5. -> Alteration of character of cervical mucus
Thick ,viscid, scanty – prevent sperm penetration
-> Interferes with tubal motility and
alters tubal transport.
8. FUNCTION OF ESTROGEN IN OCP
Inhibits FSH rise and prevents follicular growth
Improves the efficacy over progesterone only pills
provides better cycle control than progesterone only pills
prevents breakthrough bleeding
9. Progesterone
-
Prepares the uterus for implantation by proliferation of
endometrium ;
Prepares body for pregnancy
Natural Progesterone – DESTROYED by digestive system when
consumed orally .
All oral contraceptives contain PROGESTIN , a synthetic form
of progesterone
10. Role of Progestins in COC
inhibits LH surge and thereby OVULATION.
Counteract the adverse effects of estrogen on the
endometrium (Hyperplasia)
Thickens cervical mucosa and thereby sperm
penetration difficult .
15. Advantages of 3rd generation Progestins
Lipid friendly progestogens
minimize side effects such as acne, hirusitism,
nausea, and lipid changes ,
Increasing progestational effects
16. Advantages of 4th generation progestins
Drospirenone
Dienogest
Nomogestrol
All three have antiandrogenic activity ;
Drospirenone has antimineralocorticoid activity
17.
18.
19. Patient Selection &
What to do before prescribing COC
History & GPE .
H/O headache, migraine
H/O amenorrhea
Family H/O Breast Cancer
Breast Examination : any nodule etc.
Pelvic Examination
Rule out Pregnancy.
Cervical Cytology : smear examination ; any
abnormal cells.
20. THE 21 DAY PACK
-the first seven pills in a packet inhibit ovulation
-the remaining 14 pills maintain anovulation.
THE 28 DAY PACK
New users : 1st pill – 1st day of menstrual cycle
1 tab daily at same time – 21 days (21 ACTIVE PILLS)
7 DUMMIES (INACTIVE PILLS)- iron or vitamin preparations.
can start upto 5th day of bleeding – use caution for next 7days
3 WEEK ON, 1 WEEK OFF
21. Special situations
After abortion : Day after abortion
After deliver : > Non Lactating : 3 weeks
6 week(WHO)
> Lactating : no COC or After 6 months.
22. Monophasic Pills
constant dose of both estrogen and progestin
in each of the hormonally active pills throughout
the entire cycle (21 days of ingesting active
pills).
23. Bi phasic pills
contain 2 different progesterone doses.
The progesterone dose is increased about
halfway through the cycle.
24. Triphasic Pills
Minimum dosage in the 1st half of the cycle for
contraceptive purpose.
Maximum dosage given in later part to prevent
Breakthrough Bleeding.
Advantages-
minimizes undesirable side effects of COCs on
lipid profile.
Without compromising the contraceptive
efficacy
25.
26. return of pituitary and ovarian follicular activity during the
pill free interval (PFI) of 7 days
BREAKTHROUGH OVULATION occurs (20% cases) in this PFI.
Any lengthening of PFI due to omissions, malabsorption ,
vomiting ,
increases risk of breakthrough ovulation and, therefore,
pregnancy.
MISSED PILLS !!
27.
28.
29. .Take 2 pills on each of next 2 days
Another form of contraception
as backup for next 7 days
OR >2 ANYTIME
30. MISSED INACTIVE PILLS
Discard the missed pills
Nothing to worry
Continue the rest as usual
42. NEOPLASIA AND COCs
Increased risk : breast cancer
Increased risk : cervical cancer
Reduced risk : endometrial cancer
Reduced risk : ovarian cancer
Reduced risk : colon cancer
-Reduce the no. of years of
pill intake.
-Choose another method of
contraception
-Regular screening for HPV
infection.
The longer you take the
combined estrogen and progestin
pills, the lower your risk.
43. Health Benefits of COCs
Contraceptive benefits
Protection against unwanted pregnancy
Failure rate = 0.1 per 100 women years
Not intercourse related.
Reversibility.
Non Contraceptive Benefits
Regulation of menstrual cycle ( BY inhibition of ovulation and
producing PG’s)
Reduction of menorrhagia
Reduction of PMS
Protection against iron deficiency anemia.
44. Protection against health disorders
PID (thick cervical mucus)
Ectopic Pregnancy
Endometriosis
Fibroid uterus
Hirsutism
Functional ovarian cysts
Benign breast diseases
Osteopenia and post menopausal osteoporotic fractures. (increases bone mineral
density )
Autoimmune thyroiditis
Rheumatoid arthritis.
Protection against malignancies
Endometrial cancer
Epithelial ovarian cancer
Colorectal cancer
45. Adverse effects of COCs
MINOR COMPILCATIONS
NAUSEA, VOMITING, HEADACHE ,AND LEG CRAMPS
MASTALGIA
WEIGHT GAIN :Progestins have anabolic effect due to its
chemical relation to testosterone, use of low dose COCs
do not cause any weight gain.
CHLOASMA AND ACNE :
MENSTRUAL ABNORMALITIES :
BREAK THROUGH BLEEDING : due to subthreshold of
hormone levels
46. ->disturbance of drug absorption – diarrhoea, vomiting
-use of enzyme inducing drugs, missing pills , use of low
dose pills.
miscarriage ->diseases- cervical ectopy or carcinoma.
Exognous estrogen (conjugated estrogen 1.26mg or
estradiol 2mg) given daily for 7 days control the bleeding
HYPOMENNORHEA : local endometrial changes
MENORRHAGIA : usually preexisting and use of progestin
preponderance compounds is helpful.
AMENORRHEA : post pill amenorrhea >6months in <1%
cases.
LIBIDO: may be diminished – dryness of vagina . Might
even increase due to loss of fear of pregnancy.
LEUKORRHEA : due to excessive cervical mucus secretion
47. MAJOR COMPLICATIONS !
VASCULAR COMPLICATIONS :
1.) VENOUS THROMBOEMBOLISM (VTE)
Pre existing hypertension, diabetes , obesity , thrombophilias , and elederly patients
(>35 yrs) with smoking habits are the imp. Risk factors.
- Ethinyl estradiol dose 20μg reduce the incidence.
2.) ARTERIAL THROMBOSIS : similar risk factors for myocardial infarction , stroke
(ischemic and hemorrhagic).
3.) HYPERTENSION low dose rarely cause htn.
pre existing hypertension is likely to be aggravated.
Mainly changes are seen in systolic BP due to activation of RAAS.
changes reverse back to normal after 3-6 months of stoppage f pill.
DEPRESSION : not with low dose estrogen .
CHOLESTATIC JAUNDICE : susceptibility increased if any previous history of
jaundice or hepatitis.
49. DRUG INTERACTIONS
REDUCES THE EFFICACY OF:
ASPIRIN
ORAL ANTICOAGULANTS
ORAL HYPOGLYCEMICS
INCREASES THE EFFICACY OF:
BETA BLOCKERS
CORTICOSTEROIDS
DIAZEPAM
Additional contraception :
Using broad spectrum antibiotics- ampicillin, ciprofloxacin - they impair
absorption of ethinyl estradiol
When enzyme inducing drugs are used : - Barbiturates – antiepileptic
(except sodium valproate and clonazepam) – Rifampicin – protease inhibitor
(ritonavir)
HERE High dose preparations (ethinyl estradiol of 50μg or more ) are to
be used to counter balance the increased liver metabolism.
50. Progestin Only Pill (POP/MINIPILL)
NO Estrogen compound.
Very low progestin in any of the forms
LEVONORGESTRAL 75μg
NORETHISTERONE 350 μg
NORGESTRAL 30 μg
MOA : > Make cervical mucus thick and viscous.
>Prevents sperm penetration
> Endometrium becomes atrophic ; blastocyst
implantation is hindered.
51. TAKEN DAILY FROM 1ST DAY OF CYCLE AND THEN CONTINOUSLY .
DELAY >3 HRS , TAKE PILL IMMEDIATELY .
EXTRA PRECAUTIONS FOR NEXT 2 DAYS .
52. ADVANTAGES OF MINIPILLS
LACTATION PILLS , as no adverse effect on lactation.
NO “ off and on” regime.
Prescribed in patients having medical disorders – hypertension , fibroid ,
diabetes , epilepsy , smoking, h/o thromboembolism , HIV + women.
Reduces risk of PID and Endometrial cancer.
DIS-ADVANTAGES OF MINIPILLS
Acne, Mastalgia, Headache,
Breakthrough Bleeding,
Amenorrhea
Side Effects of Progestins
Simple cysts of ovary
Failure rate = 0.3- 2 HWY
CONTRA INDICATIONs
Pregnancy
Unexplained vaginal Bleeding
Recent breast cancer
•Women taking antiseizure drugs
53.
54.
55.
56. CENTCHROMAN (CHHAYA/SAHELI
)ORMELOXIFENE ,
non steroidal compound
potent anti estrogenic and weak estrogenic properties.
Preventing implantation of fertilised ovum.
30 mg (twice a week for 1st 3 months ; then once a week)
ASYNCHRONY between developing zygote and endometrium causing
implantation failure.
S/E : not to be used in PCOD , cervical cell hyperplasia, with liver (jaundice)
and kidney diseases & TB pts.
FAILURE RATE : 1-4 HWY .(less with increased doses.)
Safe to use in lactating women ; also emergency contraceptive.
Reversible ; return of fertility is immediate .
Potent antiestrogenic activity- in Mx of DUB, endometrial hyperplasia.
Used as HRT – weak estrogenic property.
58. Morning After Pills
in case of accidental unprotected exposure around the time of ovulation.
Drugs-
LEVONORGESTRAL (E.Pills) (0.75 mg) 2 doses given at 12 hour interval .
1.50 mg can be taken as single dose also
The first dose should be taken within 72 hours may taken upto 120 hours.
Effective – 75- 85 % depends on the time of intake of tablets.
MOA : > ovulation either prevented or delayed when taken in beginning of cycle.
> fertilization is interfered.
> interferes with function of corpus luteum or may cause luteolysis.
DRAWBACKS : Nausea and vomiting more intense with estrogen use.
Antiemetic (meclizine) should be prescribed.
59. COMBINED HORMONAL REGIMEN
(YUZPE METHOD)
Two tablets of Ovral
(0.25 mg Levonorgestral and 50 μg ethinyl estradiol )
as early as possoble after coitus <72 hrs &
And 2 more tablets taken 12 HOURS later.
Oral antiemetic 10 mg Metoclopramide may be taken 1 hour
before each dose to reduce the problem of nausea and
vomiting.
Ethinyl estradiol 2.5 mg : orally twice daily for 5 days
beginning soon after the exposure but not later than 72
hours.
60. ANTI PROGESTERONE (RU 486 – MIFEPRISTONE) binds competitively
to progesterone receptors and nullifies the effect of endogenous
progesterone.
Dose: A single dose of 100 mg is to be taken within 5 days of
intercourse.
Implantation is prevented due to antiprogesterone effect.
Pregnancy rate is 0-0.6%.
ULIPRISTAL ACETATE :
superior to levonorgestral .
a progesterone receptor modulator.
Single dose 30 mg to be taken orally as soon as possible or within 120
hours of coitus.
Suppressing follicular growth and endometrial growth.
Delays ovulation and inhibits implantation.
Not to be prescribed in severe hepatic dysfunction nor with severe
asthma.
