• 100 Million worldwide ( WHO1998)
• NFHS II 1999, India
– 34% female sterilisation
– OC use 2.19%
– 30% girls have first child before age 19 years
Pearl index - 0.25 per HWYears
Failure rate - 0.3% to 8% ( Perfect versus Typical Use)
• dienogest a norethindrone-like structure that acts as an
• three 19-norprogesterone derivatives nestorone
(sitruk and ware 2006)
Speroff and decherny
Antigonadotrophic- inhibits ovulation
Inhibits endometrial proliferation- ↓ menstrual bleeding
Cervical mucus thickening
Promotes salt & water excretion: ↓ wt gain, bloating, BP,
mood changes, breast tenderness
Effective against acne & hirsutism
↑HDL & ↓ LDL Cholesterol
No androgenic action
No adverse effect on lipid or glucose tolerance
No wt gain/ acne/ oily skin
Does not ↓ SHBG, does not ↑ free androgen levels
EE 30 ug
Norgestrel 300 ug
EE 30 ug
Levonorgestrel 150 ug
EE 30 ug
Levonorgestrel 150 ug
EE 50 ug
Levonorgestrel 250 ug
EE 30 ug
Desogestrel 150 ug
EE 20 ug
Desogestrel 150 ug
EE 20 ug
Levonorgestrel 100 ug
EE 30 ug
Drospirenone 3 mg
GINNETE 35,KRIMSON 35,
Cyperoterone acetate 2mg
.05mg LNG/30 ug EE -5DAYS
.075mg LNG/40 ug EE-NEXT5 DAYS
.125mg LNG/30ug EE-LAST 10 DAYS
• Triphasic preparations have been shown to
reduce acne, decrease the incidence of
ectopic pregnancy, reduce menstrual blood
loss, and lower the frequency of irregular
bleeding and menorrhagia.
Extended regimen COC
Also reffered as menstrual suppression
Shorter hormone free interval , similar efficacy.
Decreased escape ovulation , decreased ovarian activity.
Decreased mid cycle break through bleeding.
• Decreased pelvic pain ,breast tenderness ,bloating , swelling.
• Useful in perimenopausal women with vasomotor symptoms
• Eg-seasonale,sesonique,(30ug EE/150ug LNG)for 84 days
Lybrel(20ug EE/90ug LNG)
• Comparision study shows similar efficacy and side effects with
decreased break through bleeding and intermenstrual
spotting (ALEXANDER T,2006)
benefits of extended use regimen
• Reduction in risk of ovarian and endometrial
• Relief of dysmenorrhea
• Prevention and treatment of menorrhagia
• Prevention and treatment of anemia in women
with bleeding diatheses
• Prevention and treatment of excessive bleeding
related to uterine leiomyoma or adenomyosis —
Somewomen with heavy menstrual bleeding
associated with leiomyomas respond to
• Treatment of pain related to endometriosis
• Prevention of menstrual migraine
• Management of symptoms related to
POTENTIAL BENEFITS OF COC
ACOG practical bulletin no 10
Menstrual cycle regularity
Treatment of acne
Treatment of dysmenorrhea
Treatment of hirsutism
Treatment of menorrhagia
Treatment of pelvic pain from endometriosis
Treatment of premenstrual syndrome
• Treatment of bleeding from leiomyoma
• Prevention of menstrual migraines
• Improved bone mineral density in older women
• Decreased risk of endometrial, ovarian, and
• Induction of amenorrhea for lifestyle considerations
• Most common menstrual disorder in 50-90% women.
• Due to prostaglandins PGF2ALPHA and PGE2 causing increase myometrial
• 80% decrease in symptoms in primary dysmenorrhea . (ACOG2005)
• Decreases severity in secondary dysmenorrhea of endometriosis
(haukesson et al)
can be used as FIRST LINE TREATMENT(1-A)
• 4 cross-sectional surveys-improvement in pain irrespective of
progestational component,estrogen dose,monophasic or multiphasic
pill.(lippinccott andwilkins 2007)
• Extended cycle regimens are better.(1-A).(ACOG 2005)
• Not FDA approved.
• 10% fertile women suffer from menorrhagia.
• Prescribe if no structural or histological abnormality is
present or fibroid>3 cm not distorting the cavity (NICE 07)
• Can be used as first line or second line drug specially in
women who want to preserve fetility .(ACOG 10)
• 50% decrease in symptoms with both high dose (nilson and
solvel 93) and low dose COC.(larsson et al,fraser and mc carron)
• Extended cycle regimen more effective (ACOG 10)
• Can be used in perimenopausal age group after proper
evaluation but comes after LNG-IUD(86% after 3 months
),TRANEXEMIC ACID in efficacy(A)
PRE MENSTRUAL SYNDROME
PRE MENSTRUAL DYSPHORIC
• Premenstrual symptoms,PMS,PMDD-same
spectrum with varying severity.
PMS is defined as ‘the cyclic recurrence in the luteal
phase of the menstrual cycle of a combination of
distressing physical, psychological and/or
behavioural changes of sufficient severity to
result in deterioration of interpersonal
relationships and/or interference with normal
activities’ (Reid and Yen, 1981).
• Considered to be the result of complex
interaction between ovarian steroids and central
neurotransmitters.(Neng/Jmed 1998) .
• 24/4 regimen of 30ug EE/3mg drospirenone is
effective in decreasing some physical effects like
bloating,breast tenderness,headache and some
psychological manifestations by its
minerelocorticoid activity and ovarian
POLYCYSTIC OVARIAN DISEASE
• Usually is the first line treatment
• Normalize androgen levels in 18-21 days
• Non androgenic OCP’s preferred
• Suitable for contraception
• Favorable effect on CHO and lipid metabolism
• Corrects menstrual cycle disturbances
incidence of anaemia
• Frequency of dysmenorrhoea & pelvic inflammatory disease will
in risk of endometrial and ovarian cancer
ROLE IN ACNE TREATMENT
• FDA approval to three preparation
• EE WITH
• Acts by decreasing the androgens level by GnRH
suppresion and increased SHBG.
• Used along with retenoids.
• 5 clinical trials-decreases lesion no. in mod to
ROLE IN HIRSUITISM
• OCP are first-line treatment for hirsutism,
particularly in those women desiring
• OCP with DROSPIRENONE(acts as androgen
blocker,decreased androgen production and
increase SHBG) CYPROTERONE ACETATE(anti
androgenic) are used.
• Long term use recommended(A)
• “symptom relief with COC is as good 6 months after
treatment is ended”
• ”contraceptive steroidal preparations must therefore be
considered drugs of choice and are currently the only safe
and economic alternative to surgery”
(The Royal College of Obstetricians and Gynaecologists, 2000).
• “COC reduces menstrual flow,cause
decidualisation,decrease cell proliferation and increase
MERESMAN GF 2002
Upto 70% relief in symptoms of endometriosis
Vercellini et al., 2003c
• OCP can be used as first line drugs along
with GnRH agonist and danazole.
• gives good symptom relief and helps to cure
the disease to some extent.(more in mild to
• Extended therapy is recommended..
• Ever use of the combined pill was associated with
a decreased risk of nonfollicular benign tumours,
including serous and mucinous adenoma,
teratoma and endometrioma (OR 0.79, 95% CI
0.6–1.05) (Westhoff et al., 2000).
• The reduction in risk was associated with
duration of use.
• combined oral contraceptives should not be
used to treat existing functional ovarian
• Can be given to prevent future cyst formation.
• BONE MINERAL DENSITY
• Beneficial effect in women above 40 yrs using COC for
more than 5 yrs (vessey m ’98)
• younger women who use combined oral
contraceptives have a lower BMD compared with
• Case-control studies have reported no effect or
reduced risk of leiomyomas in women who use
combined oral contraceptives.
• Can be used to control menstrual pain and flow.
• BENIGN BREAST DISEASE
• Includes mainly fibrocystic diesease and
• High-dose oral contraceptives may reduce the
risk of BBD (Burkman et al., 2004)
• Degree of risk reduction depends on duration
of use (7 yrs reduce by 40%)(ROHAN TE ‘99)
• Protects against ectopic pregnancy.
• Prevent menstrual migraine- used as
continuous prophylactic therapy
• Prevents progression of reumatoid arthritis
but not a protective factor (spector and
• Barriers are better for STD/HIV protection
• 50% reduction in PID with OC users versus
non-users of any method
– Effect on cervical mucus
– Preventing unwanted pregnancies
– Reducing unsafe abortions
• Ovarian Cancer
– 1.5 to 2 times less in pill users
– CASH Study : effect within 6 months, increased to 5 times
by 10 years use
chronic suppression of ovulation
chronic gonadotropin suppression
– COC with high progestin have greater protective affect
(schildkraut et al)
– Protective effect againsy BRCA MUTATION) also (ACOG 10)
– Ex-use effect last for 15 years
• Endometrial Cancer
– 50% less risk
– Effect even with 1 year use
– Ex-use effect lasts 15 years
CASH study N. Engl. J. Med 1987
- COLORECTAL CANCER
- 18% risk reduction ,more in recent users
Used in women with disabilities for
In perimenopausal women to control AUB.
Nowadays used for decreasing the frequency
of menstruation to increase quality of life.
Take home message……
ACOG RECOMMENDATIONS 2010
• The following recommendations are based on
good and consistent scientific evidence (Level A):
• Combined oral contraceptives (OCs) should not be used to treat
existing functional ovarian cysts.
• Use of combined hormonal contraception has been shown to
decrease the risk of endometrial and ovarian cancer.
• Combined OCs have been shown to regulate and reduce menstrual
bleeding, treat dysmenorrhea, reduce premenstrual dysphoric
disorder symptoms, and ameliorate acne.
• Continuous combined hormonal contraception, depot
medroxyprogesterone acetate (DMPA), and the levonorgestrel
intrauterine system may be considered for long-term menstrual
• The following recommendations are based
on limited or inconsistent scientific evidence
• Based on the limited data available, it appears
overall that combined OCs do not increase the
risk of development of uterine leiomyomas.
• Hormonal contraception should be considered
for the treatment of menorrhagia in women
who may desire further fertility.
• Grades of Evidence
I: Evidence obtained from at least one properly designed randomized controlled
II-1: Evidence obtained from well-designed controlled trials without
II-2: Evidence obtained from well-designed cohort or case–control analytic studies,
preferably from more than one center or research group.
II-3: Evidence obtained from multiple time series with or without the intervention.
Dramatic results in uncontrolled experiments also could be regarded as this type of
III: Opinions of respected authorities, based on clinical experience, descriptive
studies, or reports of expert committees.
• Levels of Recommendations
Level A —Recommendations are based on good and consistent scientific evidence.
Level B —Recommendations are based on limited or inconsistent scientific
Level C —Recommendations are based primarily on consensus and expert opinion.