Search Encyclopedia About half of all pregnancies are unplanned, says the American Congress of Obstetricians and Gynecologists. But women today have many safe and reliable choices if they want to prevent pregnancy. Birth control can be a medicine, device, or method. Test your knowledge of contraception by taking
this quiz. 1. Which methods of birth control needs a prescription? A. Birth control pillB. Contraceptive patchC. Cervical
capD. DiaphragmE. All of the above 2. What do male condoms offer that other forms of birth control do not? A. Least chance of failureB. Best protection against STIsC. Cheapest to
useD. All of the above 3. Besides the condom, which is another barrier method of birth control? A.
DiaphragmB. IUDC. WithdrawalD. Sterilization 4. Which type of intrauterine device (IUD) is
available? A. CopperB. TitaniumC. HormonalD. A and
CE. All of the above 5. Which of these is a possible side effect of birth control pills? A. NauseaB.
Irregular bleedingC. HeadachesD. All of the aboveE. None of the above 6. How long is the
vaginal ring left in place? A. 1 weekB. 2 weeksC. 3
weeksD. 3 months 7. Which of these methods is called natural family planning? A. Tracking basal
temperatureB. Tracking changes in cervical mucusC. Tracking the menstrual cycle on a calendarD. All of the above 8. Which of these methods of sterilization is permanent? A. Tubal sterilizationB. VasectomyC. A and
BD. None of the above Medical Reviewers:
Continuing Education ActivityCurrently, there are three types of oral contraceptive pills: combined estrogen-progesterone, progesterone-only, and continuous or extended use pill. The birth control pill is the most commonly prescribed form of contraception in the US. Approximately 25% of women aged 15 to 44 who currently use contraception reported using the pill as their method of choice. The most commonly prescribed pill is the combined hormonal pill with estrogen and progesterone. Progesterone is the hormone that prevents pregnancy, and the estrogen component controls menstrual bleeding. Birth control pills are primarily used to prevent pregnancy. The effectiveness of this form of birth control is referred to as typical and perfect use. This activity reviews the indications and contraindications, pharmacology, and various formulations of oral contraceptives and highlights the role of the interprofessional team in educating patients about birth control. Objectives:
Access free multiple choice questions on this topic. IndicationsThe birth control pill is the most commonly prescribed form of contraception in the US. Approximately 25% of women aged 15-44 who currently use contraception reported using the pill as their method of choice. Oral contraceptive pills are either combined estrogen-progesterone(also called combined oral contraceptive pill- COC) or progesterone-only pill (POP). The most commonly prescribed pill is the combined hormonal pill with estrogen and progesterone. Progesterone is the hormone that prevents pregnancy, and the estrogen component controls menstrual bleeding.[1] Birth control pills are primarily used to avoid pregnancy. The type of use of medicine estimates the effectiveness of these oral contraceptive medicines.
Most women take OCP’s to prevent pregnancy, but 14% use them for non-contraceptive reasons. OCP’s can be used to address other health conditions, particularly menstrual-related disorders such as menstrual pain, irregular menstruation, fibroids, endometriosis-related pain, and menstrual-related migraines.[2][3] The FDA has formally approved combined pills for acne for specific brands.[4] Strong epidemiologic evidence supports a 50% reduction in the risk of endometrial cancer among women who have used combined OCs compared with those who have never used combined OCs. This effect lasts for up to 20 years. Combined OC use decreases the risk of ovarian cancer by 27%; the longer the duration of use, the greater the risk reduction. OCs have also been reported to reduce the risk of colon cancer by 18%. Some formulations even have indications for the treatment of acne and hirsutism.[5][6] Mechanism of ActionProgesterone is primarily responsible for preventing pregnancy. The main mechanism of action is the prevention of ovulation; they inhibit follicular development and prevent ovulation.[1] Progestogen negative feedback works at the hypothalamus to decrease the pulse frequency of the gonadotropin-releasing hormone. This, in turn, will reduce the secretion of follicle-stimulating hormone (FSH) and decreases the secretion of luteinizing hormone (LH). If the follicle isn’t developing, there is no increase in the estradiol levels (the follicle makes estradiol). The progestogen negative feedback and lack of estrogen positive feedback on LH secretion stop the mid-cycle LH surge. With no follicle developed and no LH surge to release the follicle, ovulation is prevented. Estrogen has some effect with inhibiting follicular development because of its negative feedback on the anterior pituitary with slowed FSH secretion; it’s just not as prominent as the progesterone’s effect. Another primary mechanism of action is progesterone’s ability to inhibit sperm from penetrating through the cervix and upper genital tract by making the cervical mucous unfriendly.[1] Progesterone-induced endometrial atrophy should deter implantation, but there is no proof that this occurs. Combined Oral Contraceptive (COC) The usual estrogen component is combined with a different generation of progestin components with varying degrees of androgenic and progestogenic potential. The combination is prescribed based on desirable effects and risk of adverse events with progestin component and dose of estrogen and progestin component.
Progesterone only Pill (POP) While multiple types of progestin pills are available in the US, most frequently formulations have drospirenone or norethindrone. Drospirenone suppresses ovulation and also has anti-mineralocorticoid activity. While norethindrone primarily acts by thickening cervical mucus to inhibit sperm penetration, suppressing ovulation, decreasing the mid-cycle LH and FSH peaks, which slows the movement of the ovum through fallopian tubes, and alters endometrium thickness. Some progestin compounds have more potent antiandrogenic properties and, therefore more effective in treating polycystic ovary syndrome, hirsutism, and acne.[7] AdministrationCombined Oral Contraceptive Choice of COC: Usually, Ethinyl estradiol dose is less than 50 mcg in this combination of pills. The pills can be either monophasic (same dose of both components in the active pills) or multiphasic (varying doses weekly of both or either component in the active pills). Depending on withdrawal bleeding desired by the patient and clinically recommended, it can be prescribed as a cyclic (monthly bleeding), extended cyclic (every three months bleeding), or continuous dosing(no bleeding).
Initiation: Combined oral contraceptive pills are to be taken daily at approximately the same time each day. Avoid taking them greater than 24 hours apart as this could affect efficacy. There are two methods of initiating COC for women per their priority as follow:[8]
Missed doses: If a patient misses a tablet, take the missed tablet as soon as they remember and the next tablet at the usual time (taking two pills in 1 day). If the patient misses two tablets in a row in the first or second week, take two tablets the day the patient remembers and two pills the next day, then resume 1 per day. Use additional forms of contraception until the patient begins a new cycle.[10] Check the package insert for accurate information on managing if it occurs. Emergency Contraception: It is recommended in the first week of the cycle if unprotected intercourse occurs and if two or more COC pills are missed (exception ulipristal acetate). Progesterone Only Pill (POP) Choice of POP: CDC has provided guidelines for users of POPs who have other medical conditions. POP can be used by most women, and it appears to be chosen for women who have contraindications to COC or want to avoid the estrogen component in the contraceptive pill.[11]
Initiation: The pill must be taken at the same time each day to maximize contraceptive efficacy. Use backup contraception if the patient starts POPs more than five days from the onset of menses. It can be started on any day of the menstrual cycle, but recommendations exist to begin on the first day of menses. Use a backup contraceptive (e.g., condoms) method for the first 48 hours following initiation if POP is started within the first five days of menses. Missed dose: Women who miss taking a norethindrone POP dose by more than three hours or had vomiting or severe diarrhea within three hours of taking a POP are advised to take the missed pill as soon as they remember and the next tablet at the scheduled time. Use of additional contraception (e.g., condoms) for 48 hours after the late dose is also recommended. Emergency contraception: It can be offered (except ulipristal acetate) to women who have unprotected intercourse within 48 hours of initiating POP or missed pill where backup contraception or abstinence was advised.[8] Adverse EffectsMost side effects of OCP's are mild and disappear with continued use or switching to another pill formulation. The most common adverse effect of combined oral contraceptive pills is breakthrough bleeding. Women will also complain of nausea, headaches, abdominal cramping, breast tenderness, and increased vaginal discharge or decreased libido. Nausea can be avoided by taking the medication at night before sleep. The majority of the other consequences will resolve with time or switching OCP to a different preparation. Women who have a pre-existing cardiovascular condition or smoke should not use OCs. For the first six months, OC progestogens can impair glucose metabolism in healthy adult women. Women with diabetes mellitus might need to increase insulin intake to regulate blood glucose levels within the desired range. Oral contraceptive pills can cause hypertension in 4-5% of healthy women and exacerbate hypertension in about 9-16% of women with pre-existing hypertension. Four studies on teenage women found a small negative effect of combined oral contraceptive pills on the acquisition of bone mineral density. In addition, COC use increases the risk of venous thrombotic events (VTE), especially during the first year of initiation. VTE risk increases with high Ethinyl Estradiol dose and 3rd and 4th generation progestin.[12] Stroke and/or Myocardial infarction: In a meta-analysis, which included 28 publications reported COC users were at higher risk of ischemic stroke (relative risk 1.7, 95% CI 1.5 to 1.9) and myocardial infarction (relative risk 1.6, 95% CI 1.2 to 2.1) when compared with non-users. The risks did not depend on type pr generation of progestagen. Data analysis showed the risk of ischemic stroke or myocardial infarction increases with higher doses of estrogen. This risk was highest when pills had more than 50 micrograms of estrogen. Most preparation now contains less than 50 micrograms of estrogen, making COC substantially safer to use. COC pill containing 30μg of estrogen and levonorgestrel is the safest oral form of combined oral contraceptive pills.[13] These pills do not protect against any sexually transmitted diseases (STDs). Thus, using a condom is highly recommended, especially if the partner is a stranger. Regular monitoring of the patient is necessary to ensure that she is not developing any serious side effects.[14][15] In one study, women who used COC for one year of "continuous use" were monitored for return of fertility, and 97 percent of women had spontaneous menses within 90 days after discontinuation of COCs. In women with a history of hereditary angioedema, exogenous estrogen components may induce or exacerbate symptoms of angioedema. Chloasma may occasionally occur, especially in subjects with a known history of chloasma gravidarum. If Women have a tendency to develop chloasma, avoid exposure to ultraviolet radiation and the sun while taking COCs. POP users have reported acne flare and follicular ovarian cysts. Changes in menses and unscheduled, irregular bleeding are the most commonly reported adverse effects of POPs.[16] Progestogen-only OCs have lesser systemic side effects than combined OCs but often cause menstrual changes. Their long-term effects are not yet known.[1] Both COC and POP have significant drug interactions, and hence patient medication history should be taken thoroughly before prescribing OC, including supplements. For example, co-administering OC with antiseizure medicines (phenytoin, carbamazepine, oxcarbazepine, lamotrigine, barbiturates) can result in a lower level of OC in blood and reduce the effectiveness of OC.[17] ContraindicationsCDC and WHO have set criteria for women who want to initiate COC or POP. Patients need to be screened for contraindications before starting COC or POP are summarized below, and CDC criteria are listed in The 2016 U.S. Medical Eligibility Criteria for Contraceptive Use. Combined Oral Contraceptive
Progesterone Only Pill
MonitoringCOC: The Patients should be counseled thoroughly on potential adverse reactions before initiating hormone contraceptive pills and informed to report signs and symptoms of serious adverse reactions to achieve better adherence and treatment outcomes. A healthy woman taking COCs should have an annual visit with her primary care provider for a blood pressure check and routine medical care. Monitor blood pressure in women with well-controlled hypertension being managed medically. Monitor prediabetic and diabetic women periodically as hormone contraceptives may impair glucose intolerance and is usually dose-dependent. POP: Prescribers should monitor baseline weight and BMI before initiating the POP. Drospirenone: It has an anti-mineralocorticoid activity which might cause hyperkalemia in high-risk patients (3 mg drospirenone has comparable anti-mineralocorticoid activity as 25 mg dose of spironolactone), so women with diseases which predispose to hyperkalemia or who are taking medications that increase serum potassium concentration should be monitored for serum potassium level in the first treatment cycle. Medicines that may increase serum potassium levels include potassium supplementation, potassium-sparing diuretics, angiotensin-converting enzyme inhibitors, angiotensin-II receptor antagonists, aldosterone antagonists, heparin, and non-steroidal anti-inflammatory drugs. In addition, long-term users of CYP3A4 inhibitor concomitantly administered with OC should be monitored for serum potassium levels. Strong CYP3A4 inhibitors include protease inhibitors (e.g., indinavir, boceprevir), azole antifungals (e.g., ketoconazole, voriconazole, itraconazole), and clarithromycin.[19] ToxicityIf a patient takes too many oral contraceptive pills at one time, the most likely complications will be severe headaches, nausea, or vomiting. There is no antidote to treat this condition, just treating the symptoms with antiemetics and analgesics. If the patient has other risk factors significant for increased venous thromboembolism, one may temporarily consider a prophylactic anticoagulant medication. High doses of estrogen and progesterone (the same types found in the combined OC’s) are even treatment options for menorrhagia that have led to severe or symptomatic anemia.[20][21][22] There have been no reports of serious ill effects from an overdose, including ingestion by children. However, overdosage may cause withdrawal bleeding in females and nausea. Drospirenone is a spironolactone analog with anti-mineralocorticoid properties, so monitor serum concentration of potassium and sodium and evidence of metabolic acidosis in overdose cases. Contact the local poison control center for the protocol to follow if an overdose is suspected or confirmed. Enhancing Healthcare Team OutcomesOral contraceptive pills provide patients with the option to prevent pregnancy. If the patient has medical conditions that put them at increased risk for taking combined OC or progestin OC, the prescriber should inform patients of many alternatives to prevent pregnancy. OC's are a choice made by the patient and her clinician after adequate counseling of risks and benefits. There are significant non-contraceptive uses of hormonal contraceptives, and these should be considered when counseling the patient about her options. Many OC formulations can provide menstrual regularity, treating both menorrhagia and dysmenorrhea. They can even be utilized to induce amenorrhea for lifestyle considerations. The birth control pill is prescribed by many healthcare workers, including the physician assistant, nurse practitioner, physicians, obstetricians, internists, and gynecologists. Patients' health benefits can influence the choice of contraceptive pills, so pharmacists should guide prescribers to choose affordable options for individual patients. Nurses should inform the patient about the potential adverse reactions and monitor patient vitals at each visit.[14][15] Pharmacists should perform medication reconciliation and counsel patients thoroughly for oral contraceptive use, start method, missed dose, and emphasize using a backup contraceptive method for recommended medicine if contraception is desired. All healthcare providers working as an interprofessional team can achieve maximum therapeutic benefit for women who desire to use oral contraceptive medicines. [Level 5] Review QuestionsReferences1.Baird DT, Glasier AF. Hormonal contraception. N Engl J Med. 1993 May 27;328(21):1543-9. [PubMed: 8479492] 2.Maguire K, Westhoff C. The state of hormonal contraception today: established and emerging noncontraceptive health benefits. Am J Obstet Gynecol. 2011 Oct;205(4 Suppl):S4-8. [PubMed: 21961824] 3.Proctor ML, Roberts H, Farquhar CM. Combined oral contraceptive pill (OCP) as treatment for primary dysmenorrhoea. Cochrane Database Syst Rev. 2001;(4):CD002120. [PubMed: 11687142] 4.Arowojolu AO, Gallo MF, Lopez LM, Grimes DA, Garner SE. Combined oral contraceptive pills for treatment of acne. Cochrane Database Syst Rev. 2009 Jul 08;(3):CD004425. [PubMed: 19588355] 5.Shulman LP. The state of hormonal contraception today: benefits and risks of hormonal contraceptives: combined estrogen and progestin contraceptives. Am J Obstet Gynecol. 2011 Oct;205(4 Suppl):S9-13. [PubMed: 21961825] 6.ACOG Practice Bulletin No. 110: noncontraceptive uses of hormonal contraceptives. Obstet Gynecol. 2010 Jan;115(1):206-218. [PubMed: 20027071] 7.Powell A. Choosing the Right Oral Contraceptive Pill for Teens. Pediatr Clin North Am. 2017 Apr;64(2):343-358. [PubMed: 28292450] 8.Curtis KM, Jatlaoui TC, Tepper NK, Zapata LB, Horton LG, Jamieson DJ, Whiteman MK. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR Recomm Rep. 2016 Jul 29;65(4):1-66. [PubMed: 27467319] 9.Kapp N, Curtis KM. Combined oral contraceptive use among breastfeeding women: a systematic review. Contraception. 2010 Jul;82(1):10-6. [PubMed: 20682139] 10.Korver T, Goorissen E, Guillebaud J. The combined oral contraceptive pill: what advice should we give when tablets are missed? Br J Obstet Gynaecol. 1995 Aug;102(8):601-7. [PubMed: 7654636] 11.Curtis KM, Tepper NK, Jatlaoui TC, Berry-Bibee E, Horton LG, Zapata LB, Simmons KB, Pagano HP, Jamieson DJ, Whiteman MK. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep. 2016 Jul 29;65(3):1-103. [PubMed: 27467196] 12.Nylander MC, Clausen HV. [Serious adverse effect of combined oral contraceptive pills among teenagers]. Ugeskr Laeger. 2014 Jun 23;176(26):V05130336. [PubMed: 25294576] 13.Roach RE, Helmerhorst FM, Lijfering WM, Stijnen T, Algra A, Dekkers OM. Combined oral contraceptives: the risk of myocardial infarction and ischemic stroke. Cochrane Database Syst Rev. 2015 Aug 27;(8):CD011054. [PMC free article: PMC6494192] [PubMed: 26310586] 14.McCarthy KJ, Gollub EL, Ralph L, van de Wijgert J, Jones HE. Hormonal Contraceptives and the Acquisition of Sexually Transmitted Infections: An Updated Systematic Review. Sex Transm Dis. 2019 May;46(5):290-296. [PubMed: 30628946] 15.Tepper NK, Krashin JW, Curtis KM, Cox S, Whiteman MK. Update to CDC's U.S. Medical Eligibility Criteria for Contraceptive Use, 2016: Revised Recommendations for the Use of Hormonal Contraception Among Women at High Risk for HIV Infection. MMWR Morb Mortal Wkly Rep. 2017 Sep 22;66(37):990-994. [PMC free article: PMC5657782] [PubMed: 28934178] 16.Tayob Y, Adams J, Jacobs HS, Guillebaud J. Ultrasound demonstration of increased frequency of functional ovarian cysts in women using progestogen-only oral contraception. Br J Obstet Gynaecol. 1985 Oct;92(10):1003-9. [PubMed: 3902074] 17.Crawford P. Interactions between antiepileptic drugs and hormonal contraception. CNS Drugs. 2002;16(4):263-72. [PubMed: 11945109] 18.Committee on Gynecologic Practice. ACOG Committee Opinion Number 540: Risk of venous thromboembolism among users of drospirenone-containing oral contraceptive pills. Obstet Gynecol. 2012 Nov;120(5):1239-42. [PubMed: 23090561] 19.Cremer M, Phan-Weston S, Jacobs A. Recent innovations in oral contraception. Semin Reprod Med. 2010 Mar;28(2):140-6. [PubMed: 20391327] 20.Simmons KB, Haddad LB, Nanda K, Curtis KM. Drug interactions between non-rifamycin antibiotics and hormonal contraception: a systematic review. Am J Obstet Gynecol. 2018 Jan;218(1):88-97.e14. [PubMed: 28694152] 21.Weerasinghe M, Konradsen F, Eddleston M, Pearson M, Agampodi T, Storm F, Agampodi S. Overdose of oral contraceptive pills as a means of intentional self-poisoning amongst young women in Sri Lanka: considerations for family planning. J Fam Plann Reprod Health Care. 2017 Apr;43(2):147-150. [PubMed: 27006385] 22.Nanda K, Stuart GS, Robinson J, Gray AL, Tepper NK, Gaffield ME. Drug interactions between hormonal contraceptives and antiretrovirals. AIDS. 2017 Apr 24;31(7):917-952. [PMC free article: PMC5378006] [PubMed: 28060009] Which of these is the least effective method of preventing pregnancy with typical use?Spermicide is a material that kills sperm to prevent pregnancy. It's one of the least effective birth control methods when used alone. Women get pregnant about 28% of the time when using only spermicide as birth control.
Which group of methods is most effective at preventing pregnancy with typical use?Combined hormonal contraceptives have the potential to be 99% effective if you use it correctly. However, most people don't use it correctly, so the effectiveness is around 91%. While not as effective as an IUD or implant, hormonal contraception like the pill is much more effective than barrier methods like condoms.
Which is the most effective form of contraceptive with typical use?Contraceptive implant: more than 99% effective with perfect use. They work for 3 years, but can be taken out earlier. Fewer than 1 in 100 women using the implant will get pregnant in a year. Intrauterine system (IUS): more than 99% effective.
Which of the following is a method used to prevent pregnancy?Short-acting hormonal methods, such as the pill, mini-pill, patch, shot, and vaginal ring, prevent your ovaries from releasing eggs or prevent sperm from getting to the egg. Barrier methods, such as condoms, diaphragms, sponge, cervical cap, prevent sperm from getting to the egg.
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