Hello. This lecture is about hormonal contraception. Pay attention, you may have an occasional
question on your exam. Let’s talk about how birth control actually works. There are 2 main
components. Usually, ethinylestradiol and a progestin. Ethinylestradiol actually suppresses FSH,
which suppresses ovulation. Also, the progestin actually causes atrophy of the line of the
endometrium and it causes the cervical mucus to thicken. There are other mechanisms of progestin
as well. We think that it actually alters the peristalsis of the fallopian tubes as well as inhibiting
LH surge which actually causes ovulation and myosis to resume. Let’s talk about birth control
pills in general. Typically, you have a hormone-free interval of some length. Traditionally, we
had a 7-day hormone-free interval. We noticed that FSH rises after the fourth pill-free day.
Therefore, you can select the dominant follicle and potentially your birth control method may
fail. Therefore, we've started to do shorter hormone-free intervals that reduce ovarian activity,
they lessen menstrual symptoms, and you have a shorter withdrawal bleed or your period on the
birth control. Let’s talk about some of the short hormone-free interval pills that are available.
You won’t be required to know any trade names but be familiar with the contents of the birth
control pill. Loestrin Fe has norethindrone acetate, ethinylestradiol, and ferrous fumarate.
Ferrous fumarate doesn’t have any activity to suppress ovulation. It’s just there as an added
bonus. Yaz has drospirenone and ethinylestradiol. Seasonique has levonorgestrel and ethinylestradiol.
Lybrel has levonorgestrel and ethinylestradiol. Let’s now talk about some other methods.You can
take other methods besides oral contraceptive pills. In the US, we actually do have a patch that's
transdermal. It delivers 20 mcg of ethinylestradiol and 150 mcg of norelgestromin. As you can
see with increasing weight, up to over 80 kg is associated with a higher failure rate. Therefore,
patients who are over 198 pounds cannot use Ortho Evra or the transdermal patch. Let’s now
talk about implants. There are several implants that are available, one of which is Implanon.
This contains 68 mg of etonogestrel. It’s placed in the arm and can last for a very long time up
to 3 years. Another option for younger women is Depo-Provera. You may have heard of Depo-Provera.
It’s also called Depot-medroxyprogesterone acetate. It’s usually an injectible form that can be
given monthly or every 3 months. It can cause amenorrhea and actually some bone loss that will
return to baseline after stopping it. Again, this is a better effective method for teenagers who
may not remember to take a birth control everyday. Another option for all women across the
reproductive lifespan is a levonorgestrel intrauterine device or an IUD. There are 2 available
currently that I use: Levonorgestrel, IUD Mirena which has 52 mg. It delivers a localized dose
of 20 mcg of levonorgestrel in the endometrium in the lining of the uterus. It can last for up to
5 years with reports of longer duration of 7 years. There is also another IUD called the Skyla
which is smaller and is marketed towards younger women. It has the same effectiveness as Mirena
but it has 13.5 mcg of levonorgestrel and last for only 3 years. Let’s talk about how you put an
IUD in. Usually, there is a device that comes with an intrauterine device that allows you to insert
it into the uterus. This should be done by a trained professional as there are some risks that it
go along with insertion. Insertion is associated with perforation, infection, and bleeding. No
special medication needs to be given prior to insertion and insertion is typically performed in
an office setting. Let’s now review emergency contraception. This means the morning after pill.
Perhaps your patient has had a sexual encounter that was unprotected. That means she didn’t
have barrier method contraception and no ovarian suppression. There are different regimens but I
want to call your attention to the things that are available in the US specifically plan B. Plan B
also has One-Step. What happens is that you take a pill 12 hours apart from another pill and that
usually prevents pregnancy within 72 hours. However, there is data that a longer time interval
can actually be permitted but 72 hours is most effective. Also, we have access to ulipristal
acetate or ELLA. This also needs to be taken within 72 hours and this works by modulating the
progesterone receptor. Progesterone is necessary to carry on a successful pregnancy. Let’s now
talk about female sterilization. Unfortunately, this is still a very common method in the United
States but we have alternatives that are not permanent. Remember, in the US, female sterilization
is usually told to the patient to be a permanent procedure. It is highly effective and does
decrease the risk of ovarian cancer we think by altering the blood supply to the ovary which
is shared with the fallopian tubes and the uterus. However, there are some distinct disadvantages
with permanent sterilization in the female. These include regret, especially under the age of 30.
It requires a surgery and our current recommendations are to remove tubes completely with a
salpingectomy. This decreases their risk of ovarian cancer in the future which is thought to
start in the tube. However, as you can imagine, this is not readily reversible. If failure occurs,
there is a higher risk of ectopic pregnancy if the tubes are still present.