Contraception.

Question 1

What are the various hormonal methods of contraception and what mechanism underpins their method of action?

Answer 1

1. OCP
   - combined = oestrogen only
   - mini = progestin only.
2. Implanon - progestin rod.
3. DEPOT - progesterone injection.
4. Nuvaring - local oestrogen and progesterone.
5. IUD, Mirena - local progesterone.

MOA -
Oestrogen - consistently high - decreases release of GnRH and LH surge –> stops ovulation

Progesterone - thickens cervical mucus + causes endometrial atrophy - stops sperm and unfavorable for implantation

Question 2

What are the contraindications for the different contraceptive methods?

Answer 2

COMBINED OCP:
1. Poor absorption:
malabsorptive procedures, including gastric bypass.
2. Amplificatory effects of oestrogen:
- Symptomatic gallstones without cholecystectomy.
- Hormone related cholestasis in the past.
- Breast feeding (lactation interference and transfer of oestrogen to baby)
- Breast cancer/hx of breast cancer.
3. Oestrogen metabolism:
- Cirrhosis (severe) - synthetic oestrogen (not-oestrodiole) is long lasting and has significant effects on the liver.
- Viral hepatitis
- Hepatocellular carcinoma/tumours.
4. Hypercoagulability-related issues (all increase ischemia)
- Headache with aura
- 3-4 weeks post partum, 4-6 weeks post partum if increased risk of DVT.
- HTN (systolic >159, diastolic >99)
- Ischemic heart disease, past or current.
- RF for ischemic heart disease: smoking, diabetes, HTN, dyslipidemia, older age).
- Heavy smoker
- Past stroke.
- Major surgery with prolonged immobilisation.
- Complicated valvular heart disease.
- Current DVT, past DVT, high risk DVT, known thrombophilia.
- Diabetes w. end organ damage (end-stage with vascular insuffc).
SLE - antiphospholipid Ab+

PROGESTIN-ONLY PILL
Absorption
- Malabsorptive conditions + procedures, including gastric bypass.
Effects of progesterone
- Breast cancer, current or past.
Metabolism of progesterone
- Severe cirrhosis (progesterone in high doses broken down to smaller ‘bits’ by liver - less of an effect than oestrogen).
- Hepatocellular adenoma/malignant tumour.
SLE
Antiphospholipid Ab+.

DEPOT
Effects of progesterone
	- Breast cancer, current or past. 
Hypercoagulability (ischemia risk)
	- DM with end organ damage. 
	- HTN: systolic > 160, diastolic>99. 
	- IHD - past or current, any signficant RF. 
	- Stroke, past or current. 
	- Antiphospholipid syndrome Ab+
	- Severe thrombocytopenia. 
Metabolism of progesterone
	- Severe cirrhosis (progesterone in high doses broken down to smaller 'bits' by liver - less of an effect than oestrogen). 
	- Hepatocellular adenoma/malignant tumour. 
SLE
Antiphospholipid  Ab+.

IMPLANON
Effects of progesterone
	- Breast cancer, current or past. 
Metabolism of progesterone
	- Severe cirrhosis (progesterone in high doses broken down to smaller 'bits' by liver - less of an effect than oestrogen). 
	- Hepatocellular adenoma/malignant tumour. 
SLE
Antiphospholipid  Ab+.

MIRENA
Effects of progesterone
	- Breast cancer, current or past. 
	- Cervical cancer, awaiting treatment. 
	- Ovarian cancer. 
	- Endometrial cancer. 
Foreign body in endometrium:
	- Pelvic inflammatory disease. 
	- Immediately after septic abortion. 
	- Current STI - chlamydia/GC/purulent cervicitis. 
Metabolism of progesterone
	- Severe cirrhosis (progesterone in high doses broken down to smaller 'bits' by liver - less of an effect than oestrogen). 
	- Hepatocellular adenoma/malignant tumour. 
SLE
Antiphospholipid  Ab+.

COPPER IUD
Foreign body in endometrium:
	- Pelvic inflammatory disease. 
	- Immediately after septic abortion. 
	- Current STI - chlamydia/GC/purulent cervicitis. 
Effect of copper:
	- Cervical cancer, awaiting treatment. 
	- Endometrial cancer. 
	- Ovarian cancer. 
Severe thrombocytopenia.