2. 2
Desired Outcome ofDesired Outcome of
contraception:contraception:
• prevent pregnancy
• improvements in certain health
conditions (OCs)
• management of perimenopause.
• improvements in menstrual cycle
regularity (hormonal)
3. CompositionsCompositions
• Hormonal contraceptives contain either a
combination of synthetic estrogen and
synthetic progestin or a progestin alone.
How they work?
• Progestins thicken cervical mucus, delay
sperm transport, and induce endometrial
atrophy. They also block the LH surge and
thus inhibit ovulation.
• Estrogens suppress FSH release, which may
contribute to blocking the LH surge (an acute rise of LH ),
and also stabilizes the endometrial lining and
provides cycle control.
3
4. 4
components of hormonal contraceptivescomponents of hormonal contraceptives
Estrogens:
• ethinyl estradiol (EE) and mestranol
• Mestranol → liver → EE to be active.
• 50% less potent than EE.
• doses of 20 to 50 mcg of EE.
Progestins:
• They are different in their:
• progestational activity
• Their inherent estrogenic , antiestrogenic , androgenic effects.
• Their estrogenic and antiestrogenic properties occur because
progestins are metabolized to estrogenic substances.
• Androgenic properties occur because of the structural
similarity of the progestin to testosterone.
5. • The recommendation of the American
College of Obstetricians and
Gynecologists is to allow provision of
hormonal contraception after a simple
medical history and blood pressure
measurement
5
6. 6
noncontraceptive benefits of oral contraceptivesnoncontraceptive benefits of oral contraceptives::
• decreased menstrual blood loss.
• improvement of menstrual irregularity.
• Decrease ovulatory pain
• Decrease the risk ovarian & endometrial
cancer.
• Decreased the occurrence of ectopic
pregnancy.
• decreased menstrual cramps .
• Decreased iron deficiency anemia from
period.
• Decreased risk endometriosis, uterine
fibroids, benign breast disease.
13. 13
Women Older Than 35 Years:Women Older Than 35 Years:
• Recommended: use (less than 50 mcg of
estrogen) in healthy nonsmoking women.
• Women over 35 years who smoke and take OCs
have an increased risk of MI; therefore, clinicians
should prescribe CHCs with caution, if at all, in
these patients.
• The WHO states that smoking 15 or more cigarettes
per day by women over 35 years is a contraindication to
the use of CHCs, and that the risks generally outweigh
the benefits even in those who smoke fewer than 15
cigarettes per day.
• Progestin-only contraceptive methods should be
considered for women in this group.
• Women older 35 yrs with migraine, HTN,
DM(1&2),dyslipidemia and current smoker should not take
CHCs.
14. • CHC may increase or decrease the
frequency of migraine.
• However CHCs may be considered for
healthy, non-smoker women, with migraine
that is only without aura.
• BUT not with aura.
• OCs can be used women with stable SLE
and without antiphospholipid antibodies.
• CHCs should be avoided women with
SLE ,antiphospholipid antibodies and or
vascular complication. Progestin-only
contraceptives can be used with those
patient.
14
15. Breast cancerBreast cancer
• CHCs choice should not be affected
by the presence of benign breast
disease or a family history of breast
cancer with either mutation.
• women with recent personal
history of breast cancer should not
use CHCs, but that CHCs can be
considered in women without
evidence of disease for 5 years.
15
16. ThromboembolismThromboembolism
• Estrogens have a dose-related
effect in the development VTE and
PE.
• This is especially true inwomen with
underlying hypercoagulable states or
who have acquired conditions(e.g.,
obesity, pregnancy, immobility,
trauma, surgery, and
certainmalignancies.)
16
18. General considerations for Ocs.General considerations for Ocs.
• >99% of efficacy with perfect use.
• Up to 8% of unintended
pregnancy with typical use.
• Monophasic OCs contain the same
amounts of estrogen and progestin for 21
days, followed by 7 days of placebo.
• Biphasic and triphasic pills contain
variable amounts of estrogen and
progestin for 21 days and are followed by
a 7-day placebo phase.
18
19. General considerations for Ocs.General considerations for Ocs.
extended-cycle OC:
• ↑ hormone-containing pills from 21 to 84 days 7-
day placebo phase,only 4 menstrual cycles/ year.
• One product provides hormone-containing pills
daily throughout the year.
Continuous combination regimens:
• OCs for 21 days, then very-low-dose estrogen and
progestin for an additional 4 to
7 days(at usual placebo time).
19
20. third-generation OCs:
OCs containing newer progestins:
• Desogestrel
• Drospirenone
• Gestodene
• Norgestimate
• These progestins:
• potent progestational agents
• have no estrogenic effects
• less androgenic compared with levonorgestrel
on a weight basis
• improved side-effect profiles, as improving mild to
moderate acne.
Drospirenone:
• antimineralocorticoid and antialdosterone activities
• result in less weight gain compared to use of OCs 20
21. Progestin-only minipillsProgestin-only minipills
• 28 days of active hormone per cycle
• less effective than combination OCs
• irregular and unpredictable menstrual
bleeding
• must be taken every day of the menstrual
cycle at approximately the same time.
• If taken more than 3 hours late backup
method of contraception for 48 hours.
• ectopic pregnancy is high because it does
not block ovulation.
21
22. Initiating an Oral Contraceptive:Initiating an Oral Contraceptive:
different methods:
• on the first day of bleeding
during the menstrual cycle.
• on the first Sunday after the
menstrual cycle begins.
• on the fifth day after the
menstrual cycle begins.
22
23. quick start" method:quick start" method:
• patient takes the first tablet on the
first day of her office visit.
• use a second method of
contraception for at least 7 days
• the menstrual period will be
delayed until completion of the
active tablets in the current OC
pack.
23
24. Choice of OCsChoice of OCs
• choice is based on:
• the hormonal content and dose
• preferred formulation
• coexisting medical conditions
• In women without coexisting medical
conditions, an OC containing 35mcg
or less of EE and less than 0.5 mg of
norethindrone is recommended.
24
25. 20 to25mcg20 to25mcg
• Adolescents, underweight
women<50kg. women >35years, and
those who are perimenopausal may
have fewer S/E with this dose.
• However, they are associated with
more breakthrough bleeding and an
increased risk of contraceptive failure
if doses are missed.
Overweight and obese women:
• higher contraceptive failure rates with low dose OCs
• benefit from pills containing at least 35 mcg of EE.
25
26. Who uses progestin only Ocs?Who uses progestin only Ocs?
• cerebrovascular disease
• SLE with vascular disease
• history of estrogen dependent cancer
• smokers over the age of 35
• postpartum and/or breastfeeding
• migraine headaches
• history of VTE
• cardiovascular disease
26
27. Managing Side EffectsManaging Side Effects
Many symptoms occurring in the
first cycle of OC use (e.g.,
breakthrough bleeding, nausea,
bloating), improve by the second or
third cycle of use.
Warning signs
•Women should be instructed to immediately
discontinue CHCs if they experience warning
signs often called ACHES (abdominal pain,
chest pain, headaches, eye problems, and
severe leg pain). 27
29. Managing Oral Contraceptive Drug Interactions:Managing Oral Contraceptive Drug Interactions:
• Use additional method
Rifampin:
• risk of OC failure
• additional nonhormonal contraceptive agent during rifampin
therapy.
if breakthrough bleeding during concomitant use of
antibiotics and OCs:
• use an alternate method of contraception during the period
of concomitantuse.
anticonvulsants: reduce efficacy
phenobarbital,cabamezapine,and phenytoin.
• another form of contraception such as:
• IUDs
• injectable medroxyprogesterone
• Implants.
• nonhormonal options.
29
30. d/cd/c
• The average delay in ovulation
after d/c OCs is 1 to 2 weeks.
• allow 2 to 3 normal menstrual
periods before becoming
pregnant
30
