Contraception Part II: Combined Hormonal Contraception and Progestin Only Contraceptives 2 Flashcards
monophasic vs multiphasic
fixed (Monophasic)
Fixed (same) doses of estrogen and progestin throughout cycle
Multiphasic (Triphasic or biphasic)
Fixed estrogen dose (or varying estrogen doses), progestin dose increases in three phases (triphasic) or in second half of cycle (biphasic)
why:
mimicking progestin biologically a bit, start with low odseprogestin when first products came out and go higher when needed
There are no advantage of multiphasic products over monophasic
chc Regimens
Traditional: 21/7-day or Cyclic
– 21 days followed by 7 days hormone
free interval
–Designed to mimic menstrual cycle
(28 days)
Withdrawal bleed from hormones we gave when we stop pills at 21 days
Not a true menstrual cycle
Withdrawal bleed happens 1-2 days
Altered hormone free interval (HFI)
– Shortened HFI ie 24/4 days
– Extended cycle or continuous dosing:
• Continuous: Use everyday with no HFI
• Extended cycle: taken every day with 7
day HFI every 3 months
Rationale for Shortening Hormone Free Interval
(HFI)
§ Risk of pregnancy with classic regimens (21/7)
High risk of unplanned preg if someone misses a pill
If they forget a few days, there is enough follicular development that ovulation can happen
–FSH levels may not be adequately suppressed during the 7 day HFI
–This may lead to follicular development and potential ovulation (especially if not started on the right day)
–Continuous may be more forgiving…less chance of breakthrough ovulation.
§ Some patients have symptoms during HFI
§ No physiological reason for traditional regim
when it came out in the past, very high doses were used that took a longer time to decrease
Continuous or extended use CHC may be an option for patients who
experience problems with the HFI such as:
• Painful periods
• Endometriosis
•Headaches/migraines
• PMS
• Perimenopausal symptoms
–Or any individual who does not want a period/less frequent periods
§ Safety – considered same as cyclic
§ Continuous CHC may be associated with greater incidence of spotting or
breakthrough bleeding compared to cyclic
what products should eb used?
§ Use monophasic products, 21 day packaging
§ Extended Cycle Products: Seasonale™, Seasonique™ – every 3 months cycle
Reason why is cuz when estrogen and prog used together, edometrial lining becomes very thin , atrophic
Very weak and friable and can cause spotting
Other Formulations
Transdermal matrix patch (Evra™)
Transdermal matrix patch (Evra™)
–Once weekly application x 3 weeks, HFI (patchfree) x 1 week*
§ Reports of increased VTE in comparison to COC –
data has been inconsistent (same as 3rd gen progestin)
§ May be less effective in patients > 90kg
*Note: the patch can also be used continuously regimen as well.
Other Formulations
Vaginal Contraceptive Ring (NuvaRing™)
§ Flexible, transparent ring:
§ The ring is worn for 3 weeks, and then removed X 1
week ring free interval.*
–A new ring is inserted at the end of the ring-free
interval (28 day cycle).
§ Other contraindications: uterovaginal prolapse, vaginal stenosis (tightening of walls)
*Note: the ring can also be used continuously regimen
as well. One ring can be used up to 4 weeks.
§ Does not need to be removed with intercourse.
§ If removed and left out of vagina > 3 hours then 7 days back up contraception required (if first week).
§ Do not use with a diaphragm or oil based vaginal products
§ Recent reports increased VTE in comparison to COC’s – controversial (this uses 3rd gen prog)
Newest Product on the Market
Estetrol/drospirenone (NextstellisⓇ)
§ Estetrol (E4) is a synthetic version of a native estrogen produced in the fetal liver
§ Estetrol is considered to have intrinsic tissue selective properties (Mostly acts on nucleus Less adverse effects)
§ Longer half life compared to estradiol Estetrol/drospirenone (NextstellisⓇ) 24/4 regimen
Similar effectiveness to other CHC products (containing EE), same contraindications
No acceptable evidence that estetrol is safer compared to CHC. More evidence is required.
§ Possible advantages:
–may have less effects on markers of hemostasis;
theoretically could have lower risk of VTE
compared to other COC however this evidence is
not conclusive
– weaker estrogen effects on mammary glands compared to estradiol
–Of note estetrol is not metabolized by CYP isoenzymes, however the progestin will still be
affected (see CHC drug interactions)
Patient Education When Starting CHC
benefits
Contraceptive efficacy and relation to
other contraceptives
§ Non-contraceptive benefits
Patient Education When Starting CHC
benefits
strt date
Sunday start: Start on the first Sunday after the menstrual period begins
First-day start: Start CHC on the first day of the menstrual period
Quick start method – Start the CHC same day she sees the doctor (no matter where in the menstrual cycle)
(recommended method)
§ Backup contraception required – x 7days after start (if Sunday start and Quick start method) for the first time
üTips for adherence
üAdverse effects
•Identify with the patient what would help with to remember
•i.e. reminders/notifications, take the pill at the same time as a
routine task for example in the am or going to bed…
–Important to stress that most will disappear in first 3 months
–What to do if experience adverse effects
Warning Signs - ACHES
Abdominal pain
Chest pain
Headaches
Eye Problems
Severe leg pain
üWhat to do with missed CHC AND backup contraception
–The greatest risk is missing CHC’s that lengthen the HFI (1st and 3rd week of the cycle)
- Extending HFI > 7 days could result in ovulation and preg
–Need to discuss when to consider back up contraception (x 7 days) or emergency contraception
–Additional contraceptive methods
STI Prevention and safe sex practices
üDispel fears/myths
Important to discuss that CHC does not prevent STI’s
Reassure:
§ CHCs do not prolong the return of fertility.
§ There is no reason to go on breaks from
using CHC to return fertility.
§ CHCs have not been associated with weight
gain in RCTs - can be due to water retention, see what type of prog they are on
return to fertility after stopping and ovulation kicks back in, takes 1-3 months for cycles to return (does not delay fertility)
Follow-up Plan and Monitoring
Follow-up recommended in 1 – 3 months.
The following should be assessed with follow-up:
§ Patients satisfaction with the method.
§ Check adherence and understanding of what to do if missed pills.
§ Adverse effects experienced and what they have done about it.
§ Evaluate blood pressure
§ Assess for changes in health status or new medications added/changed
Management of Adverse Effects with CHC
Breakthrough bleeding (BTB):
ØBTB is common for the first few cycles.
Your assessment imp!
Øcheck adherence
Øsmoking status
Øchange in other meds/herbals
Ø?medical conditions (malabsorption)
Øinfections - chlamydia
Continue for 3 months
It can happen if you switch to another pdt too
Smoking increases metabolism of estrogen
what to do with ongoing BTB
§ Change to different CHC (if on 10 or 20 µg EE increase dose or change different progestin)
§ Continuous:
–Can stop pill for 3 – 4 days and then resume (give a break so it’s less friable, no backup needed).
§ Other options for BTB include:
•NSAID – ibuprofen 800 mg tid x 7 days
Prostaglandins released with withdrawal bleeding, NSAIDS can prevent it
• estrogen ie 17b-estradiol 1 mg daily x 7 days
When does the breaktrhough bleeding happen?
early- mid of cycle - could be estrogen
Late cycle - progestin
Progestin-only pills (POP)
Norethindrone 0.35mg (Movisse™, generics)*
Drospirenone 4 mg (Slynd™)
Dropirenone 4th gen spironolactone derivative
Antiandrogenic, anticorticoid
When to consider:
§ Patients who need to avoid estrogen (ie migraines with aura, smokers over 35, etc).
§ Postpartum and breastfeeding
Note: POP can be used any point in reproductive cycle.
Progestin-only pills (POP) contraindications
Contraindications:
§ Category 4: current breast cancer
§ Category 3: history of breast cancer,
liver disease, inducers
(anticonvulsants, rifampin etc)
Norethindrone 0.35 mg:
§ Main contraceptive effect is on cervical mucus changes; ovulation inhibited (through LH suppression) in only 60% of users
Must be taken every day at same time due to cerical mucus changes and half-life of drug
§ Used daily with no pill breaks, no HFI
§ Start: On the first day of the menstrual cycle
(although can be started at any other time).
Recommend back-up x 48 hours.
Timing is critical as depends primarily on cervical mucus changes
Must be taken at same time each day – may not be
effective if delayed more than 3 hours
Missed by more than 3 hrs - missed pill
Drospirenone 4 mg
SEE COMPARISON table for norethindrone vs drospirenone
Main contraceptive effect is inhibits ovulation, will also have other progestin effects (i.e. thicken cervical mucus)
§ Taken daily with a 4 day HFI (24/4 regimen)
§ Does not have same 3 hour window as norethindrone.
§ Start: On the first day of the menstrual cycle, quick start (although can be started atany other time). Recommend back-up x 7 days if started at any other
time
Progestin-Only Contraceptive Injection:
Depot –medroxyprogesterone (DMPA)
Uses:
§ Long acting reversible contraception (LARC)
§ Option if need to avoid estrogen ie migraines
with aura, smokers over 35
§ Could be considered for individuals needing
contraception and on anticonvulsants
Contraindications:
§ Category 4: current breast cancer
§ Category 3: history of breast
cancer, liver disease, undiagnosed
abnormal uterine bleeding
If on an inducer
Smoker >35, aura migraines
Inducers can also induce progestins (progestin only pill), DMPA is an opion
Progestin-Only Contraceptive Injection:
Depot –medroxyprogesterone (DMPA)
§ Depot im/sq injection every 3 months (12 weeks)
§ Inhibits ovulation, thickens cervical mucus and induces endometrial atrophy.
§ Starting DMPA: start in 1st 5 days of the menstrual cycle, repeat injection every 3 months (between 12 to 13 weeks) back up contraception x 7 days if not started within 5 days of menstrual cycle
§ Delay in return of fertility – average 9 months
§ Late injections – If > 14 weeks since last injection, back-up contraceptionx 7 days
If you start 1st 5 days of menstrual cycle, no backup
Other times backup for 7 days
Progestin-Only Contraceptive Injection:
Depot –medroxyprogesterone (DMPA)
AE and risks
§ Delay in return of fertility – average 9 months - True case of delaying fertiliy among contraceptives
§ Side effects:
–Menstrual cycle disturbances – irregular bleeding, however majority of have amenorrhea (no period)
–Progestin side effects – mood, headache, breast tenderness, others -
see progestin side effects
–Weight gain – ~2.5 kg in the first year (medroxyprog has some androgenic fx and increase appetite)
Weight gain only w injection, not POP
Risks
§ Reduction in bone mineral density
Progestin only, not giving the estrogen
Not enough estrogen, get redued bone density
–most pronounced decline is first year
–BMD recovers after discontinuation
§ No evidence that increases risk of osteoporosis fracture
§ Populations of concern:
– <18 years, perimenopause
§ Can safely use aged 18 to 45 years
Is a physiologic period necessary?
NO, because giving it cfc is not normal
what would you prescribe for pt want to use oral contraceptive? they would like to have regular periods
In this scenario, pick any oral contraceptive
Ex: EE 20mcg/levonorgestreal 0.1mg with regimen - 21/7
Alesse 28’s
Sig: Take 1 daily
Mitte: 3 months x 3 refills]
Note for younger pts, lean towards ~30ug EE (30 ugEE/0.15LNG) for example
After starting combined oral contraceptive, how many days does it take to start working?
True/False The best way to start CHC is to start on first sunday of menstrual period
7 consecutive days
FALSE
late dose vs missed
remember before 24 hours= late dose
remembers after 24 hours ofusual dose = missed
Does not affect menopause (neither delay or start early)
compare 2 POP
see table
Other AE mood canges
Norethindrone causes more bloating, water rentention
Less water rention for dropsirenone
