Pocket Pediatrics: The Massachusetts General Hospital for Children Handbook of Pediatrics (Pocket Notebook Series), 2 Ed.

CONTRACEPTION

(Pediatrics 2007;120:1135; Pediatr Rev 2008;29:386)

The Oral Contraceptive Pill (OCP)

• Either combo synthetic estrogen (ethinyl estradiol [EE] or mestranol pro-drug) and progestin (of varying potency) or a progestin only pill (POP)

• Estrogen suppresses gonadotropin surge → prevention of ovulation

• Progestins thicken cervical mucus, alter tubal peristalsis, and create endometrial atrophy → deter sperm motility, egg fertilization, and implantation

• Theoretical failure rate 0.3%; typical use failure rate: 8%. 2/2 poor adherence

• “Estrogen-dominant” (full-figured, significant menstrual symptoms) pts may benefit from less estrogenic or more potently androgenic pill. “Androgen-dominant” (hirsute, acne, PCOS) pts may benefit from more estrogenic vs. less androgenic

• Generics have equivalent tolerability and efficacy; often significantly more affordable

• New extended-cycle formulations (w/ 1–4 withdrawal bleeds/yr) have good efficacy and can reduce effects of hormone w/drawal

• Benefits: Help tx DUB, dysmenorrheal, acne, hirsutism, PCOS, and dec risk of uterine and ovarian cancers

• Initiate with either monophasic or multiphasic but at low dose estrogen (20–35 mcg) and titrate up as needed after 3-mo trial. Initiate on d 1 of menstrual cycle or on Sunday after menstrual cycle begins; take pill same time every day. Encourage condoms in conjunction with OCPs. F/up 6 wk to 2 mo after initiation

OCP Side Effects, Monitoring, and Contraindications

• Estrogen side effects include blood clots, irregular menses, breast tenderness, fluid retention, nausea, increased appetite, headache, and hypertension (can trial pill containing lower estrogen dose)

• Progestin effects include menstrual Δ, bloating, mood Δ, HA, nausea, weight gain. Drospirenone (in Yasmin) has diuretic and antiandrogenic activity; caution in pts at risk of hyperK+ or with renal insufficiency

• Androgenic side effects (less common; incl acne, hirsutism, male pattern hair loss)

• Class IV contraindications: H/o DVT, PE, CVA, AMI, Factor V Leiden or other thrombophilia, migraine w/ aura or neurologic changes. (Refer to complete WHO guidelines at http://www.who.int/reproductive-health/publications/mec/3_cocs.pdf)

Other Options

• Vaginal rings: (NuvaRing®) Combined hormone-containing silicone ring, hormones absorbed vaginally, avoids 1st-pass metab. Intravaginal 3 wk, ↑ rate of pt satisfaction

• Transdermal: Absorb E&P through skin; less effective in pts >90 kg, avoids 1st-pass metab

• Each patch should be worn for 7 d before replacing, on a new site each time

• FDA warning: 60% more total estrogen in patients’ blood c/w 35 mcg OCP

• Injectable: Depot medroxyprogesterone acetate (progestin only, Depo-Provera) IM q3mo, ↓ reliance on pt adherence

• High discontinuation 2/2 side effects (menstrual irreg, wt gain, ↓ in bone density)

• Fertility can take up to 10 mo to return

• Combined injectable contraceptives injected q1mo and offer advantage of both improved adherence w/o side effect profile of progestin only injections

• Subdermal contraceptive implants: Progestin-only rod (Implanon) inserted below the skin, effective for up to 3 yr. Fertility returns promptly after removal

• Irregular bleeding is a common side effect, but diminishes with continued use

• Intrauterine devices (IUD)

• The levonorgestrel-releasing IUD has been approved for up to 5 yr of use

• Copper-containing IUD acts via a local inflammatory response

• Chance of ectopic pregnancy is <1:1,000 women yr of use

• Causes reduction in bleeding (amenorrhea by 1 yr in many users)

• Recommended in parous women with no h/o PID or ectopic preg, in monogamous relationships

Emergency Contraception (EC)

• POPs (Plan B), combined OCPs, mifepristone (not available in US)

• Methods interfere w/ : Ovulation, follicular development, and corpus luteum maturation. No evidence of effect on implantation or postovulatory events

• The sooner the better. In general, EC initiated w/i 72 hr of unprotected intercourse ↓ risk of pregnancy by ≥75%. Effectiveness shown for up to 120 hr after unprotected sex

• Plan B (OTC) consists of 2 × 0.75 mg tabs of LNG q12 hr. Single dose (1.5 mg) administration has similar effectiveness (Cochrane Database Syst Rev 2008;16;(2))

• “Yuzpe regime”: Uses OCPs as EC (less effective, large # pills, ↑ side effects)

• Patients may experience vaginal spotting, nausea/vomiting after use of EC