Download Contraception - Max Brinsmead MB BS PhD

Prescribing
Contraception
Pills, Implants, Intrauterine Devices and
Emergency Contraception
Max Brinsmead MB BS PhD
February 2015
Method
%Pregnant 1st Year Use
% Still Using
Typical Use
Perfect Use
None
85
85
Spermicides
30
15
40
Withdrawal
30
4
40
Periodic Abstinence
25
1-3
50
Female Barriers
20
5
50
Male Condoms
15
1-3
50
The Pill
8
0.3
66
Injection Depot
3
0.3
56
0.1
0.1
75
Copper IUD
1
0.6
80
Mirena IUS
0.1
0.1
85
Implanon
Female
Sterilisation
0.5
0.5
Male
Sterilisation
0.15
0.1
After 12m
100 (99)
100 (95)
Australian Contraceptive Use
 In a 2003 survey of women aged 25 – 30 yrs:
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72% were using “effective contraception”
Of these 70% were using a COC
Of these 20% were also using condoms
20-25% were using condoms only
Fewer than 5% were using other methods
 From the 2001 census women aged 18 - 40
 Withdrawal was a common method used
 3% using “natural family planning”
Combined Oral Contraceptive
 Mode of Action
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Primarily by inhibition of folliculogenesis
Suppression of FSH (and LH)
Secondarily by thickening cervical mucous
Also affects endometrium
 Advantages
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Simple
Reversible
Effective
Unrelated to coitus
Combined Oral Contraceptive
 Health Benefits
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Reduces menstrual loss
Reduces menstrual pain
Reduces pre menstrual symptoms (for most women)
Regulates menstrual bleeding
Fewer functional ovarian cysts
Some protection from Pelvic Inflammatory Disease
Less benign breast diseases
Reduced risk of symptomatic fibroids
Can reduce hirsutism and acne
Reduces risk of endometriosis
Reduces risk of rheumatoid arthritis
Reduces risk of ovarian, endometrial & colon cancer
Combined Oral Contraceptive
Disadvantages & Unwanted Effects
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Nausea
Intermenstrual (breakthrough) bleeding (BTB in this talk)
Weight gain
Chloasma (pigmentation on the face)
Acne
Candidiasis
Dysphoria i.e. Feel lousy, depressed & uninterested in sex
“Sexually available”
“Not natural”
“Sinful”
Major Risks from the Combined Oral
Contraceptive
 Thromboembolism
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Increases risk 2-fold
Absolute risk is low (2 per million per year)
One month of the pill = driving a car for one hour
Maybe only in genetically at risk women
 Breast Cancer
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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 Oral
Contraceptive
When considering the major risks of
any method of contraception…
It is important to also consider the
risks and problems that can occur
from unwanted pregnancy
Contraindications to the Combined Oral
Contraceptive (COC)
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History of arterial or venous thrombosis
Known Thrombophilia
Ischaemic heart disease or Severe Dyslipidaemia
Active liver disease
Cyanotic heart disease or pulmonary hypertension
Migraine with aura or CNS signs
Transient ischaemic cerebral attack
Age >35 years AND smoking
 Or BP >160/110
 Or migraine
Gallstones
Diabetes with retinopathy or nephropathy
Pancreatitis
Hepatic porphyria
Breast cancer
Within 21 days of childbirth
Liver tumour
COC – induced hypertension
SLE
Pemphigoid gestionis
Relative Contraindications to COC
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Pregnancy
Undiagnosed genital bleeding
Hypertension
Cholestasis of pregnancy
Obesity
Smoking
Varicose veins
Family history of thrombosis or thrombophilia
Immobility
Major surgery
Inflammatory bowel disease e.g Crohns
Hyperprolactinaemia
On drugs that increase metabolism of oestrogens
Heterozygous sickle cell anaemia
Age >40
Breast feeding
History of hypertension in pregnancy
Valvular heart disease
Anti retroviral therapy
Pill Formulations
 There is a confusingly wide range of COCs available…
 4 types of Oestrogen
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Mestranol - converts to EE in the body (present in Norinyl)
Ethinyl oestradiol (EE) in doses of 20, 30 and 50 ug
Oestradiol valerate (present in Olaira)
17ß Oestradiol (present in Zoely)
 3 (or 4) generations of oral Progestins
 First generation (no longer in use)
 Second generation
 d-Norgestrel and Norethisterone
 Third generation
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Cyproterone acetate (present in Diane, Brenda, Estelle & Juilet)
Desogestrel (present in Marvelon)
Gestodene (present in Femoden & Minulet)
Drosperinone (present in Yasmin and Angeliq)
Nomegestrol acetate (present in Zoely)
Pill Packs
 21 and 28-day packs
 The latter are called ED = Every day
 Contain 7 placebo or “sugar tablets”
 Are popular in Australia
 3-Month cycle packs
 Yaz Flex September 2012
 Triphasic formulations
 With 3-steps of Progestin dosage
 Reduce overall dose of Progestin
 Reversed sequential
 Used only for the anti-androgen Cyproteron acetate
 Be aware that most companies have two names
for the same formulation
Pill Prescribing 1
 In general I recommend a monophasic 30 ug
EE pill with a 2nd generation progestin i.e.
 Levonorgestrel or Norethisterone
 For example:
 Microgynon 30 or Levulen
 Nordette 30 or Monofeme
 Warn the patient that breakthrough bleeding is
common in the first 3 months of use
 Then modify according to symptoms/problems
 Don’t change too quickly or too many times
 “There is no ideal contraceptive”
Pill Prescribing 2
 Whilst tricyclic preparations reduce overall dose of
ingested drug they:
 Have a greater rate of breakthrough bleeding
 Are not suitable for deferring menstruation
 May have a greater risk of failure
 Third generation pills i.e. those that contain the newer
progestins should be used only in low risk women who
have unacceptable progestogenic side effects
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 The patient must be warned that they have a greater
risk of thromboembolism
 But there may be less risk of arterial disease
Pill Prescribing 3
 Choose COC’s with cyproterone acetate e.g. Diane 35
for patients with acne, hirsutism or polycystic ovarian
disorder
 For patients with persistent BTB try Norethisteronetype progestin e.g. Brevinor
 Before…
 Increasing the oestrogen e.g. Microgynon 50
 A few patients may require Microgynon 20 or 30 BD
 Then try to reduce of the oestrogen after several
months with no BTB
Pills for Difficult Patients
 For nausea…
 Take pill at night and try an anti emetic e.g. Maxolon
 For patients who conceive on the pill…
 Omit 1-2 tablets of placebo and go for longer cycles
 For dysphoria…
 Try Pyridoxine 25 mg TDS or Multi B vitamins
 Or a 3rd generation COC
 For PMT or weight problems
 Try Yasmin – the 4th generation pill
 For patients on anticonvulsants
 Use 50 ug pill or 30 ug BD and omit 1-2 placebo tablets
 For most other problems switch to POP or Mirena
 Antibiotics rarely cause problems for patient on COC
The Progestin only Pill (POP)
 Act by:
 Inhibition of ovulation
 Reduce sperm penetration of cervical mucous
 Some endometrial effects
 Useful for:
 Lactating women
 Many others for whom COC is contraindicated
 Beware – Big women may require 2/day
 > 100 Kg
The Progestin only Pill
Disadvantages:
 Must be taken at the same time each day
 (or within 3 hours of the same time each day)
 Irregular PV bleeding
 Mastalgia
 Functional ovarian cysts can occur
 Some women develop amenorrhoea and low E2
 May not protect so well from ectopic pregnancy
 Not suitable for women at risk of arterial disease
Injection (Depot Provera)
 “The POP for patients who can’t remember to take a tablet
every day”
 (But patients need to attend every 12 weeks)
 Cheap and very effective
 Problems:
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Irregular bleeding (15 – 50%)
Settles over time in most
But may last up to 18months after a single shot in a few
Uncertain return to fertility
Acne, headaches, mastalgia & dysphoria
Functional ovarian cysts can occur
Amenorrhoea & hypo oestrinism & maybe osteoporosis
Some question the risk of breast cancer but there is NO
evidence for increased risk
Implanon
 Matchstick-sized subdermal implant containing 68 mg
Etonorgestrel
 Releases 40 ug daily for at least 3 years
 Rapid return to fertility after removal
 Problems:
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Only 35% patients have “regular” periods
Amenorrhoea in 20% over time
But 15 – 20% experience frequent, irregular bledding
Headaches, mastalgia and dysphoria
Functional ovarian cysts can occur
Requires expert insertion (training)
A few nerve injuries from inappropriate deep insertion
Copper Intrauterine Device
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Safe and effective
Daily compliance not required
Effective for up to 10 years
Rapidly reversible
Can be inserted up to 5 days post ovulation for emergency
contraception
 Problems:
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Pain
Increased menstrual bleeding
Expulsion (1:20 insertions)
Perforation (1:500 insertions with experienced operator)
Infection (conflicting data but WHO says only for 1st 21 days)
Pregnancy with IUD is high risk (remove IUD asap)
Ectopic pregnancy not more common but less protection from
extrauterine than from intrauterine pregnancy
Mirena Intrauterine System
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Highly effective because daily compliance not required
Lasts 5 years
Blood concentrations of d-Norgestrel 1/10th less than POP
Reduces menstrual bleeding by 85 - 90% after 6m
“The nearly ideal contraceptive”
Has reduced the hysterectomy rate in the UK by 30%
Problems:
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Frequent bleeding in the first 3 months of use
Acne, mastalgia, weight gain & dysphoria in a few (≈1%)
Insertion expertise required (Nulliparas difficult)
A few expulsions occur
Infection in a few patients (conflicting data)
 WHO says that there is a spike lasting only 3 weeks after insertion
 Thereafter associated only with risk of STD
Max’s Maxim Number 3
Nature did not intend that a woman
should have too many menstrual periods
She is supposed to be pregnant, breastfeeding, postmenopausal or dead
And the next best alternative is being on
the Pill
Or putting the Pill into her uterus (Mirena)
The woman who is
breastfeeding
 Conception will not occur for at least six
months in a woman who is breastfeeding
 Exclusively i.e. no missed feeds, comp
feeds or solids
 Suckles regularly day and night
 Has amenorrhoea
Emergency Contraception
 Postinor 2:
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Levonorgestrel 750 ug – two tablets
Administer ASAP and repeat 12 hours
95 - 98% effective if used with 24h
60% effective if used within 48-72h
Multiple mechanisms of action
Side effects few – repeat if vomited
Contraindications – very few
 This method supersedes the Yuzpe regimen of
2x50 ug COC repeated after 12 hours
 Copper IUD very effective for up to 5 days after
coitus or ovulation
For other special cases
and difficult patients
 The WHO website has comprehensive
guidelines for all contraceptive methods
 Includes relative and absolute
contraindications with many rare medical
conditions
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