Combined oral contraceptive pills

Gynecology and Family planning

1. Combined Oral contraceptive pills

2. Non contraceptive health benefits of COC Gynaecological benefits Menstrual benefits Others Non gynaecological benefits Cancer protection

3. Menstrual benefits Regularises menses Reduces menstrual blood loss Reduce Fe deficiency anemia Reduce dysmenorrrohea Reduce PMS

4. Other gynaecological benefits Decrease functional ovarian cyst Reduces chance of fibroid Reduces acute PID Rx of perimenopausal change Rx of PCOS (Reducing acne and hirusitism and regularising bleeding) Rx of DUB Beneficial in endometriosis

5. Non gynaecological benefits ↑ bone mass Reduces Fibrocystic breast disease Fibroadenoma Acne RA

6. Cancer protection Ca Endometrium Ca Ovary Colorectal Ca Longlasting protection against Ca endometrium and hereditory epithelial carcinoma ovary Protective effect increases with duration of use Effect lastes upto 10- 15 years after discontinuation

7. Benefits Vs Risk Benefits outweigh risks Recommended for all women unless contraindicated

8. Mode of Administration 1 Pack- 21 or 28 tablets First pack Starts from day1 Continued for 21 days Pill free interval 7 days Next pack Starts after 7 days irrespective of menstruation Menstruation usually commences after 2-4 days of discontinuation of pill Some cases last 7 days contain placebo In that case, restart next pack without gap

9. Missed Pills One pill missed Take the missed as soon as remembers Then continue with pill taking No need of backup contraceptive method 2 pills missed Take 2 pills on the next 2 consecutive nights Continue with the rest of the pack as usual Backup contraceptive like barriers for one week Continue with next pack without gap If placebo present, skip that and start new pack

10. Newer Combined OCP Pills containing drospirenone Pills containing Cryproterone Acetate Pills with extended cycle length- Seasonale Ultra-low-dose pills

11. 1. Pills Containing Drospirenone Drospirenone - spironolactone analogue 3 mg Drospirenone = 25 mg spironolactone major effect- Antimineralocorticoid action Also- Antinadrogenic effect Hence resembles natural progesterone Combination available contain Ethinyl oestradiol 20-35 µg Drospirenone 3mg

12. Brands Yasmin - First made Tarana Crisanta Advantages Drospirenone counteracts the mineralocorticoid action of estrogen i. e. Ethinyl estradiol increases angiotensinogen production, which acts on RAS causing Na and water retention. It is reversed by drospirenone

13. Advantages- cntd . Less side effects like Weight gain, bloating, headache etc . Doesn’t cause HTN Useful in acne and hirusitsm due to antiandrogenic effect Useful in PCOS Relief from PMS Contraindications Women with hepatic, renal or adrenal problems  ppt. hyperkalemia Women taking ACE inhibitors, K sparing diuretics and aldosterone antagonists

14. 2. Pills containing C yproterone Acetate Cyproterone Acetate- Synthetic progesterone derived from 17- hydroxyprogesterone Has antigonadotrophic and antiandrogenic activity So firstly used in men to treat BPH MOA Competitive inhibiton of testosterone and dihydrotestosterone Also reduces 5 alfa reductase activity

15. Available combination Ethinyl estradiol 35 µm Cyproterone acetate 2mg Brand names in India Diane 35 Krimson 35 Mypil Advantage Antiadrogenic effect Useful in women with Hirusitsm Acne PCOS

16. 3. Pills with extended cycle length- Seasonale Seasonale - Combination of Ethinyl estradiol LNG Consist of 12 weeks of medication, i.e 84 week tablets+ 1 week of placebo Advantage Only 4 periods in one year Useful in Women desire lower no. of periods. Lifestyle Endometriosis Coagulopathy Anticoagulant therapy Dysmenorrhoea, menorrhagia, pms

17. 4. Ultra-low-dose Pills Combination Ethinyl estradiol 15µg Gestodene 60µg Clinical trials are ongoing Available abroad as “MINESSE”

18. Progesterone only Pills

19. Contains no estrogen Formerly, contained 1G and 2G progesterone Currently, only available formulation containing Desogestrel , the 3G progesterone Brand name- Cerazette : Recommended for breast feeding woman

20. Mode of Action D epends on the dose of formulation 60% cases- ovulation inhibited Others- Alteration of cervial mucous, Endometrial atrophy interfere implantation 20%- complete inhibition of follicular development  total amenorrhoea Remaining – Irregular bleeding

21. Administration Must be taken daily No free pill interval Must be taken at the same time If late by 3hrs, backup method must be used In breastfeeding women, pills only starts after 6wks post partum In other cases, pill must start on 1 st day of period

22. Effectiveness Used effectively in breastfeeding women, failure rate 0.5% Typical failure rate: 3-5%

23. Indications Breastfeeding- Most common No ADE in volume or composition of milk Perimenopausal women Reduced fecundity adds to the effectiveness of POP Conditions where Estrogen contraindicated SLE Cardiovascular diseae

24. Side Effects Major Disruption of menstrual pattern Reason for discontinuation- Irregular bleeding Amenorrhoea Minor Acne Breast tenderness

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