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Continuing Education for Pharmacy Technicians This program is acceptable for 3.0 hours of Continuing Education Credit (0.

30 CEU)

ADOLESCENT AND ADULT CONTRACEPTION


Prepared by: Joan M. Rider, Pharm.D.,BCPS,CDE Professor, Pharmacy Practice Experiential Coordinator Ferris State University College of Pharmacy Grand Rapids, MI Educational Objectives: Upon completion of this program the participant will:
1. 2. 3. 4.

Be familiar with menstrual cycle physiology. Be familiar with the various failure rates of the different contraceptive methods. Be familiar with the indications/contraindications to estrogen and progesterone use. Be familiar with proper hormonal balance while on a combined estrogen/progesterone product. Be familiar with the ACHES pneumonic. Be familiar with the advantages and disadvantages of progestin only products. Be familiar with other methods of contraception. Be familiar with post-coital or emergency contraception options.

5. 6. 7. 8.

Introduction 1, 2, 3
The worlds population is estimated to be >6.2 billion people and expected to continue to increase by over 89 million people or 1.7% each year. Without contraceptive use, 91% of women between the ages of 20-24 become pregnant in a 5-year interval in comparison to 80% of those aged 30-35. On average, a woman will conceive for the first time after seven months of unprotected sex, and 20-25% of women desiring pregnancy become pregnant in the first month of trying without contraception. Within one year, 80-90% of females become pregnant without use of effective contraception. On a more tragic note, teenage pregnancies occur in 1 of 10 females aged 15 to 19 years old because of inadequate or unavailable contraceptive agents.

Menstrual Cycle Physiology 2, 3


Feedback biological mechanisms involving the hypothalamus, pituitary gland, ovaries, and endometrial lining of the uterus control the average 28-day menstrual cycle.

The menstrual cycle has three phases. Each phase consists of an ovarian phase that coincides with a uterine phase. The first phase is the Follicular/Preovulatory Phase (in the Ovarian phase) and the Menstrual Phase (in the Uterine Phase). This phase is dominated by estrogen, and begins at the onset of menstruation and lasts 14 days. Estrogen levels start out low and peak prior to ovulation. When estrogen levels are low, Follicle Stimulating Hormone Releasing Factor (FSH-RF) stimulates the hypothalamus to produce Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH). FSH stimulates the ovary to produce follicles (eggs), while LH stimulates the new follicles to secrete estrogen. As estrogen levels peak this stimulates Luteinizing Hormone Releasing Factor (LRF). LRF causes LH release from the anterior pituitary and suppresses FSH. Dominate follicles mature and continue to produce more estrogen. Estrogen causes endometrial growth, increased size and tortuosity (twisting) of the uterine glands, and increased thickness and blood supply of the uterine mucosa. This is known as the proliferative phase.

The second phase takes place in the ovaries and is called the Ovulatory Phase. Estradiol (estrogen) levels >200 pg are needed for at least 50 hours to stimulate the pituitary to release a surge of Luteinizing Hormone (LH). This LH surge is responsible for final stage growth and maturation of the follicle, for initiation of ovulation, and formation of the corpus luteum. The rise in LH represents the most dramatic rise and fall of any pituitary or ovarian hormone in the menstrual cycle. Ovulation takes place on day 14 or 15 in a model 28-day cycle. The Third Phase, the Luteal/Postovulatory (Ovarian) or Secretory (Uterine) Phase, lasts 13-15 days. This is the least variable phase of the female reproductive cycle and is dominated by progesterone. Progesterone thickens the endometrium, increases tortuosity of the uterine glands, and stimulates secretion of a thick fluid in preparation for implantation of a fertilized ovum. A progesterone level of >3 ng/mL is diagnostic of ovulation. If implantation does not occur by day 23 to 25 of the cycle, deterioration of the corpus luteum decreases the levels of estrogen and progesterone. When these hormone levels decline, the endometrium cannot be maintained and it is sloughed off (menstruation). If fertilization and implantation occurs, the developing placenta produces the hormone of pregnancy, human chorionic gonadotropin hormone (HCG). This occurs within one week of conception. HCG takes the place of LH in maintaining the secretory capacity of the corpus luteum. HCG is the hormone that is detected in pregnancy tests. Some tests are able to detect HCG as early as 6 to 8 days after conception has occurred. Pregnancy can be maintained without a corpus luteum because six to eight weeks after conception occurs, the placenta secretes enough progesterone and estrogen to allow this.

Selecting a Contraceptive Method 2, 3


The efficacy of any contraceptive is dependent on many factors such as patient acceptability, ease of use, cost, availability, and the patients belief systems. All or any of these can influence failure rates. Table 1: Contraceptive Method Failure Rates
Method % Unplanned pregnancies Within First Year Typical Use 85% 26% % Unplanned pregnancies Within First Year Perfect Use (Consistent & Correct) 85% 6% 9% 3% 2% 1% 40% 20% 40% 20% 20% 19% 21% 14% 26% 9% 20% 9% 6% 4% 5% 3% 0.5% 0.1% 1.5% 0.6% 0.1% 0.3% 0.05% 0.5% 0.15% 42% 56% 42% 56% 56% 56% 61% % Of Women Still Using This Method after 1 year

Chance Spermicides (all forms) Periodic Abstinence Methods Calendar Method Ovulation Method Symptothermal* Postovulation Cervical Caps Parous women Nulliparous women Sponges Parous women Nulliparous women Diaphragm Withdrawal Female Condom Male Condom Progestin only pills Combined pills (estrogen + progestin) IUD Progesterone T Copper T380A LNg 20 Depo-Provera Norplant & Norplant -2 Female Sterilization Male Sterilization Emergency ContraceptionPreven , Ovral , et.al. Lactational Amenorrhea Method (LAM)**

40% 63%

2.0% 0.8% 0.1% 0.3% 0.05% 0.5% 0.15% 75% effective if used within 72 hours Highly effective; temporary method

81% 78% 81% 70% 88% 100% 100%

* Cervical mucus (ovulation) method supplemented calendar in the preovulatory and basal body temperature in the postovulatory phases. ** Another method of contraception must be used as soon as menses returns, breastfeeding is decreased or discontinued, or baby reaches 6 months of age.

Patient Assessment for Contraception Use2, 3 Physicians should obtain the information in Table 2 from female patients before prescribing a method of contraception. Table 2: Considerations for Contraceptive Recommendations Menstrual History Age of menarche (onset of periods) Date of LMP* Duration of average menses Regularity Cycle length Spotting or BTB** Incidence and type of PMS or PMT*** Hormonal sensitivity Contraceptive History Previous Use Response Side effects Compliance Routine Physical Examination Blood pressure Breast exam Pelvic exam Pap smear Liver function evaluation Family history Social history
* Last menstrual period ** Break through Bleeding *** Premenstrual syndrome or Premenstrual Tension

Hormonal Contraceptive Agents


Estrogen and Progesterone2, 3 Estrogen is one of the hormonal agents used in routinely pharmacological contraception. Estrogen suppresses hypothalamic release of FSH-RF and LH-RF. It also suppresses release of pituitary FSH and LH and has an antiprogestational effect on the uterus. Estrogen accelerates ovum transport and breaks down the corpus luteum thus preventing implantation and placental attachment. Progesterone is the second agent used in pharmacological contraception. Progestins slow sperm transport, increase cervical mucus, and accelerate ovum transport. This inhibits fertilization from taking place due to interference of the timing for implantation to occur. Progestins also inhibit the activation of hydrolytic spermatic enzymes required for fertilization and inhibit implantation by altering FSH/LH peaks, which decreases the amount of progesterone produced by the corpus luteum. Progestins also modify the mid-cycle FSH/LH surge, which inhibits ovulation.

Choosing a Combination Oral Contraceptive (COC) 2, 3


Most women can use any COC with <50 g ethinyl estradiol safely, however, it is most desirable to start with <35 g. A COC with a progestin content equivalent to the following: < 1mg norethindrone, <0.15 mg; desogestrel or levonorgestrel, or <0.25 mg norgestimate is desired as well. Exceptions are listed in Table 3. Table 3: Conditions Dictating Beginning With Lower Doses of Estrogen Exception/Problem Appropriate Product (s)
40-50 y/o; need to minimize risk of thrombosis; poorly controlled diabetes; heavy smoker; perimenopausal Nausea, breast tenderness, vascular headaches, leukorrhea, hypermenorrhea, chloasma, hypertension, visual changes Spotting, BTB*, dysmenorrhea Acne, hirsutism, oily skin, sebaceous cysts, weight gain Family history of atherosclerotic cardiovascular disease (for more favorable lipid profile) Gallbladder disease (need decreased estrogen/progesterone) Seizure history (OCs increase incidence of seizures) Also, seizure medications (except felbamate, gabapentin, & valproic acid) induce metabolism of estrogen & possibly progesterone causing BTB*, spotting, & pregnancy History of CVA, ischemic heart disease, uncontrolled hypertension, Type 1 DM with vascular disease, migraine due to estrogen, current liver disease (tumor, impairment), current DVT, smoker >35 y/o, breast feeding, sickle cell anemia
*BTB=Break Through Bleeding

Loestrin 1/20, Alesse Levlen, Nordette, Lo/Ovral, Low Ogestrel, Cyclessa, Yasmin Levlen, Nordette, Lo/Ovral, Low Ogestrel, Desogen, Apri, Ortho-Cept, Ortho-Cyclen, Desogen, Ortho-Cept, Ortho-Cyclen, Ortho-TriCyclen, Ovcon-35, Brevicon, Modicon, Cyclessa, Yasmin Desogen, Ortho-Cept, Ortho-Cyclen, Ortho-TriCyclen, Ovcon-35, Brevicon, Modicon Loestrin 1/20, Alesse A. Progestin only (Depo-Provera or Norplant only) B. Higher estrogen content COC (Demulen 1/50, Ovral, Ovcon-50) Progestin-only product (mini-pills, injection, implantable)

Products that contain one strength of the estrogen product, and one strength of the progestin product through out an entire cycle (e.g. Alesse, Loestrin, Desogen) are called Monophasic. Monophasic products have the advantage of producing the least amount of intermenstrual bleeding, however, they may affect lipid profiles adversely, and worsen acne. Products that contain norgestrel or levonorgestrel (e.g. Levlen, Nordette , Lo/Ovral) as the progestin drug have the highest potential to cause acne. Biphasic products (e.g. Nelova 10/11, Ortho-Novum 10/11, Jenest 28) arent used commonly due to increased periovulatory days and intermenstrual bleeding. These products contain two different strengths of the progestin product in the cycle. Triphasic products have three different strength levels for both the estrogen content and the progestin component through out the cycle. The triphasic products best mimic the three phases of

the menstrual cycle. They have minimal effects on lipid profiles, and a reduced incidence of acne. They have a higher incidence of intermenstrual bleeding, and drug interactions, which cause break through bleeding (BTB), spotting, ovulation, and pregnancy. Patients must not interchange products due to the ease of confusion with different colored tablets and different manufacturer instructions for use. With all COCs, it is important to try at least three cycles (months) on a particular therapy to determine if the appropriate agent has been prescribed or not. Table 4 is a list of available combination oral agents. Table 4: Combination Oral Contraceptive Products* Estrogen content (g) Ethinyl estradiol 20 Ethinyl estradiol 20 Ethinyl estradiol 25 Ethinyl estradiol 30 Ethinyl estradiol 30 Ethinyl estradiol 30 Ethinyl estradiol 30 Ethinyl estradiol 30 Ethinyl estradiol 30 x21 days Ethinyl estradiol 10 x5 days Ethinyl estradiol 30, 40, 30 Ethinyl estradiol 35, 35, 35 Ethinyl estradiol 35 Ethinyl estradiol 35 Ethinyl estradiol 35, 35, 35 Ethinyl estradiol 35, 35, 35 Ethinyl estradiol 35 Ethinyl estradiol 35 Ethinyl estradiol Ethinyl estradiol Ethinyl estradiol Ethinyl estradiol Ethinyl estradiol Ethinyl estradiol Mestranol 35 35 50 50 50 20, 30, 35 50 Progestin content (mg) Levonorgestrel 0.1 Norethindrone acetate 1.0 Desogestrel 0.1, 0.125, 0.15 Norethindrone acetate 1.5 Levonorgestrel 0.15 Norgestrel 0.3 Desogestrel 0.15 Drospirenone 0.03 Desogestrel 0.15 x21 days Levonorgestrel 0.05, 0.075, 0.125 Norgestimate 0.18, 0.215, 0.25 Norethindrone 0.4 Norethindrone 0.5 Norethindrone 0.5, 1.0, 0.5 Norethindrone 0.5, 0.75, 0.5 Norethindrone 0.5, 1.0 Norethindrone 1.0 Norgestimate 0.25 Ethynodiol diacetate 1.0 Norgestrel 0.5 Norethindrone 1.0 Norgestrel 0.5 Norethindrone acetate 1.0, 1.0.1.0 Norethindrone 1.0 Trade Name Alesse , Levlite Loestrin 1/20 Cyclessa** Loestrin 1.5/30 Levlen, Nordette Lo/Ovral, Low-Ogestrel-28 Desogen, Ortho-Cept, Apri Yasmin*** Mircette (2 days of placebo before start 5 days of 10 mg ethinyl estradiol)**** Tri-Levlen and Triphasil Ortho Tri-Cyclen Ovcon 35 Brevicon, Genora 0.5/35, Modicon and Nelova 0.5/35E Tri-Norinyl Ortho Novum 7/7/7 Nelova 10/11, Ortho Novum 10/11, Jenest 10/11 Jenest 1/35, Genora 1/35, OrthoNovum 1/35, Norinyl 1/35, N.E.E. 1/35, Nelova 1/35, Norethin 1/35 Ortho-Cyclen Demulen 1/35 Ovral Ovcon 50 Demulen 1/50 Estrostep & Estrostep Fe N.E.E. 1/50, Genora 1/50, Nelova 1/50, Norethin 1/50, Norinyl 1/50, Ortho-Novum 1/50
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Norinyl 1/50, Ortho-Novum 1/50


* List does not include all the generic named products available; it does include all estrogen and progestin strength products that are available ** Less estrogen than other triphasic pills; less bloating, breast tenderness, and nausea *** Drospirenone is a unique progestin, which might help weight gain and bloating; can serum potassium; it is recommended to check potassium levels during the first month of use *** *Low dose of estrogen added to help with migraines and dysmenorrhea in placebo pills

As with many therapies, pharmacological therapy with oral contraceptives can be fraught with difficulties. Side effects of either estrogen excess/deficiency, and those of progestin excess/deficiency are relatively common. The signs and symptoms of these hormonal imbalances are listed in Table 5. Table 5: Hormonal Imbalance with Combination Oral Contraceptives Estrogen Excess Estrogen Deficiency Progesterone Excess Nausea/Bloating Cervical mucorrhea Melasma/Chloasma Hypertension Migraine Headache Breast fullness, tenderness Edema Deep Vein Thrombosis (DVT) Cerebral Vascular Accident (CVA) Early/Midcycle BTB* Hypomenorrhea Increase appetite Weight gain Tiredness, fatigue Hypomenorrhea Acne, oily scalp Hair loss or Hirsutism Depression Vaginal yeast infections Breast regression Hypertension

Progesterone Deficiency Late BTB** Amenorrhea Hypermenorrhea

* Early to midcycle Break through Bleeding occurs days 1-14 of the cycle (or menses never stops completely) **Late Break through Bleeding occurs after day 14 of the cycle.

Contraindications to Combination Oral Contraceptives (COCs) 2, 3 There are many contraindications to using COCs. Table 6 divides these contraindications into four categories. The first category is Absolute Contraindications. Patients with these problems should not be prescribed COCs under any circumstance. The next two categories, Strong Relative and Relative Contraindications, require very close monitoring if the patient is ultimately prescribed a COC. The fourth category, suggests that patients are observed a little more closely than usual.

Table 6: Contraindications to Combination Oral Contraceptives (COCs) Absolute Contraindications Strong Relative Contraindications
Active or History of thromboembolic disorder History of Cerebral Vascular Accident (CVA or stroke) History of Coronary Artery Disease (CAD) Known or suspected breast cancer History of benign or malignant liver tumor Known liver disease Severe headaches; migraine or vascular Hypertension or Diabetes mellitus Active gallbladder disease Mononucleosis, acute phase Elective major surgery within the next 4 weeks Long leg cast or major injury to lower extremity Sickle cell disease Age >40 years, if +Cardiovascular (CV) risk OR Age >35 years, if smoker

Relative Contraindications
Prediabetes/Strong family history Congenital hyperbilirubinemia Undiagnosed abnormal uterine bleeding Age >45 Recent liver impairment (<1 year ago) Cardiac or renal disease Lactation or birth of a baby in the last 10 days Weight gain >10 lbs. with previous oral contraceptives Failure to establish regular menstrual cycle

May Initiate and Observe for Problems


Family history of CV disease Family history of Myocardial infarction (MI or heart attack) before age 50 in females Hypertriglyceridemia Depression Chloasma/hairloss related to pregnancy Asthma Epilepsy or Seizure Disorder Varicose veins

General Patient Instructions for Combined Oral Contraceptive (COC) Use2, 3 1. Start the pills on the first day of menses; this avoids the risk of early ovulation and the need for an alternative means of contraception. OR Start the pills on the first Sunday after menses begins and use an alternative method of contraception for the first 7 days of that cycle. Take each tablet at the same time each day. Bedtime optimizes efficacy and minimizes side effects. 2. If you forget one pill, take as soon as possible (ASAP) and take the next pill at the normal time that day. Alternative contraception unnecessary. 3. If you forget two tablets in a row in weeks 1or 2 of the packet, take two tablets when you remember and two the next day. Use an alternative form of contraception for the next 7 days. 4. If you forget two tablets in a row in week 3 of packet, discard the packet and start a new packet that day (for day 1 starters). Use an alternative form of contraception for the next 7days. For Sunday starters continue packet until the next Sunday, and then start a new packet on Sunday. Use an alternative means of contraception for the next 7 days. Expect to miss a period that month. 5. If you miss three or more in a row, discard packet and start a new packet. Sunday starters take one pill a day until Sunday and start a new packet on Sunday. Again, use an alternative form of contraception for the next 7days, and expect to miss a period that month.

6. If you become sick (have vomiting or diarrhea for several days), continue to take your pills, but use an alternative form of birth control until your next period.

Lengthening COC cycles4 Attempts to lengthen menstrual cycles from twenty-eight days to eighty-four days appear to be preferable to many females. The rationale of lengthening cycles is to have fewer periods in a year (one every 4 months versus monthly). The 28-day pill cycle was arbitrarily chosen to mimic natural menstrual cycle. Women who are not on COCs need to slough their endometrial lining monthly (have a period) because the lining becomes too thick which could lead to more problems (e.g. uterine cancer). When a woman is on a COC, endometrial thickening is suppressed, so the lining doesnt build up, as quickly. Therefore monthly bleeding isnt necessary. Barr Pharmaceuticals is testing, Seasonale, a 91-day regimen (84 active pills followed by 7 days of placebo), so one period every 4 months. The benefits of longer cycles are less menstrual pain, less PMS, fewer headaches, a lesser incidence of endometriosis, fewer periods annually, and increased contraceptive efficacy. Barre is seeking FDA approval to begin trials and hopes their product will become available in 2003. There are many published studies of women using oral contraceptives for >100 days safely and effectively. Barre chose this 91-day regimen to be practical. It rounds to four packs a year, four periods a year and may keep the amount of breakthrough bleeding down. Women can, but usually are not encouraged to do so by physicians, take four 21-day packs of COCs in a row (no 28-day packs unless the 7 sugar pills are discarded) then break for 7days before starting a new packet. This doesnt work for all COC products. You need to use monophasic products (e.g. Loestrin, Alesse, Lo/Ovral, Desogen, Orthocept) to do the 91-day pattern. Triphasic products cause too much spotting, and inconsistent hormone levels which could lead to unintentional pregnancy.

Risks and Benefits of COC Use


There are potential risks to use of COCs long term. Table 7 describes risks that have been evaluated. Table 7: Potential Risk of COC Use2, 3 Type of Risk Cervical dysplasia Cervical cancer Breast cancer Comments Risk increases after one year of use; Recommend PAP smears annually or every 6 months if woman has multiple sex partners Hard to link to COC use; lots of variables; as above PAP smears essential at annually or every 6 months if woman has multiple sex partners Very difficult to evaluate; must look at family risk (early menarche, family history of breast cancer or benign breast disease, later age at birth of first child and menopause); Routinely examine breasts for changes; Recommend baseline mammogram at age 35, and annual
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Liver Tumors Cardiovascular disease Thromboembolic events Hypertension Subarachnoid hemorrhage Diabetes Post-pill amenorrhea/galactorrhea Teratogenicity Headache Depression Gallbladder disease

changes; Recommend baseline mammogram at age 35, and annual mammogram after age 40 Risk of benign liver tumors increases with COC use; use lowest effective dose of estrogen/progestin or progestin only products; need to discontinue all if tumor develops See increased triglycerides with high estrogen/progestin products; if history of CV disease use levonorgestrel products Both estrogen and progesterone increase clot risk 2-4X normal Can develop over 3-36 months; if develops, decrease amount of estrogen/progesterone in COC Risk increased with COC use, concurrent hypertension and smoking; control blood pressure, weight, and discontinue smoking; use lower dose estrogen and progesterone COCs can interfere with blood glucose control; use lower doses of estrogen/progestin or triphasics Rare; Look for other causes VACTERL (vertebral, anal, cardiac, tracheal, esophageal, renal or radial, limb) deformities can take place; overall risk is minimal Increased risk of vascular headaches; use lower dose estrogen/progesterone or progestin-only products Attributed to estrogen excess, progestin excess, and estrogen deficiency; Check for vitamin B6 deficiency; use lower dose estrogen/progestin or progestin only products COCs cause biliary stasis and gall stone formation; use lower doses of estrogen/progestin

ACHES2, 3 The ACHES pneumonic was developed to assist health care providers look at various symptoms and lead them to diagnose potential problems that may develop from COC use. Table 8 defines ACHES in relation to use of COCs. Table 8: ACHES Pneumonic: Early Warning Signs of Potential Problems Symptom Possible Problem Abdominal Pain (severe) Gallbladder disease, hepatic adenoma, blood clot, pancreatitis Chest pain, SOB, Coughing up blood Pulmonary or myocardial embolism Headache (severe) Stroke, hypertension, migraine Eye problems: blurred vision, flashing lights, or Stroke, hypertension, temporary vascular blindness Problem Severe leg pain (calf or thigh) Blood clot in leg

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Drug Interactions2, 3 There are very few prescription medications that have no drug interactions. The main problems experienced with concurrent use of COCs and the interacting drugs listed below are spotting and break through bleeding. The most obvious concern is unintentional pregnancy. Table 9 describes drugs that potentially interact with COCs, and problems that could develop.

Table 9: Drug Interactions Interaction Drug Drugs which decrease COC enterohepatic recirculation Ampicillin, Penicillins, Cephalosporins, Chloramphenicol, Dapsone, Erythromycin, Isoniazid, Sulfonamides, Tetracyclines, TMP/SMZ -(Bactrim, Septra) Drugs which induce COC Metabolism Barbiturates (Phenobarbitol), Carbamazepine (Tegretol ), Ethosuxamide, Griseofulvin, Phenytoin, Rifampin, St. Johns Wort, Felbamate, Nelvinafir Cyclosporine Atorvastatin (Lipitor) Anticoagulants (i.e. Coumadin) Benzodiazepines (i.e. Valium, et.al.) Phenytoin (Dilantin) Prednisolone, Theophylline, Topiramate (Topamax) Insulin
*BTB=Break Through Bleeding

Problem Spotting, BTB*, pregnancy

Spotting, BTB*, pregnancy

Doubling of cyclosporine level Enhanced levels of COCs Decrease anticoagulant response Enhanced benzodiazepine response Increased phenytoin levels Decreased liver clearance of COC Decrease insulin effect

Non-Contraceptive Benefits2, 3 Other than preventing pregnancy and regulating menses, COCs may actually help decrease the incidence of other diseases and improve menstrual symptoms. Table 10 summarizes these benefits. Table 10: Non-Contraceptive Benefits of Combination Oral Contraceptives (COCs) Decreased incidence of disease Improvement in menstrual symptoms Pelvic Inflammatory Disease (PID) Fewer cramps Ovarian cancer Less flow for fewer days Endometrial cancer More predictable menses Ovarian cysts Elimination of mittelschmerz (ovulatory pain) Ectopic pregnancy Fibrocystic breast disease Premenstrual tension syndrome (PMS) Toxic shock syndrome

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Anemia Rheumatoid arthritis Duodenal ulcer

Injectable Combined Contraceptive 3, 5, 6


Pharmaceutical companies are always looking for ways to make new and improved products. (Lunelle) is the first monthly combined contraceptive product containing medroxyprogesterone acetate (MA) 25 mg and estradiol cypionate (EC) 5 mg that is available in an intramuscular (IM) injection. It comes as a suspension and in single dose vials containing 25 mg MA and EC 5 mg per 0.5 mL. Lunelle is effective for contraception during first cycle. The dose is 5 mL IM given into the arm, thigh or buttock. The first dose is given at a physicians office, and should be given within the first 5 days of the onset of a normal period or within 5 days of a first trimester abortion or no earlier than 4weeks postpartum, and no earlier than 6-weeks postpartum if breastfeeding. Second and subsequent injections should be monthly (28-30 days), and should not exceed 33 days. If 33 days between injections has been exceeded, pregnancy should be ruled out before next injection. Lunelle is pregnancy category X, and should not be knowingly administered in pregnancy. Theoretically, you may see second and subsequent shots could be given in local pharmacies. The main adverse effects noted are: weight gain (~4 lbs), heavy menstruation, absence of menses or irregular menses, vaginal spotting, mood swings, acne, breast tenderness, headache, nausea, depression and painful menstruation.

Progestin-Only Products 2, 3
What are progestin-only products? Progestin-only products, as the name suggests, only contain one product, progesterone. They are used most commonly in women who have contraindications or sensitivities to COCs because of the estrogen component. Depo-Provera is one of the most commonly prescribed progestin-only products. Depo-Provera is given in doses of 150 mg IM in the gluteal or deltoid muscle every 12-weeks. The drug is active in the body for 14 weeks, but usually given every 12-weeks for overlap and timing convenience. The injection is given during day 1-5 of the menstrual cycle or after ruling out pregnancy. The failure rate is 0.3%, which is less than COCs. Depo-Provera may interfere with a womans ability to conceive for up to 18 months after discontinuation (6 months on average). Weight gain is a concern with 3-7 lbs. average in the first year of use, with up to 16 lbs after three years of use. So, in choosing an injectable contraceptive, should one choose Depo-Provera or Lunelle? The controversy will likely be the number of annual injections. With Lunelle, monthly injections are

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needed versus one every three months with Depo-Provera . Less weight gain is experienced with Lunelle (4 lbs. versus 10 lbs. with Depo-Provera ) and a quicker return to fertility is obtained with Lunelle (2-4 months versus 4-18 months with Depo-Provera ). Lunelle is combined estrogen/progesterone product where Depo-Provera is a progestin-only product; therefore Lunelle cannot be used in estrogen sensitive females or when estrogen is contraindicated. 75% of women experience periods between inje ctions of Lunelle, where women who receive injections of Depo-Provera have irregular bleeding or stop bleeding all together. Unlike, Depo-Provera return to fertility after discontinuing Lunelle is 2-4 months versus Depo-Provera, which is 4-18 months (6 months is average). Levonorgestrel (Norplant , Norplant-2 ) 2, 3 Norplant is an implantable contraceptive. The dose of 36 mg (6-6 mg capsules) is surgically placed under the skin of the non-dominant arm every 4-5 years. Norplant should only be considered for a woman who does not intend to conceive for at least 5 years and weigh <154 lbs (70 kg). If Norplant is used in women >154 lbs., it is recommended that the capsules be replaced every three years, since the efficacy rate decreases beginning in the second year in these women. Norplant does not interfere with the ability to conceive after it is discontinued. The body rapidly metabolizes Levonorgestrel, the active drug, after the capsules are removed, so need an alternative form of contraception is needed immediately. (Fertility returns within 24 hours of removal). The failure rate is extremely low, 0.05%, which is less than combination oral contraceptive products and Depo-Provera. Norplant insertion is a minor medical procedure that is performed under local anesthesia and takes 5-10 minutes. Pregnancy must be ruled out before Norplant is inserted. The capsules are placed in non-dominant upper arm between days 1-7 of the menstrual cycle. Bruising and tenderness is common after surgery for 7-10 days. Applying ice packs for 20 minutes after surgery, and following up with warm moist heat helps with the pain. Infection is rare. Norplant removal is performed most commonly after 5 years of use. Ease of removal depends on the skill of the physician, and proper insertion. Removal is under local anesthesia, and takes about 20-60 minutes. The length of the procedure depends on the skill of the physician, initial proper insertion and adhesion development. Discomfort is minimal, where burning and pressure are the most common complaints. Complications are rare, and include rupture of the implants or infection. Table 11 describes situations to consider before choosing Depo-Provera or Norplant.

Table 11: What product should be chosen? Depo-Provera or Norplant ? Depo-Provera Candidates Contraception of at least one year desired Estrogen should be avoided Compliance problem with other forms of contraception Norplant Candidates > 5 years of contraception is desirable Estrogen should be avoided Compliance problem with other forms of contraception
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contraception IUDs should be avoided IUDs should be avoided Barrier method is undesirable Barrier method is undesirable Seizure history Seizure history Amenorrhea is UNDESIRABLE** Amenorrhea is DESIRABLE **Irregular bleeding is common in 60-70% of females in the first year; spotting and bleeding decreases in amount and duration after one year; return of regular periods and fertility may occur in >60% of patients by the 5th year Some women require a progestin-only product, but choose to take a pill versus being injected with Depo-Provera or having Norplant surgically inserted. Mini-pills or progesterone-containing pills are also available. These products are: Norgestrel (Ovrette) 0.075 mg and Norethindrone 0.35 mg (Nor-QD, Micronor) The major disadvantage in taking mini-pills is the necessity of much stricter adherence to the time of day these pills are taken than with COCs. If a woman is more than 3 hours late taking her minipill, an alternative form of birth control must be used for the next 48 hours to avoid unintended pregnancy. Also, when starting these products, a second form of birth control must be used concurrently for first two months. Failure rates are slightly higher with mini-pills than with COCs (1.1%-3.0% vs. 0.0%-3.0%). Advantages of Progestin-Only Products 2,3 One advantage of progestin-only products is that they can be used in nursing women because they do not cross into the breast milk. Also, they are an effective means of birth control for estrogen sensitive women, and safe to use in women with contraindications to estrogen containing products. (See Tables 3, 6 & 7 for contraindications) Disadvantages of Progestin-Only Products2, 3 All progestin-only products have of higher incidence of irregular bleeding and amenorrhea. Women must be advised that side effects are greatest in first year of use and include: headache, depression, nervousness, acne, breast discharge, hirsutism, weight gain, changes in appetite, and hair loss. Strict compliance is necessary in using mini-pills for contraception. Thin women, who elect Norplant, have to worry that the capsules can be seen the skin under the arm. Depo-Provera injections are painful and fertility can be impaired for up to 18 months.

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Intrauterine Contraceptive Devices (IUDs) 2, 3, 5


IUDs are another form of contraception with the benefit of not necessitating good pill taking compliance. IUDs have had somewhat of an infamous history. The Dalkon Shield is notorious for causing an increased incidence of Pelvic Inflammatory Disease (PID) with fallopian tube scarring and subsequent infertility. Until 1988 only one IUD was available in the US, Progestasert. In 1988 a second IUD became available, ParaGard T 380A. The first new product in over 10 years became available in 2001, Mirena. Progestasert contains 38 mg of progesterone with a release rate of 65 mg/day over one year, and must be replaced after one year if continued contraceptive benefit is desired. ParaGard T 380A has a polyurethane body that is wound around copper wire. It releases copper over 10 years. Mirena (LNG IUS) releases 52 mg levonorgesterol over 5 years (20 g/day initially, and 10 g/day after 5 years). To reduce liability the manufacturer insists that every patient read and sign a copy of the Patient Information for an Informed Decision. The mechanisms of action postulated for IUDs in preventing pregnancy are multiple and include things like preventing implantation and causing progesterone effects locally like: thickening of cervical mucus, preventing passage of sperm into the uterus, inhibition of sperm survival, and causing changes in the endometrium. Failure rates of IUDs are 0.6 to 2.0%. Higher rates of ectopic (tubular) pregnancies have been reported in IUD users versus non-users (3-4% versus 0.8%). If a woman has multiple sexual partners, the risk of PID is higher to begin with, but 10-fold higher in women who use IUDs. IUDs should only be used for contraception in woman in a monogamous relationship. Adverse Effects: In the first 3-6 months after insertion, spotting and bleeding are more frequent than usual (total blood loss is usually less than with regular menses); after 6 months the bleeding decreases, and 20% of women experience amenorrhea. Progestin (Progestasert and Mirena) side effects that can occur are: functional ovarian cysts, acne, back pain, breast tenderness, headaches, mood changes, and nausea. All IUDS, can become embedded in the myometrium of the uterus, thus decreasing its efficacy (may need to be removed). Also, IUDs can perforate the myometrium, and 10-15% need to be removed due to excessive bleeding or pain. 5-20% of women expel the IUDs spontaneously in the first year and the risk of tubal infertility secondary to tubal damage caused by PID is doubled for IUD users. ParaGard T 380A seems less likely to cause this versus Progestasert Vaginal Rings5, 7 NuvaRing is the first contraceptive vaginal ring that will become available. It is expected to be released in spring, 2002. NuvaRing releases low doses of estrogen, ethinyl estradiol plus a unique progestin, etonogestrel. The ring is inserted into the vagina once a month. Clinical studies are showing that it seems to work as well as combined oral contraceptives.

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Diaphragms and Cervical Caps


Diaphragms2, 3, 8 Diaphragms are soft latex or silicone rubber caps with a metal spring in the rim. Diaphragms must be properly fitted to be effective. They are available in different sizes and three different styles of construction of the circular rim. Table 12 discusses the types of diaphragms available. Table 12: Types of Diaphragms Styles Sizes Coil Spring Rim 50 to 105-mm

Arcing Spring Rim (All-Flex-Ortho) Wide-Seal (Milex Wide-Seal Arcing & Milex Wide-Seal Omniflex Coil Spring)

55 to 95-mm

60 to 95-mm

Comments For women with average vaginal muscle tone and those who can tolerate the sturdy rim and firm spring strength Must be held in the middle for insertion; most women can tolerate even those with lax vaginal muscle tone Designed to hold spermicide in place inside these diaphragms and to create a better seal between the diaphragm and vaginal wall

The goal of fitting a diaphragm is to select the largest rim size that is comfortable to the patient. A relatively common problem is selecting a diaphragm that is too small because the female is tense at her diaphragm fitting. This can be problematic in that the diaphragm can easily become dislodged during intercourse. Diaphragms that are too large can cause vaginal pressure, abdominal pain, cramping, vaginal ulceration and recurrent urinary tract infections. Women must be counseled to insert the diaphragm before intercourse (up to 6-hours before) and leave in place for at least 6 ho urs after. If intercourse is repeated, a new application of spermicide should be inserted vaginally without removing the diaphragm. Diaphragms should not be left in for more than 24-hours or inserted during menses due to increased risk of Toxic Shock Syndrome (TSS). When the diaphragm is removed, it should be washed with mild soap and water, rinsed, dried and stored in a plastic container. Do not apply talcum powder or perfumed powder on the diaphragm. It may damage the diaphragm or cause vaginal or cervical irritation or damage. Do not use Vaseline or petroleum jelly. If lubrication is needed, use contraceptive jelly. Also, if a woman loses 10-20 pounds, she must be refit for a diaphragm.

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Advantages of Using Diaphragms for Birth Control: There are several advantages to using diaphragms as a means of contraception. The diaphragm is fairly effective and gives the woman control. When used perfectly, only 6 couples in 100 become pregnant the first year using a diaphragm. The diaphragm can be put in several hours before initiation of sexual activity. Your partner can put it in as part of love-making. The diaphragm is safe and contains no hormones. Thus, there are no hormonal side effects. The penis can remain inside the vagina after ejaculation. Intercourse during a woman's period is less messy with a diaphragm because the diaphragm holds back menstrual blood. Disadvantages of Using Diaphragms for Birth Control: Despite many advantages of using a diaphragm for contraception there are always disadvantages seen as well: A physician or physicians assistant must fit the female for a diaphragm. Handwashing with soap and water is essential before putting in the diaphragm. Spermicides must be used with the diaphragm. Insertion of the diaphragm may interrupt sex. Women always have to take their diaphragm with them on vacations or trips. Use of the diaphragm increases the females risk for urinary tract infections. Some women find the diaphragm unattractive because they have to touch their vagina and cant insert the diaphragm correctly to cover the cervix. It can slip out of place during sex. When positions are changed, the diaphragm needs to be checked for correct placement over the cervix. It must be left in place 6 hours after the last act of intercourse. As stated previously, when a female gains or loses weight, has a baby, a miscarriage or abortion, a new fitting is necessary. Most importantly, if left in for too long, the diaphragm slightly increases the risk for toxic shock syndrome. Bottom line : Don't leave the diaphragm in for more than 48 hours. Cervical Caps2, 3, 9 Women who choose the Prentif Cavity-Rim Cap are interested in finding a form of birth control that is safe, effective, easy to use and unobtrusive, however most women prefer oral contraceptives. For those who have taken oral contraceptives and experience side effects or discontinue their use after extended periods of time, often find it difficult to obtain a suitable alternative contraceptive. These woman may seek The Prentif Cavity-Rim Cap. Available in the US since 1988, it is a small, flexible cuplike device made of rubber (latex) that fits closely around the base of the cervix. Caps come in 22mm, 25mm, and 28mm sizes. The cap is filled about 1/3 of the way with spermicide and suction holds it in place. It should be left in place for at least 8-hours after intercourse, but no longer than 48-hours due to increase risk of TSS. Most physicians tell patients to remove before 24 hours due to problems with odor. Cleaning of Cervical caps is done with soap and water and a new Cap must be sought annually. Most women are excellent candidates for wearing the cervical cap. Only 10% of women are not good candidates, including those who have: an unusually long or short cervix, a history of cervical lacerations or scarring, current cervicitis, an unusually shaped or asymmetrical cervix, current vaginal infection or a currently abnormal Pap smear.

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Table 13: Advantages and Disadvantages to Use of Cervical Caps for Contraception Advantages
It can be left in place for up to 48 hours allowing spontaneity Only a small application of spermicide inside the cap upon insertion is needed; no need for additional vaginal spermicide. Less messy than diaphragm, so neater for the user; cervical caps are sturdier than diaphragms, and can be used for long periods of time without deterioration Smaller than a diaphragm and less noticeable to either partner Good alternative for women who cannot use the diaphragm because of poor vaginal muscle tone May avoid urinary tract infections associated with diaphragms. Fewer and less side effects are seen than with the pill or IUDs; cramping or change in menses rarely occurs; there have been no reports any cases of toxic shock syndrome associated with cervical cap use.

Disadvantages
Women needs to be fit for a cervical cap by a health care provider The fitting MUST take place at midcycle to assure proper fit and it takes extra time (up to 30 minutes) to fit the cap. Extensive effort is needed for fitting. The best test for the fit is when the cap is used during intercourse, daily activities and exercise. By digital examination you can push, prod and try to dislodge the cap. Women need to use a backup method for the first menstrual cycle and check placement and fit before and after each act of intercourse A small percentage of partners complain of discomfort during intercourse when the cap is on the cervix There is the possibility of allergy to latex or spermicide. Difficulty with removal; Try squatting and bearing down as if having a bowel movement. Always use the index and middle finger together. Ask for help from your partner. Take a warm tub bath to relax your muscles. Lastly, obtain s Ortho Universal Introducer, as an extension of your fingers to allow, "hooking" the rim of the cap and bring the cap into the vagina. This is a prescriptive device and can be obtained from the wholesale pharmacy supplier. The cost is about $5

Most insurance plans that cover birth control will cover the cost of the cervical cap. Cash basis: very inexpensive.

Male and Female Condoms


Male Condoms2, 3, 10 Condoms are a common method of birth control used in all age groups, but especially in teens and adolescents due to ease of access. All condoms are equally effective when used properly and only differ by shape, presence or absence of lubricants, and presence or absence of spermicide on the inside and outside of them. Failure rates are 3% with perfect use and 14% with casual use. Most practitioners recommend lubricated condoms with reservoirs ends to collect the ejaculate and

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prevent breakage. Lambskin condoms may work be better for men or women who are allergic to latex or spermicide. Latex condoms are the only type of birth control, besides abstinence, that prevents the spread of Sexually Transmitted Diseases (STDs). This is the best reason to highly suggest use of condoms in teens and adolescents. Condoms should be recommended in addition to other methods of birth control in that population to help prevent the spread of STDs.

Table 14: Advantages and Disadvantages to Using of Male Condoms for Contraception Advantages
Effective and can be used immediately Does not affect breast feeding Can be used as a back up to other methods Prevents the spread of Sexually Transmitted Diseases (STDs) No systemic side effects of hormones Available ANYWHERE without a prescription

Disadvantages
Only moderately effective; failure rates 3% with perfect use and 14% with casual use. User dependent; requires motivation and continued use for efficacy May decrease sensitivity of the penis making erection more difficult Disposal of used condoms; messy Adequate storage; away from heat Breakage and slippage; Latex BETTER than Polyurethane; slippage more common than breakage BOTTOM LINE: FAILURE RATES ~10-12% ANNUALLY in the US; need alternative method of birth control and often emergency contraception Supply and resupply MUST be readily available;? Decreased spontaneity Allergic reactions to latex and spermicide

Relatively inexpensive Promotes male involvement in family planning May prolong erection and time to ejaculation May help prevent cervical cancer

Female Condoms2, 3 The Reality Female Condom became available in the US in 1994. It was the first product to become available to address womens concerns about protecting themselves from pregnancy and STDs. The Reality Female Condom is made of polyurethane versus latex, and is therefore thinner

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than the male condoms. It is more resistant than male condoms to degradation to oil-based vaginal products. A smaller circular ring at one end secures the condom around the cervix, and a large ring dangles outside the vagina protecting the external genitalia. The advantages have been less breakage than male condoms, and in test tubes it has been shown that the HIV virus cannot penetrate it. Efficacy rates are similar to male condoms. Disadvantages are squeaking of the polyurethane during intercourse, being messy, expensive and like male condoms, can only be used once.

Vaginal Spermicides2, 3, 11
Spermicides are chemicals (usually nonoxynol-9 or or octoxynol-9) that inactivate or kill sperm. They are available as creams, jellies, gels, vaginal suppositories, vaginal tablets, foams, condoms, and sponges (sponges are no longer on the US market). The order of efficacy is: Foam >Cream>Jelly>Gel>Suppositories. Vaginal suppositories are the least effective and not recommended. The failure rate is 6-26%. Spermicides cause the sperm cell membrane to break, which decreases sperm movement (motility and mobility) and their ability to fertilize the egg. Spermicides should be inserted into the vagina 30-60 minutes before intercourse. Douching should not be done for at least 8 hours following intercourse. Women and men, who have allergies to detergents, may have an allergy to spermicides. Nonoxynol-9 can cause genital irritation and ulceration, which may cause a higher risk for HIV transmission; however, nonoxynol-9 may kill some organisms responsible for STDs (e.g. herpes, chlamydia, gonorrhea, trichomonas). Table 15: Advantages and Disadvantages to Using of Spermicides for Contraception Advantages
Does not affect breast feeding Can be used as a back up to other methods Spermicides may offer protection against sexually transmitted diseases (e.g. herpes, chlamydia, gonorrhea, trichomonas) Spermicides may be discontinued by the woman on her own Spermicides are available without prescription or medical examination

Disadvantages
Spermicides may cause irritation in the vagina in some women or on the penis for some men. Inserting the spermicide or waiting for the spermicidal tablet to work may interrupt lovemaking Spermicides havent been proven as protective against HIV infection Supplies may be expensive and difficult to find

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Emergency Contraception
Emergency Contraception (Post-Coital Contraception or The Morning After Pill) 2, 3, 12-15 Emergency contraceptives are methods of preventing pregnancy after unprotected sexual intercourse. They do not protect against sexually transmitted diseases. Emergency contraception can be used when a condom breaks, after a sexual assault, or any time unprotected sexual intercourse occurs. Females should not use emergency contraceptives as their only protection against pregnancy when they are sexually active or planning to be, because they are not as effective as any ongoing contraceptive method. Emergency contraceptives available in the United States include: emergency contraceptive pills (see Table 13) and the copper-T intrauterine device. These pills, if taken within 72 hours of unprotected intercourse, are effective a preventing unintentional pregnancy at a 75% efficacy rate. The earlier theyre taken, the more effective they can be. This is an extremely controversial issue in that many people feel that using any hormone to prevent pregnancy is equal to having an abortion. For those who choose to use emergency contraception, Table 13 lists the available emergency contraceptive agents:

Table 13: Emergency Contraception Agents Drug Dosing 10 mg orally twice a day (BID) for 5 days OR 50 mg intravenously Conjugated estrogen (Premarin)* (IV) for 2 days. 2.5 mg PO BID for 5 days Ethinyl estradiol (Estinyl)* Diethylstilbestrol* 25 mg PO BID for 5 days Esterified estrogens* 10 mg PO BID for 5 days Estrone* 5 mg PO QD for 5 days 2 tablets ASAP***, then 2 tablets 12 hours later Ovral** 4 tablets ASAP, then 4 tablets 12 hours later Lo/Ovral, Levora, (white tablets) Nordette, Levlen (light orange tablets) 4 tablets ASAP, then 4 tablets 12 hours later Tri-Levlen or Triphasil (yellow tablets) 4 tablets ASAP, then 4 tablets 12 hours later Trivora (pink tablets) 5 tablets ASAP, then 5 tablets 12 hours later Alesse (pink tablets) 1 tablet ASAP, then 1 tablet 12 hours later Plan B (white tablets)
*Not used commonly due to length of regimen intercourse **Treatment of choice due to low failure rate and low rate of nausea and vomiting ***ASAP-within 72 hours of unprotected

PREVEN is an emerg ency contraceptive kit that became available a few years ago. The kit contains four tablets containing levonorgestrel 0.25 mg and ethinyl estradiol 0.05 mg, and a pregnancy test. The pregnancy test is used first to establish if pregnancy has already occurred or

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not. If the woman is not pregnant, she takes 2 of the tablets immediately, and 2 more tablets 12 hours later. Nausea occurs in 50% of woman and 20% of these will vomit. If vomiting occurs within one hour of taking any of the above regimens, the doses lost to emesis must be repeated. The side effects associated with taking these hormones are: emotional labiality, nausea and vomiting, breast tenderness, headache, and dizziness. Progestin-Only Emergency Contraception Products3, 15 A progestin-only emergency contraceptive regimen has been recently approved. Levonorgestrel (Plan B, Ovrette) is prescribed at 0.75 mg of levonorgesterol. Dosing for Plan B is: one pill within 72 hours after unprotected sex and one pill 12 hours later. If Ovrette is used instead of Plan B, it requires 20 Ovrette tablets per dose or a total regimen of 40 tablets. Plan B has been shown to decrease the risk of unintended pregnancy by 89% if taken within 72 hours. Its also been shown to decrease the risk by 95%, if taken within the first 24-hours. The obvious message here is, DO NOT delay taking emergency contraception if pregnancy is undesirable. Copper-T IUD as Emergency Contraception15 The copper-T intrauterine device (IUD) can be inserted up to five days after unprotected intercourse to prevent pregnancy. Insertion of a copper-T IUD is much more effective than use of Emergency Contraception Agents or progestin-only products (Plan B), reducing the risk of pregnancy following unprotected intercourse by more than 99%. A copper-T IUD can be left in place to provide continuous effective contraception for up to ten years. IUDs are not ideal for all women as mentioned earlier due to the risk of STDs and potentially infertility if untreated. Other Emergency Contraceptive Agents2, 3, 15 A few other agents have been used in preventing pregnancy. Danazol , which is an antigonadotropin, has been used rarely. The dose is 400 mg (2-200 mg capsules) given in three doses 12 hours apart. Mifeprostone (RU-486 or the abortion pill) is progesterone antagonist and again extremely controversial agent. The dose is 600 mg taken one time only. RU-486 is not available in US for emergency contraception. Do I need to see a Doctor and get a prescription for emergency contraceptive pills? 15, 16 In most states, you need to get a prescription from a licensed health care provider in order to get emergency contraceptive pills. However, in some states (e.g. Washington) pharmacies will provide emergency contraceptive pills without requiring you to see anyone except the pharmacist. In France, girls under the age of 18 may now receive complimentary emergency contraception without a prescription or parental approval as of January 2002. Pharmacists dispensing the drugs are require d to "speak briefly with the young women" to ensure that they know how to use the
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medication. Pharmacists are also expected to provide advice to young women seeking emergency contraception about other forms of birth control and recommend that they visit a physician regularly. France already allows emergency contraception to be distributed by nurses in junior and senior high schools. We may see this more commonly in the United States in the future.

Conclusion
There are several contraceptive agents being studied for both females and males. Youll be seeing transdermal patches (Ortho Evra), implantable progesterone (Implanon), and the vaginal ring (Nuvaring), for women, and gels, pills and IM injections for males in the future. 3, 5 The only methods of birth control that are 100% effective are abstinence and voluntary male (vasectomy) or female sterilization (tubal occlusion or complete hysterectomy). All methods described above have various efficacy rates as well as several advantages and disadvantages to use. Ultimately, the choice of a method of birth control method comes down to several factors: religious and personal beliefs, convenience, cost, ease of accessibility and use, and time desired to plan a pregnancy.

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Selected References
1. International Programs Center, US Census Bureau World POPClock Projection. http://www.census.gov/cgi-bin/ipc/popclockw. Accessed on February 11, 2002. 2. Bucci KK, Carson DS. Contraception. In: DiPiro JT, Talbert JL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. Fourth Edition. Stamford: Appleton and Lange, 1999:1327-1341. 3. Ruggiero RJ. Contraception. In: Koda-Kimble MA, Young LY, eds. Applied Therapeutics: The Clinical Use of Drugs. Seventh Edition. Philadelphia: Lippincott Williams & Wilkins. 2001; 43:1-43:23. 4. New Pill Promises Fewer Periods. http://www.msnbc.com/news/395748.asp?cp1=1. Accessed on February 6, 2002. 5. Reproductive Health Organization Launches Nationwide Education Program On New Intrauterine Contraceptive System And Other New Birth Control Methods. Available at http://www.arhp.org/pr/99047.html. Accessed on February 6, 2002. 6. Is Lunelle right for you? Available at http://store.yahoo.com/ppfastore/islunrigfory.html. Accessed on February 4, 2002. 7. NuvaRing. Available at http://www.nuvaring.com . Accessed on January 25, 2002. 8. The Diaphragm. Available at http://www.emory.edu/WHSC/MED/FAMPLAN/diaphragm.html. Accessed on March 6, 2002. 9. Tricks of the Trade. Available at http://www.cervcap.com/tricks.html. Accessed on March 6, 2002. 10. Family Planning. Available at http://www.reproline.jhu.edu/english/1fp/1methods/1condom/html/cn0a901/. Accessed on March 6, 2002. 11. Spermicides: Questions and Answers. Available at http://www.engenderhealth.org/wh/fp/cspe2.html#advantages. Accessed on March 6, 2002. 12. Glasier A, Baird D. The Effects of Self-Administering Emergency Contraception. N Engl J Med. 1998; 339:1-4. 13. Piaggio G, Hertzen H, Grimes DA, Van Look PFA. Timing of emergency contraception with levonorgestrel or the Yupze regimen. Lancet. 1999; 353:721. 14. American College of Obstetricians and Gynecologists. Emergency Oral Contraception. Clinical Management Guidelines for Obstetricians and Gynecologists. ACOG Practice Bulletin. Number 25, March 2001. 15. Not-2-Late.Com. Available at http://ec.princeton.edu/. Accessed on February 11, 2002. 16. Daily Reproductive Health Report. International News. French Government Allows Minors to Receive Free Emergency Contraception Without Prescription or Parental Approval. http://kaisernetwork.org/Daily_reports/rep_index.cfm?DR_ID=8904. Accessed on February 11, 2002.

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Continuing Education Questions 1. In what phase of the menstrual cycle is there a surge of lutenizing hormone (LH) that is the most dramatic surge of any pituitary or ovarian hormone in the menstrual cycle? a. b. c. d. e. Follicular phase Ovulatory phase Luteal phase Secretory phase Menstrual phase

2. What is the hormone detected by pregnancy tests? a. b. c. d. e. Luteinizing Hormone Follicle Stimulating Hormone Human Chorionic Gonadotropin Hormone Human Pregnancy Hormone Follicle Stimulating Hormone Releasing Factor

3. Which method of contraception has the highest failure rate of the ones listed? a. b. c. d. e. Calendar method Lactation Amenorrhea Method (LAM) Ovulation method Male Condoms Cervical cap

4. Which method of contraception has the highest failure rate of the ones listed? a. b. c. d. e. Progestasert IUD Depo Provera Norplant Mini-Pills Combination Oral Contraceptives

5. Which contraceptive product could be recommended in a female patient with a seizure disorder that is being treated with Dilantin? a. b. c. d. e. Ortho Novum 7/7/7 Depo Provera Micronor Ovrette All the above

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6. Which contraceptive product could be recommended in a female patient with a problem with acne? a. b. c. d. e. Desogen Ortho-Cept Ortho-Cyclen, Ortho-Tri-Cyclen All the above

7. Which combined oral contraceptive agent is considered a monophasic product? a. b. c. d. e. Desogen Ortho 7/7/7 Triphasil Ortho-Tri-Cyclen All the above

8. Which combined oral contraceptive agent has two placebo pills followed by 5 days of low dose estrogen to help combat migraines associated with menstruation? a. b. c. d. e. Desogen Mircette Apri Yasmin Alesse

9. A female patient misses two days of her COCs in week 3 of her cycle. She is properly instructed as to what to do with her pills. What else should she be told? a. b. c. d. e. Its not necessary to use an alternative form of contraception for the next 7 days. Expect to get your period at the normal time this month. Expect to miss a period this month. Use an alternative form of contraception for the next month. You dont need to add anything

10. Which of the following are signs/symptoms of estrogen deficiency? a. b. c. d. e. Migraine Headache Breast tenderness Late cycle break through bleeding Early/Midcycle break through bleeding Nausea/Bloating

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11. Which of the following is an absolute contraindication to using combined oral contraceptives? a. b. c. d. e. Migraine Headache Diabetes Uterine bleeding Failure to establish normal menstrual cycle Known or suspected breast cancer

12. What does the S in the ACHES pneumonic signify? a. Severe stomach problems b. Severe leg pain c. Severe sore throat d. Severe back pain e. Severe chest pain 13. Which of the following is (are) a non-contraceptive benefit(s) of COCs? a. b. c. d. e. Decreased incidence of PID Decreased incidence PMS Decreased number of periods A&B All the above

14. When should Depo-Provera be chosen for contraception versus Lunelle? a. b. c. d. e. Patient wants regular periods Patient has estrogen sensitivity Patient doesnt want to gain much weight Patient desire to become pregnant in one year All the above

15. Which of the following is a disadvantage of using mini-pills like Ovrette or Micronor? a. b. c. d. e. Cant be used in women with seizure disorders Cant be used in women with estrogen sensitivity Needs to be strictly complied with on the time taken everyday Delays fertility for months after a woman discontinues them Has multiple drug interactions

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16. Which IUD is effective for birth control up to 10 years? a. b. c. d. e. Progestasert ParaGardT Mirena All of the above None of the above

17. Which type of diaphragm is recommend for women with lax vaginal tone? a. b. c. d. e. All Flex Arcing Spring Rim Diaphragm Coil Spring Rim Milex Wide-Seal Arcing Diaphragm Milex Wide-Seal Omniflex Coil Spring Diaphragm None of the above

18. Which type of contraception has been shown to prevent the spread of sexually transmitted diseases? a. b. c. d. e. Cervical cap Lambskin male condom Female condom Latex male condom None of the above

19. Which type of spermicide is the most effective in preventing pregnancy? a. b. c. d. e. Vaginal suppository Gel Jelly Cream Foam

20. Which type of emergency contraception has been shown to prevent pregnancy at a rate of 95% when used with 24-hours? a. b. c. d. e. Preven Plan B Ovral Lo/Ovral Nordette

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