Combined Hormonal Contraceptives : includes: Combined Oral Contraceptives (Pills) Contraceptive vaginal ring Transdermal patch 2. Progestogen Only Contraceptions(POC): includes: Progestogen-only pill(POP) Implant Progestogen-only injectable Progestogen-releasing intrauterine system(LNG–IUS) Missed pills: If one pill is missed, anywhere in the pack (ie more than 24 and up to 48 hours late): The last pill missed should be taken now, even if it means taking two pills in one day. The rest of the pack should be taken as usual. No additional contraception is needed. The seven-day break is taken as normal. Emergency contraception is not needed if just one pill has been missed. However, it should be considered if other pills have been missed recently, either earlier in the current packet, or at the end of the previous packet. Missed pills: If two or more pills are missed (ie more than 48 hours late): The last pill missed should be taken now, even if it means taking two pills in one day. Any earlier missed pills should be left. The rest of the pack should be taken as usual and additional precautions (eg, condoms or abstinence) should be taken for the next seven days. The next step then depends on where in the packet the pills are missed: The next step then depends on where in the packet the pills are missed: If the pills are missed in the first week of a pack (pills 1-7): emergency contraception should be considered if the patient had unprotected sex in the pill-free interval or the first week of the pill packet. She should finish the packet and have the usual pill-free interval. If the pills are missed in the second week of a pack (pills 8-14): there is no need for emergency contraception as long as the pills in the preceding seven days have been taken correctly. The packet should be finished and the usual pill-free interval taken. If the pills are missed in the third week of a pack (pills 15-21): the next pack of pills should be started without a break - ie the pill-free interval is omitted. If taking a packet with dummy/placebo pills, these should be discarded, and the new packet started. Emergency contraception is not required. If more than seven pills are missed, the woman should start again as if starting for the first time. (Exclude pregnancy, and start a new pack on the first day of the next menstrual period.)

1. Contraception
Hormonal Contraception
Dr. Naji Majid Ahmed Hasan

2. Hormonal Contraception
2. Progestogen Only Contraceptions(POC):
includes:
 Progestogen-only pill(POP)
Implant
Progestogen-only injectable
Progestogen-releasing intrauterine system(LNG–IUS)
1. Combined Hormonal Contraceptives :
includes:
Combined Oral Contraceptives (Pills)
Contraceptive vaginal ring
Transdermal patch

3. Abbreviations:
DMPA, Depot medroxyprogesterone acetate; NET-EN, Norethisterone enanthate; LNG,
Levonorgestrel; LNG-IUS, Levonorgestrel-intrauterine system; IUD, Intrauterine devices

4. 1. Combined Hormonal Contraceptives :
• The combined oral steroidal contraceptives is the most
effective reversible method of contraception.
• Combination oral contraceptive pills (OCPs) contain various
amounts of estrogen (ethinyl estradiol) and one of a variety
of progestins.
Combined Oral Contraceptives (Pills)

5.  Composition:
1. Estrogens:
• Is ethinyl estradiol or its drivative ethinyl estradiol 3-
methyl ether(mestranol) contain between 20 μg and 35
μg of the synthetic estrogen
2. Progestogens:
• The progestogens that are used in currently available pills
are often referred to as :
*second-generation (levonorgestrel (LNG), norethisterone (NET))
*third-generation (gestodene desogestrel) and
*fourth-generation (drospirenone and dienogest).
Combined Oral Contraceptives (Pills)
NOTE :

6. Newer (third-and fourth-generation) progestogens were
developed to have advantages due to less androgenic
activity, but seem to be associated with a higher
risk of venous thrombosis than pills containing
second-generation progestogens.
In view of this, COCPs containing second-generation
progestogens are generally recommended as first
choice.
Combined Oral Contraceptives (Pills)

7. NOTE:
Fourth generation: Drospirenone which is an
analog of spironolactone is used as progestin.
It has antiandrogenic and antimineralocorticoid
action. It causes retention of K+ (hyperkalemia).
 So drospirenone should not be used in
patients with renal, adrenal or hepatic
dysfunction.

8. Some of the oral contraceptives and their composition
Combined Oral Contraceptives (Pills)

9. Mode of action:
The probable mechanism of contraception are:
1. Suppression of ovulation
2. Alteration of the character of the cervical mucus
(thick, viscid, and scanty) so as to prevent sperm
penetration.
3. Alteration of tubal motility
4. Alteration of endometrium to make it thin and
inactive, thus hampering implantation
Combined Oral Contraceptives (Pills)

10. Selection of the Patient :
History and general examination:
should be thorough, taking special care to screen cases for contraindications
(headache, migraine). Examination of the breasts for any nodules, weight,
and blood pressure are to be noted.
Pelvic examination :
to exclude cervical pathology, is mandatory. Pregnancy must be excluded.
Cervical cytology
to exclude abnormal cells, is to bedone. Thus, any woman of reproductive age
group without any systemic disease and contraindications listed, is a suitable
candidate for combined pill therapy. Growth and development of the pubertal
and sexually active girls are not affected by the use of ‘pill’.
Combined Oral Contraceptives (Pills)

11. How to Prescribe a Pill?
(Patient instruction):
New users should normally start their pill packet on day one
of their cycle.
1) One tablet daily at bed time for consecutive 21 days.
2) then have a 7 days break,
3) Next pack should be started on the eighth day,
irrespective of bleeding (same day of the week, the pill
finished).
4) Packing of 28 tablets, no break between packs. Seven of the
pills are placebo . (contain either iron or vitamin preparations).
Combined Oral Contraceptives (Pills)

13. 5) A woman can start the pill up to day 5 of the bleeding.
In that case she is advised to use a condom for the next 7
days.
6) The pill should be started on the day after abortion.
7) Following childbirth in non-lactating woman, it is
started after 3 weeks and in lactating woman it is to be
withheld for 6 months
Combined Oral Contraceptives (Pills)

14. Follow-up:
The patient should be examined after 3 months, then after 6
months and then yearly.
The patient above the age 35 should be checked more
frequently.
At each visit:
• Any adverse symptoms are to be noted.
• Examination of the breasts, weight, and blood pressure recording
• pelvic examination including cervical cytology, are to be done
• And compared with the previous records.
Combined Oral Contraceptives (Pills)

15. Missed pills:
If one pill is missed, anywhere in the pack (ie more than 24 and
up to 48 hours late):
• The last pill missed should be taken now, even if it means taking
two pills in one day.
• The rest of the pack should be taken as usual.
• No additional contraception is needed.
• The seven-day break is taken as normal.
Emergency contraception is not needed if just one pill has been
missed. However, it should be considered if other pills have been missed
recently, either earlier in the current packet, or at the end of the previous
packet.
Combined Oral Contraceptives (Pills)

16. Missed pills:
If two or more pills are missed (ie more than 48 hours late):
• The last pill missed should be taken now, even if it means taking two pills in
one day.
• Any earlier missed pills should be left.
• The rest of the pack should be taken as usual and additional precautions (eg,
condoms or abstinence) should be taken for the next seven days.
• The next step then depends on where in the packet the pills are missed:
Combined Oral Contraceptives (Pills)

17. The next step then depends on where in the packet the pills are
missed:
– If the pills are missed in the first week of a pack (pills 1-7): emergency
contraception should be considered if the patient had unprotected sex in the pill-free
interval or the first week of the pill packet. She should finish the packet and have the
usual pill-free interval.
– If the pills are missed in the second week of a pack (pills 8-14): there is no need for
emergency contraception as long as the pills in the preceding seven days have been
taken correctly. The packet should be finished and the usual pill-free interval taken.
– If the pills are missed in the third week of a pack (pills 15-21): the next pack of pills
should be started without a break - ie the pill-free interval is omitted. If taking a packet
with dummy/placebo pills, these should be discarded, and the new packet started.
Emergency contraception is not required.
• If more than seven pills are missed, the woman should start again as if starting for
the first time. (Exclude pregnancy, and start a new pack on the first day of the next
menstrual period.)
Combined Oral Contraceptives (Pills)

18. Missed pill guidelines

19. DisadvantagesAdvantages
Requires education and motivationHighly effective
Limitation in its useGood cycle control
Requires initial check up and periodic
supervision
Well-tolerated in majority
Inconvenience caused in its use due
to daily schedule
Additional non-contraceptive benefits
are many
Risk of drug interactionsLow dose pill with ‘lipid friendly’
progestins further reduces the risk
Costly but free supply through
government channel (Mala-N)
Reversibility rate is prompt
Combined Oral Contraceptives (Pills)
Failure rate—0.1 (HWY)

20.  Adverse Effects of COCs :
Combined Oral Contraceptives (Pills)

21.  Non-contraceptive benefits:
Improvement of menstrual abnormalities:
1) Regulation of menstrual cycle
2) Reduction of dysmenorrhea (40%)
3) Reduction of menorrhagia (50%)
4) Reduction of PMS
5) Reduction of Mittelschmerz syndrome
6) Protection against iron-deficiency anemia
Combined Oral Contraceptives (Pills)

22.  Non-contraceptive benefits:
Protection against health disorders :
(7) PID (thick cervical mucus)
(8) Ectopic pregnancy
(9) Endometriosis
(10) Fibroid uterus
(11) Hirsutism and acne
(12) Functional ovarian cysts
(13) Benign breast disease
(14) Osteopenia and postmenopausal osteoporotic fractures
(15) Autoimmune disorders of thyroid
(16) Rheumatoid arthritis
(17) Increases
Combined Oral Contraceptives (Pills)

23.  Non-contraceptive benefits:
Prevention of malignancies:
(18) Endometrial cancer (50%)
(19) Epithelial ovarian cancer (50%)
(20) Colorectal cancer (40%).
Combined Oral Contraceptives (Pills)

24. The combined hormonal transdermal patch
• releases 33.9 μg ethinyloestradiol/day and norelgestromin
203 μg/day.
• It is applied to the skin of the lower abdomen, buttock or arm
for 7 days, although it can be applied to any skin covered area,
except the breast.
• application of patches for a total of 21 days followed by a 7-
day hormone-free interval.
Transdermal patch

25. The combined hormonal ring :
is a flexible ring of 54 mm diameter that releases 15 μg
ethinyloestradiol and 120 μg etonorgestrel daily, and as such is
the lowest dose combined hormonal method.
• The ring is self inserted and worn in the vagina for 21 days,
followed by a 7-day hormone-free interval, during which a
withdrawal bleeding occurs.
Contraceptive vaginal ring

27. 2. Progestogen Only Contraceptions(POC):
includes:
 Progestogen-only pill(POP)
Implant
Progestogen-only injectable
Progestogen-releasing intrauterine system(LNG–IUS)

28. POP is devoid of any estrogen compound. It contains very low
dose of a progestin in any one of the following form
levonorgestrel 75 g, norethisterone 350 g, desogestrel 75 g,
lynestrenol 500 g or norgestrel 30 g. It has to be taken daily
from the first day of the cycle.
Mechanism of action:
It works mainly by making cervical mucus thick and viscous,
thereby prevents sperm penetration. Endometrium becomes
atrophic, so blastocyst implantation is also hindered. In about 2%
of cases ovulation is inhibited and 50 percent women ovulate
normally.
Progestogen-only pill(POP/MINI PILL)

29. • How to prescribe a mini pill?:
The first pill has to be taken on the first day of the cycle
and then continuously. It has to be taken regularly and at
the same time of the day. There must be no break between
the packs. Delay in intake for more than 3 hours, the
woman should have missed pill immediately and the next
one as schedule. Extra precaution has to be taken for next 2
days.
• Side-effects of all POPs include possible irregular
bleeding, persistent ovarian follicles (simple cysts) and
acne
Progestogen-only pill(POP/MINI PILL)

30. Contraindications:
(i) Pregnancy,
(ii) Unexplained vaginal bleeding,
(iii) recent breast cancer,
(iv) arterialdisease and
(v) thromboembolic disease.
Progestogen-only pill(POP/MINI PILL)

31. •
Implant

32. • A single rod (Nexplanon®) or (Implanon) containing the
progestogen etonorgestrel is the currently available method .
It is a long-term (up to 3 years) reversible contraception.
• Nexplanon® contains 68 mg of 3-keto desogestrel (a
metabolite of desogestrel) providing contraception for 3
years.
• The initial release rate of 60–70 μg/day falls gradually to
around 25–30 μg/day at the end of 3 years.
Implant

33. Mechanism of action:
It inhibits ovulation in 90% of the cycles for the first year.
It has got its supplementary effect on endometrium (atrophy)
and cervical mucus (thick) as well.
Insertion:
Nexplanon® is a flexible rod, similar in size to a match stick (40
mm × 2 mm) and is inserted subdermally 8 cm above the
medical epicondyle, usually in the inner aspect of the non-
dominant arm . It is inserted between biceps and triceps
muscles.
Implant

34.  Nexplanon® contains a small quantity of barium, which
permits it to be visualized by X-ray.
Implant

35. Removal:
Implanon should be removed within 3 years of insertion.
Removal is done by making a 2 mm incision at the tip of the
implant and pushing the rod until it pops out. It is done under
local anesthetic.
Implant

36. Advantages :
(i) Highly effective for long-term use and rapidly reversible.
(ii) Suited for women who have completed their family but do not
desire permanent sterilization.
 Efficacy of Implanon: is extremely high with Pearl indices of 0.01.
 Disadvantages:
are frequent irregular menstrual bleeding, spotting and
amenorrhea are common.
 Contraindications : are similar to POP
Implant

37. Norplant–II (Jadelle)
Two rods of 4 cm long with diameter of 2.5 mm is used. Each
rod contains 75 mg of levonorgesterel. It releases 50 mcg of
levonorgestrel per day.
Contraceptive efficacy is similar to combined pills.
Failure rate is 0.06 per 100 women years. It is used for 3 years.
The rods are easier to insert and remove.
Implant

38. The preparations commonly used are depomedroxy-
progesterone acetate (DMPA) and norethisterone enanthate
(NET-EN).
The injectable is the only hormonal method that may delay
return of fertility after discontinuation. In some cases it may take
up to 1 year after the last injection for ovulation to return. There
is no permanent impairment of fertility but this delay makes the
injectable an inappropriate method for women wishing short-
term contraception.
Progestogen-only injectable

39.  Administration:
administered intramuscularly IM (deltoid or gluteus muscle) within 5 days
of the cycle. or administered subcutaneously .
IM as Depoprovera® (150 mg)
SC as Sayana press® (104 mg)
Both have similar features , but SC are easier to give.
Dose:
* DMPA in a dose of 150 mg every three months (WHO 4 months) or 300
mg every six months;
* NET-EN in a dose of 200 mg given at two monthly.
* Depo-Sub Q provera 104 (Sayana press®), contains 104 mg of DMPA. It is
given subcutaneously over the anterior thigh or abdomen at every 90
days. It suppresses ovulation for 3 months as it is absorbed more slowly.
Progestogen-only injectable

40. Mechanism of action: as POP
Disadvantages:
Both the intramuscular and subcutaneous preparation may
cause weight gain in a minority of women and loss of bone
mineral density (BMD) (5% loss of BMD at lumbar spine) in
the first few years of use.
Progestogen-only injectable

41. NOTE:
There have been concerns over studies from countries of high
human immunodeficiency virus (HIV) prevalence (such as sub-
Saharan Africa) that have reported increased transmission and
acquisition of HIV amongst users of Depoprovera®, compared to
users of other hormonal methods.
so at present, the expert opinion of the WHO is that the injectable
can be safely used in women living with HIV or at high risk of HIV.
Condom use in addition to the injectable should also be encouraged
to protect against transmission or acquisition of HIV.
 Contraindications:
Women with high risk factors for osteoporosis, breast cancer, and
the others are same as in POP .
Progestogen-only injectable

42. The noncontraceptive benefits:
are reduces the risk of:
salpingitis,
endometrial cancer,
iron deficiency anemia,
sickle cell problems, and
endometriosis.
Progestogen-only injectable