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
