Birth control resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Birth Control Options

Female birth control options

Long acting reversible contraception(LARC): 99% effective, high rate of satisfaction, long-term use, quick return to fertility when discontinued

• IUDs (> 99% effective)
  • Copper IUD: effective for up to 10 years, used for patients with light menstrual periods, desire long-term contraception, not prefer using hormonal contraception
  • Progestin-releasing IUD, effective for up to 5 years, for patients with heavy menstrual bleeding and dysmenorrhea
• Subdermal implant (> 99% effective), effective for up to 3 years, SE: unscheduled bleeding, weight gain, headache. Ovulation and fertility occur within one month after removal
• Depot Medroxyprogesterone, IM injection given every 3 months (94% effective),
• Combined hormonal contraceptives
  • Oral contraceptive (estrogen/progestin pills) (OCPs) (91% effective)
  • Birth Control Patch (91% effective)
  • Vaginal Ring (91% effective)
• Barrier Methods
  • Diaphragm
  • Cervical Cap
  • Sponge
• Spermicide (80% failure rate if used alone). Should be used with cervical cap or diaphragm, may damage the genital epithelium and increase risk of acquiring SDIs
• Natural contraception (Natural Family Planning and Fertility Awareness)
  • Lactational Amenorrhea Method (LAM) (Breastfeeding can help with child spacing)
• Abstinence
• Permanent Sterilization

Male birth control options

Barrier contraception (Condoms) (80% effective), the only type of contraception that prevent sexual transmitted infections

Vasectomy

Withdrawal (coitus interruptus) (75% effective)

Note:

• You can use IUD in a nulliparous female
• Progestin subdermal implant is more effective that IUD (failure rate .2-.8%) and female fertilization (.5% failure rate)

Indications

• Pregnancy prevention
• Treatment of different conditions such as:
  • Polycystic Ovary Syndrome (PCOS): OCPs are used for menstrual regulation
  • Endometriosis
  • Amenorrhea
  • Dysmenorrhea
  • Premenstrual Syndrome (PMS)
  • Primary Ovarian Insufficiency (POI)
  • Heavy Menstrual Periods
  • Acne

Contraindications

Combined hormonal contraceptives

Absolute contraindications

• Pregnancy
• Less than 6 wks postpartum
• Smoking (age ≥ 35, and ≥15 cigarettes per day)
• Hypertension (systolic ≥ 160mmHg or diastolic ≥100mmHg)
• Venous thromboembolism (VTE) (current of past history)
• Prior history of throboembolic event or stroke
• Thrombophilia (factor V Leiden, APLS)
• Ischemic heart disease
• Cerebrovascular accident history
• Complicated valvular heart disease (pulmonary hypertension, atrial fibrillation, history of subacute bacterial endocarditis)
• Migraine headache with aura or focal neurological symptoms
• Breast cancer (Active)
• History of an estrogen-dependent tumor
• Diabetes with retinopathy/nephropathy/neuropathy
• Severe cirrhosis (active or severe decompensated liver disease) (impair steroid metabolism)
• Liver tumor (adenoma or hepatoma)
• Hypertriglyceredemia

Relative contraindication

• Age ≥ 35 and smoking < 15 cigarettes per day
• Adequately controlled mild hypertension
• Hypertension (systolic 140 - 159mmHg or diastolic 90 - 99mmHg)
• Migrain headache over the age of 35
• Currently symptomatic gallbladder disease
• Mild cirrhosis
• History of combined OCP-related cholestasis
• Medications that interfere with OCPs: Lamotrigine, Rifampine
• Inhirited thrombophilia carrier and family member with thrmbophilia plus thromboembolism

IUDs

• Uterine anomalies
• Active pelvic infection

Subdermal implant

• Progesterone receptor-positive breast cancer

Emergency contraception

Contraception option	Hours after intercourse	Efficacy

Side effects

Contraceptive method	Side effects
Oral contraceptive Pills (OCPs)	Breakthrough menstrual bleeding Breast Tenderness Weight gain Rare side effects Cardiovascular events (heavy smoker, over age 35 years) Deep venous thrombosis Ischemic stroke Myocardial infarction Hypertension (patients with a history of hypertension in pregnancy or with a family history of hypertension)

Do's

• Increase the levothyroxine dose in patients with hypothyroidism who started taking OCPs. OCPs (estrogen) increases the liver synthesis of thyroxin-binding globulin (TBG)
• OCPs also decrease the effect of Warfarin, so consider increasing the dose
• Oral contraceptives (estrogen) alter the transport and tissue delivery of thyroid hormone by increasing the synthesis of throxine-binding globulin , relative hypothyroid state in patients with hypothyroidism. Increase the dose of levothyroxine when starting OCPs.
• Give two forms of contraceptives and take monthly pregnancy tests for sexually active women who use Isotretinoin for acne
• Give non-oral form of contraception (IUD, implant) for one year to patients who underwent bariatric surgery to achieve weight loss goals and stabilize nutritional status

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References

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