Lecture 7 Contraception Overview Soon

OVERVIEW OF CONTRACEPTION: TRENDS IN REPRODUCTIVE HEALTH: Canadian women will:

• Contraception is important in the lives of women,
their male partners, and society as a whole
• Preferences are changing – family size and timing
of starting a family
• Being able to plan a pregnancy can have positive
impacts on health, education, workplace and
financial stability
• The Society of Obstetricians and Gynaecologists
Canada (SOGC) strongly supports appropriately
trained pharmacists to provide contraceptives and
family planning services
• Spend 3 years or fewer pregnant, attempt to conceive, or immediately post-partum
• National maternal average age at first birth is over 30 years
• Women now spend at least half their reproductive years at risk of an unintended pregnancy
• Nearly one-third of women have at least one abortion
CHALLENGES WITH CONTROLLING FERTILITY:
• 40-50% of Canadian pregnancies are unplanned
o Most unplanned pregnancies occur in women ages 20-29
o Vulnerable populations with lower education, lower income, recent immigrants, and in
rural and remote areas often have “high unmet need”
• The cost of unplanned pregnancies is high, and increases poor outcomes
• Cause is usually contraceptive non-adherence

CANADIAN WOMEN ARE USING INEFFECTIVE CONTRACEPTION:

goal is to use more effective contraception
• Pharmacists have an important role to play in this shift to more effective methods
of contraception!
• Pharmacists need to initiate the birth control conversation:
o Oral contraceptives typically 21/7 format
▪ Hormone-free interval may be unnecessarily long
o Other combination hormonal contraceptives may be more effective as do
not require daily use
o Depo-Provera, copper IUDs and levonorgestrel are more effective than
hormonal contraceptives

EFFICACY VERSUS EFFECTIVENESS:

• Efficacy = refers to number of pregnancies
prevented during correct and consistent use of
a method (perfect use)
• Effectiveness = refers to number of pregnancies
prevented during typical use
o Discussing effectiveness and typical use
provides more realistic information for
the patient and is preferred
o Methods that are dependent on user
adherence have lower effectiveness rates
(ex// anticipating sexual contact, STI risk)

CONSIDERATIONS IMPACTING PATIENT CHOICE: FOSTERING A REPRODUCTIVE LIFE PLAN:

• While the Top Tier contraceptive methods are most effective, the best
“user-method fit” also needs to consider patient personal properties:
o Safety, effectiveness, and previous use
o Accessibility, affordability, and acceptability
o Personal beliefs, culture and desire for future children
o Preferences, lifestyle and ability to be adherent
• Contraceptive cost as a barrier:
o Spending on hormonal contraceptives was almost exclusively
privately financed (through private insurance or out of pocket)
CONTRACEPTION AND STIs:
• Contraceptive care should include discussion of STIs as appropriate:
o Condom use alone
o Condom use as dual protection combined with CHC or IUD
o Condom use as a back-up if adherence with CHC not optimal
o Vaccinations such as Hep B or HPV
o Screening tests (ex// PAP Test, STI screening)
PHARMACISTS’ ACTION PLAN:
1. Provide confidential, non-judgmental & respectful family planning care
2. Improve access to highly effective contraceptive options that best
meet the needs of your patients
3. Discuss practical information on contraceptive use, adherence,
condoms, and STIs to support successful family planning outcomes
• Assisting women to consider their plans for a future pregnancy is an
important part of family planning
• Women may be unaware of the substantial decrease in fertility that occurs
by their late 30s
o Miscarriage rates also increase in their late 30s
TRANSITIONS IN CONTRACEPTIVE METHODS:
• Reproductive needs change over time:
1. Barrier method
2. Combination Hormonal Contraception (pill, patch, ring)
3. Baby and progesterone-only pill during breastfeeding
4. IUD
5. Sterilization or vasectomy
• Ongoing contraceptive consultations can help patients transition seamlessly
CONTRACEPTIVE INFORMATION TO SHARE:
• Pharmacists can promote adherence by providing accurate, practical, and
non-judgmental information on:
o The range of birth control methods
o How to use a chosen method correctly and consistently
o What to do if problems occur
o Back-up strategies (ex// EC and/or condoms)
o Information on preventing STIs when using the chosen method
Lecture 9 Over the Counter Reproductive Health Care Peterson

SPERMICIDES, FILMS AND CONTRACEPTIVE SPONGE:

SPERMICIDE: N-9 SPERMICIDES:
• Chemical agent that kills or immobilizes sperm • MOA: acts as a surfactant which destroys sperm cell membrane by
• Spermicidal agent incorporated into vehicle allowing for dispersal and altering lipid layer so that spermatozoon becomes permeable and swells,
retention of spermicide in vagina where it acts as both a physical and with breakage of plasma and acrosomal membranes
chemical barrier to sperm motility o Minimum effective dose: 100 mg N-9
o Failure rate : 18 – 28%
SPERMICIDAL AGENTS: Ineffective against HIV/ STI • May also increase genital irritation or cause epithelial disruption leading
• Spermicidal active ingredients commonly used: to easier transmission of HIV and other STIs
o Noxynol-9 (N-9) Vaginal contraceptive film • Associated with ↑ risk of E. coli UTIs due to alteration of vaginal flora
o Lactic acid
o Menfegol CONTRACEPTIVE FILM – VCF:
• Formulated in a safe, inert vehicle consisting of ≥ 1 suitable thickening • MOA: physical and chemical barrier to sperm
agents, humectants, buffering agents, preservatives & water o N-9 in film base that dissolves at body temp to form gel barrier
o Failure rate: 6 – 28%
SPERMICIDE INDICATIONS: • Effective after 15 mins and up to 3 hours after insertion
• Suitable contraceptive for women unable/unwilling to use hormonal or o Additional film required for each act of intercourse
IUD methods • Available on pharmacy shelves and online
• Dual protection with other methods of contraception as important
contributor to efficacy of contraceptive devices (sponge, male condom, CONTRACEPTIVE SPONGE – TODAY: Cannot be used during menstruation
diaphragm and cervical cap) • Small, one-size-fits-all, disposable, polyurethane foam device intended
to fit over the cervix impregnated with a spermicidal agent
SPERMICIDE CONTRAINDICATIONS: o MOA: contraceptive action primarily provided by the
Absolute • High risk for HIV spermicide impregnated in the sponge, augmented by its ability
Relative • Allergy to spermicidal agent to absorb and trap sperm Spermicide is released in
sustained manner for 10-12h
• History of TSS o Failure rate: 9-12% in nulliparous; 20-24% in parous women
• HIV positive or AIDs diagnosis • Effective for multiple acts of intercourse over 24-hour period
• Use of antiretroviral therapy o May be forgotten and left in place = toxic shock potential
- infection due to toxin-producing strains of S. aureus
Not • Women uncomfortable touching their genitals • Available on pharmacy shelves & internet -- can evolve rapidly in < 12h
associated with the use of tampons/ sponges/ IUD/
recommended • Women with personal/medical need for highly
cervical caps (but not condoms)

for: effective contraception

• N-9: women with chronic UTIs
• Sponge/film: women with abnormal vaginal
anatomy, physical disabilities or neurological
impairment which limits ability to insert or
remove the device
• Sponge: within 6 weeks of delivery, miscarriage
or abortion
LACTIC ACID SPERMICIDES – CONTRAGEL, CAYA GEL:
• MOA: some evidence that lactic acid reduces pH of vagina, reducing
sperm motility
o Marketed as a green, natural, alternative to N-9 spermicides
▪ Less irritating than N-9
o Failure rates: ??
• Compatible with latex, polyurethane and silicon devices

MALE CONDOMS: Barrier methods (condoms/ diaphragm): protect against STIs including HIV and HPV (latex condom only)

MALE CONDOMS: AVAILABILITY:

MOA: • Physical barrier • Non-prescription – various brands
o Prevents passage of sperm • Various shapes, sizes, textures, colors, lubrications
o Decreases contact with semen, bodily fluids & genital lesions • Various materials including: latex, polyisoprene,
INDICATIONS: • Prevention of pregnancy – ideally dual protection polyurethane, tactylon, lambskin
• Prevention of transmission of STIs and cervical dysplasia • Optimal fitting requires trying variety of condoms
EFFECTIVENESS: • Contraceptive failure rate: 3 – 14% o Online condom sizing charts available
• STI transmission failure rate: variable

CONDOM TYPES:
LATEX: • Manufactured from natural latex rubber; 0.3 – 0.8 mm thickness
• Offered in variety of colors, shapes, sizes, widths, lengths, textures and lubrication
• CANNOT be used by those sensitive/allergy to latex OR with oil-based lubricants Oil-based lubricants reduce integrity
in either partner Use water lubricants
• Offer BEST protection against pregnancy
POLYISOPRENE: • Manufactured from latex that has been put through a process to remove latex allergens
o Fewer medical events than latex condoms
o Transmits more heat, allowing more sensitivity
• Similar to latex in terms of preventing pregnancy & transmission of STIs (no published data)
• Cannot be used with oil-based lubricants
POLYURETHANE: • May offer better physical properties than latex condoms:
o Similar to polyisoprene in terms of warm feel; can be formulated to feel thinner than actually are; less constricting fit
o More resistant to deterioration; compatible with oil-based lubricants BUT higher slippage and breakage rates than latex
o Can be used by those sensitive or allergic to latex
o More expensive
LAMBSKIN: • Made from lamb’s intestine; cannot be used by those with lanolin sensitivity
• Not recommended because of lack of protection against STIs transmitted by viral organisms
o Lab tests have shown passage of HIV, hepatitis B & HSV through small pores on surface of lambskin condoms
Lecture 9
MALE CONDOMS (CONTINUED):
COMMON CAUSES OF CONDOM FAILURE:
1. Slippage rates: between 0.90 – 1.28%
• Associated with use of lubricants:
o ↑ rates in vaginal intercourse
o ↓ anal in vaginal intercourse
2. Breakage rates: between 2.8 – 3.42%
• Rough handling
• Lengthy/intense intercourse
• Use of oil-based lubricants
• Incorrect storage and usage after expiry date
• Failure to leave space or remove air at tip
• Concurrent use of alcohol and/or drugs
3. Late application or early removal
4. Inconsistent use; non-use; re-use
5. Applying condom inside out
Over the Counter Reproductive Health Care
ADVANTAGES VS. DISADVANTAGES:
Advantages
• Protection against STIs
• ↓ likelihood of infertility or
cervical neoplasia by ↓ risk of STIs
• Up to 80% reduction in HIV
transmission when used correctly
or consistently
• Relatively inexpensive
• Widely available and accessible
• More/less stimulation –
premature ejaculation
• No prescription required
• Convenient/portable/discreet
• Low incidence of side effects
• Enhances other contraceptive
methods
Peterson
Disadvantages
• May break or slip
• Requires motivation & responsibility to use
• Interrupts intercourse – must be put on the
penis before any genital contact
• Loss of spontaneity
• Potential latex allergy and lanolin sensitivity
to lambskin condoms
• Decreased sensation
• May interfere with maintenance of erection
• Awareness of presence
• May have unpleasant taste
• Less protection against HSV or HPV
• Must withdraw promptly after ejaculation
• Can be used only once
• N-9 lubricated condoms increase risk of E.
coli and UTIs + transmission of HIV and STIs

FEMALE CONDOMS: Not to be used with male condom

FEMALE CONDOMS: TYPES OF FEMALE CONDOMS:
MOA: • Physical barrier • FC1 – original female condom (polyurethane)
o A soft, loose, fitting sheath which acts as an intravaginal • FC2 – 2nd generation female condom (nitrile rubber)
barrier to semen and bodily fluids o More cost-effective
INDICATIONS: • Prevention of pregnancy o Efficient manufacturing process
• Prevention of transmission of STIs o No seam in the condom
EFFECTIVENESS: • Contraceptive failure rate: 5 – 21% o Softer material that is quitter during use
• STI transmission failure rate: variable (as much as male condom) o Thicker and less tear resistant

ADVANTAGES VS. DISADVANTAGES: REALITY FEMALE CONDOM:

Advantages
• Protects against pregnancy about
as well as a male condom
• Decreased risk of STIs
• Less likely to cause allergic
reaction vs. male latex condom
• Less likely to break or tear than
latex male condom
• Does not deteriorate on exposure
to oil-based lubricants
• 1. Breakage rates: 0.5 – 2.1%
No prescription required
• Shared responsibility with partners
• A woman can place it
autonomously and has full control
of effectiveness
• Adjusts well to anatomy of vagina
• Less disruptive than male condom
– can be inserted ahead of time
(up t o 8 hours prior)
• Withstands storage better than
latex – shelf-life up to 5 years
Disadvantages • Soft, thin sheath with 2 flexible rings; one unattached
• Should be used only once ring at one end (closed) and slightly larger, attached
• Costs $3-5 per condom ring at opposite end (open) of condom
• Availability issues o Inner ring is inserted into vagina & placed over
• Insertion and removal difficulties – need cervix to anchor it in place in vagina
to practice insertion and use device o Outer ring rests outside vagina & keeps condom
several times before confident with use from being pushed inside vagina during use
• Higher slippage rates than male condom
• Outer ring is somewhat cumbersome
COMMON CAUSES OF CONDOM FAILURE:
• Aesthetically unacceptable to some
• Pain during intercourse – inner ring may
cause some discomfort during coitus 2. Slippage rates: 5.1 – 6.13%
• Does not provide complete protection 3. Invagination (outer ring gets pushed in)
against all STIs 4. Misdirection (penis misses condom)
• Higher failure rate than male condom
• Polyurethane product makes crackling
and popping noise during intercourse
(noise with FC1 condom)

DIAPHRAGM AND CAPS:

DIAPHRAGM: A soft shallow silicone dome-shaped contraceptive device with either an encased flexible steel or nylon rim around its edge
Milex Wide-Seal Diaphragm SILCS Caya Diaphragm
• Flexible steel rim (arching & omniflex rim styles) + silicone dome • Nylon rim + silicone dome
o Wide rim provides increased suction and seal • Available in one size (67 mm)
• Available in eight sizes (60-95 mm) • No fitting necessary – fits most women (sized between 65-80
• Pelvic exam and fitting required by trained clinician mm for traditional diaphragm)
• Yearly replacement recommended • Replace every 2 years
CERVICAL CAP: • FemCap available online; 22, 26, 30 mm sizes (sizing based on obstetrical history)
• Replace yearly
MOA: Contraceptive devices designed to be used in conjunction with spermicidal gel providing both physical & chemical barrier to spermatozoa
INDICATIONS: • Prevention of pregnancy
• Well suited for women who do not wish to use hormonal contraception for personal or medical reasons
• Caps often used by women who cannot use a diaphragm
EFFECTIVENESS: • Diaphragm failure rate: 6-12% (N-9); 12 – 23.6% (N9 or acid buffering)
• Cap failure rate: nulliparous 14%, parous 29%
Lecture 9 Over the Counter Reproductive Health Care Peterson

DIAPHRAGM AND CAPS (CONTINUED):

CONTRAINDICATIONS AND CAUTIONS: DIAPHRAGM ADVANTAGES VS. DISADVANTAGES:
DIAPHRAGMS • Known hypersensitivity to silicon Advantages Disadvantages
& CAPS: • History of toxic shock syndrome (TSS) • Ability to insert device • Must be used with spermicide
• Use within 6 weeks of childbirth just before intercourse (most effective)
DIAPHRAGMS • Uterine prolapse, rectocele or cystocele or up to 30-60 min • Refitting is required after
• Acute or chronic – recurrent UTIs prior may allow more pregnancy, abortion, miscarriage,
• Refit required after childbirth, 2nd trimester spontaneity pelvic surgery, or significant
abortion, genital surgery or weight gain/loss > 10 lbs • Rarely causes weight loss/gain (10-20 lbs)
CAYA • Women previously fit with diaphragm sizes > 60 mm discomfort and reduced • Proper insertion requires practice
DIAPHRAGM or > 85 mm pleasure during • Some require fitting by trained
intercourse clinician
• Convenient for women • Showering after intercourse is
CAPS DISADVANTAGES VS. DISADVANTAGES: only requiring safe but bathing is not – may
Advantages Disadvantages contraceptive on an wash away spermicide
• Smaller and generally • Does not protect against occasional basis • If multiple acts of intercourse
more comfortable than a transmission of STIs or HIV occur during a 6-hour period,
- use with spermicide
diaphragm • More difficult to insert than - can be used in breastfeeding women must re-apply spermicide before
• Requires less spermicide diaphragm each act
than a diaphragm • Bacteria may grow inside the cap – • May increase risk of persistent UTI
• Inexpensive and re-usable TSS – pressure on bladder can change
• May be left in place for up • Unpleasant odor if used for longer size or rim type
to 48 hours than 48 hours • May increase risk of Toxic Shock
- can be used in breastfeeding women • Higher failure rate than diaphragm Syndrome (TSS)
• Less effective in nulliparous • Odor if left in place longer than
women recommended
- not to be used within 6 weeks of delivery Use silicone diaphragm
• Potential allergic rxn to material e.g. latex

LUBRICANTS:
PERSONAL LUBRICANTS:
• Used during intercourse to:
o Reduce friction with genital/anal tissue
o Increase comfort and pleasure during sexual intercourse
o Relieves vaginal dryness associated with:
▪ Certain medications
▪ Low estrogen levels during peri-menopause, menopause, post-partum period, breastfeeding, and immediately following menses
▪ Sexual dysfunction
• Types of lubricants: water, silicon, oil

FORMULATION: WATER-BASED FORMULATION: SILICONE

• Most are made up of one or more of the following ingredients:
o Hydrophilic polymers
o Humectants (glycols)
o Viscosity modifiers (cellulose)
o Moisturizers (cellulose, glycols)
o Preservatives (parabens, sorbates, phenoxyethanol, benzoic acid)
o pH balancing agent
• Many water based lubricants are hyperosmolar causing fluid loss from
vaginal and rectal cells resulting in fragility and damage to the epithelium,
potentially increasing the risk of transmission of STIs and HIV
o Glycerin, glycerol and glycol containing products implicated
• Alternative to water-based lubricants
• Chemically inert and water resistant
• More expensive than water-based lubricants
• Common ingredients: cyclomethicone, dimethicone, silicone,
dimethicone copolyol – all silicone liquids that combine together to
create inert silicone lubricant
FORMULATION: OIL-BASED – NOT RECOMMENDED
• Petroleum-based and other oils destroy latex upon contact (some
condoms, historically some diaphragms, and protective coatings
around some IUDs)
• Oils can be irritating, difficult to remove and can coat inside of
vagina/rectum providing a breeding ground for pathogenic bacteria

ADVANTAGES VS. DISADVANTAGES:

Lubricant Advantages Disadvantages
Water-based • Relatively low cost • Tendency to dry out during use, requiring constant reapplication
• Easily washes away with water • Incompatible with sexual activity occurring in water
• Most widely available on market • Potential for hyperosmolar products to disrupt vaginal/rectal epithelium and
increase risk of STI transmission
Silicone-based • Ideal for using in or under water • May leave an oily residue on skin/fabric
• Constant reapplication not necessary • More expensive
• Available in a variety of consistencies • Not all silicon products compatible with latex - * check label
Lecture 9 Over the Counter Reproductive Health Care Peterson

FERTILITY AWARENESS METHODS (FAM) OF CONTRACEPTION:

• Rely on an understanding of the physiology of the menstrual cycle and the timing of ovulation to schedule intercourse in order to prevent a pregnancy
• Can be also used to maximize the potential for conception
• Several FAM including Standard Days, Calendar Days, Sympto-thermal, Cervical Mucus, Two Day and Basal Body Temperature methods

BASAL BODY TEMPERATURE METHOD:

• Measure temperature daily to detect an increase of 0.2 – 0.6o C over 3 days (stays elevated till beginning of next cycle)
o When ovulation occurs, progesterone is released which causes this rise in temperature
• Use a basal thermometer which detects smaller fluctuations than a regular thermometer
• Helps predict window of next cycle (won’t help in the same cycle)
Lecture 7 Long Acting Reversible Contraception & Permanent Sterilization Soon

WHY IUC IS UNDERUSED IN CANADA: MECHANISM OF ACTION:

• Lack of awareness of Long Acting Reversible Contraception
LNG IUD:
(LARC) methods among women and providers
• Small effect on ovulation function
• Myths about IUC safety
• Strong antiproliferative effect on the endometrium
• Upfront cost
• Thickening of cervical mucus
• Lack of positive marketing
• Inhibition of sperm function
Nova-T, Flexi-T
HISTORY OF IUDs IN CANADA: COPPER IUD MECHANISM OF ACTION:
• Today’s IUDs are safe and effective – however, many Canadians • Copper++ prompts a sterile inflammatory response in uterine cavity
remember hearing about the Dalkon Shield
• Decreased motility, viability, and fertilizing capacity of sperm
• It was a device with a short but infamous history
• Interferes with fertilization and may interfere with implantation
o Introduced in 1971
• Cu-IUD recommended if BMI ≥ 30 or on CYP3A4 inducers
o Unique shield-like shape, with multifilament tail string
• After Copper IUD has been removed and menstrual period has occurred,
o No recommendations for routine STI screening
effects of copper ions disappear
o Caused thousands of adverse affects, including 18 deaths
• Impairs viability in fallopian tubes
o Removed from market in 1974
• Clinicians and patients may be influenced by this history
WHY WOMEN CHOOSE IUC:
MYTHS AND REALITIES ABOUT LARC: • Safe – low rate of complications
MYTH REALITY • Convenient and highly effective: immediate effect
Must have had a child Good choice for women o No compliance problems; reversible; “forgettable”; invisible
without children o No estrogen-related side effects
Not suitable for young women Good choice for teens o Continuation rates high; long duration of use
Cause pelvic inflammatory Does not cause PID or infertility • Insertion options:
disease and infertility o Any time during cycle once pregnancy is ruled out
o Post-abortion; post-partum
ASSOCIATION BETWEEN PID AND IUC? • Covered by many extended medical plans
• Risk of PID
Cannot be used until 4-6 weeks postpartum
o Greatest in first 20 days after insertion CAN IUC BE USED IN THESE SITUATIONS? (until ovulation occurs)
▪ PID risk drops after first 3 weeks following insertion YES NO
o Incidence of PID 1/1000 insertions • Nulliparous, nulligravid women • Known or suspected pregnancy
o Prophylactic antibiotics not cost-effective • Age < 20 • Active infection in pelvis
• Risk related to sexual practice • Previous PID (no active infection) • Unexpected vaginal bleeding
o Multiple sexual partners greatest risk for PID • Previous ectopic pregnancy • Cervical/uterine malignancy
(independent of IUC use) • Previous C-section • Distorted uterine cavity or
o Frequency of intercourse increases the risk • Previous DVT or stroke obstructing uterine fibroids
o IUC users should use condoms for protection against STIs • Smokers/obese/diabetes • Copper IUD: Wilson’s disease
• HIV/AIDs • LNG-IUD: Progestin-dependent
• If STI occurs, IUC can remain in place cancer, liver tumors
& treat women (and her partners)

LNG-IUD:

LNG-IUS INSERTION TECHNIQUE (FPs): NON-CONTRACEPTIVE EFFECTS OF LNG-IUD:

1. VISIT 1 : Rx Mirena – single visit is encouraged (F/U 12-14 wks) • Beneficial effects:
2. VISIT 2: Preferable during period (must exclude pregnancy) o Heavy menstrual bleeding reduced
a) MD to thoroughly discuss procedure ▪ Mirena (52 mg) can reduce blood loss by 74-98%;
b) Potential sources of pain: apprehension, dilation of cervix, cramping ↑ Hgb levels
o Ibuprofen 600 – 800 mg 1 hour prior o Studies suggest may reduce the need for hysterectomy
o Use local anesthetic if no prior vaginal birth o May improve dysmenorrhea, endometriosis &
▪ 5 cc 1% plain xylocaine intracervical block adenomyosis
▪ Vaginal gel (inserted by woman prior) o Amenorrhea (> 10% by 1 year)
c) Mirena insertion • Adverse effects:
o Cramping pain (2-5/10, lasts 1-2 mins) o Spotting/bleeding (↓ over time)
o Ibuprofen 600 mg 4-6 hours afterword o Some hormonal SEs (acne, breast tenderness, headaches)
• Can be inserted immediate postpartum – results in higher continuation rate o Uterine perforation (rare)
o PID slightly increased first 20 days
o Expulsion (2-10% users ~ 3 months)
• Failure: risk of pregnancy very low, but if occurs 15-50% ectopic
Lecture 7 Long Acting Reversible Contraception & Permanent Sterilization Soon

HORMONAL INJECTION DMPA: Currently used injectable hormonal contraceptive contains long-acting progestin

MEDROXYPROGESTERONE ACETATE (DEPO-PROVERA):

DOSE: 150 mg IM every 90 days
MECHANISM: ↓ FSH + LH surge, suppresses ovulation, thickens cervical mucus
PREGNANCY RATE: 6% (typical); 1 year D/C rate is 44%
INDICATIONS: Difficulty remembering, limited privacy, smokers over 35, migraine headaches, breastfeeding, endometriosis, on anticonvulsants
ADVERSE EFFECTS: Irregular periods or unwanted amenorrhea (8-66% D/C), spotting, weight gain, acne, delayed fertility, ↓ bone density, headache,
↓ chronic pelvic pain, reduced BMD (transient, reversible, no osteoporosis)

NON-CONTRACEPTIVE BENEFITS OF DMPA: DMPA LATE INJECTION: if more than 14 weeks after last injection:
• High rates of amenorrhea, ↓ dysmenorrhea and anemia Unprotected sex Pregnancy test Action
• ↓ endometrial hyperplasia, ↓endometriosis, ↓ chronic pelvic pain None within 14 days Negative Provide DMPA and backup x
• ↓ pre-menstrual tension, ↓ incidence of seizures 7 days
Within last 14 days Negative Provide DMPA and backup x
BUT not last 5 days 7 days; do a pregnancy test
CONTRAINDICATIONS: in 3-4 weeks
• Current diagnosis of breast cancer (MEC category 4) Within last 14 days Negative Give LNG AS EC and her
• Past history breast cancer or severe cirrhosis, adenoma or hepatoma AND with past 5 DMPA injections. Use
• Unexplained vaginal bleeding (before evaluation) days backup x 7 days. Do a
pregnancy test in 3-4 weeks
NOTE: drug interaction between UPA (anti-progestin) and DMPA

PERMANENT CONTRACEPTION:
FEMALE STERILIZATION: APPROPRIATE CANDIDATES:
TUBAL LIGATION • Laparoscopic • Well-informed
• Clips, rings, or cauterizing • Desire permanent end to fertility
• Outpatient setting • Not under pressure t make decision
TUBAL OCCLUSION • Micro-inserts placed into proximal fallopian tubes • ACOG 2013 policy “in a well-informed woman, age and parity
(brand name Essure) • Local anesthesia should not be a barrier to sterilization”
• Can be performed in outpatient setting
• Contraindicated within 6 weeks of abortion, RISK FACTORS FOR DECISION REGRET:
miscarriage, or delivery • Age < 30
• Relationship conflict
MALE STERILIZATION: • Shorter time from delivery
• No-scalpel vasectomy (NSV) is standard of care • Having less information about the procedure
o A small (few mms) opening is made in the skin of the scrotal sac to • Less access to alternative methods
deliver vas deferens • Decision made due to pressure from a spouse or medical
o Ligate/cauterize indication
o No scalpel or sutures required

PHARMACISTS’ ACTION PLAN:

1. Provide confidential, non-judgmental and respectful family planning care
2. Improve access to highly effective contraceptive options that best meet the needs of your patients
3. Discuss practical information on contraceptive use, adherence, condoms and STIs, to support successful family planning outcomes
 1. combined oral contraceptive (estrogen + progestins)
Lecture 8 Oral Contraceptives 2. progesterone only Soon

FEATURES OF AN IDEAL CONTRACEPTIVE: MECHANISM OF ACTION: CHC are a combination of estrogens & progestins
Synergistically
• 100% effective & forgettable • 100% safe Within brain • Inhibits ovulation by suppressing LH surge at
• 100% convenient and acceptable • Inexpensive & easy to distribute mid-cycle -ve feedback
• 100% reversible • Independent of medical profession • LH is required for follicular maturation & rupture
• Beneficial non-contraceptive SEs • Used by/obviously visible to women Within • Thickens cervical & endometrial mucus forming a
reproductive mechanical barrier
COMBINED HORMONAL CONTRACEPTIVES (CHC): genital tract • Creates a hypoplastic (underdeveloped)
• Introduced in the 1960s endometrium that isn’t receptive to implantation
o Thickens cervical mucus, alters endometrial lining
• Since that time
o Dose of estrogen & progesterone
o New progestins with fewer side effects
• Popular because of:
o Ease of administration, fairly low incidence side effects
o Modest pregnancy rate (9% with typical use)
o Standard 28-day regimen or extended/continuous use
o Poor compliance limits effectiveness  42% of unplanned pregnancies
• One electronic device study, in 1st cycle of use, 30% of women missed ≥ 3 pills

ABSOLUTE CONTRAINDICATION FOR COCs:

• Established pregnancy
Breastfeeding Use barrier methods until 4-6 weeks after delivery
• Lactation at < 6 weeks post-partum, postpartum < 3 weeks (not breastfeeding)
• Smoker > 35 years of age (≥ 15 cigarettes/day)
• Migraine with aura at any age Even if well-controlled NON-CONTRACEPTIVE HEALTH BENEFITS:
• Major surgery with prolonged immobilization; current or past hx of DVT/PE • ↑ cycle regulation, ↓ premenstrual symptoms, ↓ menstrual flow,
• Hypertension (SBP ≥ 160 mmHg or DBP ≥ 100 mmHg) ↓ dysmenorrhea, ↓ perimenopausal symptoms
•
MI
Complicated heart disease (ischemic, atrial fibrillation, valvular conditions) • ↓ acne, ↓ hirsutism, ↑ bone mineral density
• Breast cancer, livor tumor or severe cirrhosis • ↓ endometrial & ovarian cancer, ↓ fibroids
• Diabetes with microvascular complications • ↓ pelvic inflammatory disease
D/Is (oral contraceptives are metabolized by CYP3A4)
- antiepileptic: CMZ, phenytoin
CHOICE OF ORAL CONTRACEPTIVE: Synthetic COC: higher PO bioavailability SIDE EFFECTS - rifampin/ griseofulvin: use backup barrier method during therapy
- obesity: affect metabolism to compromize contraceptive efficacy, thus decrease effectiveness
Monophasic OCs • 30-35 µg > estrogen SEs than 20 µg COMMON SIDE EFFECTS in first 3 months:
Fixed-dose At night before bedtime
• 20 µg > bleeding pattern disruptions than 30-35 µg Lower dose but
higher risk • Nausea (19%), mood swings (14%), breast tenderness (11%)
due to estrogen
Multiphasic OCs • No outstanding clinical advantages/disadvantages o Compliance enhanced by counselling
Progestin-only OC • If estrogen contraindicated or if breastfeeding o Reassure pt that early SEs typically resolve in a few cycles
(minipills) • Must take same time each day • Weight gain (14%) – may concern patient
Initial choice 1. Monophasic 20-25 µg EE + low androgen progestin o Take weight when start and at follow-up
2. Adjust dose/product based on side effects • Changes in bleeding patterns – breakthrough bleeding (32%) Spotting
o Often due to taking pills irregularly
CYCLE CONTROL:
• Critical factor whether new COC user continues contraception: SERIOUS SIDE EFFECTS: pts should seek medical attention immediately
Spotting Light bleeding, does not require pad • A – abdominal pain
Breakthrough bleeding (BTB) Requires sanitary pad
• C – chest or arm pain, SOB, coughing up blood
Amenorrhea Absence of pad
• H – headaches: severe, not relieved by acetaminophen/ibuprofen
• E – eye problems, blurred vision, flashing lights
• Contributing factors to BTB
• S – swelling, redness, or pain in legs DVT
Decreased BTB Increased BTB (and spotting)
• OC with ↑ estrogen and • Missed doses
ADVERSE EFFECTS OF COCs: generally subside after 4th cycle
↑ progestin potency • Smoking
• If estrogen-related effects, switch to lower dose
• Chlamydia (check if past good control)
• If progestin-related effects, switch to alternate product
DISCONTINUATION OF COCs: • If androgen-related effects (ex// acne, hirsutism), switch to COC
• Most women who D/C do so in first 2 months with less androgenicity
• Reason for discontinuation: • If headaches, switching product may help
o Side effects (46%) o Extended COC regimen may reduce menstrual headaches
o No longer desire contraception (23%) • Vaginal dryness may improve with using ↑ EE COC, ring or POP
o Too difficult, expensive, or unsafe (14%) • Chlorasma (darkening facial skin) is rare but may not disappear
Estrogen
o Another unspecific reason (17%)
• Of those who D/C, 42% do NOT consult MD or Rxist! LONG TERM SAFETY OF COCs: Gall stones
VTE • Any EE has a higher risk than no EE
MYTHS ABOUT COCs: • ↑ risk: smoking, BMI > 35, asthma, ill health, age
• COC should have periodic pill breaks: unnecessary & risks unintended pregnancy CV risk • Newer COCs with EE < 50 µg = ↓ risk stroke & MI
o Can be continued until no longer require contraception • Smoking + COCs at > 35 yrs of age = ↑↑ risk MI
• COC has negative effect on future fertility: fertility is quickly restored After 1-2 months • Severe HTN & atypical migraines = ↑ stroke
• COC cause birth defects if get pregnant on the drug: no evidence of this
o MotherRisk at The Hospital for Sick Kids monitors all birth defects EPILEPSY AND CONTRACEPTION:
• COC must be stopped in women over 35: healthy non-smoking women can • Enzyme-inducing drugs: ↑liver metabolism of COC = ↓ effectiveness
continue until 45, then reassess • Lamotrigine: non-enzyme inducing but CAN reduce hormone levels
• COC causes acne: consider switching high androgenic activity products • Non-enzyme inducing drugs: unlikely to impact drug effectiveness
 1st dose OC either on
- the day of menses (reduce the need for alternative means of contraception) or
- the first Sunday after beginning menses (should use extra contraception for first 7 days of OCs)
Lecture 8 Oral Contraceptives Soon

CONTRACEPTION FOR ADOLESCENTS: HORMONAL PATCH: Norelgestromin – Ethinyl Estradiol (Evra)

1. MD evaluation: wt, ht, BP, pulse, pregnancy test, gonorrhea + chlamydia tests Dose • 200 µg of norelgestromin + 35 µg EE daily
2. Quick Start approach: start contraception regardless of time in cycle on day of visit • If started on day other than first day menses, use
• LARC should be considered as first-choice agent back-up x 7 days
• Stress importance of condoms (in first cycle as backup) and with every new MOA • ↓ FSH + LH surge, thickens cervical mucus
partner for STI prevention How to • Apply to buttock, abdomen, outer arm weekly x 3,
3. Follow-up and side effect monitoring are important use then 1 week patch free
• Give info on what if miss dose AEs • ↑ breast tenderness, skin irritation
4. Encourage pt to contact pharmacists or MD before discontinuing contraception • Pregnancy rate: 9% (typical)
• Avoid use > 90 kg in weight
Benefits • Improved compliance
EXTENDED OR CONTINUOUS OCs:
• Original OCs imitated average 28-day cycle 21 days of active med + 7 days hormone-free
o Withdrawal bleeding induced by ↓ hormone levels HORMONAL VAGINAL RING: Etonogestrol – Ethinyl Estradiol (NuvaRing)
o Most critical time for accurate OC dosing is before or after hormone-free Dose • 120 µg of etonogestrol + 15 µg EE released daily
interval (HFI), or will risk ovulation MOA • ↓ FSH + LH surge, thickens cervical mucus
1個⽤⾜3星期再remove for 1 week
• Extended/continuous dosing may increase effectiveness How to • Self-insertion: in 3 weeks, remove 1 wk (backup wk 1)
o Extended use: 84 days OCs, 7 days inert pills
use • If expelled > 3 hrs, reinsert ASAP, use barrier x 7 days
(wk1), finish cycle and directly start next cycle (wk 2-3)
o Continuous use: continuous OCs until 7 days breakthrough bleeding, then
AEs • Nausea, vaginitis
3 days off, restart Take OCs with no break for a year or longer
• Pregnancy rate: 9% (typical)
BENEFITS OF EXTENDED USE OCs: • Avoid concurrent use with vaginal tampons
Women who will • Seizure disorders, menstrual headaches
especially benefit: • Dysmenorrhea, menorrhagia, endometriosis PROGESTIN-ONLY PILL (POP) “MINI PILL”: Take continuously without interruption
• Premenstrual dysphoric disorder Dose • POP (Micronor) = 0.35 mg norethindrone
Potential benefits • ↓ headaches, ↓ tiredness, ↓ bloating MOA • Alters cervical mucus, inhibits sperm motility and
• ↓ menstrual pain, ↓ days of bleeding overall penetration
Compared with • No change in satisfaction, compliance or safety Indication • Estrogen-free – often used by women who:
Does not inhibit prolactin binding to receptors, thus
standard 28-day cycles o
doses not decrease breast milk as estrogens do
Post-partum, breastfeeding, perimenopausal
o Migraines with aura
POTENTIAL RISKS OF EXTENDED USE: o Smokers over 35
• Potential hyperplasia of uterine lining o Systemic lupus erythematosus
o No known cases of hyperplasia on biopsy o Risk of VTE Does not increase thromboembolic risk
• Potential pregnancy because of amenorrhea • No STI protection
o Women with good compliance are at low risk AEs • Menstrual cycle disturbances, spotting, amenorrhea
o If missed pills, use OTC pregnancy test • Pregnancy rate: 9% (typical)
o COCs not teratogenic, so not harmful in early pregnancy o If becomes pregnant, up to 10% are ectopic
o If EC required, LNG preferred
• COCs have minimal effect on bone density or ovarian cancer so extended use is
How to • Can start immediately post-partum
low risk
use • No need for exams/tests prior to starting
• No hormone free period
MYTHS ABOUT EXTENDED USE: • Must take regularly w/in 3 hrs of same time each day
Taking extended or continuous OCs will …
• … affect my future fertility
LACTATIONAL AMENORRHEA METHOD (LAM):
• … cause more side effects
Exclusive • Start immediately until < 6 months post partum
• … cause a build-up of menstrual blood breast- • Nursing q4 hours during day, q6 hours at night
• … not provide good birth control feeding • No menstrual period
• … not be normal or “natural”, women should bleed every 28 days Benefits • No cost, no Rxist, immediate start, natural
Risks • Pregnancy rate: 2% (typical) = high failure rate
• Not reliable if irregular cycle
POST-PARTUM CONTRACEPTIVE CHOICES:
Contraceptive Choice Breastfeeding Not breastfeeding
Lactational amenorrhea Immediately < 6 months No CONTRACEPTION AFTER 40:
method (LAM) • Infertility rates lower than many might expect
Progesterone-only pill > 3 weeks > 3 weeks o Age 40 = 17% ; age 45 = 55% ; age 50 = 95%
DMPA injection > 6 weeks 5 days post-partum o Among women 40 – 49, 75% of pregnancies unplanned, and
LNG-IUD > 6 weeks > 6 weeks abortion rate increasing
Copper IUD > 6 weeks > 6 weeks • Gestational diabetes, pre-eclampsia, hypertension and birth defects
Combination OC (patch, ring) > 6 weeks (SOGC) 3 weeks (SOGC) more likely to complicate pregnancy
> 6 months (WHO) • Women may safely stop contraception after menopause if:
* research suggests immediate insertion of IUD (10 mins – 48 hrs) postpartum is o 12 months without a period over age 50
associated with a higher continuation rate compared to insertion at 6 wk post-partum o 24 months without a period under age 50

FAMILY PLANNING FOR OBESE WOMEN: obesity dramatically increases the hazards of ONE KEY QUESTION FOR PRIMARY CARE PROVIDERS TO ASK WOMEN:
pregnancy (ex// diabetes, hypertension, C-section) “Would you like to become pregnant in the next year?”
• YES: pre-conception counselling & screenings to ensure in optimal
OCs BMI > 32.2 higher risk of accidental pregnancy, higher risk of VTE health for a pregnancy
Evra patch Higher failure rate in obesity • NO: counselling on full range of contraception options to ensure
IUDs Challenging to insert, but highly effective
optimal method for their circumstances
Tubal ligation Effective but risk from anesthesia
• MAYBE: clinicians offer these women a combination of both services
Lecture 8 Oral Contraceptives Soon
4 QUESTIONS TO ENGAGE PATIENTS: SHARED DECISION MAKING IN CONTRACEPTIVE COUNSELLING:
1. How many children, if any, do you hope to have? • Query to identify preferences
2. How long would you like to wait until you become pregnant (again)? • Ask open-ended questions
3. What do you plan to do to delay becoming pregnant until then? • Provide information about SEs, effectiveness, and use of method
4. What can I do to help you achieve your plan? • Give context about options
• Ensure access to method placement and removal
“TEACH-BACK” METHOD OF COUNSELLING: • Allow time for questions

HOW PHARMACISTS CAN HELP IMPROVE REPRODUCTIVE HEALTH:

• Increase access to contraception
• Contraception information
• Evaluate consistency of use
• Encourage condom use to prevent STIs
• Advice and counselling
• Pregnancy testing
• Health promotion: folic acid, healthy lifestyles, information about
family planning services

RECOMMENDED ACTION AFTER LATE/MISSED COMBINED ORAL CONTRACEPTIVES:

If one hormonal pill is late
(< 24 hours)
If one hormonal pill has been missed • No additional contraceptive protection needed
(24 to < 48 hours)
If two or more consecutive
hormonal pills have been missed
(> 48 hrs)
• Take late or missed pill ASAP 第⼆⽇發現前⼀⽇漏咗⼀粒：第⼆⽇補返，總共食2粒
• Continue taking remaining pills at the usual time (even if it means taking 2 pills on the same day)
• Emergency contraception not usually needed but can be considered (except UPA) if OC pills were missed earlier in the
cycle or in the last week of the previous cycle
• Take the most recent missed pill ASAP (any other missed pills should be discarded)
• Continue taking the remaining pills at the usual time (even if it means taking two pills on the same day)
• Use back-up contraception (ex// condoms) or avoid sexual intercourse until hormonal pills have been taken for 7
consecutive days 連續⽤其他⽅法7⽇ week 3
• If pills were missed in the last week of hormonal pills (ex// days 15 – 21 for 28-day pill packs):
o Omit hormone-free interval by finishing the hormonal pills in the current pack & starting a new pack the next day
o Use back-up contraception (ex// condoms) or avoid sexual intercourse until hormonal pills from a new pack have
been taken for 7 consecutive days
• Emergency contraception should be considered (with the exception of UPA) if hormonal pills were missed during the first
week and unprotected sexual intercourse occurred in the previous 5 days
• Emergency contraception may also be considered (with the exception of UPA) at other times as appropriate
First gen: norethindrone acetate/ ethynodiol diacetate/ lynestrenol/ norethynodre
Second gen: levonorgestrel (androgenic)
Third gen: desogestrel/ gestodene/ norgestimate
Forth gen: cyproterone/ drospirenone

Hirsutism/ acne/
weight gain/ edema
Lecture 10 Emergency Contraception / Postcoital Contraception/ Plan B Soon
UNINTENDED PREGNANCY:
• Can occur from no contraceptive method used, incorrect use of contraceptive method, contraceptive failure or sexual assault
• Can have adverse social, psychological, and economic consequences if the mother is not ready for parenting
• About 50% of pregnancies are unintended, and of those, about 45% will result in an induced abortion
• EC is a “last chance to prevent unintended pregnancy after sex”

ORAL HORMONE EMERGENCY CONTRACEPTIVE OPTIONS: Given prior to LH surge to delay ovulation
ULIPRISTAL ACETATE (UPA): LEVONORGESTREL (LNG): Progestin
• UPA is a progesterone agonist/antagonist (related to mifepristone) 30 mg PO stat • LNG is a progesterone only agent given as a single 1.5 mg
• Given prior to LH peak, prevents follicular rupture, delays ovulation up to 6 days dose (preferred) or two 0.75 mg pills 12 hours apart
• Highly effective (60-70%) up to 5 days after UPSI and well-tolerated • When given prior to LH surge, prevents follicular rupture,
unprotected sexual
intercourse delays ovulation up to 2 days
NOTES: • Moderately effective (50%) up to 3 days after UPSI,
• UPA is anti-progestin and strongly binds to progesterone receptor  delay start then declines
of progesterone-containing hormonal contraception (ex// pills, patch, ring,
injection) for 5 days, or may ↓↓ UPA effectiveness NOTES:
o Use condoms x 14 days after UPA • Provide if progesterone containing OC were missed
• If ECP requested due to missed progesterone-containing HC, prescribe LNG as • LNG metabolized by CYP3A4, so inducers (ex// St. John’s
lingering progesterone may block UPA from delaying ovulation Wort) may ↓ LNG effectiveness
• Choose LNG if breastfeeding • Effectiveness may be reduced if BMI ≥ 30
• UPA metabolized by CYP3A4, so inducers (ex// St. John’s Wort) may ↓ UPA o Preferred choice = Cu-IUD or UPA
effectiveness • Contraception can start immediately, use condoms x 7 days

UPA VS. LNG: YUZPE REGIMEN: combined hormonal contraception

• Ovral (50 mcg ethinyl estradiol + 250 mcg LNG) was first ECP
(1977), now D/C
o LNG is the effective component, EE contributes to SEs
• Yuzpe regimen = 100 mcg ethinyl estradiol + 500 mcg LNG
• Yuzpe regimen is less effective (37-40%) with substantially
more nausea and vomiting than LNG or UPA
o Only recommended if UPA/LNG not available
o Use condoms x 7 days
• UPA is more effective than LNG at preventing or disrupting ovulation
• UPA works until just prior to LH peak; LNG works until just prior to the LH surge
CAUTIONS:
• UPA maintains effectiveness up to 5 days after UPSI, while effectiveness of LNG
Breastfeeding UPA not recommended for 1 week as
gradually declines past 3 days UPA excreted in breast milk; express
breast milk and discard
SIDE EFFECTS AND SAFETY: Obesity Limited evidence that LNG + UPA EC
Side effect UPA % LNG % YUZPE % may be less effective among obese
Nausea 12.8 11.2 50.5 women
Vomiting 1 1.4 18.8 * Severe CVD, migraine, Benefits of EC outweigh risks
Dizziness 5.2 4.9 16.7 severe liver disease
Menses occurred within 7 days of 76 71 77 CYP3A4 inducers Strong CYP3A4 inducers may reduce
expected time ** effectiveness of LNG + UPA ECs
Risk of taking EC if pregnant No risk to baby
* if vomit in < 1 hour, take another dose + antinauseant e.g. dimenhydrinate NOTE: only effective for single act of UPSI, subsequent UPSI will
** menstruation should occur within 21 days of refer/test Visit a doctor/ pregnancy test if not have higher risk of pregnancy

COPPER IUDs for EC:

HOW DOES A CU-IUD WORK FOR EC?
• Cu-IUD can be inserted up to 7 days after UPSI anytime during the menstrual cycle
provided that a pregnancy test is negative
• EC effectiveness is 99.99%
o Consider as a 1st choice option for all eligible women, when > 5 days since
UPSI, if BMI ≥ 35, and if suspect day of ovulation or after ovulation
• If Cu-IUD might not be inserted within 7 days, provide ECP
EFFECTIVENESS OF CU-IUD:
• 99.9% for EC w/in 7 d of UPSI; 99% for ongoing contraception
• Cu IUD T-shaped models with the largest total copper surface
area (i.e. 380 mm2 of copper) have the lowest failure rates
• A Cu-IUD inserted for EC can remain in place for ongoing
contraception for 3-10 years depending on model

SIDE EFFECTS OF COPPER IUDS:

• Bleeding irregularities: are common; NSAIDs can inhibit prostaglandin release and reduce menstrual blood loss and spotting
o Ibuprofen 400-800 mg BID-QID x 7-10 days beginning day of menses
• Copper allergy: clinically relevant allergic dermatitis rarely reported and resolves after IUD removed; pts will experience +ve patch test to copper
• Risks: PID is infrequent (< 1%), risk drops to baseline after first 20 days; risk of perforation lower with experienced clinician; expulsion rate 2-10% in 1st year
• Adolescents: pre-insertion counselling, pre-medication with ibuprofen, guidance on managing SEs will help with post-insertion pain and bleeding
• Women interested in ongoing LARC may benefit from switching from initial Cu-IUD for EC to an ongoing LNG IUD after first month