Past history of hepatitis Patients on anticoagulants (progesterone contraceptives preferred) CHD (if CHD is predisposing to thrombosis $\rightarrow$ contraindication)

In females who are older & obese, progesterone-only pills are preferred.

Return of Fertility

Fertility returns within 3 months of stopping the pills.

OCPs are Contraceptives of Choice For

Newly married couples staying together.
After hydatidiform mole evacuation.
For spacing of pregnancy.

Contraceptive Rings

Other E and P containing contraceptives: RINGS
Advantages over pills: Less estrogen exposure, less breakthrough bleeding.

Nuva Ring

$54$ mm diam, $4$ mm thick.
Insert on day 1 of cycle.
Composition: EE ($15 \mu g$/d), Etonorgestrel ($120 \mu g$/d).
Use same ring for 3 weeks, then remove. After 1 week, insert a new ring within 3 hours of the stipulated time.

Annovera Ring

Composition: EE ($13 \mu g$/d), Segesterol acetate ($150 \mu g$/d).
Use for 3 weeks and remove for 1 week $\rightarrow$ clean and reuse till 1 year.
Not used in females with BMI $\ge 29$ due to risk of embolism.

Important Points for Rings

If a female removes ring during sexual activity and reinserts it within 3 hours: No backup contraception needed.
If reinserted after 3 hours: Backup contraception needed for 48 hours.
Annovera rings are specifically contraindicated in females with BMI $\ge 29$.

Transdermal Patch

Composition: EE ($20 \mu g$/d), Norelgestromin ($150 \mu g$/d).
Apply new patch every week for 3 weeks (on same day, not same site, not same time). 1 week patch-free.
Site: Lower abdomen, upper outer arm, buttock, upper torso, not breast.
Bathing, swimming, sauna, etc. do not lead to patch removal.

Patch Detachment

If occurs $<24$ hours: Reapply same patch, no backup needed.
If occurs $>24$ hours: New patch, new cycle begins, backup needed for 48 hours.

Only Progesterone Contraceptives

Types

Progesterone Only Pills (POPs) / Minipill:
Progesterone Implants: Implanon.
Progesterone Injection: Depot Medroxyprogesterone Acetate (DMPA).
Progesterone Containing IUCD: Mirena.

Mechanism of Action

POPs: Thicken cervical mucus.
Implants, injections, Cerazette (POP available in India): Main mechanism is Anovulation.
Other mechanisms:
- Thicken cervical mucus and inhibit tubal peristalsis.
- Sperms cannot penetrate the thickened cervical mucus $\rightarrow$ Decrease the chance of Pelvic Inflammatory Diseases, Sexually Transmitted Diseases, and ectopic pregnancy.
- Also decrease tubal peristalsis. Failure of contraception leads to increased chances of ectopic pregnancy.
  - Absolute risk decreases but relative risk increases.

Progesterone Containing Contraceptives Do Not Have Any Effect On

Carbohydrate metabolism.
Lipid metabolism.
Clotting factors.
Breast milk.