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Melanie Cole (Host): There are many birth control options available these days. There are advantages and disadvantages to each of them, but it's really important for providers to discuss with their patients as to which one might be best for them.

Welcome to Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole and joining me today is Aubrey Hudson. She's a Physician's Assistant in Obstetrics and Gynecology with the Carle Foundation Hospital. Aubrey, it's a pleasure to have you join us again today. And I love this topic because boy, there's always changes. There's always questions. Women have so many questions. So, tell us first, what are some of the new contraceptive options available right now that people may not know about?

Aubrey Hudson, PA (Guest): Yeah, I'd love to review that. Thank you for having me again. So, I have three main options today that I wanted to bring up. The first is actually a completely non-hormonal option called Phexxi, and that is a local pH changer that is inserted into the vagina up to one hour before each active intercourse. With this birth control, there can be some local irritation or male partner discomfort, but this can be a great option for those who are maybe having infrequent intercourse or really just don't have other good options for them say they are contra-indicated for hormones and IUDs, or they really just want to steer clear of hormones altogether.

Another good option that is new is a new progesterone only pill called Slynd. This is the drospirenone containing progestin that we see in Yaz and Yasmin. However, this is only the progestin. There is no estrogen. For years, we only had norethindrone as our only progesterone only option for contraceptive pills. This is given in a 24 active pills and four inactive pill fashion. So this helps to alleviate some of the irregular bleeding that can happen with other progesterone only pills. In addition to the better bleeding pattern, there tends to be a little bit more forgiveness in the timing of taking this pill. This is a great option for say you're a smoker over 35, or someone with migraines with aura. So, that can be a really nice new option.

And then there is ANNOVERA. ANNOVERA is a new vaginal contraceptive ring. It is instead of a monthly ring, like we've seen with NuvaRing. It is actually a full year's worth of hormones in a single ring.

The patient inserts it for 21 days, removes it, rinses it puts it in basically like a makeup compact, saves it out for seven days and then replaces it. Some people are using this off label in a continuous fashion for maybe three months at a time or even longer, but there is enough hormone for 13 menstrual cycles. The other nice advantage of this is that it gives an overall low dose of estrogen at only 13 micrograms per day, which is lower than the daily dose from most oral contraceptive pills.

Host: What an excellent summary that was Aubrey. So what are some of the more important contra-indications to various contraceptives that you counsel your patients on that, you find really important?

Aubrey: Sure. I think one of the main things we want to think about is especially as with the combined hormonal contraception, so that ANNOVERA that I mentioned has estrogen and progesterone and anyone that we're looking at combined hormonal contraception, we've got to think about their cardiovascular risk. And think about migraines with aura. There are a lot of women of childbearing age who have migraines with aura. And unless you ask the question, they often don't say in their past medical history, oh yeah, I get migraines. Or they don't say I get migraines and I lose vision in one eye when I get my migraine.

So asking the right questions can be really very important. Also just generally, what is their family history? What are there other potential risk factors for cardiovascular disease, obesity, smoking, looking at all of those and for the ANNOVERA, those would be contra-indications. Nice thing about the Slynd is it doesn't carry that same high risk of cardiovascular disease, worsening, as you would see for something that contains estrogen as well.

Host: So, how do you go about, because that's really good counseling advice. And some of it we've heard about and some we haven't. So how do you go about helping your patients select the one that's best for them across the childbearing age spectrum? Because certainly younger women are looking for something different than older women are.

Aubrey: Sure. And I might work backwards here. When we talk about older women, they are going to be much more likely to have higher cardiovascular risk factors, and they're much more likely to be able to be responsible. So, say a progesterone only pill in someone who's in her mid forties. She could be a good pill taker. She already had some declining fertility, so that might be a better option. On the contrary, she may be someone who really wants something that's going to last till menopause. So, we may think of maybe an IUD for her. So, I think in that age range, she may also be more worried about what's going to help with her perimenopausal bleeding.

So often in that end of the population, we will see a lot of IUD usage or some more progesterone only options. And the younger population, if we're looking teens early twenties, we've got to think about convenience and the ability to use the birth control quote "perfectly". So, the NEXPLANON is a very attractive option. The implant that stays in for three years or something like ANNOVERA. Often I have patients who are doing travel abroad and they need seven months of birth control pills and their insurance is giving them grief. If they have ANNOVERA, they have a ring, they take that ring with them. There's no going to the pharmacy.

It's theirs and then in between of course, for child spacing and for breastfeeding and after pregnancy, then having the options that are maybe more progesterone specific, or that are shorter term quickly reversible can be helpful for that child spacing for that middle age spectrum.

Host: So, then tell us when you're working with women, they're going to ask you about these complications. And they're also going to ask you about some myths and long-term effects, which one of all of these you've talked about today, Aubrey, do you think caused the most confusion among your patients?

Aubrey: I think it can be confusing when we compare progesterone only pills with estrogen containing pills because they're still taking a pill. Also with something like ANNOVERA, it still has estrogen. It still has all the same risks as taking a pill, even though you don't put it in your mouth. So, when I counsel a patient, I really try to divide my contraceptive options into things that are completely non-hormonal, things that are combined hormonal contraception, your patches, your rings, your combo pills. And then the progesterone only options and longer acting options. So, your things like your IUD, NEXPLANON, depoprovera and progesterone only pill. That way we can narrow down, okay, which things are maybe contra-indicated, we can take a whole group out. And which things are most attractive to them based on what their expectations are for bleeding patterns and their convenience factor of how diligent they can be with something they use daily, monthly, or every six years.

Host: So before we wrap up, what do you want other providers to know about counseling their patients on all the various types of birth control available out there, and the fact that these types of birth control, except for save a few, do not protect against STIs?

Aubrey: Yes. So, I think really thinking about your age of your patient and what their goals are, is very important. So, if you have a patient that you think a NEXPLANON is going to be great for, because it's super effective, but she's freaked out about needles and doesn't want to get the thing in her arm. That's not going to be a good fit. So, really listening to your patient and what the goals are. If her main goal is not getting pregnant and she doesn't care about what her periods do, then a NEXPLANON is probably her best option. So, we have to think about it, not just about the contraception, but what the potential bleeding patterns are, side effects and of course the potential to use the contraception correctly.

And you're absolutely right. I still continue to remind my patients. This is only for pregnancy prevention, continue to use condoms for STD prevention, especially in that age population under 25 or my older patients who are now divorced in their forties and actually had their tubes tied and don't need contraception, but they've got to be thinking about STDs again.

Host: That's true. And what a great point. I was just thinking about that when you even said that, because there has been a resurgence in these STIs in the over 40 crowd, and as you say, whether they're divorced or single, you know, and they don't think about that as much. So what a great point that you've made and thank you so much for coming on and telling us about the new forms of birth control that are available out there.

And that wraps up this episode of Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle sponsored educational activities, please visit our website at carleconnect.com for more information, and to get connected with one of our providers. Thanks so much for listening. I'm Melanie Cole.