Reversible Contraception Methods

Objectives of Reversible Contraception

• 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 approaches to non-directive counseling

Contraceptive Mechanisms

• All contraceptives prevent sperm from fertilizing the egg

• Copper IUDs incapacitate sperm:

• Hormonal methods prevent ovulation:

• Combined hormonal contraceptives include:

  • Combined Oral Contraceptives (COCs)
  • Emergency Contraceptive Pills
  • Combined Hormonal Vaginal Rings

• Progestin-only hormonal contraceptives include:

  • Implants
  • Injectables
  • Progestin-only Pills (POPs)
  • Progestin-only Vaginal Rings
  • Lactation Amenorrhea Method (LAM)

• Progestin-only hormonal methods often have more than one mechanism of action

• Hormonal contraceptives can thicken cervical mucus

• Hormonal IUDs can thicken cervical mucus

• Condoms block sperm

Hormonal Contraception Mechanisms

• Hormonal contraception inhibits GnRH release in the hypothalamus
• FSH release is then inhibited in the anterior pituitary
• Follicle development is stunted
• Ovulation is inhibited and passage of ovum is prevented in the ovary
• Cervial mucus is thickened
• The endometrium is unfavorable for implantation

Contraceptive Effectiveness

• Tier 1 contraceptives have less than 1 pregnancy per 100 users in one year
• Tier 1 options: implant, vasectomy, tubal occlusion, IUD
• Injectables, pills, patches and rings have 4-7 pregnancies per 100 users in one year
• Tier 3: male condoms, fertility awareness-based methods
• Tier 3: diaphragm, cervical cap, sponge, withdrawal, female condom, spermicides result in more than 13 pregnancies per 100 users annually

Method Effectiveness Strategies

• Vasectomy: Use another method for 3 months after procedure
• Injectables: Get repeat injections on time
• Pills: Take a pill each day
• Patch, ring: Keep in place, change on time
• Condoms, cervical cap, withdrawal, spermicides, diaphragm: Use correctly every time
• Fertility awareness-based methods: Abstain or use condoms on fertile days
• Newer fertility awareness methods (Standard Days, Natural Cycles, and Symptothermal): May be easier and more effective

Contraception Initiation

• Can start at any time, provided patient is not pregnant
• Start if < 7 days from normal LMP
• Start with no intercourse since start of LMP
• Start if correctly/consistently using reliable method of contraception (including condoms)
• Start if < 7 days after spontaneous or induced abortion
• Start within 4 weeks postpartum
• Start if > 85% feeds breastfeeds, is amenorrheic, and < 6 months postpartum
• CHCs, POPs, implant require backup for 7 days if > 5 days since LMP
• Depo, hormonal IUD require backup for 7 days if > 7 days since LMP
• Copper IUD requires no backup

LARC Contraindications

• LARCs (IUDs) are contraindicated in cases of distorted uterine cavity
• LARCs (IUDs) are contraindicated in cases of active pelvic infection
• LARCs (IUDs) are contraindicated in cases of known or suspected pregnancy
• LARCs (IUDs) are contraindicated in cases of unexplained vaginal bleeding
• Hormonal IUDs are contraindicated in cases of breast cancer
• Copper IUDs are contraindicated in cases of Wilson's disease or copper allergy

Copper IUDs

• Copper IUDs are non-hormonal
• Copper IUDs’ mechanism of action prevents sperm from fertilizing egg; foreign body effect of plastic frame and copper are toxic to sperm
• Copper IUDs are 99% effective
• Copper IUDs last 10-12 years
• Copper IUDs require medical visit/procedure for insertion and removal
• Copper IUDs often cause heavier bleeding and cramping common first 3-6 months
• Short course of NSAIDs or tranexamic acid can offer relief

Hormonal IUDs

• Hormonal IUDs use progestin
• Hormonal IUD has mainly local effect on uterus
• Hormonal IUD's mechanism of action prevents fertilization, foreign body effect from plastic frame and hormonal effect that thickens cervical mucus and suppresses endometrium
• Hormonal IUDs are 99% effective
• Hormonal IUDs require medical visit/procedure for insertion and removal
• Hormonal IUDs lead to lighter, shorter periods, or amenorrhea
• Hormonal IUDs can cause irregular spotting during first 3-6 months

Types of Hormonal IUDs

• Skyla lasts 3 years, contains 13.5mg progestin, initial progestin release of 14mcg/day, end of use progestin release of 5mcg/day, 3.8mm insertion device diameter, 6-12% amenorrhea rate after 1 year
• Kyleena lasts 5 years, contains 19.5mg progestin, initial progestin release of 17.5mcg/day, end of use progestin release of 7.4mcg/day, 3.8mm insertion device diameter, 12-20% amenorrhea rate after 1 year
• Liletta lasts 8 years, contains 52mg progestin, initial progestin release of 20mcg/day, end of use progestin release of 8.6mcg/day, 4.4mm insertion device diameter, 20-40% amenorrhea rate after 1 year
• Mirena lasts 8 years, contains 52mg progestin, initial progestin release of 20mcg/day, end of use progestin release of 10mcg/day, 4.4mm insertion device diameter, 20-40% amenorrhea rate after 1 year

IUD Considerations

• Screen for GC/CT before or at placement if risks are present
• Do not delay insertion for results, and treatment available if positive
• Development of Pelvic Inflammatory Disease (PID) is possible
• Treat PID and leave IUD in place
• Consider IUD removal if not improving
• If pregnancy occurs, be aware that:
  • An ectopic pregnancies with normally placed IUDs can be left in place
  • An intrauterine pregnancy requires the IUD to be removed

Nexplanon

• Nexplanon is progestin only
• Nexplanon's primary mechanism is inhibiting ovulation, secondary mechanism is preventing fertilization by changing cervical mucus and tubal motility
• Nexplanon is 99% effective
• Nexplanon is FDA approved for 3 years; data shows equal effectiveness up to 5 years of use
• Nexplanon: No pelvic exam requires for insertion; placed inner upper arm

Nexplanon Bleeding Patterns

• Common changes in bleeding patterns includes 22% amenorrhea
• Common changes in bleeding patterns includes 34% infrequent bleeding
• Common changes in bleeding patterns includes 18% prolonged bleeding
• Common changes in bleeding patterns includes 7% frequent bleeding
• 15% discontinuation due to unscheduled bleeding
• A favorable bleeding pattern in first 3 months predicts continued favorable pattern
• Unfavorable pattern has 50% chance of improving
• If no other issue and patient wants to try treatment:
  • NSAIDs x 5-10 days can be prescribed
  • Low-dose OCPs cyclically for 1-6 months can be prescribed
  • Oral conjugated estrogen 1.25mg or estradiol 2mg x 7 days can be prescribed

Depo Provera

• Depo Provera is progestin only
• Primary mechanism of action: inhibit ovulation
• Secondary mechanism of action: inhibit fertilization by changing cervical mucus and tubal motility that are unfavorable to sperm
• Is given by injection every 3 months
• IM 150mg (upper arm or buttock)
• SUBQ 104mg (anterior thigh or abdomen)
• Discrete, safe, effective (99% perfect use, 94% typical use)
• Requires office visit

Depo Side Effects and Benefits

• Noncontraceptive benefits include protection against ovarian cancer, endometrial cancer, salpingitis, ectopic pregnancy, benign breast disease, acne, and iron deficiency
• Side effects:
  • Menstrual irregularities (irregular bleeding common first few months, ~8% discontinuation due to bleeding, 50-75% amenorrhea at one year)
  • Weight gain (mean <2 kg at 1 year)
  • Delay in return to fertility (median 10 months, can last up to 18 months)
  • Decreased bone mineral density
• Greatest bone mineral density loss is 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 (ACOG, WHO)

Combined Hormonal Contraceptives (CHCs)

• CHCs include pill, patch, and ring
• Contain estrogen and progestin in many different formulations
• 20 to 35 mcg of ethinyl estradiol most common
• Progestins vary in potency, androgenicity, and side effects
• Perfect use failure rate 0.3%, typical use rate 7%

Progestin Classifications

• 17α-Hydroxyprogesterone derivatives (pregnanes)
  • Low potency
  • No androgenic effect
  • Examples: Medroxyprogesterone acetate, megestrol acetate, chlormadinone acetate, cyproterone acetate
• 19-Norprogesterone derivatives
  • Norpregnanes
    • Low potency
    • Example: Demegestone, promegestone, nesterone, trimegestone
  • Estranes - 1st Generation
    • Example: Norethisterone = norethindrone, norethisterone acetate, lynestrenol, ethinodiol acetate, norethinodrel
  • Gonanes - 2nd Generation
    • High potency
    • Androgenic action
    • Examples: Norgestrel, levonorgestrel
  • Gonanes - 3rd generation
    • High potency
    • Less androgenic
    • Examples: Desogestrel, etenogestrel, gestodene, norgestimate, dienogest.
• Spirolactone derivative
  • 4th generation
  • High potency
  • Antimineralocorticoid action
  • Example: Drospirenone

Progestins and VTE Risk

• Higher rate ratio of thrombosis is seen in users of desogestrel and gestodene

CHCs Continued

• Degree of androgenic differences between different formulations not clinically significant
• Multiphasic dosing (differing hormone dosage throughout month) introduced to provide lower hormone dosage earlier in month
• No advantage over monophasic (same dosage throughout month)
• Can use cyclically or continuously

CHCs - Mechanism & Benefits

• Mechanism of action: inhibit ovulation by suppressing GnRH, LH, FSH
• FSH suppression by estrogen most important (prevents follicular development)
• Non-contraceptive benefits include menstrual regulation and decreased bleeding/cramping
• CHCs can treat acne and PMS
• CHCs reduce ovarian cysts, decrease risk ovarian and endometrial cancer
• Increased risk thromboembolism (mainly due to estrogen)

CHC Patches

• Xulane (ethinyl estradiol and norelgestromin – EE/N) or Twirla (ethinyl estradiol and levonorgestrel - EE/LNG) are examples
• Patch is applied to skin (buttock, upper arm, lower abdomen; not on breast) weekly x 3 weeks; can take 4th week off for withdrawal bleed
• Application site issue 17% EE/N; 3% EE/LNG
• Average ethinyl estradiol (EE) concentration in EE/N patch users 60 percent higher than 35 mcg EE pill users
• May be modest increased risk VTE compared to low-dose OCP users
• Xulane label contraindicates use for users with BMI > 30 due to VTE risk
• Twirla less effective with BMI > 30

Vaginal Rings

• Options include Nuvaring (etonogestrel/ethinyl estradiol ring); and Annovera (segesterone acetate/ethinyl estradiol ring)
• Both used for 3 weeks (left in vagina) and removed for one week for withdrawal bleed
• Nuvaring changes to new ring, Annovera reusable x 13 months
• Can stay in place during intercourse or with tampon use
• Unplanned removal/expulsion can occur If < 48 hours -> reinsert ring asap, no additional steps
• If > 48 hours -> reinsert ring asap, use backup for 7 days
• Associated with increased vaginal discharge

Postpartum Contraception

• Can ovulate as soon as 4 weeks after delivery
• Unlikely to ovulate for first 6 months if > 85% feeds breastfeeds (lactational amenorrhea)
• Timing of initiation, breastfeeding, birth spacing are key considerations
• All non-estrogen containing methods can be started immediately
• CHC should start no sooner than 21 days postpartum (VTE risk)
• WHO advises delaying CHC x 6 weeks if breastfeeding (CDC ok after 30 days) due to potential effects on breastfeeding performance
• IUD expulsion rate higher immediately postpartum (10-40%)
• Odds of using IUD 6 months postpartum 2X higher for postplacental IUD vs interval insertion

Progestin-Only Pills

• POPs include Norethindrone (0.35mg) and drosperinone (4mg)
• POP's mechanism of action: multiple effects to thicken cervical mucus to inhibit sperm migration, suppress ovulation, lower midcycle FSH and LH peaks, slow movement of an egg through the fallopian tubes, and thin the endometrium
• Norethindrone POPs do not consistently suppress ovulation (50%); drosperinone decreases ovulation
• Because norethindrone has short duration of action and short half-life (norethindrone T₁/₂ 7.7 h; drosperinone 30 h)
• Must be taken at the same time each day to maximize contraceptive efficacy
• Dose considered missed if > 3 hours since should have been taken
• If missed, take pill asap and use back up until pills have been taken correctly, on time, for 2 days; consider EC if unprotected intercourse
• Drosperinone users can follow same instructions for missed pills as COC users

Pericoital Contraception

• Nonhormonal reversible methods used at time of intercourse
• Condoms = true barrier contraceptives
• Condoms prevent lower genital-tract infections and HIV transmission
• Diaphragm and cervical cap must be used with spermicide
• Diaphragm and cervical cap may decrease risk of cervical and upper genital tract infection
• Diaphragm comes in different sizes
• Diaphragm: 70mm fits most users, Caya diaphragm = single size
• Cervical cap comes in 3 sizes based on parity
• Safe, user controlled
• Failure rates higher than for hormonal methods and IUDs (typical failure 13% for condoms, ~20% for other methods)

Phexxi

• Phexxi is lactic acid-citric acid-potassium bitartrate
• Vaginal pH regulator gel; 5g pre-filled applicator inserted vaginally no more than 1 hour before intercourse; dosing repeated with each sexual act
• Maintains lower vaginal pH to immobilize sperm
• Pearl index 27.5 pregnancies per 100 users per year
• 20% report vulvovaginal burning, 11% itching

Fertility Awareness Methods

• Avoid unprotected intercourse during fertile period (five days before ovulation to 24 hours after)
• Standard days: avoid unprotected intercourse days 8-19 of cycle
• Cervical mucus/ovulation method: evaluate CM to determine whether the day is potentially fertile
  • TwoDay Method: avoid intercourse on all days when secretions noted + following day
  • Billings/Creighton methods: user observes cervical secretions; avoid intercourse on days with wet, slippery, transparent, or stretchy secretions and 4 days after

Fertility Awareness (Symptothermal)

• Evaluate cervical mucus several times per day
• Take temperature by measuring basal body temperature [BBT]
• Take temperature with thermometer upon waking
• Avoid intercourse until 3 days of higher temperatures have followed at least 6 days of lower temperatures
• Avoid intercourse until 4th day after the last day with wet secretions

Natural Cycles App

• FDA cleared
• Algorithm calculates days of the month user will be fertile based on daily body temperature readings and menstrual cycle information
• Requires temperature measurements each morning using thermometer
• App clinical study followed 15,570 people using app x 8 months
• Perfect use failure 1.8%; typical use 6.5%

Fertility Awareness - Advantages and Disadvantages

• Main advantage is no side effects
• Contraindications include irregular cycles, interruption of cycle with pregnancy, inability to track physiologic changes, lack of supportive partner
• Typical use failure is ~24%

Coitus Interruptus (Withdrawal)

• Commonly used whether as sole method or in combination
• Costs nothing, no side effects
• Typical use failure is ~20%
• Typically encourage adding a more reliable method; at least discuss effectiveness and inform of options

Emergency Contraception (EC)

• Most effective EC is the IUD with copper or LNG 52mg
• Medication is less effective with UPA (can use up to 120 hours), requires Rx, and wait 5 days to start hormonal BC
• LNG is effective if BMI > 30, can use up to 72 hours, available over the counter, and can start hormonal BC at the same time
• ECs with copper/52mg LNG IUD prevent fertilization by avoiding implantation
• LNG/Yuzpe: inhibit LH surge, delay/prevent ovulation

Patient-Centered Contraception - Listing

• Listing Methods is Providing “objective” information
• Can elicit the patient’s reproductive health goals and preferences

Promoting Certain Methods:

• Tiered effectiveness or motivational interviewing • Tiered in healthcares assumptions about patient priorities

• Create a safe space by:

• Listening

• Not making assumptions

• Elicit and address patient priorities

• Not make assumptions is to

  • Ask about the patient’s Preferences:
    • Getting a period (or not)
    • Hormones
    • Easily Stopped
    • Having something stay in your body
    • Effectiveness

• Do not make certain Assumptions – not take granted that you/the patient share the medical terminology

• ASK Permission

• Options- you do not have the answer and are not obligated