A detailed information for a final year mbbs student on oral Contraceptives.

1. ORAL CONTRACEPTIVE
PILLS
BY – PARAS ANAND
Guru Gobind Singh Medical College
Faridkot

2. types
HORMONAL NON HORMONAL
COMBINED
PREPARATIONS
SINGLE
PREPARATIONS
● PROGESTIN ONLY
PILL
(MINIPILL)
● ESTROGEN ONLY
(EMERGENCY)
● MONOPHASIC
● BIPHASIC
● TRIPHASIC
● EMERGENCY
(POST COITAL)
FEMALES MALES
● CENTCHROMAN
(SAHELI)
● GENDARUSSA
● GOSSYPOL
● CCB (NIFEDIPINE)

3. How they work ?
INHIBITION OF OVULATION

4. ->PRODUCING STATIC ENDOMETRIAL
HYPOPLASIA
 STROMAL EDEMA
 DECIDUAL REACTION
 REGRESSION Of GLANDS
making endometrium nonreceptive to the embryo.

5. -> Alteration of character of cervical mucus
 Thick ,viscid, scanty – prevent sperm penetration
-> Interferes with tubal motility and
alters tubal transport.

7. COMBINED ORAL
CONTRACEPTIVES (COC’s)
(COMBINATION OF ESTROGEN AND PROGESTERONE)
Commonly used ESTROGEN are
 Ethinyl- estradiol
 Mestranol

8. FUNCTION OF ESTROGEN IN OCP
 Inhibits FSH rise and prevents follicular growth
 Improves the efficacy over progesterone only pills
 provides better cycle control than progesterone only pills
 prevents breakthrough bleeding

9. Progesterone
-
 Prepares the uterus for implantation by proliferation of
endometrium ;
 Prepares body for pregnancy
 Natural Progesterone – DESTROYED by digestive system when
consumed orally .
 All oral contraceptives contain PROGESTIN , a synthetic form
of progesterone

10. Role of Progestins in COC
 inhibits LH surge and thereby OVULATION.
 Counteract the adverse effects of estrogen on the
endometrium (Hyperplasia)
 Thickens cervical mucosa and thereby sperm
penetration difficult .

13. E=>50 μg
E= 20-35 μg
E= 20-30 μg

15. Advantages of 3rd generation Progestins
 Lipid friendly progestogens
 minimize side effects such as acne, hirusitism,
nausea, and lipid changes ,
 Increasing progestational effects

16. Advantages of 4th generation progestins
 Drospirenone
 Dienogest
 Nomogestrol
 All three have antiandrogenic activity ;
 Drospirenone has antimineralocorticoid activity

19. Patient Selection &
What to do before prescribing COC
 History & GPE .
 H/O headache, migraine
 H/O amenorrhea
 Family H/O Breast Cancer
 Breast Examination : any nodule etc.
 Pelvic Examination
 Rule out Pregnancy.
 Cervical Cytology : smear examination ; any
abnormal cells.

20. THE 21 DAY PACK
-the first seven pills in a packet inhibit ovulation
-the remaining 14 pills maintain anovulation.
THE 28 DAY PACK
New users : 1st pill – 1st day of menstrual cycle
1 tab daily at same time – 21 days (21 ACTIVE PILLS)
7 DUMMIES (INACTIVE PILLS)- iron or vitamin preparations.
 can start upto 5th day of bleeding – use caution for next 7days
3 WEEK ON, 1 WEEK OFF

21. Special situations
 After abortion : Day after abortion
 After deliver : > Non Lactating : 3 weeks
 6 week(WHO)
> Lactating : no COC or After 6 months.

22. Monophasic Pills
 constant dose of both estrogen and progestin
in each of the hormonally active pills throughout
the entire cycle (21 days of ingesting active
pills).

23. Bi phasic pills
 contain 2 different progesterone doses.
 The progesterone dose is increased about
halfway through the cycle.

24. Triphasic Pills
 Minimum dosage in the 1st half of the cycle for
contraceptive purpose.
 Maximum dosage given in later part to prevent
Breakthrough Bleeding.
Advantages-
 minimizes undesirable side effects of COCs on
lipid profile.
 Without compromising the contraceptive
efficacy

26.  return of pituitary and ovarian follicular activity during the
pill free interval (PFI) of 7 days
 BREAKTHROUGH OVULATION occurs (20% cases) in this PFI.
 Any lengthening of PFI due to omissions, malabsorption ,
vomiting ,
 increases risk of breakthrough ovulation and, therefore,
pregnancy.
MISSED PILLS !!

29. .Take 2 pills on each of next 2 days
Another form of contraception
as backup for next 7 days
OR >2 ANYTIME

30. MISSED INACTIVE PILLS
 Discard the missed pills
 Nothing to worry
 Continue the rest as usual

40. MEDICAL ELIGIBILITY CRITERIA
(WHO)

42. NEOPLASIA AND COCs
 Increased risk : breast cancer
 Increased risk : cervical cancer
 Reduced risk : endometrial cancer
 Reduced risk : ovarian cancer
 Reduced risk : colon cancer
-Reduce the no. of years of
pill intake.
-Choose another method of
contraception
-Regular screening for HPV
infection.
The longer you take the
combined estrogen and progestin
pills, the lower your risk.

43. Health Benefits of COCs
 Contraceptive benefits
 Protection against unwanted pregnancy
Failure rate = 0.1 per 100 women years
 Not intercourse related.
 Reversibility.
 Non Contraceptive Benefits
 Regulation of menstrual cycle ( BY inhibition of ovulation and
producing PG’s)
 Reduction of menorrhagia
 Reduction of PMS
 Protection against iron deficiency anemia.

44.  Protection against health disorders
 PID (thick cervical mucus)
 Ectopic Pregnancy
 Endometriosis
 Fibroid uterus
 Hirsutism
 Functional ovarian cysts
 Benign breast diseases
 Osteopenia and post menopausal osteoporotic fractures. (increases bone mineral
density )
 Autoimmune thyroiditis
 Rheumatoid arthritis.
 Protection against malignancies
 Endometrial cancer
 Epithelial ovarian cancer
 Colorectal cancer

45. Adverse effects of COCs
 MINOR COMPILCATIONS
 NAUSEA, VOMITING, HEADACHE ,AND LEG CRAMPS
 MASTALGIA
 WEIGHT GAIN :Progestins have anabolic effect due to its
chemical relation to testosterone, use of low dose COCs
do not cause any weight gain.
 CHLOASMA AND ACNE :
 MENSTRUAL ABNORMALITIES :
 BREAK THROUGH BLEEDING : due to subthreshold of
hormone levels

46.  ->disturbance of drug absorption – diarrhoea, vomiting
 -use of enzyme inducing drugs, missing pills , use of low
dose pills.
 miscarriage ->diseases- cervical ectopy or carcinoma.
Exognous estrogen (conjugated estrogen 1.26mg or
estradiol 2mg) given daily for 7 days control the bleeding
 HYPOMENNORHEA : local endometrial changes
 MENORRHAGIA : usually preexisting and use of progestin
preponderance compounds is helpful.
 AMENORRHEA : post pill amenorrhea >6months in <1%
cases.
 LIBIDO: may be diminished – dryness of vagina . Might
even increase due to loss of fear of pregnancy.
 LEUKORRHEA : due to excessive cervical mucus secretion

47. MAJOR COMPLICATIONS !
 VASCULAR COMPLICATIONS :
1.) VENOUS THROMBOEMBOLISM (VTE)
Pre existing hypertension, diabetes , obesity , thrombophilias , and elederly patients
(>35 yrs) with smoking habits are the imp. Risk factors.
- Ethinyl estradiol dose 20μg reduce the incidence.
2.) ARTERIAL THROMBOSIS : similar risk factors for myocardial infarction , stroke
(ischemic and hemorrhagic).
3.) HYPERTENSION low dose rarely cause htn.
pre existing hypertension is likely to be aggravated.
Mainly changes are seen in systolic BP due to activation of RAAS.
changes reverse back to normal after 3-6 months of stoppage f pill.
DEPRESSION : not with low dose estrogen .
CHOLESTATIC JAUNDICE : susceptibility increased if any previous history of
jaundice or hepatitis.

48.  Metabolic effect –
 Carbohydrates- Impair glucose tolerance
insulin resistance
hyperglycemia
 Lipid – plasma lipids and lipoproteins are
increased.

49. DRUG INTERACTIONS
 REDUCES THE EFFICACY OF:
 ASPIRIN
 ORAL ANTICOAGULANTS
 ORAL HYPOGLYCEMICS
 INCREASES THE EFFICACY OF:
 BETA BLOCKERS
 CORTICOSTEROIDS
 DIAZEPAM
Additional contraception :
Using broad spectrum antibiotics- ampicillin, ciprofloxacin - they impair
absorption of ethinyl estradiol
When enzyme inducing drugs are used : - Barbiturates – antiepileptic
(except sodium valproate and clonazepam) – Rifampicin – protease inhibitor
(ritonavir)
 HERE High dose preparations (ethinyl estradiol of 50μg or more ) are to
be used to counter balance the increased liver metabolism.

50. Progestin Only Pill (POP/MINIPILL)
 NO Estrogen compound.
 Very low progestin in any of the forms
 LEVONORGESTRAL 75μg
 NORETHISTERONE 350 μg
 NORGESTRAL 30 μg
 MOA : > Make cervical mucus thick and viscous.
>Prevents sperm penetration
> Endometrium becomes atrophic ; blastocyst
implantation is hindered.

51. TAKEN DAILY FROM 1ST DAY OF CYCLE AND THEN CONTINOUSLY .
DELAY >3 HRS , TAKE PILL IMMEDIATELY .
EXTRA PRECAUTIONS FOR NEXT 2 DAYS .

52. ADVANTAGES OF MINIPILLS
 LACTATION PILLS , as no adverse effect on lactation.
 NO “ off and on” regime.
 Prescribed in patients having medical disorders – hypertension , fibroid ,
diabetes , epilepsy , smoking, h/o thromboembolism , HIV + women.
 Reduces risk of PID and Endometrial cancer.
DIS-ADVANTAGES OF MINIPILLS
Acne, Mastalgia, Headache,
 Breakthrough Bleeding,
Amenorrhea
Side Effects of Progestins
Simple cysts of ovary
Failure rate = 0.3- 2 HWY
CONTRA INDICATIONs
Pregnancy
Unexplained vaginal Bleeding
Recent breast cancer
•Women taking antiseizure drugs

56. CENTCHROMAN (CHHAYA/SAHELI
)ORMELOXIFENE ,
non steroidal compound
potent anti estrogenic and weak estrogenic properties.
Preventing implantation of fertilised ovum.
30 mg (twice a week for 1st 3 months ; then once a week)
 ASYNCHRONY between developing zygote and endometrium causing
implantation failure.
S/E : not to be used in PCOD , cervical cell hyperplasia, with liver (jaundice)
and kidney diseases & TB pts.
FAILURE RATE : 1-4 HWY .(less with increased doses.)
Safe to use in lactating women ; also emergency contraceptive.
Reversible ; return of fertility is immediate .
Potent antiestrogenic activity- in Mx of DUB, endometrial hyperplasia.
Used as HRT – weak estrogenic property.

57. Emergency Pills / PostCoital Pills
INDICATIONS :
Unprotected Intercourse
Condom rupture
 missed pills
Delay >3hrs in POP
Sexual assault / Rape

58. Morning After Pills
 in case of accidental unprotected exposure around the time of ovulation.
 Drugs-
 LEVONORGESTRAL (E.Pills) (0.75 mg) 2 doses given at 12 hour interval .
 1.50 mg can be taken as single dose also
 The first dose should be taken within 72 hours may taken upto 120 hours.
 Effective – 75- 85 % depends on the time of intake of tablets.
 MOA : > ovulation either prevented or delayed when taken in beginning of cycle.
> fertilization is interfered.
> interferes with function of corpus luteum or may cause luteolysis.
DRAWBACKS : Nausea and vomiting more intense with estrogen use.
Antiemetic (meclizine) should be prescribed.

59. COMBINED HORMONAL REGIMEN
(YUZPE METHOD)
 Two tablets of Ovral
 (0.25 mg Levonorgestral and 50 μg ethinyl estradiol )

 as early as possoble after coitus <72 hrs &
 And 2 more tablets taken 12 HOURS later.
 Oral antiemetic 10 mg Metoclopramide may be taken 1 hour
before each dose to reduce the problem of nausea and
vomiting.
 Ethinyl estradiol 2.5 mg : orally twice daily for 5 days
 beginning soon after the exposure but not later than 72
hours.

60.  ANTI PROGESTERONE (RU 486 – MIFEPRISTONE) binds competitively
to progesterone receptors and nullifies the effect of endogenous
progesterone.
 Dose: A single dose of 100 mg is to be taken within 5 days of
intercourse.
 Implantation is prevented due to antiprogesterone effect.
 Pregnancy rate is 0-0.6%.
 ULIPRISTAL ACETATE :
 superior to levonorgestral .
 a progesterone receptor modulator.
 Single dose 30 mg to be taken orally as soon as possible or within 120
hours of coitus.
 Suppressing follicular growth and endometrial growth.
 Delays ovulation and inhibits implantation.
 Not to be prescribed in severe hepatic dysfunction nor with severe
asthma.