Contraception IDM1 Handout 2024-1.pdf

CONTRACEPTION Kalumi Ayala, Pharm.D., AAHIVP, TTS Clinical Assistant Professor, Pharmacy Practice Site: Centro Ararat, Ponce P.R. [email protected] LECTURE OBJECTIVES List the advantages and disadvantages of different methods of contraception Recommend appropriate method of contraception based on each...

CONTRACEPTION Kalumi Ayala, Pharm.D., AAHIVP, TTS Clinical Assistant Professor, Pharmacy Practice Site: Centro Ararat, Ponce P.R. [email protected] LECTURE OBJECTIVES List the advantages and disadvantages of different methods of contraception Recommend appropriate method of contraception based on each individual patient’s characteristics Identify significant drug interactions with COCs and make appropriate recommendations Describe proper administration and risks of emergency contraception Formulate appropriate counseling/education for patients using hormonal contraception and/or emergency contraception METHODS OF CONTRACEPTION Nonprescription Contraceptives Periodic Abstinence Barrier Methods Spermicide Oral Contraception Progestin Only Pill Emergency Contraception METHODS OF CONTRACEPTION Combined Hormonal Contraception (CHC) Combined Oral Contraception (COC) Transdermal System Pharmacological Therapy Vaginal Ring Hormonal Contraception Progestin only pill (POP) Injectable Progestin Progestin Only Contraception Implant Non-Hormonal Contraception Copper-IUD Progestin IUD Emergency Contraception COMBINED HORMONAL CONTRACEPTIVES (CHC) AVAILABLE ESTROGEN Mestranol Ethinyl estradiol (EE) Estradiol valerate Estetrol AVAILABLE PROGESTINS Name Abbreviation Norgestrel ____ Levonorgestrel LNG Desogestrel DSG Norgestimate NGM Ethynodiol diacetate ____ Drospirenone DRSP Norethindrone acetate NETA Norethindrone NE Norelgestromin NGMN Dienogest ____ Segesterone acetate _____ COMPARATIVE ACTIVITY OF PROGESTIN Progestin Desogestrel Estrogenic Androgenic ++++ 0 +++ + 0 0 Drospirenone ++ 0 0 Levonorgestrel ++++ 0 ++++ +++ 0 +++ Ethynodiol diacetate ++ +++ + Norgestimate ++ 0 ++ Norethindrone acetate ++ ++ ++ Norethindrone ++ ++ ++ Dienogest Norgestrel ++++, pronounced effect; +++, moderate effect; ++, low effect; +, slight effect; 0, no effect Antiandrogenic progestins: dienogest, drospirenone Adapted from Facts and Comparison, eAnswers, 2015 CHOOSING A HORMONAL CONTRACEPTIVE Important Points to be Considered TO BE CONSIDERED……. ▪Weight benefits vs. potential risks ▪Patient’s lifestyle ▪Contraindications ▪Adverse effects ▪Drug interactions ▪Adherence issues ▪Hormonal content/dose (preferable to use OCS with ≤ 35 mcg ethinyl estradiol) ▪Preferred pattern of pill use CONTRAINDICATIONS TO CHC Thromboembolic disorders Cerebrovascular or coronary artery disease Valvular heart disease with thrombogenic complications Migraine headaches with focal aura Uncontrolled HTN Thrombogenic mutations Breast cancer Severe liver problems Systemic lupus erythematosus (positive or unknown antiphospholipid antibodies) Age >35 and currently smoking (≥15 cigarettes/day) Postpartum 35 and currently smoking ( 21 days U.S. Medical Eligibility Criteria for Contraceptive Use, 2016.; WHO Medical eligibility criteria for contraceptive use ADVERSE EFFECTS ASSOCIATED WITH HORMONAL COMPONENT High estrogen Nausea, breast pain, increase in blood pressure, headache, bloating Low estrogen Early-cycle breakthrough bleeding, hypomenorrhea High progestin Fatigue, irritability, breast tenderness, headaches Low progestin Late-cycle breakthrough bleeding High androgen Weight gain, acne, oily skin, increased LDL cholesterol, decreased libido Carroll S, Dean W.S. Carroll, Shannon, and Wendy S. Dean.(2009). Chapter 28. Contraception. In Linn WD, Wofford MR, O'Keefe M, Posey L. Linn W.D., Wofford M.R., O'Keefe M, Posey L Eds. William D. Linn, et al. (Eds), Pharmacotherapy in Primary Care. Retrieved September 12, 2016 from http://accesspharmacy.mhmedical.com.ezproxylocal.library.nova.edu/content.aspx?bookid=439&Sectionid=39968673. Which of the following women may be started on a combined hormonal contraceptive? A. A 30 y.o woman with an active DVT B. A 25 y.o. woman with migraine HA without aura C. A 36 y.o. woman that smokes 2 PPD D. A 28 y.o. women with a BP of 160/100 mmHg COMBINED ORAL CONTRACEPTIVES (COCS) COCS: THE GOOD Advantages (non-contraceptive benefits  Improves  Menstrual cycle disorders such as:  PMS and PMDD  Dysmenorrhea  Heavy menstrual bleeding  Menstrual symptoms  Cancer risk reduction  Endometrial, ovarian, colorectal cancer  Decreases incidence of ovarian cysts COCS: THE BAD AND THE UGLY Abdominal Pain ▪Disadvantages Increases  TG BP (within the first 3-6 months) Risk of thromboembolism Risk of stroke Risk of MI Risk of breast cancer?? Severe leg pain Chest Pain ACHES Eye problems Headache DRUG INTERACTIONS DRUGS INTERFERING WITH COC EFFICACY Anticonvulsants Antibiotics  Rifampin NNRTIs  Efavirenz, Nevirapine Protease Inhibitors  Darunavir, Atazanavir, Lopinavir, Ritonavir Natural Products  St. John’s Wort COC PATIENT EDUCATION Dosing regimen  Start day:  1st day of menses-backup method not needed  Sunday start-backup method needed  Anytime start or quick start-backup method needed  Take once daily at same time Adherence Adverse effects ACHES No protection against STDs/HIV COC PATIENT EDUCATION Missed doses: One dose: Take as soon as remembered and then take the next pill at the regular time that day (*patient will take 2 pills in 1 day*) Back-up contraception not necessary Source: For full recommendations and updates, see the U.S. Selected Practice Recommendations for Contraceptive Use webpage at http://www.cdc.gov/reproductivehealth/unintendedpregnancy/usspr.htm COC PATIENT EDUCATION Missed doses: Two or more consecutive doses: Take the most recent missed pill as soon as possible Any other missed pills should be discarded  Continue taking the remaining pills at the usual time May need to take two pills on the same day Use back-up contraception for 7 consecutive days Avoid sexual intercourse until hormonal pills have been taken for 7 consecutive days Source: For full recommendations and updates, see the U.S. Selected Practice Recommendations for Contraceptive Use webpage at http://www.cdc.gov/reproductivehealth/unintendedpregnancy/usspr.htm COC PATIENT EDUCATION Missed doses: Two or more consecutive doses: If pills were missed in the last week of hormonal pills (e.g., days 15-21 for 28-day pill packs): Omit the hormone-free interval by finishing the hormonal pills in the current pack and starting a new pack the next day. If unable to start a new pack immediately use back-up contraception or avoid sexual intercourse until hormonal pills from a new pack have been taken for 7 consecutive days. Source: For full recommendations and updates, see the U.S. Selected Practice Recommendations for Contraceptive Use webpage at http://www.cdc.gov/reproductivehealth/unintendedpregnancy/usspr.htm MONOPHASIC VS. MULTIPHASIC Monophasic  Fixed ratio of estrogen-progestin throughout cycle  1 week of placebo  Examples of monophasic: OC Estrogen (mcg) Progestin (mg) Placebo Ortho-Novum 1/35 (peach tabs) 35 EE 1 NE 7 lt green tabs Desogen (white tabs) 30 EE 0.15 DSG 7 green tabs Adapted from Facts and Comparison, eAnswers, 2015 MONOPHASIC VS. MULTIPHASIC Biphasic Fixed dose of estrogen throughout cycle Lower progestin dose during first 7-10 days of cycle Example of biphasic: OC Phase 1 Phase 2 Placebo Necon 10/11 0.5 mg NE, 35mcg EE(10 light yellow tabs) 1 mg NE, 35 mcg EE (11 dark yellow tabs) 7 white tabs Adapted from Facts and Comparison, eAnswers, 2015 MONOPHASIC VS. MULTIPHASIC Triphasic Example of Triphasic:  Constant estrogen plus increasing amounts of progestin  Constant progestin plus increasing amounts of estrogen  Increasing amounts of progestin and estrogen* Adapted from Facts and Comparison, eAnswers, 2015 MONOPHASIC VS. MULTIPHASIC Quadriphasic Changing amount of estrogen and progestin Example: Natazia® OC Phase 1 Phase 2 Phase 3 Phase 4 Placebo Natazia® 3 mg estradiol valerate (2 dark yellow tabs) 2 mg estradiol valerate, 2 mg dienogest (5 med red tabs) 2 mg estradiol valerate, 3 mg dienogest (17 light yellow tabs) 1 mg estradiol valerate (2 dark red tabs) 2 white tabs Adapted from Facts and Comparison, eAnswers, 2015 UNIQUE OCS Estrostep ® FE  Triphasic OC-estrogen content ↑ in every phase  Phase 1: 20 mcg EE  Phase 2: 30 mcg EE  Phase 3: 35 mcg EE  Constant progestin (norenthindrone acetate 1 mg), contains ferrous fumarate (7 tabs)  Has an indication for moderate acne Minastrin ® 24 FE  Monophasic OC-24/4 day regimen (EE 20 mcg, NETA 1mg)  Contains ferrous fumarate (4 tabs)  Has an indication for moderate acne UNIQUE OCS Drospirenone (DRSP) Analog of spironolactone Benefits in ↓ wt gain? Caution: renal disease, ACE inhibitors, potassium Increased risk of blood clots OCs containing DRSP:  Yasmin ® (EE 20 mcg, DRSP 3 mg)  Yaz ® 24/4 day regimen  Used for PMDD & acne  Safyral®, Beyaz ®  levomefolate calcium  Nextstellis®  Contains estetrol  Less effective in BMI>30kg/m2 TO BE CONSIDERED…… COEXISTING MEDICAL CONDITIONS Chronic HTN Thromboembolism Dyslipidemia Diabetes Breast Cancer Migraine HA OTHER THINGS TO BE CONSIDERED… Acne Obesity Estrogen Intolerance PMS/PMDD Breakthrough bleeding EXTENDED CYCLE OR CONTINUOUS CYCLE OC Extended cycle (one menstrual cycle/season)  Jolessa® (Seasonale): EE 30 mcg, LNG 0.15 mg, placebo  Active pills for 84 days, 7 days placebo  Seasonique®(Amethia): EE 30 mcg, LNG 0.15 mg, EE 10 mcg  Same as above-instead of placebo it uses EE 10 mcg  Lo Seasonique®(Amethia Lo): EE 20 mcg, LNG 0.1mg, EE 10 mcg Continuous cycle (no menses)  Amethyst ® (EE 20 mcg, LNG 90 mcg)  Active pills for 365 days-no placebo Other monophasic OCs have been used in extended dosing EXTENDED CYCLE OR CONTINUOUS CYCLE OC Advantages Disadvantages ESTROGEN/PROGESTIN TRANSDERMAL SYSTEM Xulane® patch  EE 35 mcg/NGMN 150 mcg per day  Once weekly application for 3 consecutive weeks, followed by 1 week patch free per cycle  Abdomen, buttock, torso, and upper outer arm  Placed at the beginning of menstrual cycle  Contraindicated in women with a BMI >30 kg/m2  Decreased efficacy as weight increases (≥90 kg)  More risk of thromboembolism ESTROGEN/PROGESTIN TRANSDERMAL SYSTEM Xulane® patch  Compliance vs. risks  Patch releases estrogen and progestin for 7 days  If forget to change patch on time:  Apply new patch as soon as remembered  Backup contraception method needed for 7 days*  If detached:  24 hours: apply new patch (this day of the week becomes the new patch change date); backup contraception needed for 7 days ESTROGEN/PROGESTIN TRANSDERMAL SYSTEM Twirla® patch  EE 30 mcg/LNG 120 mcg per day  Once weekly application for 3 consecutive weeks, followed by 1 week patch free per cycle  Abdomen, buttock, or upper torso (rotate sites)  Avoid prolonged exposure to water  Placed at the beginning of menstrual cycle  Contraindicated in women with a BMI >30 kg/m2  Risk of thromboembolism  Compliance vs. risks ESTROGEN/PROGESTIN TRANSDERMAL SYSTEM Twirla® patch  Managing partial or complete patch detachment Scenario Back-up contraception required for 7 days Patch “change day” remains the same? Need to start a 4week new cycle? Detached or partially detached for < 24 NO YES NO Detached or partially detached for ≥ 24 hours, or unsure duration YES NO YES ESTROGEN/PROGESTIN TRANSDERMAL SYSTEM Twirla® patch  Managing late or missed patch application Scenario Back-up contraception required for 7 days Patch “change day” remains the same? Need to start a 4week new cycle? Did not apply patch on scheduled Day 1/Week 1 of new cycle (late patch-on day) YES NO YES < 48 hours late for Patch Change Day (Day 8 or 15) NO YES NO ≥ 48 hours late for Patch Change Day (Day 8 or 15) YES NO YES Forgets to remove last patch on Day 22 NO YES NO ESTROGEN/PROGESTIN VAGINAL RING NuvaRing®  EE 0.015 mg plus etonogestrel 0.120 mg/day  Inserted vaginally, worn for 21 consecutive days (3 weeks), remove and discard for 7 ring-free days  Insert on or before the fifth day of menses  If expelled from vagina for less than 3 hours, reinsert- no backup needed  If expelled for more than 3 hours, reinsertbackup needed for 1 week* ESTROGEN/PROGESTIN VAGINAL RING Annovera®  One year reusable ring  EE 0.013 mg/day plus segesterone acetate 0.15 mg/day  Inserted vaginally, worn for 21 consecutive days (3 weeks), remove and store for 7 ring-free days  Insert between days 2 and 5 of menstrual cycle  If expelled from vagina for less than 2 hours, reinsert- no backup needed  If expelled for more than 2 hours, reinsert-backup needed for 1 week* PROGESTIN ONLY CONTRACEPTIVES PROGESTIN ONLY OC: “THE MINIPILL” “POP” Norethindrone 0.35 mg Drospirenone 4 mg Ortho Micronor, Nor-QD, Camila, Errin, Jolivette Slynd® This Photo by Unknown Author is licensed under CC BY-SA-NC PROGESTIN ONLY OC: “THE MINIPILL” “POP” Advantages: Disadvantages:  No estrogenic side effects  Rapid return of fertility  May be used in:  Lactating women  Cardiovascular risk, HTN, HA, current DVT, CVA  Smokers  Less effective than combination OC  Increases risk of menstrual irregularities  May cause amenorrhea  Adherence issues  Must be taken every day-backup protection if missed dose Norethindrone PROGESTIN ONLY OC: “THE MINIPILL” “POP” Advantages: Disadvantages:  No estrogenic side effects  Rapid return of fertility  May be used in:  Lactating women  Cardiovascular risk, HTN, HA, CVA  Smokers  Increases risk of menstrual irregularities  May cause amenorrhea  Increases risk for hyperkalemia  Avoid in patients with adrenal insufficiency, renal and hepatic impairment  DVT risk? Drospirenone PROGESTIN ONLY OC: “THE MINIPILL” “POP” Patient education: Start on first day of menses Take at same time each day Missed dose for norethindrone minipill: If 3 hours late taking pill or missed at least 1 tablet Take missed tab as soon as remembered and continue taking as usual Use additional contraception method for 48 hours PROGESTIN ONLY OC: “THE MINIPILL” “POP” Patient education: Missed dose for drospirenone minipill: If 1 dose is missed: Take as soon as remember and continue with regular schedule No backup contraception needed If 2 doses or more are missed: Take missed tab as soon as remembered and continue taking as usual Use additional contraception method for 7 days INJECTABLE PROGESTINS Intramuscular injection  Depo-Provera ®(150 mg of medroxyprogesterone) SubQ injection  Depo-SubQ Provera 104® (104 mg of medroxyprogesterone) Administered once every 3 months (day 1-7 of cycle) If administered after 7th day of cycle-backup method needed for 3 weeks INJECTABLE PROGESTINS Contraindications: Current breast cancer* Hypersensitivity to medroxyprogesterone Candidates: Contraindications to estrogen Adherence issues with other methods Contraception desired for at least 1 year Breastfeeding is desired *U.S. Medical Eligibility Criteria for Contraceptive Use, 2016.; WHO Medical eligibility criteria for contraceptive use; Depo Provera PI INJECTABLE PROGESTINS Advantages Disadvantages:  Low failure rate  Decreased or no menstrual flow or cramping  Decreased ectopic pregnancy, PID  May be used while breast-feeding  No increased risk of thromboembolism  No estrogenic side effects  Return of fertility may be delayed  Possible breakthrough bleeding  Weight gain (1 kg/year)  Decreased HDL, increased TG  Decreased bone density (Black Box Warning)  Breast cancer risk???  Office visit required (Depo-Provera) LONG-ACTING REVERSIBLE CONTRACEPTIVES (LARC) Subdermal Implant Intrauterine Devices Copper IUD etonogestrel LNG IUD LARC: SUBDERMAL PROGESTIN IMPLANTS Nexplanon® (formerly known as Implanon) Contains 68 mg of etonogestrel Releases 60 mcg/day for 1st year, Then 30 mcg/day for the next 2 years Subdermally implanted in upper arm during days: 1-5 of cycle Provides contraception for 3 years Adverse effects: amenorrhea, infrequent bleeding LARC: SUBDERMAL PROGESTIN IMPLANTS Nexplanon® (formerly known as Implanon) Contraindications: Current breast cancer* Candidates: Long-term contraception desired Contraindication to estrogen Adherence problems with other methods Need for rapid return of fertility upon D/C *U.S. Medical Eligibility Criteria for Contraceptive Use, 2016.; WHO Medical eligibility criteria for contraceptive use; Nexplanon PI LARC: SUBDERMAL PROGESTIN IMPLANTS Advantages  Low failure rate  May be used while breast-feeding  Used in those with contraindications to estrogen  No increased risk of thromboembolism  No estrogenic side effects Disadvantages  Requires insertion by trained healthcare provider  Possible breakthrough bleeding INTRAUTERINE DEVICES INTRAUTERINE DEVICES (IUD) Most effective method of contraception Types of IUD Copper IUD Paragard® Progestin-releasing IUDs Mirena ® Skyla® Liletta® Kyleena® Image:http://www.uptodate.com.ezproxylocal.library.nova.edu/contents/image?imageKey=OBGYN%2F61717&topicKey=OBGYN%2 F5419&rank=1%7E150&source=see_link&search=intrauterine+divices&utdPopup=true INTRAUTERINE DEVICES (IUD): ® PARAGARD T-shaped polyethylene frame Surface consists of fine copper wire Inserted by health care provider Can remain in place up to 10 yrs Image:http://www.uptodate.com.ezproxylocal.library.nova.edu/contents/image?imageKey=OBGYN%2F56136&topicKey=OBGYN% 2F5419&rank=1%7E150&source=see_link&search=intrauterine+divices&utdPopup=true INTRAUTERINE DEVICES (IUD): ® PARAGARD Contraindicated in:  Pregnancy  Uterus abnormalities (distortion of uterine cavity)  Current PID  Uterine, cervical or endometrial cancer  Genital bleeding of unknown etiology  Mucopurulent cervicitis  Wilson’s disease  Allergy to any component of ParaGard® U.S. Medical Eligibility Criteria for Contraceptive Use, 2016.; WHO Medical eligibility criteria for contraceptive use; Paragard PI INTRAUTERINE DEVICES (IUD): PARAGARD ® Adverse effects: ectopic pregnancy, pelvic infection, perforation, bleeding Candidates: Long term contraception desired Rapid return to fertility desired upon D/C Contraindications to hormonal contraception Do not desire side effects associated with hormonal contraception use Adherence problems with other methods INTRAUTERINE DEVICES (IUD): PROGESTIN-RELEASING IUD T-shaped polyethylene frame  Mirena®  Contains 52 mg levonorgestrel  Can be used up to 5 years  Liletta®  Contains 52 mg levonorgestrel  Can be used up to 3 years  Skyla®  Contains 13.5 mg levonorgestrel  Can be used up to 3 years  Kyleena®  Contains 19.5 mg levonorgestrel  Can be used up to 5 years http://www.uptodate.com.ezproxylocal.library.nova.edu/contents/image?imageKey= OBGYN%2F81587&topicKey=OBGYN%2F5419&rank=1%7E150&source=see_link &search=progestin+IUD&utdPopup=true INTRAUTERINE DEVICES (IUD) PROGESTIN-RELEASING IUD Contraindicated in: Pregnancy Uterus abnormalities (distortion of uterine cavity) Current PID Breast, uterine, cervical or endometrial cancer Genital bleeding of unknown etiology Mucopurulent cervicitis Acute liver disease* U.S. Medical Eligibility Criteria for Contraceptive Use, 2016.; WHO Medical eligibility criteria for contraceptive use; Mirena &Skyla PI INTRAUTERINE DEVICES (IUD) PROGESTIN-RELEASING IUD Adverse effects: ectopic pregnancy, pelvic infection, unscheduled bleeding Candidates: Long term contraception desired Rapid return to fertility desired upon D/C Contraindications to estrogen Heavy menstrual bleeding and dysmenorrhea Adherence problems with other methods INTRAUTERINE DEVICES (IUD) Advantages Long term contraception Low failure rate May be used while breastfeeding No estrogenic side effect Used in those with contraindications to estrogen Used in those with contraindications to all hormonal contraception (Copper IUD) No adherence issues Rapid return of fertility when D/C INTRAUTERINE DEVICES (IUD) Disadvantages Requires insertion by trained health care provider Bleeding Perforation Pelvic infection Ectopic pregnancy EMERGENCY CONTRACEPTION EMERGENCY CONTRACEPTION (EC) Use of drugs or a device to prevent pregnancy Not an abortifacient Not a primary contraceptive method For occasional or back-up use Candidates for EC Women who had recent unprotected sex Failure of current method of contraception http://www.uptodate.com EMERGENCY CONTRACEPTION (EC) EC Methods Plan B One Step® Next Choice One Dose ® MyWay® Take Action® Ella® Copper Yuzpe IUD EMERGENCY CONTRACEPTION (EC) Ella ® (ulipristal acetate 30mg) –RX only –Selective progesterone receptor modulator –Can be used up to 120 hours (5 days) after unprotected sex –Common ADE: headache, nausea, abdominal pain EMERGENCY CONTRACEPTION (EC) YUZPE Regimen High dose of OC Copper IUD Must be inserted within 120 hrs after intercourse Provides continue contraception CONTRACEPTION CASES MINI CASE 1 A 26 y.o is currently taking phenytoin for her seizures and is currently controlled. She would like to start taking contraception. Which of the following contraceptive methods is more likely to have an interaction with her therapy? A. Combined oral contraception B. Copper IUD C. DMPA injection D. LNG-IUD DMPA= depot-medroxyprogesterone acetate MINI CASE 2 Monday morning (8:00 am) you receive a telephone call from a patient asking a question about birth control pills. The patient visited her relatives in New York the past weekend and forgot to bring her Ortho Novum 1/35. The last pill she took was on Friday morning (8:30 am), and she states she was on her first week of her pill packet. How would you counsel this patient? MINI CASE 2 What will you tell the patient about alternative contraceptive methods? A. These methods are not necessary B. These methods are necessary for 48 hours C. These methods are necessary for 1 week D. These methods are necessary until her next menses MINI CASE 3 A 20 y.o. woman with moderate acne comes to the clinic for initial evaluation of contraception method. She reports no medical conditions. She denies tobacco and alcohol use. Which contraception methods would be most beneficial for this patient? MINI CASE 4 Monday morning, you receive a phone call from a patient asking a question about birth control pills. She was out all day Sunday and forgot to take her dose of OrthoMicronor (norethindrone-progestin ONLY pill). What would you recommend to this patient? MINI CASE 5 LT is a 30 y.o. woman that gave birth to a baby girl 3 weeks ago. She is currently breastfeeding; however, she tells you that she would like to start contraception. She would not like to get pregnant any time soon. Past medical conditions includes: HTN and hypothyroidism (controlled on meds). Which of the following hormonal methods are safe for her to use? A. Combined oral contraceptives B. Estrogen/progestin vaginal ring C. Progestin only methods D. All of the above MINI CASE 6 A 30 y.o. woman with a past medical history of osteopenia and diabetes type 2 is seeking for a contraception. She smokes 20 cigarettes per day, drinks socially and does not have time to exercise due to her busy work schedule. She would like a contraceptive option that is highly effective and that does not require a daily intake. She currently weights 220 lbs, height 5’6, BMI: 32.6 kg/m2 Which contraception is the best option for her? A. Jolessa (ethinyl estradiol/levonorgestrel) B. Depo-Provera IM injection (medroxyprogesterone) C. Xulane patch (ethinyl estradiol/norelgestromin) D. Mirena IUD (levonorgestrel) CONSIDERATIONS FOR CONTRACEPTIVE SELECTION SUMMARY Type of patient Contraceptive selection Acne Use COC with lower androgenic activity or no androgenic activity (Yaz, Estrostep Fe, Minastrin 24 Fe ) Breastfeeding Consider progestin only methods* or non-hormonal method. Estrogen contraindication (including VTE) Use progestin only methods, copper IUD Migraine with aura Avoid CHC, consider progestin only methods or copper IUD Hypertension If BP uncontrolled (>160/100 mmHg) avoid CHC, consider progestin only methods or copper IUD >35 y.o. and smokes >15 cigarettes per day Avoid CHC, consider progestin only methods or copper IUD CONSIDERATIONS FOR CONTRACEPTIVE SELECTION SUMMARY Type of patient Contraceptive selection Overweight/Obese Avoid using patch due to decreased effectiveness (in patients >90 kg; contraindicated in BMI>30. Try to avoid POP due to lack of efficacy data. Consider DMPA, IUD Wishes to avoid monthly cycle/menses Use extended or continuous formulations Hormone contraindication Use non hormonal contraception: Copper-IUD, barrier methods Osteopenia/Osteoporosis Avoid DMPA Wilson’s Disease Avoid Copper IUD Adherence problems Consider estrogen progestin transdermal patch, ring, progestin only implant, injection or IUD, Copper IUD CONSIDERATIONS FOR CONTRACEPTIVE SELECTION SUMMARY Type of patient Contraceptive Paragard (Copper IUD) up to 10 years Mirena, Kyleena (levonorgestrel IUD) up to 5 years Desires long term contraception Liletta, Skyla (levonorgestrel IUD) up to 3 years Nexplanon (etonogestrel) implant up to 3 years QUESTIONS? Contact info: Dr. Kalumi Ayala [email protected] This Photo by Unknown Author is licensed under CC BY-NC-ND