Hormonal%20contraception 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