hormonal%20contraception
HORMONAL CONTRACEPTION
Contraceptive methods are used to prevent pregnancy and sexually transmitted infections (STIs).
Contraception allows women/couples to explore plan on childbearing and family planning.
Hormonal contraception is a method with high rate of effectiveness and ease of administration. It is the widely used method of reversible contraception.
It does not protect against STIs/HIV.

Hormonal%20contraception Patient Education

Patient Education

Combined Oral Contraceptives (COCs)

  • COC may be used from menarche to menopause
  • If COC is started initially between days 1-5 of the menstrual cycle, there is no need for additional contraception
    • If started beyond this period, pregnancy should be excluded and additional contraception for 7 days is advised
  • Ovulation is effectively inhibited after COC use for 7 consecutive days
  • COC should be taken every day, at around the same time, for 21 consecutive days followed by 7 steroid-free days
    • Women using a 21-day preparation should be cautioned not to exceed the 7-day pill-free interval
  • If COC pill is taken >24 hours after the scheduled time, it is considered missed
    • For missed dose, the pill should be taken as soon as it is remembered and subsequent pills taken at the usual time
    • Delaying the start of COC by >24 hours or missing one or more doses of COC during the 1st week may decrease protective contraception
    • Use back-up contraception (eg abstinence, condom use) with missed doses in the 2nd or 3rd week of hormone use until the COC has been used for 7 consecutive days 
    • Eliminate hormone-free interval when 1 or more days of COCs are missed in the 3rd week to maintain contraception then start taking pills from the next pack
  • Contraception is not needed in the 1st 3 weeks after childbirth and it is not recommended because there is increased risk of venous thromboembolism (VTE)
  • Non-breastfeeding women should start COC 21 days postpartum
    • If started beyond this, additional contraception is needed for 7 days
  • Women should be informed on symptoms which would prompt immediate medical consultation (eg warning signs of VTE, headache, eye problems, jaundice, abdominal pain)
  • Follow-up visit 3 months after the 1st prescription of COC to assess blood pressure (BP), medical problems, and give further instructions
  • Fertility is restored within 1-2 weeks after stopping the combined OC
    • Post-pill amenorrhea is more common in women with history of very irregular menstruation but rarely persists up to 6 months

Combination Injectable Contraception

  • Administered with no more than 33 days between injections, though can be given 7 days early or late from scheduled date  
  • If started within 7 days after the start of monthly bleeding, there is no need for a back-up contraception  
    • If started beyond this period, pregnancy should be excluded and back-up contraception is advised for the 1st 7 days after the injection  
  • Return to fertility is rapid and may be as soon as 6 weeks after the last injection

Combination Transdermal Patch

  • Patch is applied to clean, dry, hair-free skin on the buttock, abdomen, upper outer arm, or upper torso on the same day each week 
    • Avoid placing the patch on exactly the same site for 2 consecutive weeks
    • Avoid irritated or broken skin, breasts or skin in contact with tight clothing or cosmetics
    • Smooth edges down upon application
    • Women should check the patch everyday, making sure all edges remain closely attached to the skin
    • Location of patch should not be changed in mid-week
  • After ruling out pregnancy, patch can be applied anytime with back-up contraception for 7 days
  • If started on 1st day of menstrual cycle, no back-up contraception is needed
  • New patch is applied every week for 3 weeks, followed by 1 patch-free week
  • If patch change is delayed by up to 48 hours in the middle of the cycle, there is no need for additional contraception
  • If the patch-free interval is >9 days, a new patch should be applied and back-up contraception for 7 days should be used
  • Early detachment of the patch and delayed removal or application are considered missed or incorrect use of contraception
  • Avoid adhesive bandages, tattoos or decals on top of the patch which may affect absorption of hormones
  • Same return of fertility as COC after discontinuing the method

Combination Vaginal Ring

  • Ring is inserted into the vagina within the first 5 days of menstruation and left in place for 3 weeks (1 cycle)
    • A cycle of continuous ring use should be followed by a 1-week ring-free interval to allow withdrawal bleeding
  • If ring is used >3 weeks, patient can take a ring-free week and then insert ring to continue 21/7 schedule  
  • If the ring-free interval is prolonged, use back-up contraception up to the first 7 days of ring use  
  • When a vaginal ring falls out or is removed for any reason, it may be placed back in within 2 hours for Segesterone acetate/ethinyl estradiol and 3 hours for Etonogestrel/ethinyl estradiol after cleaning the ring; no back-up contraception is needed
  • Fertility after discontinuation is immediate and excellent
    • Average return to ovulation is 11 days

Progestin-only Pills (POPs)

  • Initial pill may be taken within day 1-5 of the menstrual cycle and then taken once daily continuously with no hormone-free days
    • No additional contraception needed
  • Initial pill may also be taken at any other time, provided that pregnancy has already been ruled out
    • Additional contraception should be used for the 1st 48 hours
  • In postpartum women, pill can be started from day 21 with no additional contraception
    • If started after day 21, additional contraception is needed for the 1st 48 hours
  • Pills must be taken at the same time each day (at least within 3 hours) for traditional POPs
  • Efficacy is reduced if dose is delayed by >3 hours when using traditional POPs
    • Back-up contraceptive method is recommended for 48 hours if a woman is >3 hours late taking the dose
    • Back-up method may also be recommended each months at mid-cycle
  • Desogestrel, a novel POP, has a 12-hour pill intake window
    • Delay in intake of Desogestrel 75-mcg tablet up to 12 hours does not reduce contraceptive efficacy
  • Fertility returns rapidly to baseline after discontinuation
  • If patient develops new symptoms of migraine, stroke or heart disease while on POPs, discontinue use
    • Note, however, that no causal association has been linked between POP use and cardiovascular (CV) diseases [eg stroke or myocardial infarction (MI)]

Progestin-only Contraceptive Implants

  • Depending on formulation may consist of 1-6 matchstick-sized rods containing the hormone and is inserted into the inner aspect of the upper arm
  • Implant is inserted during the 1st 5-7 days of the cycle (depending on product used)
    • If inserted after this, additional contraception is required for the 1st 7 days
  • May be inserted immediately postpartum regardless of breastfeeding status 
  • Fertility is restored rapidly and completely after 3-6 weeks of removal

Injectable Progestins

  • Injectable is given within the 1st 5-7 days of menstrual cycle every 8-12 weeks (depending on product used) to provide contraception for up to 2-3 months
    • Do not massage area where shot was given for a few hours because it may reduce efficacy
  • DMPA can be given 2 weeks before or 4 weeks after scheduled injection date while Norethisterone enanthate can be given 2 weeks before or after scheduled injection date
  • Women should be counseled about the likelihood of menstrual disturbance and the potential for a delay in return to full fertility
    • May take up to 10 months for DMPA and 6 months for Norethisterone enanthate

Progestin-only Contraceptive Intrauterine System (IUD)

  • It is inserted in the uterus during the 1st 7 days of menstrual cycle (can be inserted at any time if not pregnant) and is effective for up to 5 years
  • May be inserted within 48 hours after delivery, >6 months after postpartum and immediately post abortion except for septic abortion 
    • A higher continuation rate and risk of expulsion are associated with immediate insertion postpartum or post-cesarean section
  • Can be given to breastfeeding women within 48 hours after childbirth, otherwise must wait until 4 weeks 
  • Routine antibiotic prophylaxis prior to insertion is not indicated 
  • Women should undergo a pelvic examination and STI risk assessment before IUD insertion; it is not necessary to remove the IUD during treatment for a positive test result
  • Women should be advised of the risk of PID in the 1st 20 days following insertion if she has gonorrhea or chlamydia
  • Return of fertility is rapid and complete after removal

Progesterone-releasing Vaginal Ring

  • Ring is inserted into the vagina 4-9 weeks after childbirth and left in place for 90 days  
    • Patient can use 4 rings, one after another, for 1 year after childbirth  
  • Vaginal ring is not recommended to be removed during intercourse  
    • Women who want to remove it may do so as long as the ring is put back in place within 2 hours  
  • When the ring falls out, it may be placed back immediately after washing the ring with water  
  • There is no delay in the return of patient’s fertility after stopping its use
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