contraception

Oral contraceptives
• When no contraception is used by presumably
fertile sex partners, about 90% of women will
conceive within 1 year.
• Some contraceptives have health risks.
• With the exception of women over 35 taking
the OCP, all forms of contraception are
healthier than the alternative (i.e. pregnancy
with birth).
 Different forms of contraception
• League Table
•
No method: 80 - 90
• Periodic abstinence: 2 - 20
• Diaphragm: 2 - 15
• Withdrawal: 4
• Condoms: 2
• POP: 1 - 2
• IUCD: 1 - 2
• Female sterilisation: 0.3
• COCP: 0.1
• Mirena: 0.1
• Depot progesterone: 0.1
• Male sterilisation: 0.05
 Progestin-only oral contraceptives
MOA:
• suppression of ovulation
• a variable dampening effect on the midcycle peaks of LH and
FSH;
• an increase in cervical mucus viscosity by a reduction in its
volume and an alteration of its structure;
• a reduction in the number and size of endometrial glands,
leading to an atrophic endometrium not suitable for ovum
implantation
• a reduction in cilia motility in the fallopian tube, thus slowing
the rate of ovum transport.
• Less effective as ovulation will occur part of the time.
• the "mini-pill" supplies 0.3mg of norethindrone per day
• 40% of cycles are ovulatory
• Failure rate 1-3/100 women yrs
• 30 mcg LNG (Microval, Microlut) or 350 mcg NET(Noriday)
• Timing important – effective for 27 hours
• Effective within 7 days.
• Suitable particularly for breast-feeding, over 40’s and those medically unsuited for COC.
• associated with more breakthrough bleeding and slightly higher failure rates than combined OCPs. Other adverse
effects include nausea, breast tenderness, headache, and amenorrhea.

• Administration
– start on the first day of the period
– most women start their pill on the first Sunday after the period starts (because most pill packs are arranged for a Sunday start).
Back-up contraception is needed for the first month if one chooses the Sunday start
– may be given on a monthly or three monthly cycle
• 3 month and 1 year follow-up visit
– measure blood pressure
– discuss compliance and side effects
• Routine pelvic and breast examination is not mandatory before prescribing
• Estrogen
• ethinyl estradiol
• addition of an ethinyl group to estradiol
• results in both an orally active estrogen
compound and a dramatic increase in
estrogenic potency
 Mechanism of action
• estrogen-induced
– decrease in responsiveness of the pituitary to GnRH
– suppression of gonadotropin secretion
• inhibition of the midcycle surge of gonadotropin
secretion prevents ovulation
– Combination OCPs are potent in this regard
– progestin-only pills are not
• during the follicular phase prevents follicular maturation
• suppression of ovarian steroid production
 Combination OCP
• contain both estrogen and progestin
• Estrogen - ethinyl estradiol 20 - 50 mcg
• Progesterone - levonorgestrel, norethisterone; cyproterone; desogestril (Marvelon), gestodene (Femoden, Minulet); drospirenone (Yasmin)
• Failure rate - 0.1/100 women yrs
• packaged in 21-day or 28-day cycles
• The last seven pills of a 28-day pack are placebo pills
• types of combination pills
– Monophasic pills
• contain the same dose of estrogen and progestin in each of the 21 hormonally active pills
• current pills contain on average 30 to 35 µg EE
– biphasic pill
• contain a fixed dose of 35 µg of ethinyl estradiol and an increasing dose of progestin
– Triphasic preparations
• contain varying doses of progestin or estrogen plus progestin across the 21 days
• multiphasic regimens slightly decrease total steroid content over the month but have no proven clinical advantage over monophasic preparations
• Diane
– containing ethinyl estradiol and cyproterone acetate
– prescribed for acne or hirsutism
• 20 to 25 µg preparations
– Pills containing less than 50 µg of EE have been referred to as "low-dose" pills
– Several preparations containing only 20 - 25µg of ethinyl estradiol are now available
– often used for perimenopausal women who want contraception with the lowest estrogen dose possible
– provide more than enough estrogen to relieve vasomotor flushes (which often begin during the perimenopausal transition)
– One problem that perimenopausal women often experience when taking oral contraceptives is recurrence of hot flushes and premenstrual mood disturbances
during the seven-day pill-free interval
 Non contraceptive advantages
• Cycle control
• Prevents benign breast disease, PID and
functional cysts
• Prevents epithelial ovarian and endometrial
carcinoma
• Reduces acne
• Reduces dysmenorrhea, mittelshmertz
• Protective against endometriosis
 disadvantages
• Nausea
• Breast tenderness
• Breakthrough bleeding
• Amenorrhea
• Headaches
• Can be remedied by changing type of pill
 Hormonal effects and safety
• Venous thrombosis
• HTN
• CVA
• Hepatocellular adenoma
• cancer
 contraindications
absolute relative
• CVA • Obesity
• DVT/PE • Poorly controlled HTN
• Undiagnosed vag bleeding • Anticonvulsant drug
• Known or suspected • Risk for vascular disease
pregnancy
• Lactation
• Estrogen dependant neoplasia
•
• Recent
Active liver disease
•
surgery/immobilisation
Inherited thrombophilias
• Focal migraine
• Age >35 and cig smoking
•  
• Menorrhagia in 15 y girl
• 15 y old girl presents to ED with heavy bleeding. Beta HCG is
negative
•  
• A, Investigations
• B, Immediate Mx of heavy bleeding
• C, Long term Mx
• D. Patient requesting contraception. What information do you
require and how do you manage this.
•  
 history
• Exclude co-existing pregnancy
• • LMP and usual cycle length
• • Current contraception
• • Perform HCG if necessary
• • When episode(s) of unprotected SI occurred
• Establish nature of SI – consensual or non-consensual
• Establish why Contraception is needed, Or why regular contraception was not used - counsel
•  
• General history
• Obstetric History
• (Previous subfertility), complications
• Gynaecological History
• LMP, regulartity, IMB, PCB, dysmenorrhea, dyspareunia, PV discharge, Pap-smear, Hx of PID/endometriosis
• Previous contraception, side effects
• Past Med/Surg History – DVT/PE, liver disease, epilepsy, heart disease, HTN, migraine, diabetes, cancer
• Medications – esp P450 inducers – eg antibiotics, antifungals, anti-epileptics
• Allergies
• Smoking/ETOH/Drug usage
• Family History – DVT/PE/Cancer/DM
 examination
• BMI, thyroid, CVS, Respiratory, Abdominal exam
• Pelvic examination:
• Offer pap smear, STI screening
• Urine β HCG if appropriate
• If sexual assault , needs full examination
including psychological assessment & initiation
of rape victim workup including STI screening
 consent
• Consent
•  
• Age > 16y
• Consent can be given where they are judged to be competent to make an informed consent
• Age 14-15
• Practioner need to make an judgment about the individual’s competence and consider the question of risk of
harm (current concern about the safety, welfare, and welbeing)
• If there is a risk of harm  mandatory report to DOCS
• Issue confidentiality
• This can be broken if there is risk of harm to patients or harming others
• These conditions should be made explicit to patients
• Age < 14
• Consent to be obtained from both child and legal parents or guardian except in exceptional circumstances
• Person not able to give/communicate consent (intellectual disability)
• Through guardianship
• In most cases, person responsible can give consent, but person responsible cannot give consent in following
situations and guardianship need to be approached
• Major treatment where there are objections from person
• Any treatment designed to eliminate menstruation. (incl Depo-provera)
Emergency contraceptive pill