1. ABHINAV SAWHNEY
M.PHARMACY
(PHARMACOLOGY)
AMITY INSITUTE OF PHARMACY,
AMITY UNIVERSITY
NOIDA

2. Review Different Methods of Contraception
Review the advantages and disadvantages
of each method
Choose appropriate contraception based
on different clinical situations
Review how to prescribe contraceptives

3.  Hormonal Contraceptives:
• oral, transdermal, intravaginal, IM, implanted
 Barrier Devices
• Diaphragm
• Condoms: male and female
• Cervical Caps

4. Surgical:
• Tubal Ligation, Vasectomy
Intrauterine Devices:
• IUDs: copper or progesterone
releasing

5.  Introduced in early
1960s
 Most widely used form
of reversible birth
control
 Have contraceptive and
noncontraceptive
benefits
 Estrogen + progestin
combination or
progestin alone

6. Synthetic estrogens
• Ethinyl estradiol
• Mestranol
Synthetic progestins
• Many different progestins available

7.  Ethinyl estradiol doses range from 20 -150 mcg
• Doses > 50mcg no longer available in US
• Low dose estrogen (35 mcg or less) recommended as initial
treatment
 Higher doses increase incidence of VTE
 Lower doses may result in significant breakthrough bleeding or spotting
 20 mcg dose helpful in premenopausal women or those with significant
estrogen side effects
• 50mcg dose needed in women on certain anticonvulsants
 Ex: Genora 1/50; Nelova 1/50, Ortho-Novum 1/50, Demulen 1/50

8. Progestin doses range from 0.05mg – 1mg
Differ in their androgenic, estrogenic, and
progestational activity

9. Norethindrone – ex: ortho-novum, necon
Norethindrone acetate – ex: junel,
estrostep, loestrin
Ethynodiol diacetate – ex: zovia
Medium androgenic potency

10.  High progestational and androgenic activity
 Levonorgestrel
 Most widely prescribed progestin
 Ex: Levlen, Alesse, Tri-Leven, Triphasil
 Approved for emergency contraception
 Approved for extended cycle use –ex: seasonal
 Norgestrel
• Ex: cryselle, lo-ovral

11. Norgestimate ( ortho-cyclen or tri-cyclen)
 FDA approved to treat acne
desogestrel (desogen, ortho-cept)
Gestodene – not available in US

12.  Drosperinone – new progestin derived from 17-
alpha spironolactone
• Progestogenic, antiandrogenic, and
antimineralcorticoid activity
• Ex: Yasmin: 30 mcg of ethinyl estradiol and 3 mg of
drospirenone
• Yaz:
• Useful in women with excess water retention, acne,
hirsutism
• Watch for hyperkalemia

13. Monophasic
Multiphasic - 2 or 3 different progestin
doses
 21 day regimen
 28 day regimen
• 21 active pills + 7 inert pills
• 24 active pills + 4 inert pills
 Ex: YAZ and Lo-estrin

14. Extended cycle
• Seasonale – 91 days total – 84 days active + 7 days
inactive
• Seasonique – 91 days total - 84 days active + 7 days
5mcg ethinyl.estradiol
 Useful for endometriosis, premenstrual dysphoric
disorder, or lifestyle reasons
 Efficacy unchanged
 Breakthrough bleeding common
 No risk of endometrial hyperplasia

15. If taken correctly: 99.9%
In reality: 92.4%
Return to fertility:
• Average 2 month delay in conception after OCP’s
stopped

16. Suppress ovulation
Suppress follicular development
Alter cervical mucous making sperm
penetration more difficult
Alters endometrium making implantation
less likely

17. Definite
 Decreases dysmenorrhea
 Decreased risk of ovarian cancer
 Decreased risk of endometrial cancer by 50%
 Decreased risk of pregnancy
 Treatment of Acne

18.  Stroke
• Ischemic: increased risk by 2 ½ times
 Increased risk with age, HTN, Migraine headaches
 Myocardial Infarction:
• 80% of cases of MI among OC users are in smokers
• OC are contraindicated if age>=35 and smoke >15
cig/day

19. Hepatic vein thrombosis
Portal vein thrombosis
Splenic artery thrombosis
Mesenteric artery thrombosis
Mesenteric vein thrombosis

20.  Pregnant or breastfeeding
 History of DVT, MI, Stroke, Hypercoagulable
state
 Liver disease
 Smoker >15 cig/day age> 35
 Complicated Migraine Headaches or migraines
in women > age 35
 Estrogen dependent tumor –breast,
endometrium
 Uncontrolled HTN, unexplained vaginal bleeding

21.  Side effects:
• Breakthrough bleeding – most common reason for
discontinuation
• Nausea
• Weight gain
• Mood swings
• Breast tenderness
• Headaches
• Acne, facial hair growth

22. Most common in low dose combination
pills
Most frequent in the first three months as
endometrium adjusts to lower hormone
levels
Increased rate if miss a pill
Increased rates in extended use cycles

23.  Treatment options
• Increase estrogen dose
 Bleeding early in cycle or no withdrawal bleeding
 Ex: ortho tri cyclen lo (25 mcg) to orth-tri cyclen ( 35 mcg)
• Increase progestin dose
 Bleeding after day 14 in cycle
• Change to more androgenic progestin
 Decreases bleeding at any time during cycle
 Ex: levlen ( LNG progesterone)
• Switch from extended cycle to 28 day cycle regimen

24. Related to estrogen dose
Usually most severe in first 1 – 3 cycles of
OC use
Management:
• Take with food or bedtime
• Change to OC with lower estrogen dose

25.  Related to high estrogen content
 Usually concentrated in pill-free days and first
days of cycle
 Ischemic stroke risk increased in patients with hx
of migraines
• Do not give to women with aura or focal symptoms
• Do not give to women with migraine over age 35
• Do not give if frequent or severe migraine hx

26. Meta-analysis - relative risk of ischemic
stroke among women with migraine taking
oral contraceptives, from the pooled data
of three studies, was 8.72 (95% CI 5.05-
15.05)
Risk of ischaemic stroke in people with migraine: systematic review and meta-
analysis of observational studies. AUEtminan M; Takkouche B; Isorna FC; Samii A
SOBMJ 2005 Jan 8;330(7482):63. Epub 2004.

27.  Decreased:
• Direct action on brain from progestin
• Increase in sex hormone-binding gonadotropin
induced by estrogen
 Treatment:
• OCP with less estrogenic or progestational properties
• Higher androgenic properties
 Progesteron component: levonorgestrel,dl-norgestrel,
desogestrel
 Ex: alesse, lo-ovral, levlen

28. The estrogen component of OC pills raises
serum concentrations of thyroxine-binding
globulin (TBG)
• Increased levels of total thyroxine & total
triiodothyronine
• No change in levels of free thyroxine and free
triiodothyronine
• T3 resin uptake will be low

29.  Hepatic adenoma
 Correlates with dose and duration of OCP use
 Incidence 30-40 / 1 million in OCP users
• 1 / 1 million women in non users
 Increased number, size, and risk of bleeding in
OCP users
 s/s: abdominal pain, incidental, rupture / abd
bleeding

30. IM injection of 150 mg every 12 weeks
99.7% success rate
medroxyprogesterone:
• Thickens cervical mucous-less penetrable to
sperm
• Suppresses ovulation

31. First dose given within 5 days of LMP
If given >=7th day of LMP, another form of
contraceptive should be used for 7 days
Efficacy is up to 14 weeks

32. Can’t or won’t take daily OC
Migraine headaches
Breast feeding
• Can start after 6 weeks
Efficacy: 99.7% ( theoretical and actual)

33. Irregular bleeding
• Persistent bleeding can be treated with 50 mcg of
ethinly estradiol for 14 days
Other: weight gain, headaches, dizzy,
injection site reactions
Takes about 6-9 months after last injection
for return of fertility but may be as long as
18 months

34.  Implanon (etonogestrel)
• progesterone releasing contraceptive implant
approved for 3 years
• Single plastic rod about length of toothpick
• Implant day 1-5 of cycle
• Pregnancy rates similar to IUD and sterilization
 Norplant
• No longer available due to limited supplies and
problems with removal

35. Ortho Evra:
• Releases 20 mcg ethinyl estradiol and 150 mcg of
norelgestromin per day
Each patch worn for 1 week for cycle of 3
weeks then withdrawal bleed during week
4
Caution for women with weights over 90kg
as may be less clinically effective

36. DVT risk:
• Steady state levels of estrogen much higher with
patch users then OCP users
• One study showed 2.4 OR increased risk of VTE
for patch users compared to OCP users
DVT: Deep Vein Thrombosis
VTE: Vascular thromboembolosis

37. Breast tenderness
Headache
Application site irritation
Nausea
Breakthrough bleeding

38. < 1 pregnancy / 100 users
Higher compliance rates than OCP users
and higher “perfect use” rates

39.  Delivers 15 mcg of
ethinly estradiol and
120 mcg of
etonogestrel per day
 Intravaginal for three
weeks
 Insert on or before
day 5 of LMP-use
backup for 7 days

40. Vaginitis
Leukorrhea
Weight gain
Nausea
Headache
Breakthrough bleeding

41. Similar to OCP use
Slightly higher rates of discontinuation due
to local side effects

42. Administer within 72 hours of unprotected
intercourse
• most effective if taken within 12 hours
Mechanism of action
• Inhibits ovulation, prevents implantation, or may
cause regression of corpus luteum

43. Yuzpe Regimen:
• 100mcg of ethinyl estradiol and 0.5 mg of
levonorgestrel. E.g. Ovral, Preven
(50mcg/0.25mg)
 Take 2 pills within 72 hours and 2 pills 12 hours later
• Has a 75-80% efficacy rate
• Usually requires antimetic

44. Levonorgestrel: Progesterone only, Plan B
• 0.75 mg Q 12 hrs for total of two doses
• Prevents 85%
• Less nausea and vomiting
Copper IUD inserted within 5 days is also
effective

45.  Male condom; efficacy 14/100
 Diaphragm: 20/100
 Cervical Cap:
• Never pregnant: 20/100
• Ever Pregnant: 40/100
 Today Sponge: barrier plus spermicide. Effective for 24
hours. Estimated efficacy of 89-91%
• No special fitting required

46. Levonorgestrel (Lng IUC)
• Mirena = trademark
• Progesterone secreting
• Can be left in place for 5 years
• First yr pregnancy rate 0.1-0.2%
• Irregular bleeding common early followed by
development of amenorrhea in 20%

47. Copper T (Tcu380A IUD)
• Paragard = trademark
• Copper releasing
• Approved to remain in place for 10 years
• First yr pregnancy rate 0.6-0.8%
• Heavy menses and dysmenorrhea common

48. • Highly effective
• Convenient
• High patient satisfaction
• Inexpensive over time
• No effect on fertility after removal
• Decreases risk of ectopic pregnancy compared to no
contraception
• LNg IUD can decrease risk of PID from newly acquired
STD’s once IUD in place
• Progestin thickens cervical mucous which acts as barrier to
ascending infection

49.  High initial cost
 No protection against STD’s
 Small increase risk of PID in first 20 days after
placement
• Related to contamination during insertion process and
presence of pre-existent STD’s
 If pregnancy occurs while IUD in place then
more likely to be ectopic

50. Lactation:
• Most useful in first three months
• Effective if woman is breast feeding full time and is
amenorrheic
Tubal Ligation
Vasectomy