CONTRACEPTIVES, HORMONAL

General

MONOPHASIC ORAL CONTRACEPTIVES

ethinyl estradiol/desogestrel

Pronunciation:
eth-in-il es-tra-dye-ole/dess-oh-jess-trel

Trade Name(s)

  • Apri-28
  • Desogen-28
  • Enskyce
  • Isibloom
  • Kalliga
  • Reclipsen
  • Solia

ethinyl estradiol/drospirenone

Pronunciation:
eth-in-il es-tra-dye-ole/droe-spy-re-nown

ethinyl estradiol/levonorgestrel

Trade Name(s)

  • Beyaz
  • Gianvi
  • Lo-Zumandimine
  • Loryna
  • Nikki
  • Ocella
  • Safyral
  • Syeda
  • Tydemy
  • Vestura
  • Yaela
  • Yasmin
  • Yaz
  • Zarah
  • Zumandimine

ethinyl estradiol/ethynodiol

Pronunciation:
eth-in-il es-tra-dye-ole/e-thye-noe-dye-ole

Trade Name(s)

  • Kelnor
  • Lo-Malmorede
  • Malmorede
  • Zovia 1/35–28
  • Zovia 1/50–28

ethinyl estradiol/levonorgestrel

Pronunciation:
eth-in-il es-tra-dye-ole/lee-voe-nor-jess-trel

Trade Name(s)

  • Afirmelle
  • Altavera
  • Aubra
  • Aviane-28
  • Ayuna
  • Balcoltra
  • Chateal
  • Falmina
  • Kurvelo
  • Lessina-28
  • Levora-28
  • Lutera
  • Marlissa
  • Portia-28
  • Sronyx
  • Vienva

ethinyl estradiol/norethindrone

Pronunciation:
eth-in-il es-tra-dye-ole/nor-eth-in-drone

ethinyl estradiol/levonorgestrel

Trade Name(s)

  • Alyacen 1/35
  • Aurovela Fe 1.5/30
  • Balziva-28
  • Blisovi Fe 1.5/30
  • Blisovi 24 Fe
  • Briellyn
  • Cyonanz
  • Dasetta 1/35
  • Femcon Fe
  • Finzala
  • Fyavolv
  • Gemmily
  • Generess Fe
  • Gildagia
  • Hailey 1.5/30
  • Hailey Fe 1/20
  • Hailey Fe 1.5/30
  • Jinteli
  • Junel 1/20
  • Junel 1.5/30
  • Junel Fe 1/20
  • Junel Fe 1.5/30
  • Kaitlib Fe
  • Larin 1/20
  • Larin 1.5/30
  • Larin Fe 1/20
  • Larin Fe 1.5/30
  • Loestrin 21 1/20
  • Loestrin 21 1.5/30
  • Loestrin Fe 1/20
  • Loestrin Fe 1.5/30
  • Merzee
  • Mibelas 24 Fe
  • Microgestin 1/20
  • Microgestin 1.5/30
  • Microgestin Fe 1/20
  • Microgestin Fe 1.5/30
  • Necon 0.5/35
  • Necon 1/35
  • Nexesta Fe
  • Norminest Fe
  • Nortrel 0.5/35
  • Nortrel 1/35
  • Nylia 1/35
  • Ortho-Novum 1/35
  • Philith
  • Pirmella 1/35
  • Taytulla
  • Vyfemla
  • Wera
  • Wymzya Fe
  • Zenchent
  • Zenchent Fe

ethinyl estradiol/norgestimate

Pronunciation:
eth-in-il es-tra-dye-ole/nor-jes-ti-mate

Trade Name(s)

  • Estarylla
  • Mono-Linyah
  • Mili
  • Mononessa
  • Ortho-Cyclen-28
  • Previfem
  • Sprintec

ethinyl estradiol/norgestrel

Pronunciation:
eth-in-il es-tra-dye-ole/nor-jess-trel

Trade Name(s)

  • Cryselle
  • Elinest
  • Low-Ogestrel–28

mestranol/norethindrone

Pronunciation:
mes-tre-nole/nor-eth-in-drone

Trade Name(s)

  • Necon 1/50
  • Norinyl 1/50

BIPHASIC ORAL CONTRACEPTIVES

ethinyl estradiol/desogestrel

Pronunciation:
eth-in-il es-tra-dye-ole/dess-oh-jess-trel

Trade Name(s)

  • Azurette
  • Bekyree
  • Kariva
  • Kimidess
  • Pimtrea
  • Viorele
  • Volnea

ethinyl estradiol/norethindrone

Pronunciation:
eth-in-il es-tra-dye-ole/nor-eth-in-drone

Trade Name(s)

  • Lo Loestrin Fe
  • Necon 10/11

TRIPHASIC ORAL CONTRACEPTIVES

ethinyl estradiol/desogestrel

Pronunciation:
eth-in-il es-tra-dye-ole/dess-oh-jess-trel

Trade Name(s)

  • Caziant
  • Cyclessa
  • Velivet

ethinyl estradiol/levonorgestrel

Pronunciation:
eth-in-il ess-tra-dye-ole/lee-voe-nor-jess-trel

Trade Name(s)

  • Enpresse-28
  • Levonest
  • Trivora–28

ethinyl estradiol/norethindrone

Pronunciation:
eth-in-il es-tra-dye-ole/nor-eth-in-drone

Trade Name(s)

  • Alyacen 7/7/7
  • Aranelle
  • Chabelina Fe
  • Dasetta 7/7/7
  • Leena
  • Necon 7/7/7
  • Nortrel 7/7/7
  • Nylia 7/7/7
  • Pirmella 7/7/7
  • Tri-Legest-21
  • Tri-Legest Fe
  • Tri-Norinyl-28

ethinyl estradiol/norgestimate

Pronunciation:
eth-in-il es-tra-dye-ole/nor-jess-ti-mate

ethinyl estradiol/levonorgestrel

Trade Name(s)

  • Ortho Tri-Cyclen-28
  • Tri-Estarylla
  • Tri-Linyah
  • Tri-Lo-Estarylla
  • Tri-Lo-Mili
  • Tri-Sprintec
  • TriNessa

FOURPHASIC ORAL CONTRACEPTIVES

estradiol valerate/dienogest

Pronunciation:
es-tra-dye-ole val-er-ate/dye-en-oh-jest

Trade Name(s)

  • Natazia

EXTENDED-CYCLE ORAL CONTRACEPTIVE

ethinyl estradiol/levonorgestrel

Pronunciation:
eth-in-il ess-tra-dye-ole/lee-voe-nor-jess-trel

Trade Name(s)

  • Amethia
  • Amethia Lo
  • Amethyst
  • Ashlyna
  • Camrese
  • Camrese Lo
  • Daysee
  • Dolishale
  • Iclevia
  • Introvale
  • Jaimiess
  • Jolessa
  • LoSeasonique
  • Quartette
  • Quasense
  • Seasonale
  • Seasonique
  • Setlakin
  • Simpesse

PROGESTIN-ONLY ORAL CONTRACEPTIVES

norethindrone

Pronunciation:
nor-eth-in-drone

Trade Name(s)

  • Camila
  • Errin
  • Jencycla
  • Jolivette
  • Micronor
  • Nora-BE

drospirenone

Trade Name(s)

  • Slynd

CONTRACEPTIVE IMPLANT

etonogestrel

Pronunciation:
e-toe-no-jess-trel

Trade Name(s)

  • Nexplanon

EMERGENCY CONTRACEPTIVE

levonorgestrel

Pronunciation:
lee-voe-nor-jess-trel

Trade Name(s)

  • Athentia Next
  • Fallback Solo
  • Plan B One-Step

ulipristal

Pronunciation:
u-li-priss-tal

Trade Name(s)

  • Ella
  • Logilia

INJECTABLE CONTRACEPTIVE

medroxyprogesterone

Pronunciation:
me-drox-ee-proe-jess-te-rone


Trade Name(s)

  • Depo-Provera
  • Depo-subQ Provera 104

INTRAUTERINE CONTRACEPTIVE

levonorgestrel

Pronunciation:
lee-voe-nor-jess-trel

Trade Name(s)

  • Kyleena
  • Liletta
  • Mirena
  • Skyla

VAGINAL RING CONTRACEPTIVE

ethinyl estradiol/etonogestrel

Pronunciation:
eth-in-il ess-tra-dye-ole/e-toe-noe-jess-trel

ethinyl estradiol/levonorgestrel

Trade Name(s)

  • EluRyng
  • NuvaRing

TRANSDERMAL CONTRACEPTIVE

ethinyl estradiol/levonorgestrel

Pronunciation:
eth-in-il ess-tra-dye-ole/lee-voe-nor-jess-trel

Trade Name(s)

  • Twirla

ethinyl estradiol/norelgestromin

Pronunciation:
eth-in-il ess-tra-dye-ole/nor-el-jess-troe-min

Trade Name(s)

  • Onsura
  • Xulane

Ther. Class.
contraceptive hormones

Indications

  • Prevention of pregnancy.
  • Regulation of menstrual cycle.
  • Emergency contraception (some products).
  • Treatment of heavy menstrual bleeding in women who choose to use intrauterine contraception as their method of contraception (Mirena).
  • Treatment of heavy menstrual bleeding in women who choose to use an oral contraceptive as their method of contraception (Natazia).
  • Treatment of premenstrual dysphoric disorder (Beyaz, Yaz, Yasmin).
  • Management of acne in women >14 yr who desire contraception, have no health problems, and have failed topical treatment.
  • Increase folate levels in women who desire oral contraception to reduce the risk of neural tube defects in a pregnancy that occurs while taking or shortly after discontinuing the product.

Action

  • Monophasic Oral Contraceptives: Provide a fixed dosage of estrogen/progestin over a 21-day cycle. Ovulation is inhibited by suppression of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). May alter cervical mucus and the endometrial environment, preventing penetration by sperm and implantation of the egg.
  • Biphasic Oral Contraceptives: Ovulation is inhibited by suppression of FSH and LH. May alter cervical mucus and the endometrial environment, preventing penetration by sperm and implantation of the egg. In addition, smaller dose of progestin in phase 1 allows for proliferation of endometrium. Larger amount in phase 2 allows for adequate secretory development.
  • Triphasic Oral Contraceptives: Ovulation is inhibited by suppression of FSH and LH. May alter cervical mucus and the endometrial environment, preventing penetration by sperm and implantation of the egg. Varying doses of estrogen/progestin may more closely mimic natural hormonal fluctuations.
  • Fourphasic Oral Contraceptives: Ovulation is inhibited by suppression of FSH and LH. May alter cervical mucus and the endometrial environment, preventing penetration by sperm and implantation of the egg. Doses of estrogen decrease while doses of progestin increase over the 28-day cycle.
  • Extended-cycle: Provides continuous estrogen/progestin for 84 days (365 days for Lybrel), then off for 7 days (low-dose estrogen-only tablet taken during these 7 days with LoSeasonique and Seasonique), resulting in 4 menstrual periods/yr (no periods/yr for Lybrel).
  • Progressive Estrogen: Contains constant amount of progestin with 3 progressive doses of estrogen.
  • Progestin-Only Contraceptives/Contraceptive Implant/Intrauterine Levonorgestrel/Medroxyprogesterone Injection: Mechanism not clearly known. May alter cervical mucus and the endometrial environment, preventing penetration by sperm and implantation of the egg. Ovulation may also be suppressed.
  • Emergency Contraceptive Pills (ECPs): Inhibit ovulation/fertilization; may also alter tubal transport of sperm/egg and prevent implantation.
  • Vaginal Ring, Transdermal Patch: Inhibits ovulation, decreases sperm entry into uterus, decreases likelihood of implantation.
  • Anti-acne effect: Combination of estrogen/progestin may increase sex hormone binding globulin (SHBG) resulting in decreased unbound testosterone, which may be a cause of acne.

Therapeutic Effect(s):

  • Prevention of pregnancy.
  • Decreased severity of acne.
  • Decrease in menstrual blood loss.
  • Decrease in premenstrual disphoric disorder.
  • Decrease in vasomotor symptoms or symptoms of vulvar and vaginal atrophy due to menopause.
  • Increase in folate levels and prevention of neural tube defects.

Pharmacokinetics

Absorption: Ethinyl estradiol– rapidly absorbed;  Norethindrone– 65% absorbed;  Desogestrel and levonorgestrel– 100% absorbed;  Dienogest– 91% absorbed. Others are well absorbed after oral administration. Slowly absorbed from implant, subcutaneous or IM injection. Some absorption follows intrauterine implantation.

Distribution: Unknown.

Protein Binding: Ethinyl estradiol– 97–98%;  Drospirenone– 97%;  Dienogest– 90%;  Ulipristal– >94%.

Metabolism and Excretion: Ethinyl estradiol and norethindrone– undergo extensive first-pass hepatic metabolism.  Mestranol– is rapidly converted to ethinyl estradol.  Desogestrel– is rapidly metabolized to 3-keto-desogestrel, the active metabolite. Most agents are metabolized by the liver.

Half-life: Ethinyl estradiol– 6–20 hr;  Levonorgestrel– 45 hr;  Norethindrone– 5–14 hr;  Desogestrel (metabolite)– 38 ± 20 hr;  Drospirenone– 30 hr;  Norgestimate (metabolite)– 12–20 hr;  Dienogest– 11 hr;  others– unknown;  Ulipristal– 32 hr.

TIME/ACTION PROFILE (prevention of pregnancy)

ROUTEONSETPEAKDURATION
PO1 mo1 mo1 mo†
Implant1 mo1 mo5 yr
Intrauterine system1 mo1 mo5 yr
IM1 mo1 mo3 mo
Subcutunknown1 wk3 mo
†Only during mo of taking contraceptive.

Contraindication/Precautions

Contraindicated in:

  • Hypersensitivity;
  • History of cigarette smoking and age >35 yr (↑ risk of cardiovascular or thromboembolic phenomenon);
  • History of deep vein thrombosis or pulmonary embolism;
  • Inherited or acquired coagulopathies;
  • Cerebrovascular disease
  • Coronary artery disease
  • Thrombogenic valvular heart disease or thrombogenic heart rhythms;
  • Major surgery with extended periods of immobility;
  • Diabetes and >35 yr old; diabetes with hypertension, vascular disease, or end-organ damage; or diabetes for >20 yr;
  • Headache with focal neurological symptoms or migraine headaches with aura;
  • Women >35 yr old with migraine headaches
  • Uncontrolled hypertension or hypertension with vascular disease;
  • Breast cancer, endometrial cancer, or any other estrogen- or progestin-sensitive cancer (current or history of);
  • Abnormal genital bleeding;
  • Cholestatic jaundice of pregnancy or jaundice with prior contraceptive use
  • Hepatic adenoma or carcinoma
  • Hypersensitivity to and parabens (injectable only);
  • Concurrent use of combinations containing ombitasvir/paritaprevir/ritonavir (with or without dasubavir) (↑ risk of liver enzyme elevations);
  • Drosperinone-containing products only– Renal impairment, liver disease, or adrenal insufficiency (↑ risk of hyperkalemia);
  • Intrauterine levonorgestrel only– Intrauterine anomaly, postpartum endometriosis, multiple sexual partners, pelvic inflammatory disease, liver disease, genital actinomycosis, immunosuppreession, IV drug abuse, untreated genitourinary infection, history of ectopic pregnancy;
  • Ethinyl estradiol/levonorgestrel and ethinyl estradiol/norelgestromin transdermal patches only– Body mass index ≥30 kg/m2  (↑ risk of venous thromboembolism)
  • OB:  Pregnancy
  • Lactation: Avoid use; ↑ risk of uterine rupture/perforation with intrauterine levonorgestrel.

Use Cautiously in:

  • Presence of other cardiovascular risk factors (obesity, hyperglycemia, hypertension);
  • History or family history of hypertriglyceridemia (↑ risk of pancreatitis);
  • Diabetes mellitus, bleeding disorders, concurrent anticoagulant therapy or headaches;
  • Hereditary angioedema
  • Chloasma
  • Ethinyl estradiol/norelgestromin transdermal patch only– Weight >90 kg (↓ effectiveness)
  • Ethinyl estradiol/levonorgestrel transdermal patch only– Body mass index 25–<30 kg/m  (↓ effectiveness)
  • Pedi:  Avoid use before menarche.

Adverse Reactions/Side Effects

CV: THROMBOEMBOLISM, edema, hypertension, Raynaud's phenomenon, thrombophlebitis

Derm: melasma, rash

EENT: contact lens intolerance, optic neuritis, retinal thrombosis

Endo: hyperglycemia

F and E: Drosperinone-containing products only– hyperkalemia

GI: PANCREATITIS, abdominal cramps, bloating, cholestatic jaundice, gallbladder disease, liver tumors, nausea, vomiting

GU: amenorrhea, breakthrough bleeding, dysmenorrhea, spotting, Intrauterine levonorgestrel only– uterine imbedment/uterine rupture

MS: Injectable medroxyprogesterone only– bone loss

Neuro: depression, headache

Misc: HYPERSENSITIVITY REACTIONS (INCLUDING ANAPHYLAXIS AND ANGIOEDEMA), weight change

* CAPITALS indicate life-threatening.
Underline indicate most frequent.

Interactions

Drug-Drug

Drug-Natural Products:

Concomitant use with  St. John's wort  may ↓ contraceptive efficacy and cause breakthrough bleeding and irregular menses.

Drug-Food:

Grapefruit juice may ↑ effects/risk of toxicity.

Route/Dosage

Monophasic Oral Contraceptives

PO (Adults): On 21-day regimen, take first tablet on first Sunday after menses begins (take on Sunday if menses begins on Sunday) for 21 days, then skip 7 days and begin again. Regimen may also be started on first day of menses, continue for 21 days, then skip 7 days and begin again. Some regimens contain 7 placebo tablets, so that 1 tablet is taken every day for 28 days.

Biphasic Oral Contraceptives

PO (Adults): Given in 2 phases. First phase is 10 days of smaller amount of progestin. Second phase is larger amount of progestin. Amount of estrogen remains constant for same length of time (total of 21 days), then skip 7 days and begin again. Some regimens contain 7 placebo tablets for 28-day regimen.

Triphasic Oral Contraceptives

PO (Adults): Progestin amount varies throughout 21-day cycle. Estrogen component stays the same or may vary. Some regimens contain 7 placebo tablets for 28-day regimen.

Fourphasic Oral Contraceptives

PO (Adults): Given in 4 phases. First phase contains higher amount of estrogen and no progestin. Second and third phases contains lower amount of estrogen, and increasing amounts of progestin. Fourth phase contains low dose of estrogen only. Also contains 2 placebo tablets to complete 28-day regimen.

Extended-Cycle Contraceptive

PO (Adults): Daysee, LoSeasonique, Quartette, Seasonale and Seasonique. Start taking first active pill on first Sunday after menses begins (if first day is Sunday, begin then), continue for 84 days of active pill, followed by 7 days of placebo tablets (low-dose estrogen tablets for Daysee, LoSeasonique, Quartette, and Seasonique), then resume 84/7 cycle again. For  Lybrel , begin taking the first pill during the first day of the menstrual cycle and start the next pack the day after the previous pack ends.

Progestin-Only Oral Contraceptives

PO (Adults): Start on first day of menses. Taken daily and continuously.

Progressive Estrogen Oral Contraceptives

PO (Adults): Estrogen amount increases every 7 days throughout 21-day cycle. Progestin component stays the same. Some regimens contain 7 placebo tablets for 28-day regimen.

Emergency Contraceptive

PO (Adults  and Adolescents):  Levonorgestrel 1 tablet within 72 hr of unprotected intercourse;  Lo/Ovral– 4 white tablets within 72 hr of unprotected intercourse followed by 4 more white tablets 12 hr later;  Levlen– 4 light orange tablets within 72 hr of unprotected intercourse followed by 4 more light orange tablets 12 hr later;  Tri-Levlen– 4 yellow tablets within 72 hr of unprotected intercourse followed by 4 more yellow tablets 12 hr later;  Ulipristal– 1 tablet as soon as possible within 120 hr (5 days) after unprotected intercourse or known/suspected contraceptive failure.

Injectable Contraceptive

medroxyprogesterone (Depo-Provera)

IM (Adults): 150 mg within first 5 days of menses or within 5 days postpartum, if not breast feeding. If breast feeding, give 6 wk postpartum; repeat every 3 mo.

medroxyprogesterone (Depo-Sub Q Provera 104)

SC (Adults): 104 mg within first 5 days of menses or within 5 days postpartum, if not breast feeding. If breast feeding, give 6 wk postpartum; repeat every 12–14 wk.

Intrauterine Contraceptive

 Intrauterine: (Adults): Insert one device into uterine cavity within 7 days of menses or immediately after 1st trimester abortion. Skyla should be removed or replaced after 3 yr. Kyleena, should be removed or replaced after 5 yr. Mirena should be removed or replaced after 5 yr (for treatment of heavy menstrual bleeding) or 7 yr (contraception). Liletta should be removed or replaced after 6 yr.

Vaginal Ring Contraceptive

Vag (Adults): One ring inserted on or prior to day 5 of menstrual cycle. Ring is left in place for 3 wk, then removed for 1 wk, then a new ring is inserted.

Transdermal Patch

Transdermal (Adults): Ethinyl estradiol/norelgestromin transdermal patch– Patch is applied on day 1 of menstrual cycle (or convenient day in first wk), changed weekly thereafter for 3 wk. Wk 4 is patch-free. Cycle is then repeated.  Ethinyl estradiol/levonorgestrel transdermal patch– Patch is applied during first 24 hr of menstruation and then changed weekly thereafter for 3 wk. Wk 4 is patch-free. Cycle is then repeated.

Acne

PO (Adults): Ortho Tri-Cyclen– Take daily for 21 days, off for 7 days.

Availability

Combination Estrogen/Progestin Oral Contraceptives

Oral contraceptive tablets: Usually in monthly packs with enough (21) active tablets to complete a 28-day cycle. Some contain 7 inert tablets to complete the cycle with or without supplemental iron, Beyaz and Safyral –contain 0.451 mg of levomefolate calcium/tablet

Extended-Cycle Contraceptive

Tablets: LoSeasonique– active tablets containing 0.02 mg ethinyl estradiol, 0.1 mg levonorgestrel, and 7 tablets containing 0.01 mg ethinyl estradiol;, Quartette– 42 tablets containing 0.02 mg ethinyl estradiol and 0.15 mg levonorgestrel, 21 tablets containing 0.025 mg ethinyl estradiol and 0.15 mg levonorgestrel, 21 tablets containing 0.03 mg ethinyl estradiol and 0.15 mg levonorgestrel, and 7 tablets containing 0.01 mg ethinyl estradiol;, Seasonale– 84 active tablets containing 0.03 mg ethinyl estradiol and 0.15 mg levonorgestrel and 7 inactive tablets;, Daysee and Seasonique– active tablets containing 0.03 mg ethinyl estradiol, 0.15 mg levonorgestrel, and 7 tablets containing 0.01 mg ethinyl estradiol;, Lybrel– 28 active tablets containing 0.09 mg levonorgestrel and 0.02 mg ethinyl estradiol

Levonorgestrel

Emergency contraceptive: 1.5 mg OTC

Intrauterine system (Kyleena): contains 19.5 mg levonorgestrel (releases 9 mcg/day)

Intrauterine system (Liletta): contains 52 mg levonorgestrel (releases 14.7 mcg/day)

Intrauterine system (Mirena): contains 52 mg levonorgestrel (releases 20 mcg/day)

Intrauterine system (Skyla): contains 13.5 mg levonorgestrel (releases 14 mcg/day)

Etonorgestrel

Implant: Rod contains 68 mg etonogestrel

Ulipristal

Tablets: 30 mg

Medroxyprogesterone

Injectable IM: 150 mg/mL

Injectable Subcutaneous: 104 mg/0.65 mL (in pre-filled syringes)

Vaginal Ring Contraceptive

Ring: delivers 0.015 mg ethinyl estradiol and 0.120 mg etonogestrel/day

Transdermal Patch

Patch (Xulane or Onsura): contains 0.53 mg ethinyl estradiol and 4.86 mg of norelgestromin; releases 35 mcg ethinyl estradiol/150 mcg norelgestromin per 24 hr

Patch (Twirla): contains 2.3 mg ethinyl estradiol and 2.6 mg of levonorgestrel; releases 30 mcg ethinyl estradiol/120 mcg levonorgestrel per 24 hr

Assessment

  • Assess BP before and periodically during therapy.
  • Exclude the possibility of pregnancy on the basis or history and/or physical exam or a pregnancy test before administering emergency contraceptives.
  • Acne: Assess skin lesion before and periodically during therapy.
  • Menopausal Symptoms: Assess vasomotor symptoms or symptoms of vulvar and vaginal atrophy due to menopause prior to and periodically during therapy.

Lab Test Considerations:

Monitor hepatic function periodically during therapy.

  • Estrogens only– May cause ↑ serum glucose, sodium, triglyceride, VHDL, total cholesterol, prothrombin, and factors VII, VIII, IX, and X levels. May cause ↓ LDL and antithrombin III levels.
  • May cause false interpretations of thyroid function tests.
  • Progestins only– May cause ↑ LDL concentrations. May cause ↓ serum alkaline phosphatase and HDL concentrations.
  • Drosperidone-containing contraceptives – monitor serum potassium during first treatment cycle in women on long-term treatment with strong CYP3A4 inhibitors; may ↑ serum potassium concentration.

Potential Diagnoses

Implementation

  • Do not confuse Ortho Tri-Cyclen with Ortho Tri-Cyclen Lo. Do not confuse Yasmin with Yaz.
  • PO 

    Oral doses may be administered with or immediately after food to reduce nausea. Chewable tablets may be swallowed whole or chewed; if chewed follow with 8 oz of liquid.

    • For extended-cycle tablets,  Jolessa, Quasense, Seasonale, Seasonique,  or  LoSeasonique– take active tablets for 84 days and followed by the placebo tablets for 7 days; for  Lybrel– Take 1 pill each day for 28 days, then start the next set of pills daily for the next 28 days.
    • For  Emergency Contraception:  Tablets are taken as soon as possible and within 72 hr after unprotected intercourse. Two doses are taken 12 hr apart. Emergency contraception products are available without a prescription to all women of child-bearing age.
    • Ulipristal:  Administer 1 tablet as soon as possible within 120 hr (5 days) after unprotected intercourse or a known or suspected contraceptive failure. May be taken without regard to food. If vomiting occurs within 3 hr of dose, may repeat. May be taken at any time during the menstrual cycle. Ulipristal may be less effective in women with a body mass index >30 kg/m2 .
  • SC 

    Shake vigorously before use to form a uniform suspension. Inject slowly (over 5–7 sec) at a 45° angle into fatty area of anterior thigh or abdomen every 12 to 14 wk. If more than 14 wk elapse between injections, rule out pregnancy prior to administration. Do not rub area after injection.

    • When switching from other hormonal contraceptives, administer within dosing period (7 days after taking last active pill, removing patch or ring, or within the dosing period for IM injection).
  • IM 

    Shake vial vigorously just before use to ensure uniform suspension. Administer deep IM into gluteal or deltoid muscle. If period between injections is >14 wk, determine that patient is not pregnant before administering the drug.

    • Injectable medroxyprogesterone may lead to bone loss, especially in women younger than 21 yr. Injectable medroxyprogesterone should be used for >2 yr only if other methods of contraception are inadequate. If used long term, women should use supplemental calcium and vitamin D, and monitor bone mineral density.
  • Intrauterine system: Health care providers are advised to become thoroughly familiar with the insertion instructions before attempting insertion. Following insertion counsel patient on what to expect following insertion. Give patient  Follow-up Reminder Card  provided with product. Discuss expected bleeding patterns during the first mo of use. Prescribe analgesics, if indicated. Patients should be reexamined and evaluated 4 to 12 wk after insertion and once a yr thereafter, or more frequently if clinically indicated.

Patient/Family Teaching

  • Instruct patient to take oral medication as directed at the same time each day. Pills should be taken in proper sequence and kept in the original container. Advise patient not to skip pills even if not having sex very often. Advise patient to read  Patient Guide  before starting and with each Rx refill in case of changes
  • If single daily dose is missed:  Take as soon as remembered; if not until next day, take 2 tablets and continue on regular dosing schedule.  If 2 days in a row are missed:  Take 2 tablets a day for the next 2 days and continue on regular dosing schedule, using a 2nd method of birth control for the remaining cycle.  If 3 days in a row are missed:  Discontinue medication and use another form of birth control until period begins or pregnancy is ruled out; then begin a new cycle of tablets.  For 28-day dosing schedule:  If schedule is followed for first 21 days and 1 dose is missed of the last 7 tablets, it is important to take the 1st tablet of next month's cycle on the regularly scheduled day. Advise patient taking  Natazia  to follow  Patient Guide  for what to do if a pill is missed.

    • Advise patient taking  Jolessa, Quasense, Seasonale, Sesonique,  or  LoSeasonique extended-cycle tablets  that withdrawal bleeding should occur during the 7 days following discontinuation of the active tablets. If withdrawal bleeding does not occur, notify health care professional. Advise patient taking  Lybrel  that no withdrawal bleeding should occur.
    • For initial use of  Jolessa, Quasense, Seasonale, Seasonique,  or  LoSeasonique extended cycle tablets , caution patient to use a nonhormonal method of contraception until she has taken the first 7 days of active tablets. Each 91-day cycle should start on the same day of the wk. If started later than the proper day or 2 or more days are missed, a 2nd nonhormonal method of contraception should be used until she has taken the pink tablet for 7 days. Transient spotting or bleeding may occur. If bleeding is persistent or prolonged, notify health care professional.
  • Advise patient taking extended cycle tablets that spotting or light bleeding may occur, especially during first 3 mo. Continue medication; notify health care professional if bleeding lasts >70 days.
  • Advise patient of the need to use another form of contraception for the first 3 wk when beginning to use  oral contraceptives.
  • Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and consult health care professional before taking any new medications.
  • Advise patient that a 2nd method of birth control should also be used during each cycle in which any of the following are used:  Oral contraceptives– ampicillin, corticosteroids, antiretroviral protease inhibitors, barbiturates, carbamazepine, chloramphenicol, dihydroergotamine, corticosteroids (systemic), mineral oil, oral neomycin, oxcarbazapine, penicillin V, phenylbutazone, primidone, rifampin, sulfonamides, tetracyclines, topiramate, bosentan, or valproic acid.
  • Explain dose schedule and maintenance routine. Discontinuing medication suddenly may cause withdrawal bleeding.
  • If nausea becomes a problem, advise patient that eating solid food often provides relief. If nausea persists or vomiting or diarrhea occur, use a nonhormonal method of contraception and notify health care professional.
  • Advise patient to report signs and symptoms of fluid retention (swelling of ankles and feet, weight gain), thromboembolic disorders (pain, swelling, tenderness in extremities, headache, chest pain, blurred vision), mental depression, hepatic dysfunction (yellowed skin or eyes, pruritus, dark urine, light-colored stools), or abnormal vaginal bleeding. Women with a strong family history of breast cancer, fibrocystic breast disease, abnormal mammograms, or cervical dysplasia should be monitored for breast cancer at least yearly. Risk of thromboembolism is highest in 1st yr of use and increased when a combination hormonal contraceptive is restarted after a break in use of at least 4 wk.
  • Instruct patient to stop taking medication and notify health care professional if pregnancy is suspected.
  • Caution patient that cigarette smoking during estrogen therapy may increase risk of serious side effects, especially for women over age 35.
  • Caution patients to use sunscreen and protective clothing to prevent increased pigmentation.
  • Caution patient that hormonal contraceptives do not protect against HIV or other sexually transmitted diseases.
  • Advise patient to notify health care professional of medication regimen before treatment or surgery.
  • Emphasize the importance of routine follow-up physical exams including BP; breast, abdomen, and pelvic examinations; and Papanicolaou smears every 6–12 mo.
  • Emergency Contraception:

    Instruct patient to take emergency contraceptive as directed. Advise patient that they should not take emergency contraceptives if they know or suspect they are pregnant; emergency contraceptives are not for use to end an existing pregnancy. Advise patient to contact health care professional if they vomit within 3 hr after taking ulipristal.

    • Inform patient that  ulipristal  may reduce the effectiveness of hormonal contraceptives. Advise patient to use a non-hormonal contraceptive during that menstrual cycle. Advise patient to wait at least 5 days after taking  ulipristal  to resume taking hormonal contraceptives.
    • Advise patient to notify health care professional and consider the possibility of pregnancy if their period is delayed by more than 1 wk beyond the expected date after taking  ulipristal.
    • Inform patient that emergency contraceptives are not to be used as a routine form of contraception or to be used repeatedly within the same menstrual cycle.
    • Advise patient to notify health care professional if severe lower abdominal pain occurs 3–5 wk after taking  ulipristal  to be evaluated for an ectopic pregnancy.
    • Advise female patients to avoid breast feeding if taking  ulipristal.
  • IM SC Advise patient to maintain adequate amounts of dietary calcium and vitamin D to help prevent bone loss.
  • Transdermal 

    Instruct patient on application of patch. First patch should be applied within 24 hr of menstrual period. If applied after Day 1 of menstrual period, a nonhormonal method of contraception should be used for the next 7 days. Day of application becomes  Patch Change Day. Patches are worn for 1 wk and changed on the same day of each wk for 3 wk. Wk 4 is patch-free. Withdrawal bleeding is expected during this time.

    • Apply patch to clean, dry, intact, healthy skin on buttock, abdomen, upper outer arm, or upper torso in a place where it won't be rubbed by tight clothing. Do not place on skin that is red, irritated, or cut, and do not place on breasts. Do not apply make-up, creams, lotions, powders, or other topical products to area of patch application.
    • To apply patch open foil pouch by tearing along edge using fingers. Peel pouch apart and open flat. Grasp a corner of the patch firmly and remove gently from foil pouch. Use fingernail to lift one corner of the patch and peel patch and the plastic liner off the foil liner. Do not remove clear liner as patch is removed. Peel away half of the clear liner without touching sticky surface. Apply the sticky surface and remove the rest of the liner. Press down firmly with palm of hand for 10 sec; make sure the edges stick well.
    • On  Patch Change Day  remove patch and apply new one immediately. Used patch still contains some active hormones; fold in half so it sticks to itself and throw away. Apply new patches to a new spot to prevent skin irritation; may be applied in same anatomic area.
    • Following patch-free wk, apply a new patch on  Patch Change Day , the day after Day 28, no matter when the menstrual cycle begins.
    • If patch becomes partially or completely detached for less than 1 day, reapply patch or apply new patch. If patch is detached for more than 1 day, apply a new patch immediately and use a nonhormonal form of contraception for the next 7 days. Cycle will now start over with a new  Patch Change Day. If patch is no longer sticky, apply a new patch; do not use tape or wraps to keep patch in place.
    • If patch is not changed on  Patch Change Day  in the first wk of the cycle, apply new patch immediately upon remembering and use a nonhormonal method of contraception for next 7 days. If patch change is missed for 1 or 2 days during Wk 2 or 3, apply new patch immediately and apply next patch on usual  Patch Change Day. No backup contraception is needed. If patch change is missed for more than 2 days during Wk 2 or 3, stop the cycle and start a new 4-wk contraceptive cycle by applying new patch immediately and using a nonhormonal method of contraception for the next 7 days. If patch is not removed on  Patch Change Day  in Wk 4, remove as soon as remembered and start next cycle on usual  Patch Change Day. No additional contraception is needed.
    • Advise patient referred for MRI test to discuss patch with referring health care professional and MRI facility to determine if removal of patch is necessary prior to test and for directions for replacing patch.
  • NuvaRing:

    If a hormonal contraceptive was not used in the past mo , insert  NuvaRing  between Days 1 and 5 of the menstrual cycle (Day 1 = first day of menstrual period), even if bleeding has not finished. Use a nonhormonal method of birth control other than a diaphragm during the first 7 days of ring use.  If switching from a combination estrogen/progesterone oral contraceptive , insert  NuvaRing  any time during first 7 days after last tablet and no later than the day a new pill cycle would have started. No extra birth control is needed.  If switching from a mini-pill , start using  NuvaRing  on any day of the mo; do not skip days between last pill and first day of  NuvaRing  use.  If switching from an implant , start using  NuvaRing  on same day implant is removed.  If switching from an injectable contraceptive , start using  NuvaRing  on the day when next injection is due.  If switching from a progestin-containing IUD , start using  NuvaRing  on the same day as IUD is removed. A nonhormonal method of contraception, other than the diaphragm, should be used for the first 7 days of  NuvaRing  use when switching from the mini-pill, implant, injectable contraceptive, or IUD.

    • NuvaRing  comes in a reclosable foil pouch. Instruct patient to wash hands, then remove  NuvaRing  from pouch; keep pouch for ring disposal. Using a position of comfort (lying down, squatting, or standing with one leg up), hold  NuvaRing  between thumb and index finger and press opposite sides of the ring together. Gently push folded ring into vagina. Exact position is not important for function of  NuvaRing. Most women do not feel  NuvaRing  once it is in place. If discomfort is felt,  NuvaRing  may not be inserted far enough into vagina; use finger to push further into vagina.  There is no danger of NuvaRing being pushed in too far or getting lost. Once inserted, leave  NuvaRing  in place for 3 wk.
    • Remove ring 3 wk after insertion on same day and time of insertion. Remove by hooking finger under forward rim or by holding ring between index and middle finger and pulling out. Place ring in foil pouch and dispose; do not throw in toilet. Menstrual period will usually start 2–3 days after ring is removed and may not have finished before next ring is inserted. To continue contraceptive protection, new ring must be inserted 1 wk after last one was removed, even if menstrual period has not stopped.
    • If  NuvaRing  slips out of vagina and has been out less than 3 hr, contraceptive protection is still in place.  NuvaRing  can be rinsed in cool to tepid water and should be reinserted as soon as possible. If ring is lost, insert a new ring and continue same schedule as lost ring. If  NuvaRing  has been out of vagina for more than 3 hr, a nonhormonal method of contraception, other than a diaphragm, should be used for the next 7 days.
    • If NuvaRing has been left in for an extra wk or less (4 wk total or less) , remove and insert a new ring after a 1-wk ring-free break. If  NuvaRing  has been left in place for more than 4 wk, woman should check to be sure she is not pregnant. A nonhormonal method of contraception, other than a diaphragm, must be used for the next 7 days.
    • Advise patient to avoid using other female barrier contraceptives (diaphragm, cervical cap, female condom) with Nuvaring.
  • Intrauterine system: Advise patient to notify health care professional if pelvic pain or pain during sex, unusual vaginal discharge or genital sores, unexplained fever, exposure to sexually transmitted infections, very severe or migraine headaches, yellowing of skin or whites of the eyes, very severe vaginal bleeding or bleeding that lasts a long time occurs, if a menstrual period is missed, or if  Mirena's  threads cannot be felt.

Evaluation/Desired Outcomes

  • Prevention of pregnancy.
  • Regulation of the menstrual cycle.
  • Decrease in menstrual blood loss.
  • Decrease in acne.
  • Decrease in symptoms of premenstrual dysphoric disorder.
  • Decrease in vasomotor symptoms or symptoms of vulvar and vaginal atrophy due to menopause
CONTRACEPTIVES, HORMONAL is a sample topic from the Davis's Drug Guide.

To view other topics, please or .

Emergency Central is a collection of disease, drug, and test information including 5-Minute Emergency Medicine Consult, Davis’s Drug, McGraw-Hill Medical’s Diagnosaurus®, Pocket Guide to Diagnostic Tests, and MEDLINE Journals created for emergency medicine professionals. .