Subdermal implant>99% effective

up to 3 years

The implant

• Trade name: Nexplanon®

• Up to 3 years of protection• 60 mcg etonorgestrel/day

• Implanted in upper arm• 4cm flexible, plastic rod

• Pregnancy rate• 0.1/ 100 women/year

• Mechanism of action• Suppresses ovulation in most (if not all)

users• Changes cervical mucus • Thins lining of uterus

Bleeding Patterns Definitions %*

Infrequent Less than three bleeding and/or spotting episodes in 90 days (excluding amenorrhea)

33.6

Amenorrhea No bleeding and/or spotting in 90 days

22.2

Prolonged Any bleeding and/or spotting episode lasting more than 14 days in 90 days

17.7

Frequent More than 5 bleeding and/or spotting episodes in 90 days

6.7

* % = Percentage of 90-day intervals with this pattern

Bleeding Patterns During the First Two Years with the Implant

Breast cancer

Cirrhosis/ liver tumors/ active liver disease

Unexplained vaginal bleeding

The implant should not be used in patients with…

• Insert any time in cycle as long as pregnancy can be ruled out

• Procedure is simple and quick• Clinician injects numbing medicine into arm• Slides rod under skin between bicep and tricep

The implant insertion

Hormonal IUDs

• Trade name: Mirena® or Skyla® • Up to 5 years of protection (Mirena) or 3 years

(Skyla)• Releases 20 mcg LNG/day (Mirena) or 14 mcg

LNG/Day (Skyla)

• Pregnancy rate• 0.2/100 women/year

• No long-term effect on fertility

• Mechanism of action:• Thickens cervical mucus• Suppresses endometrium• Does not reliably suppress ovulation

• Improvement of heavy periods

• Improvement of painful periods

• No periods

• Treatment of fibroids and endometriosis

Hormonal IUD: Non-Contraceptive Benefits

• Bleeding irregularities

• No period • 20% at 1 year• 50% at 5 years

• Expulsion rate• 5% over 5 years

• Perforation• Occurs in approximately 1 out of 1000 insertions

Hormonal IUD: Potential side-effects and concerns

• Trade name ParaGard®

• Up to 10 years of protection

• Pregnancy rate• 0.8/ 100 women/year

• No long-term effect on fertility

• Mechanism of action:• Increases copper ions, enzymes,

prostaglandins, and white blood cells in uterine and tubal fluids

• Impairs sperm function and prevents fertilization

Non-hormonal IUD

• No systemic side effects

• Cramping/heavy bleeding • most common in first 3 months• manage with NSAIDs

• Expulsion rate: • 2-10%

• Perforation• Occurs in approximately 1 out of 1000 insertions

Non-hormonal IUD: Potential side-effects and concerns

• Known/suspected pregnancy

• Unexplained vaginal bleeding

• Active cervicitis

• Pelvic inflammatory disease (PID) in past 3 months

• Postpartum or post-abortal infection in past 3 months

• Uterine abnormalities that interfere with insertion

• Genital tract cancer

The copper IUD should not be used in patients with…

• IUD insertion can be crampy • Usually lasts <5 minutes• Patient can take ibuprofen beforehand to

help

• Insert any time in cycle as long as pregnancy can be ruled out

• Same-day insertion the standard• No benefit to waiting until patient has

menses• Making patient return for a second visit

creates unnecessary barriers

Insertion of the IUD

• Improvement of heavy periods

• Improvement of painful periods

• Improvement of endometriosis symptoms

• Minimal drug interactions

The birth control shot: Non-Contraceptive Benefits

• 40 to 50% discontinuation at 1 year

• Irregular bleeding

• No periods• 17% at one year of use• 80% at 5 years of use

• Weight gain

• Decrease in bone mineral density (BMD)• Reversible after woman

stops using method

• Delayed return to fertility (7-12 months)

The birth control shot: Potential side-effects and concerns

Breast cancer

Cirrhosis/ liver tumors/ active liver disease

Unexplained vaginal bleeding

The shot should not be used in patients with…

• Preferred method: “Quick Start” • start immediately and use backup x 7 days

• Switch from another method→ start immediately

• If using Quick Start, woman should have a repeat pregnancy test in 3 weeks

The birth control shot: when to start

• 3 methods:Oral contraceptive pillContraceptive patchVaginal ring

• Contain estrogen and progestin

• Pregnancy rate 9/100 women/year

• Mechanism of action• Thicken cervical mucus• Suppress ovulation

Combined hormonal contraceptives

• Menstrual benefits:• shorter, more regular

period• lighter flow and

decreased anemia• less painful periods• decreased number of

periods per year

• Treatment of endometriosis

• Improvement of acne

• Prevention of functional ovarian cysts

• Decreased risk of ovarian and endometrial cancers

Pill Patch and Ring: Non-contraceptive benefits

• Discontinuation: 11% in 1st month, up to 50% 1st year• Some studies show higher

discontinuation rates for patch, lower for ring

• Breakthrough bleeding

• Nausea

• Breast tenderness

• Headaches

• Mood changes/decreased sex drive

• High blood pressure

• Weight gain

Pill Patch and Ring: Side-effects and concerns

• Smoker ≥35 years

• Personal history of venous or arterial thrombotic event (DVT/PE-blood clot, MI-heart attack, CVA-stroke)

• Complicated diabetes

• Migraine with aura

• Any migraine headache if ≥35 years

• Hypertension

• Coronary artery disease

• Active liver disease

• Breast Cancer

These methods should not be used in women who…

• Preferred method: “QuickStart” • start immediately and use backup x 7 days• may improve continuation

• Day 1 Start & Sunday start may put woman at risk for unintended pregnancy

• Switch from another method• Start immediately and backup method is not

necessary

Pill Patch and Ring: when to start

• Estrogen and progestin-containing pill that a woman takes every day

• Typical use• 21 days active pill, 7 days no/inactive pill

• 24 day regimens• 24 days active pill, 4 days no/inactive pill

• Extended regimens and continuous use

• Take pill at same time every day for maximum effectiveness

Combined Oral Contraceptives

The Patch

• Trade name: Ortho Evra® Patch• Estrogen and progestin-containing

adhesive that a woman wears on her upper arm, lower abdomen, buttocks or upper torso (excluding breasts)

• Change patch 1 x week for 3 weeks, then patch-free for 1 week

• Side effects:detachment 2% site reaction 20%

• Less effective in obese women >198lbs

The Ring

• Trade name: NuvaRing®

• Estrogen and progestin-containing flexible plastic ring a woman inserts herself into her vagina• 21 days ring in, 7 days ring out

and then insert a new ring• Extended regimens possible• Effective in 24 hours

• Can remove for up to 3 hours in a 24-hour time period

• Depo-medroxyprogesterone acetate (DMPA), or Depo- Provera

• Injected once every 12 weeks• intramuscular injection: 150 mg• subcutaneous injection: 104 mg

• Pregnancy rate• 4/100 women/year

• Mechanism of action• Primary mechanism: inhibits ovulation• Thickens cervical mucus• Thins lining of the uterus

The birth control shot

• Improvement of heavy periods

• Improvement of painful periods

• Improvement of endometriosis symptoms

• Minimal drug interactions

The birth control shot: Non-Contraceptive Benefits

Progestin-only pills

• Also known as the “mini-pill” or POPs• May be less effective than birth control

pill • need for strict compliance• “27-hour rule”

• No “pill-free interval” – active pill taken every day• Commonly used in breastfeeding women • Side effects

• irregular bleeding or no period at all

• Offer protection against STIs

• Require motivated user: must use at every act of intercourse

• Mechanism of action• Do not contain hormones• Physical barrier blocks sperm from entering the

uterus

Barrier methods

Emergency contraception

• 3 types of emergency contraception

-Oral levonorgestrel (Plan B®, Next Choice®) – Available over-the-counter for all ages

-Oral ulipristal (ellaOne®) – Progesterone receptor blocker-Copper IUD (ParaGard®) – Most effective form of EC

• Use after unprotected intercourse or underprotected intercourse

• Up to 120 hours after • Sooner is better

• Prevents unintended pregnancy• will not interrupt an established pregnancy

• Prevents or delays ovulation

• Ineffective after implantation

Emergency contraception:Mechanism of action

• No reports of serious complications/death

• Side effects with oral LNG: • nausea 25% • vomiting 10% • irregular bleeding

• Repeated use appears safe• Opportunity for contraceptive counseling

• No scheduled follow-up is required

• No evidence of birth defects

Emergency contraception: safety