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
Top Related