Presentation on theme: "Hormonal contraception"— Presentation transcript:
1 Hormonal contraception
Hormonal contraceptives contain either a combination of estrogen and progestin or a progestin alone Combined hormonal contraceptives (CHCs) Work primarily before fertilization to prevent conception. Progestins provide most of the contraceptive effect, by thickening cervical mucus to prevent sperm penetration, slowing tubal motility and delaying sperm transport, and inducing endometrial atrophy Progestins block the LH surge, therefore inhibiting ovulation. Estrogens suppress FSH release from the pituitary, which may contribute to blocking the LH surge and preventing ovulation. However, the primary role of estrogen in hormonal contraceptives is to stabilize the endometrial lining and provide cycle control
2 Estrogens. Two synthetic estrogens found in hormonal contraceptives available in the United States, ethinyl estradiol (EE) and Mestranol (not available in Jordan) Most combined Ocs contain estrogen at doses of 20 to 50 mcg of EE, Progestins. Progestins currently used in OCs include desogestrel, drospirenone, ethynodiol diacetate, norgestimate, norethindrone, norethindrone acetate, norethynodrel, norgestrel, and levonorgestrel, the active isomer of norgestrel
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4 Non-contraceptive benefits of OCs
OCs are associated with numerous noncontraceptive benefits, including relief from menstruation-related problems (e.g., decreased menstrual cramps, decreased ovulatory pain [mittelschmerz], and decreased menstrual blood loss), improvement in menstrual regularity, increased hemoglobin concentrations, an improvement in acne. Women who take combination OCs have a reduced risk of ovarian and endometrial cancer, which is detectable within 1 year and persists for years after discontinuation. Combination OCs reduce the risk of ovarian cysts, ectopic pregnancy, pelvic inflammatory disease, and benign breast disease.
5 Monophasic vs. multiphasic pills
Monophasic OCs contain the same amounts of estrogen and progestin for 21 days, followed by 7 days of placebo pills. Biphasic and triphasic pills contain variable amounts of estrogen and progestin for 21 days, also followed by a 7-day placebo phase. Over the past decade, combination multiphasic formulations have further lowered the total monthly hormonal dose without clearly demonstrating any significant clinical differences Monophasic, biphasic, and triphasic OCs attempted to reduce breakthrough bleeding and other side effects, but reviews from the Cochrane Library found no important differences in bleeding patterns based on phasic composition.
6 Monophasic vs. multiphasic pills
The reduced progestin content may be desirable for women who experience progestin-related side effects caused by too much progestin or for women who have cardiovascular disease or metabolic abnormalities. Women with side effects related to progestin deficiency (e.g., late-cycle bleeding) who desire extended cycles or who have conditions necessitating progestin dominance (e.g., benign breast disease) may do better with a mono-phasic formulation One drawback associated with triphasic COC use is the confusion caused by the different-colored tablets in each of the three different phases, making the missed-dose instructions more complicated. Monophasic formulations are preferred for women who will be taking pills continuously (i.e., skipping the placebo pills
7 Triphasic oral contraceptive
8 Extended-cycle pills and continuous combination regimens are new developments that may offer some benefits for patients in terms of side effects. Extended-cycle OCs increase the number of hormone-containing pills from 21 to 84 days, followed by a 7-day placebo phase, resulting in four menstrual cycles per year.
9 OCs containing newer progestins (e. g
OCs containing newer progestins (e.g., desogestrel, drospirenone, gestodene, and norgestimate) are sometimes referred to as third generation OCs. These progestins are potent progestational agents that appear to have no estrogenic effects and are less androgenic compared with levonorgestrel on a weight basis. Therefore, these agents are thought to have improved side-effect profiles, such as improving mild to moderate acne Drospirenone also has antimineralocorticoid and antialdosterone activities, which may result in less weight gain compared to use of OCs containing levonorgestrel
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11 Unfortunately, few clinical trials have compared OCs and sample sizes are small, so the actual relevance of these differences in progestational selectivity and lower androgenic activity remains unknown. For example, a review by the Cochrane Library concluded that there was no evidence supporting a causal association between combination OCs or combination skin patches and weight gain.
12 Progestin only pills Progestin-only pills tend to be less effective than combination OCs and are associated with irregular and unpredictable menstrual bleeding. Minipills must be taken every day of the menstrual cycle at approximately the same time to maintain contraceptive efficacy. Because minipills may not block ovulation (nearly 40% of women continue to ovulate normally), the risk of ectopic pregnancy is higher with their use than with use of other hormonal contraceptives.
13 Progestin only pills
14 Starting an OCP In the “quick start” method for initiating OCs, the patient takes the first pill on the day of her office visit (after a negative urine pregnancy test). Women should be instructed to use a second method of contraception for at least 7 days and informed that the menstrual period will be delayed until completion of the active pills in the current OC pill pack. The quick start method has been shown to be more successful in getting women to start OCs and to continue using OCs through the third cycle of use. No evidence shows increased bleeding irregularities with this method of OC initiation The quick start method provides contraceptive protection sooner and, therefore, would likely lower the risk of unintended pregnancy.
15 Starting an OCP In the first-day start method, women take the first pill on the first day of the next menstrual cycle. The Sunday start method was the most common method of initiating OCs for years. Women started OCs on the first Sunday after starting the menstrual cycle. Sunday start methods result in “period-free” weekends but may affect compliance if obtaining refills on weekends is difficult. The advantage is that bleeding usually does not occur on weekends
16 The patient taking combination OCs should expect her menses to start within 1 to 3 days after taking the last active pill. She should start another pack of pills immediately after finishing a 28- day pack (no days between) or 1 week after finishing the previous 21-day pack, even if her menses is not completed Use of an additional contraceptive method is advisable if the patient misses taking a pill or experiences severe diarrhea or vomiting for several days
17 Any woman who is a candidate for COCs can use them continuously (i. e
Any woman who is a candidate for COCs can use them continuously (i.e. skipping the placebo tablets and taking no break between pill packs). Any product may be used continuously, however monophasic pills usually are selected. Any duration of continuous pill use is acceptable, but many providers recommend taking the active pills from 3 to 4 pill packs and then stopping for 2-7 days. Alternatively, providers may prescribe products that are specifically packaged for continuous use (Seasonale and generics, Seasonique, Lybrel). Continuous pill use usually results in more breakthrough bleeding or spotting than usual pill use, so women should be informed about this
18 When to Use a Back-Up Method of Contraception
Some clinicians recommend that women use an alternative method of contraception (back-up) for the entire first cycle. Using a back-up method for one full cycle is recommended because many new users of COCs do not complete the first cycle of pills. Most pill package inserts state that a back-up method of contraception (e.g., condoms) is not necessary if women use the Day 1 start method. When using the Sunday start or Quick start methods, back-up contraception should be used for the first week (7 days) of the cycle. A back-up method is also recommended when doses are missed
19 Breakthrough Bleeding, Spotting, and Amenorrhea
Bleeding during active pills days of the cycle (intermenstrual bleeding) that requires the use of a pad or tampon is designated breakthrough bleeding (BTB), whereas a lesser amount of intermenstrual bleeding that does not require protection is called spotting. Spotting and BTB are the most frequent reasons cited by women for the discontinuation of COCs. Most clinicians will continue with the same formulation for at least 3 months if irregular bleeding is the only complaint because BTB or spotting usually resolves without intervention.
20 Breakthrough Bleeding, Spotting, and Amenorrhea
Early-cycle intermenstrual bleeding, which usually starts before the 14th day of the menstrual cycle (or never ceases completely after menses), may be caused by insufficient estrogen. Late-cycle intermenstrual bleeding, which occurs after day 14, may be caused by insufficient progestational support of the endometrium. The most common cause of BTB or spotting, especially in long-term users of COCs, is missed pills or irregular pill taking. Before making formulation adjustments, adherence should be assessed. Other possible causes of BTB or spotting include drug interactions or infection.
21 Some women experience amenorrhea while taking COC.
If intermenstrual bleeding continues to occur late in cycle after 3 months of consistent use, a formulation with the same estrogen dose and more progestin should be prescribed. If intermenstrual bleeding early in the cycle after several months of use, she should be changed to a pill with a higher ratio of estrogen to progesterone Some women experience amenorrhea while taking COC. If this occurs, pregnancy should first be ruled out. If she is not pregnant and amenorrhea is acceptable to her, then the formulation need not be changed. If she prefers a monthly menstrual period, then a product with more estrogen or less progestin or a triphasic formulation can be tried.
22 Starting OCP after delivery
In the postpartum phase, there is concern about use of CHCs because of the mother’s hypercoagulability and the effects on lactation. In the first 21 days postpartum (when the risk of thrombosis is higher), estrogen-containing hormonal contraceptives should be avoided. If contraception is required during this period, progestin-only contraceptive methods may be acceptable alternatives. It is recommended that women who are breastfeeding avoid CHCs for the first 42 days postpartum in those with risk factors for VTE and for 30 days in those without risk factors. In those women who are not breastfeeding, CHCs should be avoided for up to 42 days postpartum in those with risk factors for VTE.After 42 days postpartum, there is no restriction to the use of CHCs. Risk factors include: family history, history of DVT, age > 40
23 Choice of OCP Because all combined OCs are similarly effective in preventing pregnancy, the initial choice is based on the hormonal content and dose, preferred pattern of pill use, and coexisting medical conditions In women without coexisting medical conditions, an OC containing 35 mcg or less of EE and less than 0.5 mg of norethindrone is recommended. Adolescents, underweight women (<110 lb [50 kg]), women older than 35 years, and those who are perimenopausal may have fewer side effects with OCs containing 20 to 25 mcg of EE.
24 Choice of OCP Women weighing more than 160 lb (72.7 kg) may have higher contraceptive failure rates with low-dose OCs and may benefit from pills containing 35–50 mcg of EE. Women with regular heavy menses initially may benefit from a 50-mcg EE OC as well because of their higher endometrial activity. On the other hand, women with regular light menses can be started on 20-mcg EE OCs. Women with oily skin, acne, and hirsutism should be given low androgenic Ocs.
25 Choice of OCP Conventional regimens (21 days of active pills, 7 days of placebo) provide predictable menses. Because monophasic OCs may be easier to take, easier to identify and manage side effects, and easier to manipulate to alter the timing of the menstrual cycle, they are preferred over conventional biphasic or triphasic Ocs Extended cycle OCs either eliminate the menstrual cycle or result in only four menstrual cycles per year, so they may be associated with less dysmenorrhea and menstrual migraines. Commercially available extended-cycle OCs are available, or monophasic 28 day OCs can be cycled by skipping the 7-day placebo phase for two to three cycles(sometimes referred to as bicycling and tricycling).
26 Choice of OCP With continued use of extended-cycle OCs for 1 year, no significant changes in blood pressure, weight, or hemoglobin compared with cyclic users have been noted. However, long-term studies have not been performed to assess the risk of cancer, VTE, or changes in fertility. Continuous regimens provide a shortened pill-free interval, from the traditional 7 days to 2 to 4 days. These regimens may be beneficial for women with dysmenorrhea and menstrual migraines
27 US Medical Eligibility Criteria for Contraceptive Use: Classifications for Combined Hormonal Contraceptives Aura symptoms Blind spots or scotomas Blindness in half of your visual field in one or botheyes(hemianopsia) Seeing zigzag patterns (fortification spectra) Seeing flashing lights (scintilla) Feeling pricklingskin(paresthesia) Weakness Seeing things that aren't really there (hallucinations)
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31 Managing OC side effects
Many symptoms occurring with early OC use (e.g., nausea, bloating, breakthrough bleeding) improve spontaneously by the third cycle of use after adjusting to the altered hormone levels. However, 59% to 81% of women who stopped OCs in one study did so because of the side effects. Therefore, patient education and early reevaluation (i.e., within 3–6 months) are necessary to identify and manage adverse effects, in an effort to improve compliance and prevent unintentional pregnancies
32 Side effects of Ocs Adverse effects may hinder compliance and therefore efficacy, so they should be discussed prior to initiating a hormonal contraceptive agent Estrogen excess can cause nausea and bloating, and low-dose estrogen CHCs can cause early or midcycle breakthrough bleeding and spotting. Progestins may be associated with fatigue and changes in mood. Low-dose progestin CHCs may cause late-cycle breakthrough bleeding and spotting. Androgenic activity derived from progestins may cause increased appetite and acne
33 Side effects of Ocs Menorrhagia : غزارة الطمث a CHC regimens should be continued for at least 3 months before adjustments are made based on adverse effects.
34 Side effects of Ocs a CHC regimens should be continued for at least 3 months before adjustments are made based on adverse effects.
35 Side effects of OCs a CHC regimens should be continued for at least 3 months before adjustments are made based on adverse effects.
36 Managing OC side effects
If the patient has symptoms related to OC use, it is necessary to determine if the symptom indicates the presence or potential development of a serious illness (Table 82–5). Patients should be instructed to immediately discontinue CHCs if they experience warning signs, sometimes described as ACHES (abdominal pain, chest pain, headaches, eye problems, and severe leg pain).
37 Managing OC side effects
38 Managing Oc drug interactions
The lower the dose of hormone in the OC, the greater the risk that a drug interaction will compromise its efficacy. Women should be instructed to use an alternative method of contraception (e.g.,condoms) if there is a possibility of a drug interacting altering the efficacy of the OC. Although less well documented, these recommendations generally also apply to patients receiving transdermal and vaginal CHC products.
39 Managing Oc drug interactions
Several reviews of the interaction between antibiotics and OCs have documented a true pharmacokinetic interaction with rifampin in which the efficacy of OCs is impaired. Pharmacokinetic studies of other antibiotics have not shown any consistent interaction, but case reports of individual patients have shown a reduction in EE levels when OCs are taken with tetracyclines and penicillin derivatives. The ACOG states that ampicillin, doxycycline, fluconazole, metronidazole, miconazole, fluoroquinolones, and tetracyclines do not decrease steroid levels in women taking Ocs.
40 Managing Oc drug interactions
The Council on Scientific Affairs at the American Medical Association recommends that women taking rifampin should be counseled about the risk of OC failure and advised to use an additional nonhormonal contraceptive agent during the course of rifampin therapy. The council also recommends that women be informed about the small risk of interactions with other antibiotics, and, if desired, appropriate additional nonhormonal contraceptive agents should be considered. In addition, women who develop breakthrough bleeding during concomitant use of antibiotics and OCs (and other CHCs) should be advised to use an alternate method of contraception during the period of concomitant use.
41 Managing Oc drug interactions
Women receiving anticonvulsants for a seizure disorder require special attention with regard to hormonal contraception. Some anticonvulsants (mainly phenobarbital, carbamazepine, phenytoin) induce the metabolism of estrogen and progestin, inducing breakthrough bleeding and potentially reducing contraceptive efficacy. In addition, some anticonvulsants (i.e., phenytoin) are known teratogens. Use of condoms in conjunction with high-estrogen OCs or IUDs can be considered for these women. use of a second method of contraception for 3 months of the combined therapies and monitor bleeding patterns. If no intracycle bleeding occurs, the secondary method can be discontinued.
42 Managing Oc drug interactions
Anticonvulsants–World Health Organization (WHO) suggest that women taking anticonvulsants includingphenytoin,carbamazepine, barbiturates,primidone,topiramate, oroxcarbazepineshould not use hormonal contraception (with the exception of depo-medroxyprogesterone acetate). They add, however, that hormonal contraception is reasonable if the patient understands the risks and cannot use other methods
43 Discontinuing Oral Contraceptives and Return of Fertility.
The average delay in ovulation after discontinuing OCs is 1 to 2 weeks, but delayed ovulation is more common in women with a history of irregular menses. Post-OC amenorrhea rarely lasts 6 months. Traditionally, women are counseled to allow two to three normal menstrual periods before becoming pregnant to permit the reestablishment of menses and ovulation. However, in several large cohort and case-control studies, infants conceived in the first month after discontinuation of an OC had no greater chance of miscarriage or being born with a birth defect than those born in the general population
44 Effect of missed pills: combined hormonal contraceptives
If a single pill is missed anywhere in the packet, the forgotten pill needs to be taken when noticed and the next pill is taken when it is due, which may mean taking two pills on the same day. No additional contraception is required. Back-up contraception is generally needed if two or more consecutive hormonal pills are missed. Women should take one of the missed active (hormonal) pills as soon as possible and then continue taking one pill each day as prescribed. Depending on when she remembers her missed pill, she may take two pills on the same day. If pills were missed in the last week of hormone pills, days 15 to 21 of a 28-day pack, omit the hormone-free week by finishing the hormone pills in current pack and start a new pack the next day. If unable to start a new pack, use back-up until hormonal pills from a new pack are taken for seven consecutive days. If the two or more pills are missed in the first week of the cycle and unprotected intercourse occurs during this week, use of emergency contraception could decrease the risk of pregnancy.
45 Effect of missed pills: progestin only pills
It is important to remember that handling missed or late doses of progestin-only OCs are different. If a woman forgets a tablet or is more than 3 hours late then additional non-hormonal contraception should be used for 48 hours
46 What to do in the case of vomiting or severe diarrhea
Efficacy of OCs may be decreased when vomiting or severe diarrhea occurs, and recommendations for dosing OCs in this situation have been developed. The recommendations are based on theoretical concerns and are identical to missed tablet instructions. If vomiting or diarrhea occurs for less than 48 hours then no redosing of OCs is warranted. If vomiting or diarrhea persists greater than 48 hours then continue taking tablets and use additional non-hormonal contraception until tablets have been taken for 7 consecutive days after the vomiting or diarrhea subsides. If this scenario occurs during the last week of the hormonal tablets, then finish the tablets, skip the hormone-free tablets and begin a new pack. Additional nonhormonal contraception should be used until 7 consecutive days of tablets are taken without gastrointestinal symptoms.
47 Drugs available in jordan:
MICROGYNON Tab (Ethinylestradiol 0.03 mg & Levonorgestrel 0.15 mg) NORDETTE TABS (Ethinylestradiol 30 mcg & Levonorgestrel 150 mcg) NORDIOL TABS (Ethinylestradiol 50 mcg & Levonorgestrel 250 mcg) TRINORDIOL TABS (Ethinylestradiol mg & Levonorgestrel mg)
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49 Drospirenone and EE
50 Levonorgestrel
51 Desogestrel
52 Primolut nor : norethisterone
Each tablet contains 5 milligrams of norethisterone BP.
53 Primolut nor : norethisterone
Postponement of menstruation:In cases of too frequent menstrual bleeding, and in special circumstances (e.g. operations, travel, sports) the postponement of menstruation is possible. The dosage is 1 tablet of Primolut N three times daily, starting 3 days before the expected onset of menstruation and continuing for not longer than 10 to 14 days. A normal period should occur 2-3 days after the patient has stopped taking tablets. This method should be restricted to users who are not at risk of pregnancy during the treatment cycle.
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