CCFP Topic: Contraception – Part 2

Sonya is a 45 year-old G4P3A1 who has been using Marvelon 21 (30ug EE/150ug desogestrel) for the last 10 years since she stopped breastfeeding her youngest child. I noticed that in the last 3 months I have been having some spotting between cycles and after sex. I have normal periods on the seven days off the pill. Is this bleeding because of my birth control pills?
Sonya is otherwise healthy with no hypertension, diabetes, or cancer history. She has a BMI of 25. She is a non-smoker and does not consume alcohol. She has not started any new medications.

Knowing that inconsistent pill use, along with smoking, can be common causes of unscheduled bleeding, you ask Sonya whether there have been any recent changes in how she takes her pills lately or if she has missed any pills. Sonya tells you that she has never missed a pill and takes it consistently at the same time each day when she brushes her teeth. 

The most important thing to remember in this case is that while spotting can be a side effect for those using combined oral contraceptives, new changes in bleeding patterns for someone who has been using the same method for many years without issues requires a complete workup for AUB including ruling out pregnancy, STIs, and gynecologic pathology. You correctly complete a full workup to rule out any structural cause of this new bleeding, including a pap smear, bimanual exam, endometrial biopsy, vaginal swabs, pelvic ultrasound, and beta hCG. You also complete a CBC and ferritin to check for any anemia. The ultrasound shows a mildly thickened lining and the endometrial biopsy is negative. Given her symptom history, you are most concerned that this is a polyp, but malignancy has not been fully excluded, and you refer her on to gynecology for hysteroscopy. Sonya is found to have a polyp, which was removed at time of procedure and benign in nature. She follows up with you 3 weeks after the procedure. 

At this point you review the findings and explain that this polyp was most likely the cause of her bleeding concerns. However, you do want to discuss Sonya’s contraceptive options given her age. Perimenopausal women can and do use contraceptives of various types both for contraception as well as for regulation of abnormal bleeding. 

Patients can safely be kept on CHC until age 50 in Canada, 55 by American guidelines provided they are in perfect cardiovascular condition. That is, the patient cannot have cardiovascular risk factors including hypertension, diabetes, elevated BMI. 

Sonya meets these criteria and thus it would be reasonable for her to continue with combined oral contraceptives for another 5 years, with close monitoring for the development of hypertension or diabetes which would prompt a method switch. 

However you note that she is on a pill formulation with 30ug of EE, and suggest that switching to a pill with a lower estrogen dose, such as Alesse with 20ug of EE/100ug LNG might be better now that she is 45. 

Another appropriate option, now that the cause of her abnormal uterine bleeding has been discovered, is the placement of an LNG-IUC which if placed after age 45 can remain in place for 7 years, off label. You suggest to Sonya that she returns in 2 months for follow-up to make sure that the bleeding has resolved and you can further discuss the possibility of switching contraceptives at that time. 

You provide her with the sexandu website in the meantime so she can think about her options if she chooses to make a switch. 

Now, Sonya’s case highlights some important points regarding the importance of not assuming all abnormal uterine bleeding is pill related, especially when this bleeding is new. However, abnormal bleeding while using contraceptives can be side effect, and one that is bothersome enough for patients to stop their contraceptive use. So what are some troubleshooting options for the patient in whom it is believed that the contraceptive is a the culprit. We will consider a few quick cases. 

Key points to remember in any contraceptive start is that bleeding can be a normal side effect and careful counselling before starting the patient on a contraceptive can help prevent discontinuation. Ideally, every option should be given at least a 3 month trial before starting interventions or switching contraceptives because irregular bleeding will often resolve within 3-6 months of initiation depending on the contraceptive type.

Marsha, a 33 year-old G2P2, who has stopped breastfeeding, had experienced return of her menses with normal cycles, and who now is continuing to have irregular bleeding 5 months after starting using the oral combined contraceptive pill. She is otherwise healthy. 

You decide to review the estrogen content of her pills. Unscheduled bleeding is more common in lower-dose pills, and so trialing a switch to a pill with higher estrogen content may be beneficial. It may also be beneficial to switch to a pill with a progestin with a longer half-life, such as drospirenone, dienogest, or desogestral. You can guide whether you need higher estrogen or progesterone depending on when in the cycle the breakthrough bleeding occurs: 

eg. if BTB in the first half, days 1-9, which is dominated by estrogen, you need to increase the estrogen. In the second half, days, 10-21, which is dominated by progestin, need to increase progestin. If continuous bleeding/spotting, increase estrogen.The SOGC Canadian Contraception Consensus Part 4 of 4 Chapter 9: Combine Hormonal Contraception contains a table in the appendix delineating different pill types and hormone composition. An alternative option suggested by the SOGC is to add in a short, 7 day course of estrogen in addition to the oral contraceptive pill, such as “1.25mg conjugated estrogen or 2mg of E2” (p. 243). RX files also has a fantastic resource on selecting OCPs and trouble-shooting various side effects. 

Fatima, a 23 year-old G0 who has been using Tri-cyclen in a continuous manner for 8 months. 

She had not been having any periods previously, but now has noticed increasing spotting in the last month. Since Fatima has had at least 21 days of consecutive pill use it is safe for her to have a short, 3 to 4 day hormone free interval without risk of reducing contraceptive effectiveness. 

You advise her to do this, and warn her that she will likely experience an increase in bleeding which should resolve within 7 to 8 days. She should restart her pills after 3-4 days of cessation and continue to use them continuously if this is her preference. She can try this again if she continues to experience spotting at a later date. 

You are careful to tell Fatima that she should avoid having more than one 3 to 4 day hormone free interval per month. Longer intervals per month would increase her risk for contraceptive failure.

Lena, a 19 year-old G0 who is amongst Canada’s first recipients of the Nexplanon etonogestrel implant, unfortunately, has been experiencing prolonged bleeding which has not improved 7 months after initiation. Pregnancy and sexually transmitted infections have already been ruled out. 

The SOGC has suggested a number of possible treatment options that can be trialed in these instances. Acute, heavy bleeding should be managed emergently as per usual abnormal uterine bleeding parameters. It is recognized that there is poor evidence for effective treatment options, however various strategies have been suggested. 

Options for non-acute management of abnormal bleeding while using the Nexplanon implant can include:

• using NSAIDs for 5-7 days. 
• Mefenamic acid 500mg TID for five days has been suggested. 
• The literature for abnormal bleeding on depot-medroxyprogesterone acetate = DMPA also includes suggested doses for Ibuprofen and Celecoxib. 
  • With DMPA users, the SOCG recommends Ibuprofen 800mg BID for 5 days or celecoxib 200mg for 5 days. 
• Short-courses, 10-20 days, of combined oral contraceptives or estrogen treatment can also be trialed for those with bleeding using implants. Once again, no regimens are offered, but the SOGC suggestions for abnormal bleeding for DMPA users include “conjugated equine estrogen 0.625 to 1.25mg per day or 1-2mg of 17B-estradiol per day for 28 days” (pp. 290). 
• Addition of a 20-day course of a progesterone only pill is another option. For further information regarding trouble shooting of abnormal uterine bleeding with progestin only contraceptive options, we do recommend reviewing the SOGC Canadian Contraception Consensus (Part 3 of 4) Chapter 8 – Progestin-only contraception. 

It is also important to remember to look for and treat anemia in patients with heavy bleeding. Lena may require iron supplementation. If her bleeding concerns cannot be resolved with the above options, she may choose to switch to an alternative contraceptive method.

Ali is a 24 year-old university student who presents to your office to inquire about emergency contraception following a broken condom during intercourse with her partner. this is the third time this has happened. We don’t use anything else for contraception. 

The first question that should be asked for any patient who presents requesting emergency contraception is “when did the episode of unprotected intercourse occur?” 

This happened 2 days ago, but she was unable to get time off work to come in to the office to be seen earlier. 

You tell Ali that she is still within a safe window for any emergency contraceptive option. You also tell her that some options, such as the Levonorgestral emergency contraceptive pills, including Plan B, Norlevo, Option 2, and Next Choice, are available over the counter. They are most effective when used within 24 hours of unprotected intercourse. If she has a similar problem in the future, she can access these options quickly without coming in to see a doctor. 

You review with Ali the emergency contraceptive options, including the Levonorgestral pills, ulipristal acetate, and the copper IUD. The hormonal options can all be used within 5 days of unprotected intercourse, however they are most effective with proximity to episode of unprotected intercourse. 

Effectiveness of Plan B  is pregnancy rate of 2.2% <72 hrs, and rises to 3% risk of pregnancy by 120 hours (5 days). 

The Yuzpe method, which some patients may choose, which includes taking any combination of the patient’s own OCP that will equal 100 mcg ethinyl estradiol and 500 mcg levonorgestrel, repeated again 12 hrs later, is has a pregnancy rate of 2.5-2.9% <72 hrs. 

Ulipristal acetate is more effective than levonorgestrel generally, and particularly when the time since unprotected intercourse is longer – beyond 24 hours to the maximum of 5  days since UPI. It should be considered in all instances provided there are no contraindications or access concerns, which we will discuss further shortly.

The goal of hormonal contraceptive pills is to delay or inhibit ovulation. The copper IUD is the most effective emergency contraceptive option and can be inserted within 7 days of unprotected intercourse with the added benefit of providing long-term contraception. Pregnancy rate is <0.1% with copper IUD as emergency contraception. 

A few other important considerations when deciding on emergency contraceptive options include BMI and the use of hormonal contraceptives. 

For women with a BMI over 25, ulipristal acetate may be a more appropriate option. The fact that women require a prescription to obtain this medication and its increased cost, can however create barriers to access. 

For those women with a BMI over 30, the copper IUD is recommended as hormonal options may be less effective. 

With respect to the use of hormonal contraceptives, in the advent of a missed pill and unprotected intercourse, Levonorgestral methods are recommended over ulipristal acetate. Ulipristal acetate can interact with hormonal contraceptives and they can reduce one another’s effectiveness. 

If ulipristal acetate is used and a woman would like to start on hormonal contraceptives or a LNG-IUS, she must wait 5 days after taking the emergency contraceptive. 

Ali, who has a BMI of 23, is eligible for all options. You review the side effects of the hormonal options such as altered bleeding, nausea, headache, abdominal pain, breast tenderness, dizziness, and fatigue and discuss the insertion process, risks and benefits of IUD insertion. Ali chooses to use ulipristal acetate as she does not like the idea of an IUD, but would like to take the next most effective option given that it has been 2 days since the unprotected intercourse. 

After deciding on and prescribing ulipristal acetate and addressing Ali’s initial concern, you take a moment to review correct condom use, inquire about risk factors for repeated condom breakage, and inquire as to whether Ali would like to add another contraceptive option to increase condom efficacy. Firstly, you ask her what type of condoms she uses, how and where they are stored and if and what type of lubricants they use.

We use latex condoms and usually keep them in a side table. We occasionally use lubricants but i can’t remember what type. 

You thank Ali for sharing and discuss that condom failure rate is about 2% with perfect use and 18% with typical use. You tell her that condom breakage or slippage can occur up to 2% of the time, but this can often be mitigated by correct condom storage and use. 

You congratulate Ali on good condom storage, reiterating that latex condoms should be stored in a cool, dry place and never in direct sunlight and remind her that latex condoms should not be used beyond their expiry date. Furthermore, too much friction can lead to condom breakage, and choice of lubricants is important. Oil-based lubricants can weaken latex and increase the risk that they will break during intercourse. 

You advise Ali to check what type of lubricant they have at home, and in future to select water-based lubricants for use with latex condoms. You also remind Ali, that other oil-based products can impact latex condom integrity including using edible oils such as coconut oil or whip cream, massage oils, and some vaginal medications that are oil-based. 

Oil-based medications include hemorrhoid or burn ointments, Estrace, Vagisil, and ointments, such as clobetasol propionate. If she and her partner are going to be using an oil-based product, polyurethane or polyisoprene condoms would be safer. However, overall non-latex condoms do have a higher risk of breakage in general. 

Finally you review key components of condom use including:

•  leaving a half-inch space at the tip to collect semen, 
• pinching air out of the tip (friction against air bubbles is one of the most common causes of condom breakage), 
• and that it is important to grasp the rim of the condom at the base of the penis when withdrawing following ejaculation to avoid condom slippage. 

You ask Ali whether she would be interested in starting a hormonal contraceptive to help reduce concerns regarding unintended pregnancy in the future. She tells you she is nervous to start any contraceptives because she and her partner are getting married in 6 months and would like to try for a baby soon after. She has heard that using hormones might mean she will have trouble getting pregnant when she stops using them. She asks if you think adding spermicides would be a good idea. 

You thank Ali for sharing and tell her that spermicides can be used with condoms, but it is generally not recommended because they come with minimal benefits but significant side effects.  Spermicides contain nonoxynol-9 and come as a film or foam. Nonoxynol-9 can impact vaginal epithelium and lead to increased HIV transmission due to broken skin. For these reasons, spermicides are contraindicated for patients who are at high risk for acquiring HIV and advised against for most people. Spermicides can also increase vaginal discharge. 

However, even though spermicides may not be the best option to help reduce the risk of pregnancy in the next 6 months, it would be safe to start hormonal contraceptives. While some hormonal options, like DMPA are known to suppress ovulation for some time after cessation or use, combined oral contraceptives, the patch, and the ring do not have this effect. If there is any hormone free interval for greater than 7 days, there is a possibility of ovulation and therefore pregnancy. Fertility is typically quickly recovered after cessation of combined hormonal methods, typically within 1-3 months. 

 Fertility is restored immediately upon cessation once there has been a greater than 7 days hormone free period. (can remove this sentence when do podcast, kept only so could keep attache comment)

Ali thanks you for sharing this information and after further discussion of the various hormonal contraceptive options and screening for risk factors she decides to start on the NuvaRing. I don’t like pills but I like the idea of only having to change the ring once a month. 

You take Ali’s blood pressure and describe the possible side effects of the NuvaRing, including vaginitis and leukorrhea. You tell her that systemic side effects are less common than with other combined hormonal options, but some users do experience headaches. 

As compared to the combined oral contraceptives, there is less unscheduled bleeding and as compared to the patch the bleeding time is shorter. You also tell Ali that most women and their partners do not notice the ring during intercourse, and while it is not typically recommended it is safe to remove the ring for intercourse if they are bothered by it. If she chooses to do this, the ring should be rinsed in lukewarm water and reinserted within 3 hours to ensure ongoing contraceptive protection. 

You provide Ali with one years prescription for the NuvaRing along with her ulipristal acetate. You remind her to wait 5 days until she starts using the NuvaRing so as not to decrease the effectiveness of her emergency contraception. 

You tell her that she and her partner must continue to use condoms for the first 7 days after she starts using the NuvaRing and that condom use is always recommended for STI prevention and added backup to prevent pregnancy as no contraceptive method is 100% effective. 

Finally, you advise Ali that if her period is more than 7 days late or she has not had a period within 3 to 4 weeks of using the emergency contraceptive (i.e. when she removes the ring for her hormone free period) she should do a pregnancy test. You arrange for follow-up in 1-2 months to check in as to how she is tolerating the NuvaRing.