This document discusses various methods of contraception, including hormonal methods like oral contraceptives, barrier methods, intrauterine devices, and surgical methods like tubal ligation and vasectomy. It provides details on the mechanisms of action, effectiveness, advantages, and disadvantages of different contraceptive options to help health care providers choose appropriate contraception based on individual clinical situations.

1. ABHINAV SAWHNEY
M.PHARMACY
(PHARMACOLOGY)
AMITY INSITUTE OF PHARMACY,
AMITY UNIVERSITY
NOIDA

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.  Hormonal Contraceptives:
• oral, transdermal, intravaginal, IM, implanted
 Barrier Devices
• Diaphragm
• Condoms: male and female
• Cervical Caps

4. Surgical:
• Tubal Ligation, Vasectomy
Intrauterine Devices:
• IUDs: copper or progesterone
releasing

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. Synthetic estrogens
• Ethinyl estradiol
• Mestranol
Synthetic progestins
• Many different progestins available

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. Progestin doses range from 0.05mg – 1mg
Differ in their androgenic, estrogenic, and
progestational activity

9. Norethindrone – ex: ortho-novum, necon
Norethindrone acetate – ex: junel,
estrostep, loestrin
Ethynodiol diacetate – ex: zovia
Medium androgenic potency

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. Norgestimate ( ortho-cyclen or tri-cyclen)
 FDA approved to treat acne
desogestrel (desogen, ortho-cept)
Gestodene – not available in US

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. 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. 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. If taken correctly: 99.9%
In reality: 92.4%
Return to fertility:
• Average 2 month delay in conception after OCP’s
stopped

16. Suppress ovulation
Suppress follicular development
Alter cervical mucous making sperm
penetration more difficult
Alters endometrium making implantation
less likely

17. Definite
 Decreases dysmenorrhea
 Decreased risk of ovarian cancer
 Decreased risk of endometrial cancer by 50%
 Decreased risk of pregnancy
 Treatment of Acne

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. Hepatic vein thrombosis
Portal vein thrombosis
Splenic artery thrombosis
Mesenteric artery thrombosis
Mesenteric vein thrombosis

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.  Side effects:
• Breakthrough bleeding – most common reason for
discontinuation
• Nausea
• Weight gain
• Mood swings
• Breast tenderness
• Headaches
• Acne, facial hair growth

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.  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. 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.  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. 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.  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. 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.  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. IM injection of 150 mg every 12 weeks
99.7% success rate
medroxyprogesterone:
• Thickens cervical mucous-less penetrable to
sperm
• Suppresses ovulation

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. Can’t or won’t take daily OC
Migraine headaches
Breast feeding
• Can start after 6 weeks
Efficacy: 99.7% ( theoretical and actual)

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.  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. 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. 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. Breast tenderness
Headache
Application site irritation
Nausea
Breakthrough bleeding

38. < 1 pregnancy / 100 users
Higher compliance rates than OCP users
and higher “perfect use” rates

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. Vaginitis
Leukorrhea
Weight gain
Nausea
Headache
Breakthrough bleeding

41. Similar to OCP use
Slightly higher rates of discontinuation due
to local side effects

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. 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. 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.  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. 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. 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. • 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.  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. Lactation:
• Most useful in first three months
• Effective if woman is breast feeding full time and is
amenorrheic
Tubal Ligation
Vasectomy