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Hormonal Contraception
Ahmad Sameer Tanbouz
5th Year Medical Student - JU
Outline
 Combined [Estrogen & Progestin] Methods
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OCPs
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Transdermal Patches (Ortho Evra)
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Vaginal Ring (NuvaRing)
 Progesterone-Only Methods
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The Minipills (POPs)
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Injections
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Implants
OCPs
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Estradiol which is a natural Estrogen is NOT Orally Effective
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Ethinyl Estradiol = synthetic Estrogen – Orally Effective –
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Most contain Low dose Ethinyl Estradiol (20-35µg) plus
Progestin (Norethindrone, Norgestrel, Levonorgestrel,
Despgestrel, Norgestimate, Drospirenome)
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Failure rate (0.3% to 8%)
OCPs
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Place the body in a Pseudo-Pregnancy state by interfering
with the release of FSH & LH from the anterior pituitary
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The Pseudo-Pregnancy state suppresses ovulation &
prevents pregnancy from occurring
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Because the FSH & LH surges do not occur, follicle growth,
recruitment & ovulation do not occur
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It causes Thickening of the cervical mucus to render it less
penetrable by sperm & changes the endometrium to make it
unsuitable for implantation
Monophasic Combination Pills
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Contains a fixed dose of Estrogen & Progestin in each
tablet
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It is taken for the 1st 21 days out of 28-day monthly cycle.
During the last 7 days of each cycle, a placebo pill or no pill is
taken (21/7 regimens). Other Regimen (24/4)
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Bleeding should begin within 3 to 5 days of completion of the
21 days of hormones
Monophasic Combination Pills
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Women with menstrual-related disorders (such as
endometriosis, menorrhagia, anemia, dysmenorrhea, menstrual
irregularity, menstrual migraines, PMS, PCOS or ovarian cysts)
may benefit from extending the number of consecutive days
of hormonal pills thus increasing the length of continuous
hormonal suppression & decreasing the number of withdrawal
bleeds
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Seasonale contains 84 consecutive hormonal pills followed by
7 placebo pills, or 7 low-estrogen pills
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Lybrel – a 365-day OCP regimen – provides a combination of
Estrogen & Progestin pill each day, 365 days of the year
Multiphasic Combination Pills
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Vary the dosage of Estrogen and/or Progestin in the active hormone
pills in an effort to mimic the menstrual cycle
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It may provide a lower level of Estrogen & Progestin overall but it is
highly effective at preventing pregnancy
Non-contraceptive health benefits of OCPs
 Decrease risk of serious diseases
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Ovarian CA
Endometrial CA
Ectopic pregnancy
Severe anemia
PID – thickens cervical mucus –
Salpingitis
 Improve quality of life problems
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IDA [Iron Deficiency Anemia]
Dysmenorrhea – suppression of PG release –
Functional ovarian cysts
Benign breast disease
Osteoporosis
Non-contraceptive health benefits of OCPs
 Treat / manage many disorders
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DUB – stabilizes endometrium & shedding –
Dysmenorrhea
Endometriosis
Acne/ Hirsutism
Side Effects
 Estrogen-related:
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Nausea
Breast changes (tenderness, enlargement)
Fluid retention/bloating/edema
Weight gain (rare)
Migraine, headaches
Thromboembolic events
Liver adenoma (rare)
Side Effects
 Progestin-related:
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Amenorrhea
Headaches
Breast tenderness
Increased appetite
Decreased libido
Mood changes
Hypertension
Oily skin
Hirsutism
Complications
 Cardiovascular – DVT, PE, CVA, MI, HTN
 Cholelithiasis
 Cholecystitis
 Benign liver adenoma
 Cervical adenocarcinoma
 Retinal thrombosis
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OCPs with Estrogen >50mg can increase coagulability,
leading to higher rates of MI, stroke, thromboembolism and PE
particularly in women who smoke. At a lower doses of
estrogen (35 µg or less) women over 35 who smoke more than
one pack of cigarettes per day are still at increased risk of heart
attack, stroke, DVT & PE if they use OCPs
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The Progestin in OCPs have been found to raise LDL while
lowering HDL in pill users smoking more than 1 pack per day
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OCPs are contraindicated in women over age 35 who
smokes 15 or more cigarettes a day. These women often
benefit from Progesterone-only IUDs or permanent female or
male sterilization
Contraindications
 Absolute
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Thromboembolism
PE
CAD
CVA
Smokers over the age of 35
Breast / Endometrial CA
Unexplained vaginal bleeding
Abnormal liver function
Known or suspected pregnancy
Severe hypercholesterolemia
Severe triglyceridemia
Contraindications
 Relative
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Uterine fibroids
Lactation
DM
Sickle-cell disease
Hepatic disease
HTN
SLE
Migraine headaches
Seizure disorders
Elective surgery
Medications that reduces the efficacy of OCPs
 Barbiturates
 Carbamazepine (Tegretol)
 Phenytoin (Dilantin)
 Rifampicin
 Topiramate (Topamax)
Medications whose efficacies are changed by OCPs
 Diazepam (Valium)
 Methyldopa
 Phenothiazides
 Theophylline
 TCAs
Missed Combined OCPs
 Miss 1 pill during first 2 weeks of the cycle:
 Take 1 pill as soon as patient remembers & the next pill at
the usual time.
 Miss 2 pills in a row during first 2 weeks of the cycle:
 Take 1 pill the day patient remembers & the next pill at the
usual time.
 Back-up method of birth control & Emergency
Contraceptive method is required during next 7 days
 Missed 2 pills in a row during third week of the cycle
OR miss 3 in a row at any time:
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Throw out pack & start a new pack immediately
Back-up method of birth control required during next 7 days
Transdermal Patches – Ortho Evra
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Continuous release of 6mg Norelegestromin & 0.60mg Ethinyl
Estradiol into bloodstream
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Applied to lower abdomen, buttocks, shoulder, upper arm
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As effective as OCP in preventing pregnancy (>99% with perfect
use)
Transdermal Patches – Ortho Evra
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Women apply one patch each week for 3 weeks followed by
1 week patch-free during which they will have a withdrawal
bleed.
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It has been found that effectiveness is decreased in markedly
overweight women (greater than 90 kg)
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The patch can cause skin irritation in some users
Vaginal Ring - NuvaRing
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It releases a daily dose 15µg of Ethinyl Estradiol &120µg of
Etonogestrel
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The ring is placed in the vagina for 3 weeks and is removed for
1 week to allow for a withdrawal bleed.
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As effective as OCP in preventing pregnancy (98%)
Vaginal Ring - NuvaRing
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Because one size of vaginal ring fits all women, the vaginal ring
does not need to be fitted by a clinician
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The use of Antifungal Agents & Spermicides is permitted
 Disadvantages:
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Discomfort
Headache
Vaginal Discharge
Recurrent Vaginitis
The Minipill (POPs)
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Deliver a small daily dose of Progestin (0.35 mg
Norethindrone) without any Estrogen
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POPs have lower Progestin levels than combination pills, thus
the nickname Minipills
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Higher failure rate (1.1 – 13% with typical use, 0.51% with
perfect use) than other hormonal methods
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They are taken Every Day of the cycle with NO hormone-free
days
The Minipill (POPs)
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They are not as effective as the combination pills since failure
rate increases if punctual dosing is not achieved
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It thicken the cervical mucus making it less permeable to sperm
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It causes endometrial atrophy & ovulation suppression
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Because they contain no estrogen, POPs are ideal for
nursing mothers & women for whom estrogens are
contraindicated including women over 35 who smoke & women
with HTN, CAD, CVD, SLE, Migraines & Thromboembolism
The Minipill (POPs)
 Disadvantages:
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Irregular menses ranging from amenorrhea to irregular
spotting
POPs must be taken at the same time each day
(a delay of more than 3 hours is similar to a missed pill!!!)
Acne formation
Breast tenderness & Irritability
Missed progestin-only pills:
• If a pill is missed, it should be taken as soon as possible;
the next pill should be taken at the scheduled time. Backup
contraception should be used for the next 48 hours
Injections
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Depo-Medroxy-Progesterone Acetate (DMPA)
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It is injected IM every 3 months in a vehicle that allows the slow
release of Progestin over a 3-month period
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It acts by suppressing ovulation, thickening the cervical
mucus & making the endometrium unsuitable for
implantation
Injections
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It is one of the most effective contraceptive methods available
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This formulation carries the benefit of lower Progestin levels but
the same efficacy rates
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50% of DMPA users will have amenorrhea after 1 year of
use and 80% after 5 years of DMPA use! This makes it a good
option for women with bleeding disorders, or on anticoagulation,
or who are in military or who are mentally & physically disabled
Injections
 Advantages:
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Highly effective
Acts independent of intercourse
Only requires injections every 3 months
Reduces the risk of Endometrial CA & PID
Reduces the amount of menstrual bleeding
Useful in treatment of menorrhagia, dysmenorrhea,
endometriosis, menstrual related anemia & endometrial
hyperplasia
Injections
 Disadvantages:
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Decreased Bone Density (Reversible)
Irregular bleeding
Weight gain
Mood changes
Hair loss
Headache
After discontinuation of injections, some women may experience a
significant delay in the return of regular ovulation (6 to 18 months)
Implants
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It is a single-rod, Progestin implant that provides 3 years of
uninterrupted contraceptive coverage
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The Progestin used in Implanon is Etonogestrel – the same
Progestin used in NuvaRing –
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The device provides slow release of 68mg of Etonogestrel over
3 years
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It is the size of a matchstick & is placed in the subdermal skin of
a woman’s upper arm
Implants
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When appropriate timing of placement is utilized, Implanon is
effective 24 hours after placement & has quick return to fertility
once the device is removed by a clinician
 Advantages:
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Implantable
Provides 3 uninterrupted years of contraceptive coverage
 Disadvantages:
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The need for a clinician to insert & remove the device
Unpredictable bleeding profile