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Missed contraceptives - SOGC 2008
What effects does hormonal contraction (HC) have on menstruation?
- -Reduces dysmenorrhea, mittelschmerz, dysfxnl uterine bleeding, premenstrual dysphoric d/o, acne
- -decreases blood loss, anemia risk
- -improves menorrhagia and hot flashes
- -regulates cycle
What not cancer diseases does HC decrease incidence of?
- bacterial pelvic inflame disease (60%)
- ectopic pregnancy
- endometriosis, salpingitis
- ovarian cyst ( up to 60%)
- acne, hirsutism
- fibrocytic benign breast disease (50-75%)
Which cancers does it reduce risk of?
- Endometrial Ca (>50%) - benefit within 1 yr and lasts
- Ovarian Ca (>40%) - " "
- Colorectal Ca (possibly)
Risks of HC?
- VTE/DVT (3-4x increase)
- Arterial thrombosis (2-3x if high dose, >35, smoking, HTN, CV risk factors)
- Breast Ca (1.3x - ?2/2 delayed chirdbearing)
- Cervical Ca (1.5x - ?2/2 more partners)
- Gallbladder dz - theoretical
Drugs that cause OC failure?
excessive EtOH, antibiotics - griseofulvin, rifampin,… anticonvulsants - carbamazepine, phenytoin, antiretrovirals
Absolute Contraindications to HC
- heart disease (ischemic or valvular)
- HTN (>160/>100)
- DM with microvascular dz
- cirrhosis, liver tumour
- breast cancer, pregnancy
- <4-6 weeks postpartum & breast feeding
What to do if missed 1 pill - delayed for <24h in any week?
Take 1 pill ASAP and resume as normal until end of pack (from SOGC 2008)
What to do if ≥1 active pills missed during week 1?
Take 1 active pill ASAP and continue taking until end of pack. Back up contraception for 7 days. Consider EC if unprotected sex w/i last 5 days.
What to do if <3 pills missed during week 2 or 3?
Take 1 active pill ASAp and continue taking until end of pack. Discard any placebo pills and start new cycle of COC pills without a hormone free interval (SOGC 2008)
What is required to effectively inhibit ovulation?
1 pill daily x 7 consecutive days (during week 1)
Why is miss a pill in week 1 worse?
- During the first week of use (week 1), delay in taking one pill 24 hours (i.e. missing one or more pills) increases the HFI and may
- allow ovulation during this week. Ovulation is effectively inhibited after taking 1 active pill daily x 7 consecutive days.
Why is missing a few pills in week 2 or 3 less worse?
- Missing fewer than 3 pills in a row during week 2 or 3 is the same as having a short HFI after achieving effective inhibition of
- ovulation during the preceding week (1 pill daily x 7 consecutive days). So efficacy is not expected to be reduced, although breakthrough bleeding may occur.
What do you need to know if patient delayed or detached contraceptive patch?
Duration - <24h or ≥24h
If the patch was detached <24 hrs?
Reapply or replace with new patch ASAP. Change patch on normal day and make cycle of 3 patches.
If patch was detached ≥24h - what do you need to know?
During which week - week 1 or week2/3
If patch was detached ≥24h (or unsure how long) in week 1?
- New patch ASAP. Continue regular patch changes and 3 patches.
- Back up contraception for 7 days. Consider Emerg contraceptive if unprotected sex
Rational for approach to detached patch ≥24h in week 1?
This is analogous to missing one COC by 24h or more in week 1 - can't be sure ovulation is suppressed, so need to use back up + EC if unprotected sex.
If patch delayed <72h in week 2 or 3?
new patch ASAP… finish cycle of 3 patches as would normally (same change day). Finish cycle and start new cycle with no HFI between.
If patch delayed/detached ≥72h in week 2 or 3?
New patch ASAP, keep same change day. Finish cycle of 3 and start immediate cycle of 3 patches without HFI. Back up contraception x 7d. Consider EC if unprotected sex.
How to approach missed contraceptive ring (delayed or removed)
- Removed >3h during week 1 = missing one active pill ≥24h in week 1.
- Removal of ring < 72h in week 2 or 3 = missing < 3 pills in row week2/3
- Removal of ring >72h in week 2 or 3 = missing ≥ 3 pills in a row in week 2/3
If ring was removed in week 1?
- ≤3 hours - insert ASAP… resume as normal.
- >3 hours or unsure - insert ASAP, resume as normal, back-up x 7days. Consider EC if unprotected sex in last 5 days.
If ring removed in week 2 or 3?
- < 72 hrs - insert ASAP. Remove on scheduled removal day. Start new cycle with ring without HFI.
- ≥72 h - as above but back-up x 7days and consider EC if unprotected sex in last 5 days.
If progestin only pill is delayed > 3h or missed ≥1 pill?
- Depends on whether had unprotected sex in last 5 days
- Yes - EC recommended, back-up x 48 hrs, resume 1 pill next day and continue.
- No - take 1 pill ASAP. then continue 1 pill daily at same time. Back-up contraception x 48 h.
Approach to missed contraceptive injection?
- Depends on when last injection given - less or more than 14 weeks
- 13 to <14 weeks = next injection ASAP
- 14 or more weeks = depends if unprotected intercourse in last 14d.
If missed injection ≥14 weeks since last, and unprotected sex last 14 days?
- Do B-HCG: B-hCG -ive and unprotected sex in past 5 days - give EC and next injection ASAP. Back up x 7days. Repeat B-hCG 3/52 later.
- B-hCG -ive and more than 5 days since unprotected sex - as above but no EC.
So more than 14 weeks since last deep injection and unprotected sex >5 to 14 days ago?
B-hCG --> if -ive, then injection ASAP, back up x 7days, repeat B-hCG in 3 weeks
More than 14 week since last injection and no unprotected sex in last 14 days?
B-hCG, if -ive then injection ASAP and back-up x 7 days