Combined Oral Contraceptives



Conversations About Contraception

• Start the conversation- with every teen!

o Are you currently trying to get pregnant? (do not assume the answer is no)

o If no, what are you doing to prevent a pregnancy?

o For males, consider asking if they are currently seeking to become a father. If not, have they discussed with their sexual partner(s) how they will plan to prevent a pregnancy, and/or what they would do if a pregnancy occurred.

• Assess their level of knowledge

o Have you tried anything before? What? What did/didn’t you like?

o What are your friends using? What have you heard about ___?

• Assess what options will be medically viable (see below, CDC and WHO resources on contraindications to various forms of contraception)

o Past Medical History

o Family History

• Review the options: The recommendation is to offer contraceptives in order of most effective to least effective (assuming patient has no contraindications to a certain type of contraceptive). Always recommend that the patient uses barrier protection for STI prevention, in addition to any other form of contraceptive the patient chooses.

o (Abstinence) ( most effective

o Long-Acting Reversible Contraception (LARC): Intrauterine Devices (IUD’s), implantable rods

o DepoProvera® shot

o NuvaRing®, OrthoEvra® patch (both contain estrogen and a progestin)

o Combined hormonal oral contraceptives (COCP’s, contain estrogen and a progestin)

o Progestin-only oral contraceptives

o Barrier protection (most commonly, male condoms)

o Other (e.g., you can consider discussing natural family planning, withdrawal, etc. depending on patient—these are all better than nothing!)

o (Nothing) ( least effective

• Help them think about what method will fit in their lifestyle

o Daily schedule

o Ability to adhere to daily medications in the past

o Comfort with- procedure (Nexplanon®, IUD); vaginal placement (NuvaRing®); something on the skin (OrthoEvra®); injections (DepoProvera®)

o Will they get in trouble if someone finds pill/patch/ring? Do they need a more private method (IUD, Nexplanon®, DepoProvera®)?

Let’s talk more about LARC! This should be the first line for most patients. This recommendation is now supported by the AAP and ACOG. These are IUD’s (can be copper or levonorgestrel (LNG)-containing) and the implantable rod. They are the most effective forms of contraception (other than abstinence) that we have available. When “listing”contraceptives for a patient, these should always be discussed first (higher uptake if presented early in the conversation). With LARCs, return to conception is possible immediately upon device removal.

• Want to know where your patients can have a LARC device placed (if not done in your office)? Check out . You can find local providers by zip code.

| |Procedure Notes |Mechanism of Action |Duration |Other |

|Copper IUD (ParaGuard®)|Placement typically is done as an office procedure (though |Copper ions kill sperm; may |10 years |Hormone free. |

| |in special circumstances, such as girls with developmental |disrupt implantation though this | |Menses continue with same regularity; may be heavier |

| |delays, it can be done under anesthesia).  Placement is |is debated | |Can be used as emergency contraception if placed with|

| |typically well tolerated, though most patients experience | | |in 5 days of unprotected intercourse |

| |some cramping at the time of the procedure.  While it can | | |Can be placed immediately postpartum |

| |vary by provider and patient, the actual procedure usually | | | |

| |only takes a few minutes. | | | |

| | | | | |

| |There is an increased risk of infection during the first | | | |

| |approximately 20 days after placement, likely related to | | | |

| |introduction of microbes during the procedure.  Ongoing | | | |

| |increased risk of infection WAS a concern with an old type | | | |

| |of IUD that is no longer on the market (and has not been | | | |

| |for many years) due to the filaments that were used in the | | | |

| |string of the IUD.  Current IUD’s have monofilament strings| | | |

| |and do not promote infection in the way this old IUD did. | | | |

| | IUD’s are considered safe even in patients with history of| | | |

| |prior infection or more “risky” behaviors (ex- multiple | | | |

| |partners).  Patients should be screened for infection at | | | |

| |the time of placement, and treated if infection is present.| | | |

|Levonorgestrel (LNG) | |Thickened cervical mucus |Liletta and |5 yrs |Very low systemic hormone levels. |

|IUD (Mirena®, Liletta®,| |diminishes number of sperm |Mirena (52mg) | |Also highly effective (more than pill) at treating |

|Kyleena®, and Skylaa®) | |passing through cervix. | | |dysmenorrhea and at treating heavy menstrual bleeding|

| | |LNG effects within uterus leads | | |/ abnormal uterine bleeding |

| | |to thinning of endometrium and | | |Periods typically become lighter and less frequent |

| | |environment not amenable to sperm| | |over time (approximately 90% of patients).  Many |

| | |survival, fertilization or | | |(approximately 40%) patients will develop amenorrhea |

| | |implantation | | | |

| | | |Kyleena (19.5mg)|5 yrs |Lower systemic hormone levels. Women will likely |

| | | | | |continue to have periods, which may be lighter. |

| | | |Skylaa® |3 yrs |Lowest systemic hormone levels. Most patients |

| | | |(13.5mg) | |continue to have regular periods. |

|Etonorgestrel (ENG) |Inserted into arm, procedure is very simple with minimal |Thickened cervical mucus |3 yrs |Radio-opaque |

|implant (Nexplanon®) |discomfort and is typically done in the office.  Training |diminishes number of sperm | | |

| |is easy to obtain. |passing through cervix. | | |

| | |ENG effects within uterus leads | | |

| | |to thinning of endometrium and | | |

| | |environment not amenable to sperm| | |

| | |survival, fertilization or | | |

| | |implantation. | | |

| | |Inhibition of ovulation. | | |

Quick Tips for Prescribing Oral Contraceptive Pills

For most cases it is good just to have a few pills in mind that you reach for

• A low estrogen (20mcg) ( less estrogen related side effects (breast tenderness, nausea, headaches, mood changes) but more breakthrough bleeding

• Mid estrogen (30-35mcg) ( may see a few more estrogen related side effects but less breakthrough bleeding.

o A norgestimate containing pill ( good choice for PCOS because the particular progestin it contains is less androgenic.

o A norgestrel containing pill ( good for AUB/HMB because of the particular progestin it contains

• A progesterone only ( for use when someone cannot have or does not want an estrogen containing pill, but wants to be on the pill (i.e. does not want to use a different progestin-only method, such as IUD or DepoProvera®). Mechanism of action includes cervical mucus changes. Peak efficacy is about 3hrs after it is taken, efficacy really starts to wear off at about 20hrs. SO, good to ask pt when they most commonly have intercourse- for many teens it is often after school so a good time to take it would actually be at lunch IF they can remember to take it then (the BEST time is whenever they will remember it- but if they will take it anytime, you can be nuanced and think about this!)

Having those 4 "categories" in your arsenal will serve you well for most cases where you want to start the pill.

Who cannot use contraceptives with estrogen?

Some of the most common contraindications to combined oral contraceptives (not exhaustive list- check out WHO or CDC website if other conditions exist in your patient).

Category 3 (theoretical or proven risks usually outweight the advantages)

• s/p Roux-en-Y (*also true for POP’s, due to decreased absorption)

• Controlled HTN

• History of DVT/PE without risk factors

• Known hyperlipidemia, depending on other cardiac risk factors

• Development or worsening of migraines on COCP’s

• IBD and on steroids, severe disease, immobilizations, vitamin deficient

• Severe hepatatitis

Category 3, require dosing adjustements if used

• Phenytoin, carbamazepine, barbituates, primidone, topiramate, oxcarbazepine ( decreased efficacy of COCP’s so need to use minimum 30ug pills (*also true for POP’s)

• Lamotrigine ( levels decrease while on COCP’s, and can then significantly increase during placebo week, so need to be taken continuously and when starting may need to increase dose of lamotrigine (work with neurologist)

• Rifampin ( decreased efficacy of COCP’s so need to use minimum 30ug pills

Category 4 (contraindicated)

• Uncontrolled HTN

• History of DVT/PE with risk (known estrogen associated, pregnancy associated, idiopathic, known thrombophilia, active cancer, recurrent)

• Major surgery w/ prolonged immobilization

• Known thrombophilia (factor V Leiden, protein S, protein C, antithrombin deficiency, prothrombin mutation)

• Pulmonary HTN

• SLE with positive or unknown antiphospholipid Ab’s (*also true for POP’s)

• Migraine with aura

• s/p solid organ transplant with graft failure/rejection

Common Myths Among Providers

• Cannot use IUD’s in people with history of cervicitis/PID.

(FALSE- this is class 1-2 recommendation. See procedure notes in table above. ALL patients should always be screened for infection at the time of placement, and treated if infection is present.

• COCP’s cause breast cancer

(FALSE (mostly)- many studies have shown little to no effect on breast cancer, but there is increased diagnosis of breast cancer among women taking COCP’s thought to be due to detection bias (more exams and mammography) and COCP’s promoting cancer cells that were already there. There may be some increase in patients on high-dose estrogen pills (50mcg or more). Importantly for the adolescent population, after 10yrs off the pill there is no increase in diagnosis and by age 55yrs, risk is the same for those who did/did not use the pills.

• Cannot prescribe COCP’s to people with a family history of DVT

(FALSE- this is category 2 (benefit generally outweighs risk). Must think about the cause for family member’s DVT, and consider whether or not this is likely heritable. Many providers practicing in this area would screen for known heritable mutations (but some would not) if no clear cause.

• Need to do a pelvic exam prior to starting hormonal birth control

(FALSE

Know How to Respond to Common Concerns Among Patients and Parents—Think and Plan for What You Might Say to These Common Concerns

• Will make me fat (It is notable that on a population level, weight gain is seen with DepoProvera®. This side effect is absent or very uncommon with other methods. Though remember that at an individual level, everyone’s body is different.)

• Won’t be able to get pregnant when I come off (not true- though return to fertility may take some time depending on method. DepoProvera® is the longest. Many recommend waiting a couple months after stopping most methods though can become pregnant right away)

• Will cause hair loss (can be seen with DepoProvera®)

• Will cause/treat acne (can increase with progesterone only methods; may be helped by estrogen containing methods)

• Link to mood concerns (A study published in JAMA Psychiatry in Fall 2016 described that women who were prescribed hormonal birth control were more likely to be prescribed antidepressants. Authors note this could indicate a link between birth control use and depression. This received a lot of attention in the press. After careful review of the study, I have been discussing this (roughly) as follows—“A large Danish study does indicate that women taking contraceptives may experience a slightly higher rate of being diagnosed with depression. The study has some major limitations and therefore, this may or may not be related to the contraceptive. For example, pelvic pain, severe period cramps, acne and PMDD are all also associated with depression, and are reasons that people take contraceptives. This was not teased out in the study. Unintended pregnancy also can have a negative impact on mental health. Therefore, my take away from this study is that we should be vigilant for mood changes in women using contraceptives, and that this is an area that deserves more study. However, birth control has many indications and in most cases the potential benefits outweigh this potential risk. If you start a method and have mood symptoms that persist beyond the first month or two, we would like to see you back in clinic to see if you would do better with a different method and make sure that you are screened for depression.”)

• Won’t remember (a great reason to consider LARC. Many patients find success using a cell phone alarm. On , patients can also sign up for text reminders. Pairing with something that is already a habit- such as toothbrushing- can also be helpful.)

• Will make me feel sick (most people have no side effects; if they do, typically resolve within 3 months. Pregnancy makes people feel sick too)

• The blood will back up if I don’t get a period (not true- talk about methods that thin the endometrium and why it is therefore ok not to get a period. This can be especially confusing for women with PCOS or other conditions causing unopposed estrogen who have been told that it is important to get regular periods to decrease the risk of endometrial hyperplasia and endometrial cancer)

• It is dangerous to go on the ___ and not get your period (not true- see above)

Emergency Contraception

• Copper IUD

o Can be placed within 5 days of unprotected intercourse. 

o Most effective form of EC. 

o Added benefit of providing ongoing contraceptive benefit for up to 10 years. 

o Requires access to a provider trained to place the copper IUD within 5 days of unprotected intercourse, and willingness/desire of the young woman to undergo the procedure.

• Ulipristal acetate (UPA) 30mg (Brand name Ella®)

o Selective progesterone receptor modulator

o Can prevent or delay ovulation even after lutenizing hormone (LH) starts to peak.  UPA is therefore the superior option for use right around the time of ovulation. 

o Requires a prescription from a provider in some jurisdictions and can be dispensed directly by the pharmacist in other jurisdictions. 

o Not stocked by all pharmacies.  It can be obtained online and shipped overnight through PRJKT RUBY (). 

• Levonorgestrel (LNG-EC) 1.5mg

o Available without a prescription to males and females

o Most widely used form of EC in the United States. 

o Less expensive than UPA. 

o LNG-EC is most effective when used within 72 hours of unprotected intercourse, but maintains some efficacy out to 5 days (120 hours)

o LNG-EC is not effective once LH starts to peak. 

• Yupze method

o Least effective and not well tolerated

o Involves taking multiple combined hormonal contraceptive pills 12 hours apart. 

o Dosing regimens by type of OCP can be found at , but are not included here because this method is generally no longer utilized due to the wide availability of other, more effective options.

The risk of pregnancy is highest around the time of ovulation; sperm can live for up to 5 days in the reproductive tract. Ovulation occurs 14 days prior to the menstrual period.  Predicting the date of the next menstrual period, and therefore determining the expected fertile window, can be more difficult in teens who are not yet regular and are still having anovulatory cycles.  However, if the patient is felt to be within her fertile window, recommend more strongly considering the IUD or UPA even if somewhat more difficult to obtain.  The effectiveness of medical EC is also diminished in women with a BMI >25kg/m2; the copper IUD remains the most effective option, but among medication options, UPA is preferred.  For all young women, regardless of fertility timing or weight status, the use of LNG-EC is preferred over nothing. 

Additional Resources

• Medical Eligibility for Contraceptives (Particularly useful if you have a patient with a medical condition and want to make sure no contraindications to the contraceptive option you/they are considering): (CDC)

New guidelines come up and these are updated. For the most recent version, use a search engine to search for “Medical Eligibility for Contraception” and look at the WHO or CDC site. There is also a free, user-friendly app for this you can download onto your phone! Look for “CDC Contraception” in the app store.

• Rates of failure with perfect/typical use: Trussel, James. “Contraceptive Failure in the United States.” Contraception vol 83 (2001) p397-404

• Managing Contraception for Your Pocket (book) by Zieman et. al., My favorite pocket resource.  It is very useful and inexpensive (around $10) .  Great for troubleshooting phone calls and side effects, choosing a method, dosing, etc.

• A good website to send your patients to look at and do some "homework" regarding their contraception options.  You can click on the different types of contraception.  I would usually open it up with the patients in my office to show them how to navigate, and might be fun for you to poke around too! My only complaint about this site is sometimes it takes them a little while to update it.

• For your older adolescent patients, is awesome. This is a sex-positive site and potentially not suitable for young adolescents; I generally use it with college students, and older/more mature high school students.. I recommend you peruse it yourself before you start guiding patients there—just so you know what it’s about and can decide for whom you think it is appropriate. Contains all sorts of info about different methods of contraception, safe sex, healthy relationships, and other awesome goodies. It is in a format very friendly to young people, with videos, jokes, etc. This site can also be used to get free text reminders sent to patients’ (or your!) phone—e.g. daily pill reminders, appointment and refill reminders, etc.

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