• Hormonal contraceptives are among the safest & most effective medications prescribed.
• Hormonal contraceptives all include a progestin that prevents pregnancy by;
– Suppressing ovulation (inhibiting release of LH/FSH from the pituitary.
– Thickening the cervical mucus, and
– Altering the endometrium.
• Either combined (estrogen and progesterone) or progestin-only forms are available.
– Combined methods include the pill, patch, and vaginal ring.
– Progestin-only methods include the mini-pill, injection, patch, implant, and progesterone-containing IUD.
A- Combined Hormonal Contraceptives:
• These are preparations of synthetic progestin and estrogen.
• Progestin performs the majority of the contraceptive effect,
• Estrogen is added only to maintain the stability of the endometrium (and minor contribution to ovulation inhibition).
• Estrogen component is responsible for, – Monthly withdrawal bleeding and decreased irregular vaginal bleeding. – Majority of the medical risks associated with combined contraceptive use.
– The WHO Medical Eligibility Criteria for Contraceptive Use can be consulted when weighing the risks associated with estrogen-containing hormonal contraception (e.g., pill, patch, and ring) provision to patients.
* Combined contraceptives are the most reliable methods.
– They are Available, cheap, and effective (the failure rate is about 0.1-1 /HWY).
– Reversible methods, can be discontinued easily.
– They are not related to and not affect sexual act.
– Combined contraceptives decrease the incidence of;
– Epithelial ovarian tumors, – Salpingitis due to the viscid cervical mucus.
– Endometrial carcinoma, and – Endometriosis.
* Non-contraceptive uses:
– Menstrual related conditions;
– Postpone menstruation.
– Irregular menstruation and DUB.
– Spasmodic dysmenorrhea.
– Lactation related;
– Can suppress lactation (risk of DVT).
– Medical conditions;
– Endometriosis and hirsutism.
* Disadvantages; (complications and side effects)
A. Menstrual complications:
1- Vaginal bleeding:
• Minimal bleeding although pills taken regularly.
• Double the dose during this cycle and next cycles.
* Break through bleeding: • Heavy bleeding like menses during the course of pills.
2- Hypomenorrhea; 2ry to endometrial atrophy (Progestogen effect).
• First you have to exclude possibility of pregnancy.
• Shearman syndrome (post pill amenorrhea),
– Missed periods for more than 3 cycles after pills stoppage.
– Caused by persistent suppression of the hypothalamus or secondary to hyperprolactinemia.
– Treated by clomiphene and/or Bromocriptine.
B. Vascular complications:
1- Thrombo- embolism:
– Due to increased fibrinogen and factors VII, IX and X.
– Mainly related to estrogen,
– Recent studies referred that Gestodene and Desogestrel containing medications can cause TED twofold more than medications containing Levonorgestrel and Norethindrone.
– Salt and water retention together with increased rennin are the main causes.
– Risk is increased with longer duration of use and also with older age.
3- Coronary heart diseases:
– Increased level of triglycerides and low-density lipoprotein (LDL).
– The risk is increased in hypertensive women and smokers.
4- Cerebrovascular disease:
– A small increased risk of hemorrhagic stroke and subarachnoid hemorrhage and a somewhat greater increased risk of thrombotic stroke has been found.
– Smoking, hypertension, and age over 35 years are associated with increased risk.
– Women who develop warning symptoms such as headache, blurred or lost vision, or other transient neurologic disorders should shift to another method of contraception.
C. Metabolic complications:
1- The liver:
– Liver functions may undergo impairment (slight and transient).
– Cholestasis may be complicated with gall stones.
– Decrease in glucose tolerance may result in diabetes mellitus.
– Increase in triglyceride levels.
3- Breast milk:
– Quality and quantity of milk are affected due to block of PRL receptors.
D. Anticosmetic effects:
1. Pigmentation in face and other body parts e.g. Chloasma.
2. Acne appear as a complication of progestogen content.
3. Breast manifestations e.g. engorged and tender breast.
4. Weight gain due to salt and water retention.
E. Other complications:
1. Estrogen related:
– Headache, mastalgia, and telangectasia
– Nausea and vomiting, 2ry to gastric irritation.
– Leucorrhea 2ry to cervical erosion and monilial vaginitis.
2. Progestin related:
– Mood changes and depression.
– Fatigue and mild weight gain,
– Libido decrease
A1: Combined Oral Contraceptives;
• Also referred to as “The pill” or “COCs”.
• COCs are highly effective but require the patient to remember pills daily. Failure rate increases if pills are missed.
• Three weeks of active hormones are followed by 1 week of placebo. During the week off active pills, withdrawal bleeding will occur.
* Monophasic pills;
• Each packet containing 21 active pills.
• Each tablet contains estrogen and progestogen.
• Monophasic pills are associated with less breakthrough bleeding.
• According the estrogen dose they are classified into:
* Biphasic pills;
• Administration as dual dose pills.
* Triphasic pills;
• Administration as triple dose pills.
• First pill preferred to be at 5th day of menstruation.
• Continue to take pills daily till the strip (21 pills) consumed.
• Followed by one week off during which withdrawal bleeding allowed.
• Start the next strip also at 5th day of withdrawal bleeding.
* Drug interaction.
* Spotting, irregular menses, and nausea are common with initiation of pills and generally resolve within the first 1 to 3 months.
* Additional advantages of pills;
• COCs may be used to manage dysmenorrhea, menorrhagia, metrorrhagia, premenstrual symptoms, and mild acne.
• COCs decreases the risk of ovarian and uterine cancer.
A2: Combined Contraceptive Injections;
• Combined contraceptive injections contain a combination of estrogen and progestin and must be injected once a month.
• Similar to combination birth control pills, these injections combine synthetic estrogen and progestin.
• After each shot, hormonal levels peak & gradually ↓ until next injection.
– Cyclofem is made up of estradiol cypionate & medroxyprogesterone.
– Mesigyna is made up of estradiol valerate and norethisterone enanthate.
– Shots are injected into the muscle of the upper arm, thigh, or buttocks.
– This method of birth control must be administered every 28 to 30 days (and must not exceed 33 days following the date of the previous injection).
– Managing late injections;
* If she is < 7 days late for a repeat injection,
– She can receive her next injection.
– No need for tests, evaluation, or a backup method.
* If she is > 7 days late with no possibility of pregnancy,
– She can receive her next injection.
– With a backup method for the next 7 days after injection.
* If she is > 7 days late with possibility of pregnancy,
– She can not receive her next injection.
– She have to exclude possibility of pregnancy at first.
* Additional advantages:
– Administered once monthly (not need to be minded daily).
– Reversible with rapid return to fertility.
– Safe and highly effective (> than 99%).
– Less Menstrual disturbances (less than Progestin only injections).
* Additional disadvantages:
– Estrogen related side effects, e.g. Nausea, Vomiting, and Headache.
– Not protect against STDs.
– Irregularities of menstruation (minimal).
A3: Combined Transdermal Hormonal Contraceptive;
• Also referred to as Ortho Evra.
– The contraceptive patch contains norgestimate (progestin) and ethinyl estradiol and works in the same way as COCs.
– It is applied weekly to any body location (other than the breast) for 3 weeks, followed by a patch-free withdrawal bleeding week.
* Additional advantages;
– Weekly use may increase compliance over the daily dosing of COCs.
– Transdermal delivery avoids hepatic first-pass metabolic effects.
– Maintains steady serum hormone levels without the peaks and troughs seen with pills.
* Additional disadvantages;
– Local adhesive reactions to the patch are rare (<5%), and adhesion is reliable.
– The patch is less effective in women who weigh >90 kg.
– Controversy about its VTE effect versus pills.
– The patch provides approximately 60% more total estrogen than a typical birth control pill containing 35 µg ethinyl estradiol.
– The daily peak in estrogen is approximately 25% less with the patch compared to pills.
A3: Combined Hormonal Vaginal Ring;
• Also referred to as Nuva Ring.
– This flexible ring, 5 cm diameter and 4 mm thickness, releases ethinyl estradiol and etonogestrel (progestin).
– It is placed in the vagina for 3 weeks, then removed for 1 week, during which withdrawal bleeding occurs.
– The ring may be removed for up to 3 hr, including during intercourse.
– If the ring is out of the vagina for >3 hr, backup contraception should be used until the ring has been back in place for 7 days.
* Additional advantages;
– Patients report increased satisfaction and compliance and a lower incidence of side effects and breakthrough bleeding than COCs and the patch.
– The lowest, steady-state hormonal level of estrogen is achieved with the ring, compared to the patch and COCs. – May decrease vaginal yeast and bacterial infections due to local estrogen effect;
* Additional disadvantages;
– Coital problems and expulsion of the device are rare.
– May increase leucorrhea.
B- Progestin- Only Contraceptives;
• These are synthetic progestin preparations that prevent pregnancy without the use of estrogen; therefore, they can be used in many women with contraindications to combined contraceptive use (e.g., history of thromboembolic disease).
• Used mainly in breast-feeding women without causing a ↓ in breast milk production.
• Bleeding patterns with progestin-only methods are more variable.
• Breast-feeding women.
– It does not affect the milk supply.
– Breast-feeding further reduces the chance of pregnancy.
• Women cannot take estrogen, e.g.
– Smoker and are older than 35.
– Hypertensive women, small to moderate.
– Women with heart disease.
– Long-standing, poorly controlled diabetes.
– Women with thromboembolic disorders.
– Migraine headaches with auras, that can’t tolerate estrogen in COCs.
• Heavy, painful menstrual periods. Progestin reduces heavy bleeding and cramping.
• Have anemia from heavy menstrual bleeding.
• Have sickle cell disease, studies proved that shots can decrease sickle cell crisis.
♦ ♦♦ ♦ Available and highly Effective (> 99%).
♦ ♦♦ ♦ It avoids side effects of estrogen.
♦ ♦♦ ♦ No inhibition of lactation so it is could be used in lactating women.
♦ ♦♦ ♦ Women prefer a form of birth control that does not interfere with sexual act.
♦ ♦♦ ♦ Suitable for short
– or long-term birth control.
– It can be stopped at any time.
– Shots may delay fertility from 12 weeks to 18 months.
• Non contraceptive uses;
– Decrease risk of ovarian cancer (controversy).
– Offer some protection against endometrial cancer.
– Decrease menorrhagia and associated anemia.
– Decrease symptoms of endometriosis.
– Decrease cramps. – Shrink size of fibroids.
– Reduce the risk of pelvic inflammatory disease (PID).
– Some studies reported decrease vaginal yeast infection (moniliasis).
– Reduced frequency and severity of sickle cell crises.
♦ ♦♦ ♦ Most side effects of the progestin-only birth control methods go away after the first few months of use. Side effects include:
• Irregular menstrual cycles.
• Spotting or bleeding between menstrual periods.
• Amenorrhea, mainly due to endometrial atrophy.
• Breasts tenderness.
• Headache and dizziness.
• Nausea. • Weight gain, especially with the birth control shot.
♦ ♦♦ ♦ Less commonly progestin side effects include depression and chloasma (skin pigmentation over upper lip, under the eyes, or on the forehead).
B1: Progestin-only Pills;
♦ ♦♦ ♦ Also, referred to as; Birth control mini-pills, Micronor, Ovrette.
♦ ♦♦ ♦ Lower doses of progestin (Norethindrone) than COCs.
♦ ♦♦ ♦ Taken daily with no hormone-free interval.
♦ ♦♦ ♦ Must be taken at the same time each day.
♦ ♦♦ ♦ More than 3 hr (WHY?!!) of delay should be considered a missed pill, and so,
– Take a pill as soon as she remember.
– Use another backup method for the next 48 h.
– If she have had sex in the past 5 days, consider emergency contraception.
B2: Progestin-only Injectable;
♦ ♦♦ ♦ Also, referred to as; Depo Provera.
♦ ♦♦ ♦ Progestin-only injectables contain a progestin like the natural hormone progesterone, two types: medroxyprogesterone acetate (DMPA) and norethisterone enanthate (NET-EN).
– DMPA, the most widely used, also known as the shot, Depo-Provera, Depo, Megestron, and Petogen.
– NET-EN is also known as norethindrone enanthate, and Noristerat.
* Additional advantages;
– DMPA decrease sickle cell crises and improve anemia.
– DMPA may increase seizure threshold and can therefore be recommended to patients with a history of seizure disorder.
* Additional disadvantages;
– Menometrorrhagia is common after the first injection.
– 50% of women after the first year,
– 80% after 5 years.
– Delayed return of fertility up to 18 months is possible.
– Weight gain; overall 5 to 8 pounds/year (compared to 5 pounds/year COCs).
– Hair loss in some patients with DMPA has been reported.
– DMPA may decrease bone mineral density (BMD), especially in adolescents, (reversible).
B3: Progestin-only Implants;
♦ ♦♦ ♦ Also, referred to as; Implanon.
– The only implant currently available in the United States is Implanon.
– A 5-year (two-rod) implant (Jadelle) is approved for use.
– The prior implant used, Norplant, had multiple rods (six).
– Implanon; a single rod, 4 cm × 2 mm (size of a match), releases etonogestrel for 3 years.
– It is placed under the skin of the upper (usually non dominant) arm and injected from a preloaded syringe.
– An experienced clinician must perform the insertion and removal process.
– However, if the implant is inserted during the first five days of a woman’s period, she is protected for that cycle and beyond.
– If a woman receives an implant outside the first five days of her period, she should use a backup method of contraception for the following week after insertion to prevent pregnancy.
* Special advantages:
• Effective; Most effective form of birth control (Failure rate is 0.05%).
• Rapid acting; Works quickly after insertion
• Long acting; Works for up to 3 years (4 years off-label)
• Reversible; Fertility returns quickly after removal (Ovulation starts six weeks after removal)
• Does not contain estrogen • Does not related to sexual act.
• 20% women have no more periods while using it.
* Special disadvantages:
• Irregular menstrual bleeding or spotting
• Pain or scarring at insertion site
• Possible small increase in weight
• Headache, acne, ovarian cysts, or change in mood can possibly occur
* Special contraindications:
• Women should not use Implanon if they Are, or think they are
, – Pregnant
– Are allergic to etonorgestrel
– Have a history of breast cancer
– Have vaginal bleeding that has not been explained
– Are breastfeeding in the first 6 weeks postpartum (Why?!!)
– Have severe liver disease
B4: Progestin-Releasing IUS:
• See IUDs, before.
Hormonal Contraceptives PPT(power point presentations):
Hormonal contraceptives videos:
Menstrual Cycle & Oral Contraceptives video
How Birth Control Pills Work, Animation video