Hormonal contraception

Hormonal contraception refers to birth control methods that act on the endocrine system. Almost all methods are composed of steroid hormones, although in India one selective estrogen receptor modulator is marketed as a contraceptive.

1. Hormonal Contraception Prepared By: 1. Bibhu Prasad Sahu (GM/16/058) 2. Subhrajyoti Roy (GM/16/139) 3. Protiksha Saha (GM/16/024) 4. Biswarup Boxi (GM/16/087)

2. I n t r odu c tion World’s population expected to reach 9 billion by 2050. India accounts for 18% of World’s population… !!! Annually, 529,000 maternal deaths & 50 million morbidity. In India, contraceptive prevalence is 48.3% . 21% of all pregnancies resulting live births are unplanned….!!! If unmet need for contraception was met, we can avoid 52 million unwanted pregnancies 25-50% of maternal deaths

3. 1 / 1 3 / 2 15 Dr Shashwat Jani. 9909944160 3

4. Advantages Most effective, long-term reversible contraception available Most methods offer complete privacy Require no planning before intercourse Disadvantages Require a visit to a healthcare professional May cause common hormonal side effects Products containing estrogen may be associated with rare, but serious health risks Not effective against STD

5. HORMONAL CONTRACEPTION ORAL CONTRACEPTION COMBINED , P ROGESTERONE ONLY PILLS (MINI PILLS) NON- ORAL CONTRACEPTION TRANSDERMAL PATCHES INJECTABLE CONTRACEPTION IUDs IMPLANTS VAGINAL RINGS

6. ORAL CONTRACEPTION

7. Commonly known as the “ Pill “ Widely Accepted & Most Effective Reversible method of Fertility Control. In 1951, India was the 1 st country in world to introduce COC in National programme of Family Planning. 1. The Combined Oral Pill

8. Contain Synthetic Estrogen/Progestin Modern E 2 Dosage ≤ 50 Mcg Despite Diversity, Side Effects and Efficacies Similar Requires Patient Compliance May Be Monophasic or Triphasic COC:Estrogen + Progestrogen

9. Estrogens: Ethinyl estradiol Mestranol Progestins: Ethynodiol diacetate Norethindrone acetate Norethindrone Norgestrel Levonorgestrel Desogestrel Norgestimate Drospirenone 2 nd Generation 3 rd Generation Spironolactone Derived

10. Types of COC

11. 1) Monophasic Contains Estrogen & Progesterone in same amount in Each pill . Divided in 2 subgroups : Low dose pills : EE 30 – 35 microgm Very low dose pills : EE 15 – 25 microgm. Mala - N dl – NGL 0.15 mg EE 0.03 mg Mala - D l – NGL 0.15 mg EE 0.03 mg

12. 2 ) Multiphasic Contains low or variable amounts of E and P in 2 ( biphasic ) or 3 ( triphasic ) phases of cycles. Biphasic : constant EE – 35 microgm progestogens : low in first 10 days higher in next 11 days . NOT POPULAR – MORE FAILURE RATE . NOT AVAILABLE IN INDIA … 

13. 3. Triphasic : Triquilar – - 0.03 EE +0.5mg l-norgestrel (1 - 6) - 0.03 EE +0.75mg l-norgestrel (7-11) - 0.03 EE +0.125mg l-norgestrel (12 - 21) Total monthly intake – 0.68mg EE +1.92mg progesterone Ad v . – high efficacy rates few side effects less break through bleeding does not affect s.cholesterol & LIPIDS Disadv. – high pregnancy rates if errors in pill intake .

14. Mechanism of Action Suppresses LH / FSH Release (E 2 FSH, P LH) Progestin Thickens Cervical Mucus and Alters Endometrium Major Effect Is Anovulation and Impairment of Sperm Transport and Oöcyte Implantation

15. A d v antages: Highly effective Provides noncontraceptive health benefits Private Does not require vaginal insertion Allows to control cycle Disadvantages: Must be taken daily Side effects may lead to discontinuation Associated with rare, but serious health risks, such as blood clots and stroke

16. Non-Contraceptive Benefits of OCPs Improvement D y smen o rr h ea Acne Hirsutism Anemia Cycle Regulation Reduction Risks Colorectal Cancer (18-40%) Endometrial Cancer PID (10 – 70%) Osteo p o r o s i s Osteopenia Cleveland Journal of Medicine 2004

17. Administration New User : 1 st day of Cycle . Daily 1 tab. Preferably at night for consecutive 21 days. Continued for 21 days and then 7 days break ( with iron tablets ) . Next pack of Pill should be started on 8 th day , IRRESPECTIVE OF BLEEDING ( same day of the week , pill finished ). Simple Regimen of “ 3 WEEKS ON & 1 WEEK OFF “ No break between packs. Can start pill up to 5 days of bleeding with extra precaution with condom for next 7 days.

18. Missed Pill Regime (WHO)

19. Extended Use of COC… ( Seasonale) Available since 2003 150µg of LNG + 30µg of EE Only Active Pills taken continuously for 84 days, then break for 7 days. Fewer periods (4 in a year) Pearl index- 0.78 Breakthrough bleeding/ spotting – First few cycles

20. Lactating Women – Progestogen only pills / Combined pills after 6 months Non Lactating Women – Combined oral pills after 3 to 6 weeks or after menstruation 1 st / 2 nd Trimester abortion – during first 7 days. Amenorrhea : At any time after excluding pregnancy + barrier method for 7 days.

21. Follow up … Examined after 3 months , then after 6 months and then yearly . Ask for any symptoms… Examination for breast , pelvis, BP & weight & cervical cytology.

22. How long can be continued …??? In properly selected patient without any risk factor , benefits are more , and so can be continued up to age of 50 with careful monitoring. Offers dual advantage of Contraception and HRT. For spacing of birth : 3 – 5 years.

23. Side Effects Breakthrough Bleeding (≤ 25%) Amenorrhea Breast Tenderness, Nausea ? HTN ? Weight Gain

24. R i sk s Thromboembolism (≥ 35 yo, Smoker) MI (Smokers Only): < 15 cig/day: 3X Risk > 15 cig/day : 21X Risk Liver Adenomas (Very Rare)

25. Mini pills PREPARATIONS Norethindrone – 0.350 mg ( micronor/cerazette) Levonorgestrel – 0.075 mg ( Neogest ) Norgestrel - 0.030 mg ( Norgeston ) Ethynodiol diacetate – 0.5 mg ( Femulen ) INDICATIONS : Age > 40 Yrs. Lactating Women. MECHANISM : Cervical Mucus Thickning :- Effect starts in 2-4 hrs. & last for 20–24 hrs. Inhibits Ovulation Involute Endometrium

26. 2. MINI PILLS Schedule 1 st day of M.C. and a backup method for 7 days 6 wks after delivery – no backup method Missed Tablet – Backup method for 48 Hrs. Failure Rate - 3- 10 % Lactating Women – 0.5 % Advantages Can be used above 16 yrs of age, Smokers & obesity Be s t i n DM , C V S Di s eases & SLE Disadvantages Irregular Bleeding, Acne, Mastalgia, Amenorrhoea

27. Contraindications Pregnancy Breast Cancer Unexplained Vaginal bleeding

28. NON- ORAL CONTRACEPTION

29. 1. The Contraceptive Patch (Evra Patch) Advantages: Efficacy comparable to OCPs Weekly application encourages compliance Does not require vaginal insertion Disadvantages : Application site reactions may occur May not be as effective in women weighing more than 198 pounds May produce side effects similar to OCPs, with higher rate of transient breast pain Noncontraceptive health benefits theoretically similar to combination OCPs, but not as well documented May be visible on the skin OCP = Oral Contraceptive Pill

30. 2. Injectable Hormonal Contraception Advantages: Highly effective Convenient three month administration schedule encourages adherence Private Useful when estrogen should be avoided Decreases risk of endometrial cancer Disadvantages: Irregular bleeding and amenorrhea frequently occur Weight gain, abdominal pain, and depression are common side effects Prolonged use may decrease bone mass

31. Depo Provera: -every 3 months - Medro x y progest i n Acetate 150 mg. T y pes

32. Main Side-Effects: Am e n o rr h e a AUB Weight Gain Hair Loss

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