Download Rini Banerjee Ratan, MD

Rini Banerjee Ratan, MD
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Rini Banerjee Ratan, MD
D EPA RT M E N T OF OBST ET R I C S & GYNECO LOGY
COLUMBIA
UNIVERSITY
COLLEGE
OF
PHYSICIANS
& SURGEONS
HISTORY
OBJECTIVES

To review the mechanisms of action of combination
estrogen-progestin oral contraceptives

To understand the indications, contraindications and
efficacy of currently available contraceptive methods

To understand the non-contraceptive benefits of
combination oral contraceptives

To understand the risks and side effects associated
with estrogen-progestin oral contraceptives
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
 1921 – Ludwig Haberlandt demonstrated temporary
hormonal contraception in a female rabbit by
transplanting ovaries from a second pregnant animal
 1930s – Structure of steroid hormones determined
High doses of estrogen inhibit ovulation
 1938 - First orally active semisynthetic steroidal
estrogen, EE (17α-ethynylestradiol) synthesized
Case Studies
 EE is the estrogen in nearly all OCs
currently used
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
HISTORY
TODAY
 1957 – Enovid – first combination OC approved by
FDA for treatment of menstrual disorders
 1989 –FDA removed all age limits for OC use for
healthy, non-smoking women
 1960 – FDA approves Enovid to be marketed as
contraceptive
 Today, OC use may be continued until menopause
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
Case Studies
Rini Banerjee Ratan, MD
PRIMARY CONTRACEPTIVE METHODS
AMONG WOMEN AGE 15 TO 44 YEARS:
UNITED STATES 2002
COMBINATION ORAL CONTRACEPTIVE PILLS
Why so popular?
 Simple
 Effective
 Not dependent on partner use
 Safe
MMWR Weekly 2005; 54:152 2008 UpToDate
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
MECHANISMS OF ACTION: ESTROGEN
MECHANISMS OF ACTION: PROGESTERONE
Primary:
 Atrophy of endometrium, making it less suitable for
implantation
 Prevent ovulation
 Inhibition of mid-cycle gonadotropin surge
 Alterations in cervical mucus, making it less
permeable to penetration by sperm
Secondary:
 Impairment of normal tubal motility
 Inhibit follicular development
 Suppression of ovarian steroid production
 Possible decrease in responsiveness of the pituitary to
gonadotropin-releasing hormone.
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
ORAL CONTRACEPTIVE PREPARATIONS:
Monophasic Pills:
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
ORAL CONTRACEPTIVE PREPARATIONS:
Low Androgenic Activity
 All 21 hormonally active pills contain the same
amount of estrogen and progestin
 Ethynodiol
• Demulen 1/35
 Current OCs contain 20-35 mcg EE
 Norgestimate
• Ortho-Cyclen
• Ortho-Tricyclen
Multiphasic Pills:
 Introduced in 1970s-80s to further lower steroid dose
 Desogestrel
 Varying doses of estrogen and/or progestin
 No proven clinical advantage over monophasic pills
• Desogen
• Ortho-Cept
 Drospirenone
• Yasmin
• Also effective for acne and hirsutism
Adapted from: Osathanondh, R, Stelluto, MR, Carlson, KJ. Contraception. In: Primary Care of Women, Carson, KJ,
Eisenstat (Eds), Mosby, St Louis, 1995.
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
Rini Banerjee Ratan, MD
ORAL CONTRACEPTIVE PREPARATIONS:
NEW DEVELOPMENTS:
Lower Estrogen Pills: Lo Loestrin Fe
Natazia:
 24 pills contain 10mcg EE + 1mg norethindrone
 Estradiol valerate +new progestin Dienogest
 2 pills contain 10mcg EE only
 First four-phase OC
 2 pills contain 75mg ferrous fumarate
 Varying doses of estradiol valerate (1, 2 or 3 mg)
 One year, open-label, unpublished study of > 1000
women ages 18 to 35 with BMI <35kg/m2
 26 hormonally active pills
 2 hormone-free pills
 Pregnancy rate was 2.92 pregnancies per 100
women-years of use (95% CI 1.94-4.21)
Jensen JT. Evaluation of a new estradiol oral contraceptive: estradiol
valerate and dienogest. Expert Opin Pharmacother.
2010;11(7):1147.
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
INITIATION
INITIATION
Screening Requirements
Quick Start
 Careful medical history
 Begin taking OCs on the day prescription is given
 Blood pressure measurement
 Pregnancy must be reasonably excluded
 Documentation of body mass index
 Use back-up method of contraception for first 7 days
Not necessary to perform prior to starting OC:
Sunday Start
 Pap smear
 Begin taking OCs on first Sunday after period starts
 STI testing
 Most pill packs arranged for Sunday start
to avoid withdrawal bleed on weekend
 Breast examination
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
MAINTENANCE REGIMENS
 Monthly cycle
 Extended cycle
 Continuous
 Hormone-free interval may be 0, 2,4 or 7 days
 Compliance increased if prescription given for 1 year
 OC follow-up may be addressed at routine periodic
exams scheduled for other health maintenance issues
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
Rini Banerjee Ratan, MD
MISSED PILLS?
EFFICACY
 If a single pill is missed:
 Theoretical failure rate 0.1%
• Take the pill as soon as noticed
• Take the next pill when it is due
• No additional contraception required
 Actual failure rate 8%
 If ≥ 2 consecutive pills are missed:
Why the difference?
• Back-up method of contraception should
be used for 7 days
 Missed pills
 Failure to resume after pill-free interval
 If ≥ 2 consecutive pills are missed in first week of cycle:
• Consider use of Emergency Contraception if intercourse occurs
 If ≤ 7pills are left in pack after the missed pill,
• Finish pack and begin new pack the next day
(skip hormone-free days)
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
 Large cohort study of 17,032 women participating in
the Oxford-Family Planning Association showed no
association between weight and risk of unintended
pregnancy in women using either POP or COC
 Retrospective cohort study of women in HMO taking
COC (<35 mcg EE) found women >70.5 kg had a
higher risk of pregnancy (RR 1.6, 95% CI 1.1-2.4)
Vessey M. Oral contraceptive failures and body weight: findings in a large cohort study. J Fam Plann
Reprod Health Care. 2001 Apr;27(2):90-1.
Risks & Side Effects
Case Studies
Risks & Side Effects
 Based on available evidence, the decreased efficacy
of oral contraceptives in obese women would result in
an additional 2-4 pregnancies per 100 woman-years
of oral contraceptive use
 Insufficient evidence for recommending specific EE
dose or for using a higher dose OC
Holt VL, Scholes D, Wicklund KG, Cushing-Haugen KL, Daling JR. Body mass index, weight, and oral
contraceptive failure risk. Obstet Gynecol. 2005;105(1):46.
Holt VL, Cushing-Haugen KL, Daling JR. Body weight and risk of oral contraceptive failure. Obstet
Gynecol. 2002;99(5 Pt 1):820.
Indications & Efficacy
Indications & Efficacy
The Bottom Line: OCs are OK
 Conflicting data
Mechanisms
Mechanisms
EFFICACY IN OBESE WOMEN:
EFFICACY IN OBESE WOMEN
Introduction
Introduction
Case Studies
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
NONCONTRACEPTIVE BENEFITS
NONCONTRACEPTIVE BENEFITS
Treatment of Hyperandrogenism: Acne and Hirsutism
Treatment of Menstrual Disorders: Menorrhagia
 Inhibition of gonadotropin secretion, resulting in
increased binding of androgens and thereby a
decrease in ovarian androgen secretion
 Progestins suppress ovulation and cause endometrial
atrophy over time
 Increase in serum SHBG concentrations, resulting in
decrease in serum free androgen concentration
 Reduction of monthly menstrual blood flow
 Inhibition of adrenal androgen secretion
Treatment of Menstrual Disorders: Dysmenorrhea
 Lighter, shorter predictable periods
 CAUTION: Levonorgestrel-containing preparations may
aggravate hyperandrogenism and should be avoided
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
 Shortening pill-free interval may reduce symptoms
associated with menses (headache, pelvic pain)
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
Rini Banerjee Ratan, MD
NONCONTRACEPTIVE BENEFITS
NONCONTRACEPTIVE BENEFITS
Treatment of Endometriosis
Risk Reduction of Endometrial Cancer
 Induce decidualization and atrophy of endometrial
tissue
 Use of estrogen-progestin OC decreases risk of
endometrial cancer by 50% or greater
 May be as effective as GnRH agonist for pain control
 Protective effect persists for > 10 to 20 years after
cessation of use
Treatment of Premenstrual dysphoric disorder (PMDD)
 Likely due to progestin component and suppression of
endometrial proliferation
 To minimize hormonal fluctuations
 Efficacy has not been studied in clinical trials
Mueck AO, Seeger H, Rabe T. Hormonal contraception and risk of endometrial cancer: a systematic
review. Endocr Relat Cancer. 2010 Dec;17(4):R263-71.
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
NONCONTRACEPTIVE BENEFITS
ABSOLUTE CONTRAINDICATIONS
Risk Reduction of Ovarian Cancer
 Venous thromboembolism
 Prolonged use of oral contraceptives (OCs) reduces
the risk of ovarian cancer
 Pregnancy
 Larger reductions in ovarian cancer risk occur with
increasing duration of OC use
 Hepatocellular adenoma or malignant hepatoma
• RR decreased by ~20 % for each 5 years of use
• By 15 years, risk reduced by 50%
Case Studies
 Cirrhosis
 Undiagnosed abnormal uterine bleeding
 Coronary artery disease
 Protective effect persists for 30 years after cessation
of OCs, although effect attenuated over time
• Less pronounced reduction with mucinous tumors
 Complicated valvular heart disease
 Women with inherited thrombophilias
Collaborative Group on Epidemiological Studies of Ovarian Cancer, Beral V, Doll R, Hermon C, Peto R,
Reeves G. Ovarian cancer and oral contraceptives: collaborative reanalysis of data from 45
epidemiological studies including 23,257 women with ovarian cancer and 87,303 controls.. Lancet.
2008;371(9609):303.
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
ABSOLUTE CONTRAINDICATIONS
 Age ≥35 years and smoking ≥15 cigarettes per day
 Hypertension
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
WHO AND CDC GUIDELINES
BOX. Categories for Classifying Hormonal Contraceptives and IUDs
1 = A condition for which there is no restriction for the use of the
contraceptive method.
2 = A condition for which the advantages of using the method generally
outweigh the theoretical or proven risks.
3 = A condition for which the theoretical or proven risks usually outweigh the
advantages of using the method.
4 = A condition that represents an unacceptable health risk if the
contraceptive method is used.
(systolic ≥160 mmHg or diastolic ≥100 mmHg)
 History of stroke
 Breast cancer
 Migraine with aura
 Systemic lupus erythematosus
(positive or unknown antiphospholipid antibodies)
http://www.cdc.gov/Mmwr/preview/mmwrhtml/rr59e0528a13.htm
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
Rini Banerjee Ratan, MD
DRUG INTERACTIONS
 Metabolism of OCs accelerated by any drug that
increases liver microsomal enzyme activity
 Contraceptive efficacy of OCs likely to be decreased in
women taking these drugs
Antibiotics
 Rifampin is the only antibiotic proven to decrease
serum EE and progestin levels
 Back-up contraception is NOT required for any other
antibiotic
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
DRUG INTERACTIONS
DRUG INTERACTIONS
Anticonvulsants
Anticonvulsants
 WHO recommends that women taking following
medications should NOT use hormonal contraception
 Anticonvulsants that do not appear to reduce
contraceptive efficacy include:
Case Studies
(except DMPA)
 In one study, COCs decreased plasma concentrations of lamotrigine by
45-60%
Contraceptive Technology Update June 2004; 25:61.
Introduction
Mechanisms
Indications & Efficacy
T
Gabapentin
Levetiracetam
Tiagabine
Lamotrigine
Phenytoin
Carbamazepine
Barbiturates
Topiramate
Oxcarbazepine
Risks & Side Effects
Wilbur K, Ensom MH. Pharmacokinetic drug interactions between oral contraceptives and
second-generation anticonvulsants. Clin Pharmacokinet. 2000;38(4):355.
Case Studies
DRUG INTERACTIONS
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
OC WHILE BREASTFEEDING
 St. John’s Wort induces cytochrome P450, which may
accelerate OC metabolism and decrease therapeutic
efficacy
 Theoretical risk
Estrogen-progestin contraceptives may suppress milk
production in the early postpartum period
CDC
 Delay initiation of OCs until 30 days postpartum if no
additional risk factors for VTE
ACOG
 Delay initiation of OCs until at least four
weeks postpartum, and then only if
lactation well-established
WHO
 Delay initiation of OCs until six months
postpartum
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
Introduction
Mechanisms
Indications & Efficacy
Photo courtesy of
www.breastfeeding.com
Risks & Side Effects
Case Studies
Rini Banerjee Ratan, MD
RISKS: CARDIOVASCULAR DISEASE
RISKS: CARDIOVASCULAR DISEASE
Myocardial Infarction
Hypertension
 Thrombotic mechanism rather than development of
atherosclerotic plaques
 Nurses' Health Study prospectively evaluated 70,000
nurses aged 25 to 42 years who used OC <35mcg EE
 Some, but not all, studies report that OC use may be
associated with an increased risk of MI
 Adjusted for age, weight, smoking, family history, and
other risk factors
 MI is a very rare event in healthy women of
reproductive age, so even a doubling of the risk would
result in an extremely low attributable risk
 Relative Risk of hypertension compared with women
who never used OCs was 1.8 for current users and
1.2 for previous users.
 Women who use OC are not at increased risk for
coronary heart disease later in life
LidegaardØ, Løkkegaard E, Jensen A, Skovlund CW, Keiding N. Thrombotic stroke and myocardial infarction
with hormonal contraception. N Engl J Med. 2012;366(24):2257.
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
RISKS: CARDIOVASCULAR DISEASE
Chasan-Taber L, Willett WC, Manson JE, Spiegelman D, Hunter DJ,
Curhan G, Colditz GA, Stampfer MJ. Prospective study of oral
contraceptives and hypertension among women in the United States.
Circulation. 1996;94(3):483.
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
RISKS: VENOUS THROMBOEMBOLISM
Stroke
Stroke
 Small but significant increase in ischemic stroke risk
 Small but significant increase in ischemic stroke risk
 OC preparations containing <50 mcg EE associated
with a lower risk of stroke than high-dose pills.
 OC preparations containing <50 mcg EE associated
with a lower risk of stroke than high-dose pills.
 Absolute risk of stroke was very low in young women
(11.3 per 100,000 patients per year)
 Absolute risk of stroke was very low in young women
(11.3 per 100,000 patients per year)
 Risk appears to be similar for different progestins
 Risk appears to be similar for different progestins
 No increased risk of hemorrhagic stroke
 No increased risk of hemorrhagic stroke
 If stroke develops, STOP OC and DO NOT RESUME use
 If stroke develops, STOP OC and DO NOT RESUME use
Petitti DB, Sidney S, Bernstein A, Wolf S, Quesenberry C, Ziel Stroke in users of low-dose oral contraceptives.. N
Engl J Med. 1996;335(1):8.
Petitti DB, Sidney S, Bernstein A, Wolf S, Quesenberry C, Ziel Stroke in users of low-dose oral contraceptives.. N
Engl J Med. 1996;335(1):8.
Schwartz SM, Siscovick DS, Longstreth WT Jr, Psaty BM, Beverly RK, Raghunathan TE, Lin D, Koepsell TD. Use
of low-dose oral contraceptives and stroke in young women. Ann Intern Med. 1997;127(8 Pt 1):596.
Schwartz SM, Siscovick DS, Longstreth WT Jr, Psaty BM, Beverly RK, Raghunathan TE, Lin D, Koepsell TD. Use
of low-dose oral contraceptives and stroke in young women. Ann Intern Med. 1997;127(8 Pt 1):596.
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
SIDE EFFECTS
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
SIDE EFFECTS
Breakthrough Bleeding
Amenorrhea
 Most common side effect
 Common with continuous and extended regimens
 Most common cause is missed pills
 Reassurance
 Increases with lower doses of EE
Sexual function
 Observe for 3 cycles before intervention
 Consider cervical examination to rule out polyp, etc.
 No definitive evidence of negative effect on libido
Weight Gain
Fibroids
 Review of 44 trials found no evidence to support a
causal relationship between OC use and weight gain
 Safe to use - OCs do not cause fibroids to grow
ESHRE Capri Workshop Group, Collins J, Crosignani Endometrial bleeding. Hum Reprod Update.
2007;13(5):421.
Petitti DB, Sidney S, Bernstein A, Wolf S, Quesenberry C, Ziel Stroke in users of low-dose oral contraceptives.. N
Engl J Med. 1996;335(1):8.
Gallo MF, Lopez LM, Grimes DA, Schulz KF, Helmerhorst FM. Combination contraceptives: effects on
weight.. Cochrane Database Syst Rev. 2006.
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Schwartz SM, Siscovick DS, Longstreth WT Jr, Psaty BM, Beverly RK, Raghunathan TE, Lin D, Koepsell TD. Use
of low-dose oral contraceptives and stroke in young women. Ann Intern Med. 1997;127(8 Pt 1):596.
Case Studies
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
Rini Banerjee Ratan, MD
SIDE EFFECTS
CONCLUSIONS
Postpill Amenorrhea
 If no menses 3 months after discontinuing OC, begin
usual evaluation for amenorrhea
Headache
 No evidence to support strong association
 Do NOT use in patients with migraines + focal symptoms
 Do NOT use in patient with pseudotumor cerebri
 Oral contraceptives are a safe, reliable method of
contraception which have numerous noncontraceptive
benefits as well
 Most important mechanism of action for OCs is
estrogen-induced inhibition of midcycle LH surge,
thereby preventing ovulation
 OCs can be started at any time during the cycle
 Frequency tends to improve with continued use
Petitti DB, Sidney S, Bernstein A, Wolf S, Quesenberry C, Ziel Stroke in users of low-dose oral contraceptives.. N
Engl J Med. 1996;335(1):8.
Schwartz SM, Siscovick DS, Longstreth WT Jr, Psaty BM, Beverly RK, Raghunathan TE, Lin D, Koepsell TD. Use
of low-dose oral contraceptives and stroke in young women. Ann Intern Med. 1997;127(8 Pt 1):596.
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
CONCLUSIONS
CASE STUDY 1
 Missed pills are a common cause of contraceptive
failure - back-up contraception should be advised for
seven days after two missed pills
22 year old woman presents to your office requesting
birth control. She reports that her menses are regular,
but increasingly heavy and painful. She also has
worsening facial acne.
 A number of medical conditions pose an unacceptable
health risk for OC use. The WHO and CDC have
published medical eligibility criteria (tables) for
contraceptive use
Relevant History:
Plans
to begin graduate school in fall
Non-smoker
Monogamous
partner
Normotensive
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
CASE STUDY 1
CASE STUDY 2
Good Options:
19 year old woman who is planning to become sexually
active presents to your office requesting OCs. She takes
Levetiracetam for a seizure disorder. Her last seizure
was 6 months ago.
 OC with low androgenic activity
• Norgestimate
• Desogestrel
• Drospirenone
Relevant History:
Avoid:
Non-smoker
 OC with levonorgestrel may aggravate symptoms of
hyperandrogenism
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
Normotensive
Levetiracetam
Introduction
Mechanisms
levels are therapeutic
Indications & Efficacy
Risks & Side Effects
Case Studies
Rini Banerjee Ratan, MD
CASE STUDY 2
THANK YOU!
 Questions?
Good Options:
 OC use is acceptable for this patient
 Continue to follow Levetiracetam levels
 OC with 20mcg EE
Introduction
Mechanisms
Indications & Efficacy
Risks & Side Effects
Case Studies
REFERENCES

ACOG Practice Bulletin. Emergency Contraception. Number 69. December 2005

ACOG Practice Bulletin. Intrauterine Device. Number 59. January 2005

ACOG Practice Bulletin. Use of Hormonal Contraception in Women With Coexisting Medical Conditions . Number 73. June 2006

ACOG Patient Education Pamphlet. Birth Control. 2007

ACOG Patient Education Pamphlet. Birth Control Pills. 2006

ACOG Patient Education Pamphlet. Hormonal Contraception – Injections, Implants, Rings and Patches. 2007

Dempsey-Fanning, Angela. Medical Student Presentation on Contraception. Columbia University P&S 2007-8.

Fulfilling the Promise: Public Policy and U.S. Family Planning Clinics, New York: Alan Guttmacher Institute 2000.

Finer LB; Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod
Health. 2006 Jun;38(2):90-6.

Forrest JD, Timing of reproductive life stages, Obstetrics & Gynecology, 1993, 82(1):105–111.

Planned Parenthood® Federation of America, Inc. Birth Control - Health Topics. www.plannedparenthood.com

Singh S et al. Adding it Up: Benefits of Investing in Sexual and Reproductive Health Care, New York: AGI, 2004.

World Health Organization Department of Reproductive Health and Research (WHO/RHR) and Johns Hopkins Bloomberg School
of Public Health/Center for Communication Programs (CCP), INFO Project. Family Planning: A Global Handbook for Providers.
Baltimore and Geneva: CCP and WHO, 2007.

Zieman M. Overview of Contraception. 2008 UpToDate

Zieman M. Hatcher RA et al. A Pocket Guide to Managing Contraception. Tiger, Georgia: Bridging the Gap Foundation, 2007.
DELIVERY SYSTEMS FOR COMBINED
HORMONAL CONTRACEPTION
Transdermal Patch
Vaginal Ring
Introduction
PROGESTIN-ONLY PILLS
Contraceptive Counseling
Methods
Summary
Case Studies
EMERGENCY CONTRACEPTION
Advantages
 Do not contain estrogen
Mechanisms
Inhibits/delays ovulation
Prevents fertilization
Prevents implantation
Disadvantages
 Irregular cycles
 Efficacy vulnerable and highly
dependent on consistent and correct use
Methods
Progesterone-only
Combined
pills
oral contraception pills
IUD
There are NO medical contraindications to EC
Introduction
Contraceptive Counseling
Methods
Summary
Case Studies
Introduction
Contraceptive Counseling
Methods
Summary
Case Studies
Rini Banerjee Ratan, MD
EMERGENCY CONTRACEPTIVE PILLS:
75-95% EFFECTIVE
100 women
after a single
act of
unprotected
intercourse
8
pregnancies
1-2
pregnancies
Placement of copper IUD within 5 days of
unprotected intercourse is >99% effective
Introduction
Contraceptive Counseling
Methods
Summary
Case Studies
RHEDI/The Center for Reproductive Health Education In Family Medicine,
Montefiore Medical Center, New York City. Copyright ©2007 RHEDI.