# Presentation: 353722

## Contraceptive Update

**John Kulig, MD, MPH**
**Principal Medical Consultant**
**April 25, 2007**

## Slide 2

## Oral Contraceptive Pills

## New progestins

- 1st generation:
- 	norethindrone
- 2nd generation:
- 	norgestrel
- 	levonorgestrel

- 3rd generation:
- 	desogestrel
- 	norgestimate
- new:
- 	drospirenone
- 	Yasmin®/Yaz®

## Generic oral contraceptive pills

- Alesse® => Aviane®
- Cyclessa® => Velivet®
- Demulen® => Zovia®
- Desogen®/OrthoCept® => Apri®
- Mircette® => Kariva®
- Nordette® => Portia®
- Ortho-Cyclen® => Sprintec®
- Ortho-Novum® => Nortrel®
- Ortho Tri-Cyclen® => Tri-Sprintec®
- Triphasil®/Tri-Levlen® => Trivora®

## Seasonale®/Seasonique®

- extended regimen combined oral contraceptive pills with ethinyl estradiol and levonorgestrel
- 91 day cycles - 84 days on –
- 	7 days off
- 4 menstrual cycles per year –
- 	one each season

## Noncontraceptive benefits of OCs

**Noncontraceptive benefits of OCs**

- decrease menstrual flow (lighter, shorter periods)
- decrease menstrual cramps (no ovulation)
- improve anemia (lighter, shorter periods)
- improve acne (estrogen effect)
- protect against ovarian and endometrial cancer
- decrease benign breast disease
- decrease ovarian cyst formation
- prevent ectopic pregnancy
- protect against some causes of PID
- protect against osteoporosis

## Oral contraceptives and risk of breast cancer

- study of 4575 women with breast cancer and 4682 controls - age 35 to 64 years at interview
- relative risk 1.0 [0.8-1.3] for current OC users
- relative risk 0.9 [0.8-1.0] for previous OC users
- similar results in white and black women
- relative risk did not increase with longer use or with higher estrogen dose
- no increased risk associated with initiation of OC use in adolescence
- 					      NEJM 2002;346:2025-2032

## Emergency Contraception

## Slide 10

## Mifepristone (RU486)

**Mifepristone (RU486)**

## Should EC be prescribed in advance of need?

- women receiving EC in advance are two to three times more likely to use them, but not to use them repeatedly (US/Scotland)
- 80% of women who received EC in advance began treatment within 24 hours of intercourse vs 40% of women who needed to fill an EC prescription
- no more likely to engage in sexual activity
- no more likely to use their regular contraceptive less consistently

## Should EC be prescribed in advance of need?

- fewer than one third of female adolescents have heard of EC (1998 data)
- 17% of young women report no use of contraception at most recent intercourse
- 20% of women report forced sexual intercourse and 72% were under age 20 at the time of the experience (NCHS)
- lack of clinician availability on weekends may disproportionately affect adolescents

## Should EC be made available without a clinician’s prescription?

- Arguments _in favor_ of OTC availability:
- improved public health
- delays in treatment lead to more unintended pregnancies
- easier access to EC 24 hours a day
- safe for self-medication
- same dose for all women
- same medications safely used for contraception for decades
- serious adverse effects do not occur, even with inappropriate use

## Should EC be made available without a clinician’s prescription?

- Arguments _opposed_ to OTC availability:
- no clinician contact to discuss potential side effects
- missed opportunity for contraceptive counseling
- may make refusal of sexual intercourse more difficult
- EC is a euphemism for induced early abortion
- EC might unintentionally be used in pregnancy
- EC use might undermine use of non-emergency contraception, including barrier methods

## Does knowledge of EC alter adolescent sexual behavior?

- study of 916 male and 852 female students age 14-15 in 12 schools in UK
- single lesson on emergency contraception
- improved knowledge persisted six months later in comparison with controls
- no difference in sexual activity, intent to use EC or use of EC
- 					Ref: BMJ 2002:324:1179-1183

## Progestin-only Injectable Contraception

## Slide 18

## Depo-Provera

-  depot medroxyprogesterone acetate
-   150 mg IM _or_ 104 mg SC
- 	 once every 12 weeks
-  irregular bleeding => amenorrhea
-     within 2 years  (70%)
-  concerns:
-   weight gain
-   hair loss/acne
-   osteoporosis risk

## ContraceptivePatch

## Slide 21

## Ortho Evra

- seven day contraceptive patch
- 1 3/4 inch three layer adhesive patch
- contains both estrogen and progestin
- applied to the buttocks, lower abdomen or upper body
- newly applied weekly for three weeks, then one week off for menses
- less effective in women over 198 pounds
- approved by the FDA in November 2001

## Ortho Evra

- Side effects leading to discontinuation:
- nausea (2%)
- moodiness (1.5%)
- headache (1.1%)
- breast discomfort (1%)
- irritation at application site (1.9%)
- Inadvertent detachment uncommon (1.9%), even with exercise, humid climates, saunas, hot tubs

## ContraceptiveVaginal Ring

## Slide 25

## NuvaRing

- contraceptive vaginal ring - 2 inch diameter
- worn for 21 days => removed for 7 days to allow menses => replaced with new ring
- releases 120 mcg of etonogestrel and 15 mcg of ethinyl estradiol daily
- one size only - does not require fitting
- cannot be inserted incorrectly
- no increase in vaginal infections/discharge
- 3 hour window after inadvertent removal

## ContraceptiveImplant

## Slide 28

## Implanon

- progestin-only contraceptive implant
- single flexible 4 cm rod inserted under the skin of the upper arm
- contains 68 mg etonogestrel - releases
- 	40 mcg daily - 3 year efficacy
- no pregnancies in 73,000 monthly cycles
- irregular menstrual bleeding common
- clinician visit for insertion and removal

## Intrauterine Contraceptive System

## Slide 31

## Mirena

- levonorgestrel-releasing intrauterine system - 20 mcg daily - 5 year efficacy
- highest risk of PID within 20 days of insertion
- irregular menstrual bleeding common in first 3-6 months
- clinician visit for insertion and removal

## Slide 33

## Advances in barrier contraception

**“****invisible condom”  (PRO 2000****R****)**
**colorless, odorless vaginal microbicidal gel**
**contraceptive/antimicrobial barrier**
**effective against HSV/HIV/Chlamydia**
**no irritation of vaginal tissues**
**safety trials underway**

## Slide 35