Contraception: Pt-Specific Factors

Question 1

Acne or Hirsutism

Answer 1

Use COC with a progestin that has lower androgenic activity
-norgestimate (Sprintec 28)
or no androgenic activity
-drospirenone (Yaz, Yasmin)

Question 2

Breastfeeding

Answer 2

Choose progestin-only (POP) or nonhormonal methods

Question 3

Estrogen CI

Answer 3

Choose progestin-only (POP) or nonhormonal methods

Question 4

Migraine

Answer 4

If with aura, choose progestin-only or nonhormonal method
-do not use estrogen

If no aura, choose any method

Question 5

Fluid retention or Bloating

Answer 5

Choose a product containing drospirenone

Question 6

Heavy menstrual bleeding (menorrhagia)

Answer 6

Natazia (a COC) and Mirena (a levonorgestrel-releasing IUD) are indicated for this condition

COCs with only 4 placebo pills (rather than 7) or continuous/extended regimens will minimize bleeding time

Question 7

Hypertension

Answer 7

If BP uncontrolled, some estrogen formulations are contraindicated

Choose progestin-only or nonhormonal method

Question 8

Mood changes/disorders

Answer 8

Use monophasic COC
-extended cycle or continuous with drospirenone is preferred

Question 9

Nausea

Answer 9

-Take at night, with food
-Consider decreasing estrogen dose or switching to a progestin-only method, vaginal ring or nonhormonal method (ideally after a 3 month trial)

Question 10

Overweight

Answer 10

Choose any method

Counsel patient about the possibility of reduced effectiveness with the contraceptive patch
-Do not use the patch in obesity (BMI ≥ 30

Do not use DMPA if trying to avoid weight gain

Question 11

Postpartum

Answer 11

Do not use CHCs for 3 weeks, or for 6 weeks if patient has additional risk factors for VTE

Can use progestin-only or nonhormonal method during this time

Question 12

Premenstrual dysphoric
disorder

Answer 12

Choose a product containing drospirenone (e.g. Yaz)

An SSRI antidepressant may be needed

Question 13

Spotting/Breakthrough bleeding

Answer 13

Common when initiating extended cycles or continuous regimens; usually resolves within 3-6 months.

When starting conventional formulations, wait 3 cycles before switching
-If early or mid-cycle spotting occurs, the estrogen dose may need to be increased
-If later in the cycle, the progestin dose may need to be increased

Question 14

Wishes to avoid monthly cycle/menses

Answer 14

Use extended (91-day) or continuous formulations

Alternative: monophasic 28-day formulation & skip placebo pills.