Subdermal implant

>99% effective
up to 3 years
The implant

• Trade name: Nexplanon®

• Up to 3 years of protection
• 60 mcg etonorgestrel/day

• Implanted in upper arm

• 4cm flexible, plastic rod

• Pregnancy rate
• 0.1/ 100 women/year

• Mechanism of action
• Suppresses ovulation in most (if not all)
users
• Changes cervical mucus
• Thins lining of uterus
Bleeding Patterns During the First Two Years
with the Implant

Bleeding Patterns Definitions %*

Infrequent Less than three bleeding and/or 33.6
spotting episodes in 90 days
(excluding amenorrhea)

Amenorrhea No bleeding and/or spotting 22.2

in 90 days

Prolonged Any bleeding and/or spotting 17.7

episode lasting more than 14
days in 90 days

Frequent More than 5 bleeding and/or 6.7

spotting episodes in 90 days

* % = Percentage of 90-day intervals with this pattern

The implant should not be used in patients with…

Breast Cirrhosis/ liver Unexplained

cancer tumors/ active vaginal bleeding
liver disease
The implant insertion

• Insert any time in cycle as long as pregnancy can be ruled out

• Procedure is simple and quick
• Clinician injects numbing medicine into arm
• Slides rod under skin between bicep and tricep
Hormonal IUDs

• Trade name: Mirena® or Skyla®

• Up to 5 years of protection (Mirena) or 3 years
(Skyla)
• Releases 20 mcg LNG/day (Mirena) or 14 mcg
LNG/Day (Skyla)

• Pregnancy rate
• 0.2/100 women/year

• No long-term effect on fertility

• Mechanism of action:
• Thickens cervical mucus
• Suppresses endometrium
• Does not reliably suppress ovulation
Hormonal IUD:
Non-Contraceptive Benefits

• Improvement of heavy periods

• Improvement of painful periods

• No periods

• Treatment of fibroids and endometriosis

Hormonal IUD:
Potential side-effects and concerns

• Bleeding irregularities

• No period
• 20% at 1 year
• 50% at 5 years

• Expulsion rate
• 5% over 5 years

• Perforation
• Occurs in approximately 1 out of 1000 insertions
Non-hormonal IUD

• Trade name ParaGard®

• Up to 10 years of protection

• Pregnancy rate
• 0.8/ 100 women/year

• No long-term effect on fertility

• Mechanism of action:
• Increases copper ions, enzymes,
prostaglandins, and white blood cells in
uterine and tubal fluids
• Impairs sperm function and prevents
fertilization
Non-hormonal IUD:
Potential side-effects and concerns

• No systemic side effects

• Cramping/heavy bleeding
• most common in first 3 months
• manage with NSAIDs

• Expulsion rate:
• 2-10%

• Perforation
• Occurs in approximately 1 out of 1000 insertions
The copper IUD should not be used in patients with…

• Known/suspected • Postpartum or post-

pregnancy abortal infection in
past 3 months
• Unexplained vaginal
bleeding • Uterine
abnormalities that
• Active cervicitis interfere with
insertion
• Pelvic inflammatory
disease • Genital tract cancer
(PID) in past 3 months
Insertion of the IUD

• IUD insertion can be crampy

• Usually lasts <5 minutes
• Patient can take ibuprofen beforehand to
help

• Insert any time in cycle as long as pregnancy can be

ruled out
• Same-day insertion the standard
• No benefit to waiting until patient has
menses
• Making patient return for a second visit
creates unnecessary barriers
The birth control shot:
Non-Contraceptive Benefits

• Improvement of heavy periods

• Improvement of painful periods

• Improvement of endometriosis symptoms

• Minimal drug interactions

The birth control shot:
Potential side-effects and concerns

• 40 to 50% discontinuation • Weight gain

at 1 year
• Decrease in bone mineral
• Irregular bleeding density (BMD)
• Reversible after woman
• No periods stops using method
• 17% at one year of
use • Delayed return to fertility (7-
• 80% at 5 years of use 12 months)
The shot should not be used in patients with…

Breast Cirrhosis/ liver Unexplained

cancer tumors/ active vaginal bleeding
liver disease
The birth control shot: when to start

• Preferred method: “Quick Start”

• start immediately and use backup x 7 days

• Switch from another method→ start immediately

• If using Quick Start, woman should have

a repeat pregnancy test in 3 weeks
Combined hormonal contraceptives

• 3 methods:
Oral contraceptive pill
Contraceptive patch
Vaginal ring

• Contain estrogen and progestin

• Pregnancy rate 9/100 women/year

• Mechanism of action
• Thicken cervical mucus
• Suppress ovulation
Pill Patch and Ring: Non-contraceptive benefits

• Menstrual benefits: • Improvement of acne

• shorter, more regular
period • Prevention of functional
• lighter flow and ovarian cysts
decreased anemia
• Decreased risk of ovarian and
• less painful periods
endometrial cancers
• decreased number of
periods per year

• Treatment of endometriosis
Pill Patch and Ring: Side-effects and concerns

• Discontinuation: 11% in • Headaches

1st month, up to 50% 1st year
• Some studies show higher • Mood changes/decreased
discontinuation rates for sex drive
patch, lower for ring
• High blood pressure
• Breakthrough bleeding
• Weight gain
• Nausea

• Breast tenderness
These methods should not be used in women who…

• Smoker ≥35 years • Any migraine

headache
• Personal history of if ≥35 years
venous or arterial
thrombotic event • Hypertension
(DVT/PE-blood clot,
MI-heart attack, CVA- • Coronary artery
stroke) disease

• Complicated diabetes • Active liver disease

• Migraine with aura • Breast Cancer

Pill Patch and Ring: when to start

• Preferred method: “QuickStart”

• start immediately and use backup x 7 days
• may improve continuation

• Day 1 Start & Sunday start may put woman

at risk for unintended pregnancy

• Switch from another method

• Start immediately and backup method is not
necessary
Combined Oral Contraceptives

• Estrogen and progestin-containing pill that a woman

takes every day

• Typical use
• 21 days active pill, 7 days no/inactive pill

• 24 day regimens
• 24 days active pill, 4 days no/inactive pill

• Extended regimens and continuous use

• Take pill at same time every day for maximum

effectiveness
The Patch

• Trade name: Ortho Evra® Patch

• Estrogen and progestin-containing
adhesive that a woman wears on her
upper arm, lower abdomen,
buttocks or upper torso (excluding
breasts)
• Change patch 1 x week for 3 weeks,
then patch-free for 1 week
• Side effects:
detachment 2%
site reaction 20%
• Less effective in obese women
>198lbs
The Ring

• Trade name: NuvaRing®

• Estrogen and progestin-
containing flexible plastic ring a
woman inserts herself into her
vagina
• 21 days ring in, 7 days ring out
and then insert a new ring
• Extended regimens possible
• Effective in 24 hours
• Can remove for up to 3 hours
in a 24-hour time period
The birth control shot

• Depo-medroxyprogesterone acetate (DMPA), or

Depo- Provera

• Injected once every 12 weeks

• intramuscular injection: 150 mg
• subcutaneous injection: 104 mg

• Pregnancy rate
• 4/100 women/year

• Mechanism of action
• Primary mechanism: inhibits ovulation
• Thickens cervical mucus
• Thins lining of the uterus
The birth control shot:
Non-Contraceptive Benefits

• Improvement of heavy periods

• Improvement of painful periods

• Improvement of endometriosis symptoms

• Minimal drug interactions

Progestin-only pills

• Also known as the “mini-pill”

or POPs
• May be less effective than birth
control pill
• need for strict compliance
• “27-hour rule”
• No “pill-free interval” – active pill
taken every day
• Commonly used in breastfeeding
women
• Side effects
• irregular bleeding or no period at all
Barrier methods

• Offer protection against STIs

• Require motivated user: must use at every act of

intercourse

• Mechanism of action
• Do not contain hormones
• Physical barrier blocks sperm from entering the
uterus
Emergency contraception

• 3 types of emergency
contraception
-Oral levonorgestrel (Plan B®, Next
Choice®) – Available over-the-counter
for all ages
-Oral ulipristal (ellaOne®) –
Progesterone receptor blocker
-Copper IUD (ParaGard®) –
Most effective form of EC
• Use after unprotected
intercourse
or underprotected intercourse
• Up to 120 hours after
• Sooner is better
Emergency contraception:
Mechanism of action

• Prevents unintended pregnancy

• will not interrupt an established pregnancy

• Prevents or delays ovulation

• Ineffective after implantation

Emergency contraception: safety

• No reports of serious
complications/death

• Side effects with oral LNG:

• nausea 25%
• vomiting 10%
• irregular bleeding

• Repeated use appears safe

• Opportunity for contraceptive counseling

• No scheduled follow-up is required

• No evidence of birth defects