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Hormonal contraceptives
Oral contraceptive pills (OCPs) contain synthetic hormones, usually a combination of estrogen and progestin, that prevent pregnancy through multiple mechanisms. They work by inhibiting ovulation, thickening cervical mucus, and thinning the uterine lining. Common estrogen and progestin components include ethinyl estradiol and levonorgestrel. OCPs are generally safe and effective when used correctly, with failure rates around 0.1% per year. They also provide non-contraceptive benefits like reducing menstrual cramps and risk of certain cancers. Doctors should screen for contraindications before prescribing OCPs.
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Hormonal contraceptives
- 1. Hormonal contraceptives Oral ContraceptivePills Dr. Woothvasita Mondal MBBS, MS SR, Dept of OBG, IQCMC
- 2. What is OCP? OralContraceptive Pills. • Pills which is taken orally and it prevents pregnancy.
- 3.
- 4. Types of OCP Hormonal •COC (Combined oral contraceptives) • POP (Progesterone Only Pills) Non-Hormonal • Centchroman (Saheli)
- 5. What’s in “ThePill” • 15-50 micrograms estrogen (ethinyl estradiol is a synthetic form of estrogen, which is used most commonly) • Varying amounts of progestagen component (commonly levonorgestrel) • Types of Regimens – 21-day or 28-day pack 5
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- 7. Combined mode ofaction of estrogen and progestin • Prevents ovulation • Thickens mucous in cervix • Thins endometrium 7
- 8.
- 9. Mechanism of anovulation •Inhibit ovulation: Both hormones acts synergistically on the HPO axis. • The release of GnRH from the hypothalamus is prevented through a negative feedback mechanism.
- 10. Mechanism of anovulation •So, no peak release of FSH & LH from the anterior pituitary occurs. • So, follicular growth is either not initiated or if initiated –recruitment doesn’t occur. • Resulting Anovulation.
- 11. The 21 daypack • The first seven pills in a packet inhibit ovulation. • The remaining 14 pills maintain anovulation.
- 12. Estrogen • Primary femalesex hormone • Roles of estrogen: –To develop secondary female sex characteristics –Thicken the endometrium –Regulate menstrual cycle 12
- 13. Combined Hormonal contraceptives Combinationof estrogen & progesterone. Commonly used estrogens are: • Ethinyl-estradiol • Mestranol (3 methyl ether of Ethinyl-estradiol)
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- 16. Functions of estrogenin OCP 1. Improves the efficacy over progesterone only pills. 2. Inhibits FSH rise & prevents follicular growth. 3. It provides better cycle control than progesterone only pills 4. It prevents Break through bleeding. 16
- 17. Progesterone • Produced by –Adrenal glands – Gonads – Brain – Placenta (only during pregnancy) Primary Effect- prepares uterus for implantation by the proliferation of endometrium; prepares body for pregnancy 17
- 18. Progesterone • Natural progesterone-destroyed by digestive system when consumed orally ALL oral contraceptives contain progestin, synthetic form of progesterone 18
- 19. Different progestogens canbe classified According to their steroid structure 1. -PREGNANES (derived from the progesterone molecule), 2. -ESTRANES (derivatives of testosterone), and 3. -GONANES Timing of their introduction into the market. 1st, Generation 2nd, Generation 3rd, Generation 4th, Generation
- 20. Progestins according to their steroid structure - pregnanes(derived from the progesterone), CPA estranes (derivatives of testosterone), norethisterone 19-nortestosterone LNG,DSG,GSD GONANES
- 21. Generations 1st <1973 Norethisterone 2nd1973-1989 LNG, Norgestimate 3rd 1990-2000 Desogestrel, Gestodene 4th > 2000 Drospirenone
- 22. Progestins 1st generation Norethisterone family 2nd generation LNGfamily 3rd Generation DSG,GSD, norgestimate 4th Generation Drospirenone chlormadinone
- 23. Combined Hormonal contraceptives Combinationof estrogen & progesterone. Commonly used Progestins are: • Levonorgestrel • Norethisterone • Desogestrel • Drospirenone.
- 24. Role of progestinsin COC • Primarily inhibits LH surge & thereby ovulation. • Counteract the adverse effects of estrogen on the endometrium (Hyperplasia) • Thickens cervical mucosa & thereby sperm penetration difficult.24
- 25. Advantages of 3rd generationsof progestins • Lipid friendly progestogens. • to minimize androgenic side effects such as acne, hirsutism, nausea, and lipid changes while • increasing progestational effects 25
- 26. Advantages of 4th generationsof progestins • Drospirenone. • Dienogest, • Nomegestrol • All three progestogens have antiandrogenic activity; • drospirenone has antimineralocorticoid activity. 26
- 27. Dosage of EEin COCs 27
- 28. Commonly available COCs inthe market 28 Brand Name Progestin Estrogen Pack Mala-D , Mala-N Levonorgestrel 150 mcg Ethinyl Estradiol 30 mcg 21+7 tab pack Loette, Femilon Desogestrel 150mcg Ethinyl Estradiol 20 mcg 21 tab pack Yasmin, Dronis Drospirenone 3 mg Ethinyl Estradiol 30 mcg 21 tab pack
- 29. What to dobefore prescribing COC • A proper history and general examination is important before prescribe. • H/O headache, migraine, • H/O amenorrhoea • Family H/O Breast cancer 29
- 30. What to dobefore prescribing COC • Breast examination for any nodule • Weight and BP • Pelvic examination to rule out any cervical pathology • Pregnancy must be excluded • A cervical smear should be taken before. 30
- 31. Instruction for pilluse New user • New users should normally start their pill pack on Day 1 of their menstrual cycle. • 1 tab daily preferably at the same time (e.g. bed time) • Continue upto 21 days and then a 7 days gap. 31
- 32. Instruction for pilluse New user • During this 7 days period there will be withdrawl bleeding. • Then start new pack on the 8th day (irrespective of the withdrawl bleeding) • 3 wks & 1 wk off • Pill which contains 28 tabs have 7 placebo tablets, so no need to give a gap. 32
- 33. What if shedid not started on Day1 • She can start upto day 5. • But has to take additional precaution (condom) for next 7 days. 33
- 34. Special situations • Afterabortion: the day after abortion • After delivery: • If non-lactating after 6 wk (WHO) ? • Lactating: no COC. 34
- 35. Follow up • Checkthe patient after 3 months, 6 month and then once every yearly. • More frequent check if >35 yr. • Ask for any adverse effects • Examine breasts, weight, BP. • Pelvic examination if required. 35
- 36. Miss pill • Ifforgets to take one pill (late upto 24 hr). • She should take the missed pill at once and continue the rest as schedule. • There is nothing to worry. 36
- 37. If one pillhas been missed (more than 24 hours and up to 48 hours late) Next pill on usual time Keep taking active pills as usual Take a pill as soon you remember
- 38. ???Doctor, I missed 2pills in the middle of my pack. What should I do?
- 39. If two pillshave been missed (more than 48 hours late) • Return to next day active pill • Avoid sex or use extra method next 7 days. • EC if already had sex. If pills are missed in week 1 (Day 1-7) • Finish the active pills • Start a new pack from day 22 with no PFI • EC if already had sex • Extra method next 7 days If pills are missed in week 3 (Day 15-21)
- 40. If two pillshave been missed in 2nd wk (Day 8-14) • No indication for EC if the pills in the preceding 7 days have been taken consistently and correctly • Take 2 tab as soon remembers & continue the rest as usual. • Condoms should be used or sex avoided until 7 consecutive active pills have been taken.
- 41. Any time >2miss pills • The most recent missed pill should be taken as soon as possible, leave any earlier missed pills. • Condoms should be used or sex avoided until 7 consecutive active pills have been taken. • EC according to the situation • Start a new pack from day 22 with no PFI
- 42. Missed inactive pills •Discard the missed pill • Nothing to worry • Continue the rest as usual. 42
- 43. Efficacy • As acontraceptive. • Failure rates are 0.1 per 100 women year. 43
- 44.
- 45. Contra-indications WHO MEC Cat4 •Circulatory disease (present or Past) • Liver disease • Others 45
- 46. WHO MEC Cat4 Circulatorydisease (present or Past) • Arterial/venous thrombosis • Severe Htn • H/O stroke • Heart disease (valvular, ischaemic) • Diabetes with vascular involvement • Migraine with aura 46
- 47. WHO MEC Cat4 Liverdisease • Active liver disease • Liver adenoma • Liver carcinoma 47
- 48. WHO MEC Cat4 Others •Pregnancy • Breast feeding (post partum upto 6 wk) • Major surgery or prolonged immobilization • Estrogen dependent cancers (Breast cancer) 48
- 49. WHO MEC Cat3 •Benign liver tumour • Breast feeding (post partum from 6 wk to 6 month) • Heavy smoker (>20 cig/day) • Past H/O breast cancer • Hyperlipidaemia • Unexplained vaginal bleeding 49
- 50. WHO MEC Cat2 •Age ≥40 yr • Smoker <35yr • H/O jaundice • Mild Htn • Gallbladder disease • Diabetes • Sickle cell ds • Headache • Cancer cervix or CIN 50
- 51. Ideal candidates • Age:menarche to 40 yr • Newly married/ frequent sexual activity • Non obese • Normotensive • Can take pills regularly without missing. • No contraindications. 51
- 52. Drug interaction Reduces theefficacy of • Aspirin • Oral anticoagulants • Oral hypoglycaemics Increases the efficacy of • Beta blockers • Cortico-steroids • Diazepam 52
- 53. Additional contraceptives if: • Usingbroad spectrum antibiotics (ampicillin, tetracycline) • Using enzyme inducing drugs (Burbiturates, Anti-epileptics, Nevirapine). 53
- 54. Minor adverse effectsof COCs • Nausea, vomiting • Mastalgia • Weight gain • Cholasma & acne • Menstrual abnormalities (Break- through bleed, Hypomenorrhoea, Menorrhagia, Post pill amenorrhoea) • Loss of libido • White vaginal discharge (leukorrhoea) 54
- 55. Major adverse effects •Hypertension • Depression • Vascular complications (venous/ arterial thrombo-embolism) • Cholestatic jaundice 55
- 56. Caution if develop •Severe migraine • Visual or speech disturbance • Sudden chest pain • Unexplained fainting attack • Severe cramps & pain in legs • Excessive weight gain • Severe depression 56
- 57. COC & neoplasia Protectsagainst: • Endometrial Ca • Epithelial ovarian Ca • Colorectal Ca No direct relation with Breast cancer & cervical cancer with low dose estrogen COCs. 57
- 58. Advantages • Highly effective •Good cycle control • Convenient to use • Not intercourse related • Reversible • Additional non-contraceptive benefits. 58
- 59. Non-contraceptive benefits. Improvement ofmenstrual abnormality: • Cycle regulation • ↓Dysmenorrhoea • ↓Menorrhagia • ↓ PMS • ↓ Mittelsmerz’s syndrome • Protect against anemia • In patients with PCOS. 59
- 60. Non-contraceptive benefits Protects against •PID (thickens Cervical mucosa) • Ectopic pregnancy • Endometriosis • Fibroid uterus • Hirsutism & acne • Functional ovarian cyst • Benign breast disorder • Osteopenia 60
- 61. Non-contraceptive benefits Protects againstCancers • Endometrial Ca • Epithelial ovarian Ca • Colorectal Ca 61
- 62. Dis-advantages • Requires education& motivation • Requires initial check-up & follow- up • Risk of drug interaction & failure • Side effects may develop • Many contra-indications are there. • Miss pill problems. 62
- 63.
- 64. Triphasic pills • Estrogen& progesterone dosage vary over the course of the cycle. • Minimum dosage in the 1st half of the cycle for contraceptive purpose. • Maximum dosage given in later part of cycle to prevent Break through bleeding. 64
- 65. Triphasic pills Sharing-AG, Triquilar 65 1st6 tablets 50 mcg LNG 30 mcg EE Next 5 tablets 75 mcg LNG 40 mcg EE Last 10 tab 125 mcg LNG 30 mcg EE
- 66. Triphasic pills-Advantage • Itminimizes undesirable side effects of COCs on lipid profile • Without compromising the contraceptive efficacy. 66
- 68. ???What if Ivomit or have diarrhoea?
- 69. If you vomit •Take another pill as soon as possible. • If you do not vomit this second pill and it is taken on the same day, then nothing to worry. within 2-3 hours of taking a pill • Then follow the same as missing pills . If you continue to vomit
- 70. Diarrhoea •No affect onthe absorption of the pill. Mild diarrhoea •consider this as the same as missing pills. Severe diarrhoea
- 71. What happens if Idon't have a withdrawal bleed between packs? ???
- 72. No withdrawal bleedbetween packs • It is quite common for there to be no bleeding between pill packs. • You are not likely to be pregnant if you have taken the pill correctly and have not vomited or taken any medicines that can interfere with the pill. • Start the next pack after the usual seven-day break and continue to take pill as usual.
- 73. See your doctoror nurse if: 1. You don't have any bleeding after the next pack (two packs in total); or 2. You have not taken the pill correctly; or 3. You have any reason to think that you may be pregnant. A pregnancy test may be advised, considering the circumstances.
- 74. Doctor, I am Bleedingwhilst on the pill & I am Worried. ???
- 75. Bleeding whilst onthe pill (breakthrough bleeding) • During the first few months, while your body is adjusting to the pill, you may have some vaginal bleeding in addition to the usual bleeding between packs. • This is not serious but more of a nuisance. It may vary from spotting to a heavier loss like a light period. • Do not stop taking your pill. This usually settles after the first 2-3 months.
- 76. Can I delayor skip a withdrawal bleed (period)? ???
- 77. Can I delayor skip a withdrawal bleed (period)? • There are times when it is useful not to have vaginal bleeding, for example, during exams or holidays or any ceremony. • Bicycling/Tricycling may be done- using monophasic pills (most commonly used), you can go straight into your next pack without a break. Have the usual seven-day break at the end of the second /third packet.
- 78.