BIRTH CONTROL MADE SIMPLE

Richard Wahl, M.D. Department of Pediatrics University of Arizona rwahl@u.arizona.edu May 11, 2011

Too Much Estrogen:

Nausea, bloating, breast tenderness, hypertension, melasma, headache.

Too Little Estrogen:

Break-through bleeding (early or mid-cycle), spotting, hypomenorrhea.

Too Much Progestin:

Breast tenderness, headache, fatigue, mood swings.

Too Little Progestin:

Break-through bleeding (late cycle).

Too Much Androgen:

Increased appetite, weight gain, acne, oily skin, hirsutism, decreased libido, increased breast size, breast tenderness, Lipids: increased LDL, decreased HDL. Progestin Activity: Androgenic Potency: (Desogestrel ! Norgestrel ! Levo-norgestrel) > Norethenidrone Medroxyprogesterone acetate > (Norgestrel ! Levo-norgestrel) > (Norethindrone ! Ethynodiol) > (Desogestrel ! Norgestimate = non-androgenic) > (Drospirenone = anti-androgenic)

Low Dose Monophasic OCPs

Brand Names
Alesse Aviane Levlite Lutera Loestrin 1/20 Microgestin 1/20 Levlen Levora Nordette Portia Lo/Ovral Cryselle Loestrin 1.5/30 Microgestin 1.5/30 Desogen Apri Ortho-Cept Yasmin Ocella Zarah Demulen 1/35 Zovia 1/35 Ortho-Cyclen MonoNessa Ovcon-35 Modicon Brevicon Orho-Novum 1/35

Ethinyl Progestin estradiol

20 mcg 20 mcg 30 mcg 30 mcg 30 mcg 30 mcg 30 mcg Levo-norgestrel 0.1 mg Norethindrone 1 mg Levo-norgestrel 0.15 mg Norgestrel 0.3mg Norethindrone acetate 1.5 mg Desogestrel 0.15 mg Drospirenone 3 mg

Estrogen Progestin Androgen Comments potency potency potency

+ + + + + + + ++ ++ +++ +++ ++ +++ ?? ++ ++ ++/+++ ++/+++ ++ Spotting more likely. Missed pills problematic. Osteopenia? (20 mcg EE ! relative hypoestrogenemia) Minimize spotting or breakthrough bleeding.

++

Non-androgenic. 2x risk DVT vs. LNG3 Anti-androgenic. PCOS Tx. Spironolactone analog. New: > 2x risk DVT vs. LNG10

35 mcg 35 mcg 35 mcg 35 mcg 35 mcg

Ethynodiol diacetate 1 mg Norgestimate 0.25 mg Norethindrone 0.4mg Norethindrone 0.5 mg Norethindrone 1 mg

++ ++ ++ ++ ++

++ + + + ++/+++

0
+ + ++

Low androgen activity. No reports of incr. DVT risk. Femcon Fe Chewable

(50 mcg Mestranol = 35 mcg Ethinyl Estradiol)

Biphasic OCPs
Brand Names Ethinyl Progestin estradiol
Mircette Azurette Kariva 20 mcg x 21 days, 0 x 2 days, 10 x5 days Desogestrel 0.15 mg x 21 days

Estrogen Progestin Androgen Comments potency potency potency + +++ Non-androgenic. 0

Less break-through bleeding. 2x increased DVT risk.

Triphasic OCPs
Estrostep Fe Tilia Ortho TriCyclen Lo Cyclessa Triphasil Tri-Levlen Ortho TriCyclen TriNessa Tri-Norinyl Ortho-Novum 7/7/7 20 mcg x5 30 mcg x7 35 mcg x9 25 mcg x 21 days 25 mcg x 21 days 30 mcg x7 40 mcg x5 30 mcg x10 35 mcg x 21 days 35 mcg x 21 days 35 mcg x 21 days Norethindrone 1 mg x 21 days Norgestimate 0.18 mg x7, 0.215 x 7, 0.25 x7 Desogestrel 0.1 mg x7 0.125 x7, 0.15 mg x 7 Levo-norgestrel 0.05 mg x6, 0.075 mg x 5, 0.125 mg x 10 days Norgestimate 0.18 mg x7, 0.215 x 7, 0.25 x7 Norethindrone 0.5 mg x7, 1mg x9, 0.5 x 5 Norethindrone 0.5 mg x7, 0.75 x7, 1 mg x7 + ++/+++ ++ FDA Acne indication

+ + ++

+ +++ +

0 0
+/++

Low androgen activity. No reports of incr. DVT risk. 2x increased DVT risk3 Good for mid-cycle spotting. Higher estrogen dose preovulation. FDA Acne indication No reports of incr. DVT risk.

++

0
+/++ +/++

++ ++

+/++ +/++

Extended Cycle OCP

Seasonale Jolessa Seasonique Yaz 30 mcg Levo-norgestrel 0.15 mg + ++ ++/+++ Continuous 84-day cycle, then 7 days off. Increased spotting or cyclic bleeding. No hormone-free days. Less spotting than above? Similar to Yazmin. Lower Estrogen, 24/4 day cycle. > 2x risk DVT vs. LNG10 Continuous OCP. Early spotting/BTB, then improves Estradiol instead of EE. Dienogest: anti-androgenic 4-phase pill, with 2 day hormone-free break Possible increased DVT risk.

30mcg x84 days Levo-norgestrel 10mcg x 7 days 0.15 mg 20 mcg x 24 Drospirenone 3 mg days 20 mcg Estradiol (3mg 1mg) Levo-norgestrel 0.09 mg Dienogest (new) (! Drospirenone) (2mg 3mg)

+ +

++ ??

++/+++

+/++

Lybrel Natazia
(New July 2010)

+ ?

+ +++

Progestin-Only Pills
Micronor Nor-QD --Norethindrone 0.35 mg

Irregular menses, but reduced overall blood loss. OK for breastfeeding.

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Other Hormonal Contraceptives

Depo-Provera Depo-SubQ ----Medroxy-progesterone acetate 150 mg IM Medroxy-progesterone acetate 104 mg SQ Levo-norgestrel
20 mcg/day x 5 years No Hormone, x 10 years

0 0 0 0 0 0
++?

+++ +++

++++ ++++

Q 12 weeks. Irregular menses ! amenorrhea. Osteopenia. Delayed return of fertility. Improves epilepsy, sickle cell. IUD cost: ! $500 Insertion: ! $300 See reference 11. No longer available in U.S. Active form of desogestrel. Possible increased DVT risk. Vaginal ring x 3 weeks. Increased vaginal discharge. Possible increased DVT risk. 1 patch weekly x 3 weeks. Poor cycle control. Tricycle with 9 patches. Increased DVT risk

Mirena IUD (or IUS) ParaGard (Copper T 380A) IUD Norplant rods --Implanon implant NuvaRing Vaginal insert Ortho Evra Patch --EE 15 mcg/day EE 20 mcg/day

+++

++/+++

0
++ ++/+++ +++

0
++

Levo-norgestrel 36 mg
x 6 rods = 216 mg; Over 5 years = 0.12 mg/day.

Etonogestrel 0.06 mg/day x 3 years Etonogestrel 0.12 mg/day x 3 weeks Norelgestromin (Norgestimate) 150 mcg/day

0 0 0

+++

Emergency Contraception
Plan B Next Choice Plan B One Step ellaOne or ella --Levo-norgestrel 0.75 mg each tablet Levo-norgestrel 1.5 mg Ulipristal acetate 30 mg Initial dose < 72 120 Hrs. May take both tabs together. Check HCG +++ +++ Take pill < 72 120 Hr of unprotected sex. Check HCG Selective progesterone receptor modulator. 1 dose given < 72 120 Hr of unprotected sex. (cf. RU-486/mifepristone). More effective than Plan B.8,9

+++

+++

Missed Contraceptive Doses7

1. Combined OCP (Monophasic, Triphasic, etc.) a. Missed 1 active pill < 24 hr late: Take missed pill ASAP. May take 2 pills same day. b. Missed 1 or more active pills, > 24 hr late: i. During week 1: Take pill ASAP, use back-up x 1 week, consider EC if unprotected sex past 5 days. ii. During week 2 3 and < 3 missed pills: Take 1 pill ASAP, continue active pills until pack finished, then discard inactive pills and start new pack. iii. During week 2 3 and > 3 missed pills: Take 1 pill ASAP, continue active pills until pack finished, then discard inactive pills and start new pack. Back-up method x 1 week, consider EC for unprotected sex during missed pills until 7 active pills have been taken. c. Continuous/Extended OCP: missed pill after 21 days of continuous OCP use: i. < 7 days missed: Re-start OCP; no special precautions. ii. > 7 days missed: Take pill ASAP, use back-up x 1 week, consider EC if unprotected sex past 5 days. Contraceptive Patch (Ortho-Evra) a. Patch detached < 24 hr: Reapply or replace ASAP, patch change day stays the same, complete usual cycle of 3 patches. b. Patch delayed or detached > 24 hr: i. During week 1 and detached > 24 hr (or uncertain): Apply new patch ASAP, patch change day stays the same, complete usual cycle of 3 patches. Back-up protection x 1 week and consider EC if sex past 5 days. ii. During week 2 3 and detached < 72 hr: Apply new patch ASAP, patch change day stays the same. Finish course of 3 patches and immediately start new patch cycle with no off-week.

2.

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c.

iii. During week 2 3 and detached > 72 hr: Apply new patch ASAP, patch change day stays the same. Finish course of 3 patches and immediately start new patch cycle with no off-week. Back-up protection x 1 week, consider EC for prolonged omission. Extended wear (> 9 days): i. Patch 1 or 2 left on for 9 to 11 days: Apply new patch, change day stays the same. Finish course of 3 patches and immediately start new patch cycle with no off-week. ii. Patch 1 or 2 left on for > 12 days: Same as above plus back-up protection x 7 days and consider EC if sex past 5 days. iii. Extended wear of Patch 3: No concern unless left on past scheduled start of new patch cycle.

3.

Contraceptive Ring (NuvaRing) a. Removal for < 3 hr: Reinsert ASAP. Removal day (day 21 after taking ring out of foil) unchanged. b. Insertion delayed > 24 hr or removal for > 3 hr: i. Week 1 and removal > 3 hr (or uncertain): Reinsert ASAP. Removal day (day 21 after taking ring out of foil) unchanged. Back-up x 7 days and consider EC if sex past 5 days. ii. Week 2 3 and removal < 72 hr: Reinsert ASAP. Removal day (day 21 after taking ring out of foil) unchanged. Then start new cycle with new ring and no ring-free period. iii. Week 2 3 and removal > 72 hr: Reinsert ASAP. Removal day (day 21 after taking ring out of foil) unchanged. Then start new cycle with new ring and no ring-free period. Back-up protection x 7 days and consider EC if repeated or prolonged omission. c. Ring left in for > 28 days: i. For 28 35 days: Insert new ring with no ring-free period. Keep until scheduled removal day (day 21 after taking ring out of foil). ii. For > 35 days: Same as above plus back-up protection x 7 days and consider EC if sex past 5 days. Progestin-Only Pills (Micronor, Nor-QD) a. Delayed > 3 hr or missed > 1 pill: i. If unprotected sex past 5 days: EC recommended. Continue pill next day, taking same hour daily. Back-up protection x 48 hr. ii. No unprotected sex past 5 days: Take pill ASAP, continue one pill daily, taking same hour each day. Backup protection x 48 hr. Depot Medroxyprogesterone Acetate Injections (Depo-Provera) a. Last injection < 14 weeks ago: give next injection ASAP. b. Last injection > 14 weeks ago: i. If unprotected sex < past 5 days and urine HCG negative: Provide EC, give next injection ASAP, backup protection x 1 week. Repeat HCG in 3 weeks. ii. If unprotected sex > past 5 days and urine HCG negative: Give next injection ASAP, back-up protection x 1 week. Repeat HCG in 3 weeks. iii. No unprotected sex past 14 days and urine HCG negative: Give next injection ASAP, back-up protection x 1 week.

4.

5.

References:
1. 2. 3. 4. 5. 6. 7. 8. Gupta N, Corrado S, Goldstein M: Hormonal contraception for the adolescent. Pediatr Rev 2008, 29(11):386-396 Hatcher RA. Contraceptive Technology, 19th edition. 2008, Thomson Reuters, New York Petitti DB. Clinical practice. Combination estrogen-progestin oral contraceptives. N Engl J Med 2003;349(15):1443-1450. Comparison of oral contraceptives: a summary. Prescriber's Letter 2010;26(7):231207 (Updated June 2010) Natazia (Estradiol Valerate and Dienogest). Prescriber's Letter 2010;26(7): 260706 Missed doses of hormonal contraceptives. Prescribers Letter 2009;25(1):250120 Guilbert, E, et al. Missed hormonal contraceptives: new recommendations. J Obst Gyn Can 2008;30(11): 1050-62. Fine P, Mathe H, et al. Ulipristal acetate taken 48-120 hours after intercourse for emergency contraception. Obstet Gynecol. 2010;115(2 Pt 1):257-263. 9. Glasier AF, Cameron ST, Fine PM, et al. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis. Lancet. 2010;375(9714):555-562. 10. Jick SS, Hernandez RK. Risk of non-fatal venous thromboembolism in women using oral contraceptives containing drospirenone compared with women using oral contraceptives containing levonorgestrel: case-control study using United States claims data. BMJ. 2011;342:d2151. 11. Yen S, Saah T, Adams Hillard PJ. IUDs and AdolescentsAn Under-Utilized Opportunity for Pregnancy Prevention. Journal of Pediatric and Adolescent Gynecology. 2010;23(3):123-128. Birth Control Made Simple 2011 Page - 4

(Hatcher RA. Contraceptive Technology, 18th edition. 2004, Ardent Media, New York)

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