This document summarizes information about combined oral contraceptive pills (COCPs). It discusses their contraceptive effects through progesterone prevention of ovulation and estrogen inhibition of follicular development. It also lists their non-contraceptive benefits such as reduced cancer risks. The document describes different COCP preparations including estrogen and progestin components and monophasic, biphasic, triphasic and quadriphasic formulations. It provides information on why 21 or 24 day preparations are used and discusses the progestins drospirenone and cyproterone acetate.

1. COCP
Dr.Kavinda Hewawitharana

2. Contraceptive effect
• Progesterone is primarily responsible for preventing pregnancy
• main mechanism of action is the prevention of ovulation
• inhibit follicular development and prevent ovulation
• Estrogen has some effect with inhibiting follicular development
• its negative feedback on the anterior pituitary with slowed FSH
secretion
• not as prominent as the progesterone’s effect

3. Non-contraceptive benifits
• Reduce risk of colonic CA
• ‘’ ‘’ ovarian CA
• ‘’ ‘’ endometrial CA
• Reduce benign breast disease
• Reduce benign ovarian cysts
• Reduce benign uterine mass
• ‘’ HMB
• ‘’ Dysmenorrhoea
• ‘’ PMS
• ‘’ Hirsutism

4. Preparations
• usual estrogen component is combined with a different generation of
progestin components with varying degrees of androgenic and
progestogenic potential
• prescribed based on desirable effects and risk of adverse events with
progestin component and dose of estrogen and progestin
component.
• Currently drugs have setup to minimum dose of estrogen with its
maximal effect to avoid side effects

5. • Estrogen component: Estradiol, Ethinylestradiol, or Estetrol
• First-generation progestin: Norethindrone acetate, Ethynodiol diacetate,
Lynestrenol, Norethynodrel
• Second generation progestin: Levonorgestrel,dl-Norgestrel
• Third generation progestin: Norgestimate, Gestodene, Desogestrel
• Fourth generation progestin: Drospirenone, Cyproterone acetate

6. Phasic preparations-Monophasic
• Monophasic birth control pills have the same amount of estrogen and
progestin in each active pill
• less likely to cause side effects that could result from fluctuating
hormones
• This is the most common type

7. Phasic preparations-Biphasic preparations
• Biphasic birth control pills change the level of hormones one time
during the pill pack
• deliver the same amount of estrogen each day, but the level of
progestin is increased about halfway through the pill cycle.
• During the first half of the cycle, the progestin/estrogen ratio is
usually lower.
• During the second half of the cycle, the progestin/estrogen ratio
tends to be higher

8. Phasic preparations-Triphasic preparations
• contain three different doses of hormones
• hormone combination changes approximately every seven days
throughout the pill pack.
• the amount of estrogen may change as well as the amount of
progestin
• no evidence-based advantage over monophasic pills in relation to
their adverse effect profile or cycle control

9. Phasic preparations-Quadriphasic OCP
• contains oestradiol valerate and desogestrel
• is formulated with an oestrogen step-down and progestogen step-up
sequence

10. Why we need phasic pills?
• Lower the total hormone dosage you may receive in each pill pack.
• They are also designed to more naturally mimic your body's
menstrual cycle
• But should not messed up with pills-each dose changed tablet has
different colour and should follow those in a row , otherwise not
effective

11. Why day 21 or 24 preparations?
• Some COCP has active 21 pills while others have 24
• Why 24?not 21
• reduce the chance of contraceptive failure
• ‘’ ‘’ breakthrough ovulation
• delay or avoid a withdrawal bleeding
• This is most easily achieved with monophasic regimens in which each active pill
contains the same amount of oestrogen and progestogen and the inactive pills
are skipped
• But now there are commercial preparations/formulations for this task with better
progesterone forms

12. Drospirenone
• 4th genereation progestogen
• Anti-mineralocorticoid activity(3 mg drospirenone has comparable
anti-mineralocorticoid activity as 25 mg dose of spironolactone)
• Anti-androgenic
• no negative metabolic effects on women with PCOS, and some
studies reported favorable metabolic effects

13. Cyproterone ; how about this?
• has high antiandrogenic activity
• controversy remains regarding whether CPA has a transiently negative
effect on carbohydrate metabolism and lipid profiles
• Unlike drospirenone – no anti-mineralocorticoid effect as former

14. Comparison of CYP and DPN
• Cyproterone acetate and drospirenone containing OCs have similar
effects regarding carbohydrate/lipid metabolism and oxidative stress
parameters.
• Cyproterone acetate containing OCs seem to be more effective to
treat clinical hirsutism in patients with PCOS after 12 months of
treatment
• Both drugs have adrenal influence which is more prominent with
drospirenone containing OCs.

15. Which one we select?
• 21 or 24
• Cyp or Dpn
• Monophasic or polyphasic
• Open for discussion………………