Contraception

Oral Contraception

• Progestin- inhibit ovulation and thickens cervical mucus
• Estrogen- maintains endometrium and prevents unscheduled bleeding and inhibits follicular development.

1. Fixed combined dosaging- estrogen and progestin 3 weeks
2. Combination phasic (biaphasic, triphasic) 2 to 3 different amounts of E & P from 5 to 11 days. Idea is to lower total dose of steroid administrated without increasing incidence unscheduled bleeding.
3. Daily Progestin- progestin without estrogen once a day without steroid free interval.

All formulations made from synthetic steroids no natural estrogens or progestins.

Progestins- 19 nortesterone- resembled testosterone (some degree and and androdenic activity) two types- estranges and gonanes.

• Estranes- norethindrone, norethindrone acetate, and ethinyodiol diacetate
• Gonanes- greater progestional activity either dextro or levo (only levo active form) levonorgestrel and less androgenic forms of levo, desogestrel, norgestimate, and gestodene

C21 progestin- medroxyprogesterone acetate and megastol. Only used as injectable.

Estrogens- Ethinyl estradiol 3 methyl ether (mestranol)

• First generation OC formulations 50 ug or >
• Second generation OC 20-35 ug
• Third generation OC contains desogestrel, norgestimate and gestodene

Estrogen- progestin combinations the most effective OC that consistently inhibits midcyclic surge and thus prevents ovulation

Progestin- only don’t consistently inhibit ovulation must be taken the same time daily.

Estrogen causes nausea (CNS effect), breast tenderness, and fluid retention (doesn’t exceed 3-4 lbs) do not decreased sodium excretion. Minor changes decreased vitamin A, B-complex, and C. Higher doses greater than 50 ug estrogen depression and mood change by decreasing serotonin levels.

• Proteins (globulins) estrogen increase factor V, VIII, X,fibrinogen, thrombosis, and angiotension increased blood pressure. Progestins decrease SHBG. Formulations with less progestins cause increase in SHBG should be used in treating women with hyperandrogenism or PCO.

Progestins- androgenic properties, weight gain, acne, and nervousness.

*Healthy females > 35 years can use OCP’S till 50-55 years of age without doing TSH, weighing risks and benefits

*Chronic hypertension > 35 years progestin/IUD no increase in cardiovascular disease

* Chronic hypertension < 35 years well controlled OCP’s can be used.

*Lipid disorders

• Estrogen- decreases LDL, increases HDL and TG mildly but no increased risk of atherogenesis
• Progestins- increase LDL and decrease HDL and TG. Their net effect lipid increase.

*Smoking > 35 years- increase thromboebolism (MI/stroke twice risk)

• Diabetes- no affect, normal HbA1c

*Migraine (most common type headache tension not migraine)

• Without aura
• With aura- visul flickening, uncolored zigzag lines progressing laterally to perpherial field.

*Migraine < 35 years old, non smoker and no focal neurological signs OCP can be used.

*Breast cancer- used with mixed results. Benign fibrocystic and family history not a contraindication to use low dose.

*Fibroids- OCP’s do not increase growth but decrease bleeding and dysmenorrheal

*Post partum/breastfeeding- start 4 weeks PP non-breastfeeding mother (otherwise decrease milk production and caloric intake). Breastfeeding progestin only pill.

*Anticonvulsants decrease hepatic enzymes and decrease estrogen and progestin.

*Barbiturates, carbamezipine, Felbamate, Phenytoin, Topamax, Vigaboltin decrease steroid. (some clinicians may give dose > 50 ug estrogen or consider back up IUD/condoms

*Antibiotics- only refampin decreases steroids. Fucanazole does not actually increase steroids. Terazol vagina; insert no effect on nuva ring.

*Antiretrovirals- unknown

*SSRI- fluoxetine no affect. St John’s wort increases metabolism and breakthrough bleeding.

DMPA- should be continued only after 2 years if no other birth control adequate. DXA should not be considered because 12 months bone mineral returns to normal.

Miscellaneous:

• Estrogen increased in patch compared to OCP or vaginal ring
• Female with thromboembolism should not take OCP’s unless currently on anticoagulation
• Stopping OCP’s prior to surgery, may be reasonable but to be effective > 6 weeks, so weigh risk of pregnancy with risk of thromboembolism and surgery.
• Factor V-8 times risk DVT, Factor V and OCP’s 30 times the risk.
• Obesity with OCP’s increase thromboembolism consider progestins.
• Plan B no risk thromboembolism
• Mild lupus OCP can be used better progestin IUD
• Sickle cell DMPA no side affects
• OCP’s decrease ovarian and uterine cancer and decreases risk of PID.
• Increases breast and cervical cancer
• Progestin only pill > 3 hour delay with administration so backup method for 48 hours

Sterilization-minilap /CS/laparoscopy

• Parkland, spring clip, silastic, or falope ring

Essure- complications initial tubal patency

• Expulsion/misplacement device
• Failure to deplot and repeat use
• 3 months HSP if not confirmed repeat for 6 months with use of protection

Vasectomy- complication rate 1%- hematoma

• ?? sperm antibodies can cause prostate cancer > 20 years