hormonal contraception ahmad sameer tanbouz 5 th year medical student - ju
TRANSCRIPT
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Hormonal Contraception
Ahmad Sameer Tanbouz
5th Year Medical Student - JU
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Combined [Estrogen & Progestin] Methods
OCPs
Transdermal Patches (Ortho Evra)
Vaginal Ring (NuvaRing)
Progesterone-Only Methods
The Minipills (POPs)
Injections
Implants
Outline
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OCPs
Estradiol which is a natural Estrogen is NOT Orally Effective
Ethinyl Estradiol = synthetic Estrogen – Orally Effective –
Most contain Low dose Ethinyl Estradiol (20-35µg) plus
Progestin (Norethindrone, Norgestrel, Levonorgestrel,
Despgestrel, Norgestimate, Drospirenome)
Failure rate (0.3% to 8%)
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OCPs
Place the body in a Pseudo-Pregnancy state by interfering
with the release of FSH & LH from the anterior pituitary
The Pseudo-Pregnancy state suppresses ovulation &
prevents pregnancy from occurring
Because the FSH & LH surges do not occur, follicle growth,
recruitment & ovulation do not occur
It causes Thickening of the cervical mucus to render it less
penetrable by sperm & changes the endometrium to make it
unsuitable for implantation
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Monophasic Combination Pills
Contains a fixed dose of Estrogen & Progestin in each tablet
It is taken for the 1st 21 days out of 28-day monthly cycle. During the last 7 days of each cycle, a placebo pill or no pill is taken (21/7 regimens). Other Regimen (24/4)
Bleeding should begin within 3 to 5 days of completion of the 21 days of hormones
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Monophasic Combination Pills
Women with menstrual-related disorders (such as endometriosis, menorrhagia, anemia, dysmenorrhea, menstrual irregularity, menstrual migraines, PMS, PCOS or ovarian cysts) may benefit from extending the number of consecutive days of hormonal pills thus increasing the length of continuous hormonal suppression & decreasing the number of withdrawal bleeds
Seasonale contains 84 consecutive hormonal pills followed by 7 placebo pills, or 7 low-estrogen pills
Lybrel – a 365-day OCP regimen – provides a combination of Estrogen & Progestin pill each day, 365 days of the year
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Multiphasic Combination Pills
Vary the dosage of Estrogen and/or Progestin in the active hormone pills in an effort to mimic the menstrual cycle
It may provide a lower level of Estrogen & Progestin overall but it is highly effective at preventing pregnancy
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Non-contraceptive health benefits of OCPs
Decrease risk of serious diseases Ovarian CA Endometrial CA Ectopic pregnancy Severe anemia PID – thickens cervical mucus – Salpingitis
Improve quality of life problems IDA [Iron Deficiency Anemia] Dysmenorrhea – suppression of PG release – Functional ovarian cysts Benign breast disease Osteoporosis
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Non-contraceptive health benefits of OCPs
Treat / manage many disorders DUB – stabilizes endometrium & shedding – Dysmenorrhea Endometriosis Acne/ Hirsutism
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Side Effects
Estrogen-related: Nausea Breast changes (tenderness, enlargement) Fluid retention/bloating/edema Weight gain (rare) Migraine, headaches Thromboembolic events Liver adenoma (rare)
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Side Effects
Progestin-related: Amenorrhea Headaches Breast tenderness Increased appetite Decreased libido Mood changes Hypertension Oily skin Hirsutism
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Complications
Cardiovascular – DVT, PE, CVA, MI, HTN
Cholelithiasis
Cholecystitis
Benign liver adenoma
Cervical adenocarcinoma
Retinal thrombosis
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OCPs with Estrogen >50mg can increase coagulability, leading to higher rates of MI, stroke, thromboembolism and PE particularly in women who smoke. At a lower doses of estrogen (35 µg or less) women over 35 who smoke more than one pack of cigarettes per day are still at increased risk of heart attack, stroke, DVT & PE if they use OCPs
The Progestin in OCPs have been found to raise LDL while lowering HDL in pill users smoking more than 1 pack per day
OCPs are contraindicated in women over age 35 who smokes 15 or more cigarettes a day. These women often benefit from Progesterone-only IUDs or permanent female or male sterilization
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Contraindications
Absolute Thromboembolism PE CAD CVA Smokers over the age of 35 Breast / Endometrial CA Unexplained vaginal bleeding Abnormal liver function Known or suspected pregnancy Severe hypercholesterolemia Severe triglyceridemia
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Contraindications
Relative Uterine fibroids Lactation DM Sickle-cell disease Hepatic disease HTN SLE Migraine headaches Seizure disorders Elective surgery
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Medications that reduces the efficacy of OCPs
Barbiturates
Carbamazepine (Tegretol)
Phenytoin (Dilantin)
Rifampicin
Topiramate (Topamax)
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Medications whose efficacies are changed by OCPs
Diazepam (Valium)
Methyldopa
Phenothiazides
Theophylline
TCAs
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Missed Combined OCPs Miss 1 pill during first 2 weeks of the cycle:
Take 1 pill as soon as patient remembers & the next pill at the usual time.
Miss 2 pills in a row during first 2 weeks of the cycle: Take 1 pill the day patient remembers & the next pill at the usual time. Back-up method of birth control & Emergency Contraceptive method
is required during next 7 days
Missed 2 pills in a row during third week of the cycle OR miss 3 in a row at any time: Throw out pack & start a new pack immediately Back-up method of birth control required during next 7 days
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Transdermal Patches – Ortho Evra
Continuous release of 6mg Norelegestromin & 0.60mg Ethinyl
Estradiol into bloodstream
Applied to lower abdomen, buttocks, shoulder, upper arm
As effective as OCP in preventing pregnancy (>99% with
perfect use)
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Transdermal Patches – Ortho Evra
Women apply one patch each week for 3 weeks followed by
1 week patch-free during which they will have a withdrawal
bleed.
It has been found that effectiveness is decreased in markedly
overweight women (greater than 90 kg)
The patch can cause skin irritation in some users
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Vaginal Ring - NuvaRing
It releases a daily dose 15µg of Ethinyl Estradiol &120µg of
Etonogestrel
The ring is placed in the vagina for 3 weeks and is removed for
1 week to allow for a withdrawal bleed.
As effective as OCP in preventing pregnancy (98%)
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Vaginal Ring - NuvaRing
Because one size of vaginal ring fits all women, the vaginal ring
does not need to be fitted by a clinician
The use of Antifungal Agents & Spermicides is permitted
Disadvantages: Discomfort Headache Vaginal Discharge Recurrent Vaginitis
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The Minipill (POPs) Deliver a small daily dose of Progestin (0.35 mg
Norethindrone) without any Estrogen
POPs have lower Progestin levels than combination pills, thus
the nickname Minipills
Higher failure rate (1.1 – 13% with typical use, 0.51% with
perfect use) than other hormonal methods
They are taken Every Day of the cycle with NO hormone-free
days
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The Minipill (POPs) They are not as effective as the combination pills since failure
rate increases if punctual dosing is not achieved
It thicken the cervical mucus making it less permeable to sperm
It causes endometrial atrophy & ovulation suppression
Because they contain no estrogen, POPs are ideal for
nursing mothers & women for whom estrogens are
contraindicated including women over 35 who smoke & women
with HTN, CAD, CVD, SLE, Migraines & Thromboembolism
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The Minipill (POPs)
Disadvantages: Irregular menses ranging from amenorrhea to irregular
spotting POPs must be taken at the same time each day
(a delay of more than 3 hours is similar to a missed pill!!!) Acne formation Breast tenderness & Irritability
Missed progestin-only pills:• If a pill is missed, it should be taken as soon as possible;
the next pill should be taken at the scheduled time. Backup contraception should be used for the next 48 hours
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Injections Depo-Medroxy-Progesterone Acetate (DMPA)
It is injected IM every 3 months in a vehicle that allows the slow
release of Progestin over a 3-month period
It acts by suppressing ovulation, thickening the cervical
mucus & making the endometrium unsuitable for
implantation
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Injections It is one of the most effective contraceptive methods available
This formulation carries the benefit of lower Progestin levels but
the same efficacy rates
50% of DMPA users will have amenorrhea after 1 year of
use and 80% after 5 years of DMPA use! This makes it a
good option for women with bleeding disorders, or on
anticoagulation, or who are in military or who are mentally &
physically disabled
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Injections Advantages:
Highly effective Acts independent of intercourse Only requires injections every 3 months Reduces the risk of Endometrial CA & PID Reduces the amount of menstrual bleeding Useful in treatment of menorrhagia, dysmenorrhea,
endometriosis, menstrual related anemia & endometrial hyperplasia
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Injections Disadvantages:
Decreased Bone Density (Reversible) Irregular bleeding Weight gain Mood changes Hair loss Headache
After discontinuation of injections, some women may experience a
significant delay in the return of regular ovulation (6 to 18
months)
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Implants It is a single-rod, Progestin implant that provides 3 years of
uninterrupted contraceptive coverage
The Progestin used in Implanon is Etonogestrel – the same
Progestin used in NuvaRing –
The device provides slow release of 68mg of Etonogestrel over
3 years
It is the size of a matchstick & is placed in the subdermal skin of
a woman’s upper arm
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Implants When appropriate timing of placement is utilized, Implanon is
effective 24 hours after placement & has quick return to fertility
once the device is removed by a clinician
Advantages: Implantable Provides 3 uninterrupted years of contraceptive coverage
Disadvantages: The need for a clinician to insert & remove the device Unpredictable bleeding profile
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