Contraception

Oral Contraception

  1. Fixed combined dosaging- estrogen and progestin 3 weeks
  2. Combination phasic (biaphasic, triphasic) 2 to 3 different amounts of E & P from 5 to 11 days. Idea is to lower total dose of steroid administrated without increasing incidence unscheduled bleeding.
  3. Daily Progestin- progestin without estrogen once a day without steroid free interval.

All formulations made from synthetic steroids no natural estrogens or progestins.

Progestins- 19 nortesterone- resembled testosterone (some degree and and androdenic activity) two types- estranges and gonanes.

C21 progestin- medroxyprogesterone acetate and megastol. Only used as injectable.

 

Estrogens- Ethinyl estradiol 3 methyl ether (mestranol)

Estrogen- progestin combinations the most effective OC that consistently inhibits midcyclic surge and thus prevents ovulation

Progestin- only don’t consistently inhibit ovulation must be taken the same time daily.

 

Estrogen causes nausea (CNS effect), breast tenderness, and fluid retention (doesn’t exceed 3-4 lbs) do not decreased sodium excretion. Minor changes decreased vitamin A, B-complex, and C. Higher doses greater than 50 ug estrogen depression and mood change by decreasing serotonin levels.

Progestins- androgenic properties, weight gain, acne, and nervousness.

*Healthy females > 35 years can use OCP’S till 50-55 years of age without doing TSH, weighing risks and benefits

*Chronic hypertension > 35 years progestin/IUD no increase in cardiovascular disease

* Chronic hypertension < 35 years well controlled OCP’s can be used.

*Lipid disorders

 

*Smoking > 35 years- increase thromboebolism (MI/stroke twice risk)

*Migraine (most common type headache tension not migraine)

*Migraine < 35 years old, non smoker and no focal neurological signs OCP can be used.

*Breast cancer- used with mixed results. Benign fibrocystic and family history not a contraindication to use low dose.

*Fibroids- OCP’s do not increase growth but decrease bleeding and dysmenorrheal

*Post partum/breastfeeding- start 4 weeks PP non-breastfeeding mother (otherwise decrease milk production and caloric intake). Breastfeeding progestin only pill.

*Anticonvulsants decrease hepatic enzymes and decrease estrogen and progestin.

*Barbiturates, carbamezipine, Felbamate, Phenytoin, Topamax, Vigaboltin decrease steroid. (some clinicians may give dose > 50 ug estrogen or consider back up IUD/condoms

*Antibiotics- only refampin decreases steroids. Fucanazole does not actually increase steroids. Terazol vagina; insert no effect on nuva ring.

*Antiretrovirals- unknown

*SSRI- fluoxetine no affect. St John’s wort increases metabolism and breakthrough bleeding.

DMPA- should be continued only after 2 years if no other birth control adequate. DXA should not be considered because 12 months bone mineral returns to normal.

Miscellaneous:

 

Sterilization-minilap /CS/laparoscopy

Essure- complications initial tubal patency

Vasectomy- complication rate 1%- hematoma

Author
Dr. Khalil

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