Contraceptions

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Contraceptions

  1. 1. ABHINAV SAWHNEY M.PHARMACY (PHARMACOLOGY) AMITY INSITUTE OF PHARMACY, AMITY UNIVERSITY NOIDA
  2. 2. Review Different Methods of Contraception Review the advantages and disadvantages of each method Choose appropriate contraception based on different clinical situations Review how to prescribe contraceptives
  3. 3.  Hormonal Contraceptives: • oral, transdermal, intravaginal, IM, implanted  Barrier Devices • Diaphragm • Condoms: male and female • Cervical Caps
  4. 4. Surgical: • Tubal Ligation, Vasectomy Intrauterine Devices: • IUDs: copper or progesterone releasing
  5. 5.  Introduced in early 1960s  Most widely used form of reversible birth control  Have contraceptive and noncontraceptive benefits  Estrogen + progestin combination or progestin alone
  6. 6. Synthetic estrogens • Ethinyl estradiol • Mestranol Synthetic progestins • Many different progestins available
  7. 7.  Ethinyl estradiol doses range from 20 -150 mcg • Doses > 50mcg no longer available in US • Low dose estrogen (35 mcg or less) recommended as initial treatment  Higher doses increase incidence of VTE  Lower doses may result in significant breakthrough bleeding or spotting  20 mcg dose helpful in premenopausal women or those with significant estrogen side effects • 50mcg dose needed in women on certain anticonvulsants  Ex: Genora 1/50; Nelova 1/50, Ortho-Novum 1/50, Demulen 1/50
  8. 8. Progestin doses range from 0.05mg – 1mg Differ in their androgenic, estrogenic, and progestational activity
  9. 9. Norethindrone – ex: ortho-novum, necon Norethindrone acetate – ex: junel, estrostep, loestrin Ethynodiol diacetate – ex: zovia Medium androgenic potency
  10. 10.  High progestational and androgenic activity  Levonorgestrel  Most widely prescribed progestin  Ex: Levlen, Alesse, Tri-Leven, Triphasil  Approved for emergency contraception  Approved for extended cycle use –ex: seasonal  Norgestrel • Ex: cryselle, lo-ovral
  11. 11. Norgestimate ( ortho-cyclen or tri-cyclen)  FDA approved to treat acne desogestrel (desogen, ortho-cept) Gestodene – not available in US
  12. 12.  Drosperinone – new progestin derived from 17- alpha spironolactone • Progestogenic, antiandrogenic, and antimineralcorticoid activity • Ex: Yasmin: 30 mcg of ethinyl estradiol and 3 mg of drospirenone • Yaz: • Useful in women with excess water retention, acne, hirsutism • Watch for hyperkalemia
  13. 13. Monophasic Multiphasic - 2 or 3 different progestin doses  21 day regimen  28 day regimen • 21 active pills + 7 inert pills • 24 active pills + 4 inert pills  Ex: YAZ and Lo-estrin
  14. 14. Extended cycle • Seasonale – 91 days total – 84 days active + 7 days inactive • Seasonique – 91 days total - 84 days active + 7 days 5mcg ethinyl.estradiol  Useful for endometriosis, premenstrual dysphoric disorder, or lifestyle reasons  Efficacy unchanged  Breakthrough bleeding common  No risk of endometrial hyperplasia
  15. 15. If taken correctly: 99.9% In reality: 92.4% Return to fertility: • Average 2 month delay in conception after OCP’s stopped
  16. 16. Suppress ovulation Suppress follicular development Alter cervical mucous making sperm penetration more difficult Alters endometrium making implantation less likely
  17. 17. Definite  Decreases dysmenorrhea  Decreased risk of ovarian cancer  Decreased risk of endometrial cancer by 50%  Decreased risk of pregnancy  Treatment of Acne
  18. 18.  Stroke • Ischemic: increased risk by 2 ½ times  Increased risk with age, HTN, Migraine headaches  Myocardial Infarction: • 80% of cases of MI among OC users are in smokers • OC are contraindicated if age>=35 and smoke >15 cig/day
  19. 19. Hepatic vein thrombosis Portal vein thrombosis Splenic artery thrombosis Mesenteric artery thrombosis Mesenteric vein thrombosis
  20. 20.  Pregnant or breastfeeding  History of DVT, MI, Stroke, Hypercoagulable state  Liver disease  Smoker >15 cig/day age> 35  Complicated Migraine Headaches or migraines in women > age 35  Estrogen dependent tumor –breast, endometrium  Uncontrolled HTN, unexplained vaginal bleeding
  21. 21.  Side effects: • Breakthrough bleeding – most common reason for discontinuation • Nausea • Weight gain • Mood swings • Breast tenderness • Headaches • Acne, facial hair growth
  22. 22. Most common in low dose combination pills Most frequent in the first three months as endometrium adjusts to lower hormone levels Increased rate if miss a pill Increased rates in extended use cycles
  23. 23.  Treatment options • Increase estrogen dose  Bleeding early in cycle or no withdrawal bleeding  Ex: ortho tri cyclen lo (25 mcg) to orth-tri cyclen ( 35 mcg) • Increase progestin dose  Bleeding after day 14 in cycle • Change to more androgenic progestin  Decreases bleeding at any time during cycle  Ex: levlen ( LNG progesterone) • Switch from extended cycle to 28 day cycle regimen
  24. 24. Related to estrogen dose Usually most severe in first 1 – 3 cycles of OC use Management: • Take with food or bedtime • Change to OC with lower estrogen dose
  25. 25.  Related to high estrogen content  Usually concentrated in pill-free days and first days of cycle  Ischemic stroke risk increased in patients with hx of migraines • Do not give to women with aura or focal symptoms • Do not give to women with migraine over age 35 • Do not give if frequent or severe migraine hx
  26. 26. Meta-analysis - relative risk of ischemic stroke among women with migraine taking oral contraceptives, from the pooled data of three studies, was 8.72 (95% CI 5.05- 15.05) Risk of ischaemic stroke in people with migraine: systematic review and meta- analysis of observational studies. AUEtminan M; Takkouche B; Isorna FC; Samii A SOBMJ 2005 Jan 8;330(7482):63. Epub 2004.
  27. 27.  Decreased: • Direct action on brain from progestin • Increase in sex hormone-binding gonadotropin induced by estrogen  Treatment: • OCP with less estrogenic or progestational properties • Higher androgenic properties  Progesteron component: levonorgestrel,dl-norgestrel, desogestrel  Ex: alesse, lo-ovral, levlen
  28. 28. The estrogen component of OC pills raises serum concentrations of thyroxine-binding globulin (TBG) • Increased levels of total thyroxine & total triiodothyronine • No change in levels of free thyroxine and free triiodothyronine • T3 resin uptake will be low
  29. 29.  Hepatic adenoma  Correlates with dose and duration of OCP use  Incidence 30-40 / 1 million in OCP users • 1 / 1 million women in non users  Increased number, size, and risk of bleeding in OCP users  s/s: abdominal pain, incidental, rupture / abd bleeding
  30. 30. IM injection of 150 mg every 12 weeks 99.7% success rate medroxyprogesterone: • Thickens cervical mucous-less penetrable to sperm • Suppresses ovulation
  31. 31. First dose given within 5 days of LMP If given >=7th day of LMP, another form of contraceptive should be used for 7 days Efficacy is up to 14 weeks
  32. 32. Can’t or won’t take daily OC Migraine headaches Breast feeding • Can start after 6 weeks Efficacy: 99.7% ( theoretical and actual)
  33. 33. Irregular bleeding • Persistent bleeding can be treated with 50 mcg of ethinly estradiol for 14 days Other: weight gain, headaches, dizzy, injection site reactions Takes about 6-9 months after last injection for return of fertility but may be as long as 18 months
  34. 34.  Implanon (etonogestrel) • progesterone releasing contraceptive implant approved for 3 years • Single plastic rod about length of toothpick • Implant day 1-5 of cycle • Pregnancy rates similar to IUD and sterilization  Norplant • No longer available due to limited supplies and problems with removal
  35. 35. Ortho Evra: • Releases 20 mcg ethinyl estradiol and 150 mcg of norelgestromin per day Each patch worn for 1 week for cycle of 3 weeks then withdrawal bleed during week 4 Caution for women with weights over 90kg as may be less clinically effective
  36. 36. DVT risk: • Steady state levels of estrogen much higher with patch users then OCP users • One study showed 2.4 OR increased risk of VTE for patch users compared to OCP users DVT: Deep Vein Thrombosis VTE: Vascular thromboembolosis
  37. 37. Breast tenderness Headache Application site irritation Nausea Breakthrough bleeding
  38. 38. < 1 pregnancy / 100 users Higher compliance rates than OCP users and higher “perfect use” rates
  39. 39.  Delivers 15 mcg of ethinly estradiol and 120 mcg of etonogestrel per day  Intravaginal for three weeks  Insert on or before day 5 of LMP-use backup for 7 days
  40. 40. Vaginitis Leukorrhea Weight gain Nausea Headache Breakthrough bleeding
  41. 41. Similar to OCP use Slightly higher rates of discontinuation due to local side effects
  42. 42. Administer within 72 hours of unprotected intercourse • most effective if taken within 12 hours Mechanism of action • Inhibits ovulation, prevents implantation, or may cause regression of corpus luteum
  43. 43. Yuzpe Regimen: • 100mcg of ethinyl estradiol and 0.5 mg of levonorgestrel. E.g. Ovral, Preven (50mcg/0.25mg)  Take 2 pills within 72 hours and 2 pills 12 hours later • Has a 75-80% efficacy rate • Usually requires antimetic
  44. 44. Levonorgestrel: Progesterone only, Plan B • 0.75 mg Q 12 hrs for total of two doses • Prevents 85% • Less nausea and vomiting Copper IUD inserted within 5 days is also effective
  45. 45.  Male condom; efficacy 14/100  Diaphragm: 20/100  Cervical Cap: • Never pregnant: 20/100 • Ever Pregnant: 40/100  Today Sponge: barrier plus spermicide. Effective for 24 hours. Estimated efficacy of 89-91% • No special fitting required
  46. 46. Levonorgestrel (Lng IUC) • Mirena = trademark • Progesterone secreting • Can be left in place for 5 years • First yr pregnancy rate 0.1-0.2% • Irregular bleeding common early followed by development of amenorrhea in 20%
  47. 47. Copper T (Tcu380A IUD) • Paragard = trademark • Copper releasing • Approved to remain in place for 10 years • First yr pregnancy rate 0.6-0.8% • Heavy menses and dysmenorrhea common
  48. 48. • Highly effective • Convenient • High patient satisfaction • Inexpensive over time • No effect on fertility after removal • Decreases risk of ectopic pregnancy compared to no contraception • LNg IUD can decrease risk of PID from newly acquired STD’s once IUD in place • Progestin thickens cervical mucous which acts as barrier to ascending infection
  49. 49.  High initial cost  No protection against STD’s  Small increase risk of PID in first 20 days after placement • Related to contamination during insertion process and presence of pre-existent STD’s  If pregnancy occurs while IUD in place then more likely to be ectopic
  50. 50. Lactation: • Most useful in first three months • Effective if woman is breast feeding full time and is amenorrheic Tubal Ligation Vasectomy

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