This document discusses issues with progestin-based contraception including problems with timing of administration, potential weight gain, and irregular bleeding. It notes that progestin-only pills have a short duration of action of 20-24 hours and desogestrel is 97% effective at inhibiting ovulation. Missed pills for methods like DMPA can still be safe if administered slightly late. Weight gain may be higher in women using DMPA who start with a higher BMI, and the mechanism is thought to involve increased food intake and water retention. Irregular bleeding is a major reason for discontinuing methods, ranging from 10-25% for progestin-only pills to 46% for implants. Strategies are provided to

1. Problems with progestin-
based contraception
Dr Voon Hian Yan, MRCOG
9th September 2017
The Waterfront Hotel

2. EFFICACY

3. SAFETY

4. PROBLEMS
TIMING
WEIGHT
GAIN BLEEDING

5. Timing
PROBLEMS SOLUTIONS

6. Progestin-only Pills
•Short duration of action and half-life
•Maximum serum levels reached about 2 hours after
ingestion
•Effect persists for 20-24 hours before returning to
baseline

7. Desogestrel
•75ug daily
•3rd generation progestin
•97% inhibition of ovulation
•12 hour window

8. MISSED PILLS

9. DMPA and timing
• Peak concentration 3/52 after
• persists at 0.4 ng/mL through
day 84.
• Undetectable between days
120-200
• Safe even if administered 2/52
late
LNG-IUS and timing
• If inserted >45 years old..
CAUTION: Noristerat 200mg

10. PROBLEMS
TIMING
WEIGHT
GAIN BLEEDING

11. DMPA vs Non-hormonal contraception (Cu-IUCD)
Attrition bias

12. DMPA vs COC

13. DMPA
•Higher baseline BMI = greater weight gain
•Women who gain >5% baseline weight at 6/12 may
experience continued weight gain

14. Desogetrel vs No hormonal method

15. LNG-IUS vs Cu-IUCD

16. SUBDERMAL IMPLANT & WEIGHT GAIN
• Levonogestrel implant (immediate vs 3/12 delay insertion)
• 200 patients on each arm
• Open label, randomized controlled trial
RESULTS: At 3 months post-randomization

17. MECHANISM OF WEIGHT GAIN ?
Increase in
food intake
Action on
hypothalamus
Water
retention Increase in fat
deposition

18. WEIGHT ISSUES
•POP=No causal association
•DMPA=2-3 kg after 2-3years
•Implant =No causal association
•LNG-IUS= No statistical significance
*Difficult to quantify and adjust for confounders
*What level of weight gain is “acceptable”?

19. PROBLEMS
TIMING
WEIGHT
GAIN BLEEDING

20. Unscheduled bleeding is a big problem
METHOD DISCONTINUATION RATE
(due to bleeding)
POP 10-25%
DMPA 26%
LNG-IUS 19%
IMPLANT 46%

21. EXPECTED BLEEDING PATTERN
POP
20%
amenorrhoeic
40%
regular
40%
erratic
DMPA 35%
amenorrhoeic
3/12
70%
amenorrhoeic
1 year

22. EXPECTED BLEEDING PATTERN
IMPLANT
30%
amenorrhoeic
1yr
IUS
Unpredictable
bleeding pattern
50%improve with continued use
20%
amenorrhoeic
1yr
>predictable
bleeding pattern
with prolonged use
50%
oligo

23. PATHOPHYSIOLOGY
•Endometrial atrophy
•Disruption of endometrial angiogenesis
•Fragile venous network

24. <3/12 of initiation
•Check medication intake
•Assess clinical history of STD
•UPT if suspicious
•Reassure

25. >3/12 after initiation
•Exclude pregnancy
•Revisit recent cervical smears
•Speculum exclude local cause
Consider endometrial assessment TVS/Biopsy

26. Bleeding on POP
? Prescribe Desogestrel
?Increasing dose ex. 2 tablets
? Change to another form of POP

27. Bleeding on POP
? Prescribe Desogestrel
?Increasing dose ex. 2 tablets
? Change to another form of POP

28. Bleeding on DMPA /Implant / IUS
? Tranexamic acid
?Add cyclical COC
? Mefenamic acid
?Continuous COC

29. NOVEL APPROACHES IN
PUBLIC HEALTH

31. Summary: Taking control
Few
contraindications
DMPA weight gain
2-3kg after 2-3 years
Onset of unscheduled
bleeding is common
Strategies to arrest
bleeding

32. sgh-og.com
(counselling videos, forms, local guidelines)
www.e-network.boards.net
(Forum and archived scenario-based discussions)