What alternatives are available for a patient experiencing mood symptoms and anxiety while taking Femme Tab 20/100 (ethinyl estradiol and levonorgestrel)?

Alternative Contraceptive Options for Patients Experiencing Mood Symptoms and Anxiety with Femme Tab 20/100

For patients experiencing mood symptoms and anxiety while taking Femme Tab 20/100 (ethinyl estradiol and levonorgestrel), switching to a vaginal ring or a different combined hormonal contraceptive with a different progestin formulation is recommended as the first-line alternative.

Understanding the Current Issue

Femme Tab 20/100 contains ethinyl estradiol (EE) and levonorgestrel, which is a combined oral contraceptive (COC). Mood symptoms and anxiety are recognized adverse effects that can occur with hormonal contraceptives, particularly those containing certain progestins.

Alternative Contraceptive Options

First-Line Alternatives

1. Vaginal Ring (NuvaRing)

   • Contains 15 μg ethinyl estradiol and 120 μg etonogestrel
   • Advantages:
     • Simplest regimen with comparable efficacy (9% typical-use failure rate) 1
     • May have fewer mood-related side effects due to steady hormone delivery
     • Doesn't require daily administration
   • Usage: Insert for 3 weeks, remove for 1 week (or continuous use)

2. Combined Hormonal Contraceptives with Different Progestin

   • Consider COCs containing norgestimate or newer generation progestins
   • Evidence suggests COCs with norgestimate/EE may improve mood symptoms 2
   • Example: COC containing 250-mcg norgestimate/35-mcg EE has shown improvement in negative mood symptoms in women with severe premenstrual symptoms

Second-Line Alternatives

1. Non-Hormonal Methods

   • Copper IUD (Cu-IUD)

     • Highly effective (0.8% failure rate) 3
     • No hormonal side effects that could affect mood
     • Long-acting (up to 10 years)

   • Barrier methods (condoms, diaphragms)

     • No hormonal effects on mood
     • Higher typical failure rates (14-20%) 3

2. Progestin-Only Methods (with caution)

   • Research suggests progestin-only methods may increase likelihood of mood disorders in some women 4
   • Consider only if combined methods are contraindicated
   • Options include:
     • Progestin-only pills
     • Implants
     • Injectable contraception (DMPA)

Decision-Making Algorithm

1. Assess severity of mood symptoms

   • If mild to moderate: Consider switching to vaginal ring or COC with different progestin
   • If severe (affecting daily functioning): Consider non-hormonal methods

2. Consider patient's contraceptive needs

   • Desire for high efficacy: Recommend vaginal ring or different COC formulation
   • Preference for non-daily method: Recommend vaginal ring
   • History of poor adherence: Recommend vaginal ring or LARC options

3. Evaluate other risk factors

   • Age >35 years + smoking: Avoid all combined hormonal methods 3
   • History of thrombosis: Avoid combined hormonal methods, consider non-hormonal options 3
   • Severe hypertension or cardiovascular risk: Avoid combined hormonal methods 5

Important Considerations

• Timing of mood symptoms: If symptoms occur primarily premenstrually, a COC with norgestimate might actually improve symptoms 2

• Previous contraceptive experience: Women with previous adverse hormonal contraceptive experiences may be more susceptible to mood side effects 6

• Monitoring: Any new contraceptive method should be evaluated after 1-3 months to assess for side effects and efficacy 1

• Non-contraceptive benefits: When switching methods, consider other benefits like reduced menstrual bleeding or improvement in acne 1

Caution

• Avoid abrupt discontinuation of current method without having a new method in place
• Counsel on the need for backup contraception during the transition period
• Be aware that approximately 4-10% of COC users report mood-related side effects regardless of formulation 6
• The LNG-IUD has been associated with psychiatric symptoms including depression in some studies and should be used with caution in patients with existing mood concerns 7

Summary

When addressing mood symptoms and anxiety related to Femme Tab 20/100, the vaginal ring or a COC with a different progestin composition (particularly norgestimate) offers the best balance of contraceptive efficacy while potentially reducing mood-related side effects. For patients with severe symptoms or contraindications to combined hormonal methods, non-hormonal options like the copper IUD provide excellent efficacy without hormonal mood effects.