1. Hormonal implants (Norplant) have the most use experience and clinical trials. Norplant is no longer marketed in the United States. Implanon is approved by the Food and Drug Administration (FDA).
Table 1. Symptoms of a Serious or Potentially Serious Nature
|Serious: Pills Should Be Stopped Immediately|
|Loss of vision, proptosis,||Retinal artery thrombosis|
|Unilateral numbness,||Hemorrhagic or thrombotic|
|weakness, or tingling||stroke|
|Severe pains in chest, left arm,||Myocardial infarction|
|Severe pains, tenderness or||Thrombophlebitis|
|swelling, warmth, or|
|palpable cord in legs|
|Slurring of speech||Hemorrhagic or thrombotic|
|Hepatic mass or tenderness||Liver neoplasm|
|Potentially Serious: Pills May Be Continued with Caution|
|While Patient Is Being Evaluated|
|Absence of menses||Pregnancy|
|Spotting or breakthrough||Cervical, endometrial, or|
|Breast mass, pain, or swelling||Breast cancer|
|Right upper quadrant pain||Cholecystitis, cholelithiasis, or|
|Midepigastric pain||Thrombosis of abdominal|
|artery or vein, myocardial|
|infarction, or pulmonary|
|Migraine (vascular or||Vascular spasm, which may|
|throbbing) headache||precede thrombosis|
|Severe nonvascular headache||Hypertension, vascular spasm|
|Jaundice, pruritus||Cholestatic jaundice|
|Uterine size increase||Leiomyomata, adenomyosis,|
Implanon has two advantages over Norplant: Implanon is one implant, and the effectiveness rate is not affected by obesity.
a. Composition and mode of action: Norplant consists of six soft plastic implants, each filled with 36 mg of levonorgestrel daily. Levonorgestrel suppresses the LH surge responsible for ovulation. Ovulation occurs in about two thirds of all cycles with Norplant. Levonorgestrel thickens and decreases the amount of cervical mucus and blocks sperm penetration. It suppresses estrogenic maturation of the endometrial lining.
b. Effectiveness rate.
(1) About 1% of women are pregnant within the first 5 years of using Norplant. The rate goes up to 2% in the sixth year. Therefore removal and reinsertion is advised after 5 years. Implanon is reinserted after 3 years (Tables 5-3 and 5-4).
(2) If fertilization does occur, it is more likely to be an ectopic pregnancy. Table 5-3 shows ectopic pregnancy rates per 1000 women-years with different types of birth control. The failure rate is increased by carbamazepine, phenytoin, phenobarbital, primidone, phenylbutazone, and rifampin.
c. Side effects most commonly occur in the first few months and can include irregular menses, headaches, weight change, breast tenderness, acne, hirsutism, depression, mood swings, galactorrhea, amenorrhea, and hair loss. Menstrual irregularities are the most common reason for discontinuation.
d. Fertility returns quickly after discontinuation. Plasma levels of levo-nogestrel are subcontraceptive level within 24 hours of removal.
e. Indications: Women who breast-feed: The implant may be inserted in noncompliant patients while in hospital. However, most studies do not start the method before 4 weeks postpartum. Biodegradable systems, such as capronor and norethindrone pellets, will eliminate removal. Undesirable side effects will be eliminated by the use of less androgenic progestins such as desogestrel, gestodene, norgesti-mate, or ST 14356.
|Table 1 Choosing Oral Contraceptives (OCs)|
|Step 1||Step 2||…………………….
|Can this individual be prescribed a pill with estrogen?
Definitely refrain from prescribing a pill with estrogen to women with a history of a cerebrovascular accident, ischemic heart disease, uncontrolled hypertension, insulin- dependent diabetes with vascular disease, classic migraine with neurologic impairment that has increased with estrogen, breast cancer, estrogen-dependent neoplasia, active hepatic disease with impaired liver function at the present time, benign or malignant liver tumor, or deep vein thrombosis. Some clinicians would make an exception and provide combined OCs to women following postpartum pelvic vein thrombosis or women whose thrombophlebitis has resulted from trauma or IV. Also, in most instances refrain from providing combined pills to women over 35 who smoke. Breast-feeding women, in general, should avoid estrogen.
|YES, she can use an
estrogen. NO, it would be best if she did not use an estrogen. Therefore, you can consider: A. Progestin-only pills, such as:
Micronor (0.35 mg
norethindrone daily) NOR QD (0.35 mg
nonrethindrone daily) Ovrette (0.075 mg nogestrel daily) Norplant (5-year levonorgestrel implants) Depo-Provera (1 50 mg medroxyprogesterone acetate injection every 3 months) B. Intrauterine device Copper T 380-A Progestasert System
C.Condoms (male or female)
D.Diaphragm, cervical cap
E.Foam, vaginal contraceptive film, suppository
|Therefore, you may choose between any of the following OCs based on: Number of micrograms of ethinyl estradiol Availability of pill Ease of remaining on schedule because of pills Price of pills to clinic* Price of pills to client* Prior experience of this individual woman or the clinician caring for this woman with a special pill||Other clinical considerations that may help in OC choice:
A. To minimize the risk potential
for thrombosis caused by estrogen in a woman 40 to 50 years of age or a woman at increased risk for thrombosis from another cause (e.g., diabetic or heavy smoker), prescribe: Loestrin 1/20
B. To minimize nausea, breast tenderness, vascular headaches, and estrogen-mediated side effects, prescribe:
Loestrin 1/20 Or a 30-^g pill, such as: Desogen Levlen
Loestrin 1.5-30 Lo-Ovral Nordette Ortho-Cept C. To minimize spotting and/or breakthrough bleeding, prescribe: Lo-Ovral, Nordette, or Levlen
A new progestin pill: Desogen, Ortho-Cept, Ortho-Cyclen, or Ortho Tri-Cyclen
D. To minimize androgen effects such as acne, hirsutism, oily skin, sebaceous cysts, pilonidal cysts, or weight gain, prescribe: Desogen, Ortho-Cept
Ortho Tri-Cyclen Ortho Cyclen
Ovcon-35, Brevicon, or Modicon
(of norethindrone pills) Demulen-35 (of ethnodiol diacetate pills)
E. To produce the most favorable lipid profile, prescribe:
Ortho Cyclen or Ortho Tri-Cyclen Desogen or Ortho-Cept Ovcon-35, Brevicon, or Modicon (of norethindrone pills)
|table 2 .Rates of Ectopic Pregnancy per 1000 woman
Years by Contraceptive Method and for All U.S. Women
|All U.S. women||1.50|
|table 2. Norplant Capsules :Gross Cumulative Pregnancy
Rates at 5 Years of Use by Weight and Type of Tubing