Lecture Beni-Suef University

1. Hormonal Contraception
By Dr. Nesreen Abdelfattah Abdallah Shehata
Associate professor in Obstetrics and Gynecology
Faculty of Medicine - Beni-Suef University

2. Points to be considered:
 What is contraception?
 Types?
 Mechanisms of action.
 Complications.
 Contraindications
 Other indications for methods of contraception

3. Currently available reversible methods of
contraception fall into two broad categories,
hormonal and non-hormonal.

4. Combined? Hormonal? contraception
 Oral: combined oral contraceptive pill
(COCP)
Transdermal: contraceptive patch
Vaginal: combined contraceptive vaginal
ring

5. COCP
 Types of hormones in each pill:
--Ethinyl estradiol 20-50? μg. Most women now use the so-called ‘low-
dose’ pills containing 20–35 μg. Low-dose pills are potentially safer since
the cardiovascular risks of the pill are mainly due to oestrogen. The lowest
dose pill 15 μg is as effective as 30 μg but is associated with breakthrough
bleeding due to less endometrial control.
-- Progestogens used in currently available pills fall into three groups: first-
and second generation progestogens (e.g. norethisterone and
levonorgestrel), third-generation progestogens (gestodene, desogestrel
and norgestimate) and newer progestogens with anti-androgenic activity
such as drospirenone and dienogest.
Co-cyprindiol is a preparation containing ethinylestradiol in combination
with the anti-androgen cyproterone acetate, which is licensed for the
treatment of severe acne and hirsutism.

6. COCP
 Way of administration: Most combined pill preparations are taken for 21 days
followed by a 7-day break when withdrawal bleeding usually occurs.
 Preparations: Combined pills are available as monophasic preparations, in
which every pill in the packet contains the same dose of steroids, and as
biphasic, triphasic and, more recently, tetraphasic preparations in which the
dose of both steroids changes during the cycle.

7. Contraceptive Patch
 Only one contraceptive patch is currently available (20 cm2 in size) and it
delivers 20 μg ethinylestradiol and 150 μg norelgestromin daily.
 Each patch lasts 7 days, three patches being used consecutively with a patch-
free interval in week 4 when withdrawal bleeding occurs.
 The effectiveness is not significantly different from combined pills.

8. Vaginal Ring
 A combined contraceptive vaginal ring releasing 15 μg ethinylestradiol and 120
μg etonorgestrel daily .
 The ring is made of soft ethylene-vinyl-acetate copolymer, has an outer
diameter of 54 mm and a crosssectional diameter of 4 mm.
 Designed to last for 3 weeks, a 7-day ring-free interval.

9. Mode of Action
Combined Hormonal contraception

10.  The principal mode of action of combined hormonal contraception is inhibition
of ovulation.
 Oestrogen inhibits pituitary FSH, suppressing the development of ovarian
follicles, while progestogen inhibits the development of the LH surge.
 Additional contraceptive properties of combined hormonal contraceptives
include changes in characteristics of cervical mucus that interfere with sperm
transport, possible alteration in tubal motility, endometrial atrophy and impaired
uterine receptivity.

11. Contraindications
 World Health Organization developed a system addressing medical eligibility
criteria for contraceptive use in which the conditions are classified into one of
four categories.
 Category 1 includes conditions for which there is no restriction for use of the
method
 category 2 indicates that the method may generally be used but that more
careful follow-up is required.
 Category 3 conditions are those for which the risks of the method generally
outweigh the benefits (relatively contraindicated). Use the method only if there
is no acceptable alternative.
 category 4 includes conditions that represent an unacceptable health risk if the
contraceptive method is used (absolutely contraindicated).

12. Relative contraindications:
 Hypertension ˂ 160/100 or adequately
treated ˂140/90.
 Diabetes mellitus controlled.
 Smoking (even less than 15
cigarettes/day) and age 35 or over
Obesity (BMI ≥ 35 kg/m2).
 Migraine or past history.
 Breast cancer, with more than 5 years
without recurrence.
 Breast-feeding until 6 months post
partum
 Current or medically treated
gallbladder disease
 Family history of venous
thromboembolism in first-degree
relative under age of 45years
Absolute contraindications:
 Hypertension: systolic ≥ 160 mmHg or
diastolic ≥ 100 mmHg
 Diabetes with vascular disease or
nephropathy, retinopathy or
neuropathy
 Smoking ≥ 15 cigarettes/day and age
≥ 35 years.
 Migraine with aura
 Current breast cancer
 Breast-feeding < 6 weeks postpartum
 Acute viral hepatitis.
 Severe cirrhosis
 Benign or malignant liver tumours
 Current or history of deep vein
thrombosis/pulmonary embolism

13. Risks and side effects

14. Minor side effects:
 Combined hormonal contraception affects almost every system in the
body. Contraceptive steroids are metabolized by the liver and affect the
metabolism of carbohydrates, lipids, plasma proteins, amino acids,
vitamins and clotting factors.
 Fluid retention, nausea and vomiting, chloasma, mastalgia and breast
enlargement.
 All but chloasma (which gets worse with time) improve within 3–6
months.
 A different dose of oestrogen or type of progestogen or a different
delivery system may help if time alone does not solve the problem.

15. Serious side effects:
 Cardiovascular disease: The adverse effect on clotting is related to the dose
of oestrogen and, for pills, lower doses are theoretically associated with
reduced risk. There is a threefold to fivefold increase in the risk of venous
thromboembolism (VTE) associated with combined pill use. The risk is higher in
obese women.
 Malignant disease: Many studies showed that use of the combined pill was
associated with a small increase in the risk of breast cancer. The increased risk
persists for 10 years after stopping the pill. In a recent studies, women with
persistent infection with human papillomavirus (HPV) using hormonal
contraception (mainly combined) for more than 5 years had an increased risk of
cervical cancer.
 There is substantial evidence that the oral contraceptive pill protects
against ovarian, endometrial and colon cancer.
 Drug interactions: --A number of medicines (some anticonvulsants,
antifungals, antiretrovirals and antibiotics) induce liver cytochrome P450 and
will thus reduce the efficacy of low-dose hormonal contraception. – The use of
combined hormonal contraception increases the clearance of lamotrigine and
reduces serum levels of this drug. This increase seizures.

16. Progestogen-only contraception
Oral:Progestogen-only pills
Injectables: DMPA
Subdermal: Implant
Intrauterine:Mirena

17. A number of types of progestogen-only pills are
available. The older formulations contain a very low
dose of second-generation progestogen which does
not consistently inhibit ovulation. A newer pill contains
the third generation progestogen desogestrel at a
dose sufficient to inhibit ovulation in almost every
cycle.

18. Long-acting depot medroxyprogesterone acetate (DMPA) is given by deep
intramuscular injection, 150 mg every 12weeks. A new micronized
preparation of DMPA that is administered subcutaneously is licensed. This
micronized preparation is a lower dose (104 mg DMPA), but has the same
efficacy as the intramuscular preparation and is given at the same injection
intervals. Since it is administered subcutaneously, this affords the
possibility of self-administration.

19. The first contraceptive implant to become available was a
six-rod system known as Norplant® . The currently
available implant (Implanon®) is a single rod, containing
Desogestrel providing contraception for 3 years. The
implant is preloaded into a sterile disposable inserter and
is inserted subdermally on the inner aspect of the non-
dominant arm above the elbow. It is inserted and removed
using local anaesthetic.

20. The intrauterine system (Mirena®) has a T-shaped plastic frame with a reservoir
on the vertical stem containing 52 mg levonorgestrel releasing 20 μg/ day for at
least 5 years. The IUS is inserted and removed using the same procedures as
for copper IUD insertion.
The IUS is licensed for the management of heavy menstrual bleeding.

21. Mechanism of Action:
 The injectable, implant and desogestrel-containing progestogen-only pill inhibit
ovulation. Older progestogen-only pill formulations inhibit ovulation only
inconsistently.
 All progestogen only contraception, regardless of the route of administration,
affect cervical mucus, reducing sperm penetrability and transport, and all (but
particularly the IUS, which has little effect on ovarian activity but causes marked
endometrial atrophy) have an effect on the endometrium compromising
implantation if ovulation and fertilization occur.

22. Indications and contraindications
 Progestogen-only contraception is commonly prescribed for women in whom
oestrogen is absolutely or relatively contraindicated, for example women with
cardiovascular disease, migraine, diabetes or mild hypertension.
 Breast-feeding women are advised to use progestogen only methods since
oestrogen impairs milk production.
 There are few contraindications to use of progestogen only methods. A history
of breast cancer (within last 5 years) is category 4 and postpartum sepsis or
septic abortion (IUS method only).

23. Side effects:
 Bleeding disturbances: High levels of irregular vaginal bleeding? in pills and
implants. This is due partly to their effect on ovarian function. In the normal
cycle, ovulation determines regular menstruation. Inconsistent ovulation and
fluctuating endogenous oestrogen production from irregular follicle growth lead
to irregular bleeding. However, there is also evidence to suggest that
progestogen-only methods directly affect the vasculature of the endometrium,
increasing the chance of bleeding.
 Headache, nausea, bloating, breast tenderness and weight and mood change.
 Oily skin and acne can be a problem, particularly with the more androgenic
progestogens levonorgestrel and norethisterone.
 Bone mineral density: Reduction due to complete inhibition of ovulation by
DMPA injection leading to hypoestrogenism and amenorrhea.

24. Other indications of hormonal contraceptive
methods:
 The commonest benefit of hormonal methods is an improvement in menstrual
bleeding patterns (including amenorrhoea).
 Hirsutism
 Endometriosis

25. Thank you