Hormonal contraception (Combined Hormonal Contraceptives)

Combined Hormonal Contraceptives :
includes:
Combined Oral Contraceptives (Pills)
Contraceptive vaginal ring
Transdermal patch

2. Progestogen Only Contraceptions(POC):
includes:
Progestogen-only pill(POP)
Implant
Progestogen-only injectable
Progestogen-releasing intrauterine system(LNG–IUS)

Missed pills:
If one pill is missed, anywhere in the pack (ie more than 24 and up to 48 hours late):
The last pill missed should be taken now, even if it means taking two pills in one day.
The rest of the pack should be taken as usual.
No additional contraception is needed.
The seven-day break is taken as normal.

Emergency contraception is not needed if just one pill has been missed. However, it should be considered if other pills have been missed recently, either earlier in the current packet, or at the end of the previous packet.

Missed pills:
If two or more pills are missed (ie more than 48 hours late):
The last pill missed should be taken now, even if it means taking two pills in one day.
Any earlier missed pills should be left.
The rest of the pack should be taken as usual and additional precautions (eg, condoms or abstinence) should be taken for the next seven days.
The next step then depends on where in the packet the pills are missed:


The next step then depends on where in the packet the pills are missed:
If the pills are missed in the first week of a pack (pills 1-7): emergency contraception should be considered if the patient had unprotected sex in the pill-free interval or the first week of the pill packet. She should finish the packet and have the usual pill-free interval.
If the pills are missed in the second week of a pack (pills 8-14): there is no need for emergency contraception as long as the pills in the preceding seven days have been taken correctly. The packet should be finished and the usual pill-free interval taken.
If the pills are missed in the third week of a pack (pills 15-21): the next pack of pills should be started without a break - ie the pill-free interval is omitted. If taking a packet with dummy/placebo pills, these should be discarded, and the new packet started. Emergency contraception is not required.
If more than seven pills are missed, the woman should start again as if starting for the first time. (Exclude pregnancy, and start a new pack on the first day of the next menstrual period.)

1. Contraception Hormonal Contraception Dr. Naji Majid Ahmed Hasan

2. Hormonal Contraception 2. Progestogen Only Contraceptions (POC): includes : Progestogen -only pill(POP) Implant Progestogen -only injectable Progestogen -releasing intrauterine system(LNG–IUS) Combined Hormonal Contraceptives : includes : Combined Oral Contraceptives (Pills) Contraceptive vaginal ring Transdermal patch

3. Abbreviations: DMPA , Depot medroxyprogesterone acetate; NET-EN, Norethisterone enanthate ; LNG, Levonorgestrel ; LNG-IUS , Levonorgestrel -intrauterine system; IUD, Intrauterine devices

4. 1. Combined Hormonal Contraceptives : The combined oral steroidal contraceptives is the most effective reversible method of contraception . Combination oral contraceptive pills (OCPs) contain various amounts of estrogen ( ethinyl estradiol) and one of a variety of progestins . Combined Oral Contraceptives (Pills)

5. Composition: Estrogens: Is ethinyl estradiol or its drivative ethinyl estradiol 3-methyl ether( mestranol ) contain between 20 μg and 35 μg of the synthetic estrogen Progestogens: The progestogens that are used in currently available pills are often referred to as : * second-generation ( levonorgestrel (LNG) , norethisterone ( NET ) ) * third-generation ( gestodene desogestrel ) and * fourth-generation ( drospirenone and dienogest ). Combined Oral Contraceptives (Pills) NOTE :

6. Newer (third-and fourth-generation ) progestogens were developed to have advantages due to less androgenic activity , but seem to be associated with a higher risk of venous thrombosis than pills containing second-generation progestogens . In view of this, COCPs containing second-generation progestogens are generally recommended as first choice. Combined Oral Contraceptives (Pills)

7. NOTE: Fourth generation: Drospirenone which is an analog of spironolactone is used as progestin. It has antiandrogenic and antimineralocorticoid action. It causes retention of K + (hyperkalemia ). So drospirenone should not be used in patients with renal, adrenal or hepatic dysfunction.

8. Some of the oral contraceptives and their composition Combined Oral Contraceptives (Pills)

9. Mode of action: The probable mechanism of contraception are: 1 . Suppression of ovulation 2 . Alteration of the character of the cervical mucus (thick, viscid, and scanty) so as to prevent sperm penetration. 3 . Alteration of tubal motility 4 . Alteration of endometrium to make it thin and inactive, thus hampering implantation Combined Oral Contraceptives (Pills)

10. Selection of the Patient : History and general examination: should be thorough, taking special care to screen cases for contraindications (headache , migraine). Examination of the breasts for any nodules , weight, and blood pressure are to be noted . Pelvic examination : to exclude cervical pathology, is mandatory . Pregnancy must be excluded . Cervical cytology to exclude abnormal cells, is to bedone . Thus, any woman of reproductive age group without any systemic disease and contraindications listed , is a suitable candidate for combined pill therapy. Growth and development of the pubertal and sexually active girls are not affected by the use of ‘pill’. Combined Oral Contraceptives (Pills)

11. How to Prescribe a Pill ? (Patient instruction ): New users should normally start their pill packet on day one of their cycle . One tablet daily at bed time for consecutive 21 days. then have a 7 days break , Next pack should be started on the eighth day , irrespective of bleeding (same day of the week, the pill finished ). Packing of 28 tablets, no break between packs . Seven of the pills are placebo . (contain either iron or vitamin preparations). Combined Oral Contraceptives (Pills)

12. 5) A woman can start the pill up to day 5 of the bleeding. In that case she is advised to use a condom for the next 7 days. 6) The pill should be started on the day after abortion . 7) Following childbirth in non-lactating woman , it is started after 3 weeks and in lactating woman it is to be withheld for 6 months Combined Oral Contraceptives (Pills)

13. Follow-up: The patient should be examined after 3 months, then after 6 months and then yearly. The patient above the age 35 should be checked more frequently. At each visit: Any adverse symptoms are to be noted. Examination of the breasts, weight, and blood pressure recording pelvic examination including cervical cytology, are to be done And compared with the previous records . Combined Oral Contraceptives (Pills)

14. Missed pills : If one pill is missed, anywhere in the pack ( ie more than 24 and up to 48 hours late ): The last pill missed should be taken now, even if it means taking two pills in one day. The rest of the pack should be taken as usual. No additional contraception is needed. The seven-day break is taken as normal . Emergency contraception is not needed if just one pill has been missed. However, it should be considered if other pills have been missed recently, either earlier in the current packet, or at the end of the previous packet . Combined Oral Contraceptives (Pills)

15. Missed pills : If two or more pills are missed ( ie more than 48 hours late ): The last pill missed should be taken now, even if it means taking two pills in one day. Any earlier missed pills should be left. The rest of the pack should be taken as usual and additional precautions ( eg , condoms or abstinence) should be taken for the next seven days. The next step then depends on where in the packet the pills are missed : Combined Oral Contraceptives (Pills)

16. The next step then depends on where in the packet the pills are missed : If the pills are missed in the first week of a pack (pills 1-7) :  emergency contraception  should be considered if the patient had unprotected sex in the pill-free interval or the first week of the pill packet. She should finish the packet and have the usual pill-free interval. If the pills are missed in the second week of a pack (pills 8-14) : there is no need for emergency contraception as long as the pills in the preceding seven days have been taken correctly. The packet should be finished and the usual pill-free interval taken. If the pills are missed in the third week of a pack (pills 15-21) : the next pack of pills should be started without a break - ie the pill-free interval is omitted. If taking a packet with dummy/placebo pills, these should be discarded, and the new packet started. Emergency contraception is not required. If more than seven pills are missed, the woman should start again as if starting for the first time. (Exclude pregnancy, and start a new pack on the first day of the next menstrual period .) Combined Oral Contraceptives (Pills)

17. Missed pill guidelines

18. Disadvantages Advantages Requires education and motivation Highly effective Limitation in its use Good cycle control Requires initial check up and periodic supervision Well-tolerated in majority Inconvenience caused in its use due to daily schedule Additional non-contraceptive benefits are many Risk of drug interactions Low dose pill with ‘lipid friendly’ progestins further reduces the risk Costly but free supply through government channel (Mala-N) Reversibility rate is prompt Combined Oral Contraceptives (Pills) Failure rate—0.1 (HWY)

19. Adverse Effects of COCs : Combined Oral Contraceptives (Pills)

20. Non-contraceptive benefits: Improvement of menstrual abnormalities: Regulation of menstrual cycle Reduction of dysmenorrhea (40%) Reduction of menorrhagia (50%) Reduction of PMS Reduction of Mittelschmerz syndrome Protection against iron-deficiency anemia Combined Oral Contraceptives (Pills)

21. Non-contraceptive benefits: Protection against health disorders : (7 ) PID (thick cervical mucus) ( 8) Ectopic pregnancy (9) Endometriosis ( 10) Fibroid uterus ( 11) Hirsutism and acne ( 12) Functional ovarian cysts ( 13) Benign breast disease (14 ) Osteopenia and postmenopausal osteoporotic fractures ( 15) Autoimmune disorders of thyroid ( 16) Rheumatoid arthritis ( 17) Increases Combined Oral Contraceptives (Pills)

22. Non-contraceptive benefits: Prevention of malignancies : (18) Endometrial cancer (50%) ( 19) Epithelial ovarian cancer (50%) ( 20) Colorectal cancer (40%). Combined Oral Contraceptives (Pills)

23. The combined hormonal transdermal patch releases 33.9 μg ethinyloestradiol /day and norelgestromin 203 μ g/day . It is applied to the skin of the lower abdomen, buttock or arm for 7 days, although it can be applied to any skin covered area, except the breast. application of patches for a total of 21 days followed by a 7-day hormone-free interval. Transdermal patch

24. The combined hormonal ring : is a flexible ring of 54 mm diameter that releases 15 μg ethinyloestradiol and 120 μg etonorgestrel daily, and as such is the lowest dose combined hormonal method. The ring is self inserted and worn in the vagina for 21 days, followed by a 7-day hormone-free interval, during which a withdrawal bleeding occurs. Contraceptive vaginal ring

25. 2. Progestogen Only Contraceptions (POC): includes : Progestogen -only pill(POP) Implant Progestogen -only injectable Progestogen -releasing intrauterine system(LNG–IUS)

26. POP is devoid of any estrogen compound. It contains very low dose of a progestin in any one of the following form levonorgestrel 75 g, norethisterone 350 g, desogestrel 75 g, lynestrenol 500 g or norgestrel 30 g. It has to be taken daily from the first day of the cycle . Mechanism of action : It works mainly by making cervical mucus thick and viscous, thereby prevents sperm penetration . Endometrium becomes atrophic, so blastocyst implantation is also hindered. In about 2% of cases ovulation is inhibited and 50 percent women ovulate normally. Progestogen -only pill (POP/MINI PILL)

27. How to prescribe a mini pill ?: The first pill has to be taken on the first day of the cycle and then continuously . It has to be taken regularly and at the same time of the day . There must be no break between the packs. Delay in intake for more than 3 hours, the woman should have missed pill immediately and the next one as schedule. Extra precaution has to be taken for next 2 days. Side-effects of all POPs include possible irregular bleeding, persistent ovarian follicles (simple cysts) and acne Progestogen -only pill (POP/MINI PILL)

28. Contraindications: Pregnancy , ( ii) Unexplained vaginal bleeding, ( iii) recent breast cancer, ( iv) arterialdisease and ( v) thromboembolic disease. Progestogen -only pill (POP/MINI PILL)

29. Implant

30. A single rod ( Nexplanon ®) or ( Implanon ) containing the progestogen etonorgestrel is the currently available method . It is a long-term (up to 3 years) reversible contraception. Nexplanon ® contains 68 mg of 3-keto desogestrel (a metabolite of desogestrel ) providing contraception for 3 years. The initial release rate of 60–70 μg /day falls gradually to around 25–30 μg /day at the end of 3 years. Implant

31. Mechanism of action: It inhibits ovulation in 90% of the cycles for the first year. It has got its supplementary effect on endometrium (atrophy) and cervical mucus (thick) as well. Insertion : Nexplanon ® is a flexible rod, similar in size to a match stick (40 mm × 2 mm) and is inserted subdermally 8 cm above the medical epicondyle, usually in the inner aspect of the non-dominant arm . It is inserted between biceps and triceps muscles. Implant

32. Nexplanon ® contains a small quantity of barium , which permits it to be visualized by X-ray. Implant

33. Removal : Implanon should be removed within 3 years of insertion. Removal is done by making a 2 mm incision at the tip of the implant and pushing the rod until it pops out. It is done under local anesthetic . Implant

34. Advantages : (i) Highly effective for long-term use and rapidly reversible. (ii) Suited for women who have completed their family but do not desire permanent sterilization. Efficacy of Implanon : is extremely high with Pearl indices of 0.01. Disadvantages : are frequent irregular menstrual bleeding, spotting and amenorrhea are common. Contraindications : are similar to POP Implant

35. Norplant–II ( Jadelle ) Two rods of 4 cm long with diameter of 2.5 mm is used. Each rod contains 75 mg of levonorgesterel . It releases 50 mcg of levonorgestrel per day. Contraceptive efficacy is similar to combined pills. Failure rate is 0.06 per 100 women years. It is used for 3 years. The rods are easier to insert and remove. Implant

36. The preparations commonly used are depomedroxy -progesterone acetate (DMPA) and norethisterone enanthate (NET-EN). The injectable is the only hormonal method that may delay return of fertility after discontinuation. In some cases it may take up to 1 year after the last injection for ovulation to return. There is no permanent impairment of fertility but this delay makes the injectable an inappropriate method for women wishing short-term contraception. Progestogen -only injectable

37. Administration : administered intramuscularly IM (deltoid or gluteus muscle) within 5 days of the cycle. or administered subcutaneously . IM as Depoprovera ® (150 mg) SC as Sayana press® (104 mg) Both have similar features , but SC are easier to give. Dose : * DMPA in a dose of 150 mg every three months (WHO 4 months) or 300 mg every six months; * NET-EN in a dose of 200 mg given at two monthly. * Depo -Sub Q provera 104 ( Sayana press®), contains 104 mg of DMPA. It is given subcutaneously over the anterior thigh or abdomen at every 90 days. It suppresses ovulation for 3 months as it is absorbed more slowly. Progestogen -only injectable

38. Mechanism of action: as POP Disadvantages : Both the intramuscular and subcutaneous preparation may cause weight gain in a minority of women and loss of bone mineral density (BMD) (5% loss of BMD at lumbar spine) in the first few years of use. Progestogen -only injectable

39. NOTE : There have been concerns over studies from countries of high human immunodeficiency virus (HIV) prevalence (such as sub-Saharan Africa) that have reported increased transmission and acquisition of HIV amongst users of Depoprovera ®, compared to users of other hormonal methods. so at present, the expert opinion of the WHO is that the injectable can be safely used in women living with HIV or at high risk of HIV. Condom use in addition to the injectable should also be encouraged to protect against transmission or acquisition of HIV. Contraindications : Women with high risk factors for osteoporosis, breast cancer, and the others are same as in POP . Progestogen -only injectable

40. The noncontraceptive benefits: are reduces the risk of: salpingitis , endometrial cancer, iron deficiency anemia, sickle cell problems, and endometriosis. Progestogen -only injectable