Contraceptive Methods Volume I Ana H. Corona, DNP, FNP-BC July 2013 Revised

Learning Objectives COURSE OBJECTIVE: The purpose of this course is to provide an overview of the historical, legal, social and cultural issues surrounding the practice of contraception/family planning; the factors involved in choosing and using contraception; and the advantages and disadvantages of various methods of contraception. Outline the personal and public health benefits of contraception/family planning. Identify the social and cultural issues involved in contraception/family planning. Discuss the trends and disparities in use of contraception. Identify populations of women at high risk of unintended pregnancy. Delineate the factors affecting use of contraception. List the advantages and disadvantages of available contraceptive methods.

Methods of Contraception Categories Fertility awareness Situational Spermicidal Barrier Long-acting reversible Shorter-term hormonal Permanent (sterilization) Clinical interruption of pregnancy (medical/surgical abortion) These methods demonstrate differing levels of effectiveness, side effects, cost, ease of use, and other advantages and disadvantages.

What are they? Prescription tablets taken once a day There are two main types: 1.Combination pill which contains two female hormones similar to the body’s own estrogen and progesterone 2.Progestin-only pill (or mini-pill) which does not contain estrogen (are more likely to cause breakthrough bleeding) Available under a variety of brand names with various strengths and formulations Failure rate: 80 per 1000 women per year O r a l c o n t r a c e p t i v e s

5 COCs: Mechanisms of Action Suppress ovulation Change endometrium making implantation less likely Thicken cervical mucus (preventing sperm penetration) Reduce sperm transport in upper genital tract (fallopian tubes)

Oral Contraceptives The estrogen compound used in most oral contraceptives is estradiol and is always used with a progestin. May cause fluid retention. Blood Pressure should be checked periodically Effects on Reproduction. When used throughout a menstrual cycle with progesterone: Estrogen changes the cellular structure of the endometrium and prevents implantation of a fertilized egg.

Progesterone A high level of progesterone is maintained which blocks the actions of LH (stimulates corpus luteum), and FSH and prevents ovulation. The result is that no new egg follicles are developed and no ovulation occurs. It changes the lining of the uterus and makes it more difficult for the fertilized egg to implant. Keeps the cervical mucus thick and sticky serves as barrier against entry of sperm into the uterus. Inhibiting sperm transport by reducing fallopian tube mobility.

8 Combined Oral Contraceptives Types Monophasic: All 21 active pills contain a fix dosage (same amount) of Estrogen & Progestin (E/P) throughout the cycle. Biphasic: 21 active pills contain 2 different E/P combinations (e.g., 10/11) Triphasic: 21 active pills contain 3 different E/P combinations (e.g., 6/5/10)

What are the advantages? 1. One of the most effective reversible birth control methods when taken consistently and reliably 2. Simple and easy to use 3. Regulates menstrual cycle and reduces cramps 4. Does not interfere with intercourse 5. Decreases acne 6. Reduces the risks of endometrial and ovarian cancer 7. May reduce perimenopausal symptoms

What are the Disadvantages? 1. Must be taken every day. The progestin-only pill must be taken at the same time every day 2. May cause irregular bleeding or spotting 3. Effectiveness may be reduced by other medications 4. Should not be used by women over the age of 35 who smoke 5. May increase the risk of thromboembolic disease In users of these oral contraceptives, particularly in women who have certain blood disorders or a family history of blood clots 6. Does not protect against STIs 7. May increase the number of headaches 8. May not be suitable for breastfeeding women

11 Who Can Use COCs Women: Of any reproductive age or parity who want highly effective protection against pregnancy Who are postpartum and are not breastfeeding (begin after third week) Who are postabortion (start immediately or within 7 days). Women with Anemia Irregular menstrual cycles Severe menstrual cramping

12 COCs: Who Should Not Use COCs should not be used if a woman: –Is pregnant (known or suspected) –Is breastfeeding (can take progestin only) –Is jaundiced (symptomatic viral hepatitis or cirrhosis) –Has ischemic heart disease or stroke (current or history of) –Has blood clotting disorders (deep vein thrombophlebitis or pulmonary embolus)

13 COCs: Who Should Not Use - continued COCs should not be used if a woman: –Is a smoker and age 35 years or older –Has diabetes (> 20 years duration) –Has headaches (migraine) –Has high blood pressure –Has breast cancer –Has liver tumors –Has to undergo major surgery with prolonged bed rest

14 COCs: Conditions Requiring Precautions COCs are not recommended unless other methods are not available or acceptable if a woman: –Is < 4 weeks postpartum (even if not breastfeeding) –Has unexplained vaginal bleeding (only if serious problem suspected) –Has high blood pressure –Has a history of breast cancer –Has symptomatic gall bladder disease –Is taking drugs for epilepsy (phenytoin or barbiturates) or tuberculosis (rifampin).

15 COCs: Conditions for Which There Are No Restrictions Age Diabetes (uncomplicated or < 20 years duration) Endometriosis Genital tract cancers (cervical, endometrial or ovarian) High blood pressure - mild hypertension Pregnancy-related benign jaundice (cholestasis) Trophoblastic disease (benign or malignant)

16 COCs: When to Start Anytime you can be reasonably sure the client is not pregnant Days 1B7 of the menstrual cycle Postpartum: –after 4 weeks if not breastfeeding Post-abortion (immediately or within 7 days)

17 COCs: Common Side Effects Amenorrhea High blood pressure Nausea/dizziness/vomiting Bleeding/spotting Acne Breast fullness or tenderness (mastalgia) Chest pain (especially if it occurs with exercise) Depression (mood change or loss of libido)

18 COCs: Client Instructions Take 1 pill each day, preferably at same time of day. Take first pill on first to seventh day (first day preferred) after beginning of your menstrual period. Some pill packs have 28 pills. Others have 21 pills. When 28-day pack is empty, immediately start taking pills from a new pack. When 21-day pack is empty, wait 7 days and begin taking pills from new pack.

19 COCs: Client Instructions If you forget to take 1 pill, take it as soon as you remember, even if it means taking 2 pills on 1 day. If you forget to take 2 or more pills, you should take 2 pills every day until you are back on schedule. Use a backup method (e.g., condoms) or do not have sex for 7 days. If you miss 2 or more menstrual periods, you should go to the clinic to check to see if you are pregnant.

ACHES Abdominal pain (severe) Chest pain (severe), cough, shortness of breath Headache (severe), dizziness, weakness, or numbness Eye problems (vision loss or blurring), speech problems Severe leg pain (calf or thigh)

Morning after pill Norgestrel and ethinyl estradiol are administered as soon after unprotected intercourse as possible and repeated 12 hrs after. Should be no longer than 72 hours after unprotected sexual intercourse Emergency Pill Plan B Levonorgestrel

Seasonale I tablet every day for 91 day regimen Women can predict having menstrual cycle every 3 months

What is it? It contains a hormone called progesterone; it does not contain estrogen The injection is given in the upper arm or buttocks every 12 to 13 weeks (every 3 months, four times a year) How does it work? Prevents the ovary from releasing an egg Thickens the cervical mucus making it difficult for sperm to get to the egg Changes the lining of the uterus making implantation difficult Failure rate: 30 per 1000 women per year I n j e c t a b l e c o n t r a c e p t i v e

1. One of the most effective reversible birth control methods available 2. Does not contain estrogen 3. No daily contraceptive routine required; 1 injection lasts for 3 months 4. Effectiveness is not reduced by other common medications 5. May be suitable for breastfeeding women or women who smoke 6. With continued use, menstrual cycles cease in over half of users after the first year, and two-thirds of users after two years of use 7. Improves symptoms of endometriosis 8. Reduces the risk of endometrial cancer 9. Effective immediately when given during the first 5 days of a normal menstrual period 10. it is inexpensive What are the advantages?

1. Initially, irregular bleeding is the most common side effect 2. Decrease in bone mineral density which may be reversible when a woman stops taking the injection. Calcium supplementation is advised. 3. May be associated with weight gain in some women 4. Takes an average of nine months after the last injection for the ovaries to start releasing eggs again 5. Does not protect against STIs 6. The lack of a monthly period may be bothersome for some women What are the Disadvantages?

Side-Effects of Hormonal Contraception During the 1 st few months on hormonal contraception: Irregular bleeding, spotting Nausea Mood swings Bloating Breast tenderness Headaches