• Some physicians wait 2-3 wks to start due to possible prolonged bleeding time and hypercoagulable state
• Some sources say wait until 6 wks due to concerns of neonate exposure to hormones
• Pelvic rest recommended for 6 wks

• Low-Dose OC
• 30-35 mcg ethinyl estradiol
• Metabolically neutral progestin
• Likely, multiphasic

Patient Instructions: Progestin-Only

When to start, when to take pill, what to do if missed pill

• Begin on day 1 of menstrual cycle
• Take one pill every day continuously at same time (+ 3 hrs)
• Use another birth control method for next 48 hrs if more than 27 hrs between pills or miss 1 pill

Patient Instructions: COC

When to start, when to take pill

• Begin on day 1 or Sunday after start of menstrual cycle
• Take one pill daily for 21 days; then may take placebo pills (28 day pills) or stop for 7 days

• 1st Sunday after start of menstrual cycle
• Must use back-up for 1st 7 days

• 3.0 mg Drosperinone/30 mcg Ethinyl Estradiol
• Drosperinone -- synthetic spironolactone analog
• Indicated for acne
• Monophasic  -- 21 active yellow tabs, 7 inert white tabs per cycle
• Take at same time each day
• Initiate therapy on day 1 on menstrual cycle or 1st Sunday after start of menstrual cycle or quick start

• 3.0 mg Drosperinone/20 mcg Ethinyl Estradiol
• Indicated for PMDD and acne
• 24 days active/4 days inactive dosing regimen -- extended amount of hormone release
• Shorter bleeding time
• Better for pts with anemia

• ACEI
• ARBs
• K+ sparing diuretics
• K+ supplements
• Aldosterone antagonists
• NSAIDs (chronic use)

• 24 active "white" pills
• Take for week 1, 2, 3, and 1st part of week 4
• 4 brown pills containing iron -- great for pts with anemia
• Shorter, lighter periods "without blood tests"

• 1st chewable birth control
• Must be followed by full glass of water
• 21 active pills + 7 "reminders"
• All 7 pills contain 75 mg ferrous fumarate

• 0.15 mg L-norgestrel, 30 mcg Ethinyl Estradiol
• Monophasic COC
• 91 day regimen -- 84 active pills followed by 7 inactive pills
• 4 periods per year

• Levonorgestrol 0.15 mg and 30 mcg Ethinyl Estradiol (84 days), 10 mch Ethinyl Estradiol (7 days)
• Proposed less breakthrough bleeding

• 90 mcg Levonorgestrel, 20 mcg Ethinyl Estradiol
• 1st and only low dose COC taken 365 days of the yr
• No scheduled menstrual period
• High incidence of breakthrough bleeding or spotting (eps during 1st 3 months of use)

• Drospirenone/Ethinyl Estradiol/Levomefolate Calcium
• Levomefolate Calcium is a metabolite of folic acid -- it's added just in case the pt gets pregnant
• The metabolite prevents neural tube defects such as spinal bifida

• Weekly Transdermal Patch
• Apply one patch weekly for 3 weeks, 4th week patch free
• Apply to clean, dry skin on buttocks, abdomen, upper outer arm, or upper torso
• Fold prior to disposal, don't flush
• Increased compliance
• Each patch suppresses ovulation up to 9 days
• If pt is patch free for > 9 days, apply new patch and use back up for 7 days
• Can start within 1st 24 hrs of menses or the Sunday after menses, need 7 day back up

• Flexible, combined hormonal ring
• Same CI/efficacy as OCP
• Insert ring for 21 days, 7 day ring free
• 1st time users: insert day 1-5, if inserted day 2-5, need 7 day back up
• Increased compliance
• Provides protection for up to 35 days
• Cannot be out for more than 3 hrs a day -- if > 3 hrs during week 1 or 2, reinsert and use backup for 7 days

Medoxyprogesterone Acetate

MOA

• Inhibits ovulation
• Thicks cervical mucus
• Thins endometrial lining

Dosage Regimen

• 150 mg deep IM injection in upper arm or buttock every 12 wks (2 wk grace period)
• For 1st injection, give within the 1st 5 days of cycle if not breastfeeding, if not use back up for 7 days

Side Effects

• Unpredictable bleeding
• Weight gain
• Decrease bone mineral density
• Depression

Discontinuing Oral Contraceptives/Return of Fertility

• Average ovulation delay = 1-2 wks
• Depo-Provera can take up to 18 months -- not recommended for pts that want to start a family soon
• Intrauterine Contraceptives -- immediate return of fertility

• Levonorgestrol Releasing Intrauterine Device
• Inserted in uterus
• Provides protection up to 5 yrs
• Check threads monthly
• Lighter periods or none
• Uterine cramps, bleeding after placements
• MD checks placement 1-3 months after insertion

• Not an abortifacient, does not disrupt an implanted fetus
• If taken before ovulation, ECPs disrupt normal follicular development and maturation, blocks LH surge, inhibit ovulation
• Alter endometrium to help inhibit implantation
• May affect tubal transport of sperm or ova if taken after ovulation

• 2 white tablets of levonorgestrel 0.75 mg each
• 1 tablet within 72 hrs after unprotected sex or OC failure then 1 tablet 12 hrs later
• May take both at same time -- no decrease in effectiveness or change in adverse effects

• Levonorgestrel 1.5 mg
• Take within 72 hrs of unprotected sex
• Same SE as 2-step Plan B

• Does not work if pregnant
• Prevents ovulation and fertilization by altering tubal transport
• Inhibit implantation by altering endometrium
• Not effective once implantation occurs

• May notice changes in menstrual bleeding
• Menses may be delayed, but if delayed more than one week, pregnancy should be expected
• NVD
• Abdominal pain
• Fatigue
• Headache
• Menstrual changes
• Dizziness
• Breast tenderness
• Risk of ectopic pregnancy

• Take 1st dose within 72 hrs, then follow with 2nd dose 12 hrs later
• Nausea and vomiting: may pretreat with antiemetic, such as meclazine, phenergan, compazine

• Suppress FSH, preventing development of a dominant follicle
• Suppress LH
• Stabilize endometrial lining -- helps with bleeding control, causes endometrium to thin
• Potentiates progestin's action
• Induction of luteolysis (degradation of CL, not allowing implantation)
• Accelerated ovum transport

• Suppress FSH and LH surge, inhibiting ovulation
• Thickens cervical mucus
• Atrophies (thins) endometrium -- inhibition of implantation
• Inhibits capacitation of sperm
• Slows ovum transport -- increases risk of ectopic pregnancy

• Anti-mineralocorticoid activity -- counteracts the aldosterone-stimulating effects of estrogens
• Anti-androgenic -- do not give to pts with low sex drive or libido
• Estrogen-induced sodium and water retention is reduced --> less increase in BP, less weight gain
• More favorable effect on HDL and LDL than other progestins
• Potential for hyperkalemia

Most androgenic progestin

Most common progestin in OCs

• Because there is no estrogen, you do not get completel suppression of FSH and LH --> higher risk for unplanned pregnancies
• Smaller window for not taking pill (3 hr)

• Fewer cramps/less pain
• Less flow for fewer days
• More predictable menses
• Elimination of mittelschmerz

Decreased Incidence of:

• Endometrial and ovarian cancer
• Pelvic inflammatory disease
• Ovarian cysts
• Ectopic pregnancy (combo products ONLY)
• Fibrocystic breast disease
• PMS and TSS
• Anemia
• Acne

• Estrogen-dominant, low androgen COCs
• Androgens (testosterone) increases risk for acne

Brand Names that decrease acne include:

• Ortho Tri-Cyclen -- high estrogen to progestin ratio
• Estrostep
• Yasmin -- anti-androgenic
• YAZ -- anti-androgenic

• NV (most common)
• Headaches
• Dizziness
• Spotting and bleeding
• Mood changes including depression
• Possible weight gain (due to estrogen)
• Vaginal candidiasis (increased levels of glycogen, lactic acid, and altered pH)

• Nausea/Dizziness
• Cyclic weight gain, edema
• Breast fullness, tenderness
• Breakthrough Bleeding
• Contact lenses fail to fit
• Abdominal cramping

• Spotting
• Breakthrough Bleeding
• Amenorrhea
• Mood Changes
• Headaches
• Hot Flashes

• Nausea
• Bloating
• Hypermenorrhea
• Hyperpigmentation
• HTN
• Migraine Headache
• Leg Cramps
• Cervical Mucorrhea

• Irritability
• Early and/or midcycle breakthrough bleeding
• Nervousness

• Increased appetite
• Weight gain
• Hypomenorrhea
• Oily skin and hair
• Acne
• Hair loss or hirsutism
• Depression

• Late Breakthrough Bleeding
• Weight loss
• Hypermenorrhea
• Amenorrhea

• Oily skin
• Acne
• Increased appetite
• Weight gain
• Hirsutism
• Increased LDL cholesterol
• Effects on carbohydrate metabolism

• Myocardial infarction and ischemic stroke
• Venous Thromboembolism
• HTN
• Cholethiasis/Cholecystitis -- gallbladder disease
• Visual changes

ACHES

• Abdominal pain
• Chest pain
• Headaches which are severe
• Eye problems -- blurred or loss of vision
• Sever leg pain

• Smokers > 35 yrs of age
• History of thromboembolic events
• Nursing Moms (low-dose COC's can also be used)
• History of estrogen-related headaches
• Uncontrolled HTN
• Any estrogen-related side effect