Page 502 - TNFlipTest

GY16 Gynecology
Contraception Toronto Notes 2019
Starting Hormonal Contraceptives
• thoroughhistoryandphysicalexam,includingbloodpressureandbreastexam
• canstartatanytimeduringcyclebutidealifwithin5dofLMP
• follow-upvisit6wkafterhormonalcontraceptivesprescribed
• pelvicexamnotrequiredasSTIscreeningcanbedonebyurineandpapsmearscreeningdoesnotstart
until >21 yr
Table 8. Combined Estrogen and Progestin Contraceptive Methods
Advantages
Highly effective
Reversible
Cycle regulation
Decreased dysmenorrhea and heavy menstrual bleeding (less anemia)
Decreased benign breast disease and ovarian cyst development
Decreased risk of ovarian and endometrial cancer Increased cervical mucus which may lower risk of STIs Decreased PMS symptoms
Improved acne
Osteoporosis protection (possibly)
Side Effects
Estrogen-related
Nausea
Breast changes (tenderness, enlargement) Fluid retention/bloating/edema
Weight gain (rare)
Migraine, headaches
Thromboembolic events
Liver adenoma (rare)
Breakthrough bleeding (low estradiol levels)
Progestin-related
Amenorrhea/breakthrough bleeding Headaches
Breast tenderness
Increased appetite
Decreased libido Mood changes HTN
Acne/oily skin* Hirsutism*
* Androgenic side effects may be minimized by prescribing formulations containing desogestrel, norgestimate, drospirenone, or cyproterone acetate
Table 9. Selected Examples of OCPs
Contraindications
Absolute
Known/suspected pregnancy
Undiagnosed abnormal vaginal bleeding
Prior thromboembolic events, thromboembolic disorders (Factor V Leiden mutation; protein C or S, or antithrombin III deficiency), active thrombophlebitis
Cerebrovascular or coronary artery disease
Estrogen-dependent tumours (breast, uterus)
Impaired liver function associated with acute liver disease
Congenital hypertriglyceridemia
Smoker age >35 yr
Migraines with focal neurological symptoms (excluding aura)
Uncontrolled HTN
Relative
Migraines (non-focal with aura <1 h) DM complicated by vascular disease SLE
Controlled HTN
Hyperlipidemia Sickle cell anemia Gallbladder disease
Drug Interactions/Risks
Rifampin, phenobarbital, phenytoin, griseofulvin, primidone, and St. John’s wort can decrease efficacy, requiring use of back-up method
No evidence of fetal abnormalities if conceived on OCP
No evidence that OCP is harmful to nursing infant but may decrease milk production; not recommended until 6 wk postpartum in BF and non-BF moms, ideally ≥3 mo postpartum ifBF
Irregular breakthrough bleeding often occurs in the first few months after starting OCP; usually resolves after three cycles
Progestin only contraceptives must be taken at the same time every day
Missed Combined OCPs Miss1pillin<24h
• Take 1 pill ASAP, and the next pill at the
usual time
Miss≥1pillinarowin1stwk
• Take 1 pill ASAP, and continue taking one
pill daily until the end of the pack
• Use back-up contraception for 7 d; EPC
may be necessary
Miss <3 pills in 2nd or 3rd wk of cycle
• Take 1 pill ASAP, and continue taking one pill daily until the end of the pack
• Do not take placebo (28-d packs) or do not take a hormone free interval (21-d packs)
• Start the next pack immediately after finishing the previous one
• No need for back-up contraception
Miss ≥3 pills during the 2nd or 3rd wk
• Take 1 pill ASAP, and continue taking one
pill daily until the end of the pack
• Don’t take placebo (28-d packs) or do not take a hormone free interval (21-d packs)
• Start the next pack immediately after finishing the previous one
• Use back-up contraception for 7 d; EPC may be necessary
SOGC Committee Opinion on Missed Hormonal Contraceptives: New Recommendations.
JOGC 2008;30:1050-1062. http://www.sogc.org/ guidelines/documents/gui219ECO0811.pdf
Type
Alesse®
Tri-cyclen®
Yasmin® and Yaz®
Active Compounds (estriol and progestin derivative)
20 μg ethinyl estradiol and 0.5 mg levonorgestrel
35 μg ethinyl estradiol and 0.180/0.215/0.250 mg norgestimate Triphasic oral contraceptive (graduated levels of progesterone)
Yasmin®: 30 μg ethinyl estradiol
+ 3 mg drospirenone (a new progestin) Yaz®: 20 μg ethinyl estradiol + 3 mg drospirenone – 24/4-d pill (4 d pill free interval)
Drospirenone has antimineralocorticoid activity and antiandrogenic effects
Advantages
Low dose (20 μg) OCP Less estrogen side effects
Low androgenic activity can help with acne
Decreased perception of cyclic weight gain/bloating
Fewer PMS symptoms Improved acne
Disadvantages
Low-dose pills can often result in breakthrough bleeding
If this persists for longer than
3 mo, patient should be switched to an OCP with higher estrogen content
Triphasic OCPs not ideal for continuous use >3 weeks in a row (unlike monophasic formulation)
Hyperkalemia (rare, contraindicated in renal and adrenal insufficiency)
Check potassium if patient also on ACEI, ARB, K+-sparing diuretic, heparin Continue use of spironolactone
PROGESTIN-ONLY METHOD
Table 10. Progestin Only Contraceptive Methods
Indications
Suitable for postpartum women (does not affect breast milk supply)
Women with contraindications to combined OCP (e.g. thromboembolic or myocardial disease) Women intolerant of estrogenic side effects of combined OCPs
Mechanism of Action
Progestin prevents LH surge Thickening of cervical mucus
Decrease tubal motility
Endometrial decidualization
Ovulation suppression – oral progestins (not IM) do not consistently suppress compared to combined OCPs
Side Effects
Irregular menstrual bleeding Weight gain
Headache
Breast tenderness
Mood changes Functional ovarian cysts Acne/oily skin Hirsutism
Contraindications
Absolute
None