Contraceptives

Combined Hormonal Contraceptives

Components: Estrogen + Progestin

• Regulates cycles, reduces dysmenorrhea, acne
• Decreases risk of endometrial and ovarian cancer

Contraindications:

• Aura migraine
  • Aura migraine -> increased risk of blood clots in the brain
  • Estrogen also increase the risk of clotting -> increase risk of stroke
• Clotted history (DVT/PE)
• Hypertension (uncontrolled)
• Estrogen-sensitive cancer
  • Or any untyped breast or uterine cancer that may be hormone sensitive
  • Makes it worse
• Smoker >35 years old
  • DVT
• Breast feeding
  • High estrogen levels can delay or blunt lactogenesis Stage II, reducing both volume and consistency of milk.

Progestin-Only Contraceptives

• Mini-pill (oral) - requires strict daily timing
• Depot medroxyprogesterone (DMPA) - IM injection every 3 months
• Progestin IUDs
• Etonogestrel Implant - lasts 3 years
• Benefits:
  • Safe in breastfeeding, history of DVT/PE
  • Reduces endometrial cancer risk
• Side Effects:
  • Irregular bleeding (esp. initial months)
  • DMPA: Weight gain, ↓ bone mineral density

Intrauterine Devices (IUDs)

Copper IUD

• Non-hormonal, lasts 10 years
• Causes local inflammation toxic to sperm
• Most effective EC (within 5 days)

Progestin IUDs

• Thickens cervical mucus, thins endometrium
• Lasts 3-8 years depending on type
• Good for menorrhagia, endometriosis

Barrier Methods

• Male/Female condoms – STI prevention
• Diaphragm, cervical cap, sponge – less effective, need fitting

Permanent Methods

• Tubal ligation
• Vasectomy
  • Best for completed families
  • Vasectomy takes ~3 months for full azoospermia

Methods of Emergency Contraception

Copper IUD

• Most effective method (>99%)
• Insert within 5 days of unprotected intercourse
• Non-hormonal; toxic to sperm & ova
• Doubles as long-term contraception
• Contraindications: Active pelvic infection, uterine anomaly

Ulipristal Acetate

• Selective progesterone receptor modulator (SPRM)
• Use within 5 days (120 hours)
• More effective than Plan B, especially close to ovulation or in higher BMI
• Prescription only
• Delay starting hormonal contraception for 5 days (can reduce effectiveness)
• Backup method x7 days after resuming contraception

Levonorgestrel (Plan B)

• Progestin-only pill
• Most effective within 72 hours (3 days), can use up to 5 days
• Available OTC, no age restrictions
• Less effective if BMI >25 or near ovulation
• No need to delay resuming contraception