Contraceptives

• Oral Contraceptives
  • Reduced efficacy with: Phenytoin, phenobarbital, carbamazepine, oxcarbazepine, topiramate, lamotrigine
  • CI: Thromboembolism, estrogen tumors, active liver disease, pregnancy, uterine bleeding
• Typical Use Effectiveness
  • 1) 3-year Etonogestrel implant: 99.95%
  • 2) Vasectomy: 99.85%
  • 3) Levonorgestrel IUD: 99.8%
  • 4) Female Sterilization: 99.5%
  • 5) Copper-T IUD: 99.2%
  • 6) DMPA: actual 94%, theoretical 99.8%
  • 7) OCPs: actual 91%, theoretical 99%
  • 8) Male Condoms: actual 82%, theoretical 98%
  • 9) Female Condoms: actual 79%, theoretical 95%
• P450 induces, decrease efficacy
  • Phenobarbital, phenytoin, rifampin
• Postpartum Contraception
  • If <1 month: Copper IUD or Progestin-only contraception due to risk of VTE and breastfeeding risk with Estrogen
• Age ≥35 and smoker ≥15cigs/day: No estrogen containing drugs
  • Use DMPA
• Progestin Only (Subdermal Implant ≥ Pill)
  • No increase in VTE risk, can be used during breastfeeding
  • Thickens cervical mucus, thins endometrium, inhibits ovulation
  • Suppression of ovulation occurs unpredictably and not in all cycles
  • Must be taken within 3 hours every day
  • Kept up to 3 years, decreases bleeding in 50%, amenorrhea in 20%
  • Unscheduled bleeding is mcc of discontinuation
• Intravaginal Rings (NuvaRing)
  • Inserted for 3 weeks, removed to allow bleeding
  • Increased risk of DVT
  • Release estrogen and progesterone
  • CI: ≥35 and smoke ≥15 cigs/day
• Combined Oral Contraceptive
  • Estrogen/Progestin Contraceptives
    • Suppress ovulation via FSH/LH dampening (no surge)
    • Inhibits ovulation
    • Thickens cervical mucus, thins endometrium, alters uterus, fallopian tube motility
  • Benefits: Endometrial and ovarian cancer risk reduction, menstrual regulation, hyperandrogenism treatment
  • Suppression of ovulation occurs predictably
  • Yaz and Yasmin
    • Contain drospirenone (progestin w/aldosterone antagonist effect to help combat premenstrual bloating
  • Risks: VTEs, Hypertension, Hepatic adenoma, stroke/MI, Cervical Cancer
  • CI: ≥35 and smoke ≥15 cigs/day, Severe HTN (≥160/100), migraine w/aura, breast cancer, liver disease, multiple CVD RF
• Depot Medroxyprogesterone Acetate (DMPA)
  • Progesterone only, every 3 months
  • Suppresses pulsatile release of GnRH inhibiting ovulation, thickens cervical mucus, decreases motility of fallopian tube cilia, thins endometrium
  • Good for Sickle cell disease (reduces crises), Epilepsy (intrinsic anticonvulsant)
  • Bad for causing weight gain, unscheduled bleeding, mood changes
• Intrauterine Device
  • Release copper or progesterone
  • Most effective preventative measures
    • 10 year Copper-T or 5-year Levonorgestrel-containing one
  • Avoid copper if anemic or heavy menstrual bleeding
  • CI: Abnormal uterine anatomy, cervical stenosis, leiomyoma, suspected pregnancy, PID in the past, Wilson disease
  • SE: Small risk of abortion, uterine perforation, expulsion
• Subcutaneous Implant
  • Etonogestrel (Nexplanon), slowly releases progesterone over 3 years
  • SE: Irregular bleeding, especially in 1st 6 months
    • Breast pain
• Transdermal Contraceptive Patch
  • CI: ≥35 and smoke ≥15 cigs/day
  • Must be changed weekly, 99% effective, nothing to remember daily
  • Not approved for women ≥200lbs, patch may fall off, Nausea, headache, weight gain, irregular bleeding, breast pain
• Tubal Ligation
• Emergency Contraception
  • Copper (0-120)
  • Ulipristal
  • Progestin only (Levonorgestrel up to 72)
  • Ethinyl Estradiol + Levonorgestrel (Yuzpe Regimen)
    • 2 pills 12 hours apart within 72 hours
    • Can be used up to 120 hours, reduced efficacy
  • Oral Contraceptives