Hormonal Contraception – Ask the Expert by Dr Terri Foran
Contents
1. Contraception Troubleshooti Terri Fen Health Ed Brisbane 21 June 2015 Faculty of Sexual and Reproductive Health Care eshttp www fsrh org pdfs UK MEC2009 pdf Soe ee a a a es ae a it teh i eho tweets eae WS SS Nee are Sa cen Barbara asked about the significance of the VTE risk in the just published BMJ Study i gt e y Annual Risk per 10 000 Worst case Scenario VTE No hormonal contraception and not pregnant ES VTE On COCP containing levonorgestrel or norethisterone Transdermal patches and Vaginal rings VTE On COCP containing desorgestrel gestodene drospirenone 29 VTE Immediate postpartum periods PCO 4 Stratification not apparent in prospective s ies7 e Most women who have a VTE on the COCP would be at significantly higher risk in their first pregnancy 1 Reid R et al Int J Gynaecol Obstet 2011 112 3 252 6 2 Lidegaard O et al BMJ 2011 343 06423 3 Lidegaard O et al BMJ 2012 344 e2990 4 Simpson EL et al BJOG 2001 108 1 56 60 5 Reid RL et al J Fam Plann Reprod Health Care 2010 36 117 122 6 Vinogradova Y et al BMJ 2015 350 h2135_7 Dinger JC et al Contraception 2007 75 344 54 _8 Dinger J et al Contraception 2014 89 253 263 26 Jun 15 Tricky Contraceptive Questions Where do I find the Answers a g 7 i e WHO Medical EligibilityCriteria e Faculty of Sexual and Reproductive Health Care In UK P 7 e Australian Family Planning Organisations2. preparations 4 e Consider reducing Pill fedinterval or encourage extended use e Consider Vaginal ring as an option 1 Holt VL et al Obstet Gynecol 2002 99 5 Pt 1 820 827 4 2 Holt VL et al Obstet Gynecol 2003 105 1 46 Which brings us to Quick Start Outside strict licenced use but aims at reduking barriers to initiation Possibility of pre existing pregnancy should not preclude initiation of COCP POP DMPA Implant Ring on the day of visit regardless of time in cycle Not applicable to IUDs Determine current pregnancy risk Remember a negative pregnancy test cannot exclude an early ae road sex has occurred in the previous 3 weeks Advise additional cover for 7 days of active hormone or 2 days for POP A follow up pregnancy test required No evidence of teratogenesis gt erate is OK until day 45 of pregnancy No significant difference in bleedin conventional start atterns over 4 1 Westhoff C et al Fertli Steril 2003 79 322 329 4 26 Jun 15 Contraception and Weight Gain i l Cochrane COCPs and Patches Available evidence was insufficient to determine the effect of combination contraceptiveg on weight but no large effect wasevident of weight gain when using PO contraception overall quality of evidence moderate to low mean gain lt 2kgs in firstiz months e POP one study only2 LNG Norethisterone minimal weight gain Etonogestrel Implant LNG IUDs Mean weig
3. do not recommend it for prophylaxis on long haul flights 345 e VTE can occur even on anticoagulant therapy 4 e An overall rate of 5 5 of recurrent VTE during the initial 3 months of treatment 1 Kahn SR Peai Chest 2012 141 Suppl 2 195 226 e 7 0 in another large registry study 2 Cesarone MR et al Angiology 2002 53 1 1 6 3 American College of Chest Physicians Evidence Based Clinical Practice Guidelines Chest 2012 141 2_suppl 7S 4 Watson HG et al Br J Haematol 201 Jan 152 1 31 4 5 https www surgeons org media 19372 VTE_Guidelines pdf_ some questions on the COCP at perimenopause e Can safely ontifiu Combined contraception until age 50 provided no identified risk factors e Combined c ntraception helps maintain bone density regulates and reduces bleeding combats vasom symptoms e BUT higher ae haa risk of MI CVA and VTE in older w en S e Consideratio Low oestrogen dose preferable 2omcgm EE Ring d First or second generation COCPs preferable Increasing role of estradiol pill If vasomotor symptoms in consider shortening the pi extended regimen oestradiol patch e LARCs have definite advantages in this group 1 FSRH Guidelines 2010 http www fsrh org pages clinieal_guidance asp Heather asked about Jaydess pa e Not yet marketed in Australia presently bging evaluated by the TGA for PBS listing e Effective for up to 3 years 14ugm day compared with Mirena s 20 e Amenor
4. e Contraceptive Handbook 60 e Talk Line 1300 658 886 Faculty of Sexual and Reproductive Health Care ms AFTENER 3 OYGINA SPOUT CONTRACEPTIVE MOGs LEVELS Ot DICHA COMTEACEFOVE PCAC Y l eshttp www fsrh org pag es Clinical Guidance 4 VTE PE and Combined Contraception e Most epidemiologists regard ORs oveik h around 2 0 as below the threshold for public health concern unless high absolute risk At most a doubling of the VTE risk for the newer progestogelis translates into an additional 4 6 attributable cases per 10 000 users per year and I hope this answers Chris s question Risk of death from VTE is approximately one hund and could be counterbalanced by choosing to drive for 2 hours less each year P BUT remember to ask about Family History before COCP use e VTE in first degree relative under 45 FSRHC 3 Over 45 FSRHC 2 Remind women to list COCP on their medication Nr Consider starting new patients on one of the older Pills 1 Bitzer J et al J Fam Plann Reprod Health Care doi 10 136 jfprhc 2013 100624 7 2 Guillebaud J et al Contraception Your Questions Answered 6th Edition 2012 Churchill Livingstone London GBR Page 186 _3 FSRHC MEC Guidelines 2010 Chris asked about Aspirin and VTE Prevention a e Aspirin is useful for brevention of arterial thrombosis but not veno s e It does not reduce VTE risk in high risk patients e American UK and Australian authorities
5. production Increasing liver production of SHBG which binds circulating androgens May take up to 6 months for maximal effect Anti androgenic progestogens also occupy androgen receptors further preventing the action of circulating androgensjmay work fastet e BUT minimal evidence that one OCP is better than another for acne j L Arowojolu AO et al Combined oral contraceptive pills for treatment of acne Cochrane Database of Systematic Q Contraception and Weight Gain i i e 2 e So what is the evidence e Anecdotally weight gain idiosyncratic and may vary with COCP preparation e In the first year on a 20 megm COCP 12 of women gained more than 2kg 73 of women experience no change 2kg 13 6 of women lost more than 2kg weight Drospirenone preparations may be helpful when fluid retention the issue Vaginal Ring weight gain comparable to 30mcgEE DRSP OCP over ramths 1 Endrikat et al Contraception 1995 52 229 235 2 Foidart JM Climacteric 2005 8 Suppl 3 28 34 Milsom I et al Hum Reprod 2006 21 230 Some Practical Suggestions for the Overweight Patient e Long acting reversible methods IUDs Implant provide high efficacy in this group while avoiding the increased risk of VTE e Monitor for weight jo DMPA e Some evidence that COCPs may be less forgiving in the overweight patient e If combined contraception is the choice and no other contraindications e Consider avoiding very low dose
6. 2006 21 573 578 2 Klipping C et al J Fam Plann Reprod Health Care 2012 38 84 93 Sulak PJ et al Obstet Gynecol 2000 95 261 266 I P L asked what to do when heavy bleeding continues on the COCP e Consider possibility of underlying pathology 7 endometriosis fibroids bleeding diathesis e Expect about 40 50 reduction in bleeding on most COCPs consider extended cycling e Norethisterone Pills most suppressive of pM e Estradiol estradiol valerate Pills F e Qlaira e 88 reduction in bleeding e 15 20 of women in trials experienced no bleeding at 12 months e Zoely e 30 of women experienced no withdrawal bleeding at 12 mths e Consider LNG IUD up to 90 reduction in blee when fibroids adenomyosis endometriosis3 1 Fraser IS et al Eur J Contracept Reprod Health Care 2011 16 4 258 269 2 Mansour D et al Eur J Contracept Reprod Health Care 2011 16 g 1990 97 8 690 6 eding even 26 Jun 15 on Progestogen only LARCs e Due to thin fragile relativelyunder oestrog nised endometrium usually light but occasionally heavy e Dont forget alternative diagnoses J e Minimal evidence for managing irregular bleeding e COCP for women with no contraindication to its use e Generally 1 3 mth trial e Some women use concurrently as requ e 5 day course of an NSAID e Mefenamic acid 500mgs BD e Ibuprofen 800mgs tds e 5 day course of tranexamic acid BR BD e Some gynaes suggest sieht E might wor
7. days Exception is Zoely Qlaira when it is advisable to commence new Pill instead of placebo pills or on day of Ring removal Rapid reversal of Implants LNG IUDs and Cop j e So preferably start the other method a week bef ore removing them or advise additional cover for one week DMPA cover extends at least 2 weeks past date of scheduled next injection 3 If a woman s preferred contraceptive meent not available usually with m fo FUD insertion al bridging Mr contraceptive should be offered COCP POP DMPA j l 1 FSRHC htp MaE h org pdfs CEUGuidanceQuickStartin Mapntraeeption pdf Heather asked Whats new g b i e Our present 1 5 mgs LNGECP Bu e Not abortifacient does not interfere with embryo attachment and no effect on Te pregnancy i e Primary action is to delay ovulation making window of efficacy relatively sh e Less effective when taken just p e Less effective in heavier women e Before TGA 30 rA Ulipristal acetate ECP e Selective progesterone receptor modulator to ovulation Directly inhibits follicle rupture e More effective than LNG if takemright on ovulation A e More effective than LNG if take days after USI 4 e Secondary effects on endometriu ay augment effect3 g 1 Meng CX et al Fertil Steril 2009 91 256 64 Davidoff F et al JAMA 6 296 1775 1778 2 Davidoff weddi T TT 1 Caya Website http www caya eu en _Gemzell Danielsson K Contraception 2010 82 404 9 Thanks for all t
8. han COCP e Woman must still require contraception to access RBS benefit e A LNG IUD inserted after 45 can be left in situ for 7 years off licence e Contraceptive Implants are safe to use but more irregular bleeding pattern though usually light and no effect on vasomotor symptoms e DMPA trend to no bleeding over time but coneerns re bone density does help with flushes e Copper IUDs bleeding may be an issue N e A copper IUD inserted after 40 can be left in until the menopause off licence A 1 FSRHC http www fsrh org pdfs ContraceptionOver4o uly10 pd IUD use in Young Adolescents l A gt Be aware of legal and child protection issues which vary from State to State FSRHC 2 under 20 years Both copper and hormonal IUDs highly effective and convenient e CHOICE Women under 21 using non LARCs were twice as likely to have an unintended pregnancy as their older sisters e CHOICE High continuation rates of UDs Implants 67 at 2 years in 14 19 year olds almost twice that of non LARCs e So when Diana asked whether LARCs are a better choice for adolescents than an OCP a resounding YES Higher risk of expulsion due to nulliparity and smaller uterine size Jaydess May be technically more difficult to insert Option of N sedation User must be accepting of change in bleeding pattern Access may be problematic limited number of inserters costs etc Timing can be difficult consider bridging contraception
9. he great questions ih b IT S A ZEN DIAPHRAGM 26 Jun 15 Heather asked Whats new ih i Diaphragms no longer marketed in Australia Can still obtain from overseas websites if size known But one size fits most now available over web Family ene Clinics Clinical trials indicate failure rate of 14 18 with consistent use Manufacturer suggests AR lactic acid gel CAYA gel F Australian FPOs suggest that clinician check for correct fit before use Device containing antivirals in therim in de a YA device from some
10. ht gain comparable to copper IUD users e DMPA e Some evidence that DMPA may be a weight gain in some women 7 e Cochrane Progestogen only methods We ther evidence 1 Gallo MF et al 201 CDBSR Issue 9 Art No CDo03987 2 Lopez LM et al CDBSR 2013 Issue 7 Art No CDoo8815 y Ball MJ et al Contraception 1991 44 3 223 33 4 Urbancsek J Contraception 1998 58 109S 15S 5 Anderssson K et al Contraception 1994 49 56 72 6 Trussell J C 3 b In Contraceptive Technology 19 ed New York NY Ardent Media Inc 2007 Bonny AE et al Journal of Adolescent Health 2009 45 4 423 5 Bruce asked when contraceptive cover is achieved after starting various methods e When no previous contraception immediate cover achieved when method initiated e Most Pills COCP and POP day 1 5 of cycle with active start e Qlaira Ring Zoely day 1 of cycle e Contraceptive Implant day 1 to 5 of cycle e DMPA day 1 5 of cycle e LNG IUD day 1 7 of cycle e Copper IUD until 5 days after expected ovulation e Product information states method can be initiated later in cycle provided pregnancy can be confidently excluded Contraceptive cover then achieved at e LNG IUD Copper IUD 7 days i e COCP including Zoely Ring Implant injectabl 7 days e Qlaira 9 days e POP 2 days 4 h ON tion pdf Changing from one Method to Another l From one COCP to another commence few Pill after ushal placebo pill free period either 4 or 7
11. k red e If bleeding persists consider change of method e Consider early initiation if occurs in year 3 of Implanon NXT last few weeks of DMPA 1 Read C Harvey C Bateson B et al Joint Statement Bleeding pattern changes with progestogen only long acting reversible contraceptives ZEST Healthcare Communications 2010 Syd A Deborah and K P asked about bleeding with extended useCOCP 4 e Can tricycle quadricycle most not COCPs sagt significant BTB e No evidence but if possible I always get them to fe one or two conventional cycles before attempting extended use 10 BTB at 12 months in trials of conventionally cycled low dose OCPs e But best potential for longer extended use with most suppressive progestogens norethisterone nomegestrol acetate dienogest and gestodene probably the best e Yaz Flex is the only licenced extended use preparation in Australia 20 in trials took it to max 126 days __ e If more than 3 days of BTB take 4 day break and resume rather than persist with active pills3 4 1 Mansour D et al Eur J Contraception Reprod Health Care 2011 16 6 430 43 2 Klipping C et al J Fam Plann reprod Health Care 2012 38 73 83 3 Sulak PJ et al Am J Obs amp Gyn 2006 oo 935 41 K P also asked about acne and various Combined Contraceptives e All COCPs help control acne 50 z reduction in lesions by e Providing constant oestrogen dose Suppressing ovarian androgen production Suppressing sebum
12. rhoea less common than with Mirena e Disadvantage 30mm e Some women prefer a more regular bleeding pattern for e or personal reasons e Slightly smaller than Mirena bothin width and length silver band distinguishes on X ray e May hold advantage in use in nul liparotis women e May better suit those with smalleruterine cavity e Real advantages for menstrual management in very young adolescents living with a disability 26 Jun 15 Fiona had some questions on Perimenopausal Contraception gt Safe to stop contraception after 2 En amenorrhoea in those under 50 and 1 year in those over 50 FSH is not a reliable indicator of menopause in women on combined contraception even if measured in pill free interval FSH useful in those using POC but only if over 50 and amenorrhoeic need 2 FSH gt 30 U ml 6 weeks apart HRT is not contraceptive Natural conception rate at 50 around 1 in 1000 so discussion around acceptable risk worth having In 1997 Dawn Brooke delivered vara conceived son in the UK at age 59 L 1 FSRHC http wwwfsrh org pdfs ContraceptionOver4ojuly10 pdf 2 Guinness Book of Records The LARCS at Perimenopause e Mirena is an excellent choice in appropriate patients since it provides excellent and very convenient contraceptive cover reduces bleeding and can very safely be used as the progestogen component of HRT for control of vasomotor symptoms e Risks of VTE CVA etc those of HRT rather t
13. with DMPA 7 1 Winner B N Engl J Med 2012 366 1998 2007 2 O Neil Callahan M et al 2013 Obstet Gynecol 122 5 1083 9 Deborah asked about managing BTB e 20 40 of women will experience BTB in first 3 months on COCP even higher on 2omcrgm LNG Pills reassure and persist check pill taking a If new symptom A F ra Check use of preparations which interfere with Pill including Hypericum Y e Consider chlamydia pregnancy other pathology e Try different progestogen norethisterone nomegestrol acetate and dienogest have reputation for better endometrial suppression e Triphasics no evidence of better cycle ontrol e Change delivery system NuvaRing has better cycle control than 3omcrgm LNG COCP e As last resort increase oestrogen 1 Van Vliet HAAM et al Cochrane Database Sys Rev 2006 3 CDo032 4 Ingrid asked about the Safety of Extended Use COCP e e Used since 1960s for treatment of endom triosis dysmenorrhoea and heavy menstrual bleeding e Safety of continuous COCP re established to 12 months e Extended use of EE DRSP regimen over 2 years found no significant differences iz parameters haemostatic variables carbohydrate metabolism e Benefits e Less dysmenorrhoea less anaemia e Side effects more common during hormone free days than during active treatment in standard OC regimen3 e Missed pills less likely to contribute to failure e Higher incidence of BTB 1 Edelman A Human Reproduction
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