All right, we'll ahead and get started. Thank you all so much for joining us today. My name is Maria Bremmer, physician Liaison with Benioff children's hospitals. We are very excited to have Schloberger Chen present with us today for our CME presentation, one of our second to last ones of 2023 as a reminder, you all are muted. If you have questions, please uh type everything into the Q and A and Doctor Burton will get to your questions at the conclusion of her lecture as always because this is CME when this uh lecture ends today, uh an evaluation will populate in your browser, please fill that out so you can get CME credit. You will also receive an email tomorrow to remind you to fill out the evaluation and you can find the evaluation in the link in that email. Also, if there's any issues, reach out to one of your liaisons, we're happy to help you. Um in going along with the CME topic, we are gonna start building our 2024 CME uh schedule. There's going to be a survey going out this at the end of this week. So please take the time, couple of minutes to let us know what you'd like to learn about and have credit for next year. It really is uh integral in our, in our building of our program and scheduling speakers and topics. So if you can take a couple of minutes, fill those out, we go through all those surveys and make sure that you are learning about topics that you wanna, uh, hear about for 2024. So we appreciate if you can do that. We have two more top lectures at the end for December on sleep apnea and at at the end of December, right before the holidays hit, we have 11 of our cardiologists. So please look into your emails, registration links to those. And as always, if you need have any questions or concerns, reach out to one of your liaisons and we are happy to help with any thing you may need. Without further ado I would like to introduce Doctor Sloan Berger Chen. She sees patients at our Mountain Zion campus at the Berkeley outpatient Center and recently just started clinic at Benioff Children's in Oakland with her gyygyn population. Welcome, Doctor Burger Chen. Hi there. Um Stop sharing. There you go. Ok, there we go. Let me click share and you see. Yes, that looks good. Ok, great. Ok. So today we're just gonna do a real brief overview of just contraception. Um what's available, what's coming down the road and some um and I'll take just whatever questions you have at the end for sort of nuances of choices, um objectives were previously stated. Um And so just like a quick overview of what do patients want in a contraceptive method. Um So prevention of pregnancy is primary um ease of use would be another consideration side effects. Um was number three. having a choice of method was another. Um And then always just um keeping in mind um kind of what their goals are for contraception and then conception. Um And uh if they're wanting to do any other side of um have any other side effects that are positive with a contraceptive too like menstrual management. Um So those are all just choices um that are helpful. Um When you're counseling a patient in there, uh contraceptive choice, um Just statistics, uh 46 million women are looking for and um even ages 15 to 49 who are sexually active um are seeking. Um Sorry, that's a um not seeking to be fragment and 88% of those. So the largest majority will be seeking contraceptive methods. Um The smallest group of those are gonna be the ones that we generally see and that's that youngest group of 15 to 24 year olds. Um That's the lowest user. So our counseling and intervention for prevention of unplanned pregnancy, especially in these younger age groups, it's gonna be um paramount in helping prevent unplanned pregnancies. Um And keep it in mind those identifying also as non-hispanic white have higher rates of use. So maybe reaching out to our people of color or gender um fluid patients also and including them in their contraceptive needs is also very important as providers. Um This is a really helpful slide. I mostly just include it. So you have some resource for that. This comes from the bed cider.org website. If you're not familiar with it, it's fantastic. It's a really great graphic to have in and around your office. Um Just so that they can see just roughly sort of how many pregnancies occur with the use of each method. Um And so I'll just leave that for you within the slide deck so that you can use that or pull that up on your own. So when you're counseling, what type of history and exam is really relevant for choosing contraception. So I think paramount is a lot of people have a barrier of concern that they're gonna need a pelvic exam or something inter um invasive um that is uh necessary for them to have a contraceptive um prescription of some kind. And so I like to clear that up right away. A lot of people especially coming to the gynecologist, their moms, pump them up in the car, they're gonna have a pap smear and tonguey things put inside of them. So I usually like to clear that up from the first visit that that's not required for needing contraception. Of course, if they're gonna choose one of the lark methods, especially like an IUD, that's gonna be a little bit more invasive than just a prescription. The next thing is just making sure that you've taken a thorough history that you have some good idea of what their menstrual cycles are like prior to starting contraception. Um and identifying any abnormalities that may need, need to be addressed before you move into that um area of contraception. Um And then blood pressure is also important, sometimes they'll pick up some pre hypertension or hypertension even in the younger patients. Um And that's an important uh relative contraindication to some contraceptive use. Um medical history, sort of renal disease, liver disease. Those types of things are also important. Um risks for hyper coagulation. Uh sickle cell is a potential risk when you're thinking. So all those medical conditions that may um influence your choice of contraception are important to glean from that um history, uh family history of blood clots, early strokes, cancers, those types of things are also important and social history in particular for things like smoking, not a lot of data on vaping. I know that's become unfortunately very popular in the adolescent population but not a lot of risk. Um Not a lot of evidence right now for thrombolic risk related to vaping. So it's still cigarette smoking, migraines with aura often comes up. So a really good headache history is a true migraine with aura. Um they are still considered a relative contraindication but our um mec um category four. So alternative to estrogen containing is preferred. Um and uh many times people will do a pregnancy test or SS T I testing before. And just from previous statistics, really, a very small percentage of people will present um and be actively pregnant at the time for their initial contraceptive contraceptive start and counseling visits. Um and then VTE is probably the thing we worry most about for estrogen containing contraception. So this is a just a quick slide. Um regarding the relative risk, the most dangerous risk is of course, gonna be pregnancy and the uh immediate postpartum period and then just keeping in mind depending on the patient population that you see. So factor five, Liden is um uh 5 to 7% of European populations are carriers for Factor five. Liden where is less than 1% of Asian african-american. Um And if you have a patient who develops a VT within the first month of contraceptive estrogen containing contraceptive start a work up should be considered and referral to hematology for further evaluation. So factor five, Liden, homozygote, you have an 80 time increased risk. Heterozygote is still increased risk. Um The second most common inherited is the um PT 2012 A um factor as well, which increases your PTE risk. But overall general population and um currently, most of the CO CS are combined oral contraceptives on the market are considered low dose. So that's 35 mcg or less. Um And your relative risk is just very slightly increased compared to um a non coc taking population. High dose refers to 50 mcg or higher, which are very rarely used, I think. Um sometimes we use the um birth control pill taper for heavier menstrual bleeding or people who are presented to the emergency room. So that would fall into that category where you're giving somebody four birth control pills um at a time. Um uh And so that would fall into those higher risk categories. So you're getting up to 60 100 mcg of ethanol estradiol and that um definitively is included in this high dose risk. Um Another thing I think we should all consider is these young patients that we see are still building their bone peak, um bone development, it sort of peaks at about 15 and continues till about 30. Those are very rough numbers. So when we're choosing, we need to really also consider that um we don't wanna go too low with the estrogen on their birth control pills cause um as we've seen with Depo Provera, we can really inhibit the acquisition of bone mass during that time. So for an adolescent patient, I will always choose it to begin with. Uh if they're choosing a combined oral contraceptive, a 30 mcg ay estradiol pill plus a progestin um for uh prevention of bone loss or continuation of bone mass accrual. Um, a Lark method is not gonna, um, interrupt this, um, slint, which is, I mean, we'll get to it as a newer Justin know only, um, pill, uh, does not seem to have the same levels of bone loss as some of the others. Um, and, but there's no long term data with regards to fracture risk, but it's just something keeping in mind when you're choosing a dose. Um I think most of us are familiar with the Depo Provera. Um And there seems to be the same sort of inhibition of bona cru um with both the hunt 150 mg dose as well as 100 and 4 mg dose of the medroxyprogesterone acetate. 100 and four is the lower dose. Um that can also be given subcutaneously. Um, but has been relatively difficult for some people to get um stock at. So it's not quite as commonly used as 100 and 50 miligram dose. Um This is for bed cider as well. When I'm doing a counseling visit, I usually pull up this graphic so that patients, first of all, I think often will come just with the idea of a birth control pill. I really don't have the idea that there's so many um um choices available to them. And so I usually pull up this graphic during the counseling visit so we can sort of look through each one and I can answer their questions directly and see sort of what appeals to them and kind of group subtypes for them. Um So just to discuss the lark about 6 to 10% of all adolescent patients, this is their um formula of choice. Still by far, a combined oral birth control is the most common, but this um is also increasingly more common. Um and really favorable side effects. You have two sort of subtypes. You have the hormonal containing on the left. Um those contain um in the t part of the reservoir. Um A levonogestrel which is a progestin which has some androgenic activity um that can be formulated both in the high dose for Mirena or Liletta, that's a 52 mg dosing and that can be in place for 7 to 8 years with good contraceptive effect, less than 1% failure. Um And the Klena which is um a mid dose. So a smaller dose than the Mirena or the lilita can be in place for up to five, five years and then you have the lowest dose which is the scala and that's a 13.5 mg dosing and can be in place for about three years. Um The Klena and Skyla are the same size and a little bit smaller. They were initially designed for nippers patients. Um but the Mirena or Lilita can also be used in the nulliparous patient population. Um Mirena or Lalita have higher incidence of amenorrhea or um menstrual suppression. So that could be favorable or unfavorable, depending on what the patients desire. Some patients like their menstrual cycles. Um And so, um a Klena or Skyla lower dose are more likely to have some bleeding. Skyler is more likely to have a regular menstrual cycle unaffected. Um But that's part of the counseling for the patient's choice as well. Some people don't feel like they want that long term commitment. Um And so you have those options when offering, there is also nonhormonal form and that's a copper. Um I think traditionally, it was not offered for the lupus patients, but we offer it to anyone who wants it. It's common for people who don't want any type of hormones. Um It can be in place for 10 to 12 years, also less than 1%. Um Failure rate can also be used as emergency deception within about 72 hours of unprotected intercourse and has been shown to be very effective and as a use for emergency contraception as well. I think for this, um the greatest counseling point is that heavier bleeding and cramping can be experienced. It tends to even out um at about six months. But when initially, um in meeting the patient and hearing sort of their menstrual cycles, if they have four days cycles that are relatively light, their menstrual cycles are most likely going to change. And so having them be prepared for that change and offering them options for management like um an NSAID could be helpful in both reducing the cramping associated with their menstrual cycles and volume of blood flow. Um I think the other thing for Iu Ds, they're such an excellent contraceptive, they prevent less pregnancy. Um both at less than 1%. However, pregnancies that do occur are very unlikely to occur in the uterine cavity. So if they do get pregnant, they have a higher incidence of that pregnancy being outside of the uterine cavity or an ectopic pregnancy. So I just make sure that I drive that clinical counseling point home with patients. So if they do have a concern that they are pregnant and they have a positive pregnancy test, that they need to get um care immediately and then get evaluated just to make sure that they're not having an ectopic pregnancy. Um Nexplanon is uh relatively new. It's um used for 3 to 5 years. It's a matchstick style, uh size contraceptive implant that goes in the underarm. It's very quick and easy to place. Um I think the greatest fear people express is um that it's scary the needle, but there's really not much needles they see. So really talking people off the ledge about that they can also turn their head or have a support person. So that's been the most common concern that younger people have brought to me that the their friends have told them that there's some giant needle involved. And really there, there is not, they can't see the giant needle. It's very nicely um um housed within the applicator. Um, irregular bleeding is the really common side effect associated with Ninon. That um uh quite a few, you know, about one out of five will take out the explan on just for the totally unpredictable bleeding patterns. There hasn't been one single um formulation of uh to prevent this. We people have tried maneuvering and birth control pills and even aromatase inhibitors and um nsaids and Doxycycline. And there hasn't just been one formulation that seems to help. Um So it's a little bit unpredictable in that way, it's an excellent, excellent contraceptive. Um And um but you still will get about 20% will have menstrual suppression. And so if that's the goal for the patient, I'm just being very clear that it may not be the best formulation of menstrual suppression is what they're looking for. Moving on to some different sort of formulated um combined contraceptives. There's sort of Zoo Lane on the left which has been present um available for quite some time. Um Concerns for patients is they've had difficulty getting it to stick. So just walking them through um the places to put the patch as well as how to place it properly. Um uh is kind of a helpful counseling point for those. So you wanna um counsel them if they want it over a bony prominence, not like a fatty prominence, not anywhere where um clothing is gonna rub regularly on it. They want to put it on skin that's clean and dry. Often they can do an alcohol wipe prior to placement if they're having problems with slippage. Um They wanna push down from the middle of the patch and then out to the edges and then around the, around the outer edges of the patch to get it to stick really well. This is a patch that's changed weekly. Um It's a chronic accumulating estrogen dose. However, so there may be a higher thromboembolic wrist associated with these patches versus something like a combined oral contraceptive. Overall, some of the estrogenic side effects may be a little bit higher as well. So like things like headaches or breast tenderness may be more common for your patients when they're using this patch. But patients who have difficulty swallowing pills are at risk for pregnancy need menstrual cycle control are all um excellent candidates for something like the patch, a newer formulation. Um so they change the progestin type. So, um is this newer one called Tola? It is still um nongeneric. So many patients will need to use the um discount card available on the website to get the discount when they pick it up at the pharmacy. Um Overall, the estrogen um cumulative estrogen effect is a little bit lower with the Tola. Um So thromboembolic risk may be mediated or a little bit less but some of the estrogenic side effects too, may be less, it's used in just the same way. It's a little bit of a different shape. Um It's changed weekly. Um and the main concern for this is that it is um potentially much more expensive um leave an adjuster for some patients. Um Can this is what's also in the IUD can have some androgenic side effects for some patients. Um mostly um things like acne, some people will notice some hair ch changes, but acne is one of the bigger ones for le atrial breakthrough, bleeding might be a little bit more common when using the Levan atrial as well. But both are really great options, especially for people who don't wanna s um swallow pills or have trouble remembering a daily medication. Um Yeah, so this is a newer patch as I um stated. Um and um it's very effective but um also has a BM I limitation as do you see um combined oral contraceptives. So, um with higher BM I patients, this would not be a good choice. So ring rings, um I think a lot of people know about maneuvering um which has been out for quite some time. It's something that they change um monthly. Sorry, that's an error there, it says weekly, but it's um changing monthly. Um and they take it out uh at the fourth week um to experience a menstrual cycle that can be from 5 to 7 days. It can also be used continuously for people who wish menstrual suppression. Um As I, a lot of times people will complain of increased vaginal discharge. I sort of like say it's like getting something in your eye that you kind of tear up because something foreign is present. Um, but it, it shouldn't be copious discharge and it certainly doesn't induce higher risk of things like vaginitis or vaginal infection. But some people do notice increased discharge formulation. Um Another counseling point for the ring is it cannot be out of the vagina for more than two hours. So I encourage patients to keep it in when they are sexually active. But if they need to remove it, you need to remember to put it back in within two hours or it loses its efficacy. Um, a newer formulation, um, is this in a larger size, is this, um, Aloe Vera which can be used the same ring versus the new ring, which needs to be a new ring each month. Um The Aloe Vera is designed for a 12 month total use. It can be quite expensive. So there's a discount card available. Um I have had trouble getting pharmacies to have it ordered in. So there's a delay in that as well. Um But for somebody who's been using the NuvaRing and wants to transition somebody who's going off to college, for example, it's a really excellent choice. Um, it's a little wider, a little thicker. Um, and it was designed to be used in a similar way as NuvaRing where you leave it in for three weeks, take it out for a menstrual break between or a bleed break between 5 to 7 for 5 to 7 days. Um you could probably use it continuously though no studies have been done. But if a patient wants to use it continuously, it it does, it should not change their efficacy. Um Another benefit is that it doesn't like ning require refrigeration. Um Some of the side effects that have been reported, um some increased headaches and that might be the continuous estrogen that that's being distributed. Um some nausea, vaginal discharge, um but good cycle control overall and high satisfaction, less than 2% discontinued for side effects. Um And again, I'm still counseling if you choose it that they can use it for continuous use. If they break through bleed, they can take it out for a 5 to 7 day um bleed break and then put the same Annovera back in. Um just a little note on birth control, everybody sort of has their magic formula. But um there are monophasic and triphasic types of pills. Triphasics were designed for with variable dosing to mitigate some of the side effects efficacy has not changed. Um But I find more people get into trouble trying to use a triphasic and try to improve whatever the problem was. Um So I generally stick with monophasic. I think most gynecologists also prefer just using a monophasic pill, often the side effects are related either to the dose of estrogen or the type of progestin that's in the pill. So manipulating that versus sort of the variable dosing throughout the month can be a little bit um less challenging. Um but e are they equally efficacious um monophasic pills are designed with um different placebo intervals. So there's a four day interval and there's a seven day interval. Um and both the efficacy does not change depending on the interval for the placebo. Again. Um Just remind her again about choosing a 30 mcg which may be more bone pro or it's thought to be more bone protective. Um Also, if you're treating ovarian cysts, you want something like a 30 mcg pill, the lower dose may allow for more granulosa cell development. Um And so they may still continue to get cysts where a 30 mcg is a little bit more suppressive and they're less likely to get cysts associated. Um with that 30 mcg pill use um continuous. This is a slide that I give to patients if they're choosing to use continuous birth control pills just for menstrual management um is the primary and sometimes patients forget to restart their pills if they're taking a placebo break. So this is just a little um diagram that I offer to them. But as essential, usually they will just continue pack after pack as the provider. You just need to remember that they need to have um that written in the sig so that the pharmacy is distributing the number of pills that they um need um all at once instead of them having to go back each month or every three weeks. Really? Um So you wanna write in the sig that patient will be using it continuously. The primary um problem that occurs when patients are using it continuously is they'll develop some breakthrough bleeding over time, mostly because they have sort of an unstable endometrium. Um that's been really thinned by the process. And so generally, we'll recommend that they take a 5 to 7 day placebo break at that time again, at the is not affected as long as they restart their pack after their 5 to 7 day break. Um And this generally um is sufficient for um fixing their breakthrough bleeding. Um And yeah, so I just encourage them to communicate with me if they're having those issues. Um So there is a newer birth control pill that has been recently released. Um This is called nelli again, is expensive. So if you're thinking of providing it for a patient, you would wanna look up the um copay card. Um So this is a newer estrogen. So it is sterile, sorry, another typo. Um So this is similar to what's made um during a pregnancy. Um So it is different than the Ethan estradiol that has been um in the other formulated birth controls. Um And uh it's combined with drain on which is the progestin that was um initially introduced in the Yaz and Yasmin formulations. Um So, patients who are sensitive to the Ethan estradiol effects um uh or um are unable to metabolize it, well, may be good candidates for this Erol. Um I think it's so new, we haven't really found like who's the best candidate for this. Um And it was not studied in patients under the age of 18. Um but I have a patient with congenital hepatoma. Um and Ethan Estrada is broken down pretty significantly in the liver. And so I'm thinking maybe estra would be a good choice for that patient, but it's still sort of out unknown as to what is the perfect patient for this. But it is kind of exciting for another option being available. Um It does not bind to the sex hormone binding globulin. So maybe not the best choice for somebody with PC OS, for example. Um they would not necessarily get the testosterone lowering effects um that um is more helpful with some of the other formulations. Um has a little bit of a longer half life. Um And again, as I mentioned on the previous slide, it's not, it does not use the liver enzymes for breakdown part of the bioavailability is a little bit different because of the um or bioidentical formulation. Um it remains to be seen but it may offer a decreased thromboembolic risk. So somebody um maybe who has like an auto, like an autoimmune condition, who is maybe slightly at risk for thromboembolic risk, um maybe a candidate for something like this and it, it still does offer um prevention of bone loss. Um unscheduled bleeding was one of the more common side effects that was concerned. But again, this one sort of still developing as um who might be the perfect candidate for it. But in patients with unique medical conditions, it's nice to know that there might be something out there that might be more um better formulated for them. So I'm gonna just move on to the progestin only contraceptives now. So these work a little bit different. They were not designed to inhibit ovulation with the caveat being slim, which I'll talk about a little bit. Um But generally, these are designed to thicken cervical mucus. They affect tubal motility to decrease the likelihood of sperm and egg meeting. They also cause endometrial atrophy to prevent um and decrease the likelihood of implantation. Um Some will at certain doses suppress ovulation, but that's not how they were designed to work. Um They are remain as they remain effective. But as I discussed, ovulatory inhibition is really only about 50%. Typical use failure is about 5%. So a little um less than a combined oral contraceptive but fairly equal. Um I talked a little bit about that. Um the three hour window um for so if you are not taking this the pill within the same three hour window. Um, the efficacy was thought to be decreased and that I think is, um, a little bit more flexible than at once we thought. Um, but we still encourage people to take it within the same time frame, mostly also for remembering to take the pill. Um, the newer formulation of Slint has a little bit longer therapeutic window too, which is helpful and a better inhibition rate for ovulation um and excellent pregnancy prevention rate um as well. Um So the typical and traditional progesterone only we're familiar with noosed. Um There are no placebos and I think that's really important, especially if somebody is changing from one that did contain placebos. You don't want someone taking a week off between pills or packs, you need to remember to take each pack one after the other and there is no placebo break. Um During that time, the newer formulation is strain. Um That's a 4 mg um, brand named Slint. Um And a again, I mentioned it does not have the same therapeutic window. Uh Progesterone only would be excellent choices for people with migraines, hypertension. We use them for postpartum patients and they can also be used safely for smokers. Again, sland it was just approved in 2019 has the longer half life that is a four day placebo regimen. Um And there is more ovulation suppression even after um missing pills. It seems to continue gus of the longer therapeutic window. The negative for lin is um complaints a little bit more of irregular bleeding in general progestin only formulations um do have the common complaint of irregular bleeding and that includes Lacs explan on as we already talked about the implant as well as the oral formulations. So, what's coming down the pipes? Um So there is a phase two trial of a male contraceptive trial. It's two B um and that is to inhibit um testosterone production and thereby inhibiting um sperm production. Um There is a newer vaginal gel capsule like a like a plug, almost a polymer. Um When I first saw it remind me of sea monkeys if I can date myself or you like put it into water and it expands. Um But it's essentially just a barrier form of contraception um that patients can carry with them. There is a estradiol. So um a 17 beta estradiol and progestin pill that is in development as well, I think also like the next Stellas pill with the um a sterile formulation um unique to which patient populations this might be um used for. But um interesting to know it's a little bit more um bioidentical if I can use that mar marketing term. Um and a newer copper IUD is um being in the in the works. It's a smaller dose, um a smaller size as well for ease of placement. Um There is also a copper ball IUD um Also in development. So that's what's coming down the pipes and very soon, so early 2024 we will be um happy to receive an over the counter pill. Um So this progestin only pill is a um different than the heather or Micronor pill that we've been used to using. This is a progestin called norgestrel. Um It's excellent for preventing contraception. Um This uh pill was formulated a long time ago, first uh marketed in 1973 was very effective and was removed from the market mostly for financial reasons for the company and was taken up um recently to redevelop this new over the counter available um pill. Um for perfect use, it's gonna be one tablet a day. You need to kinda keep within that therapeutic window and wanna use backup contraception and this is for package instructions to use um backup if you've taken your pill outside of the therapeutic window. So a barrier form of contraception and like the um pill that was designed the North syndrome pill. Hello. Um No, there is no break between packs. So we should welcome this within the next few months. Hopefully to our shelves. Um I the state regulations have not been um as far as age restrictions, et cetera have not been really um discussed yet. Um but like plan B or the emergency contraceptions, we're hoping that um adolescents at least greater than 16 for most states will be available to purchase this online or in their drug stores. Um Again, it works just the way the other progestins work by um thickening cervical mucus vaginal atrophy. I mean, sorry, not vaginal atrophy, uterine atrophy. Um and um more so than suppression of ovulation. Um excellent safety data, 30 plus years of safety data use um and irregular bleeding cause it's a progesterone only is also very, very common. Um and just to review what types of emergency contraception are available, I talked a little bit about the copper IUD being um the possibility um leaving a gr I think we're all familiar with Plan B being available. I generally send people home um with a prescription for it just as a reminder. Um If they are not choosing a contraceptive or they're choosing to use be contraceptives just so that they have something um available to them. Ella can be used in a greater therapeutic window. So leave. Um the Plan B is best used within 72 hours. Whereas Ella, which is a progestin um receptor modulator can be used for up to five days. Um And that does not seem to decrease the effectiveness of the medication. Um I just keep this slide there. So when is the medication effective? It's gonna be a little bit different for the combined oral contraceptives than for the progestins. So if they're doing a menstrual, start the contraceptive pill that is combined will be effective within five days. Um And if they're doing a random start. So mid cycle start, um they need to um they, it will be effective within seven days. Um It's a little bit different for the progestin only. So, contraception begins um within about two days of starting the pill no matter when you are taking them. So it is effective fairly quickly. But we recommend that they use a condom, especially within the 1st 2 to 4. I usually to say within the first week of start. Um, just to make sure that they are understanding, um, that it's important to use that as well. Um Yeah, and then again, we've, I've talked to over and over again about the therapeutic window. So you wanna use it within about three hours. If you miss that therapeutic window, you're gonna take the next pill and use backup for the next two days. Um, slander works a little bit more similar to the quick start as the combined oral contraceptive. So if you take it within the first five days, you're productive from pregnancy right away. So in the days, one through five of your menstrual cycle, if you take it any other time, it's seven days and you wanna use condoms during that time. Um And again, the slit therapeutic window is a little bit greater. Um I just include this slide for you as well. Um And I think probably we can move to taking some questions. What do you do if you miss a pill, I'll leave that in for you to look at um some resources if you're not familiar this um mec um is an app that you can use so that you can cross select between birth control type and underlying medical conditions. And that's really helpful as well. This is a scarlet teen and they have like a birth control bingo. That's fun to share. Um And then I just have some, um, you know, commonly asked question answers to questions, but I think um maybe we could go ahead and start taking questions at this point cause it looks like we just have about 15 more minutes, 1520 minutes left. OK. There are a handful of questions, there are some people asking um in the chat about uh getting some of the references that you have have uh cited and I want to let everybody know we will be sending out her slides for your reference too. We can get those to you by the end of the day. Yeah. Oh Yeah. I tried to put a bunch of references in the slide deck for you too, like with the mec and some other um references for you just to have. Um Yeah. OK, perfect. So we have an attendee asking, it says it seems like people will be, will give estrogen with migraines with a a. Can you expand on this? And she cites a migraine with a a and birth control um study it looks like um I think uh if, if you're gonna use the M AC data, it's a category four, which means against choice to use a Cine. So I think overall a young person is very low risk at stroke. I mean, that's the thing that we're talking about here. So migraine with aura increases your stroke risk about three times um normal. But you have to also consider like that for a 40 year old counseling that's gonna be very different. So like mec data doesn't differentiate whether you're 15 or 40. Um So I think it's case by case, um some patients uh have very significant menstrual migraines and their combined oral contraceptives are actually very helpful for them. So I think case by case, um it, it's just counseling for the patient if they um are a candidate for another choice that's preferred. Um because we know that the data is a bit um that their stroke risk may be compounded. Um But I take each individual, I don't usually use like 100% this or 100% that so choice by choice, we kind of um counsel based on that, but if we don't choose it. Um a again, you have to also consider if you're gonna use a 10 or 20 mcg for five years, you're also impacting their bone health. Um So I think you have to really think about where you're, you know, picking your poison, like which direction you want. There's so many available options. Do we need to pick like a low dose. Could we pick something like a slint, for example, would be an excellent choice for somebody who had migraines. Um You're not gonna impact their bone health. It's really great. Um Contraception, it's easy to use. Um So those are things that are usually like in their your nuanced counseling use. Um It looks like, thank you. Oh, sorry, go ahead. Like I hope that answered that question. But I think um yeah. Um and then I think that same person is answering. I always do local anesthesia for IU Ds. Um I offer Ibuprofen 6 to 800 with food prior to the procedure. Um I usually have have a counseling visit before so we can set them up for success. Like have the makeup playlist, bring a support person um offer like a heating pad or a heat pack. Um If they're really anxious, sometimes I'll give them 0.5 or one of Ativan after they've been counseled properly. Um um without having the Ativan on board and then I usually will do about 10 CCS of lidocaine into the cervix. Um And most patients will rate their IUD placement pain about 5 to 7 out of 10. Great. Thank you. Next question is asking how long does it take before the ring is effective? The ring can be used in the same way as a combined oral contraceptive pill. Ok. Um And then we have to be asking for the hand out for patients with the coc that you provided. Is that in the slides or is that separate? Hm. This one? Yes, this is from the website. This is the one from bedside. I think they, at some point they were also making like handouts that they would mail to your office. Um, but this is from Planned Parenthood. You can find it on the beds sider website. It's excellent. They had a poster at some point which is a nice thing to keep in your rooms if you put, put those up. Ok, great. Thank you. Next person's asking is Opill good for emergency contraception. Um I don't know of any data out there, but it would be interesting to know it. Um It doesn't work. Um you know, the leave in atrial pill um is the Plan B and it, it's a very large dose, but in theory, it could be, I don't know of data out there on that, but that would be a really interesting and exciting way to use this. Um But with Plan B which has been well studied available, I don't know why you would choose one over the other um at this point, but it would be a really great next step. Next. Ok. Next question is asking, will there be ac OC pill for OTC use or just Progeston only? Yeah, I don't know if they're gonna make it. I doubt they'll make a combined oral contraceptive use just mostly for the thromboembolic risk. Um, that people can't be well enough screened for over the counter. I think that's why they went with this progestin only. Um, but I don't know, I'm not family planning so I don't really keep like my finger on the pulse of all of the latest and greatest. But, um, yeah, I don't, I don't know, but I think that's why they went with progesterone only because of thrombolic risk. Although in other countries, you can you like combin oral contraceptives over the counter? Ok. Next question is asking, can you use Ella and Plan B when on O PC? You can use both of them when um but they would potentially decrease the efficacy that um Ella is a selective um progesterone receptor modulator. Um But I don't know why you would take them if you were taking your birth control pills regularly. Ok. I believe you answered this. I just wanted to ask just in case, do you uh do you premedicate for pain before IUD insertion into poly pas uh patients? I, I do I offer um 6 to 800 mill. So generally at their counseling visit, we talk about how we're gonna put it. Um the IUD in and um uh I will give them a prescription and make sure that they've eaten before their visit um too so that if they forget to take it, that we can give it to them from the office. Thank you. And I apologize. I have a one year old upstairs and I, I think you guys can probably hear banging. I'm sorry about that. Um, that's questions asking. I've never heard of the three hour therapeutic window. Does this refer to taking the medication at the same time daily? Yeah, I think, um, that, that's what the therapeutic window is so that when the medication kind of, um, is leaving your system. So, um, I think we've always told people with progestin only that they have to take it exactly the same time every day. But the therapeutic window is a little greater with sly, but it's probably within 2 to 3 hours. So I try to encourage people for both combined and progestin only to take the pill within the same amount of time, mostly just for them to remember. But um I think we uh older counseling was that if you missed your pill and you didn't take it at exactly the same time, it wouldn't be effective. But I think we know now that that's not exactly true. Great. Thank you. Next question is asking if a patient chooses to use coc pills continuously. Do you recommend they occasionally take a break to bleed? And if so how often I don't recommend it, they don't have to, um, but if they do develop breakthrough bleeding, um then they, I would recommend they take a 5 to 7. There's not really a benefit to it. The main thing is to prevent breakthrough bleeding. Um There's no lining that's accumulating when you're on a birth control pill, you're very in endometrium. And so, um a lot of, I think patients conceptions too is that somehow they've got all this build up inside of them that's getting trapped. So just making sure that I can kind of demystify that for them is helpful as part of their country, um uh their counseling visit. Um, but it, it's not required, it doesn't change efficacy. It was really just designed um for a reminder that you weren't pregnant and the original designers had some idea that um patients would like to have a menstrual cycle. So they built it in that way. Um So really, I just filled it in if they're having break their bleeding. Thank you. Those questions asking. Can you elaborate on the type and dose used to stop heavy bleeding? Oh, that's a whole another talk. Um So I, I mean, heavy bleeding, it really just depends on the type of patient what they're doing if it's just regular monthly menstrual cycles. Um I will um offer them all the same menstrual suppression I think I have uh down here. Um So for menstrual suppression, um it depends on what their goals are if their goals are complete amenorrhea or just dosing. I mean, the leave atrial IUD is by far and away. My first choice, but it's not always a patient's first choice. It's excellent contraception. It's excellent at dec seeing birth control. And then other than that, it's usually something like a whatever they're gonna be so comfortable with. But you're gonna have reduction in volume of flow with progestin only. You're gonna have reduction in volume of flow with combined um contraceptives, you're gonna have reduction in flow with Delora. So all of them should reduce volume. But if it's an uh so for heavy menstrual bleeding, all can be effective. Here's sort of the efficacy of each type, but that's to achieve amenorrhea. Yeah, I put all that in there too. So if you wanna just see the numbers, perfect. Thank you. And like I said, we will share these slides with everyone. So they can reference to um those questions asking if you can review Ya use how, so it just ask if you can review y you not. So um Ya is a 20 mcg pill. So again, would not be my first choice in general for a patient in this age group um just for bone health. So Yasmine would be um the choice I would choose. Um There is data available that the um Ya and Yasmine formulation of the Ethan estradiol with um drone um may um probably do increase your thromboembolic events slightly higher than other combined oral contraceptives. So that might be sort of what you um are wondering about. So who would I use Ya or Yasmine in people who are not tolerating other formulations? Um I think we were hoping that the benefit of the drain um would be helpful for PC OS patients because it's formulated similarly to spironolactone. Um And however, it really hasn't been any different in effects for PC OS management than any other combined oral contraceptives. So I really wouldn't choose it just for that either. Um, so, um, I don't, it's not a formulation I use with, with any regularity. Um, but it, it's available and if other formulations aren't working and somebody's committed to wanting to use a combined oral contraceptive, then I probably would start with the Eine first. Great. Thank you. Um This person is asking about it just says, what about PC OS? Um What about PC OS? Um So no context. So, I mean PC OS again, another um PC OS is a difficult um diagnosis to make in young people. Um They need to have their menstrual cycles established for 2 to 3 years before we can make the diagnosis. They need to have a series of um criteria that they meet irregular menstrual cycles, all sorts of other di doses. Um They have high circulating androgens, um and low sex hormone binding globulin which contributes to the high um sex uh androgens. And so, any combined oral contraceptive will lower um the androgens by increasing availability of sex hormone binding globulin. So, um uh other than the next Tellis. Um so for PC OS, if you're trying to lower androgens, all the combined hormone contraceptives should be effective um, in doing that. But it's, um, it's a lifestyle change. It's, um, you know, there, there's so much to management of PC OS that just a birth control pill alone is, is, um, part of the management, but there is, you know, all the metabolic dysfunction that needs to be evaluated. And so, um, yeah, that's a whole another talk, but I don't know what specifically your question was, but I won't, I don't choose Yasmine specifically just for PC OS. If that, that is where that was going. Great. Thank you. Those questions asking, is there a certain coc that's best to also help with acne? Um I have a slide on that too. A lot of people ask. So the, the one Ortho tricycline was what was um re um sought the FDA approval for that. But again, if um you are um looking for decreasing circulating androgen. So part of why PC OS is a really difficult diagnosis to make it cause in puberty, you have high levels of circulating androgens. That's how puberty works. It's how you get the changes of puberty. So um increasing your circulating sex hormone binding globulin is gonna pull out some of that acne, I mean, some of those androgens and decrease the likelihood of um androgens associated acne. So all potentially all um hormonal com combined hormonal contraception could be effective for that. Now, the caveat is things like the levo nostril pills which are very popular. Um Ha lenos is a little bit of an angiogenic um progestin. So maybe that would not be my first choice for management of acne. Um So those are like your Seasonique, your seasonal pills. Um Also the IUD uh hormonal IU DS are impregnated with the Levo AOL. So those can be androgenic and about 10 to 15% of people will get worsening acne because of that small amount of circulating LR atrial in their system. So those are things I counsel patients about. If they choose an IUD, I also will offer them some spironolactone. Um If they're concerned about their acne or if it's somebody who already has acne issues through PC OS. So I try to um keep those things in mind when I'm offering um a contraceptive type. Great. Thank you. That looks like all the questions. Unless there are any last minute that come through in the last couple of moments. I wanted to thank you Doctor Berger Chen for, for presenting to us today. We really appreciate it. It's always helpful um to learn about everything you have to say. If you um as a reminder when this webinar ends, please stay in your browser because your eval will pop up and you can fill that out for your CND credit. If you don't have time right now, you can get to it when your e the email is sent tomorrow around lunch time, it will be in your inboxes then and then this will be reposted to our med connection side if you wanna reference it and we will get the slides out to everybody also by the end of the week. Thank you so much for speaking to us today. Thank you for taking the time out of your day and we hope you all have a good rest of your Tuesday.