#85: Contraceptives: Pills, mini pills, and tiny pills

March 5, 2018 | By Molly Heublein

Contraception simplified with clinical pearls from reproductive health and family planning experts, Dr Angeline Ti, and Dr Moira Rashid. We cover it all including: the menstrual cycle, mechanism of action for various methods of birth control, hormonal versus nonhormonal contraceptives (e.g. intrauterine devices, patches, pills, rings, implants), patient counseling, and lots of resources to make your job easier. Women’s health correspondent, Dr Molly Heublein returns as cohost. Take our self-assessment quiz!

Written by: Molly Heublein, MD, Beth Garbitelli and Sarah Roberts, MPH. Edited by Matt Watto, MD

Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.

Take our self-assessment quiz!

Clinical Pearls

1. When starting a conversation about birth control, ask your patient what characteristics of contraception are important to her, e.g. effectiveness, side effects, having or not having a period, how often it has to be used, etc.
2. Effectiveness of birth control: Copper IUD >99%; Hormonal IUD or implant >99%; Medroxyprogesterone depot injection 94-99%; Pills (progestin only or combined OCPs), patch, ring 91-99%, hormonal emergency contraception 58-94%, (Reproductive Access Fact Sheet Aug 2017); Copper IUD = most effective emergency contraception (approaches 100% BJOG 2010)
3. Hormonal birth control methods prevent pregnancy by suppressing ovulation, thickening cervical mucus, and thinning the endometrium. Hormonal methods also affect the fallopian tubes, where sperm motility is slowed.
4. Spotting and irregular menstrual bleeding is common within the first three months of using a hormonal contraceptive method. Practitioners can reassure patients that it’s safe to not have a period at all.
5. There are hormonal (levonorgestrel) and non-hormonal intrauterine devices (IUDs). The length of time an IUD remains effective ranges from 3-12 years, depending on the device.
6. Hormonal birth control and cancer: Slight known increased risk of breast cancer, but protective against ovarian, endometrial, and colon cancer.
7. Oral contraceptives dosing rule of thumb: Start patient on medium-dose pill formulation and adjust based on side effects.
8. Emergency Contraception: Offer a prescription because over-the-counter levonorgestrel pills cost ~$50 a pill. Both ulipristal acetate (given w/in 72-120 hours) and levonorgestrel (given w/in 72 hours) pills may be less effective in obesity, but this effect may be less pronounced with ulipristal acetate (Jatlaoui. Contraception 2016). A copper IUD (placed w/in 5 days) may also be used for emergency contraception (Wu et al. BJOG 2010).

Keep reading on below for our In-depth Show Notes!

Case from Kashlak: A woman comes to talk with her doctor about contraception. She is 22 years old, healthy, non-smoker and has no personal or family history of migraine with aura, venous thromboembolism, or cardiovascular disease. Her periods are regular. Her BMI is 24. Blood pressure is normal. This is an ideal case with a healthy patient who has no restrictions in terms of medical eligibility.

1. Framing the conversation: Try to get a sense of the patient’s preferences. Ask which characteristics of contraception are important to her, e.g. effectiveness, side effects, having or not having a period, how often it has to be used, whether it is a device that must be inserted, etc. Also ask what she has tried before and what worked/didn’t work for her.
2. It can help to have a visual: Reproductive Health Access Project has a nice one.  Do not pull out the chart and start describing every method, as this can lead to information overload. Consider what the patient says is important to her and go from there.  
3. In a normal menstrual cycle, the menses is followed by the follicular phase. During this time the ovaries develop follicles, and eventually a dominant follicle emerges. The dominant follicle starts to produce estrogen which leads to a surge in LH (luteinizing hormone) followed by ovulation. Meanwhile, the endometrium is building up/getting thicker to support a potential pregnancy, and cervical mucus thins out to allow easier access for sperm. After ovulation the body enters the luteal phase where the ovaries and corpus luteum are now producing progesterone in order to get the body ready to support potential pregnancy. If no fertilization and no implantation occurs, then the hormone levels decline, menstruation occurs, the endometrium thins and sloughs off and the cycle continues.
4. Hormonal contraception (progesterone +/- estrogen) work in a variety of ways such as suppressing ovulation via the hypothalamic-pituitary-ovarian axis, thickening cervical mucus, and thinning the endometrium. Hormonal methods prevent both fertilization and implantation. None of these methods cause abortions. They block the sperm and the egg from getting together in different ways.
5. Long acting reversible contraceptives (LARCS) are the most effective type of contraception. The etonogestrel implant (in the inner arm, lasts up to 4 years) and the medroxyprogesterone depot injection (q3 mo injection) are both progesterone agents. It is important to prepare patients for side effects: in the first 3 months of use it is very common to have spotting and breakthrough bleeding.
6. With IUDs, hormonal vs. non-hormonal is the main decision point. Levonorgestrel IUDs (Mirena, Liletta, Skyla, and now Kylena) usually suppress menstruation. There is also the non-hormonal copper IUD. This is a good option for women who have a contraindication to hormones or who don’t want them. It is approved for 10-12 years. IUD can be removed any time the patient wishes.
7. Counseling on Risks with IUDs: Risks are low. Very low risk of perforation of uterus during insertion. Those who become pregnant w/IUD (which is rare), have increased chance of ectopic pregnancy.
8. Training on LARC insertion: Train through on-job in local hospital or area (easiest during residency). ACOG has a list of places for training on LARC insertion. Note: for etonogestrel Implant, must be trained through Merck.
9. Amenorrhea: Many women are wary about not having a period while on hormonal contraception, but you can reassure them it’s OKAY.
10. Birth control pills are a popular option for women who want to control method of use themselves.
11. Monophasic/Biphasic/Triphasic: Different dosings of pill. Mono: one, steady dose throughout month, Bi: two different doses, Tri: three. This was an attempt to have more natural mimic of hormonal cycle, but efficacy/side effects similar across all.
12. OCPs: How do you decide on dosing? Usually start on medium (30 micrograms estradiol) because low-dose pills have higher incidence of breakthrough bleeding and higher discontinuation rate. Adjust dose based on side effects.
13. Estrogen + Progesterone Ring or Patch: Similar counseling for ring and patch as with estrogen pills. Patch has higher hormone levels. Patch is once a week, vaginal ring is once a month, so good option for patient who does not want to take daily pill.
14. Estrogen + progesterone OCPs common side effects include breast tenderness, nausea, mood fluctuations, breakthrough bleeding. Thrombosis/PE are very rare, but the risk is non-zero. Patients with true migraines + aura have increased stroke risk with estrogen birth control, so should avoid this. The CDC Medical Eligibility Criteria (MEC) go in depth about safety of hormonal OCPs depending on underlying medical conditions
15. What is a minipill? Minipill is a progesterone only pill, good for women who cannot have estrogen.  It is safe for use while breastfeeding, but unforgiving i.e. requires taking it daily on a strict schedule.
16. Breast cancer risk: NEJM Study, known, small association with combined oral contraception and incidence of breast cancer, but because of small effect, patients not generally counseled. CDC MEC do not consider family history breast cancer a contraindication to hormonal contraception (Rating 1, No restriction). Patients w/prior or current breast cancer should not be given hormonal contraception (Rating of 3, 4 theoretical, or unacceptable risk respectively)
17. Hormonal birth control benefits: Reduces the rates of ovarian, endometrial, colon cancer.
18. Emergency Contraception: Offer a prescription because over-the-counter levonorgestrel pills cost ~$50 a pill. Both ulipristal acetate (given w/in 72-120 hours) and levonorgestrel (given w/in 72 hours) pills may be less effective in obesity, but this effect may be less pronounced with ulipristal acetate (Jatlaoui. Contraception 2016). A copper IUD (placed w/in 5 days) may also be used for emergency contraception (Wu et al. BJOG 2010).
19. Emergency contraception mechanism of action: Pills work by suppressing ovulation. Copper ions from IUD create toxic environment for sperm and creates local inflammatory response that does not allow implantation.

Goal:
Listeners will learn the basics of hormonal and nonhormonal contraception. Listeners will be comfortable discussing and counseling patients on the various methods of birth control and learn the best practices for prescribing.

Learning objectives:
After listening to this episode listeners will…

1. Explain basic physiology of the menstrual cycle
2. Explain the mechanism of action for hormonal contraception
3. Counsel patients on various form of hormonal and nonhormonal contraceptives
4. Recall the benefits, risks and side effects for different methods of birth control
5. Initiate hormonal contraception for birth control and adjust the dose as needed
6. Understand options for emergency contraception and counsel patients on use

Time Stamps

• 00:00 Disclaimer
• 00:35 Intro
• 01:32 Guest bios
• 03:45 One liners, app recommendations, picks of the week
• 09:32 Picks of the week
• 12:45 Intro to contraception and a clinical case
• 13:33 Starting a conversation about contraception
• 16:55 Is having a period needed? And, which agents cause amenorrhea?
• 19:28 The menstrual cycle reviewed
• 23:29 Pros and Cons of long acting progesterone only agents
• 26:55 Choosing between IUDs
• 30:00 Who should get a copper IUD
• 30:53 Mechanism of hormonal IUDs
• 31:37 Risk with IUDs
• 34:05 Why are there so many OCPs?
• 36:05 Counseling patients on risks of OCPs
• 38:00 Risk of breast cancer with hormonal contraception
• 42:10 Benefits of hormonal contraception
• 43:38 Migraines and hormonal contraception
• 44:53 Mono- vs bi- vs triphasic pills. Does it matter?
• 46:15 Starting dose for OCPs
• 48:31 Is the mini pill effective?
• 49:37 Patches and rings
• 51:15 Take home points
• 52:40 Whoops, almost forgot emergency contraception!
• 56:32 How do copper IUDs work?
• 58:10 The Curbsiders recap the episode, plus some clinical pearls from Molly about birth
• 65:00 Outro

Disclosures: Dr Ti, Dr Rashid and The Curbsiders report no relevant financial disclosures for this episodes.

Recommendations from the show:

• Angeline: CDC medical eligibility criteria (MEC) app.
• Moira: Also likes the CDC app, recommends the Contraception Point-of-Care app.

Picks of the week:

• Matt: book, Brag! The art of tooting your own horn without blowing it by Peggy Klaus
• Molly: book, Black man in a white coat by Dr. Damon Tweedy  
• Angeline: book, Hunger: A memoir of (my) body by Roxane Gay
• Moira: Killing the black body by Dorothy Roberts

Links and recommended reading

1. Mørch LS, Skovlund CW, Hannaford PC, Iversen L, Fielding S, and Lidegaard Ø. Contemporary Hormonal Contraception and the Risk of Breast Cancer. N Engl J Med 2017; 377:2228-2239 DOI: 10.1056/NEJMoa1700732 http://www.nejm.org/doi/full/10.1056/NEJMoa1700732
2. Contraceptive Technology Conference: http://www.contraceptivetechnology.org/conference/san-francisco/
3. UCSF Beyond the Pill: http://beyondthepill.ucsf.edu
4. Bedsiders.org: https://www.bedsider.org
5. Emergecy Contraception efficacy rates: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4216625/ http://ec.princeton.edu/questions/eceffect.html
6. ACOG LARC Program: Clinical Training Opportunities https://www.acog.org/-/media/Departments/LARC/LARC-Clinical-Training-Opportunities-Replaceable.pdf?dmc=1&ts=20180206T1958559704
7. Centers for Disease Control & Prevention. US Medical Eligibility Criteria (US MEC) for Contraceptive Use, 2016. https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html