HORMONAL

CONTRACEPTION

dr.Abd.Harris Pane, SpOG

Department of Obstetric & Gynecology

Faculty of Medicine
Islamic University of North Sumatra
Medan
 INTRODUCTION
Two types of estrogen are used in combined
OCs: ethinyl estradiol and mestranol.
Mestranol is a prodrug that is converted

in vivo to ethinyl estradiol.

Several different progestins, of varying

degrees of progestational potency, are used

in combined OCs
 INTRODUCTION
The progestins may also have :
estrogenic,
antiestrogenic, or
androgenic
activity.
 Progestins
Progestins can be classified according to
their chemical structure as an:
1. Estrane (norethindrone, ethynodiol
diacetate)
or as a:
2. Gonane (levonorgestrel, desogestrel,
norgestimate).
 Progestins
In general, the gonane progestins appear
to be more potent than the estrane
derivatives (smaller doses
can be used), but otherwise
differences between the estrane and
gonane compounds are difficult to
characterize
Newer progestins (norgestimate and

desogestrel) have been shown to have

little or no androgenic activity.
 Progestins
When administered in combination with
ethinyl estradiol, produce a net
estrogen-dominant effect,
which may explain the effects seen on:
1. Hepatic proteins (increased levels of sex
hormonebinding globulin),
2. Lipid metabolism (increased levels of
triglycerides and high-density
lipoprotein-cholesterol), and on
3. Haemostatic variables (increased levels
of fibrinogen, plasminogen, and Factor
VII).
 EFFICACY
The combined OC is a highly effective
method of reversible contraception.
With perfect use, the combined OC is

99.9% effective in preventing pregnancy.

However, typical user failure rates range

from 3 - 8%.
Poor patient compliance is a major factor

in limiting effectiveness.
The effect of body weight on the efficacy of

the combined OC is controversial.

 EFFICACY
A retrospective cohort study found that women weighing
70.5 kg or more had a significantly increased risk of
combined OC failure compared with women of lower body
weight.
The relative risk of failure was 2.6 among low dose
combined OC users and 4.5 among very-low-dose
combined OC users.
However, a large cohort study failed to find evidence

of any influence of body weight on the risk of

accidental pregnancy in combined OC users.
Further studies are required before recommendations

can be made.
 MECHANISM OF ACTION

The combined OCs multiple mechanisms

of action may contribute to its high
efficacy.

Its main mechanism of action is to suppress

gonadotropin secretion, thereby inhibiting
ovulation.
 MECHANISM OF ACTION
Other mechanisms of action include:
1. Development of endometrial atrophy,
making the endometrium unreceptive to
implantation;
2. Production of viscous cervical mucus that
impedes sperm transport;
3. Possible effect on secretion and peristalsis
within the fallopian tube, which interferes
with ovum and sperm transport.
 INDICATIONS
In the absence of contraindications, use of the
combined OC may be considered for any woman
seeking a reliable, reversible, coitally-
independent method of contraception.
It is particularly suited for women who wish

to take advantage of its noncontraceptive

benefits.
The use of condoms is still recommended in
combined OC users for protection against
sexually transmitted infections (STIs) and
human immunodeficiency virus (HIV).
 CONTRAINDICATIONS

The World Health Organization (WHO) has

developed a list of absolute and relative
contraindications to the use of combined
OCs, based on the available evidence of
risks
ABSOLUTE CONTRAINDICATIONS
1. < 6 weeks postpartum if breastfeeding
2. Smoker over the age of 35 ( 15 cigarettes per day)
3. Hypertension (systolic 160mm Hg or diastolic 100mm
Hg)
4. Current or past history of venous thromboembolism (VTE)
5. Ischemic heart disease
6. History of cerebrovascular accident
7. Complicated valvular heart disease
8. Migraine headache with focal neurological symptoms
9. Breast cancer (current)
10. Diabetes with retinopathy/nephropathy/neuropathy
11. Severe cirrhosis
12. Liver tumour (adenoma or hepatoma)
 RELATIVE CONTRAINDICATIONS
1. Smoker over the age of 35 (< 15 cigarettes per
day)
2. Adequately controlled hypertension
3. Hypertension (systolic 140159mm Hg,
diastolic 9099mm Hg)
4. Migraine headache over the age of 35
5. Currently symptomatic gallbladder disease
6. Mild cirrhosis
7. History of combined OC-related cholestasis
8. Users of medications that may interfere with
combined OC metabolism
NON-CONTRACEPTIVE BENEFITS
1. Cycle regulation
2. Decreased menstrual flow
3. Increased bone mineral density
4. Decreased dysmenorrhea
5. Decreased peri-menopausal symptoms
6. Decreased acne
7. Decreased hirsutism
8. Decreased endometrial cancer
9. Decreased ovarian cancer
10. Decreased risk of fibroids
11. Possibly fewer ovarian cysts
12. Possibly fewer cases of benign breast disease
13. Possibly less colorectal carcinoma
14. Decreased incidence of salpingitis
15. Decreased incidence or severity of moliminal symptoms
 SIDE-EFFECTS
Some combined OC users will experience
minor side-effects, most commonly during
the first 3 cycles.
These side-effects may lead to
discontinuation of the combined OC.
Reassurance and adequate counseling
about expected common side-effects can
help to prevent unnecessary discontinuation
and enhance compliance.
 SIDE-EFFECTS
The most common reason patients
discontinue combined OC use is:

1. Abnormal menstrual bleeding,

2. Nausea,
3. Weight gain,
4. Mood changes,
5. Breast tenderness,
6. Headache.
MYTHS AND MISCONCEPTIONS
1. The combined OC causes cancer.
Fact:
The combined OC reduces the risks of

ovarian and endometrial cancer.

The risk of ovarian cancer is reduced by at

least half in women who use combined

OCs.
A meta-analysis of 20 studies of combined

OC use indicated that the risk of ovarian

cancer decreased with increasing duration
of OC use.
MYTHS AND MISCONCEPTIONS
2. Women on the combined OC should have
periodic pill breaks.
Fact:
This is unnecessary.
Pill breaks place a woman at risk for
unintended pregnancy and cycle
irregularity.
MYTHS AND MISCONCEPTIONS
3. The combined OC affects future fertility.
Fact:
Fertility is restored within 1 to 3 months after

stopping the combined pills.

4. The combined OC causes birth defects if a

woman becomes pregnant while taking it.
Fact:
There is no evidence that the combined OC
causes birth defects if it is taken inadvertently
during pregnancy.
MYTHS AND MISCONCEPTIONS
5. The combined OC must be stopped in all women over
35 years old.
Fact:
Healthy, non-smoking women may continue to use the

combined OC until menopause.

6.The combined OC causes acne.

Fact:
Acne improves in women using the combined OC due
to a decrease in circulating free androgen.
All combined OCs will result in an improvement of acne
 INJECTABLE
CONTRACEPTIVES
Introduction

Injectable contraceptives contain

hormonal drugs that provide
women with safe, highly
effective, and reversible
contraceptive protection.
 Two types of injectable
contraceptives :
1. Progestogen-only formulations that
contain a progestogen hormone and are
effective for 2 or 3 months; and,

2. Combined formulations that contain

both a progestogen and an estrogen and
are effective for 1 month
Progestogen -only formulations

Consist of DMPA (depot medroxy-

progesterone acetate) and NET-EN
(norethisterone enanthate).
DMPA is the injectable formulation
most widely used worldwide.
DMPA is injected every 3 months.
NET-EN is injected every 2 months.
Combined formulations
The most extensively studied
formulations are known by their
brand names,
Mesigyna/Norigynon, Cyclofem;
Monthly injectable.
Mesigyna contains the same
progestogen as NET-EN.& contains
an added estrogen.
 IMPLANT
Norplant (Levonorgestrel) :
Implantable for 5 Years
Similar Side Effects as Depo-Provera
Average Yearly Failure Rate: 0.8/100 (Increases : >
2/100 after 5 years)
Occasionally Difficult to Remove
Jadena/Indoplant (Levonorgestrel) :
Implantable for 3 Years
Implanon
(DesogestrelEtonogestrel)) :
Implantable for 3 Years
Implanon
 Introduction
Implanon is a subdermal implant containing
etonogestrel, which is a metabolite of
desogestrel, a third generation progestagen.
Etonogestrel has poor affinity for androgen

receptors and therefore gives fewer androgenic

side effects compared to the older second
generation progestagens, such as levonorgestrel.
Implanon is an effective form of contraception

,with a Pearl Index of 0.00-0.07, ie. Pregnancy risk

is lower than that seen after tubal occlusion or
vasectomy.
How does Implanon work?
Etonogestrel does not completely inhibit
follicle stimulating hormone secretion from the
pituitary.
Some follicular activity is seen in the ovaries,

resulting in physiological levels of serum

oestradiol.
Etonogestrel also produces thickening of the

cervical mucus, preventing sperm penetration.

Progestagenic changes are also seen in the

endometrium, with a decrease in endometrial

thickness.
 Is it readily reversible?
The implant can be removed at any time at the
womans request but must be removed at three
years.
Serum etonogestrel levels become undetectable

within a few days after removal of the implant.

Studies have shown that pre-existing levels of

fertility return rapidly, with 94% of women

having ovulated within one month of rod
removal.
Changes of usual menstrual pattern will be seen in
all women who use the implant.
IUDs contains Progestin
Levonorgestrel-releasing device (Mirena) or
Prigestase release Progestin are currently
available.
Mirena is also referred to as a

levonorgestrel-releasing intrauterine system

(LNG-IUS).
 EFFICACY
The failure rate of the levonorgestrel-
releasing intrauterine system was 0.09 per
100 WY and
The ectopic pregnancy rate was 0.02 per 100

WY.
The LNG-IUS should be replaced every 5

years.
NON-CONTRACEPTIVE BENEFITS

Menorrhagia responds favourably to use of

the LNG-IUS, with reported reductions in
menstrual blood loss of 74 to 97% and
favourable effects on hemoglobin levels.
In 2 studies of women scheduled to undergo

hysterectomy for menorrhagia, 64 to 80% of

women randomized preoperatively to LNG-IUS
insertion subsequently cancelled their
hysterectomy, compared with 9 to 14% of
women randomized to receive other medical
treatments.
NON-CONTRACEPTIVE BENEFITS

Dysmenorrhea may also improve in LNG-

IUS users.
A randomized controlled study found that

use of the LNG-IUS protects against

endometrial hyperplasia in women on
tamoxifen.
Small reports support a beneficial effect in

the treatment of fibroid-related

menorrhagia.
 SIDE EFFECTS
1. BLEEDING
2. PAIN OR DYSMENORRHEA
3. HORMONAL
4. FUNCTIONAL OVARIAN CYSTS
 1. BLEEDING
Users of the LNG-IUS experience a reduction
in menstrual blood loss of between 74 and
97%.
Women using the LNG-IUS have an average
of 16 days of bleeding or spotting at 1 month
after insertion, and this decreases to an
average of 4 days by 12 months after
insertion.
1. BLEEDING
The cumulative termination rates for
bleeding problems after 5 years of use are
up to 14% for the LNG-IUS.
Between 16 and 35% of LNG-IUS users will

become amenorrheic after one year of

use.
Since information received in advance will

improve user satisfaction, patients should

be carefully counselled regarding potential
menstrual changes prior to IUD insertion.
2. PAIN OR
DYSMENORRHEA
Up to 6% of copper IUD and LNG-IUS users
will have discontinued use at 5 years
because of pain.
Pain may be a physiological response to the

presence of the device, but the possibility of

infection, malposition of the device
(including perforation), and pregnancy
should be excluded.
The LNG-IUS has been associated with a

decrease in menstrual pain.

3. HORMONAL
The LNG-IUS appears to exert some systemic
hormonal effects, even though the daily dose of
levonorgestrel is extremely low.
Hormonal side effects include depression, acne,

headache, and breast tenderness.

Most studies report a low incidence of such
adverse effects, which appear to be maximal at
3 months after insertion and then decrease.
Although weight gain has been reported as a
side effect of LNG-IUS use, a large trial reported
no significant difference in weight gain over 5
years in LNG-IUS users and copper IUD users.
4. FUNCTIONAL OVARIAN CYSTS

Functional ovarian cysts have been

reported in up to 30% of LNG-IUS users.
Since these cysts usually resolve

spontaneously, they should be managed

expectantly.
 RISKS

1. UTERINE PERFORATION
2. INFECTION
3. EXPULSION
4. FAILURE
 TROUBLESHOOTING
1. LOST STRINGS
2. PREGNANCY WITH AN IUD IN PLACE
3. AMENORRHEA OR DELAYED MENSES
4. PAIN AND ABNORMAL BLEEDING
5. DIFFICULTY REMOVING THE IUD
6. STI IDENTIFIED WITH IUD IN PLACE
7. ACTINOMYCOSIS ON PAP SMEAR
Thank you