hernandez RK. Risk of non-fatal venous thromboembolism in women using oral contraceptives containingdrospirenone compared with women using oral contraceptives containing levonorgestrel: case-control study using UnitedStates claims data. BMJ. 2011;342:d2151.

11. Yen S, Saah T, Adams Hillard PJ. IUDs and AdolescentsAn Under-Utilized Opportunity for Pregnancy Prevention.Journal of Pediatric and Adolescent Gynecology. 2010;23(3):123-128.


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(Hatcher RA. Contraceptive Technology, 18th edition. 2004, Ardent Media, New York)

birth control made simple 2013 university of arizona

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