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Home Gynecology and Obstetrics

Hormonal Contraceptives

Dr.Galal Baligh by Dr.Galal Baligh
June 19, 2020
in Gynecology and Obstetrics
233 5
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Hormonal Contraceptives

Hormonal Contraceptives

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Contents hide
1 A- Combined Hormonal Contraceptives:
1.1 * Contraindications:
1.2 * Advantages:
1.3 * Disadvantages; (complications and side effects)
1.3.1 A. Menstrual complications:
1.3.2 B. Vascular complications:
1.3.3 C. Metabolic complications:
1.3.4 D. Anticosmetic effects:
1.3.5 E. Other complications:
1.4 * Variables:
1.4.1 A1: Combined Oral Contraceptives;
1.5 * Brands:
1.5.1 A2: Combined Contraceptive Injections;
1.6 * Brands:
1.6.1 A3: Combined Transdermal Hormonal Contraceptive;
1.6.2 A3: Combined Hormonal Vaginal Ring;
2 B- Progestin- Only Contraceptives;
2.1 * Indications:
2.2 * Contraindications:
2.3 * Advantages:
2.4 • Non contraceptive uses;
2.5 * Disadvantages:
2.6 * Variables:
2.6.1 B1: Progestin-only Pills;
2.6.2 B2: Progestin-only Injectable;
2.7 * Brands;
2.8 * Administrations;
2.8.1 B3: Progestin-only Implants;
2.8.2 B4: Progestin-Releasing IUS:
3 Hormonal Contraceptives PPT(power point presentations):
4 Hormonal contraceptives videos:
4.1 Menstrual Cycle & Oral Contraceptives video

• 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.

Hormonal Contraceptives
Hormonal Contraceptives

* Contraindications:

– 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.

Hormonal Contraceptives
Hormonal Contraceptives

 

* Advantages:

* 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:

* Spotting;

• 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).

3- Amenorrhea;

• 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.

2- Hypertension:

– 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.

2- Metabolism:

– 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

* Variables:

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.

* Brands:

* Monophasic pills;

• Each packet containing 21 active pills.

• Each tablet contains estrogen and progestogen.

• Monophasic pills are associated with less breakthrough bleeding.

Hormonal Contraceptives
Hormonal Contraceptives

• According the estrogen dose they are classified into:

* Biphasic pills;

• Administration as dual dose pills.

* Triphasic pills;

• Administration as triple dose pills.

* Administration:

• 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.

Hormonal Contraceptives
Hormonal Contraceptives

• Remember;

* Drug interaction.

Hormonal Contraceptives
Hormonal Contraceptives

* 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.

* Brands:

– Cyclofem is made up of estradiol cypionate & medroxyprogesterone.

– Mesigyna is made up of estradiol valerate and norethisterone enanthate.

* Administration:

– 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.

* Brands;

– The contraceptive patch contains norgestimate (progestin) and ethinyl estradiol and works in the same way as COCs.

* Administrations;

– It is applied weekly to any body location (other than the breast) for 3 weeks, followed by a patch-free withdrawal bleeding week.

Hormonal Contraceptives
Hormonal Contraceptives

* 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.

* Brands;

– This flexible ring, 5 cm diameter and 4 mm thickness, releases ethinyl estradiol and etonogestrel (progestin).

* Administrations;

– 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.

* Indications:

• 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.

* Contraindications:

Hormonal Contraceptives
Hormonal Contraceptives

* Advantages:

♦ ♦♦ ♦ 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.

* Disadvantages:

♦ ♦♦ ♦ 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).

* Variables: 

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).

* Brands;

– 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.

Hormonal Contraceptives
Hormonal Contraceptives

* Administrations;

Hormonal Contraceptives
Hormonal Contraceptives

* 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.
– Amenorrhea,

– 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.

* Brands:

– 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).

* Administrations;

– 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

Hormonal Contraceptives
Hormonal Contraceptives

B4: Progestin-Releasing IUS:

• Mirena-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

Tags: ContraceptionInfertility
Dr.Galal Baligh

Dr.Galal Baligh

OB-GYN Specialist

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