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BIRTH CONTROL MADE SIMPLE Richard Wahl, M.D.

Department of Pediatrics
University of Arizona
September 16, 2010

Too Much Estrogen:


Nausea, bloating, breast tenderness,
hypertension, melasma, headache.

Too Little Estrogen:


Break-through bleeding (early or mid-cycle),
spotting, hypomenorrhea.

Too Much Progestin:


Breast tenderness, headache, fatigue, mood swings.

Too Little Progestin:


Break-through bleeding (late cycle).

Too Much Androgen:


Increased appetite, weight gain, acne, oily skin, hirsutism, decreased libido, increased breast size, breast tenderness,
Lipids: increased LDL, decreased HDL.

Progestin Activity: (Desogestrel ≈ Norgestrel ≈ Levo-norgestrel) > Norethenidrone

Androgenic Potency: Medroxyprogesterone acetate > (Norgestrel ≈ Levo-norgestrel) > (Norethindrone ≈ Ethynodiol) >
(Desogestrel ≈ Norgestimate = non-androgenic) > (Drospirenone = anti-androgenic)

Low Dose Monophasic OCPs

Brand Names Ethinyl Progestin Estrogen Progestin Androgen Comments


estradiol potency potency potency
Alesse Aviane 20 mcg Levo-norgestrel + ++ ++ Spotting more likely.
Levlite Lutera 0.1 mg Missed pills problematic.
Loestrin 1/20 20 mcg Norethindrone 1 mg + ++ ++ Osteopenia? (20 mcg EE ≈
Microgestin 1/20 relative hypoestrogenemia)
Levlen Levora 30 mcg Levo-norgestrel + +++ ++/+++ Minimize spotting or break-
Nordette Portia 0.15 mg through bleeding.
Lo/Ovral 30 mcg Norgestrel 0.3mg + +++ ++/+++
Cryselle
Loestrin 1.5/30 30 mcg Norethindrone acetate + ++ ++
Microgestin 1.5/30 1.5 mg
Desogen Apri 30 mcg Desogestrel 0.15 mg + +++ 0 Non-androgenic.
Ortho-Cept 2x increased DVT risk.
Yasmin 30 mcg Drospirenone 3 mg + ?? Anti-androgenic. PCOS Tx.
Ocella Zarah
- Spironolactone analog.
Demulen 1/35 35 mcg Ethynodiol diacetate ++ ++ ++
Zovia 1/35 1 mg
Ortho-Cyclen 35 mcg Norgestimate 0.25 mg ++ + 0 Low androgen activity.
MonoNessa No reports of incr. DVT risk.
Ovcon-35 35 mcg Norethindrone 0.4mg ++ + + Femcon Fe “Chewable”
Modicon 35 mcg Norethindrone 0.5 mg ++ + +
Brevicon
Orho-Novum 1/35 35 mcg Norethindrone 1 mg ++ ++/+++ ++

(50 mcg Mestranol = 35 mcg Ethinyl Estradiol)


Biphasic OCPs

Brand Names Ethinyl Progestin Estrogen Progestin Androgen Comments


estradiol potency potency potency
Mircette 20 mcg x Desogestrel 0.15 mg + +++ 0 Non-androgenic.
Azurette 21 days, x 21 days Less break-through bleeding.
Kariva 0 x 2 days, 2x increased DVT risk.
10 x5 days

Triphasic OCPs

Estrostep Fe 20 mcg x5 Norethindrone 1 mg + ++/+++ ++ FDA Acne indication


Tilia 30 mcg x7 x 21 days
35 mcg x9
Ortho Tri- 25 mcg x Norgestimate 0.18 mg + + 0 Low androgen activity. No
Cyclen Lo 21 days x7, 0.215 x 7, 0.25 x7 reports of incr. DVT risk.
Cyclessa 25 mcg x Desogestrel 0.1 mg x7 + +++ 0 2x increased DVT risk
21 days 0.125 x7, 0.15 mg x 7
Triphasil 30 mcg x7 Levo-norgestrel 0.05 ++ + +/++ Good for mid-cycle spotting.
Tri-Levlen 40 mcg x5 mg x6, 0.075 mg x 5, Higher estrogen dose pre-
30 mcg x10 0.125 mg x 10 days ovulation.
Ortho Tri- 35 mcg x Norgestimate 0.18 mg ++ + 0 FDA Acne indication
Cyclen 21 days x7, 0.215 x 7, 0.25 x7 No reports of incr. DVT risk.
TriNessa
Tri-Norinyl 35 mcg x Norethindrone 0.5 mg ++ +/++ +/++
21 days x7, 1mg x9, 0.5 x 5
Ortho-Novum 35 mcg x Norethindrone 0.5 mg ++ +/++ +/++
7/7/7 21 days x7, 0.75 x7, 1 mg x7

Extended Cycle OCP

Seasonale 30 mcg Levo-norgestrel + ++ ++/+++ Continuous 84-day cycle,


Jolessa 0.15 mg then 7 days off. Increased
spotting or cyclic bleeding.
Seasonique 30mcg x84 days Levo-norgestrel + ++ ++/+++ No hormone-free days.
10mcg x 7 days 0.15 mg Less spotting than above?
Yaz 20 mcg x 24 Drospirenone 3 mg + ?? Similar to Yazmin. Lower
days
- Estrogen, 24/4 day cycle.
Lybrel 20 mcg Levo-norgestrel + + +/++ Continuous OCP. Early
0.09 mg spotting/BTB, then improves
Natazia Estradiol Dienogest (new) ? +++ Estradiol instead of EE.
(3mg → 1mg) (≈ Drospirenone)
- Dienogest: anti-androgenic
(New July 2010) (2mg → 3mg) 4-phase pill, with 2 day
hormone-free break

Progestin-Only Pills

Micronor --- Norethindrone 0 + + Irregular menses, but


Nor-QD 0.35 mg reduced overall blood loss.
OK for breastfeeding.

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Other Hormonal Contraceptives

Depo-Provera --- Medroxy-progesterone 0 +++ ++++ Q 12 weeks. Irregular menses


acetate 150 mg IM à amenorrhea. Osteopenia.
Depo-SubQ --- Medroxy-progesterone 0 +++ ++++ Delayed return of fertility.
acetate 104 mg SQ Improves epilepsy, sickle cell.

Mirena IUD (or IUS) Levo-norgestrel 0 +++ ++/+++ IUD cost: ∼ $500
20 mcg/day x 5 years Insertion: ∼ $300
ParaGard (Copper T 380A) IUD No Hormone, x 10 years 0 0 0
Norplant “rods” --- Levo-norgestrel 36 mg 0 ++ ++ No longer available in U.S.
x 6 rods = 216 mg; Over 5
years = 0.12 mg/day.
Implanon --- Etonogestrel 0.06 0 ++/+++ 0 Active form of desogestrel.
“implant” mg/day x 3 years DVT concern.
NuvaRing EE 15 Etonogestrel 0.12 ++? +++ 0 Vaginal ring x 3 weeks.
Vaginal insert mcg/day mg/day x 3 weeks Increased vaginal discharge.
DVT concern.
Ortho Evra Patch EE 20 Norelgestromin +++ + 0 1 patch weekly x 3 weeks.
mcg/day (Norgestimate) Poor cycle control.
150 mcg/day “Tricycle” with 9 patches.
Increased DVT risk.

Emergency Contraception

Plan B --- Levo-norgestrel +++ +++ Initial dose < 72 – 120 Hrs. May
Next Choice 0.75 mg each tablet
- take both tabs together. Check HCG
Plan B One Step Levo-norgestrel +++ +++ Take pill < 72 – 120 Hr of
1.5 mg
- unprotected sex. Check HCG
ellaOne or ella Ulipristal acetate Selective progesterone receptor modulator. 1 dose given < 72 – 120 Hr of
(New Aug 2010) 30 mg unprotected sex. (cf. RU-486/mifepristone). More effective than Plan B.

Missed Contraceptive Doses (See Ref. 7: Society of Ob-Gyn of Canada, November 2008)

1. Combined OCP (Monophasic, Triphasic, etc.)


a. Missed 1 active pill < 24 hr late: Take missed pill ASAP. May take 2 pills same day.
b. Missed 1 or more active pills, > 24 hr late:
i. During week 1: Take pill ASAP, use back-up x 1 week, consider EC if unprotected sex past 5 days.
ii. During week 2 – 3 and < 3 missed pills: Take 1 pill ASAP, continue active pills until pack finished, then
discard inactive pills and start new pack.
iii. During week 2 – 3 and > 3 missed pills: Take 1 pill ASAP, continue active pills until pack finished, then
discard inactive pills and start new pack. Back-up method x 1 week, consider EC for unprotected sex
during missed pills until 7 active pills have been taken.
c. Continuous/Extended OCP: missed pill after 21 days of continuous OCP use:
i. < 7 days missed: Re-start OCP; no special precautions.
ii. > 7 days missed: Take pill ASAP, use back-up x 1 week, consider EC if unprotected sex past 5 days.

2. Contraceptive Patch (Ortho-Evra)


a. Patch detached < 24 hr: Reapply or replace ASAP, patch change day stays the same, complete usual cycle of 3
patches.
b. Patch delayed or detached > 24 hr:
i. During week 1 and detached > 24 hr (or uncertain): Apply new patch ASAP, patch change day stays the
same, complete usual cycle of 3 patches. Back-up protection x 1 week and consider EC if sex past 5 days.
ii. During week 2 – 3 and detached < 72 hr: Apply new patch ASAP, patch change day stays the same. Finish
course of 3 patches and immediately start new patch cycle with no off-week.

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iii. During week 2 – 3 and detached > 72 hr: Apply new patch ASAP, patch change day stays the same. Finish
course of 3 patches and immediately start new patch cycle with no off-week. Back-up protection x 1 week,
consider EC for prolonged omission.
c. Extended wear (> 9 days):
i. Patch 1 or 2 left on for 9 to 11 days: Apply new patch, change day stays the same. Finish course of 3
patches and immediately start new patch cycle with no off-week.
ii. Patch 1 or 2 left on for > 12 days: Same as above plus back-up protection x 7 days and consider EC if sex
past 5 days.
iii. Extended wear of Patch 3: No concern unless left on past scheduled start of new patch cycle.

3. Contraceptive Ring (NuvaRing)


a. Removal for < 3 hr: Reinsert ASAP. Removal day (day 21 after taking ring out of foil) unchanged.
b. Insertion delayed > 24 hr or removal for > 3 hr:
i. Week 1 and removal > 3 hr (or uncertain): Reinsert ASAP. Removal day (day 21 after taking ring out of
foil) unchanged. Back-up x 7 days and consider EC if sex past 5 days.
ii. Week 2 – 3 and removal < 72 hr: Reinsert ASAP. Removal day (day 21 after taking ring out of foil)
unchanged. Then start new cycle with new ring and no ring-free period.
iii. Week 2 – 3 and removal > 72 hr: Reinsert ASAP. Removal day (day 21 after taking ring out of foil)
unchanged. Then start new cycle with new ring and no ring-free period. Back-up protection x 7 days and
consider EC if repeated or prolonged omission.
c. Ring left in for > 28 days:
i. For 28 – 35 days: Insert new ring with no ring-free period. Keep until scheduled removal day (day 21 after
taking ring out of foil).
ii. For > 35 days: Same as above plus back-up protection x 7 days and consider EC if sex past 5 days.

4. Progestin-Only Pills (Micronor, Nor-QD)


a. Delayed > 3 hr or missed > 1 pill:
i. If unprotected sex past 5 days: EC recommended. Continue pill next day, taking same hour daily. Back-up
protection x 48 hr.
ii. No unprotected sex past 5 days: Take pill ASAP, continue one pill daily, taking same hour each day. Back-
up protection x 48 hr.

5. Depot Medroxyprogesterone Acetate Injections (Depo-Provera)


a. Last injection < 14 weeks ago: give next injection ASAP.
b. Last injection > 14 weeks ago:
i. If unprotected sex < past 5 days and urine HCG negative: Provide EC, give next injection ASAP, back-
up protection x 1 week. Repeat HCG in 3 weeks.
ii. If unprotected sex > past 5 days and urine HCG negative: Give next injection ASAP, back-up protection x
1 week. Repeat HCG in 3 weeks.
iii. No unprotected sex past 14 days and urine HCG negative: Give next injection ASAP, back-up protection x
1 week.

References:
1. Gupta N, Corrado S, Goldstein M: Hormonal contraception for the adolescent. Pediatr Rev 2008, 29(11):386-396
2. Hatcher RA. Contraceptive Technology, 19th edition. 2008, Thomson Reuters, New York
3. Petitti DB. Clinical practice. Combination estrogen-progestin oral contraceptives. N Engl J Med 2003;349(15):1443-1450.
4. Comparison of oral contraceptives: a summary. Prescriber's Letter 2010;26(7):231207 (Updated June 2010)
5. Natazia (Estradiol Valerate and Dienogest). Prescriber's Letter 2010;26(7): 260706
6. Missed doses of hormonal contraceptives. Prescriber’s Letter 2009;25(1):250120
7. Guilbert, E, et al. Missed hormonal contraceptives: new recommendations. J Obst Gyn Can 2008;30(11): 1050-62.
8. Fine P, Mathe H, et al. Ulipristal acetate taken 48-120 hours after intercourse for emergency contraception. Obstet Gynecol.
2010;115(2 Pt 1):257-263.
9. Glasier AF, Cameron ST, Fine PM, et al. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised
non-inferiority trial and meta-analysis. Lancet. 2010;375(9714):555-562.

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(Hatcher RA. Contraceptive Technology, 18th edition. 2004, Ardent Media, New York)

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