Birth Control Optionsin 21st Century • Peter L. Stevenson, MD FACOG Associate Clinical Professor Wayne State University School of Medicine Detroit Michigan
Contraception Overview • Barriers • Chemicals BEST USED TOGETHER • Hormones • PG only • E & PG • Emergency Contraception • Sterilization • Other • IUD’s • Rhythm & Withdrawl • Termination & RU486 (mifepisterone)
Contraceptive Efficacy • All methods are USER DEPENDANT • (OK, not IUD and sterilization) • Failures of ALL methods decrease with: • Increasing age • Increasing socioeconomic status • Increasing education • Increasing income • Lose sight of effectiveness • concerned w/ risk
Contraceptive safety • Risk of Death on OCP’s ?? • Risk of Death from Pregnancy ?? • OCP’s & Breast Cancer • NOT Pseudo Pregnancy • DVT on 3rd Generation Progestin
Contraceptive safety • Increased risk death from unintended pregnancy • Prior Breast cancer • Valvular heart disease • Diabetes: insulin-dependent Class N, R, T or D • Prior GYN cancer • Epilepsy • Hypertension (>160 / >100 mm Hg) • History of bariatric surgery within the past 2 years • HIV/AIDS • Ischemic heart disease • Peripartum cardiomyopathy
Contraceptive safety • Increased risk death from unintended pregnancy • Malignant gestational trophoblastic disease • Severe (decompensated) cirrhosis • Sickle cell disease • Solid organ transplantation within the past 2 years • Stroke • Systemic lupus erythematosus • Thrombogenic mutations • Tuberculosis
Contraceptive safety • Drug/OCP Interactions & Effectiveness • Myth of Antibx • Griseofulvin, Rifampin -- decreased maybe, but…? • NOT Amp, tetraC, cephalo, cipro, et al.
Contraceptive safety • Drug -- Drug Interactions • Anti-Seizure meds maybe… • Old drugs (dilantin, phenobarb, etc) doubtful, only theory • Protease Inhibitors in HIV Pts YES • 3 T’s: potent cytochrome P450 inducers • Tegretol DECREASED EFFECTIVENESS • Tri-Leptal for BOTH OCP • Topamax & anti-seizure Rx
Contraceptive safety • Drug/OCP Interactions & Effectiveness • Anti-Seizure Meds • Phenobarb, Tegretol, Dilantin -- doubtful • Topamax, Tri-leptal & Tegretol • -- DANGEROUS!! Seizures & Pregnancy!! • NO CHANGE TO OCP or Neuro Rx: • Gabapentin (Neurontin), lamotrigine (Lamictal), levetiracetam (Keppra), and tiagabine (Gabitril)
‘Future’ Contraceptives • Male Birth Control Pills • Bridge, for sale, great view • Vaccines • Pg Receptor Modulator • Shorter Lasting Implant • Implanon (lasts 3 years) • Vaginal Ring • NuvaRing (3 weeks, one ring)
Barriers & Chemicals • Condoms • Diaphragm • Cervical Cap • All better with Spermicides • Spermicides • Nonoxinyl-9 • Surfactant – Soap! • Disrupts Acrosomal Membrane
IUD’s • Safe & Effective NOT abortifacient! • Patient Selection • Mature • Monogamous • Multiparous • Poor choice if severe menses • Heavy bleeding OR Bad Cramps
IUD’s • Safe & Effective • Copper Bearing: Paraguard 10 years • Inhibits ovulation • Thickens Cervical Mucous • Decidualizes Endometrium (hostile) • Interferes with tubal motility • KILLS SPERM!
IUD’s • Safe & Effective • Progestin Containing: Mirena 5 years • Inhibits ovulation • Thickens Cervical Mucous • Decidualizes Endometrium (hostile) • MAY decrease mentrual bleeding & DUB!
Sterilization • Permanent • Vasectomy • Easier • Safer • Cheaper • Quicker • Less Painful • Excellent method for ‘other men’
Sterilization • Permanent • Tubal Occlusion • (nothing gets tied...) • Laparoscopic - Band, Clip, Ring, Cautery • Hysteroscopic - Dacron, Cautery • Open - Pomeroy, Yoshida, Irving • Salpingectomy, Fibriectomy
Hormonal Contraception • Progestin Only • Micronor, Nor Q D • Depo Provera • Implanon • ? Weight Gain • ? Body Mass related failure
Hormonal Contraception • Estrogen & Progestin • Monophasic • Ultra Low Dose ( ≤20 mcg) • Low Dose ( 30-35 mcg) • Multiphasic • Different Regimens • ? • Key Difference = Progestin Component
Hormonal Contraception • Excess Estrogen • Nausea • Headache • Breast Tenderness • Blood Clots • MI & Stroke • Excess Progestin • Moodiness • Bloating • Weight Gain • Acne • Hair Loss
Hormonal Contraception • Inadequate Estrogen • BTB • EARLY < day 10 • Don’t stop menses • Inadequate Progestin • BTB • LATE > day 15 • Start menses early
Hormonal Contraception • Need spectrum of OCP’s to suit all pt’s • Dr. Dickey’s “Managing…Pill Patient” • Very few ‘name brand’ OCP’s on market • Very difficult to manage side effects… • All OCP’s help acne • All DAW OCP’s are equally effective • ? Generic 20 mcg OCP’s
Hormonal Contraception • Spectrum of OCP’s • Estrogen: Low to High • Pg only OCP (no Estrogen) Micronor • Lo Lo Estrin ~10 • Mircette, Alesse, Levlite 20 • Cyclessa or Estrostep ~20 • Lo-Estrin 1/20 20 • Safyral, Desogen, Ortho Cept 30 • Femcon 35, O/N 1/35, Nordette 35 • Ovral or Ovcon 50 50
Hormonal Contraception • Spectrum of OCP’s • Progestin: Low to High • Yasmin/Yaz • Desogen • Ovcon 35 • Lo-Estrin 1.5/30 • Safyral • Nordette,O/N 1/35,Norinyl • Ortho Cyclen • Lo Ovral • Ovral
Hormonal Contraception • Problems with OCP’s • Unrelieved Dysmenorrhea • Menorrhagia • Amenorrhea • Acne • Moodiness • BTB
Hormonal Contraception • Alternatives to OCP’s • Patch: Ortho Evra • Skin Irritation • Worse Cramps DVT 3X OCP • Glue Ring Death 3X DVT on OCP!!* • Headaches • *???Yaz and Yasmin? doubtful
Hormonal Contraception • Alternatives to OCP’s • Vaginal Ring: Nuvaring • Body Friendly • Ring Toss • ?Continuous Cycling • Not 21days/7days • No ‘first pass’ effect => lower dose
Hormonal Contraception • NUVARING
Hormonal Contraception • Alternatives to OCP’s • Implant: Implanon • Single Rod - Upper Arm • ?Efficacy in Obese Women • Like all Pg-only, irregular bleeding • Effective 36 months
Rate-controlling membrane: (0.06 mm) 100% EVA Core: 40% ethylene vinyl acetate (EVA) 60% etonogestrel (68 mg) IMPLANON™ 4 cm • IMPLANON™ is not radio-opaque 2 mm Release Rate: 60 μg/day to 70 μg/d initially then decreases to 25 μg/d to 30 μg/d by end of third year IMPLANON™ [package insert]. Roseland, NJ: Organon USA Inc; 2006.
Hormonal Contraception • Emergency Contraception • Initiate < 72 hours after coitus ( < 24 hrs) • Plan B is high dose oral Pg only • Preven is high dose EE & Pg • Yuzpe Method: Ovral 2 PO BID • Ovral 2 PO BID x 2 days • Any 35mcg OCP 4 po BID x 1-2 days • 5mg EE x 5 days (huge dose!!) • Irregular Bleeding • 75% Effective
Other Contraception • Termination of Pregnancy • First Trimester = Suction D & C • Second Trimester • D & E • Saline/PG Injection • RU-486 mifepisterone • High dose synthetic Prostaglandins (Cytotec) • Progesterone Receptor Blocker • Most effective (80%) in mid first trimester (<9 wks)
Other Contraception • Termination of Pregnancy • Misoprostol (Cytotec) synthetic Prostaglandin • High dosage (200-1600mcg daily) • RU-486 mifepisterone • Progesterone Receptor Blocker • Usually given in combination with • High dose synthetic Prostaglandins (Cytotec) • Most effective (80%) in mid first trimester (<9 wks)
Contraceptive Failure Rates
2009 CDC WHO Contraceptive Failure Rates
Birth Control Optionsin 21st Century • Peter L. Stevenson, MD FACOG Associate Clinical Professor Wayne State University School of Medicine Detroit Michigan
IMPLANON™ Applicator IMPLANON™ [package insert]. Roseland, NJ: Organon USA Inc; 2006.
