Prescribing Prescribing ContraceptionContraception

Pills, Implants, Intrauterine Devices and Pills, Implants, Intrauterine Devices and Emergency ContraceptionEmergency Contraception

Max Brinsmead MB BS PhDMax Brinsmead MB BS PhDFebruary 2015February 2015

MethodMethod %Pregnant 1%Pregnant 1stst Year Use Year Use % Still Using% Still Using

Typical UseTypical Use Perfect UsePerfect Use After 12mAfter 12m

NoneNone 8585 8585

SpermicidesSpermicides 3030 1515 4040

WithdrawalWithdrawal 3030 44 4040

Periodic AbstinencePeriodic Abstinence 2525 1-31-3 5050

Female BarriersFemale Barriers 2020 55 5050

Male CondomsMale Condoms 1515 1-31-3 5050

The PillThe Pill 88 0.30.3 6666

Injection DepotInjection Depot 33 0.30.3 5656

ImplanonImplanon 0.10.1 0.10.1 7575

Copper IUDCopper IUD 11 0.60.6 8080

Mirena IUSMirena IUS 0.10.1 0.10.1 8585

Female Female SterilisationSterilisation 0.50.5 0.50.5

100 (99)100 (99)

Male Male SterilisationSterilisation 0.150.15 0.10.1 100 (95)100 (95)

Australian Contraceptive Australian Contraceptive UseUse

In a 2003 survey of women aged 25 – 30 yrs:In a 2003 survey of women aged 25 – 30 yrs: 72% were using “effective contraception”72% were using “effective contraception” Of these 70% were using a COCOf these 70% were using a COC Of these 20% were also using condomsOf these 20% were also using condoms 20-25% were using condoms only20-25% were using condoms only Fewer than 5% were using other methodsFewer than 5% were using other methods

From the 2001 census women aged 18 - 40From the 2001 census women aged 18 - 40 Withdrawal was a common method usedWithdrawal was a common method used 3% using “natural family planning”3% using “natural family planning”

Combined Oral ContraceptiveCombined Oral Contraceptive

Mode of ActionMode of Action Primarily by inhibition of folliculogenesisPrimarily by inhibition of folliculogenesis Suppression of FSH (and LH)Suppression of FSH (and LH) Secondarily by thickening cervical mucousSecondarily by thickening cervical mucous Also affects endometriumAlso affects endometrium

AdvantagesAdvantages SimpleSimple ReversibleReversible EffectiveEffective Unrelated to coitusUnrelated to coitus

Combined Oral ContraceptiveCombined Oral Contraceptive Health BenefitsHealth Benefits

Reduces menstrual lossReduces menstrual loss Reduces menstrual painReduces menstrual pain Reduces pre menstrual symptoms (for most women)Reduces pre menstrual symptoms (for most women) Regulates menstrual bleedingRegulates menstrual bleeding Fewer functional ovarian cystsFewer functional ovarian cysts Some protection from Pelvic Inflammatory DiseaseSome protection from Pelvic Inflammatory Disease Less benign breast diseasesLess benign breast diseases Reduced risk of symptomatic fibroidsReduced risk of symptomatic fibroids Can reduce hirsutism and acneCan reduce hirsutism and acne Reduces risk of endometriosisReduces risk of endometriosis Reduces risk of rheumatoid arthritisReduces risk of rheumatoid arthritis Reduces risk of ovarian, endometrial & colon cancerReduces risk of ovarian, endometrial & colon cancer

Combined Oral ContraceptiveCombined Oral Contraceptive

Disadvantages & Unwanted EffectsDisadvantages & Unwanted Effects NauseaNausea Intermenstrual (breakthrough) bleeding (BTB in this talk)Intermenstrual (breakthrough) bleeding (BTB in this talk) Weight gainWeight gain Chloasma (pigmentation on the face)Chloasma (pigmentation on the face) AcneAcne CandidiasisCandidiasis Dysphoria i.e. Feel lousy, depressed & uninterested in sexDysphoria i.e. Feel lousy, depressed & uninterested in sex ““Sexually available”Sexually available” ““Not natural”Not natural” ““Sinful”Sinful”

Major Risks from the Combined Major Risks from the Combined Oral ContraceptiveOral Contraceptive

Thromboembolism Increases risk 2-foldIncreases risk 2-fold Absolute risk is low (2 per million per year)Absolute risk is low (2 per million per year) One month of the pill = driving a car for one hourOne month of the pill = driving a car for one hour Maybe only in genetically at risk womenMaybe only in genetically at risk women

Breast Cancer Increases risk 1.24x Absolute risk low (1 per 1000 women to age 45) Unrelated to duration of use or other risk factors Disappears 10 years after use Cancers are clinically less advanced

Cervical Cancer Some data suggests increased risk of progression of CIN

Cardiovascular Disease Data incomplete

Benign Liver Tumours 1:100,000 users

Major Risks from the Combined Major Risks from the Combined Oral ContraceptiveOral Contraceptive

When considering the major risks of When considering the major risks of any method of contraception…any method of contraception…

It is important to also consider the It is important to also consider the risks and problems that can occur risks and problems that can occur

from unwanted pregnancyfrom unwanted pregnancy

Contraindications to the Combined Oral Contraindications to the Combined Oral Contraceptive (COC)Contraceptive (COC)

History of arterial or venous thrombosisHistory of arterial or venous thrombosis Known ThrombophiliaKnown Thrombophilia Ischaemic heart disease or Severe DyslipidaemiaIschaemic heart disease or Severe Dyslipidaemia Active liver diseaseActive liver disease Cyanotic heart disease or pulmonary hypertensionCyanotic heart disease or pulmonary hypertension Migraine with aura or CNS signsMigraine with aura or CNS signs Transient ischaemic cerebral attackTransient ischaemic cerebral attack Age >35 years AND smokingAge >35 years AND smoking

Or BP >160/110Or BP >160/110 Or migraineOr migraine

GallstonesGallstones Diabetes with retinopathy or nephropathyDiabetes with retinopathy or nephropathy PancreatitisPancreatitis Hepatic porphyriaHepatic porphyria Breast cancerBreast cancer Within 21 days of childbirthWithin 21 days of childbirth Liver tumourLiver tumour COC – induced hypertensionCOC – induced hypertension SLESLE Pemphigoid gestionisPemphigoid gestionis

Relative Contraindications to COCRelative Contraindications to COC

PregnancyPregnancy Undiagnosed genital bleedingUndiagnosed genital bleeding HypertensionHypertension Cholestasis of pregnancyCholestasis of pregnancy ObesityObesity SmokingSmoking Varicose veinsVaricose veins Family history of thrombosis or thrombophiliaFamily history of thrombosis or thrombophilia ImmobilityImmobility Major surgeryMajor surgery Inflammatory bowel disease e.g CrohnsInflammatory bowel disease e.g Crohns HyperprolactinaemiaHyperprolactinaemia On drugs that increase metabolism of oestrogensOn drugs that increase metabolism of oestrogens Heterozygous sickle cell anaemiaHeterozygous sickle cell anaemia Age >40Age >40 Breast feedingBreast feeding History of hypertension in pregnancyHistory of hypertension in pregnancy Valvular heart diseaseValvular heart disease Anti retroviral therapyAnti retroviral therapy

Pill FormulationsPill Formulations There is a confusingly wide range of COCs available…There is a confusingly wide range of COCs available… 4 types of Oestrogen4 types of Oestrogen

Mestranol - converts to EE in the body (present in Norinyl)Mestranol - converts to EE in the body (present in Norinyl) Ethinyl oestradiol (EE) in doses of 20, 30 and 50 ugEthinyl oestradiol (EE) in doses of 20, 30 and 50 ug Oestradiol valerate (present in Olaira)Oestradiol valerate (present in Olaira) 17ß Oestradiol (present in Zoely)17ß Oestradiol (present in Zoely)

3 (3 (or 4or 4) generations of oral Progestins) generations of oral Progestins First generation (no longer in use)First generation (no longer in use)

Second generation Second generation d-Norgestrel and Norethisteroned-Norgestrel and Norethisterone

Third generationThird generation Cyproterone acetate (present in Diane, Brenda, Estelle & Juilet)Cyproterone acetate (present in Diane, Brenda, Estelle & Juilet) Desogestrel (present in Marvelon)Desogestrel (present in Marvelon) Gestodene (present in Femoden & Minulet)Gestodene (present in Femoden & Minulet) Drosperinone (present in Yasmin and Angeliq)Drosperinone (present in Yasmin and Angeliq) Nomegestrol acetate (present in Zoely)Nomegestrol acetate (present in Zoely)

Pill PacksPill Packs 21 and 28-day packs21 and 28-day packs

The latter are called ED = Every dayThe latter are called ED = Every day Contain 7 placebo or “sugar tablets”Contain 7 placebo or “sugar tablets” Are popular in AustraliaAre popular in Australia

3-Month cycle packs3-Month cycle packs Yaz Flex September 2012Yaz Flex September 2012

Triphasic formulationsTriphasic formulations With 3-steps of Progestin dosageWith 3-steps of Progestin dosage Reduce overall dose of ProgestinReduce overall dose of Progestin

Reversed sequentialReversed sequential Used only for the anti-androgen Cyproteron acetateUsed only for the anti-androgen Cyproteron acetate

Be aware that most companies have two names Be aware that most companies have two names for the same formulationfor the same formulation

Pill Prescribing 1Pill Prescribing 1 In general I recommend a monophasic 30 ug In general I recommend a monophasic 30 ug

EE pill with a 2EE pill with a 2ndnd generation progestin i.e. generation progestin i.e. Levonorgestrel or NorethisteroneLevonorgestrel or Norethisterone

For exampleFor example:: Microgynon 30 or LevulenMicrogynon 30 or Levulen Nordette 30 or MonofemeNordette 30 or Monofeme

Warn the patient that breakthrough bleeding is Warn the patient that breakthrough bleeding is common in the first 3 months of usecommon in the first 3 months of use

Then modify according to symptoms/problemsThen modify according to symptoms/problems Don’t change too quickly or too many timesDon’t change too quickly or too many times

““There is no ideal contraceptive”There is no ideal contraceptive”

Pill Prescribing 2Pill Prescribing 2 Whilst tricyclic preparations reduce overall dose of Whilst tricyclic preparations reduce overall dose of

ingested drug they:ingested drug they: Have a greater rate of breakthrough bleedingHave a greater rate of breakthrough bleeding Are not suitable for deferring menstruationAre not suitable for deferring menstruation May have a greater risk of failureMay have a greater risk of failure

Third generation pills i.e. those that contain the newer Third generation pills i.e. those that contain the newer progestins should be used only in low risk women who progestins should be used only in low risk women who have unacceptable progestogenic side effectshave unacceptable progestogenic side effects

AndAnd The patient must be warned that they have a greater The patient must be warned that they have a greater

risk of thromboembolismrisk of thromboembolism But there may be less risk of arterial diseaseBut there may be less risk of arterial disease

Pill Prescribing 3Pill Prescribing 3

Choose COC’s with cyproterone acetate e.g. Diane 35 Choose COC’s with cyproterone acetate e.g. Diane 35 for patients with acne, hirsutism or polycystic ovarian for patients with acne, hirsutism or polycystic ovarian disorderdisorder

For patients with persistent BTB try Norethisterone-For patients with persistent BTB try Norethisterone-type progestin e.g. Brevinortype progestin e.g. Brevinor

Before…Before… Increasing the oestrogen e.g. Microgynon 50Increasing the oestrogen e.g. Microgynon 50 A few patients may require Microgynon 20 or 30 BDA few patients may require Microgynon 20 or 30 BD

Then try to reduce of the oestrogen after several Then try to reduce of the oestrogen after several months with no BTBmonths with no BTB

Pills for Difficult PatientsPills for Difficult Patients

For nausea…For nausea… Take pill at night and try an anti emetic e.g. MaxolonTake pill at night and try an anti emetic e.g. Maxolon

For patients who conceive on the pill…For patients who conceive on the pill… Omit 1-2 tablets of placebo and go for longer cyclesOmit 1-2 tablets of placebo and go for longer cycles

For dysphoria…For dysphoria… Try Pyridoxine 25 mg TDS or Multi B vitaminsTry Pyridoxine 25 mg TDS or Multi B vitamins Or a 3Or a 3rdrd generation COC generation COC

For PMT or weight problemsFor PMT or weight problems Try Yasmin – the 4Try Yasmin – the 4thth generation pill generation pill

For patients on anticonvulsantsFor patients on anticonvulsants Use 50 ug pill or 30 ug BD and omit 1-2 placebo tabletsUse 50 ug pill or 30 ug BD and omit 1-2 placebo tablets

For most other problems switch to POP or MirenaFor most other problems switch to POP or Mirena Antibiotics rarely cause problems for patient on COCAntibiotics rarely cause problems for patient on COC

The Progestin only Pill The Progestin only Pill (POP)(POP)

Act by:Act by: Inhibition of ovulationInhibition of ovulation Reduce sperm penetration of cervical mucousReduce sperm penetration of cervical mucous Some endometrial effectsSome endometrial effects

Useful for:Useful for: Lactating womenLactating women Many others for whom COC is contraindicatedMany others for whom COC is contraindicated

Beware – Big women may require 2/dayBeware – Big women may require 2/day > 100 Kg> 100 Kg

The Progestin only PillThe Progestin only Pill

Disadvantages:Disadvantages: Must be taken at the same time each dayMust be taken at the same time each day (or within 3 hours of the same time each day)(or within 3 hours of the same time each day) Irregular PV bleedingIrregular PV bleeding MastalgiaMastalgia Functional ovarian cysts can occurFunctional ovarian cysts can occur Some women develop amenorrhoea and low E2Some women develop amenorrhoea and low E2 May not protect so well from ectopic pregnancyMay not protect so well from ectopic pregnancy Not suitable for women at risk of arterial diseaseNot suitable for women at risk of arterial disease

Injection (Depot Provera)Injection (Depot Provera) ““The POP for patients who can’t remember to take a tablet The POP for patients who can’t remember to take a tablet

every day”every day” (But patients need to attend every 12 weeks)(But patients need to attend every 12 weeks) Cheap and very effectiveCheap and very effective ProblemsProblems::

Irregular bleeding (15 – 50%)Irregular bleeding (15 – 50%) Settles over time in mostSettles over time in most But may last up to 18months after a single shot in a fewBut may last up to 18months after a single shot in a few Uncertain return to fertilityUncertain return to fertility Acne, headaches, mastalgia & dysphoriaAcne, headaches, mastalgia & dysphoria Functional ovarian cysts can occurFunctional ovarian cysts can occur Amenorrhoea & hypo oestrinism & maybe osteoporosisAmenorrhoea & hypo oestrinism & maybe osteoporosis Some question the risk of breast cancer but there is NO Some question the risk of breast cancer but there is NO

evidence for increased riskevidence for increased risk

ImplanonImplanon Matchstick-sized subdermal implant containing 68 mg Matchstick-sized subdermal implant containing 68 mg

Etonorgestrel Etonorgestrel Releases 40 ug daily for at least 3 yearsReleases 40 ug daily for at least 3 years Rapid return to fertility after removal Rapid return to fertility after removal ProblemsProblems::

Only 35% patients have “regular” periodsOnly 35% patients have “regular” periods Amenorrhoea in 20% over timeAmenorrhoea in 20% over time But 15 – 20% experience frequent, irregular bleddingBut 15 – 20% experience frequent, irregular bledding Headaches, mastalgia and dysphoriaHeadaches, mastalgia and dysphoria Functional ovarian cysts can occurFunctional ovarian cysts can occur Requires expert insertion (training)Requires expert insertion (training) A few nerve injuries from inappropriate deep insertionA few nerve injuries from inappropriate deep insertion

Copper Intrauterine DeviceCopper Intrauterine Device Safe and effectiveSafe and effective Daily compliance not requiredDaily compliance not required Effective for up to 10 yearsEffective for up to 10 years Rapidly reversibleRapidly reversible Can be inserted up to 5 days post ovulation for emergency Can be inserted up to 5 days post ovulation for emergency

contraceptioncontraception

ProblemsProblems:: PainPain Increased menstrual bleedingIncreased menstrual bleeding Expulsion (1:20 insertions)Expulsion (1:20 insertions) Perforation (1:500 insertions with experienced operator)Perforation (1:500 insertions with experienced operator) Infection (conflicting data but WHO says only for 1Infection (conflicting data but WHO says only for 1stst 21 days) 21 days) Pregnancy with IUD is high risk (remove IUD asap)Pregnancy with IUD is high risk (remove IUD asap) Ectopic pregnancy not more common but less protection from Ectopic pregnancy not more common but less protection from

extrauterine than from intrauterine pregnancyextrauterine than from intrauterine pregnancy

Mirena Intrauterine SystemMirena Intrauterine System Highly effective because daily compliance not requiredHighly effective because daily compliance not required Lasts 5 yearsLasts 5 years Blood concentrations of d-Norgestrel 1/10Blood concentrations of d-Norgestrel 1/10 thth less than POP less than POP Reduces menstrual bleeding by 85 - 90% after 6mReduces menstrual bleeding by 85 - 90% after 6m ““The nearly ideal contraceptive”The nearly ideal contraceptive” Has reduced the hysterectomy rate in the UK by 30%Has reduced the hysterectomy rate in the UK by 30% ProblemsProblems::

Frequent bleeding in the first 3 months of useFrequent bleeding in the first 3 months of use Acne, mastalgia, weight gain & dysphoria in a few (≈1%)Acne, mastalgia, weight gain & dysphoria in a few (≈1%) Insertion expertise required (Nulliparas difficult)Insertion expertise required (Nulliparas difficult) A few expulsions occurA few expulsions occur Infection in a few patients (conflicting data)Infection in a few patients (conflicting data)

WHO says that there is a spike lasting only 3 weeks after insertionWHO says that there is a spike lasting only 3 weeks after insertion Thereafter associated only with risk of STDThereafter associated only with risk of STD

Max’s Maxim Number 3Max’s Maxim Number 3

Nature did not intend that a woman Nature did not intend that a woman should have too many menstrual periodsshould have too many menstrual periods

She is supposed to be pregnant, breast- She is supposed to be pregnant, breast- feeding, postmenopausal or deadfeeding, postmenopausal or dead

And the next best alternative is being on And the next best alternative is being on the Pillthe Pill

Or putting the Pill into her uterus (Mirena)Or putting the Pill into her uterus (Mirena)

The woman who is The woman who is breastfeedingbreastfeeding

Conception will not occur for at least Conception will not occur for at least six six monthsmonths in a woman who is breastfeeding in a woman who is breastfeeding

Exclusively i.e. no missed feeds, comp Exclusively i.e. no missed feeds, comp feeds or solidsfeeds or solids

Suckles regularly day and nightSuckles regularly day and night Has amenorrhoeaHas amenorrhoea

Emergency ContraceptionEmergency Contraception Postinor 2Postinor 2::

Levonorgestrel 750 ug – two tabletsLevonorgestrel 750 ug – two tablets Administer ASAP and repeat 12 hoursAdminister ASAP and repeat 12 hours 95 - 98% effective if used with 24h95 - 98% effective if used with 24h 60% effective if used within 48-72h60% effective if used within 48-72h Multiple mechanisms of actionMultiple mechanisms of action Side effects few – repeat if vomitedSide effects few – repeat if vomited Contraindications – very fewContraindications – very few

This method supersedes the Yuzpe regimen of This method supersedes the Yuzpe regimen of 2x50 ug COC repeated after 12 hours2x50 ug COC repeated after 12 hours

Copper IUD very effective for up to 5 days after Copper IUD very effective for up to 5 days after coitus or ovulationcoitus or ovulation

For other special cases For other special cases and difficult patientsand difficult patients

The WHO website has comprehensive The WHO website has comprehensive guidelines for all contraceptive methodsguidelines for all contraceptive methods

Includes relative and absolute Includes relative and absolute contraindications with many rare medical contraindications with many rare medical conditionsconditions

Any Questions or Any Questions or Comments?Comments?

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