Contraception Case File
Eugene C. Toy, MD, Patti Jayne Ross, MD, Benton Baker III, MD, John C. Jennings, MD
CASE 44
A 25-year-old G2P2002 desires contraception for the next 3 years. She reports that she had a deep venous thrombosis when she took the combination oral contraceptive pill 2 years ago. She cannot remember to take the pill every day and wants contraception that will allow her to be spontaneous. She does not take any medications and has no known allergies to medications. Menarche was age 13. Menstrual cycle is every 28 days, lasting for 7 days. She has quarter- size clots the first 3 days of her menstrual cycle. She has been married for 3 years and denies any sexually transmitted infections. Her blood pressure is 120/70 mm Hg, heart rate is 80 beats per minute (bpm), and temperature is 99°F (37.2°C). Heart and lung examinations are normal. The abdomen is nontender and without masses. Pelvic examination reveals a normal anteverted uterus and no adnexal masses.
» What would be the best contraceptive agent for this patient?
» What would be contraindications to the proposed contraceptive agent?
ANSWER TO CASE 44:
Contraception
Summary: A 25-year-old multiparous woman, in a stable monogamous relationship, desires long-term contraception. She has had a deep venous thrombosis (DVT) while taking a combination oral contraceptive pill, is forgetful about taking pills every day, and wants contraception that will allow spontaneity. She reports heavy menses. Physical examination is within normal limits.
- Best contraceptive agent for this patient: The levonorgestrel-releasing intrauterine device (LNG-IUD).
- Contraindications to the proposed contraceptive agent: Contraindications include pregnancy, current or recent history of pelvic inflammatory disease, current sexually transmitted disease, current or recent puerperal or postabortion sepsis, purulent cervicitis, undiagnosed abnormal vaginal bleeding, malignancy of the genital tract, known uterine anomalies fibroids distorting the uterine cavity in a way incompatible with IUD insertion, or allergy to any component of the IUD.
ANALYSIS
Objectives
- Know the various types of contraceptive agents including indications and contraindications, mechanisms of action, and efficacy.
- Know benefits, risks, and contraindications for the combination oral contraceptive pill.
- Know about intrauterine devices.
- Know about emergency contraception.
Considerations
Each form of contraception has advantages and disadvantages, and the individual patient situation should be evaluated to find the best contraceptive choice. Factors that assist the physician in the counseling of the patient include agents requiring more patient action, such as remembering to take a pill each day, or putting on a barrier device (diaphragm or condom), duration of contraception desired,
history of sexually transmitted infections, amount of vaginal bleeding, medical conditions, and contraception side effects. Because of the history of DVT, estrogen- containing contraception agents would be contraindicated. The desire for spontaneity would make barrier methods less desirable. Options for this patient would include depot medroxyprogesterone acetate (DMPA), nexplanon (progestin subdermal implant in the arm), or the levonorgestrel IUD. Because of the heavy menses, this 25-year-old would most benefit from a levonorgestrelreleasing intrauterine device or a progestin containing device (ie, Nexplanon), since the progestin would cause the endometrial lining to be thinner and decrease the amount of menstrual bleeding. LNG-IUD is a device placed inside the uterus by a provider during an office visit and can be left in place for up to 5 years. The progestin implant is inserted subdermally in the arm by a provider and can be left in place for up to 3 years. Both methods do not rely on the patient’s memory for effectiveness. The progestin in these devices is released slowly over time and can decrease the amount and frequency of menses. The IUD does not protect against sexually transmitted infections. Also, this patient has had a DVT, which is a contraindication to any form of contraception that contains a combination of estrogen and progestin, like the combination oral contraceptive pill, patch, or ring. DMPA is not as effective as the LARCs (long acting reversible contraceptive options).
APPROACH TO:
Contraception
DEFINITIONS
INTRAUTERINE CONTRACEPTIVE DEVICES: Small T-shaped device, usually plastic with or without copper or a progestin, placed in the endometrial cavity as a method of long-term contraception.
TYPICAL USE EFFECTIVENESS: Overall efficacy in actual use, when forgetfulness and improper use occur.
PERFECT USE EFFECTIVENESS: Efficacy of a method when always used correctly, consistent, and reliably.
BARRIER CONTRACEPTIVE: Prevents sperm from entering upper female reproductive tract.
STEROID HORMONE CONTRACEPTION: Synthetic estrogen and/ or progestin to provide contraception in various methods, including oral contraceptive pills, contraceptive patch, contraceptive ring, contraceptive injection, and implant.
YUZPE REGIMEN: Use of specific oral contraceptive regimen first reported by Dr Yuzpe, consisting of two tablets of 100 to 120 mcg of ethinyl estradiol, and 500-600 mcg of levonorgestrel at time zero and two tablets after 12 hours.
PLAN B (PROGESTIN ONLY): Levonorgestrel 0.75 mg taken orally at time zero and the same dose after 12 hours within 72 hours of unprotected intercourse.
PLAN B ONE-STEP: Enteric-coated levonorgestrel 1.5 mg taken as one pill.
ULIPRISTAL (ELLA): Selective progesterone receptor modulator taken as one dose.
CLINICAL APPROACH
Contraceptive agents have different effectiveness, which are characterized as theoretical (or perfect) and with typical use (see Table 44– 1). The various agents each have particular advantages and disadvantages and unique factors that may make one method better suited for a particular patient. Thus, the history and physical examination should focus on a patient’s preference of method, factors such as the ability to remember to take a pill every day, and other medical conditions (see Table 44– 2).
Barrier contraceptives prevent sperm from entering the upper female reproductive tract. Various forms include the male condom, female condom, vaginal diaphragm, cervical cap, and spermicides. The male condom is made of latex, polyurethane, or animal tissue. It is a sheath placed on an erect penis prior to intercourse and ejaculation. The latex condom is the most effective method of contraception to prevent transmission of sexually transmitted infections. It is the second most commonly used method of reversible contraception in the United States. The female condom is a sheath with two polyurethane rings. One ring is placed inside the vagina at the closed end of the sheath and provides an insertion mechanism and anchor. The second ring is at the outer edge of the device and is outside the vagina providing coverage for the labia and the base of the penis. The vaginal diaphragm must be fitted by a physician. It should be placed 1 to 2 hours before intercourse, should be used with a spermicide, and should be left in place for at least 8 hours after coitus. Drawbacks include higher rate of urinary tract infections and increased risk of ulceration to the vaginal epithelium with prolonged usage.
The cervical cap is also fitted by a physician. Compared to a diaphragm, the cap can be left in place for up to 48 hours and is more comfortable. It also carries a risk of ulceration and infection of the cervix if left in place for too long. However, the cap is only for use in women with normal cervical cytology due to concern of traumatizing the cervix. Spermicides include gels, foams, suppositories, and jellies placed in the vagina. The active agent is nonoxynol-9 which disrupts the sperm cell membrane and provides a mechanical barrier. The contraceptive sponge is made of polyurethane impregnated with 1 mg of nonoxynol-9 and does not have to be inserted into the vagina before each act of intercourse. Because barrier methods are used only at time of coitus, the advantages include low cost, decreased transmission of certain sexually transmitted infections with condoms (not cervical cap or diaphragm), and no exposure to continuous hormones or ongoing IUD use. Disadvantages include relatively high failure rate (approximately 20%) due to required use with each act of intercourse.
Oral contraceptives were initially marketed in the United States in 1960. These quickly became the most-used method of reversible contraception among women. Oral steroid contraceptives come in combination pills at a fixed dose or a phased dose, or a progestin-only pill (minipill). The main effect of the progestin is to inhibit ovulation and cause cervical mucus thickening. The main effect of the estrogen is to maintain the endometrium, prevent unscheduled bleeding, and inhibit follicular development. The most common side effects are relatively mild and include nausea, breast tenderness, and fluid retention.
The main risks of combined hormonal contraception are due to the estrogen component and include venous thromboembolism, strokes in patients with migraines with aura, myocardial infarction in women who are heavy smokers (>15 cigarettes per day), and who are age 35 and older. There are many noncontraceptive benefits of hormonal oral contraceptives including decreasing the risk of developing ovarian, colon or endometrial cancer, shortening the duration of menses, decreasing blood loss during menses, improving pain from dysmenorrhea and endometriosis, decreasing abnormal uterine bleeding, and improving acne.
The contraceptive patch delivers norelgestromin and ethinyl estradiol transdermally. It is worn on the buttocks, upper outer arm, lower abdomen, or upper torso excluding the breast. It is changed weekly for 3 weeks followed by a week without a patch to allow for withdrawal bleed. In women weighing >90 kg, efficacy may be less. A recent FDA warning indicated the risk of DVT was twice that of OCP, although the data is conflicting. The contraceptive ring allows steroids to be absorbed through the vaginal epithelium into circulation. The ring is worn for 21 days and then removed for 7 days to allow for withdrawal bleed. The patch and ring have similar efficacy and side effects to combination oral contraceptives.
Only one injectable contraceptive is currently available in the United States, DMPA. It is administered subcutaneously every 3 months. Women receiving the injection have a relatively low pregnancy rate (but higher than that of LARCs). There is a significant disruption of the normal menstrual cycle that usually leads to amenorrhea.
A single subdermal implant, placed in a woman’s upper arm, releases a steady amount of etonogestrel. The duration of action for this implant, named Nexplanon, is 3 years. Return to fertility is delayed about 2 weeks after cessation of pills, patches, or rings, but can take up to 9 to 10 months stopping contraceptive injection. Postpill amenorrhea may persist for up to 6 months.
An intrauterine contraceptive device is a small device, usually plastic with or without copper or a progestin, placed in the endometrial cavity as a method of contraception. Four IUDs are currently available in the United States: the copper T380A and three levonorgestrel-releasing intrauterine devices; the 5-year version (Mirena) and two 3-year versions, Skyla which is smaller and designed for younger women, and Liletta which is marketed for affordability. The copper T380A is approved for use for 10 years and has a 10-year cumulative pregnancy rate comparable to that of sterilization. Many mechanisms of action have been described for the coppercontaining IUD, including inhibition of sperm migration and viability, change in transport speed of the ovum, and damage to or destruction of the ovum.
The levonorgestrel-releasing intrauterine device (Mirena) releases 20 μg of levonorgestrel daily and is approved for use for 5 years; Skyla releases 14 μg/ day and is approved for 3 years; and Liletta releases 18.6 μg/ day and is approved for 3 years. The main effect of the progestin is to cause thickening of the cervical mucus and decreasing fallopian tube motility, suppressing ovulation, and thinning the endometrium. The small amount of steroid causes minimal amounts of systemic side effects, and it also decreases menstrual bleeding due to the local effect on the endometrium. The levonorgestrel-releasing IUD also has noncontraceptive benefits and can be used to treat patients with menorrhagia, dysmenorrhea, and pain due to endometriosis and adenomyosis.
All IUDs have the advantage of requiring a single act of motivation for long-term use. The unintended pregnancy rate during the first year of use is 0.2% to 0.6%. They also have rapid return to fertility after removal of the device. Insertion has an infrequent association with uterine perforation (1:1000) and transiently increases the risk of upper genital infection (1:1000) due to endometrial contamination.
WHO contraindications to IUD insertion include current pregnancy, current sexually transmitted infection, current or pelvic inflammatory disease within the past 3 months, unexplained vaginal bleeding, malignant gestational trophoblastic disease, untreated cervical cancer, untreated endometrial cancer, uterine fibroids distorting the endometrial cavity, current breast cancer (for levonorgestrel-releasing IUD only), anatomical abnormalities distorting the uterine cavity, known pelvic tuberculosis, and allergy to component of IUD or Wilson disease (for copper-containing IUD).
Emergency contraception is the therapy for women who have had unprotected sexual intercourse, including victims of sexual assault. It is also known as the “morning after pill.” The three most common regimens are progestin Plan B (two doses 12 hours apart), Plan B One-Step which is an enteric-coated levonorgestrel pill, and Ulipristal (ella) which is a progesterone agonist/ antagonist. The copper IUD is another option (see Table 44– 3). The combination oral contraceptive method, known as the Yuzpe method, which consists of two tablets of 100 to 120 mcg (total 200-240 mcg) of ethinyl estradiol, and 500-600 mcg (total of 1000-1200 mcg) of levonorgestrel in two doses, 12 hours apart, is only rarely used due to GI side effects. The efficacy of the pharmacologic methods is accepted to be about a 75% reduction in pregnancy rate, thus decreasing the risk of a midcycle coital pregnancy from 8 per 100 to about 2 per 100.
The mechanisms of action may include inhibition of ovulation, decreased tubal motility, and, possibly, interruption of implantation. There are no medical conditions where the risk of emergency contraception outweighs the benefits. Therefore, women with cardiovascular disease, migraines, liver disease, or who are breast feeding may use emergency contraception.
The major side effect of emergency contraception is nausea and/ or emesis. Emergency contraception should not be used in patients with a suspected or known pregnancy, or those with abnormal vaginal bleeding. Those women who do not have onset of menses within 21 days following the emergency contraception should have a pregnancy test.
The copper IUD can be inserted up to 5 days after unprotected intercourse for emergency contraception. Women who receive the copper IUD under emergency conditions often choose to maintain the IUD for contraception. The levonorgestrel- releasing IUD is not effective for emergency contraception.
Emerging Concepts
At the time of this writing, postplacental IUD insertion was gaining interest in the United States. The insertion of an IUD immediate after delivery (within 10 minutes of placental expulsion) or at the time of hysterotomy closure during cesarean seems to be efficacious; however, there seems to be a higher expulsion rate.
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CASE CORRELATION
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COMPREHENSION QUESTIONS
44.1 A 17-year-old G0P0 woman desires a reversible form of contraception. After reviewing the various options, she chooses depot medroxyprogesterone acetate. Which of the following tests is most likely to be abnormal after 2 years of use?
A. Dual energy x-ray absorptiometry (DEXA) scanB. Serum glucose levelC. Serum creatinine levelD. Ultrasound of the gallbladder
44.2 Which of the following patients can safely receive combination oral contraceptive pills?
A. 35-year-old woman with diabetes with peripheral circulatory problemsB. 37-year-old woman who smokes cigarettes, about 1 pack (20 cigarettes)per dayC. 25-year-old woman with persistent tension headachesD. 30-year-old whose blood pressure is 160/ 90 mm Hg
44.3 A 28-year-old G1P1 woman has been prescribed an oral contraceptive agent. She was counseled about some risks, but also some benefits. Which of the following is a benefit of combination oral contraception?
A. Decreased risk of breast cancerB. Decreased gallstone formationC. Decreased deep venous thrombosis riskD. Decreased benign breast masses
44.4 A 28-year-old woman experienced an episode of unprotected intercourse. Her last menstrual period was about 2 weeks previously. She receives a combination oral contraceptive agent for emergency contraception. Which of the following is the most common side effect of the Yuzpe regimen (combination OC)?
A. Vaginal spottingB. Nausea and/ or vomitingC. Elevation of liver function enzymesD. Glucose intoleranceE. Renal insufficiency
44.5 A 25-year-old nulliparous woman is being evaluated for possible IUD insertion. Which of the following characteristics is most acceptable for IUD use?
A. Current sexually transmitted diseaseB. NulliparityC. Recent pelvic inflammatory diseaseD. Enlarged uterus with an irregular cavity
44.6 A 29-year-old G1P1 woman requests emergency contraception for unprotected intercourse. She is given choices between the progestin-only (Plan B) regimen versus the Yuzpe (combination OC) regimen. Which of the following is the main effect of the progestin-only regimen as compared with the Yuzpe regimen in EC?
A. Higher ectopic pregnancy rateB. Less effective prevention of pregnancyC. Less nauseaD. More liver dysfunction
ANSWERS
44.1 A. Depot medroxyprogesterone acetate is associated with loss of bone mineral density particularly in adolescents. If it is the best type of contraception for the patient, then the loss in bone mineral density should not discourage the use of the agent, but it should be considered in the choice of the contraception agent.
44.2 C. Tension headaches are not a contraindication for oral contraceptive agents. Migraines with aura increase the risk of strokes in patient who take combination hormonal contraception. Other contraindications to combination hormonal contraception include diabetes with vascular disease, heavy smoker over the age of 35, and uncontrolled hypertension.
44.3 D. Oral contraceptives have many beneficial effects including decreasing the risk of endometrial and ovarian cancer, and decreasing the risk of benign breast disease; there may be a slight increase in risk of breast cancer and incidence of gallstones.
44.4 B. Because of the high dose of estrogens, nausea and vomiting are the most
common side effects.
44.5 B. Nulliparity is not a contraindication to IUD insertion. Contraindications include pregnancy, current or recent history of pelvic inflammatory disease, current sexually transmitted disease, current or recent puerperal or postabortion sepsis, purulent cervicitis, undiagnosed abnormal vaginal bleeding, malignancy of the genital tract, known uterine anomalies or fibroids distorting the uterine cavity in a way incompatible with IUD insertion (Note: Small fibroid [3-4 cm] not impinging on the uterine cavity is not a contraindication), or allergy to any component of the IUD or Wilson disease.
44.6 C. As compared to the combination OC regimen, the progestin-only method has better efficacy and fewer side effects (nausea). Thus, it is the preferred method. Patients who are given the combination OC agents usually require an antiemetic agent.
CLINICAL PEARLS
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» Emergency contraception is effective when initiated within 72 hours of intercourse. » Emergency contraception consists of high-dose combination hormones, high-dose progestin, or insertion of an a copper IUD. » The main side effects of combination hormonal emergency contraception therapy are nausea and vomiting. » An advantage of copper IUD insertion for emergency contraception is that it can be retained for continuous long-term contraception. » The levonorgestrel-releasing IUD can be used to improve bleeding profiles in patients with abnormal uterine bleeding. » Nonuser-dependent methods (long acting reversible contraception) like the IUD and the subdermal implant, have the lowest failure rates. » Oral contraceptives decrease the risk of ovarian and endometrial cancer; there may be a slightly increased risk of breast cancer. » It decreases the duration of menses and the amount of blood loss per cycle. » Smoking >15 cigarettes per day over the age of 35 years is an absolute contraindication for combination hormonal contraceptives. » Sickle cell crisis and epilepsy occur less often with DMPA. » The contraceptive patch may be associated with a greater risk of DVT. |
REFERENCES
American College of Obstetricians and Gynecologists. Adolescents and long-acting reversible contraception: implants and intrauterine devices. ACOG Committee Opinion 539. Washington, DC; 2012.
American College of Obstetricians and Gynecologists. Contraception for adolescents. Guidelines for Adolescent Health Care. 2nd ed. Washington, DC; 2011:43-63.
American College of Obstetricians and Gynecologists. Depot medroxyprogesterone acetate and bone effects. ACOG Committee Opinion 602. Washington, DC; 2014.
American College of Obstetricians and Gynecologists. Emergency contraception. ACOG Practice Bulletin 112. Washington, DC; 2010. (Reaffirmed 2013.)
American College of Obstetricians and Gynecologists. Increasing use of contraceptive implants and intrauterine devices to reduce unintended pregnancy. ACOG Committee Opinion 495. Washington, DC; 2009. (Reaffirmed 2011.)
American College of Obstetricians and Gynecologists. Long-acting reversible contraception: implants and intrauterine devices. ACOG Practice Bulletin 121. Washington, DC; 2011. (Reaffirmed 2013.)
American College of Obstetricians and Gynecologists. Noncontraceptive uses of hormonal contraceptives. ACOG Practice Bulletin 110. Washington, DC; 2010. (Reaffirmed 2012.)
American College of Obstetricians and Gynecologists. Use of hormonal contraception in women with coexisting medical conditions. ACOG Practice Bulletin 73. Washington, DC; 2006. (Reaffirmed 2011.)
Centers for Disease Control and Prevention (CDC). U.S. medical eligibility criteria for contraceptive use, 2010. MMWR Recomm Rep. 2010;59(RR-4):1-86.
Centers for Disease Control and Prevention. U.S. selected practice recommendations for contraceptive use, 2013. MMWR. 2013;62:1-60.
Fine PM. Update on emergency contraception. Adv Ther. 2011;28(2):87-90.
Mishell DR Jr. Family planning. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, PA: Mosby Elsevier; 2007:275-325.
Nelson AL. Family planning: reversible contraception, sterilization, and abortion. In: Hacker NF, Gambone JC, Hobel CJ, eds. Essentials of Obstetrics and Gynecology. 5th ed. Philadelphia, PA: Saunders; 2009:304-314.
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