Hormonal Contraception: Combination OCPs

Contain Synthetic Estrogen/Progestin Modern E2 Dosage 50 Mcg Despite Diversity, Side Effects and Efficacies Similar Requires Patient Compliance May Be Monophasic or Triphasic

Combination OCPs: Mechanism of Action

Suppresses LH / FSH Release (E2 FSH, P LH) Progestin Thickens Cervical Mucus and Alters Endometrium Major Effect Is Anovulation and Impairment of Sperm Transport and Ocyte Implantation

Combination OCPs: Additional Benefits

Menstrual Regulation Decreased Risk of Anemia Ovarian, Endometrial CA: Risk Lower PID Risk Prevention of Benign Breast Disease

Combination OCPs: Side Effects

Breakthrough Bleeding ( 25%) Amenorrhea Breast Tenderness, Nausea H/A (+/) ?HTN ?Weight Gain

Combination OCPs: Risks

Thromboembolism ( 35 yo, Smoker) MI (Smokers Only):

< 15 cig/day: 3X Risk > 15 cig/day : 21X Risk

Liver Adenomas (Very Rare)

Depo-Provera:
Inhibits Ovulation 150 mg q3months (14 day grace period) Delayed Ovulation After Discontinuation Main Side-Effects:

Amenorrhea AUB Weight Gain Hair Loss

Norplant:
Implantable for 5 Years Similar Side Effects as Depo-Provera Avg. Yearly Failure Rate: 0.8/100 (Increases : > 2/100 after 5 years) Occasionally Difficult to Remove

Barrier Methods:
Diaphragm: High Failure Rates Must Remain in ~6 Hrs post-coitus Best if Combined with Spermicide UTI Potential Condom: STD Protection, Inconsistent Use by Men Female Condom: Cumbersome, Learning Curve Today Sponge: As seen on Seinfeld

IUD: Overview
ParaGard (CuT380A), Progestasert Very Effective (~ TL), Reversable Risks OVERBLOWN Monogamy Essential, However Does Not Protect Against STDs Can Remain for 10 Years

IUD: Mechanisms of Action

NOT ABORTIFACIENT!!!!!!!! Prevents Conception: Sperm Transport Inhibited Sperm Survival / Capacitation Diminished Prevents Implantation: hCG Levels = 0

IUD: Work-up
History: STDs, Sexual History, Ectopic PEx: Size / Configuration of Uterus Cervical Cultures, Pap Counseling

IUD: Contraindications
Lack of Monogomy, High Risk for STDs Abnormal Uterine Bleeding Current Pelvic Infection (GC, Chl) Actinomyces on Pap ???Nulliparity Pregnancy Wilsons Dz, Cu Allergy (both rare)

IUD: Complications
PID: Usually 20 Insertional Contamination Unproven Role for Prophylactic ABx Hypermenorrhea Expulsion Perforation (< 0.1%) Failure: IUD Should be Removed ??Ectopic

Emergency Contraception
IUD, OCPs Specific OCP Regimens Given 72 Hours After Unprotected Intercourse ~ 75% Effective Yuzpe Method: Ovral 2 tabs po now and 2 tabs 120 later May Cause Nausea Consider Dispensing at Yearly Visit

Special Circumstances
Postpartum/Postabortion: IUD, Progestins, Combination OCPs* Anticonvulsant/Antibiotic Use: TCN Probably OK Most Anticonvulsants Impair Efficacy of Hormonal Contraceptives

* may affect lactation before milk flow established