Hormonal Contraception Considering Benefits Risks and Age Melissa

Hormonal Contraception Considering Benefits, Risks, and Age Melissa Sanborn Advisor: Bettye Hollins, Ph. D.

Objectives • Familiarize with non-contraceptive benefits • Determine risks of hormonal contraceptives • Identify patients most at risk for adverse effects • Age-related considerations • Physician Assistant Role

Non-contraceptive Benefits • Androgen excess disorders – Seborrhea, Acne, Hirsutism, Alopecia – Estrogen, antiandrogenic progestins-Estrostep, Ortho Tri. Cyclen, Yasmin, Tri Cilest • Hypoestrogenic states – Turner’s Syndrome, premature ovarian failure, radiation, chemotherapy, bilateral oophorectomy, and in adolescents with eating disorders and exercise-induced amenorrhea • Ovarian Cancer – Progestin-related; 4 yr. Use=40%↓; 12 yr. Use=60%↓ • Endometrial Cancer – Duration associated; 1 yr. Use=20%↓; 4 yr. Use=60%↓ • Colorectal Cancer

Non-contraceptive benefits • Dysmenorrhea – Decreased endometrial proliferation, uterine motility & cramping from decreased flow volume & prostaglandins • Menorrhagia – Ovulatory dysfunction vs. nonovulatory dysfunction • Endometriosis – Thin endometrium and decrease menstrual flow • PMS / PDD – Prevent ovulation and fluctuations of ovarian steroids; provide stabile hormone levels

Non-contraceptive Benefits • Polycystic Ovarian Syndrome & Functional Ovarian Cysts – Using anti-androgenic effects of progestins • Benign Breast Disease – Progestin and estrogen-related • Preserved Bone Mineral Density – All estrogen doses • Rheumatoid Arthritis – Sex hormone effect on cellular immune response

Non-contraceptive Benefits • Protect Long-Term Fertility – PID, TSS, Ectopic Pregnancy – Thickens cervical mucus, thins the uterine lining • Menstrual Migraines – Monophasic & Extended cycling to minimize estrogen withdrawal period • Prevent Pregnancy – Special Populations

Adverse Effects • Stroke – Hypertension, Migraine, & Smoking • Myocardial Infarction – Age > 35 & Smoke • Hypertension – Controlled vs. Uncontrolled • Venous Thromboembolic Disease – Greatest documented risk with COCs – Weigh risks of pregnancy – Consider other VTE risk factors

Adverse Effects • Metabolic Disorder – Progestin and carb metabolism & insulin sensitivity • Liver Dysfunction – Oral and non-oral effects • Dyslipidemia – Estrogen- ↑HDL & Triglycerides, ↓ LDL – Progestin- ↓HDL & Triglycerides, ↑ LDL

Adverse Effects • Development of Fibroids/Cysts – Incomplete H-P-O axis inhibition • Breast Cancer – ↑ detection & diagnosis, ↓ mortality & metastasis • Bone Mineral Density Loss – Progestin-only injections • Sexual Dysfunction

Adverse Effects • • • Mood Disturbances Weight Gain Headache Nausea Irregular Bleeding Patterns Breast Tenderness and Enlargement

Adolescent to Young Adult • Initiation – Counseling-options, psychosocial aspects, limitations, expected side effects & followup, barrier method contraception • Adherence – Administration schedule and route – Tolerability – Safety in the population

Young Adult to Perimenopause • Return to Fertility – OCP≅Patch≅Ring≅IUS/IUD≅Implant – DMPA has longer return to fertility • Breastfeeding – Progestin-only-timing is important • No further children desired – Choices similar to general female population, consider all options versus risks

Perimenopause to Menopause • • • Pregnancy risks Acceptance Tolerability Initiation Continuation Safety

Role of the Physician Assistant • Appropriate selection • Management • Communication – Limitations – Instructions for Proper Use – Expected or Possible Adverse Effects – Follow Up Schedule – Resources