Hormonal Contraception

Question 1

when was contraception legalized in Canada?

Answer 1

late 1960s.
1965 first family planning clinic opened
1969 contraception decriminalized

Question 2

what is most effective contraceptive methods?

Answer 2

IUD
implant
sterilization

Question 3

what are moderately successful forms of birth control?

Answer 3

pills
ring
patch
injection

Question 4

what are less effective forms of birth control

Answer 4

condom
diaphragm
withdrawn
FAM

Question 5

what are emergency contraceptives?

Answer 5

copper IUD
ullipristal
levonogestrel
yuzpe regimen

Question 6

what do unsafe sexual behaviours lead to?

Answer 6

unplanned pregnancies, negative health and social incomes

Question 7

review slide 8 on contraceptives for the hormones!

Answer 7

ok!

Question 8

how does FSH behave during menstrual cycle?

Answer 8

starts moderate, drops before ovulation, spikes after, then goes down to moderate levels

Question 9

how does estrogen behave during menstrual cycle

Answer 9

starts low, increases drastically before ovulation, then drops a bit before spiking in luteal phase before dropping off for real

Question 10

how does LH respond to menstrual cycle

Answer 10

starts low, spikes at ovulation, then drops down low again

Question 11

how does progesterone respond to menstrual cycle

Answer 11

starts low, increases steadily until a dramatic increase in the luteal phase, then it drops down low again

Question 12

what are some initial considerations before starting hormonal contraception?

Answer 12

-patient’s contraceptive needs and demographics
-medical history (chronic conditions, weight, vitals, pregnancy and breastfeeding status, medications)
-physical exam: biannual examination, cervical inspection, STI screening if considering IUD
-social history: smoking, risk of non adherence

Question 13

preventative hormonal contraception

Answer 13

produces unnatural state of anovulation in individual who isn’t pregnant or lactating
estrogen and progesterone combos or progestogen only
fail rates are 0.3% if used correctly, 9% with typical use

Question 14

mechanism of action for estrogen and progesterone combination

Answer 14

metabolized in the liver by CYP P450 enzymes. primarily inhibits ovulation, thickens cervical mucus. can interfere with fertilization by altering tubal mobility of ovum. inflammation and atrophy of endometrial lining.

Question 15

The Pill

Answer 15

combined oral contraceptive, containing ethinyl estradiol and progestogens.
depends on which day first pill is taken, generally 48-72 hours to start working, but max effectiveness may not be reached for several days.

drug interactions: drugs that induce CYP P450 enzymes (antiepileptics) or inhibit them (antibiotics)

regimens
- monophasic: fixed dose
-biphasic/triphasic: different doses during cycle
- cyclical regimen:
- hormone pill taken 21 days, blanks/nothing taken 7 days
- shortened pill free interval (4 day) or extended pill free interval (84 days)
- pill free allows withdrawal bleeding to prevent endometrial hyperplasia
-continuous regimen: no pill free interval

admin instructions
- 1 pill same time every day
missed dose? risk of failure. adjust regimen. depends on how much was missed, when it was missed, and if there was sexual inter course.
back up: use alternative form of additional contraception for entire first cycle, if missed doses, severe diarrhea and during antibiotic therapy.

Question 16

Transdermal Combo Contraceptive Patch (Evra Patch)

Answer 16

ethinyl estradiol and norelgestromin
more uniform release of hormone throughout the day, not effective in individuals 90kg+

regimen
- cyclical: 1 patch, once a week for 3 weeks, then 1 week hormone free
- continuous: no hormone free days
instructions: apply path same day once a week on abdomen, butt, or arm. back up is individualized.

Question 17

Vaginal combo ring (NuvaRing)

Answer 17

flexible colourless ring containing ethinyl estradiol and etonogestrel
more uniform release of hormone throughout the day
regimen
- cyclical: 1 ring inserted and left for 3 weeks, hormone free week
- continuous: no hormone free days
patient instructions:
compress and insert into vagina, leave in place. can miss dose or fall out. back up is personalized

Question 18

estrogen and progestogen combinations benefits + risks

Answer 18

pill, ring, patches
benefits: fewer bleeding days, pain and flow relief
risks: irregular/unscheduled bleeding, lack of realization of pregnancy

Question 19

progestogen only ORAL contraceptives mechanism of action

Answer 19

less effective than COCs. considered if estrogen contraindicated or poorly tolerated.
thickens cervical mucus and inhibits cervical sperm penetration. time dependent: consistent use is necessary to maintain efficacy as effective on cervical mucus decreases rapidly 22 hours after dosing. same drug interactions as combo.

Question 20

mini pill

Answer 20

oral progestin
regimen: taken once daily at same time, no pill free interval
instructions: take 1x a day at same time. if delay is greater than 3 hours, consider missed dose. back up is individualized

Question 21

Depot Medroxyprogesterone Acetate (DMPA) or Depo-Provera

Answer 21

an injection
less effective than combination
mechanism: suppresses ovulation, absorbed slowly from injection site
drug interaction: not super relevant with CYP P450 enzyme
regimen: intramuscular injection ever 3 months, usually 5 days after menses
same missed dose procedure are COCs, and back up is individualized

Question 22

IUD

Answer 22

interuterine device
may be considered in all patients with no adherence concerns
mechanism: foreign body prevents fertilization, impairs sperm transport. slow release of levonorgestrel causes thickening of cervical mucus, antiproliferatve effect on endometrium and suppression of ovulation.
not relevant with CYP P450 enzymes
inserted by trained clinician, replace in 3 or 5 years
no missed doses, back up is individualized

Question 23

emergency hormonal contraception

Answer 23

method of avoiding unplanned pregnancies after unprotected sex or contraceptive failure, before implantation
not a routine form of contraception

Question 24

progestogen only (levonorgestrel) or Plan B

Answer 24

inhibits ovulation, thickening of cervical mucus, interference with implantation, no effect on existing pregnancy.
most effective within 72 hours of unprotected intercouse or suspected contraceptive failure. earlier the better. may work up to 5 days
regimen: 1 dose taken ASAP, ideally within 72 hours of intercourse
drug interactions: avoid use with CYP P450 inducers, if possible (defeats purpose of getting progestogen in)

Question 25

UPA

Answer 25

ulipristal acetate, emergency contraceptive
prevents progesterone from occupying its receptor by competitive inhibition. inhibits/delays ovulation by preventing LH peak and postponing follicular rupture. most effective within 120 hours of intercourse or contraceptive failure
1 dose within 120 hours
consider avoiding use with CYP P450 inducers or other hormonal contraceptives (it will compete with the other hormones… why)

Question 26

risks of contraceptives

Answer 26

breast cancer, cardiovascular risks (heart attack, stroke, blood clots), depression

Question 27

adverse effects of combination contraceptives

Answer 27

acne, bleeding irregularities (spotting, absence of menstruation, painful/heavy menses), breast tenderness, ectopic pregnancy, nausea, headache, dizziness, sexual dysfunction, weight gain, excessive hair growth, bone weakness, etc

Question 28

drug interactions with contraceptives

Answer 28

many medications may increase or decrease hormonal activity (COCs, progestins, etc)

Question 29

how to manage risks?

Answer 29

benefits vs risk with patient and prescriber
provide education
shared decision making

Question 30

how to manage adverse effects?

Answer 30

assess severity of adverse effects and rule out other conditions
many effects (nausea, headache, spotting) diminish with continued use (3-6 months)
ensure proper use, follow up duration of use, ensure adherence
consider alternative types of hormonal contraception

Question 31

how to manage drug interactions?

Answer 31

assess if interaction is long term or short term, consider manipulating regimen with prescriber
consider alternate contraception not affected by drug interactions, or modification of other interacting drugs

Question 32

considerations in HIV

Answer 32

hormonal contraception’s doesn’t protect against transmission and acquisition. need correct use of barrier contraception to reduce transmission

Question 33

considerations in postpartum or breastfeeding women

Answer 33

if sexual intercourse resumes within 6 weeks postpartum, exclude the pregnancy prior to initiating hormonal contraception.
preventative: barrier, progestin only, IUD. avoid COCs if less than 6 weeks post partum and breast feeding (increased clot risk and reduced milk production)
emergency: levonorgestrel may be used without effect on breastfeeding
ulipristal may be used pp, breast feeding to be avoided for first 24 hours of having dose (preferably 1 week), in which milk should be be expressed and discarded