Progestin-Only Contraceptives Quiz

Reversible Contraception

• Jill Brown, MD MPH MHS FACOG, CAPT (R) USPHS, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University presented on reversible contraception.

Objectives

• Describe the mechanism of action of contraceptive methods
• Discuss effectiveness, risks, and benefits of reversible contraceptive methods
• Describe barriers to initiation and maintenance of different contraceptive methods
• Familiarize with approach to non-directive counseling

Mechanisms of Action

• All contraceptives prevent fertilization
• Incapacitates Sperm:
  • Copper IUD
• Prevents Ovulation:
  • Hormonal Contraceptives (Combined)
    • Combined Oral Contraceptives (COCs)
    • Emergency Contraceptive Pills
    • Combined Hormonal Vaginal Rings
  • Hormonal Contraceptives (Progestin-only)*
    • Implants
    • Injectables
    • Progestin-only Pills (POPs)
    • Progestin-only Vaginal Rings
  • Lactation Amenorrhea Method (LAM)
• • Progestin-only hormonal methods have more than one mechanism of action.
• Thickens Cervical Mucus:
  • Hormonal Contraceptives (Progestin-only)*
  • Hormonal IUDs
  • Implants
  • Injectables
  • Progestin-only Pills (POPs)
  • Progestin-only Vaginal Rings
• Blocks Sperm
  • Male Condoms
  • Female Condoms

Hormonal Contraception Mechanisms

• The presentation discussed the hormonal cycles, specifically the follicular and luteal phases, FSH, LH release, and follicle development.
• Estrogen and Progesterone play critical roles in the ovarian cycle and uterine cycle, leading to ovulation and preparation for implantation.
• Progesterone inhibits mid-cycle LH release and ovulation.

Comparing Contraceptive Methods

• Effectiveness is tiered, with implants and vasectomy as the most effective, and condoms and withdrawal as less effective
• Methods with higher effectiveness have lower pregnancy rates per 100 users in one year (Pearl Index).

IUD Considerations

• Screen for GC/CT before or at placement if screening is not current or risk factors are present.
• Do not delay insertion for results; can treat if comes back positive.
• Development of Pelvic Inflammatory Disease (PID)
• Treat PID and leave IUD in place
• Consider IUD removal if not improving
• Pregnancy
• Ectopic - IUD can generally be left in place
• Intraueterine IUD should be removed.

LARCS-Copper IUD

• Non-hormonal
• Primary mechanism prevents sperm from fertilizing the egg; foreign body effect of plastic frame and copper are toxic to sperm.
• 99% effective
• Lasts 10-12 years
• Heavier bleeding and cramping common first 3-6 months, decreasing with use.

LARCS - Hormonal IUDs (Levonorgestrel)

• Progestin only; mainly local effect on uterus
• Mechanism of action: primarily prevent fertilization; foreign body effect from plastic frame and hormonal effect -> thicken cervical mucus, suppress endometrium.
• 99% effective
• Lighter, shorter periods, or amenorrhea
• Irregular spotting common first 3-6 months.

Hormonal IUDs Types

Numerous types of hormonal IUDs, differing in duration of use and total progestin, initial progestin/day release, length of progestin, device diameter, and amenorrhea rates after one year.

Nexplanon (Etonogestrel Implant)

• Progestin only
• Mechanism of action: primary = inhibit ovulation, secondary = inhibit fertilization by causing changes in cervical mucus and tubal motility unfavorable to sperm.
• 99% effective
• FDA approved for 3 years; data showing effectiveness for up to 5 years; placed inner upper arm, no pelvic exam needed.

Depo-Provera (Depot-Medroxyprogesterone Acetate)

• Progestin only
• Mechanism of action: primary = inhibit ovulation, secondary = inhibit fertilization by causing changes in cervical mucus and tubal motility unfavorable to sperm, given by injection
• IM 150mg (upper arm or buttock)
• SUBQ 104mg (anterior thigh or abdomen)
• Discrete, safe, effective (99% perfect use, 94% typical use)
• Requires office visit
• Non-contraceptive benefits (protection from ovarian cancer, endometrial cancer, salpingitis, ectopic pregnancy, benign breast disease, acne, and iron deficiency)
• Side effects: menstrual irregularities (irregular bleeding; ~8% discontinuation); weight gain; delay in return to fertility up to 18 months (median 10 months); bone mineral density decreased.

Depo and Bone Mineral Density

• Greatest loss in first 1-2 years of use, then plateaus.
• DMPA does not reduce peak bone mass or increase osteoporotic fracture risk later in life.
• Skeletal health concerns should not limit duration of use of DMPA.

Combined Hormonal Contraceptives (CHCs)

• Pill, patch, ring
• Estrogen and progestin - many different formulations
• 20 to 35 mcg of ethinyl estradiol most common
• Individual progestin potencies, androgenicity, and side effects vary
• Perfect use failure 0.3%, typical use 7%

Progestin Classification

• Various progestin types with differing potencies, androgenic effects, and generations.

Progestin and VTE Risk

• Various progestin types and their risk of venous thromboembolism (VTE).

CHCs (cont.)

• Degree of androgenic differences between different formulations is not clinically significant.
• Multiphasic dosing is introduced to provide lower hormone dosage earlier in the month but doesn't provide a significant advantage over monophasic dosing.
• Can use cyclically or continuously.
• Mechanisms of action to inhibit ovulation, suppress FSH and LH, and affect cervical mucus

Transdermal Patch

• Xulane (ethinyl estradiol and norelgestromin - EE/N) or Twirla (ethinyl estradiol and levonorgestrel - EE/LNG)
• Weekly application
• Application site issues may occur; average EE concentrations are higher in patch users than in pill users.
• Risk of VTE may be present in some formulations, and risk increases with BMI > 30.

Vaginal Ring

• Nuvaring (etonogestrel/ethinyl estradiol ring); and
• Annovera
• Reusable over time; Can stay in place during intercourse
• Unplanned removal may require backup contraceptive method.

Postpartum Contraception

• Ability to ovulate as soon as four weeks following delivery; unlikely to ovulate for first six months if breastfeeding
• Timing of initiation important, breastfeeding, birth spacing
• Non-estrogen-containing contraceptive methods can be started promptly post delivery
• Delay in CHC start varies by expert committee guidance (6 weeks, some later)
• IUD expulsion rate higher immediately postpartum.

Progestin-only Pills (POPs)

• Norethindrone (0.35mg) and drosperinone (4mg)
• Actions include thickening cervical mucus, suppressing ovulation, suppressing FSH and LH, and thinning endometrium.
• Norethindrone POPs don't consistently suppress ovulation; drosperinone does
• POPs have short half-life; it is critical to take them at the same time each day.
• Missed doses require taking the missed pill immediately and using backup for 2 days until regular schedule resumes

POPs (cont.)

• Doses missed if more than 3 hours late should be addressed with immediate administration and backup to time.

Pericoital Contraception (Condons, Diaphragm, Cervical Cap, Sponge, Phexxi)

• Nonhormonal reversible methods used at the time of intercourse
• Condoms, diaphragms, cervical caps, sponges, and Phexxi are considered barrier contraceptives.
• Use with spermicide can further reduce risk of cervical and upper genital infection.
• Failure rates are higher than for hormonal methods and IUDs.

Phexxi

• Vaginal pH regulator gel
• Maintain lower vaginal pH to immobilize sperm
• Single-use applicators
• Pearl Index 27.5 pregnancies per 100 users per year.

Fertility Awareness Methods

• Avoid intercourse during the fertile period (5 days before ovulation to 24 hours after);
• Standard Days, Cervical mucus, TwoDay method, Billings/Creighton
• Symptothermal method: monitor cervical mucus and basal body temperature.

Natural Cycles App

• FDA-cleared app that calculates fertile days based on daily body temperature readings.

Fertility Awareness (cont.)

• Main advantage is lack of side effects.
• Relative contraindications include irregular cycles, pregnancy interruption of cycle, inability to track physiological changes, and lacking support.

Withdrawal

• Commonly used, either as sole method or in combination.
• No cost and no side effects.
• Less effective than other methods.

Emergency Contraception (EC)

• IUD: Most effective, not impacted by BMI; can use either copper or LNG 52mg; visit required for insertion, Provides ongoing contraception; no backup needed
• Medication: Less effective than IUD; Can use up to 120 hrs; Requires Rx; Must wait 5 days before starting hormonal BC; Can use up to 72 hrs; Available OTC in many places; Can start hormonal BC at same time.

Emergency Contraception (cont.)

• Copper or LNG-containing IUDs prevent implantation of the egg if fertilization has occurred.
• UPA (progesterone receptor modulator) lowers LH levels to prevent ovulation.

How do we talk about contraception?

• Listing all methods; Promoting certain methods

Limitations

• Listing all methods may not elicit patients' goals and preferences
• Promoting certain methods may be based on healthcare provider preferences or assumptions.

Patient-Centered Contraceptive Counseling

• Full range of options
• Patient preferences
• Maximize access

Additional Notes

• The slides presented various contraceptive methods with their pros and cons, mechanisms of action, and considerations.
• Important factors like patient preferences, side effects, and effectiveness should be discussed and considered when counselling patients.