The ideal contraceptive for a woman with HIV will help prevent pregnancy as well as the transmission of HIV and STIs. Dual contraception using condoms plus an additional contraceptive is the best strategy. Preexposure (PrEP) and postexposure (PEP) prophylaxis should be available to partners regardless of contraceptive method used.
There does not appear to be an association between the use of non-injectable hormonal contraception and risk of HIV acquisition. Studies regarding the risk of HIV acquisition with the use of progestin-only DMPA injectable are conflicting, and the CDC continues to recommend it.
SUMMARY:
Combined hormonal contraception (pill, patch and ring) and progestin-only pills
Considered MEC cat. 1 for patient who are not on antiretrovirals or are not clinically well
For patients who are taking antiretrovirals, can decrease hormone levels but are still considered safe (either cat. 1 or 2 depending on which antiretroviral is being used)
Protease inhibitors, pharmacologic boosters, and efavirenz can cause decreased effectiveness of hormonal contraception
Fostemsavir: can cause increased levels of ethinyl estradiol and raise risk of thromboembolic events | Dosing of ethinyl estradiol should not be higher than 30 mcg daily
Contraceptive implants are highly effective and benefits outweigh risks in women with HIV (MEC cat. 1)
Injectable depot medroxyprogesterone acetate (DMPA) is safe and effective (MEC cat. 1) and does not appear to have interactions with antiretrovirals
Studies regarding increased risk of HIV transmission and acquisition are conflicting.
Intrauterine devices, both copper containing and levonorgestrel-releasing
MEC cat. 1 for women with HIV who are clinically well and on antiretrovirals, with no known drug interactions with antiretrovirals
For women with HIV who are not clinically well or not on antiretrovirals, initiation of IUD is considered MEC cat. 2, but continuation for an already placed IUD is cat. 1
Limited data suggest a low risk of pelvic inflammatory disease and no changes in genital shedding of HIV RNA
Condoms reduce transmission of HIV between discordant partners but are not represent optimal contraception, with an annual pregnancy rate of over 15% per year. Should be used concurrently with another contraceptive method
Spermicides: not recommended due to potential of causing genital lesions
Nonoxynol-9, the active ingredient in most formulations, can cause genital lesions and may increase the likelihood of HIV transmission to a partner
KEY POINTS:
HIV infection does not pose a barrier to sterilization, which remains an appropriate contraceptive option
Emergency contraception including hormone-based (progestin-only pills, ulipristal acetate, combined oral contraceptives), and the copper IUD should be offered to women with HIV whenever appropriate
Emergency contraception interventions are intended to prevent an unplanned pregnancy after unprotected or inadequately protected intercourse. Contraceptive failure or failure to use contraception are common indications for use.
CLINICAL ACTIONS:
Offer emergency contraception (EC) to all women who have had unprotected or inadequately protected intercourse and who do not desire pregnancy
There are no exclusionary health conditions –women who have contraindications to oral contraceptives can be given EC
Offer EC to all reproductive-aged women who have sustained sexual assault
No clinical examination or pregnancy testing is necessary
Treatment should be initiated as soon as possible, and should be made available up to 5 days after unprotected or inadequately protected intercourse
If menses are delayed by a week or more, a woman who has received EC should have a pregnancy test and clinical evaluation
EC may be used more than once even in the same menstrual cycle
Regular contraception should be started immediately after EC and women should abstain or use barrier contraception for 14 days or until onset of next menses
Those receiving uripristal acetate should delay starting hormonal contraception until 5 days after use
SYNOPSIS:
All of the methods below are effective only before a pregnancy is established. Hormonal EC does not pose a risk to an established pregnancy and is not associated with embryonal developmental abnormalities. Adverse effects for all of the oral methods include nausea and headache as well as irregular bleeding. Adverse effects for the copper IUD include perforation, changes in menses or dysmenorrhea. Pregnancy rates after EC range from 0% to 2.2% and may be impacted by body weight.
KEY POINTS:
Uripristal acetate, a selective progesterone receptor modulator, is given as a single 30 mg dose
Requires a prescription
Efficacy may be reduced in women with BMI ≥30
Effective up to 5 days after unprotected intercourse
FDA approved for EC
Progestin only EC, either 1 tablet Levonorgestrel in a single dose (1.5 mg) or as a split dose (1 dose of 0.75 mg of levonorgestrel followed by a second dose of 0.75 mg of levonorgestrel 12 hours later)
May be less effective in women with BMI ≥25
1 tablet formulation available over the counter without age restriction
2 tablet formulation available over the counter to women ≥17 years with photo ID
Effective for up to 3 days after unprotected intercourse
FDA approved for EC
Copper IUD insertion
Requires office visit and insertion by a clinician
Efficacy not impacted by body weight
Effective up to 5 days after unprotected intercourse
Safe and effective but not FDA labeled for use as EC
LNG-IUDs “are currently being investigated” (ACOG PB) | Recent RCT suggests LNG-IUD is not inferior to copper IUD (see ‘Related ObG Topics’)
Combined progestin-estrogen pills
Can use a variety of formulations (see ‘Learn More – Primary Sources’ WHO entry below for a list of appropriate formulations)
Two doses every 12 hours
All aim for 100 to 120 micrograms of ethinyl estradiol and 0.5 to 0.6 milligrams of levonorgestrel per dose
Requires a prescription
Effective up to 5 days after unprotected intercourse
Safe and effective but not FDA labeled for use as EC
Shen et al. (Cochrane Review, 2017) sought to determine which emergency contraceptive method is the most effective, safe and convenient to prevent pregnancy
METHODS:
Systematic review and meta-analysis
Pooled data from different databases and literature
Primary outcome was observed number of pregnancies
Secondary review outcomes were side effects and changes in menses
RESULTS:
115 trials with 60,479 women were included
Pharmacologic emergency contraceptives were ranked as follows (from most to least effective)
Mifepristone
Mid-dose mifepristone (25 mg to 50 mg) associated with fewer pregnancies than low-dose (less than 25 mg)
Ulipristal acetate (a selective progesterone receptor modulator)
Levonorgestrel
Inconclusive whether single-dose levonorgestrel (1.5 mg) or two-dose regimen (0.75 mg 12 hours apart) is superior
No statistical difference identified between Cu-IUD and mifepristone
Nausea and vomiting
Yuzpe > Mifepristone
Yuzpe > Levonorgestrel
Menstrual irregularities
Ulipristal acetate users are more likely than levonorgestrel to have delayed menstruation
Menstrual delay was more common with mifepristone than with any other intervention and appeared to be dose-related
Obesity: The authors cite results from Jatlaoui and Curtis (Contraception, 2016) systematic review
Levonorgestrel
4-fold increase risk of pregnancy in obese women (BMI ≥ 30 kg/m2) compared to BMI ≤ 25 kg/m2
At weight of 80 kg, pregnancy rate > 6% which is the same as probability without contraception
At weight < 75 kg, rate of pregnancy < 2%
Ulipristal acetate
2-fold increase risk of pregnancy in obese women (BMI ≥ 30 kg/m2) compared to BMI <30 kg/m2 but CIs wide and did not reach statistical significance
However, other analyses did not demonstrate consistent association when adjusting for other covariates
CONCLUSION:
Levonorgestrel and mid-dose mifepristone were more effective than Yuzpe with fewer side effects
Cu-IUD is the most effective emergency contraceptive along with mifepristone and the only method that will provide ongoing contraception and not weight sensitive
With respect to obesity, data is considered limited and poor to fair quality but suggests reduced effectiveness, especially with levonorgestrel
Expert Opinion: Over-the-Counter Contraceptives for Adolescents
PURPOSE
This article by Upadhya et al. (JAH, 2017) aimed to review the regulatory and scientific issues with changing oral contraceptives (OCs) to over-the-counter status for adolescents under 18 years of age.
METHODS
Expert Opinion
RESULTS
This review delves into information about: 1) how the process of switching a drug to over-the-counter status works, 2) risk of pregnancy and the safety of OC use in adolescents, 3) adolescents’ ability to properly use OCs, 4) access to over-the-counter OCs, 5) effects on sexual risk behaviors, 6) potential in reduction of occasions for doctors to inform adolescents about reproductive health care. There is strong rationale for allowing adolescents access to over-the-counter OCs if there occurs any regulatory change. OCs are effective and safe for adolescents, and easy access to OCs, condoms, and emergency contraception increases their use while not increasing sexual risk behaviors.
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Disclaimer
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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