Contraception

1. With all patients, especially adolescents, young men, postpartum women, and perimenopausal women, advise about adequate contraception when opportunities arise.

2. In patients using specific contraceptives, advise of specific factors that may reduce efficacy (e.g., delayed initiation of method, illness, medications, specific lubricants).

3. In aiding decision-making to ensure adequate contraception:

   1. Look for and identify risks (relative and absolute contraindications).

   2. Assess (look for) sexually transmitted disease exposure.

   3. Identify barriers to specific methods (e.g., cost, cultural concerns).

   4. Advise of efficacy and side effects, especially short-term side effects that may result in discontinuation.

4. In patients using hormonal contraceptives, manage side effects appropriately (i.e., recommend an appropriate length of trial, discuss estrogens in medroxyprogesterone acetate [Depo–Provera]).

5. In all patients, especially those using barrier methods or when efficacy of hormonal methods is decreased, advise about post-coital contraception.

6. In a patient who has had unprotected sex or a failure of the chosen contraceptive method, inform about time limits in post-coital contraception (emergency contraceptive pill, intrauterine device).

Prescribing contraception

• Start contraception if reasonably certain not pregnant

  • Pregnancy test >2w after last episode of unprotected intercourse

  • ≤7d after start of normal menses or spontaneous/induced abortion

  • No sex since start of last normal menses

  • Correctly, consistently using reliable contraception

  • 4w postpartum

  • Fully breastfeeding and <6 months postpartum

  • Back-up contraception for 7d if >7d after menses started

Special populations

• Postpartum, breastfeeding, smokers >35 years old

  • Consider progestin-only

• Medical comorbidities

  • Consider LARCs

• >50 years old

  • Consider progestin-only or non-hormonal method (consider avoiding estrogen)

    • After amenorrhea x 12 months

      • No need for contraception if using non-hormonal method and >50yo (if <50yo advised to wait 2 years)

      • Consider FSH x 2 (>6 weeks apart) if >30IU/L then contraception required for another 12 months

• >55 years old can discontinue contraception (even if menstrual cycles continue, spontaneous conception very unlikely)

Emergency contraception

• Copper IUD - failure rate of <1% (>95% effective)

  • Effective up to 5 days (limited evidence up to 7 days) after unprotected intercourse, provided pregnancy ruled out

• Hormonal/oral (less effective if BMI>30 or weight ≥80kg), side effects include headache, irregular bleeding , N/V

  • Ulipristal acetate 30mg PO x1 - failure rate of 1.4% (~75% effective)

    • Effective up to 5 days

    • Hormonal contraception can be initiated up to 5 days after unprotected sex with backup for first 14d

  • Levonorgestrel 1.5 mg PO x1 (or 0.75mg q12h x2) - failure rate of 2.2% (~50% effective)

    • Effective up to 72h (proven efficacy up to 96h, limited efficacy up to 120h)

    • Hormonal contraception can be initiated the day of (or after) with backup for first 7d

  • Combined OCP (Yuzpe) 100-120mcg ethinyl estradiol plus 500-600 mcg levonorgestrel (5 pills of Alesse) q12h x2 - least effective

    • Effective up to 72h

• Note: Approx. 5% risk of pregnancy if unprotected sex, but up to 30% if 1-2d prior to ovulation

• Only contraindications are pregnancy (and active pelvic infection/cervicitis for IUD)

Combined OCP

Efficacy

• Failure rate

  • Perfect-use 0.3%

  • Typical-use 9%

Formulations

• Mono vs multiphasic (no proven clinical advantage of multiphasic pills)

• Estrogen (ethinyl estradiol)

  • Standard 30mcg (Marvelon, Yasmin), 35mcg (Ortho 1/35)

  • Low 25mcg (Tri-Cyclen Lo), 20mcg (Alesse)

  • Very Low 10mcg (Lo Loestrin Fe)

• Progestins have both progestogenic and androgenic activity (newer selective progestins have no proven advantage and associated with possible higher risk of VTE)

  • First generation (Norethindrone acetate, Ethynodiol diacetate, Lynestrenol, Norethynodrel)

  • Second generation (dl-Norgestrel, Levonorgestrel)

  • Third generation (Desogestrel, Gestodene, Norgestimate)

  • Unclassified

    • Drosperinone

    • Cyproterone acetate (Diane) often prescribed for acne or hirsutism, but higher risk of VTE

• Shorter pill-free interval, continuous pill

  • Seasonale or Seasonique (91-day cycle)

  • Lybrel 20mcg ethinyl estradiol/levonorgestrel 0.09mg

  • Break-through bleeding occurs early cycles, but decreases over time

Contraindications to Estrogen

• Migraine with aura (≥5 min reversible visual/sensory/speech/motor symptom that is accompanied within 60 mins by a headache)

• Smoker age ≥35 years and smoking ≥15 cigarettes per day

• Uncontrolled hypertension (>160/100)

• Acute DVT/PE

• History of DVT/PE, not on anticogulation, with risk factor (history of estrogen-associated DVT/PE, pregnancy-associated DVT/PE, idiopathic DVT/PE, known thrombophilia including antiphospholipid syndrome/SLE, active cancer with the exception of non-melanoma skin cancer, history of recurrent DVT/PE)

• Current or history of vascular disease, ischemic heart disease, stroke, complicated valvular disease (pulmonary hypertension, risk of atrial fibrillation, history of subacute bacterial endocarditis)

• Liver disease (severe cirrhosis, hepatocellular adenoma, malignant hepatoma)

• <4 weeks postpartum or peripartum cardiomyopathy

• Major surgery with prolonged immobilization

• Complicated solid organ transplantation (graft failure, cardiac allograft vasculopathy)

• Active breast cancer

Note: Only contraindication to progestin-only pills is current breast cancer, relative contraindications include liver disease

Interactions with other medications

• Decreased effectiveness with anticonvulsants (phenytoin, phenobarbitol), antiretrovirals, rifampin (not other antibiotics)

Side effects

• Common in first three months, tend to improve with time

  • Nausea - Take pill at bedtime or with meal (consider lower estrogen)

  • Breast tenderness (consider lower estrogen)

  • Headache

  • Breakthrough bleeding (r/o smoking, noncompliance, cervical/uterine disease, pregnancy, consider increase estrogen)

  • No evidence of weight gain

• Consider Progestin-only for Hypertension

Non-Contraceptive Benefits/Risks

• Benefits

  • Cycle regulation, predictable bleeds

  • Decreased menstrual flow, anemia

  • Decreased acne, hirsutism

  • Decreased dysmenorrhea, premenstrual symptoms

  • Decreased perimenopausal symptoms

  • Decreased risk of fibroids, ovarian cyst

• Risks

  • VTE RR 2-3 (compared to pregnancy RR 6 and postpartum RR 115)

    • 10 / 10,000 woman-years (COC users) vs. 4-5 / 10,000 woman-years (non-users)

  • UNCLEAR risk of gallbladder disease, possible increase in symptomatic gallstones when used for 15 years

• Other

  • NOT associated with increased risk of MI or CVA if no risk factors

  • NOT associated with increased risk of major birth defects if taken before/during pregnancy

  • Cancer

    • Decreased ovarian, endometrial, colorectal cancer

    • Possible association with cervical cancer (causation not demonstrated)

    • Decreased risk of benign breast disease

    • Possible increase in breast cancer in current/recent COC users

      • 5 / 1000 COC-users vs. 4 / 1000 non-users will be diagnosed with breast cancer before 39 years-old

Follow-up

• Weight (BMI), BP

• Contraindications (Smoking, Migraines, Liver disease, Thromboembolic disease, Cardiovascular risk factors, Cancer)

  • Stop OCP at age 50yo, consider taper or switch to HRT if vasomotor symptoms

• STI screen

Missed Combined OCP

• If missed pill <24h in any week

  • Take most recent pill ASAP (even if it means two pills the same day) and continue taking remaining pills until end of pack

• If missed pills in first week

  • Take most recent pill ASAP (even if it means two pills the same day) and continue taking remaining pills until end of pack

  • Back up x 7d*

• If missed pills during second or third week

  • Take most recent pill ASAP (even if it means two pills the same day) and continue taking remaining pills until end of pack and start new cycle of OCP without a hormone-free interval

  • Back-up contraception if 3 or more consecutive doses/days of OCP missed

*if unprotected intercourse in last 5 days and not on active hormone x 7 consecutive days, there is a risk of ovulation and unintended pregnancy consider emergency contraception

Missed Progestin only pills

• >3h delay

  • Take most recent pill ASAP and continue taking remaining pills until end of pack

  • Back-up x 48h

  • If unprotected intercourse in last 5 days, EC recommended