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BIRTH CONTROL MADE SIMPLE

Richard Wahl, M.D. Department of Pediatrics University of Arizona May 16, 2012

Too Much Estrogen:
Nausea, bloating, breast tenderness, hypertension, melasma, headache.

Too Little Estrogen:
Break-through bleeding (early or mid-cycle), spotting, hypomenorrhea, osteopenia.

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.

0

++

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)

15 mg x 7 Levo-norgestrel 0.125 x7.05 mg x6. 0. Early spotting/BTB.Biphasic OCPs Brand Names Ethinyl Progestin estradiol Mircette Azurette Kariva 20 mcg x 21 days. DVT risk. 2x increased DVT risk. Increased spotting or cyclic bleeding. 0. + ++ +++ + ++ + 0 35 mcg x 21 days 35 mcg x 21 days Norethindrone 0.15 mg 20 mcg x 24 Drospirenone 3 mg days 20 mcg Estradiol (3mg → 1mg) Levo-norgestrel 0. then 7 days off. 1mg x9. No reports of incr. DVT risk. Higher estrogen dose preovulation. 0 Less break-through bleeding.75 x7.215 x 7. but reduced overall blood loss. FDA Acne indication No reports of incr. Page . 30mcg x84 days Levo-norgestrel 10mcg x 7 days 0. 0. Less spotting than above? Similar to Yazmin. 24/4 day cycle. 0. 2x increased DVT risk3 Good for mid-cycle spotting.125 mg x 10 days Norgestimate 0.5 mg x7.35 mg 0 + + Irregular menses.075 mg x 5.5 mg x7. Dienogest: anti-androgenic 4-phase pill. with 2 day hormone-free break Possible increased DVT risk.15 mg x 21 days Estrogen Progestin Androgen Comments potency potency potency + +++ Non-androgenic. 0.25 x7 Desogestrel 0.25 x7 + ++/+++ ++ FDA Acne indication + + 0 0 +/++ Low androgen activity. 10 x5 days Desogestrel 0. No hormone-free days. 0 x 2 days. then improves Estradiol instead of EE.15 mg + ++ ++/+++ Continuous 84-day cycle.5 x 5 Norethindrone 0. OK for breastfeeding. 1 mg x7 ++ ++ +/++ +/++ +/++ +/++ Extended Cycle OCP Seasonale Jolessa Seasonique Yaz 30 mcg Levo-norgestrel 0. 0. LNG10 Continuous OCP. 0. 0.18 mg x7. > 2x risk DVT vs.215 x 7.1 mg x7 0. 0.18 mg x7.2 Birth Control Made Simple 2012 .09 mg Dienogest (new) (≈ Drospirenone) (2mg → 3mg) + + ++ ?? ++/+++ +/++ Lybrel Natazia (New July 2010) + ? + +++ - Progestin-Only Pills Micronor Nor-QD --Norethindrone 0. Triphasic OCPs Estrostep Fe Tilia Ortho TriCyclen Lo Generic in 2016? Cyclessa Triphasil Tri-Levlen Ortho TriCyclen TriNessa Tri-Spintec 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 Norethindrone 1 mg x 21 days Norgestimate 0. Lower Estrogen.

IUD cost: ∼ $500 Insertion: ∼ $300 See reference 11. Poor cycle control.9 “Fake” emergency contraception. b. During week 2 – 3 and < 3 missed pills: Take 1 pill ASAP.3 2. Birth Control Made Simple 2012 Page . < 7 days missed: Re-start OCP.06 mg/day x 3 years Identical to Implanon Etonogestrel 0. Finish course of 3 patches and immediately start new patch cycle with no off-week. Back-up protection x 1 week and consider EC if sex past 5 days. > 7 days missed: Take pill ASAP. consider EC if unprotected sex past 5 days. Increased DVT risk Mirena IUD (or IUS) ParaGard (Copper T 380A) IUD Norplant “rods” --Implanon “implant” Nexplanon NuvaRing Vaginal insert --- +++ ++/+++ 0 ++ ++/+++ 0 ++ Levo-norgestrel 36 mg x 6 rods = 216 mg. ii. Active form of desogestrel.5 mg Ulipristal acetate 30 mg Levo-norgestrel 1. RU-486/mifepristone). iii.75 mg each tablet Levo-norgestrel 1. then discard inactive pills and start new pack. complete usual cycle of 3 patches.8. patch change day stays the same. Improves epilepsy. b. > 24 hr late: i. During week 2 – 3 and > 3 missed pills: Take 1 pill ASAP. consider EC if unprotected sex past 5 days. 1 dose given < 72 – 120 Hr of unprotected sex. use back-up x 1 week. Possible increased DVT risk. Continuous/Extended OCP: missed pill after 21 days of continuous OCP use: i. Back-up method x 1 week. etc. Missed 1 or more active pills. More effective than Plan B. ii. Possible increased DVT risk. (cf. sickle cell. Increased vaginal discharge.5 mg ?? Initial dose < 72 – 120 Hrs. Combined OCP (Monophasic. then discard inactive pills and start new pack. Vaginal ring x 3 weeks. . Patch detached < 24 hr: Reapply or replace ASAP. Patch delayed or detached > 24 hr: i. Contents uncertain. Osteopenia. consider EC for unprotected sex during missed pills until 7 active pills have been taken. ii. Check HCG +++ +++ Take pill < 72 – 120 Hr of unprotected sex. use back-up x 1 week.) a. FDA Press Release 7/28/2011. No longer available in U. May take 2 pills same day. not FDA approved. During week 1: Take pill ASAP. Missed 1 active pill < 24 hr late: Take missed pill ASAP. c. Etonogestrel 0. Delayed return of fertility.12 mg/day x 3 weeks 0 --EE 15 mcg/day Radiopaque on X-ray ++? +++ 0 Ortho Evra Patch EE 20 mcg/day Norelgestromin (Norgestimate) 150 mcg/day +++ + 0 Emergency Contraception Plan B Next Choice Plan B One Step ellaOne or ella Evital --Levo-norgestrel 0. Triphasic. no special precautions. x 10 years 0 0 0 0 0 0 +++ +++ ++++ ++++ Q 12 weeks. Contraceptive Patch (Ortho-Evra) a. continue active pills until pack finished. complete usual cycle of 3 patches. patch change day stays the same. Manufactured in Dominican Republic? - +++ +++ Missed Contraceptive Doses7 1. Check HCG Selective progesterone receptor modulator.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. During week 2 – 3 and detached < 72 hr: Apply new patch ASAP. continue active pills until pack finished. During week 1 and detached > 24 hr (or uncertain): Apply new patch ASAP. May take both tabs together. patch change day stays the same. 1 patch weekly x 3 weeks. Irregular menses  amenorrhea.S.

back-up protection x 1 week. Last injection < 14 weeks ago: give next injection ASAP. 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.4 . Then start new cycle with new ring and no ring-free period. 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. No unprotected sex past 14 days and urine HCG negative: Give next injection ASAP. Then start new cycle with new ring and no ring-free period. 29(11):386-396 Hatcher RA. Prescriber’s Letter 2009. J Obst Gyn Can 2008. 9. 10. taking same hour each day. 3.30(11): 1050-62. 2008. Combination estrogen-progestin oral contraceptives. Corrado S.342:d2151. b. Removal day (day 21 after taking ring out of foil) unchanged. Delayed > 3 hr or missed > 1 pill: i. ii. Extended wear (> 9 days): i. et al. give next injection ASAP. Fine PM. Saah T. No unprotected sex past 5 days: Take pill ASAP. Finish course of 3 patches and immediately start new patch cycle with no off-week. Removal day (day 21 after taking ring out of foil) unchanged. Ulipristal acetate taken 48-120 hours after intercourse for emergency contraception. Week 2 – 3 and removal > 72 hr: Reinsert ASAP. Finish course of 3 patches and immediately start new patch cycle with no off-week. 2010. If unprotected sex < past 5 days and urine HCG negative: Provide EC. 6. 2010. Adams Hillard PJ. Back-up protection x 48 hr. Insertion delayed > 24 hr or removal for > 3 hr: i. Lancet. Keep until scheduled removal day (day 21 after taking ring out of foil). iii. 5. Fine P. taking same hour daily. 11. Extended wear of Patch 3: No concern unless left on past scheduled start of new patch cycle. Contraceptive Technology. Clinical practice. ii. ii. E. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis. backup protection x 1 week. ii. iii. Goldstein M: Hormonal contraception for the adolescent. Obstet Gynecol. continue one pill daily. If unprotected sex past 5 days: EC recommended. 2. change day stays the same. et al.25(1):250120 Guilbert. New York Petitti DB. Thomson Reuters. Prescriber's Letter 2010. Repeat HCG in 3 weeks. 7. Mathe H. Depot Medroxyprogesterone Acetate Injections (Depo-Provera) a. Comparison of oral contraceptives: a summary. 5. IUDs and Adolescents—An Under-Utilized Opportunity for Pregnancy Prevention. If unprotected sex > past 5 days and urine HCG negative: Give next injection ASAP.26(7): 260706 Missed doses of hormonal contraceptives.26(7):231207 (Updated June 2010) Natazia (Estradiol Valerate and Dienogest).349(15):1443-1450. iii. ii. 8. Week 1 and removal > 3 hr (or uncertain): Reinsert ASAP. b. Contraceptive Ring (NuvaRing) a. Ring left in for > 28 days: i. back-up protection x 1 week. Week 2 – 3 and removal < 72 hr: Reinsert ASAP. consider EC for prolonged omission. Jick SS. During week 2 – 3 and detached > 72 hr: Apply new patch ASAP. Pediatr Rev 2008.23(3):123-128.115(2 Pt 1):257-263. Back-up x 7 days and consider EC if sex past 5 days. Back-up protection x 1 week. Gupta N. Removal for < 3 hr: Reinsert ASAP. Prescriber's Letter 2010. 2010. BMJ. Cameron ST. Missed hormonal contraceptives: new recommendations. c. patch change day stays the same. et al. For 28 – 35 days: Insert new ring with no ring-free period. References: 1. Back-up protection x 7 days and consider EC if repeated or prolonged omission. Nor-QD) a. Hernandez RK. 4. Yen S. Removal day (day 21 after taking ring out of foil) unchanged. Repeat HCG in 3 weeks. 19th edition. Progestin-Only Pills (Micronor. Journal of Pediatric and Adolescent Gynecology. Birth Control Made Simple 2012 Page . Backup protection x 48 hr. 2011. Patch 1 or 2 left on for 9 to 11 days: Apply new patch. Glasier AF. 4. Last injection > 14 weeks ago: i.3.375(9714):555-562. For > 35 days: Same as above plus back-up protection x 7 days and consider EC if sex past 5 days. Continue pill next day. c. Removal day (day 21 after taking ring out of foil) unchanged. N Engl J Med 2003.

18th edition. Ardent Media. Contraceptive Technology.5 . 2004.(Hatcher RA. New York) Birth Control Made Simple 2012 Page .