Contraception

Birth control , contraception and

fertility control
contraception aims to prevent pregnancy.
A woman can get pregnant if a man's sperm reaches one of her eggs (ova).
Contraception tries to stop this happening by:
•keeping the egg and sperm apart
•stopping egg production
•stopping the combined s perm and egg (fertilized egg) attaching to the
lining of the uterus
 KEY CONCEPTS
•Unintended pregnancy is a public health issue. Most unintended pregnancies that
occur are due to inconsistent use or nonuse of contraceptives.
•The desired goal of treatment with all methods of contraception is to prevent
pregnancy.
•Counseling on the optimal use of the contraceptive method and providing strategies
for minimizing sexually transmitted infections/diseases (STIs/STDs) must be provided
to all patients being initiated on contraceptives and for those also using contraception
on an ongoing basis.
 KEY CONCEPTS
The following must be considered when selecting a contraceptive method:
the effectiveness of the method, the no contraceptive benefits and side effects of the method, attitude of the patient
and of the sexual partner toward a contraceptive method, the ability to use the method correctly (which may alter the
effectiveness of the method), and the ability to pay for the method.
Patient-specific factors (eg, frequency of intercourse, age, smoking status, desire for return to fertility, concomitant
diseases, medications, and drug–drug interactions) must be evaluated when selecting a contraceptive method.
Contraceptive methods are Nonhormonal and hormonal.
Some medications may alter the effects of hormonal contraceptives or vice versa; therefore, a patient’s concomitant
medications should be assessed for drug–drug interactions with hormonal contraceptives.
Accurate and timely counseling on the management of missed doses is critical for contraceptive effectiveness
Emergency contraception (EC) may prevent pregnancy after unprotected intercourse or when regular contraceptive
methods have failed
 General Approach for contraception:
Nonpharmacologic Therapy
Fertility Awareness-based Methods
Motivated couples may use fertility awareness-based methods that entail avoiding sexual intercourse during
the days of the menstrual cycle when conception is likely to occur.
These typically include calendar-based methods such as the standard days or rhythm methods. In addition,
There are many technology apps available for these methods; however, the Food and Drug Administration
(FDA) approved the first app in this category (Natural Cycles) in 2018. (you can find the
link for the app below)
The major drawbacks of these methods are the relatively high pregnancy rates and avoidance of intercourse
for several days during each menstrual cycle.
Apple app store: https://apps.apple.com/lr/app/natural-cycles-contraception/id765535549

Google Play store: https://play.google.com/store/apps/details?id=com.naturalcycles.cordova&hl=en&gl=US

General Approach for contraception:
Nonpharmacologic Therapy
Barrier Techniques
The effectiveness of barrier methods depends almost exclusively on motivation to use them
consistently and correctly.

These methods include condoms, diaphragms, cervical caps, and sponges.

A major disadvantage is higher failure rates than most hormonal contraceptives; thus, provision of
counseling and an advanced prescription for emergency contraception (EC) are recommended for all
patients using barrier methods as their primary means of contraception.
General Approach for contraception:
pharmacologic nonhormonal Therapy
Spermicides and Spermicide-Implanted Barrier Techniques:

Spermicides, most of which contain nonoxynol-9, are chemical surfactants that destroy sperm cell
walls and act as barriers that prevent sperm from entering the cervical os.

They are available as creams, films, foams, gels, suppositories, sponges, and tablets.

Spermicides offer no protection against STI/STDs. In fact, when used frequently (more than two times
per day), nonoxynol-9 may increase the risk of transmission of HIV by causing small disruptions in the
vaginal epithelium

The vaginal contraceptive sponge contains 1 g of the spermicide nonoxynol-9.

Nonpharmacological
& pharmacological
Non-hormonal
contraceptive
Hormonal
Contraception
Hormonal contraceptives contain a combination of estrogen and progestin or a progestin alone.
Oral contraceptive (OC) preparations first became available in the 1960s, but options have expanded to include a
transdermal patch, a vaginal contraceptive ring, and long-acting injectable, implantable, and intrauterine
contraceptives.
Combined hormonal contraceptives (CHCs) contain both estrogen and progestin and work primarily before fertilization
to prevent conception.
Progestins provide most of the contraceptive effect by thickening cervical mucus to prevent sperm penetration, slowing
tubal motility, delaying sperm transport, and inducing endometrial atrophy it also block the LH surge, therefore
inhibiting ovulation.
Estrogens suppress FSH release from the pituitary, which may contribute to blocking the LH surge and preventing
ovulation. However, the primary role of estrogen in hormonal contraceptives is to stabilize the endometrial lining and
provide cycle control
 Estrogens
Three synthetic estrogens found in hormonal contraceptive are:

• ethinyl estradiol (EE)

• mestranol,

• estradiol valerate.

Ethinyl estradiol is the most used estrogen in hormonal contraceptive products.

Most combined OCs, transdermal patch, and vaginal ring contain estrogen at doses of 20 to 50 mcg of
EE
Progestins
Progestin is a term used for a synthetic progesterone.

A variety of progestins are available, and they vary in their pregestational activity and differ with
respect to inherent estrogenic, antiestrogenic, and androgenic effects.

Estrogenic and antiestrogenic properties are secondary to the extent of progestins’ metabolism to
estrogenic substances.

Androgenic activity depends on two variables: the presence of sex hormone (testosterone)-binding
globulin (SHBG-TBG) and the androgen-to-progesterone activity ratio.

If the amount of SHBG-TBG is decreased, free testosterone levels increase, and androgenic side effects
are more prominent
Injectable Progestins
Steroid hormones provide longer-term contraception when injected into the skin. Sustained progestin
exposure blocks the LH surge, thus inhibiting ovulation.
Should ovulation occur, progestins reduce ovum motility in the fallopian tubes, Even if fertilization
occurs, progestins thin the endometrium, reducing the chance of implantation.
Women who may benefit from injectable progestins are those who are breastfeeding, those who are
intolerant to estrogens (ie, have a history of estrogen-related headache, breast tenderness, or
nausea) or those with concomitant medical conditions or contraindications in which estrogen is not
recommended.
In addition, injectable progestins are beneficial for women with adherence issues; they have lower
failure rates than CHC methods
Depot Medroxyprogesterone Acetate
Depo-Provera (DMPA) is similar in structure to naturally occurring progesterone by deep intramuscular injection in the gluteal or
deltoid muscle or subcutaneously in the abdomen or thigh within 5 days of onset of menstrual bleeding.

If it is administered at any other time of the menstrual cycle, then it is recommended to use an additional nonhormonal
contraceptive backup method for 7 days.

Although these injections may inhibit ovulation for up to 14 weeks, the dose should be repeated every 3 months (12 weeks) to
ensure continuous contraception.

With perfect use, the efficacy of DMPA is more than 99%; The primary mechanism of action is suppression of ovulation.

Menstrual irregularities are the most frequent adverse effects of DMPA and are most common in the first year of use..

Other adverse effects, including breast tenderness and depression, occur less commonly. Weight gain is a concern for many
women using DMPA, has also been associated with short-term bone loss in younger women of reproductive age.
Long-acting Reversible
Contraception (LARC)
It refers to a category of hormonal and nonhormonal contraceptives that include IUDs and implants.
This type of contraception is highly efficacious in preventing pregnancy, but the effects are quickly
reversible upon removal.

As LARC does not require effort or adherence by the patient once they are inserted, perfect-use and
typical-use efficacy rates do not differ, and the efficacy rate is like that of surgical options such as
tubal ligation.
Intrauterine Devices
Currently, five IUDs are available, all are T-shaped and are medicated, one with copper and four with and clinicians must
receive training from the manufacturer prior to insertion or removal of the IUDs.

These IUDs have several possible mechanisms of action, including inhibition of sperm migration, damaging ovum or
disrupting transport, and possibly damaging the fertilized ovum.

Efficacy rates with IUDs are greater than 99% with both perfect and typical use and should not be inserted in the
presence of current pregnancy, current pelvic inflammatory disease (PID), current STI/STD, puerperal or postabortion
sepsis, purulent cervicitis, undiagnosed abnormal vaginal bleeding, malignancy of genital tract, uterine anomalies or
fibroids distorting uterine cavity, allergy to an IUD component, or Wilson’s disease (for copper IUD).

If an IUD is already in place and the patient contracts an STI/STD, the IUD in most cases can remain in place while the
STI/STD is being treated.

The major adverse effect associated with IUDs is irregular menstrual bleeding
 Othe methods of contraception
1. Transdermal Contraceptives

2. Vaginal Rings

3. Subdermal Progestin Implants

Oral
Contraceptives
(OC’s)
Oral Contraceptives (OC’s)
With perfect-use OCs have a 99% efficacy rate, but with typical-use up to 7% of users may become
pregnant.
Monophasic OCs contain the same amounts of estrogen and progestin for 21 days, followed by 7-day
placebo phase.
Multiphasic pills (biphasic,triphasic, or quadriphasic) contain variable amounts of estrogen and progestin
for 21 days, also followed by a 7-day placebo phase.
Progestin-only “minipills” (28 days of active hormone per cycle) Minipills must be taken every day of the
menstrual cycle at approximately the same time to maintain contraceptive efficacy. If a progestin-only OC is
taken more than 3 hours late, patients should use a backup method of contraception for 48 hours. Minipills
may not block ovulation (nearly 40% of women continue to ovulate normally), so the risk of ectopic
pregnancy is higher with their use than with other hormonal contraceptives
Progestin-only OCs are less effective than combination OCs and are associated with irregular and
unpredictable menstrual bleeding
Initiating an Oral Contraceptive

Oral contraceptives may be initiated by 3 different methods:

on the first day of bleeding during the menstrual cycle

on the first Sunday after the menstrual cycle begins

the quick start method

The first day method is when the woman starts the OC on the first day of her menstrual cycle. The
women should be instructed to use a second method of contraception (typically recommend condoms)
for at least 7 days after initiation for maximum effectiveness.
The “Sunday start” method is to begin pills on the first Sunday after the menstrual cycle begins, as
this may provide for weekends free of menstrual periods. Women should also be instructed to use a
second method of contraception (typically recommend condoms) for at least 7 days after initiation for
maximum effectiveness. It may be preferable to have women use additional contraception for the
entire first cycle, due to user failure in the first month.
 The “quick start” method for initiating OCs, the patient takes the first tablet on the day of her office
visit. Women should be instructed to use a second method of contraception for at least 7 days and
potentially until she begins her next menstrual cycle to ensure optimal effectiveness. The woman
should be informed that the menstrual period will be delayed until completion of the active tablets in
the current OC pack
Choice of Oral Contraceptive

Because all combined OCs are similarly effective in preventing pregnancy , the initial choice is based
on the hormonal content and dose, preferred formulation, and coexisting medical conditions
Managing Oral Contraceptive Side Effects
Many side effects occurring with early OC use (eg, nausea, bloating, breakthrough bleeding) improve
spontaneously by the third cycle of use after adjusting to the altered hormone levels.
Women should be counseled to continue their OC for 2 to 3 months before a change is made to adjust the
hormonal content unless a serious adverse effect is present.
Despite the 2 to 3 month adjustment period, a large majority of women who discontinue OCs do so
because of the side effects.
Patient education and early reevaluation within 3 to 6 months are necessary to identify and manage
adverse effects, to improve adherence
Patients should be instructed to consult with their provider immediately and likely should discontinue CHCs
if they experience serious warning signs, described as ACHES (Abdominal pain, Chest pain, Headaches, Eye
problems, and Severe leg pain).
Symptoms of a Serious or
Potentially Serious Nature
Associated with Combined
Hormonal Contraception
Drug Monitoring
Table for
Hormonal
Contraception
Drug Monitoring Table for
Hormonal Contraception
Managing Oral Contraceptive
Drug Interactions
The effectiveness of an OC is sometimes limited by drug interactions that interfere with GI
absorption, increase intestinal motility by altering gut bacteriologic flora, and alter the metabolism,
excretion, or binding of the OC.

Women should be instructed to use an additional method of contraception if there is a possibility of a

drug interaction altering the effectiveness of the OC

If a woman is going to be receiving an interacting medication for more than 2 months, it is suggested
to switch oral contraception to depot medroxyprogesterone acetate (DMPA) or an intrauterine device
to avoid the interaction and eliminate the need for long-term additional nonhormonal contraception.
 Examples of Oral Contraceptive
Drug Interactions
1. Of all antibiotics, rifampin is the one with a true documented pharmacokinetic interaction, Women
receiving concomitant rifampin (or derivatives) and OCs should be counseled on the possibility for
decreased efficacy. The mechanism of action is likely the inhibition of enterohepatic recirculation
2. Women receiving certain anticonvulsants for a seizure disorder should be offered another form of
contraception such as DMPA or LARC methods rather than OCs, Some anticonvulsants (mainly
phenobarbital, carbamazepine, phenytoin) induce the metabolism of estrogen and progestin, inducing
breakthrough bleeding and potentially reducing contraceptive efficacy In addition, some
anticonvulsants are known teratogens. Use of combined OCs with lamotrigine may decrease the
effectiveness of lamotrigine and increase the possibility of worsening the seizure disorder
3. HIV antiretrovirals such as protease inhibitors which, depending on the HIV medication, may decrease
OC effectiveness or the OC may possibly alter the levels of protease inhibitor.
Missed Doses of Oral
Contraceptives
Specific instructions should be given regarding what to do if a tablet is missed. For women who routinely have difficulty
with adhering to daily dosing, counseling regarding other options such as the vaginal ring, transdermal patch, DMPA,
implants, or IUDs should be provided.
For combined hormonal OCs, if one tablet is missed or late then take the tablet as soon as remembered and continue
taking the rest of the tablets as prescribed. Typically, no additional nonhormonal contraception methods are warranted.
If two or more consecutive tablets are missed, then take one missed tablet as soon as remembered and discard the
missed tablets. Continue taking the OC tablets as scheduled which means two tablets may need to be taken on the same
day (ie, one of the missed tablets and one of the regularly scheduled tablets).
If tablets were missed in the last week of hormonal tablets, finish the remaining active tablets (tablets with hormone)
and then omit the hormone-free interval (skip taking the placebo tablets) and start a new pack of tablets. For both of
these scenarios, counsel patients to use additional nonhormonal contraception until tablets of active hormone have
been taken for 7 consecutive days.
Discontinuing Oral Contraceptives
and Return of Fertility
There is no evidence that OC use decreases subsequent fertility; there are similar findings with the
transdermal patch and vaginal ring.3 The average

delay in ovulation after discontinuing OCs is 1 to 2 weeks. However, delayed ovulation is more
common in women with a history of irregular menses. If

amenorrhea does continue beyond 6 months, women should be counseled to see a physician for
further fertility workup
Medical Eligibility
Criteria for
Contraceptive Use:
Classifications for
Combined Hormonal
Contraceptives
 Category 1:
No restriction (method can be used)
1. Thalassemia, iron 10. Minor surgery without surgery; restrictive 26. Postabortion 35. Uterine fibroids
deficiency anemia immobilization procedures
27. Non-breastfeeding >42 36. Use of SSRIs
2. Mild compensated 11. Depression 18. History of pelvic surgery days postpartum
cirrhosis 37. Use of broad-spectrum
12. Gestational diabetes 19. HIV infected or high risk 28. Severe dysmenorrhea antibiotics, antifungals,
antiparasitics
3. Benign ovarian tumors mellitus 29. Sexually transmitted
20. Malaria infections
4. Benign breast disease or 13. Endometrial
family history of cancer cancer/hyperplasia, 21. Multiple sclerosis 30. Varicose veins
endometriosis without prolonged
5. Family history of cancer immobility 31. Vaginal bleeding-
14. Epilepsy irregular pattern without
6. Schistosomiasis 22. Ovarian cancer heavy
15. Gestational trophoblastic 23. Past ectopic pregnancy 32.
7. Cystic fibrosis disease bleeding or heavy,
prolonged bleeding
24. Parity, parous, or
8. Cervical ectropion 16. Nonmigrainous nulliparous
headaches 33. Thyroid disorders
9. Viral hepatitis 25. PID
(carrier/chronic) 34. Tuberculosis
17. History of bariatric
 Category 2:
Advantages generally outweigh theoretical or
proven risks
1. Age ≥40 (in the absence of disease without other VTE risk 22. Stable SLE without 28. for those with increased
other comorbid conditions factors antiphospholipid risk of VTE)
that increase CVD risk) 8. Gallbladder disease; antibodies
symptomatic and treated 15. Breastfeeding 42 days or 29. Acute flare of viral
2. Sickle cell disease bycholecystectomy or more postpartum 23. Unexplained vaginal hepatitis occurring during
asymptomatic bleeding before evaluation use
3. Undiagnosed breast mass 16. Non-breastfeeding 21-42
9. Migraines without aura days postpartum 24. Uncomplicated valvular 30. of product (continuation,
4. Cervical cancer and heart disease category 3 or 4 for
awaiting treatment; 10. History of pregnancy- 17. without risk factors for VTE initiation of product)
cervical intraepithelial related cholestasis 25. Use of antiretrovirals other
neoplasia 18. Rheumatoid arthritis on or than fosamprenavir
11. History of high blood off (category 1 or 2 depending
5. Family history (first-degree pressure during pregnancy on agent)
relatives) of DVT/PE 19. immunosuppressive
12. Benign liver tumors; focal therapy 26. Use of St. John’s wort
6. Major surgery without nodular hyperplasia
prolonged immobilization 20. Smoking and <35 years old 27. Inflammatory bowel
13. Obesity disease (possibly category
7. Diabetes mellitus (type 1 21. Uncomplicated sold organ 3
or type 2), nonvascular 14. Breastfeeding 30-42 days transplantation
 Category 3:
Theoretical or proven risks usually outweigh the
advantages
1. Breastfeeding 21-30 days symptomatic and medically and age ≥35 (possibly category 4 depending
postpartum with or without risk treated on severity[initiation])
factors for VTE 13. Use of fosamprenavir
7. History of bariatric surgery; 19. Multiple sclerosis with prolonged
2. Breastfeeding 30-42 days malabsorptive procedures (COCs 14. Use of certain anticonvulsants immobility
postpartum with risk factors for only, vaginal ring/transdermal (phenytoin, carbamazepine,
VTE patch category 1) barbiturates, primidone, 20. Current or history of superficial
topiramate, oxcarbazepine, and venous thrombosis
3. Non-breastfeeding 21-42 days 8. History of cholestasis, past COC- lamotrigine)
postpartum with other risk related
factors for VTE 15. Use of rifampicin or rifabutin
9. Hypertension; systolic blood therapy
4. Past breast cancer and no pressure 140-159 mm Hg or
evidence of disease for 5 years diastolic 90-99 mm Hg 16. Diabetes with vascular disease or
>20 years duration
5. History of DVT/PE (not on 10. Adequately controlled
anticoagulant therapy or hypertension 17. Multiple risk factors for arterial
established on anticoagulant cardiovascular disease (older age,
therapy for at least 3 months), 11. Peripartum cardiomyopathy, smoking, diabetes, low HDL, high
but lower risk for recurrent normal or mildly impaired LDL, or high triglycerides and
DVT/PE cardiac function ≥6 months hypertension))

6. Current gallbladder disease, 12. Smoking <15 cigarettes per day 18. Acute flare of viral hepatitis
 Category 4:
Unacceptable health risk (method not to be used)
1. Breastfeeding or non- 6. History/higher risk of deep 12. Hypertension with vascular 17. Complicated solid organ
breastfeeding <21 days venous disease transplantation
postpartum thrombosis/pulmonary
embolism (established on 13. Current and history of 18. History of cerebrovascular
2. Current breast cancer ischemic heart disease accident
7. anticoagulant therapy for 3
3. Severe (decompensated) months or greater) 14. Benign hepatocellular 19. SLE; positive or unknown
cirrhosis adenoma or malignant liver antiphospholipid antibodies
8. Thrombogenic mutations tumor
4. Current deep venous 20. Complicated valvular heart
thrombosis/pulmonary 9. Major surgery with 15. Peripartum cardiomyopathy, disease
embolism prolonged immobilization moderately or severely
impaired cardiac function;
5. History/higher risk of deep 10. Migraines with aura, any age normal or mildly impaired
venous cardiac function <6 months
thrombosis/pulmonary 11. Systolic blood pressure ≥160
embolism (not on mm Hg or diastolic ≥100 mm16. Smoking ≥15 cigarettes per
anticoagulant therapy) Hg day and age ≥35
Special
Considerations
with Combined
Hormonal
Contraceptive Use
Women Older than 35 Years
Use of a CHC in women older than 35 is controversial, The risks and benefits of using CHCs in women
greater than 35 must be considered on an individual basis. It is recommended that use of CHCs (with less
than 50 mcg of estrogen) may be considered in healthy nonsmoking women.

Formulations with lower doses of estrogen (less than 30 mcg) have increased the use of CHCs in these
women. In addition to the benefit of pregnancy prevention, they may improve or decrease the chance of
developing perimenopausal and menopausal symptoms and increase bone mineral density (BMD).

However, the benefits of using CHCs must be weighed against the risks in women older than 35. The
increased risk of VTE should be considered especially in perimenopausal women older than 40

CHCs should not be recommended in women older than 35 years with migraine (with aura), uncontrolled
hypertension, smoking, or diabetes with vascular disease.
Smoking
OCs with 50 mcg EE or more were associated with MI in women who smoked cigarettes

practitioners should prescribe CHC with caution, if at all, to women older than 35 years who smoke.

Smoking 15 or more cigarettes per day by women in this age group is a contraindication to CHCs, and
the risks generally outweigh the benefits of CHCs in those who smoke fewer than 15 cigarettes per
day.

Progestin-only or nonhormonal contraceptive methods should be considered for women in this

group.
Hypertension
CHCs can cause small increases (ie, 6-8 mm Hg) in blood pressure, regardless of estrogen dosage. Use of low-dose CHC is
acceptable in women younger than 35 years with well-controlled and frequently monitored hypertension.

If a CHC-related increase in blood pressure occurs, discontinuing the CHC usually restores blood pressure to pretreatment values
within 3 to 6 months.

Systolic blood pressure ≥ 160 mm Hg or diastolic blood pressure ≥ 100 mm Hg is considered a contraindication to the use of
CHCs.

Hypertensive women who have a systolic blood pressure of 140 to 159 or diastolic blood pressure of 90 to 99 mm Hg should also
avoid CHCs as the risks generally outweigh the benefits.

Risks versus benefits should be considered for women who have additional cardiovascular risk factors along with hypertension.

Women with hypertension who are taking potassium-sparing diuretics, angiotensin-converting enzyme inhibitors, angiotensin
receptor blockers, or aldosterone antagonists may have increased serum potassium concentrations if they are also using an OC-
containing drospirenone, which has anti-aldosterone properties
 Dyslipidemia
Generally, synthetic progestins may adversely affect lipid metabolism by decreasing high-density lipoprotein (HDL) and
increasing low-density lipoprotein (LDL).

Estrogens tend to have more beneficial effects by enhancing removal of LDL and increasing HDL levels. Estrogens may also
moderately increase triglycerides

the lipid effects of CHCs theoretically can influence cardiovascular risk, the mechanism of increased cardiovascular disease
in CHC users is believed to be due to thromboembolic and thrombotic changes, not atherosclerosis.

It is generally acceptable to use CHCs in women with dyslipidemia as the single cardiovascular risk factor.

However, careful consideration should be taken in women with dyslipidemia along with other cardiovascular risk factors
and in many cases alternative methods of contraception may be recommended
Diabetes
Any effect of CHCs on carbohydrate metabolism is thought to be due to the progestin component.

However, most products used today with formulations containing low doses of progestins do not
significantly alter insulin, glucose, or glucagon release or daily insulin requirements.

CHCs do not appear to alter the hemoglobin A1C values or accelerate the development of
microvascular complications in women with diabetes.

Therefore, nonsmoking women younger than 35 years with diabetes but no associated vascular
disease can safely use CHCs.

Diabetic women with vascular disease (eg, nephropathy, retinopathy, neuropathy, or other vascular
disease) or diabetes of more than 20 years duration should not use CHCs
Migraine Headaches
Women with migraine headaches may experience a decreased or an increased frequency of migraine
headaches when using CHCs, a higher risk of stroke in women experiencing migraine with aura
compared to women with simple migraine
women with non migrainous headaches may also use CHCs without restriction.
Women of any age who have migraine with aura should not use CHC and women who develop
migraines with aura while receiving CHC should discontinue use and consider a progestin-only
option.
Women developing migraines without aura while receiving CHCs should have their headaches
evaluated to determine severity, evaluate for signs of an aura, and to discuss the risk versus benefit of
CHC use.
Breast Cancer
the relationship between OCs and breast is under investigation and a small increase in the relative
risk of having breast cancer diagnosed while combined OCs are taken and for up to 10 years following
discontinuance.

Women with current or history of breast cancer should not use CHCs
Thromboembolism
Estrogens increase hepatic production of factor VII, factor X, and fibrinogen in the coagulation
cascade, therefore increasing the risk of thromboembolic events (eg, deep vein thrombosis and
pulmonary embolism). These risks are increased in women who have underlying hypercoagulable
states (eg, deficiencies in antithrombin III, protein C, and protein S; factor V Leiden mutations,
prothrombin G2010 A mutations) or who have acquired conditions (eg, obesity, pregnancy,
immobility, trauma, surgery, and certain malignancies) that predispose them to coagulation
abnormalities
Therefore, for women who are at an increased risk of thromboembolism (eg, older than 35 years,
obesity, smoking, personal or family history of venous thrombosis, prolonged immobilization), it
would be prudent to first consider low-dose oral estrogen contraceptives containing older
progestins, progestin-only contraceptive methods, or barrier methods
Obesity
The prevalence of obesity continues to rise each year among all age groups including women of
childbearing age. It has been hypothesized that women with increased body weight have increased
basal metabolic rates and induction of hepatic enzymes, leading to increased hormonal clearance and
decreased serum concentrations of hormonal contraceptives.

In addition, women who are obese have more adipose tissue, increasing hormonal sequestration, and
decreased free hormone serum concentrations resulting in lower efficacy

Regardless of body weight, intrauterine devices (IUDs), implants, and DMPA have very low failure
rates, and progestin-only contraceptives are considered safe in obese women, It should be noted that
DMPA is associated withmore weight gain than other methods
Postpartum Use of CHCs
In the postpartum phase, there is concern about use of CHCs because of the mother’s
hypercoagulability and the effects on lactation.

In the first 21 days postpartum (when the risk of thrombosis is higher), estrogen-containing hormonal
contraceptives should be avoided. If contraception is required during this period, progestin-only
contraceptive methods may be acceptable alternatives.

It is recommended that women who are breastfeeding avoid CHCs for the first 42 days postpartum in
those with risk factors for VTE and for 30 days in those without risk factors.

After 42 days postpartum, there is no restriction to the use of CHCs.

Systemic Lupus Erythematosus (SLE)
Contraception is important in women with systemic lupus erythematosus (SLE) because the risks
associated with pregnancy are high in this population.

CHCs should be avoided in women with SLE and antiphospholipid antibodies or vascular
complications and the risks outweigh the benefits of progestin-only contraceptive use in patient
population, The copper intrauterine device may be the best option in this situation.

For patients with SLE without antiphospholipid antibodies or vascular complications, progestin-only
contraceptives or the copper intrauterine device may be an alternative to CHCs

however, those with SLE and severe thrombocytopenia should avoid the copper intrauterine device
and depot medroxyprogesterone acetate injection
Vomiting and Severe Diarrhea While on
Oral Contraceptives
Efficacy of OCs may be decreased when vomiting or severe diarrhea occurs, and recommendations for
dosing OCs in this situation have been developed.

If vomiting or diarrhea occurs for less than 48 hours then no redosing of OCs is warranted. If vomiting
or diarrhea persists greater than 48 hours then continue taking tablets.

If this scenario occurs during the last week of the hormonal tablets, then finish the tablets, skip the
hormone-free tablets, and begin a new pack.

Patients should be instructed to use additional nonhormonal contraception until tablets have been
taken for 7 consecutive days after the vomiting or diarrhea subsides
Special cases
Emergency Contraception
Emergency contraception (EC) is used to prevent unintended pregnancy after unprotected or inadequately
protected sexual intercourse (eg, no contraception, condom breakage, contraceptive mishap, or
nonadherence, sexual assault).
Progestin-only and progesterone receptor modulator products are approved by the FDA and recommended
as first-line EC options. Insertion of (copper IUD) or prescribing higher doses of combined OCs (Yuzpe
method) are other options.
Determining the exact effectiveness rate of EC is difficult; however, the range has been reported to be
between 59% and 94%.46 Evidence reported that EC may prevent an average of 75% of expected
pregnancies when taken appropriately. It is recommended that women have an advanced prescription on
hand or access to an OTC formulation to maximize the effectiveness of EC.
Common adverse effects of EC include nausea, vomiting, and irregular bleeding
 Pregnancy Termination
For various reasons, medications may be needed for pregnancy termination.

Medications used in early pregnancy (≤70 days) termination include mifepristone, misoprostol, and methotrexate, with
misoprostol typically being used in combination with either mifepristone or methotrexate or used alone.

1. Mifepristone is a steroid that binds progesterone receptors and causes abortion by blocking progesterone, softening the
cervix, and increasing prostaglandin synthesis, Boxed warnings for mifepristone include infection and bleeding.

2. Misoprostol is a prostaglandin E1 analog. Off-label uses include abortion, labor induction, preventing and treating
postpartum hemorrhage, cervical ipening for medical procedures, and treatment of early pregnancy loss. Side effects of
misoprostol may include stomach upset, diarrhea, headache, dizziness, and fever

3. Methotrexate is an immunomodulator that has a variety of uses. It works by inhibiting dihydrofolate reductase and
ultimately inhibits DNA synthesis, repair, and cell replication. This medication affects the rapidly dividing cells in the placenta
causing abortion. In combination with misoprostol, methotrexate is effective as an abortifacient through the first 7 weeks of
a pregnancy. Side effects of the regimen include nausea, vomiting, diarrhea, chills, weakness, and fever.