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Jenni Keehbauch, MD
I wish to thank Ann Klega for her Contributions
After the mother leaves the room, she asks for a prescription for birth control.
Can you prescribe it without her mother’s knowledge?
Contraception can be given without parental consent if the minor is…
Married Ever been pregnant May suffer from probable health hazard if
contraception not given
Florida Statute 381.0051 Family Planning
Condoms: 2-12% COCs: 0.3-9%
Better compliance with patch or vaginal ring
Injections: .2-6% Female sterilization: 0.5% LNG-IUD: 0.2% Nexplanon: 0.2%
Used with permission from Dr. G. Lamvu
CDC US SPR, 2013
Hormones decrease production of testosterone
Stop sperm production through the pituitary and hypothalamus
No male hormonal contraceptive is ready for clinical use
The Cochrane Library 2010 Issue 1. Chichester, UK: John Wiley and Sons, Ltd
a. Ortho Novum 1/35, 4 tabs q 12 X 2
b. Levonorgestrel 0.75 mg, 2 tab x 1 (Plan B)
c. Alesse 5 pills PO q 12 hr x 2
d. All of the above
e. None, too late
Lancet. 2002;360(9348):1803-10
Next Choice - two levonorgestrel 0.75-mg tablets taken 12 hours apart or as a 1.5-mg
Plan B One Step - levonorgestrel 1.5mg tablet taken once
Ella - one ulipristal acetate 30-mg tab
Copper IUD – most effective
Use after implantation does not interrupt an established pregnancy
Contraceptive failure (condom broke/fell
off/never came out of wallet)
Missed doses of COC
3 doses of 30-35mcg, 2 doses of 20-25mcg
POP taken more than 3 hours late
More than 2 weeks late for depo
Sexual assault
What are her options?
Contraceptive Methods
Oral Contraceptives
Combined oral contraceptives
Extended use
Continuous
Progesterone only
Alternatives to Oral
NuvaRing
Ortho Evra
Depo-Provera
Implanon
Mirena
Ethinyl Estradiol (EE) Dose < 20 mcg Ultra Low 25 – 35 mcg Low 50 mcg High
Estrogen Dose
Minimizing
Estrogen
Side Effects
• Breast
Tenderness
•Nausea
•Vascular risk
Enhancing
Cycle
Control
•BTB/BTS
•Amenorrhea
1st Generation 2nd Generation 3rd Generation 4th Generation
Norethindrone Norgesterel
Levonorgesterel
Desogesterel,
Norgestimate
Drospirenone
More androgenic
More
progestational
More
progestational
Higher
thrombosis
Anti-mineral-
corticoid
Higher
thrombosis
Progesterone Dose
Minimizing
Progesterone
Side Effects
• Weight gain
•Fatigue
•Breast tenderness
•Mood changes
Enhancing
Cycle
Control
•Reduction in
bleeding
•Decreased
dysmenorrhea
0
2
4
6
8
10
12
Non U
sers
CO
C
Dro
sper
inone
Pre
gnan
cy
DVT Risk
Androgen Dose
Minimizing
Androgen
Side Effects
• Acne/Hirsutism
•Weight gain
•Lipid effects
More Estrogen
Improving
quality of
life
•Libido
More
Progestational
Menstrual benefits
Regulates cycles
Less blood loss
Less dysmenorrhea
Less PMS
Prevention of Ovarian and Endometrial Cancer
Decreased benign breast disease
Decreased ectopics Improved androgen
symptoms Increased bone mass
All COCs increase SHBG and decrease testosterone resulting in less acne and hirsutism
Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD004425
Decreased risk of endometrial cancer with as little as 3 months of use and decreased risk by 60% after 5 years
Decreased risk of ovarian cancer by 60% after 2 yrs
Protection remains for 15 years after cessation of OCP’s
Must be taken daily Does not protect from STD’s Increased Chlamydial infection Risk of arterial vascular disease/DVT
desogestrel or gestodene have a 2X greater risk Increased risk of breast and cervical cancer
Assuming 5 year usage of OCP’s in 100,000 women
20% increased risk for breast and cervical cancer (screened cancers)
50% decreased risk in ovarian and endometrial cancer (non-screened cancers)
There would be 44 fewer cancers diagnosed BMJ 2009;339:b2895
Category 1 - No restrictions in use Category 2 - Advantages generally outweigh concerns Category 3 - Exercise caution and monitor for adverse effects Category 4 - Refrain from using
Available online
http://www.cdc.gov/reproductivehealth/unintendedpregnancy/usmec.htm#a
http://www.who.int/reproductivehealth/publications/family_planning/mec_mobile_app/en/
App: (iphone) CDC US Medical Eligibility Criteria for
Contracpetive use 2010 Free http://www.cdc.gov/reproductivehealth/unintendedpregnancy/usmec.htm
http://www.cdc.gov/reproductivehealth/unintendedpregnancy/usmec.htm#a
History DVT/PE Hypercoaguable HTN> 160/100 Major surgery Breast Cancer CAD/CVD Postpartum <3wk
Migraines with aura Servere cirrhosis Diabetes w/
microvascular dz Over 35 and >15 cigs
Post-partum < 30 days if breastfeeding or risk for VTE
Undiagnosed abnormal uterine bleeding > 35 years old and light smoker Hypertension Gallbladder disease Migraine and age >35 Taking Meds that effect liver enzymes:
rifampin, griseofulvin, anti-convulsants,
St John’s Wort, barbituates...
Over 100 options Focus on a few that you know really well No clear rationale to use Biphasic or Triphasic
COC
Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD003553 Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD002032.
COMPARISON OF ORAL CONTRACEPTIVES Reference Drugs Estrogen Progestin Comments
ULTRA LOW-DOSE MONOPHASIC PILLS
Alesse
EE 20 mcg Levonorgestrel (LNG)
0.1 mg
Low estrogen, progesterone
Good choice to minimize risk of estrogen side effects like nausea, breast tenderness
headache, etc.
Decreased hormonal risk: CAD, CVA, etc
Loestrin 1/20 EE 20 mcg Norethindrone High progesterone, medium androgen
Minimize estrogen side-effects: nausea, bloating, nausea
Good for dysmenorrhea
LOW-DOSE MONOPHASIC PILLS <35 mcg
Ortho – Cept
Desogen
EE 30 mcg Desogestrel 0.15 mg Increased risk of DVT with desogestrel over other progestins.
Low androgen, high progesterone
Good for dysmenorrhea/acne
Yasmin EE 30 mcg Drospirenone 3 mg Antimineralocorticoid activity. May decrease cyclic fluid retention. Not high enough
levels of anti-mineralcorticoid for PCOS treatment
Can increase potassium.
Loestrin Fe 1.5/30 EE 30 mcg Norethindrone High Androgen/High progesterone;
May increase libido
Good for dysmenorrhea
Sprintec
Ortho-Cyclen
EE 35 mcg Norgestimate 0.25 mg CHEAP
Low progestin, low androgen
Good choice to minimize spotting and/or BTB and minimize androgenic effects.
Medium estrogen good for ovarian cyst suppression
Demulen 1/35 EE 35 mcg Ethynodiol diacetate High progesterone, low androgen
Ovcon-35 EE 35 mcg Norethindrone 0.4 Medium estrogen, low progesterone, low androgen
Better lipid profile with higher estrogen/progesterone ratio
Necon 0.5/35 EE 35 mcg Norethindrone 0.5 Medium estrogen, low progesterone, low androgen
Nordette EE 30 mcg LNG 0.15 mg High androgen, May increase libido
Quick Start •Start on day Rx given , regardless of where in cycle, if preg reasonably excluded •Increased compliance •Requires 7 days back up contraception if >5 days after menstruation begins
First Day Start •Start on first day of next menstruation •Maximum contraceptive effect •No back up needed
Traditional Start / Sunday Start •Start 1st Sunday after menstruation begins •Avoids withdraw bleeding on weekend •Requires 7 days back up contraception if >5 days after menstruation begins
No signs/symptoms of pregnancy and meets any of the following:
<8 days after start of nl menses
No intercourse since start of last menses
Correctly and consistently using reliable method of contraception
<8 days after induced or spontaneous abortion
Within 4 weeks postpartum
Fully or nearly fully (>85%) breastfeeding, amenorrheic,
and < 6 months post partum
US SPR, June 21,2013, Vol. 62, No. 5
Use an OCP with higher Progesterone to stabilize the endometrium
Loestrin 1.5/30
Desogen
Ortho-Cept
Demulen 1/35
Most ocps incresase SHBG thus
decrease circulating free testosterone.
Levonorgesterol and norgesterol due not
increase SHBG, and may be more
androgenic
Use an OCP with Low Estrogenic/Progesterone activity
Examples
Alesse
Try progestins with the most potent
androgenic activity
Desogestrel
Levonorgestrel
Any may provide a placebo effect
Change to contraceptive with Low estrogen/progesterone
Alesse Change to progesterone only contraceptive Avoid triphasics/biphasics Change to Extended or Continuous Cycle
Most studies suggest that use of extended-cycle contraceptives results in fewer menstrual symptoms such as headache, bloating and menstrual pain
Cochrane Database Syst Rev 2005; 20 (3):CD004695.
Avoid COC’s in patients with Aura or focal neurological signs (WHO 4)
Avoid starting in women with migraines >/= 35 (WHO 3)
20 mcg ethinyl estradiol/ 150 mcg norelgestromin per day
Transdermal: 3 wks on 1 off Failure rate: 1-2% perfect use Cost: $45 per month
Advantage
Ease of use
No daily management
Better adherence
Disadvantage
Site reaction (20%)
Increased DVT risk and hormonal side effects
Weight limit (<198#)
15 mcg ethinyl estradiol/ 120mcg etonorgestrel
Vaginal ring placed for 3 weeks removed for 1 Less side-effects than COCs Failure: 1-2% perfect use Cost: $25-35
Advantage Low dose estrogen
No sizing needed
Inserted and removed by user
Disadvantage May feel during
intercourse: remove and replace within 3 hours
May increase leukorrhea
Disadvantages
Not immediately reversible
Decrease in bone mineral density (LOE 3)
Weight gain, worsening depression, acne
No STI protection
Obstet Gynecol 2009;114:279-284.
Etonogestrel (progestin only) Subdermal rod 3 years Cost: $500 (prior approval with insurance
needed)
Advantages
Contraception within 24 hrs
Ovulation resumes within 3 weeks of discontinuing
Great for nulliparous
Disadvantages
Increased DVT risk
Irregular bleeding (20%)
Headache
Weight gain, acne
Norplant
6 capsule implanted in upper arm
Effective for 5yrs
Produced in US 1991-2002 (some availability until 2004)
Removal complication rate of 6-7%
Levonorgestrel (progesterone only) Primarily inhibits fertilization Also thickens mucus, slows transport,
inhibits capacitation and decreases ovulation
Failure: 0.1% Cost: $650
Longterm, but reversable Reduction in dysmenorrhea and menstrual
bleeding (70-90%) Can be used in treatment of endometrial
hyperplasia May avoid surgery1
May decrease the risk of PID
1. BJOG.2001;108(1):74-86
Spotting for up to 3-6 mos Expulsion (2-10%) Perforation 1:1000 PID risk immediately after insertion STI (trichomonas) Inflammatory paps
Uterine anomaly Active pelvic infection (PID) or STD in last 3 months Pregnancy Abnormal uterine bleeding that has not been
evaluated Current GYN cancer Gestational Trophoblastic Disease (GTD)
US Selected Practice Recommendations for Contraceptive Use, 2013
WHO Selected Practice Recommendations for Contraceptive Use, 2nd Ed.
US Medical Eligibility Criteria for Contraceptive Use, 2010