Women's Health Review 2024 PDF

Women’s Health Review Contraception Review Contraception To prevent an unintended pregnancy Many non-contraceptive indications for hormonal contraception Combined Contraception Progestogen-Only Oral COCs (daily) POPs (daily)...

Women’s Health Review Contraception Review Contraception To prevent an unintended pregnancy Many non-contraceptive indications for hormonal contraception Combined Contraception Progestogen-Only Oral COCs (daily) POPs (daily) DMPA Depot Injection (3m) Longer- Vaginal Ring (3w) Etonogestrel Implant (3y) Acting Levonorgestrel IUD (5y) Contraception Combined Contraception Contraindications migraine >35 yr and/or migraine with aura smoking >35 yr uncontrolled hypertension history of, or increased risk of, VTE Hormonal Contraception Drug Interactions estrogens and progestogens both impacted by CYP3A4 inducers e.g. anti-epileptics, St John’s Wort, griseofulvin, rifamycins only options unaffected by CYP3A4 inducers: levonorgestrel IUD, DMPA and copper IUD COC Drug Choice – Estrogen Component Ethinylestradiol synthetic derivative of estradiol, 15-20 x more potent than oral estradiol low dose = 20 mcg standard dose = 30-35 mcg high dose = 50 mcg Estradiol (only in Zoely®) natural estrogen, previously used only in HRT/MHT Estetrol (E4) (only in Nextstellis®) naturally occurring estrogen; unclassified estrogen dose No evidence that estrogen choice offers any clinical benefits (AMH 2024) COC Drug Choice – Progestogen Component 2nd Generation: levonorgestrel and norethisterone only COCs with levonorgestrel or norethisterone are PBS-subsidised 3rd Generation: gestodene, desogestrel, cyproterone less androgenic activity than levonorgestrel but increased VTE risk cyproterone is used to treat androgenisation (e.g. severe acne, hirsutism) 4th Generation: drospirenone, dienogest and nomegestrol advantage over other COCs unclear less data regarding VTE risk Newer progestogens are less androgenic > more beneficial effect on acne, cause less hirsutism, cause less weight-gain However, not listed on PBS > more expensive  COC Brands AMH 2024 Counselling of COCs Most COCs contain 21 days active pills +/- 7 days inactives, except: Yaz® and Zoely® (24+4); Qlaira® (26+2); Seasonique® (84+7 mono EE pills) Active pills need to be taken consecutively with ≤36 hours between doses Hormone-free interval (HFI) should not exceed 7 days When are they covered for contraception? After 7 actives have been taken What do they do if they miss? Refer to APF table COCs Missed Pill Advice Note: Missed doses of contraceptives section of APF26 also addresses late insertion or unscheduled removal of combined vaginal ring APF26 pp 412-414 Counselling of COCs Commencing a COC: Open each packet and confirm where/when patient starts Compare Yaz® (left) and Levlen® (right) Extended regimen - tricycling COCs running 3 cycles of active hormone pills together, omitting the placebo pills pill-free period may be reduced to 4 days decreases frequency of menses provides relief of dysmenorrhoea avoid PMS, withdrawal headaches prevent endometriosis avoid pill failure prevent herpes outbreaks with menstruation avoid unacceptably heavy or painful withdrawal bleeds Progestogen Only Pills (POPs) Indicated when combined contraception is contraindicated or not desired Traditional POPs (PBS) contained levonorgestrel (Microlut®) or norethisterone (Noriday®) MOA is to thicken cervical mucus; all tablets are the same must be taken very strictly to be effective, within 3-hour window New POP (Non-PBS) contains drospirenone (Slinda®) MOA is to prevent ovulation; has 24 actives and 4 inactive tablets APF uses same missed pill advice and 7-day rule as COCs  POP Low COC Estrogen Dose High PBS Prog Low Dose Standard Dose ↑ Triphasic High Dose Only Monophasic Monophasic ↓ Multiphasic Monophasic Non-PBS Other Progestogen Only Options LARCs (PBS) depot medroxyprogesterone acetate (DMPA) injection (Depo- Provera®, Depo-Ralovera®) 3 monthly IM injection; associated with weight gain small decrease in BMD; not for adolescents or >50 years etonogestrel implant (Implanon®) 3 years, implant into upper arm; avoid with CYP3A4 inducers levonorgestrel-releasing IUD (Mirena®, Kyleena®) 5 years contraceptive cover Mirena® also indicated for HMB and adjunct to estrogen in MHT Longer Acting Combined Contraception Vaginal ring (Non-PBS) ethinyloestradiol/etonogestrel-releasing vaginal ring (NuvaRing®) inserted for 3 weeks, removed for 1 week same precautions and contraindications as COCs Contraceptive Choice Adolescents COC or etonogestrel implant; IUDs acceptable but more likely to expel DMPA is least preferred as BMD reduction more significant Postpartum None required for 21 days; progesterone-only may be used any time Delay combined contraception until >21 days postpartum due to VTE risk Breastfeeding Progesterone only, barrier methods and IUDs can all be used >40 Years Contraception should continue for 1 year if >50 yr or 2 years if