This document discusses combined oral contraceptives (COCs), also known as birth control pills. It provides details on the history, mechanisms of action, types, effectiveness and side effects of COCs. It notes that COCs were first approved for use in the 1960s and are now used by over 100 million women worldwide. The document also discusses newer male and female contraceptive methods that are still being researched or tested.

1. Combined Oral
Contraceptives
Dr Shashwat K. Jani.
M.S. ( Gynec )
Diploma in Endoscopy.
Assistant Professor, Smt. N.H.L. Medical College.
Sheth V. S. General Hospital, Ahmedabad.
( M ) : 99099 44160.
E- mail : drshashwatjani@gmail.com

2. Introduction
 World’s population expected to reach 9 billion by 2050.
 India accounts for 18% of World’s population… !!!
 Annually, 529,000 maternal deaths & 50 million
morbidity.
 In India, contraceptive prevalence is 48.3% .
 21% of all pregnancies resulting live births are
unplanned….!!!
 If unmet need for contraception was met, we can avoid
52 million unwanted pregnancies
25-50% of maternal deaths
( Hindin MJ, Lancet. 2007;370:1297-8 )
Dr Shashwat Jani. 9909944160 2

3. Dr Shashwat Jani. 9909944160 3

4. Dr Shashwat Jani. 9909944160 4

5.  1st Clinical trials of COC were
described by John Charles Rock &
Goodwin Pincus with approval of
marketing in USA in 1960.
Within 5 years it was used by 30
millions women all over the world.
At the moment , COC is used by over
100 million women worldwide.
Dr Shashwat Jani. 9909944160 5

6. Combined Oral Contraceptives ( COC )
 Commonly known as the “ Pill “
Widely Accepted & Most Effective
Reversible method of Fertility Control.
 In 1951, India was the 1st country in
world to introduce COC in National
programme of Family Planning.
Dr Shashwat Jani. 9909944160 6

7. COC : Estrogen + Progestogen
 Estrogen :
2 types : - Ethinyl Estradiol ( EE )
- Mestranol ( Not used )
Dr Shashwat Jani. 9909944160 7

8. PROGESTOGENS :
( 4 Groups )
1 ) Norethisterone Group : ( 1st generation Pills )
Moderate Androgenic property ….
Norethisterone,
Norethisterone Acetate ,
Ethiynoidal diacetate ,
Lynestrenol
2 ) Norgestrel : ( 2nd generation pills )
Strong Progestogenic & Androgenic property….
Dr Shashwat Jani. 9909944160 8

9. 3 ) 19 – nor testosterone derivatives :
( 3rd generation pills )
Anti ovulatory function by suppressing Gonadotropin…
Desogestrel,
Gestodene,
Norgestimate.
4 ) Spironolactone analogue :
Antiandrogenic & Anti mineralocorticoid …
Drosperinone ( DRSP )
Dr Shashwat Jani. 9909944160 9

10. A comparison of various progestins…
Progestin Estro-genic
Anti-estrogenic
Andro-genic
Antiandro
-genic
Antimineralo
-corticoid
Progesterone - - - + +
Older progestins:
MPA
-
-
+
-
-
Norethisterone
-
+
+
-
-
Levonorgestrel
-
+
+
-
-
Newer progestins:
Desogestrel
Cyproterone
acetate
-
-
-
-
-
-
-
+
-
-
Drospirenone - - - + +

11. Types of COC
Dr Shashwat Jani. 9909944160 11

12. 1) Monophasic
 Contains Estrogen & Progesterone in same
amount in Each pill .
 Divided in 2 subgroups :
- Low dose pills : EE 30 – 35 microgm
- Very low dose pills : EE 15 – 25 microgm.
Mala - N
• dl – NGL 0.15 mg
• EE 0.03 mg
Mala - D
• l – NGL 0.15 mg
• EE 0.03 mg
Dr Shashwat Jani. 9909944160 12

13. 2 ) Multiphasic
 Contains low or variable amounts of E and P in 2
( biphasic ) or 3 ( triphasic ) phases of cycles.
 Biphasic : constant EE – 35 microgm
progestogens : low in first 10 days
higher in next 11 days .
NOT POPULAR – MORE FAILURE RATE .

NOT AVAILABLE IN INDIA …
Dr Shashwat Jani. 9909944160 13

14.  Triphasic :
Triquilar –
- 0.03 EE +0.5mg l-norgestrel (1 - 6)
- 0.03 EE +0.75mg l-norgestrel (7-11)
- 0.03 EE +0.125mg l-norgestrel (12 - 21)
Total monthly intake – 0.68mg EE +1.92mg progesterone
• Adv. – high efficacy rates
- few side effects
- less break through bleeding
- does not affect s.cholesterol & LIPIDS
• Disadv. – high pregnancy rates if errors in pill intake .
Dr Shashwat Jani. 9909944160 14

15. Mechanism of action:
1 ) Inhibition of Ovulation :
 both hormones act on Hypothalamo pituitary
axis , suppress release of FSH & LH from Ant.
Pituitary.
E – inhibits FSH.
P – inhibits preovulatory LH Surge , less effect
on FSH.
Dr Shashwat Jani. 9909944160 15

16. 2 ) Endometrial Hyperplasia :
 stromal oedema , decidual reaction &
regression of glands making endometrium
nonreceptive to embryo.
3 ) Cervical mucus :
thick , viscid , scanty .
impaired sperm transport & penetration.
4 ) May affect tubal motility & alter tubal
transport.
Dr Shashwat Jani. 9909944160 16

17. Selection of the patient
 Detail history ( headache , migraine , etc…)
 Thorough general examination
( Breast , blood pressure… )
 Pelvic examination to exclude cervical
pathology.
 Cervical cytology
 Rule out any other contraindications.
Dr Shashwat Jani. 9909944160 17

18. Checklist for Prescribing COC…
Last menstrual period, rule out pregnancy
Less than 6 months postpartum & lactating?
Age, Cigarette smoking, h/o migraine
Known case of diabetes or hypertension
History of stroke, MI or thrombosis
h/o jaundice/ liver disease
h/o breast/ genital tract malignancies
h/o drug intake: Antitubercular, antiepileptic
Dr Shashwat Jani. 9909944160 18

19. Administration
New User :
- 1st day of Cycle .
- Daily 1 tab. Preferably at night for consecutive 21 days.
- Continued for 21 days and then 7 days break ( with
iron tablets ) .
- Next pack of Pill should be started on 8th day ,
IRRESPECTIVE OF BLEEDING ( same day of the week , pill
finished ).
- Simple Regimen of “ 3 WEEKS ON & 1 WEEK OFF “
- No break between packs.
 Can start pill up to 5 days of bleeding with extra
precaution with condom for next 7 days.
Dr Shashwat Jani. 9909944160 19

20. Missed Tablets :
1 missed – Take 2 tablets next day .
2 or 3 missed – Take 2 tablets on two consecutive
days and continue the rest of the pack.
+Another Contraceptive for 1 week.
Dr Shashwat Jani. 9909944160 20

21. • Lactating Women – Progestogen only pills /
Combined pills after 6 months
• Non Lactating Women – Combined oral pills
after 3 to 6 weeks or after menstruation
• 1st / 2nd Trimester abortion – during first 7
days.
• Amenorrhea : At any time after excluding
pregnancy + barrier method for 7 days.
Dr Shashwat Jani. 9909944160 21

22. Extended Use of COC…
(Seasonale)
Available since 2003
150μg of LNG + 30μg of EE
Only Active Pills taken continuously for 84 days,
then break for 7 days.
Fewer periods (4 in a year)
Pearl index- 0.78
Breakthrough bleeding/ spotting – First few
cycles

23. Follow up …
 Examined after 3 months , then after
6 months and then yearly .
 Ask for any symptoms…
 Examination for breast , pelvis, BP & weight &
cervical cytology.
Dr Shashwat Jani. 9909944160 23

24. Effectiveness…
Failure rate : 0.1%
Failure rate are mainly
due to missed pills.
Dr Shashwat Jani. 9909944160 24

25. How long can be continued …???
In properly selected patient without
any risk factor , benefits are more ,
and so can be continued up to age of
50 with careful monitoring. Offers
dual advantage of Contraception and
HRT.
For spacing of birth : 3 – 5 years.
Dr Shashwat Jani. 9909944160 25

26. Advantages…
• Prevention of pregnancy
India - MMR 1per 57 i.e. 400 in 1,00,000
2/5th of these deaths can be prevented by use
of OCs
• Cyclical Stabilisation
Great social advantage.
Withdrawl bleeding is predictable &
postponed safely by taking more low dose pills
contineously .
Dr Shashwat Jani. 9909944160 26

27. • Cure of Menstrual Disorders
Dysmenorrhoea & Ovulation pain – By inhibiting
ovulation & production of PG .
Menorrhagia & Metrorrhagia - Norgestrel High dose oral
pills more useful.
Lessens PMT.
• Protection against Cancer
a) Endometrial cancer- Reduction by 50 %
effect persists for 15 yrs.
b) Ovarian Cancer – Reduction by 40 %
effect persists for 10 yrs.
c) Choriocarcinoma – Indirectly prevention by preventing
pregnancy.
Dr Shashwat Jani. 9909944160 27

28. • Protection against benign tumors
1) Fibrocystic and Fibroadenomatous disease
2) Ovarion Functional Cysts
1) Follicular Cyst – 50 %
2) Corpus Luteum Cyst – 80 %
3) Fibroid Uterus - Reduction by 30%
Low Dose OC’s reduce fibroid ( WHO 1996)
Dr Shashwat Jani. 9909944160 28

29. • Protection against diseases
1) Ectopic Pregnancy
2) PID
3) Anaemia and Malnutrition
4) Endometriosis
5) Acne and Hirsutism
6) DUB
7) Osteoporosis
• Simplicity and Attractiveness
• No Affection on Future fertility ( 3 months )
Dr Shashwat Jani. 9909944160 29

30. Emergency Contraception…
1) Yuzpe regimen –
0.1mg EE + 1 mg dl-Norgestrel
1st dose Within 72 Hrs of Contact
Repeated after 12 Hrs.
2) Ovral
1st dose 2 tablets within 72 hrs.
2nd dose 2 tablets after 12 hrs.
3) Overal – L
1ST dose 4 tablets within 72 hrs.
2nd dose 4 tablets after 12 hrs.
Dr Shashwat Jani. 9909944160 30

31. Minor Side Effects…
• Nausea, Vomiting and Lack of appetite
• Break through bleeding
• Menorrhagia and irregular bleeding
• Oligomenorrhoea and Amenorrhoea
• Breast changes – Heaviness and Tenderness
• Vaginal Discharge – Cx -erosion, dysplasia causes
leucorrhoea
• Headache and Migraine
• Chloasma
• Wt. Gain
• Psychosexual Trouble – Depression, Loss of Libido
• Others - Leg Cramps, Dimness of Vision
Dr Shashwat Jani. 9909944160 31

32. Major Side Effects…
• Cardiovascular Diseases
1) MI – Increased Risk in heavy smokers
2) Ischaemic Stroke - 1.5 times more
3) Haemorrhagic Stroke – double risk
4) Venous Thromboembolism – Risk increases
with age, recent surgery and thrombophilia
• Hypertension - In women more than 35 Yrs.
• Carcinogenecity
1) Breast Cancer
2) Cervical Cancer
Dr Shashwat Jani. 9909944160 32

33. Interaction With Drugs…
1) Barbiturates , Sulphonamides, Rifampicin
and Anticonvulsant interfere with OC’s and
failure rate increases
2) Interaction with antidiabetic drugs
3) Vit. C aggravates the effect of COC.
Dr Shashwat Jani. 9909944160 33

34. Absolute Contraindications…
(WHO Category IV)
• Migraine, with focal Neurological Symptoms
• Pregnancy and breast feeding ( 6 Months)
• Severe Hypertension
• Complicated valvular heart disease
• D.M. with vascular complications
• Active hepatitis, liver tumors
• Major Surgery
• Prolonged Immobilization .
Dr Shashwat Jani. 9909944160 34

35. Indications of Withdrawal :
 Severe migraine
Visual or speech disturbances
Sudden chest pain
Unexplained fainting attack or acute vertigo
Severe leg cramps
Excessive weight gain
Severe depression
Prior to surgery ( Atleast 6 weeks )
Patient wants pregnancy … 
Dr Shashwat Jani. 9909944160 35

36. NEWER
CONTRACEPTIVES
Dr Shashwat Jani. 9909944160 36

37. MALE
 GOSSYPOL :
- A Chinese drug … !!!

- extract from Cotton seed.
- Oral 10 – 20 mg daily for 3 months then 20 mg
twice weekly.
- Inhibit Spermatogenesis by acting on
seminiferous tubules.
- S/E : fatigue, decrease libido, hypokalamic
paralysis.
Dr Shashwat Jani. 9909944160 37

38. Polyurethane Male Condom
• Stronger and thinner than
latex condoms
• Better heat transmission
• Can safely be used with oil-based
lubricants
• Can be used by those with
latex allergies

39.  GnRH Analogues :
- decline in sperm density , sperm motility,
decrease in testosterone level.
- Marked loss of libido makes it unacceptable .
Add back therapy with Testosterone is given.
Dr Shashwat Jani. 9909944160 39

40. Male Hormonal Contraception
• Recent trials at Andrology Clinic,
Concord Hospital
• Depo Provera plus testosterone
implants 3 monthly.
• Very low sperm count (less than 1
million per ml) in all men on trial -
80% had no sperm.
• Few side-effects
• Similar regime using an oral
progestogen and testosterone
implants being trialed in UK
• Implants and testosterone also
being trialled.

41. RISUG :
- “Reversible Inhibition of Sperm Under
Guidence . “
- Developed by IIT & AIIMS.
- clear polymer gel made of Styrene maleic
anhydrate ( SMA ) mixed with Dimethyl
Sulphoxide ( DMSO ) injected in to Vas
deferens  partially blocks Vas , preventing
sperm from coming in to ejaculate.
- Phase I & Phase II trials cleared.
- VASALGEL is similar to it.
Dr Shashwat Jani. 9909944160 41

42. Intra Vas Device ( IVD ) – Shug :
- 2 devices inserted in to each Vas .
- Needs special surgical skill.
- wider trials needed.
Dr Shashwat Jani. 9909944160 42

43. Voegeli’s Heat Method
• A small increase in the temperature of the testes has a
large negative impact on the production of sperm
(spermatogenesis).
• Voegeli’s program for temporary sterilization is as
follows:
“A man sits in a [shallow or testes-only] bath of 116
degrees Fahrenheit for forty-five minutes daily for
three weeks.
Six months of sterility results, after which normal
fertility returns.
For longer sterility, the treatment is repeated. ”
• .
Dr Shashwat Jani. 9909944160 43

44. Artificial Cryptorchidism/ Suspensories
(a) testes in normal position;
(b) testes raised to near inguinal canal; testes held in
place with
(c) briefs with ring of soft rubber or (d) ring alone.
Dr Shashwat Jani. 9909944160 44

45. Gendarussa
• First nonhormonal male contraceptive pills.
• Developed by Indonesia.
• Active ingredient in Gendarussa disrupts an
enzyme in the sperm head, which weakens
the ability of the sperm to penetrate the
ovum.
• The effect is short term and reversible –
having no effect on male hormones.
• Still under clinical trials…
Dr Shashwat Jani. 9909944160 45

46. Nifedipine – CCB
• CCBs also partially block the calcium channels
within the cell membranes of sperm. This
affects sperm function rather than production.
• A man taking nifedipine produces a normal
amount of sperm, and the sperm appear
functional when viewed through a
microscope. But in vitro tests show that these
sperm cannot fertilize an egg.
Dr Shashwat Jani. 9909944160 46

47. Male Vaccines …
• Scientists are trying to isolate, identify, and
produce Anti sperm surface antigens which
will hinder sperm – egg without side effects.
• Will take long time…
Dr Shashwat Jani. 9909944160 47

48. Other Ongoing trials…
• Use of following as Male Contraceptives…
1 ) Neem extracts.
2 ) retinoic receptor antagonist
3 ) papaiya seed extracts
4 ) olealonic acid
Dr Shashwat Jani. 9909944160 48

49. FEMALE
Many researches are going
on for development of newer
Contraceptives for females which are
either Non Hormonal OR having low
dose of Estrogen and newer
Progestogens.
Dr Shashwat Jani. 9909944160 49

50. PATH Women’s Condom
• Polyurethane condom
pouch
• Foam dots improve
adherence to vaginal
walls
• Soft outer ring
• Dissolving capsule
Dr Shashwat Jani. 9909944160 50

51. SILCS Diaphragm
• Cervical barrier device
• One-size-fits most
• Developed with input
from women and
men in multiple
countries
• Regulatory application
in Europe & US.
Dr Shashwat Jani. 9909944160 51

52. Centchroman ( Saheli )
• Ormeloxifene .
• research product of CDRI , Lucknow
• Non steroidal , potent anti estrogenic , weak
estrogenic.
• Prevent implantation of fertilized ovum .
• Orally 30 mg twice weekly for first 3 months
then once a week.
• Avoided in PCOD, liver , kidney disease.
Dr Shashwat Jani. 9909944160 52

53. Non contraceptive uses …
• DUB
• Endometrial Hyperplasia
• Endometriosis
• Breast cancer
• HRT
Dr Shashwat Jani. 9909944160 53

54. Combined Injectable
Contraceptives
• CYCLOFEM :
- DMPA 25 mg + Ostradiol cypionate 5 mg.
• MESIGYNA :
- NET- EN 50 mg + Oestradiol valerate 5 mg.
• Given within first 5 days of menstruation
• Next dose on same date of each month.
Dr Shashwat Jani. 9909944160 54

55. New formulation of Depo-Provera:
Depo-subQ Provera 104, for delivery with Uniject
Depo-subQ Provera 104:
 New formulation for subQ injection
 30% lower dose (104 mg vs. 150 mg)
 Rapid onset of action
 Same effectiveness, same length of protection (>3 months)
 Approved by USFDA (2005) and UK
 Potential for home- and self-injection
 Available for roll-out in 2011; Acceptability studies to begin in
mid-2010
Uniject:
 Single dose, single package
 Prefilled, sterile, non-reusable
 Short needles for subQ injection (easier use by non-clinical
personnel/CHWs)
 Compact; easy to use and store
Potential “home
run”

56. Transdermal delivery system
• Nestorone ( newer progestin ) :
- Available as Cream & Patch.
- Patches used like pills : 3 weeks ON 1 week OFF.
Dr Shashwat Jani. 9909944160 56

57. VAGINAL RINGS
• LNG ring covered by silastic tube .
• Delivers 20 microgm / day
• Replaced every 3 months.
Dr Shashwat Jani. 9909944160 57

58. Combined Ring – NUVA RING :
• Soft, transperent, ethinyl
vinyl ring
• Releases EE 15 microgm
+ Etonogestrel daily over
a period of 21 days.
• Then removed , after 1
week ( bleeding ) new
ring inserted.
• S/E : headache,
leucorrhea, vaginitis
Dr Shashwat Jani. 9909944160 58

59. LNG ROD
• Implant with total 150 mg of LNG
( 75 mg / rod ) is found effective for 5 years.
UNIPLANT
• Single rod implant
• Nomegestrol 38 mg.
• Releases 100 microgm / day.
• For 1 year.
Dr Shashwat Jani. 9909944160 59

60. Biodegradable
• Cipronor ( Single Capsule) – IMPLANTS :
- LNG 26 mg
- begins to disappear after 12 months.
• INJECTABLE :
- Microsphere of 0.06 – 0.1 mm diameter with
Norethindrone with or without EE.
- Given over Gluteal muscle.
- Once injected , can’t be removed.
Dr Shashwat Jani. 9909944160 60

61. Quinacrine pellet
• It acts as Sclerosing agent
• Inserted transcervically through hysteroscope
in proliferative phase.
• Repeated in next cycle.
• Long term results are awaited.
Dr Shashwat Jani. 9909944160 61

62. Frameless IUD - Gynefix
• Made of 6 copper beads ( 330 sqmm of Cu )
on monofilament polypropylene thread.
• Thread is knotted at one end , embeded in to
fundal myometrium up to 1 cm.
• Reduced risk of Expulsion, Dysmenorrhoea,
Bleeding , Infection.
• Can be used in Nulliparous.
• Removed with Hook.
Dr Shashwat Jani. 9909944160 62

63. Gynefix
Dr Shashwat Jani. 9909944160 63

64. ESSURE
• Transcervical
sterilisation
• 4 cm long , 2 mm
diameter microcoil
• Spring like device
• Inserted in each
fallopian tube through
hysteroscope.
• Tube is blocked
permanently when scar
tissue grow inside.
Dr Shashwat Jani. 9909944160 64

65. Dr Shashwat Jani. 9909944160 65