Ecological tales about ladybugs
At the edge of a large, very large meadow, on a long emerald blade of grass lived a tiny Ladybug. Little Ladybug...
Oral contraception is the choice of a modern woman. Method of contraception: combined oral contraceptive (COC)
First a mystery. Let's say you have a hundred women. Of these, you gave a third into sexual slavery to the editorial office of the magazine (by the way, thank you). And of this third, another third are black. Attention, question: what is the Pearl index? Right. This is an index of failures, showing how many women out of a hundred, using the chosen means of protection for a year, will eventually become pregnant. The lower it is, the better the product. For example, for condoms this index is up to 12, which is quite a lot. What does black concubines have to do with it, you ask. Yes, the image is beautiful.
We collected the data on the Pearl index in a table, and described the remaining pros and cons of all known contraceptives (both male and female) in detail.
1. Condoms
Better than anything they protect against infections. Efficiency - 85-90% (less only for mycoplasmosis and herpes).
Safe, even indifferent to health, if you are not allergic to latex.
They need to be bought, kept in your pocket and put on on time (according to the Sanders-Graham-Crosby study, 50% of women do not have this skill: they put their partner in protection after the start of the act).
There is nothing to add to what has been said. Just to get a little boring. According to science, to achieve an impressive 95% effectiveness of a condom, you need to:
● inspect the condom packaging for damage;
● do not put it on inside out...
● ...and on the erect penis, to the end (follow me, Beavis, we said “end”!);
● always leave a spout at the end to collect sperm (you will be surprised, but this actually somehow increases the effectiveness of your latex friend);
● use exclusively water-based lubricants (leave butter to the heroes of “Tango in Paris”).
2. Barrier contraception
In our editorial office, full of hypocrites, and even Old Believers, there was not a person who could, without embarrassment, write down all the words of the expert on female contraception Tatyana Kaznacheeva, Ph.D., Associate Professor of the Department of Reproductive Medicine and Surgery of the Faculty of Education and Science of Moscow State Medical University. Therefore, warn your woman: it is better to get information about suppositories and sponges not from a men's magazine or even from a women's magazine, but from a conversation with a personal gynecologist. However, we learned something. The diaphragm and the female condom, according to Tatyana, have not taken root in our country, despite the fact that “this rare condom, due to its larger surface area, is capable of protecting against STIs to a greater extent than the male condom.” Well, as for spermicidal products (creams, vaginal tablets and suppositories), their only advantage is their availability. There are at least three disadvantages.
Spermicides can cause irritation and allergies not only for her, but also for you.
They are so ineffective that young anemones are not recommended to use them at all due to frequent misfires.
Most products need to be administered 20–30 minutes before the act and renewed with each subsequent one, and this is not always convenient.
3. Vasectomy
This method, with a stretch, can also be classified as a barrier method, only the barrier to the sperm is not foam tablets and latex, but your surgically tied vas deferens. Vasectomy does not affect sperm count, which is something that lovers of sperm count will appreciate.
Contraception is always with you, it does not require you to download new firmware and generally take care of its maintenance.
A vasectomy is only suitable if you have already had some children. Because it may not work out anymore...
- ...since reconstructive surgery is a procedure several orders of magnitude more complex than basic knot tying. Its result is unpredictable. It often happens that it is completely impossible.
4. Female sterilization
Almost one hundred percent effective.
One operation for life.
It is regulated by law and even in our liberal (ha ha) country it is prohibited for nulliparous women under 35 years of age.
A real operation - with preparation, hospitalization, anesthesia.
Conditionally irreversible. Reconstructive surgery is possible, but there are a lot of reservations.
There is, however, a method of reversible sterilization, when spiral-shaped devices are inserted into the mouths of the fallopian tubes, making it impossible for the egg and sperm to rendezvous. But this method is not widespread in our country, to put it mildly.
5. COC tablets
Few side effects. With continuous use for two years or more, they reduce the likelihood of developing various female diseases. No new ones are added.
Long history of observations and quality control: tablets have been used in the civilized world for 50 years.
They require daily intake and, as a result, the presence of a certain amount of gray matter in a woman’s head. If the dosage regimen is violated, COCs lose effectiveness.
They are not subject to strict male control: it is impossible to understand by the type of pills what your woman is drinking - contraceptives or glycine, which means that deception and intrigue are likely (well, suddenly).
Bad reputation: if your woman has decided that she will not “go on hormones,” then it will be logically impossible to convince her. Moreover, side effects like weight gain and headaches do occur even with the most modern wheels. True, noticeably less often than with “classical” drugs.
If your woman is prejudiced only by the form of release of combined contraceptives, you can offer her a skin patch or vaginal ring. You don’t even have to blatantly lie that these remedies are more gentle and less hormonal. This is often true. Oh yes, there are also mini-pills! These do not contain estrogens at all, and besides, they are more harmless purely visually - due to their size.
Combined contraceptive male educational program
Gynecologist, Ph.D., Medical Adviser, MSD Pharmaceuticals LLC
COOK
Pills containing the female hormones estrogen and progesterone should be taken daily for three weeks, then take a week's break during which menstruation occurs. The main mechanism of action is suppression of egg maturation. There are pills that do not contain estrogen, they contain analogues of progesterone (one of the female hormones) and are just as reliable as combination pills. Such drugs may be recommended for breastfeeding women or those for whom estrogens are contraindicated. The tablets are often packaged in a blister with a picture of flowers, but this is not necessary. They look like any other small tablets.
Patch
It also contains analogues of two female sex hormones. The patch, measuring 4.5 by 4.5 cm, is self-adhered by the woman to a clean, dry butt. That is, sorry, skin. The mechanism of action is the suppression of ovulation. The color is beige and does not peel off by itself.
Flexible vaginal ring
Designed on the principle of a multilayer membrane. Continuously releases minimal (due to localization they should not be large) doses of estrogen and progestogen, which are absorbed into the blood through the mucous membrane of you know what. It couldn’t be simpler: a flexible ring with a diameter of 5.4 cm is inserted by the woman herself, you know where (following the example of a tampon). The location of the ring does not affect its effectiveness. The ring remains inside for three weeks, and, like a cat’s litter box, it’s best not to forget to change it. There is a one-week break between the removal of the old and the introduction of the new. The ring effectively suppresses the release of the egg. By the way, as private surveys show, some people really like it when their partner knows where (in none of our articles has this bashful euphemism been repeated such a terrifying number of times. - Editor's note) there is such a nice ring. This supposedly improves the sensation.
6. Injections and implants
The merciless need to take pills every day often leads to truly Zen riddles like “I forgot to take them for three days. Can I take three pills at once now?” In order not to answer endless questions from endless forum visitors, doctors came up with long-lasting solutions.
Long-term effect: 3 months for injections and up to 5 years for implants.
They do not require feats of self-discipline. Injections need to be done quite rarely, which the organizer or secretary will always remind you of - after all, she is also interested in this.
All procedures are invasive and require a visit to the doctor. You can theoretically cope with an intramuscular injection, but not with subcutaneous implantation.
No matter how few side effects modern drugs cause, in this case they are irreversible: if the injection is given and something goes wrong, then the entire duration of the drug will expire.
7. Intrauterine devices
The effectiveness of some “spiral” solutions is up to 99%.
It’s very convenient to use: set it and forget it. Moreover, not for myself, but for her. And you have nothing to do with it at all. Although no, you will have to periodically monitor the position, forgive the details, of the “antennae” of the intrauterine device and monitor the service life. However, this mission is also unlikely to be entrusted to you.
Can be used as early as six weeks after birth. You're so paranoid.
There are no draconian restrictions on age and smoking, characteristic of COCs.
Any foreign object in the body reduces local resistance to infection and gladly aggravates and aggravates its course, if it has already appeared. This also applies to the spiral.
Your partner can no longer catch an STI. That is, both you and all her other men are now required to use condoms. So give them all this magazine - let them know that this is not a joke, and generally photocopy the article.
Conventional copper intrauterine devices can, especially at first, cause discomfort, pain and all sorts of bleeding. Expensive hormonal systems like Mirena are almost devoid of such effects; their main disadvantage is the price, that is, the only parameter of the IUD that, for once, concerns you.
There is one more important point to remember. This hellish remedy is famous for one unpleasant fact: pregnancy is still possible when using it. The sperm unites with the egg - life actually begins, but things do not go further than that. The resulting zygote cannot adhere to the wall of the uterus due to the local effects created by the spiral, so in some cases it does not care about the health of the mother and nests wherever it wants. It's called an ectopic pregnancy, and it's no laughing matter. Go to the hospital immediately!
8. Natural methods
They are always with you, you don’t need to buy them at the pharmacy. That is, you only pay with them for sex!
Most so-called natural contraceptive methods do not work at all and are based on myths. Even for interrupted coitus, the Pearl index is very high, and for other tricks and subterfuges it is even higher.
Again, there are studies showing the harm of interrupted intercourse for prostate health. They are not supported by the proper apparatus of evidence, but they are still somehow alarming.
“I have safe days”, “She is breastfeeding. I read somewhere that it is possible”, “I went to the sauna, and sperm remain alive only at temperatures below 36 degrees” - what phrases do not resonate with joy in the hearts of irresponsible partners! Some even still believe in a lemon stuck in you know where (that’s it, this phrase will not be used again), and that you can’t get pregnant in the cowgirl position. Ha! I wouldn't believe it! Cash costs - zero. Zero hassle. Guarantees - well, let's say, not zero, but they are rather absent, if the word “guarantee” is correctly understood.
In general, natural methods are among the most unreliable. Indeed, overheating of the scrotum sometimes prevents conception. And during the period of breastfeeding or severe stress, some women experience confusion and even complete loss of the ovulation mechanism. However, you should not rely on these vagaries of nature. Cunning spermatozoa are contained not only in sperm, but also in lubricant; they live in the communication routes, sometimes for ten days in a row (that is, they can hold out and greet the dawn of a “dangerous” day with a whoop). Do not consider all these dances with tambourines as serious methods of contraception and turn your attention, for example, to the most reliable method, according to experts. We saved it for last, of course.
Conclusion
Just so you know, our consultants tried not to use the word “contraception” at all. Allegedly, there is a connotation of undesirability in it, and it should say “family planning.” Because the thing here is this: today you don’t plan it, but tomorrow amniotic fluid may well hit your head.
Therefore, in most cases, especially with unfamiliar partners with whom you don’t even plan to have breakfast yet, doctors recommend using the “double Dutch method.” This is when a woman drinks COCs and a man uses a condom. Even in the case of the most chaotic lifestyle, such a tandem brings to zero not only the likelihood of pregnancy, but also the risk of contracting an STI.
Well, if you both realized that children are exactly the reason you need to take out another consumer loan from the bank, you can always abandon the Dutch method.
Combination pills (combined oral contraceptives - COCs) are the most widely used form of hormonal contraception.
Based on the content of the estrogen component in the tablet in the form of ethinyl estradiol (EE), these drugs are divided into high-dose, containing more than 40 meg of EE, and low-dose - 35 meg or less of EE. In monophasic preparations, the content of estrogen and gestagen components in the tablet remains unchanged throughout the menstrual cycle. In biphasic tablets, in the second phase of the cycle the content of the gestagen component increases. In three-phase COCs, the dose of gestagen is increased stepwise in three stages, and the dose of EE increases in the middle of the cycle and remains unchanged at the beginning and end of the dose. The variable content of sex steroids in two- and three-phase preparations throughout the cycle made it possible to reduce the total course dose of hormones.
Combined oral contraceptives are highly effective reversible means of preventing pregnancy. The Pearl index (IP) of modern COCs is 0.05-1.0 and depends mainly on compliance with the rules for taking the drug.
Each combined oral contraceptive (COC) tablet contains estrogen and progestogen. Synthetic estrogen, ethinyl estradiol (EE), is used as the estrogenic component of COCs, and various synthetic progestogens (synonymous with progestins) are used as progestogen components.
Progestin contraceptives contain only one sex steroid - gestagen, which provides a contraceptive effect.
Benefits of combined oral contraceptives
Contraceptive
- High efficiency when taken daily IP = 0.05-1.0
- Quick effect
- Lack of connection with sexual intercourse
- Few side effects
- The method is easy to use
- The patient can stop taking it herself.
Non-contraceptive
- Reduce menstrual bleeding
- Reduce menstrual pain
- May reduce the severity of anemia
- May help establish a regular cycle
- Prevention of ovarian and endometrial cancer
- Reduce the risk of developing benign breast tumors and ovarian cysts
- Protects against ectopic pregnancy
- Provide some protection against pelvic inflammatory disease
- Provides prevention of osteoporosis
Currently, COCs are very popular all over the world due to the benefits that are listed below.
- High contraceptive reliability.
- Good tolerance.
- Availability and ease of use.
- Lack of connection with sexual intercourse.
- Adequate control of the menstrual cycle.
- Reversibility (full restoration of fertility within 1–12 months after discontinuation of use).
- Safety for most somatically healthy women.
- Therapeutic effects:
- regulation of the menstrual cycle;
- elimination or reduction of dysmenorrhea;
- reduction of menstrual blood loss and, as a result, treatment and prevention of iron deficiency anemia;
- elimination of ovulatory pain;
- reducing the incidence of inflammatory diseases of the pelvic organs;
- therapeutic effect for premenstrual syndrome;
- therapeutic effect in hyperandrogenic conditions.
- Preventive effects:
- reducing the risk of developing endometrial and ovarian cancer, colorectal cancer;
- reducing the risk of benign breast tumors;
- reducing the risk of developing iron deficiency anemia;
- reducing the risk of ectopic pregnancy.
- Removing the “fear of unwanted pregnancy.”
- The possibility of “postponing” the next menstruation, for example, during exams, competitions, or rest.
- Emergency contraception.
Types and composition of modern combined oral contraceptives
Based on the daily dose of the estrogen component, COCs are divided into high-dose, low-dose and micro-dose:
- high-dose - 50 mcg EE/day;
- low-dose - no more than 30–35 mcg EE/day;
- microdosed, containing microdoses of EE, 15–20 mcg/day.
Depending on the combination regimen of estrogen and progestogen, COCs are divided into:
- monophasic - 21 tablets with a constant dose of estrogen and progestogen for 1 cycle of administration;
- biphasic - two types of tablets with different ratios of estrogen and progestogen;
- triphasic - three types of tablets with different ratios of estrogen and progestogen. The main idea of three-phase is a reduction in the total (cyclic) dose of progestogen due to a three-step increase in its dose during the cycle. Moreover, in the first group of tablets the dose of progestogen is very low - approximately the same as in a monophasic COC; in the middle of the cycle, the dose increases slightly and only in the last group of tablets corresponds to the dose in the monophasic drug. Reliable suppression of ovulation is achieved by increasing the dose of estrogen at the beginning or middle of the dosing cycle. The number of tablets of different phases varies in different preparations;
- multiphase - 21 tablets with a variable ratio of estrogen and progestogen in tablets of one cycle (one package).
Currently, low- and micro-dose drugs should be used for contraception. High-dose COCs can be used for routine contraception only for a short time (if it is necessary to increase the dose of estrogen). In addition, they are used for medicinal purposes and for emergency contraception.
Mechanism of contraceptive action of combined oral contraceptives
- Suppression of ovulation.
- Thickening of cervical mucus.
- Endometrial changes that prevent implantation. The mechanism of action of COCs is generally the same for all drugs; it does not depend on the composition of the drug, the dose of components and phase. The contraceptive effect of COCs is provided mainly by the progestogen component. EE contained in COCs supports endometrial proliferation and thereby ensures cycle control (no intermediate bleeding when taking COCs). In addition, EE is necessary to replace endogenous estradiol, since when taking COCs there is no follicular growth and, therefore, estradiol is not secreted in the ovaries.
Classification and pharmacological effects
Chemical synthetic progestogens are steroids and are classified according to their origin. The table shows only progestogens included in hormonal contraceptives registered in Russia.
Classification of progestogens
Like natural progesterone, synthetic progestogens cause secretory transformation of the estrogen-stimulated (proliferative) endometrium. This effect is due to the interaction of synthetic progestogens with endometrial progesterone receptors. In addition to their effect on the endometrium, synthetic progestogens also act on other target organs of progesterone. The differences between synthetic progestogens and natural progesterone are as follows.
- Higher affinity for progesterone receptors and, as a result, a more pronounced progestogenic effect. Due to their high affinity for progesterone receptors in the hypothalamic-pituitary region, synthetic progestogens in low doses cause a negative feedback effect and block the release of gonadotropins and ovulation. This underlies their use for oral contraception.
- Interaction with receptors for some other steroid hormones: androgens, gluco- and mineralocorticoids - and the presence of corresponding hormonal effects. These effects are relatively weakly expressed and are therefore called residual (partial or partial). Synthetic progestogens differ in the spectrum (set) of these effects; some progestogens block receptors and have a corresponding antihormonal effect. For oral contraception, the antiandrogenic and antimineralocorticoid effects of progestogens are favorable; the androgenic effect is undesirable.
Clinical significance of individual pharmacological effects of progestogens
A pronounced residual androgenic effect is undesirable, as it can cause:
- androgen-dependent symptoms - acne, seborrhea;
- a change in the spectrum of lipoproteins towards the predominance of low-density fractions: low-density lipoproteins (LDL) and very low-density lipoproteins, since the synthesis of apolipoproteins and the destruction of LDL are inhibited in the liver (an effect opposite to the influence of estrogens);
- worsening carbohydrate tolerance;
- increase in body weight due to anabolic effects.
Based on the severity of androgenic properties, progestogens can be divided into the following groups.
- Highly androgenic progestogens (norethisterone, linestrenol, ethynodiol diacetate).
- Progestogens with moderate androgenic activity (norgestrel, levonorgestrel in high doses - 150–250 mcg/day).
- Progestogens with minimal androgenicity (levonorgestrel in a dose of no more than 125 mcg/day, gestodene, desogestrel, norgestimate, medroxy-progesterone). The androgenic properties of these progestogens are detected only in pharmacological tests and in most cases have no clinical significance. WHO recommends the use of oral contraceptives with low androgenic progestogens.
The antiandrogenic effect of cyproterone, dienogest and drospirenone, as well as chlormadinone, is of clinical significance. Clinically, the antiandrogenic effect is manifested in a reduction in androgen-dependent symptoms - acne, seborrhea, hirsutism. Therefore, COCs with antiandrogenic progestogens are used not only for contraception, but also for the treatment of androgenization in women, for example, with polycystic ovary syndrome (PCOS), idiopathic androgenization and some other conditions.
Severity of antiandrogenic effect (according to pharmacological tests):
- cyproterone - 100%;
- dienogest - 40%;
- drospirenone - 30%;
- chlormadinone - 15%.
Thus, all progestogens included in COCs can be ranked in accordance with the severity of their residual androgenic and antiandrogenic effects.
Taking COCs should start on the 1st day of the menstrual cycle; after taking 21 tablets, take a 7-day break or (with 28 tablets per package) take 7 placebo tablets.
Rules for missed pills
The following rules are currently in place regarding missed pills. In cases where less than 12 hours have passed, it is necessary to take the tablet at the time when the woman remembered to miss the dose, and then the next tablet at the usual time. No additional precautions are required. If more than 12 hours have passed since the missed date, you must do the same, but within 7 days take additional measures to prevent pregnancy. In cases where two or more tablets are missed in a row, you should take two tablets per day until you return to your regular schedule, using additional methods of contraception for 7 days. If bleeding begins after missing tablets, it is better to stop taking the tablets and start a new pack after 7 days (counting from the start of missing tablets). If you miss even one of the last seven hormone-containing tablets, the next pack must be started without a seven-day break.
Rules for changing medications
The transition from higher-dose drugs to low-dose drugs is carried out with the start of taking low-dose COCs without a seven-day break on the day after the end of the 21st day of taking high-dose contraceptives. Replacement of low-dose drugs with high-dose ones occurs after a seven-day break.
Symptoms of possible complications when using COCs
- Severe chest pain or shortness of breath
- Severe headaches or blurred vision
- Severe pain in the lower extremities
- Complete absence of any bleeding or discharge during a pill-free week (pack of 21 tablets) or while taking 7 inactive pills (from a 28-day pack)
If any of the above symptoms occur, urgent consultation with a doctor is required!
Disadvantages of combined oral contraceptives
- The method depends on the users (requires motivation and discipline)
- Possible nausea, dizziness, breast tenderness, headaches, as well as spotting or moderate bleeding from the genital tract and mid-cycle
- The effectiveness of the method may be reduced when taking certain medications simultaneously.
- Thrombolytic complications are possible, although very rare.
- The need to replenish the contraceptive supply
- Does not protect against STDs, including hepatitis and HIV infection
Contraindications to the use of combined oral contraceptives
Absolute contraindications
- Deep vein thrombosis, pulmonary embolism (including a history), high risk of thrombosis and thromboembolism (with extensive surgery associated with prolonged immobilization, with congenital thrombophilia with pathological levels of coagulation factors).
- Coronary heart disease, stroke (history of cerebrovascular crisis).
- Arterial hypertension with systolic blood pressure 160 mm Hg. Art. and above and/or diastolic blood pressure 100 mm Hg. Art. and higher and/or with the presence of angiopathy.
- Complicated diseases of the valvular apparatus of the heart (hypertension of the pulmonary circulation, atrial fibrillation, history of septic endocarditis).
- A combination of several factors for the development of arterial cardiovascular diseases (age over 35 years, smoking, diabetes, hypertension).
- Liver diseases (acute viral hepatitis, chronic active hepatitis, liver cirrhosis, hepatocerebral dystrophy, liver tumor).
- Migraine with focal neurological symptoms.
- Diabetes mellitus with angiopathy and/or disease duration of more than 20 years.
- Breast cancer, confirmed or suspected.
- Smoking more than 15 cigarettes per day over 35 years of age.
- Lactation.
- Pregnancy. Relative contraindications
- Arterial hypertension with systolic blood pressure below 160 mmHg. Art. and/or diastolic blood pressure below 100 mm Hg. Art. (a single increase in blood pressure is not a basis for diagnosing arterial hypertension - the primary diagnosis can be established when blood pressure increases to 159/99 mm Hg during three visits to the doctor).
- Confirmed hyperlipidemia.
- Vascular headache or migraine that appeared while taking COCs, as well as migraine without focal neurological symptoms in women over 35 years of age.
- Gallstone disease with clinical manifestations in history or currently.
- Cholestasis associated with pregnancy or COC use.
- Systemic lupus erythematosus, systemic scleroderma.
- History of breast cancer.
- Epilepsy and other conditions requiring the use of anticonvulsants and barbiturates - phenytoin, carbamazepine, phenobarbital and their analogues (anticonvulsants reduce the effectiveness of COCs by inducing microsomal liver enzymes).
- Taking rifampicin or griseofulvin (for example, for tuberculosis) due to their effect on liver microsomal enzymes.
- Lactation from 6 weeks to 6 months after birth, postpartum period without lactation up to 3 weeks.
- Smoking less than 15 cigarettes per day over 35 years of age. Conditions requiring special monitoring while taking COCs
- Increased blood pressure during pregnancy.
- Family history of deep vein thrombosis, thromboembolism, death from myocardial infarction before the age of 50 years (1st degree of relationship), hyperlipidemia (assessment of hereditary factors of thrombophilia and lipid profile is necessary).
- Upcoming surgery without prolonged immobilization.
- Thrombophlebitis of superficial veins.
- Uncomplicated heart valve diseases.
- Migraine without focal neurological symptoms in women under 35 years of age, headache that began while taking COCs.
- Diabetes mellitus without angiopathy with a disease duration of less than 20 years.
- Gallstone disease without clinical manifestations; condition after cholecystectomy.
- Sickle cell anemia.
- Bleeding from the genital tract of unknown etiology.
- Severe dysplasia and cervical cancer.
- Conditions that make it difficult to take pills (mental illnesses associated with memory impairment, etc.).
- Age over 40 years.
- Lactation more than 6 months after birth.
- Smoking under 35 years of age.
- Obesity with a body mass index of more than 30 kg/m2.
Side effects of combined oral contraceptives
Side effects are most often mild and occur in the first months of taking COCs (in 10–40% of women), subsequently their frequency decreases to 5–10%.
Side effects of COCs are usually divided into clinical and dependent on the mechanism of action of hormones. Clinical side effects of COCs are in turn divided into general and those causing menstrual irregularities.
- headache;
- dizziness;
- nervousness, irritability;
- depression;
- discomfort in the gastrointestinal tract;
- nausea, vomiting;
- flatulence;
- bile duct dyskinesia, exacerbation of cholelithiasis;
- tension in the mammary glands (mastodynia);
- arterial hypertension;
- change in libido;
- thrombophlebitis;
- leukorrhea;
- chloasma;
- leg cramps;
- weight gain;
- deterioration of tolerance to contact lenses;
- dryness of the vaginal mucous membranes;
- increasing the overall coagulation potential of the blood;
- an increase in the transition of fluid from vessels to the intercellular space with a compensatory delay in the body of sodium and water;
- changes in glucose tolerance;
- hypernatremia, increased osmotic pressure of blood plasma. Menstrual irregularities:
- intermenstrual spotting;
- breakthrough bleeding;
- amenorrhea during or after taking COCs.
If side effects persist longer than 3–4 months after starting treatment and/or intensify, the contraceptive drug should be changed or discontinued.
Serious complications when taking COCs are extremely rare. These include thrombosis and thromboembolism (deep vein thrombosis, pulmonary embolism). For women's health, the risk of these complications when taking COCs with an EE dose of 20–35 mcg/day is very small - lower than during pregnancy. However, at least one risk factor for the development of thrombosis (smoking, diabetes, high obesity, hypertension, etc.) is a relative contraindication to taking COCs. A combination of two or more of these risk factors (for example, a combination of obesity and smoking over the age of 35 years) generally excludes the use of COCs.
Thrombosis and thromboembolism, both when taking COCs and during pregnancy, can be manifestations of latent genetic forms of thrombophilia (resistance to activated protein C, hyperhomocysteinemia, deficiency of antithrombin III, protein C, protein S, antiphospholipid syndrome). In this regard, it should be emphasized that routine determination of prothrombin in the blood does not provide insight into the hemostatic system and cannot be a criterion for prescribing or discontinuing COCs. If latent forms of thrombophilia are suspected, a special study of hemostasis should be performed.
Fertility restoration
After stopping the use of COCs, the normal functioning of the hypothalamic-pituitary-ovarian system is quickly restored. More than 85–90% of women are able to become pregnant within 1 year, which corresponds to the biological level of fertility. Taking COCs before the start of the conception cycle does not have a negative effect on the fetus, the course or outcome of pregnancy. Accidental use of COCs in the early stages of pregnancy is not dangerous and is not a reason for abortion, but at the first suspicion of pregnancy, a woman should immediately stop taking COCs.
Short-term use of COCs (for 3 months) causes an increase in the sensitivity of the receptors of the hypothalamic-pituitary-ovarian system, therefore, when COCs are discontinued, tropic hormones are released and ovulation is stimulated. This mechanism is called the “rebound effect” and is used in some forms of anovulation.
In rare cases, amenorrhea is observed after discontinuation of COCs. It may be a consequence of atrophic changes in the endometrium that develop when taking COCs. Menstruation appears when the functional layer of the endometrium is restored independently or under the influence of estrogen therapy. In approximately 2% of women, especially in the early and late periods of fertility, after stopping taking COCs, amenorrhea lasting more than 6 months is observed (the so-called post-pill amenorrhoea - hyperinhibition syndrome). The nature and causes of amenorrhea, as well as the response to therapy in women who used COCs, do not increase the risk, but may mask the development of amenorrhea with regular menstrual-like bleeding.
Rules for individual selection of combined oral contraceptives
COCs are selected for a woman strictly individually, taking into account the characteristics of her somatic and gynecological status, individual and family history. The selection of COCs occurs according to the following scheme.
- A targeted interview, assessment of somatic and gynecological status and determination of the category of acceptability of the combined oral contraceptive method for a given woman in accordance with WHO eligibility criteria.
- Selection of a specific drug, taking into account its properties and, if necessary, therapeutic effects; counseling a woman about the method of combined oral contraception.
- Observation of the woman for 3–4 months, assessment of tolerability and acceptability of the drug; if necessary, a decision to change or cancel the COC.
- Clinical observation of the woman during the entire period of use of COCs.
The woman's survey is aimed at identifying possible risk factors. It necessarily includes the following number of aspects.
- The nature of the menstrual cycle and gynecological history.
- When was your last menstruation, did it proceed normally (pregnancy should be ruled out at this time).
- Is your menstrual cycle regular? Otherwise, a special examination is necessary to identify the causes of the irregular cycle (hormonal disorders, infection).
- The course of previous pregnancies.
- Abortion.
- Previous use of hormonal contraceptives (oral or other):
- were there any side effects; if so, which ones;
- for what reasons did the patient stop using hormonal contraceptives?
- Individual history: age, blood pressure, body mass index, smoking, taking medications, liver disease, vascular disease and thrombosis, diabetes mellitus, cancer.
- Family history (diseases in relatives that developed before the age of 40): arterial hypertension, venous thrombosis or hereditary thrombophilia, breast cancer.
In accordance with the WHO conclusion, the following examination methods are not relevant to assessing the safety of COC use.
- Breast examination.
- Gynecological examination.
- Examination for the presence of atypical cells.
- Standard biochemical tests.
- Tests for pelvic inflammatory diseases, AIDS. The drug of first choice should be a monophasic COC with an estrogen content of no more than 35 mcg/day and a low androgenic gestagen. Such COCs include Logest, Femoden, Zhanin, Yarina, Mercilon, Marvelon, Novinet, Regulon, Belara, Miniziston, Lindinet, Silest "
Three-phase COCs can be considered as reserve drugs when signs of estrogen deficiency appear against the background of monophasic contraception (poor cycle control, dry vaginal mucosa, decreased libido). In addition, three-phase drugs are indicated for primary use in women with signs of estrogen deficiency.
When choosing a drug, the patient's health status should also be taken into account.
In the first months after starting to take COCs, the body adapts to hormonal changes. During this period, intermenstrual spotting or, less commonly, breakthrough bleeding may appear (in 30–80% of women), as well as other side effects associated with hormonal imbalance (in 10–40% of women). If adverse events do not go away within 3–4 months, the contraceptive may need to be changed (after excluding other causes - organic diseases of the reproductive system, missed pills, drug interactions). It should be emphasized that currently the choice of COCs is large enough to suit most women who are indicated for this method of contraception. If a woman is not satisfied with the first choice drug, the second choice drug is selected taking into account the specific problems and side effects encountered by the patient.
Selecting a COC
| Clinical situation | Drugs |
| Acne and/or hirsutism, hyperandrogenism | Preparations with antiandrogenic progestogens: “Diane-35” (for severe acne, hirsutism), “Zhanin”, “Yarina” (for mild to moderate acne), “Belara” |
| Menstrual irregularities (dysmenorrhea, dysfunctional uterine bleeding, oligomenorrhea) | COCs with a pronounced progestogenic effect (“Mikroginon”, “Femoden”, “Marvelon”, “Janine”), when combined with hyperandrogenism - “Diane-35”. When DMB is combined with recurrent hyperplastic processes of the endometrium, the duration of treatment should be at least 6 months |
| Endometriosis | Monophasic COCs with dienogest (Janine), or levonorgestrel, or gestodene or progestin oral contraceptives are indicated for long-term use. The use of COCs can help restore generative function |
| Diabetes mellitus without complications | Preparations with a minimum estrogen content - 20 mcg/day (intrauterine hormonal system "Mirena") |
| Initial or re-prescription of oral contraceptives in a patient who smokes | For smoking patients under 35 years of age, COCs with minimal estrogen content are recommended; for smoking patients over 35 years of age, COCs are contraindicated. |
| Previous use of oral contraceptives was accompanied by weight gain, fluid retention in the body, and mastodynia | "Yarina" |
| Poor control of the menstrual cycle has been observed with previous use of oral contraceptives (in cases where causes other than oral contraceptives have been excluded) | Monophasic or three-phase COCs |
Basic principles of monitoring patients using COCs
- Annual gynecological examination, including colposcopy and cytological examination.
- Once or twice a year, examination of the mammary glands (in women with a history of benign tumors of the mammary glands and/or breast cancer in the family), once a year, mammography (in perimenopausal patients).
- Regular blood pressure measurement. When diastolic blood pressure increases to 90 mm Hg. Art. and above, stop taking COCs.
- Special examinations according to indications (if side effects develop, complaints arise).
- In case of menstrual dysfunction, exclude pregnancy and transvaginal ultrasound scanning of the uterus and its appendages. If intermenstrual bleeding persists for more than three cycles or appears with further use of COCs, you must adhere to the following recommendations.
- Eliminate errors in taking COCs (skipping pills, non-compliance with the dosage regimen).
- Rule out pregnancy, including ectopic.
- Exclude organic diseases of the uterus and appendages (fibroids, endometriosis, hyperplastic processes in the endometrium, cervical polyp, cancer of the cervix or uterine body).
- Rule out infection and inflammation.
- If the above reasons are excluded, change the drug in accordance with the recommendations.
- In the absence of withdrawal bleeding, the following should be excluded:
- taking COCs without 7-day breaks;
- pregnancy.
- If these reasons are excluded, then the most likely reason for the absence of withdrawal bleeding is endometrial atrophy due to the influence of progestogen, which can be detected by endometrial ultrasound. This condition is called “silent menstruation”, “pseudoamenorrhea”. It is not associated with hormonal disorders and does not require discontinuation of COCs.
Rules for taking COCs
Women with regular menstrual cycles
- The initial dose of the drug should be started within the first 5 days after the start of menstruation - in this case, the contraceptive effect is ensured already in the first cycle, additional measures to protect against pregnancy are not necessary. Taking monophasic COCs begins with a tablet marked with the corresponding day of the week, multiphasic COCs with a tablet marked “start of use”. If the first pill is taken later than 5 days after the start of menstruation, an additional method of contraception is required in the first cycle of taking COCs for 7 days.
- Take 1 tablet (dragée) daily at approximately the same time of day for 21 days. If you miss a pill, follow the “Rules for Forgotten and Missed Pills” (see below).
- After taking all (21) tablets from the package, take a 7-day break, during which withdrawal bleeding (“menstruation”) occurs. After the break, begin taking tablets from the next package. For reliable contraception, the break between cycles should not exceed 7 days!
All modern COCs are produced in “calendar” packages designed for one cycle of administration (21 tablets - 1 per day). There are also packs of 28 tablets; in this case, the last 7 tablets do not contain hormones (“pacifiers”). In this case, there is no break between packs: it is replaced by taking a placebo, since in this case patients are less likely to forget to start taking the next pack on time.
Women with amenorrhea
- Start taking it at any time, provided that pregnancy has been reliably excluded. Use an additional method of contraception for the first 7 days.
Women breastfeeding
- Do not prescribe COCs earlier than 6 weeks after birth!
- The period from 6 weeks to 6 months after birth, if a woman is breastfeeding, use COCs only if absolutely necessary (the method of choice is mini-pills).
- More than 6 months after birth:
- with amenorrhea, the same as in the section “Women with amenorrhea”;
- with a restored menstrual cycle.
“Rules for forgotten and missed pills”
- If 1 tablet is missed.
- If you are less than 12 hours late in taking the pill, take the missed pill and continue taking the drug until the end of the cycle according to the previous regimen.
- Delay in appointment by more than 12 hours - the same actions as in the previous paragraph, plus:
- if you miss a pill in the 1st week, use a condom for the next 7 days;
- if you miss a pill in the 2nd week, there is no need for additional means of protection;
- if you miss a pill in the 3rd week, after finishing one pack, start the next one without a break; There is no need for additional means of protection.
- If 2 or more tablets are missed.
- Take 2 tablets per day until regular dosing, plus use additional methods of contraception for 7 days. If bleeding begins after missing tablets, it is better to stop taking tablets from the current package and start a new package after 7 days (counting from the start of missing tablets).
Rules for prescribing COCs
- Primary purpose - from the 1st day of the menstrual cycle. If treatment is started later (but no later than the 5th day of the cycle), then additional methods of contraception must be used in the first 7 days.
- Post-abortion appointment - immediately after the abortion. Abortion in the first and second trimesters, as well as septic abortion, belong to category 1 conditions (there are no restrictions on the use of the method) for prescribing COCs.
- Prescription after childbirth - in the absence of lactation, start taking COCs no earlier than the 21st day after birth (category 1). If there is lactation, do not prescribe COCs; use mini-pills no earlier than 6 weeks after birth (category 1).
- Switching from high-dose COCs (50 mcg EE) to low-dose ones (30 mcg EE or less) - without a 7-day break (so that the hypothalamic-pituitary system does not become activated due to a dose reduction).
- Switching from one low-dose COC to another after the usual 7-day break.
- Switch from a mini-pill to a COC on the 1st day of the next bleeding.
- Switching from an injection drug to a COC on the day of the next injection.
- It is advisable to reduce the number of cigarettes you smoke or quit smoking altogether.
- Follow the regimen of taking the drug: do not skip taking pills, strictly adhere to the 7-day break.
- Take the drug at the same time (in the evening before bed), with a small amount of water.
- Have the “Rules for Forgotten and Missed Pills” on hand.
- In the first months of taking the drug, intermenstrual bleeding of varying intensity is possible, usually disappearing after the third cycle. If intermenstrual bleeding continues at a later date, you should consult a doctor to determine its cause.
- In the absence of a menstrual-like reaction, you should continue taking the pills as usual and immediately consult a doctor to exclude pregnancy; If pregnancy is confirmed, you should immediately stop taking COCs.
- After stopping the drug, pregnancy may occur in the first cycle.
- The simultaneous use of antibiotics and anticonvulsants leads to a decrease in the contraceptive effect of COCs.
- If vomiting occurs (within 3 hours after taking the drug), you must additionally take 1 more tablet.
- Diarrhea that continues for several days requires the use of an additional method of contraception until the next menstrual reaction occurs.
- For sudden localized severe headache, migraine attack, chest pain, acute visual impairment, difficulty breathing, jaundice, increased blood pressure above 160/100 mmHg. Art. Immediately stop taking the drug and consult a doctor.
ICD-10
Y42.4 Oral contraceptives
Every woman who has regular sex life thinks about how to prevent unwanted pregnancy. Today there are many methods of contraception, but one of the most popular is taking birth control pills. How combined oral contraceptives work and how they should be taken so as not to harm the body is a question that worries many young ladies.
In contact with
Contraceptive pills (OC) refer to the oral method of contraception. Regardless of the type of hormonal contraceptives, the basis of such pills is female sex hormones that regulate estrogen levels and block ovulation, as a result of which fertilization of the egg becomes impossible.
The contraceptive effect is also achieved due to a specific effect on the uterine mucosa; it begins to produce more thick mucus, which prevents sperm from penetrating the fallopian tube. If you take COCs for a long time, the ovaries begin to work in a different mode, creating an artificial feeling of pregnancy.
Many girls are afraid to take such contraceptives, because there is an opinion that they often provoke side effects and cause multiple complications. It is immediately worth noting that modern drugs have a gentle effect on the body; if they are selected correctly, the risk of side effects will be minimized.
The undoubted advantage of oral contraceptives is that they help normalize hormonal levels, which improves the condition of the skin (fights), hair and nails. Currently, doctors around the world prescribe COCs not only as a contraceptive, but also as a means to help regulate hormone production and normalize the menstrual cycle. Also, numerous clinical studies have confirmed that taking birth control reduces the likelihood of ovarian and cervical cancer.
It is important to know! You cannot select a product in this pharmaceutical category on your own. They should be prescribed by a gynecologist after taking hormones and a physical examination. If the drug is selected properly, taking into account the individual characteristics of the body, it will not only not provoke complications, but, on the contrary, will have a positive effect on the functioning of the female body.
Many girls mistakenly believe that COCs are taken only to prevent pregnancy, but in fact the range of use of these pills is much wider. Main indications for their use:
Both microdosed COCs and high-hormone birth control pills help women get rid of many diseases. If the drug was prescribed by a gynecologist to combat the above pathologies after undergoing tests, you should not be afraid to drink it, the risk of complications will be minimized.
According to statistics, birth control pills provide a 99% guarantee of preventing unwanted pregnancy, but, unfortunately, not everyone can take them. You should stop taking COCs in the following cases:
- the formation of neoplasms of a benign or malignant nature on the reproductive organs;
- kidney and liver diseases;
- bearing a child and lactation period;
- presence of cardiovascular diseases;
- migraine;
- high blood pressure;
- tendency to form blood clots;
- diabetes;
- 3 and 4 degrees of obesity.
Take note! If the likelihood of complications is minimal, you should refuse birth control pills, since taking them can provoke irreversible reactions and cause irreparable harm to health.
Instructions for taking COC tablets
Regardless of the type, drugs of this pharmaceutical category begin to be taken on the first day of menstruation. Experts advise taking multiphase medications in a certain sequence, which is indicated on the package, and after that taking a week's break. On break days (or when taking inactive pills), menstruation begins, after which they begin to drink a new pack. It should be noted that some COCs contain 28 tablets per package (active and dummy), and there is no need to take breaks when taking them. The next pack is started after the last tablet in the previous pack runs out.
Attention! Before taking OK, in any case, you must read the accompanying instructions completely (each drug has its own characteristics and specific administration).
Most gynecologists advise drinking OK at night, so the restructuring of the body will be less noticeable. For 7 days after taking the first tablet from the first pack, it is recommended to use a barrier method of contraception, since the effect of the drug has not yet taken full effect.
57. Hormonal methods of contraception. Mechanism of action. Classification by composition and methods of application. Contraindications. Complications.
Classification of hormonal methods of contraception
Combined estrogen-progestin contraceptives:
Oral: Monophasic , Two-phase , Three-phase
Parenteral: NovaRing vaginal ring, Evra transdermal contraceptive system
Purely progestogen contraceptives:
Oral: Mini-pills (Microlut, Exluton, Charozetta)
Parenteral: Levonorgestrel implants Normplant, Medroxyprogesterone injections, Intrauterine hormonal system with levonorgestrel Mirena
COMBINED ORAL CONTRACEPTIVES
Each tablet contains estrogen (ethinyl estradiol) and progestogen (synthetic progestins).
Mechanism of contraceptive action of COCs:
●suppression of ovulation; ●thickening of cervical mucus;
●changes in the endometrium that prevent implantation.
Contraceptive effect - progestogen component. Ethinyl estradiol - supports
proliferation of the endometrium and ensures cycle control (no intermediate bleeding when taking COCs), is necessary for replacing endogenous estradiol, because When taking COCs, there is no follicle growth and estradiol is not produced in the ovaries.
pharmacological effects
Synthetic progestogens cause secretory transformation estrogen-stimulated (proliferative) endometrium.
Have antiandrogenic and antimineralocorticoid effects
Progestogens. Based on the severity of androgenic properties, progestogens can be divided into:
●Highly androgenic progestogens (noethisterone, linestrenol, ethynodiol).
●Progestogens with moderate androgenic activity (norgestrel, levonorgestrel in high doses, 150–250 mcg/day).
●Progestogens with minimal androgenicity (levonorgestrel in a dose of no more than 125 mcg/day, including triphasic), ethinyl estradiol + gestodene, desogestrel, norgestimate, medroxyprogesterone).
Clinically, the antiandrogenic effect leads to a reduction in androgen-dependent symptoms - acne, seborrhea, hirsutism.
Side effects of combined oral contraceptives.
More often - in the first months of taking COCs (in 10–40% of women)
Excessive estrogen influence: headache, increased blood pressure, irritability, nausea, vomiting, dizziness, mastodynia, chloasma, deterioration of varicose veins, deterioration of tolerance to contact lenses, weight gain.
Insufficient estrogenic effect: headache, depression, irritability, reduction in the size of the mammary glands, decreased libido, vaginal dryness, intermenstrual bleeding at the beginning and middle of the cycle, scanty menstruation.
Excessive influence of progestogens: headache, depression, fatigue, acne, decreased libido, vaginal dryness, worsening varicose veins, weight gain.
Insufficient progestogenic effect: heavy menstruation, intermenstrual bleeding in the second half of the cycle, delayed menstruation.
Serious complications are thrombosis and thromboembolism.
Contraindications to the use of combined oral contraceptives
●deep vein thrombosis, pulmonary embolism (including history), ●coronary heart disease, stroke; ●arterial hypertension.
●a combination of factors for the development of cardiovascular diseases (age over 35 years, smoking, diabetes, hypertension); ●liver diseases; ●lactation in the first 6 weeks after birth
●migraine with focal neurological symptoms;
●diabetes mellitus with angiopathy and/or disease duration of more than 20 years;
●breast cancer, confirmed or suspected;
●smoking more than 15 cigarettes per day over the age of 35;●pregnancy.
Fertility restoration
After stopping taking COCs, the normal functioning of the hypothalamus-pituitary-ovarian system is quickly restored. More than 85–90% of women are able to become pregnant within one year, which corresponds to the biological level of fertility.
Rules for taking combined oral contraceptives
All modern COCs are produced in “calendar” packages designed for one administration cycle (21 tablets - one per day). There are also packs of 28 tablets, in which case the last 7 tablets do not contain hormones (“dummy”). Women with amenorrhea should start taking it at any time, provided that pregnancy has been reliably excluded. An additional method of contraception is required for the first 7 days.
ORAL CONTRACEPTIVES CONTAINING PROGESTAGEN ONLY (MINIPILES) contain only microdoses of progestogens (300–500 mcg), which is 15–30% of the progestogen dose in combined estrogen-progestogen preparations.
Mechanism:
●cervical factor ●uterine factor ●tubal factor ●central factor.
The main drugs of the class include Microlut©, Exluton©, Charozettau©. Take continuously at the same time of day, starting from the 1st day of the menstrual cycle.
After childbirth, if a woman is breastfeeding, the drug should be taken 6–8 weeks after the birth of the child.
Contraindications the same as when prescribing COCs.
Side effects:
●menstrual cycle disorders; ●nausea, vomiting; ●depression; ●increase in body weight;
●decreased libido; ●headache, dizziness ●breast engorgement.
PARENTERAL DRUGS
Classification
●Injections - medroxyprogesterone. ●Implants - desogestrel.
●Transdermal contraceptive system.
●Intrauterine hormonal system that secretes levonorgestrel (Mirena©).
●Vaginal ring - etonogestrel + ethinyl estradiol (NovaRing©).
INJECTION DRUGS (DEPO DRUGS)
Mechanism of action:
●suppression of ovulation; ●thickening of cervical mucus
●changes in the structure of the endometrium, which complicates implantation;
●decreased contractile activity of the fallopian tubes.
Advantages of injectable contraceptives:
●long action; ●ease of use;
●high reliability (no user errors).
Disadvantages of injectable contraceptives:
●delayed restoration of fertility;
●impossibility to stop contraceptive protection at any time desired by the patient;
●the need for regular visits to the clinic for repeated injections.
SUBCUTANEOUS IMPLANTS (CAPSULES)
Mechanism of action: ●suppression of ovulation ●effect on the endometrium
●change in the consistency of cervical mucus
●suggest the possibility of levonorgestrel influencing the activity of enzymes involved in the process of sperm penetration into the egg.
TRANSDERMAL CONTRACEPTIVE SYSTEM EURA
The Evra transdermal contraceptive system is a combined estrogen-progestogen contraceptive. Evra is a thin beige patch, each patch contains 600 mcg ethinyl estradiol and 6 mg norelgestromin. 150 mcg of norelgestromin and 20 mcg of ethinyl estradiol enter the systemic circulation per day.
During one menstrual cycle - 3 patches, each for 7 days. The patch must be replaced on the same day of the week. Then there is a 7-day break, during which a menstrual-like reaction occurs. The mechanism is similar to that of COCs.
Advantages of the patch:
●ease of use; ●release of minimal doses of hormones;
●lack of the effect of primary passage through the liver and gastrointestinal tract;
●quick restoration of fertility after withdrawal;
●possibility of use in women of different ages;
●possibility of independent use (without the participation of medical personnel);
●small number of side effects.
Disadvantages of the patch:
●sometimes the patch may come off, it can be washed off with water, etc.;
●if the loss of the patch is not noticed by the woman within 48 hours, pregnancy may occur;
●limited number of body areas to which the patch can be applied;
●possibility of local adverse reactions.
HORMONE-CONTAINING IUDs
Mirena is a levonorgestrel-releasing system that combines high contraceptive effectiveness and the therapeutic properties of hormonal contraceptives (COCs and subcutaneous implants). The shelf life of Mirena is 5 years.
Mechanism of action - a combination of the mechanisms of action of the IUD and levonorgestrel, due to which:
●the functional activity of the endometrium is suppressed: endometrial proliferation is inhibited, atrophy of the endometrial glands develops, pseudodecidual transformation of the stroma and vascular changes, which prevents implantation;
●motility of sperm in the uterine cavity and fallopian tubes decreases.
Advantages of the method:
●reliable contraceptive effect; ●high safety;
●reversibility of the contraceptive effect (fertility is restored after 6–24 months);●lack of connection with sexual intercourse and the need for self-control;
●reduction of menstrual blood loss (in 82–96% of patients);
●therapeutic effect for idiopathic menorrhagia;
●possibility of use for small MMs.
Contraindications to the use of Mirena © :
●acute thrombophlebitis or thromboembolic conditions;●breast cancer;
●acute hepatitis;●severe liver cirrhosis, liver tumors;
●ischemic heart disease; ●general contraindications to the use of IUDs.
Side effects and complications when using Mirena ©:
●during the first 3–4 months - systemic effects - changes in mood, headache, mastalgia, nausea, acne; ●possible development of functional ovarian cysts
●possible menstrual cycle disorders: ♦acyclic uterine bleeding
♦oligo and amenorrhea develop in 20% of cases
HORMONE-CONTAINING VAGINAL CONTRACEPTIVE RING NOVARING The vaginal route of hormone administration is used.
15 mcg of ethinyl estradiol and 120 mcg of etonogestrel, which are the active metabolite of desogestrel, are released from the ring per day.
The vaginal route of administration allows you to achieve significant advantages: stable hormonal levels; lack of primary passage through the liver and gastrointestinal tract.
mechanism of action - suppression of ovulation. In addition, it causes an increase in the viscosity of cervical mucus.
Each ring is intended for use during one menstrual cycle. The woman inserts and removes it herself, insert it from the 1st to the 5th day of the menstrual cycle, for 3 weeks into the vagina, then remove it and take a 7-day break, then the next ring. During the first 7 days of using the vaginal ring, you must use a condom. Adverse reactions and contraindications similar to COCs and transdermal systems.
EMERGENCY CONTRACEPTION
a method of preventing pregnancy after unprotected intercourse.
Mechanism - suppression or delay of ovulation, disruption of the fertilization process, egg transport and blastocyst implantation.
The effect is possible when used within the first 24–72 hours after unprotected sexual intercourse.
Currently used for emergency contraception:
●KOK; ●progestogens; ●copper-containing VMC.
USPE METHOD
Twice doses of 100 mcg ethinyl estradiol and 0.5 mg levonorgestrel. The first dose must be taken within 72 hours after unprotected sexual intercourse. The second - 12 hours after the first dose.
For the purpose of emergency contraception, almost all modern contraception can be used. COOK in appropriate doses: 8 tablets of a low-dose COC (containing 30-35 mcg ethinyl estradiol), taken in two doses with a 12-hour interval, or 4 tablets of a high-dose COC (containing 50 mcg ethinyl estradiol), also taken in two doses with a 12-hour interval.
Contraindications- pregnancy, as well as conditions in which estrogens are contraindicated (history of thromboembolism, severe liver disease, bleeding of unknown etiology, breast and endometrial cancer).
Side effects : nausea (51%), vomiting (19%), mastalgia, bleeding.
EMERGENCY CONTRACEPTION WITH PROGESTAGENS they use the drug postinor©, containing 0.75 mg of levonorgestrel in one tablet, and escapelle©, containing 1.5 mg of levonorgestrel in one tablet.
Use 2 tablets of Postinor©: the first tablet within 48 hours after unprotected sexual intercourse, the second - after 12 hours. Escapelle© - once no later than 72 hours after unprotected sexual intercourse.
EMERGENCY CONTRACEPTION USING COPPER-CONTAINING INTRAUTERINE DEVICES
For this purpose, an IUD is inserted into the uterus within 5 days after unprotected sexual intercourse. This method is not indicated for nulliparous women, as well as for patients with a high risk of developing inflammatory diseases of the genital organs, primarily STIs, the increased risk of which occurs when there is a large number of sexual partners and casual sexual relationships.
Each tablet combined oral contraceptives (COCs) contains estrogen and progestogen. Synthetic estrogen - ethinyl estradiol - is used as an estrogenic component of COCs, and various synthetic progestogens (synonym - progestins) are used as a progestogen component.
Mechanism of contraceptive action of COCs:
- suppression of ovulation;
- thickening of cervical mucus;
- changes in the endometrium that prevent implantation.
Contraceptive effect of COCs provides a progestogen component. Ethinyl estradiol in COCs supports endometrial proliferation and provides cycle control (no intermediate bleeding when taking COCs).
In addition, ethinyl estradiol is necessary to replace endogenous estradiol, since when taking COCs there is no follicle growth and, therefore, estradiol is not produced in the ovaries.
The main clinical differences between modern COCs - individual tolerability, frequency of adverse reactions, features of the effect on metabolism, therapeutic effects, etc. - are due to the properties of the progestogens they contain.
CLASSIFICATION AND PHARMACOLOGICAL EFFECTS OF COCs
Chemical synthetic progestogens - steroids; they are classified by origin.
Like natural progesterone, synthetic progestogens cause secretory transformation of the estrogen-stimulated (proliferative) endometrium. This effect is due to the interaction of synthetic progestogens with endometrial PR. In addition to their effect on the endometrium, synthetic progestogens also act on other organs that are the targets of progesterone. The antiandrogenic and antimineralocorticoid effects of progestogens are favorable for oral contraception; the androgenic effect of progestogens is undesirable.
The residual androgenic effect is undesirable, as it can be clinically manifested by the appearance of acne, seborrhea, changes in the lipid spectrum of the blood serum, changes in carbohydrate tolerance and weight gain due to anabolic effects.
Based on the severity of androgenic properties, progestogens can be divided into the following groups:
- Highly androgenic progestogens (noethisterone, linestrenol, ethynodiol).
- Progestogens with moderate androgenic activity (norgestrel, levonorgestrel in high doses, 150–250 mcg/day).
- Progestogens with minimal androgenicity (levonorgestrel in a dose of no more than 125 mcg/day, including triphasic), ethinyl estradiol + gestodene, desogestrel, norgestimate, medroxyprogesterone). The androgenic properties of these progestogens are detected only in pharmacological tests; in most cases they have no clinical significance. WHO recommends the use of COCs with low androgenic progestogens. Studies have found that desogestrel (active metabolite - 3-ketodesogestrel, etonogestrel) has high progestogenic and low androgenic activity and the lowest affinity for SHBG, therefore, even in high concentrations, it does not displace androgens from its connection. These factors explain the high selectivity of desogestrel compared to other modern progestogens.
Cyproterone, dienogest and drospirenone, as well as chlormadinone, have an antiandrogenic effect.
Clinically, the antiandrogenic effect leads to a reduction in androgen-dependent symptoms - acne, seborrhea, hirsutism. Therefore, COCs with antiandrogenic progestogens are used not only for contraception, but also for the treatment of androgenization in women, for example, with PCOS, idiopathic androgenization and some other conditions.
SIDE EFFECTS OF COMBINED ORAL CONTRACEPTIVES (COCs)
Side effects most often occur in the first months of taking COCs (in 10–40% of women); subsequently, their frequency decreases to 5–10%. Side effects of COCs are usually divided into clinical and mechanism-dependent.
Excessive estrogen influence:
- headache;
- increased blood pressure;
- irritability;
- nausea, vomiting;
- dizziness;
- mammalgia;
- chloasma;
- deterioration of tolerance to contact lenses;
- increase in body weight.
Insufficient estrogenic effect:
- headache;
- depression;
- irritability;
- reduction in the size of the mammary glands;
- decreased libido;
- vaginal dryness;
- intermenstrual bleeding at the beginning and middle of the cycle;
- scanty menstruation.
Excessive influence of progestogens:
- headache;
- depression;
- fatigue;
- acne;
- decreased libido;
- vaginal dryness;
- deterioration of varicose veins;
- increase in body weight.
Insufficient progestogenic effect:
- heavy menstruation;
- intermenstrual bleeding in the second half of the cycle;
- delay of menstruation.
If side effects persist longer than 3–4 months after starting treatment and/or intensify, then the contraceptive drug should be changed or discontinued.
Serious complications when taking COCs are extremely rare. These include thrombosis and thromboembolism (deep vein thrombosis, pulmonary embolism). For women's health, the risk of these complications when taking COCs with a dose of ethinyl estradiol 20–35 mcg/day is very small - lower than during pregnancy. Nevertheless, the presence of at least one risk factor for the development of thrombosis (smoking, diabetes mellitus, high degrees of obesity, arterial hypertension, etc.) serves as a relative contraindication to taking COCs. A combination of two or more of these risk factors (for example, smoking over the age of 35 years) generally excludes the use of COCs.
Thrombosis and thromboembolism, both when taking COCs and during pregnancy, can be manifestations of latent genetic forms of thrombophilia (resistance to activated protein C, hyperhomocysteinemia, deficiency of antithrombin III, protein C, protein S; APS). In this regard, it should be emphasized that routine determination of prothrombin in the blood does not give an idea of the hemostatic system and cannot be a criterion for prescribing or discontinuing COCs. When identifying latent forms of thrombophilia, a special study of hemostasis should be performed.
CONTRACEPTIONS TO THE USE OF COMBINED ORAL CONTRACEPTIVES
Absolute contraindications to taking COCs:
- deep vein thrombosis, pulmonary embolism (including a history), high risk of thrombosis and thromboembolism (with extensive surgery associated with prolonged immobilization, with congenital thrombophilia with pathological levels of coagulation factors);
- coronary heart disease, stroke (history of cerebrovascular crisis);
- arterial hypertension with systolic blood pressure 160 mm Hg. or more and/or diastolic blood pressure 100 mm Hg. and more and/or with the presence of angiopathy;
- complicated diseases of the valvular apparatus of the heart (hypertension of the pulmonary circulation, atrial fibrillation, history of septic endocarditis);
- a combination of several factors for the development of cardiovascular diseases (age over 35 years, smoking, diabetes, hypertension);
- liver diseases (acute viral hepatitis, chronic active hepatitis, liver cirrhosis, hepatocerebral dystrophy, liver tumor);
- migraine with focal neurological symptoms;
- diabetes mellitus with angiopathy and/or disease duration of more than 20 years;
- breast cancer, confirmed or suspected;
- smoking more than 15 cigarettes per day over the age of 35;
- lactation in the first 6 weeks after birth;
- pregnancy.
RESTORATION OF FERTILITY
After stopping taking COCs, the normal functioning of the hypothalamus-pituitary-ovarian system is quickly restored. More than 85–90% of women are able to become pregnant within one year, which corresponds to the biological level of fertility. Taking COCs before conception does not have a negative effect on the fetus, the course or outcome of pregnancy. Accidental use of COCs in the early stages of pregnancy is not dangerous and does not serve as a basis for abortion, but at the first suspicion of pregnancy, a woman should immediately stop taking COCs.
Short-term use of COCs (for 3 months) causes an increase in the sensitivity of the receptors of the hypothalamus-pituitary-ovarian system, therefore, when COCs are discontinued, tropic hormones are released and ovulation is stimulated.
This mechanism is called the “rebound effect” and is used in the treatment of some forms of anovulation. In rare cases, amenorrhea may be observed after discontinuation of COCs. Amenorrhea may be a consequence of atrophic changes in the endometrium that develop when taking COCs. Menstruation appears when the functional layer of the endometrium is restored independently or under the influence of estrogen therapy. In approximately 2% of women, especially in the early and late periods of fertility, amenorrhea lasting more than 6 months (hyperinhibition syndrome) can be observed after stopping taking COCs. The frequency and causes of amenorrhea, as well as the response to therapy in women who used COCs, do not increase the risk, but may mask the development of amenorrhea with regular menstrual-like bleeding.
RULES FOR INDIVIDUAL SELECTION OF COMBINED ORAL CONTRACEPTIVES
COCs are selected for women strictly individually, taking into account the characteristics of their somatic and gynecological status, individual and family history. The selection of COCs is carried out according to the following scheme:
- A targeted interview, assessment of somatic and gynecological status and determination of the category of acceptability of the combined oral contraceptive method for a given woman in accordance with WHO eligibility criteria.
- Selection of a specific drug, taking into account its properties and, if necessary, therapeutic effects; counseling a woman about the COC method.
decision to change or cancel COCs.
- Clinical observation of the woman during the entire period of use of COCs.
In accordance with the WHO conclusion, the following examination methods are not relevant to assessing the safety of COC use:
- examination of the mammary glands;
- gynecological examination;
- examination for the presence of atypical cells;
- standard biochemical tests;
- tests for PID, AIDS.
The drug of first choice should be a monophasic COC with an estrogen content of no more than 35 mcg/day and a low androgenic gestagen.
Three-phase COCs can be considered as reserve drugs when signs of estrogen deficiency appear against the background of monophasic contraception (poor cycle control, dry vaginal mucosa, decreased libido). In addition, three-phase drugs are indicated for primary use in women with signs of estrogen deficiency.
When choosing a drug, you should take into account the characteristics of the patient’s health condition (Table 12-2).
Table 12-2. Selection of combined oral contraceptives
| Clinical situation | Recommendations |
| Acne and/or hirsutism, hyperandrogenism | Drugs with antiandrogenic progestogens |
| Menstrual irregularities (dysmenorrhea, dysfunctional uterine bleeding, oligomenorrhea) | COCs with a pronounced progestogenic effect (Marvelon©, Microgynon©, Femoden©, Janine©). When dysfunctional uterine bleeding is combined with recurrent hyperplastic processes of the endometrium, the duration of treatment should be at least 6 months |
| Endometriosis | Monophasic COCs with dienogest, levonorgestrel, desogestrel or gestodene, as well as progestin COCs are indicated for long-term use. The use of COCs can help restore generative function |
| Diabetes mellitus without complications | Preparations with a minimum estrogen content - 20 mcg/day |
| Initial or re-prescription of COCs in a smoking patient | If you smoke under the age of 35, use COCs with minimal estrogen content. For smoking patients over 35 years of age, COCs are contraindicated |
| Previous use of COCs was accompanied by weight gain, fluid retention in the body, and mastodynia | Yarina© |
| Poor control of the menstrual cycle has been observed with previous COC use (in cases where other causes other than COC use have been excluded) | Monophasic or three-phase COCs (Tri-Mercy©) |
The first months after starting to take COCs serve as a period of adaptation of the body to hormonal changes. At this time, intermenstrual spotting bleeding or, less commonly, “breakthrough” bleeding (in 30–80% of women), as well as other side effects associated with hormonal imbalance (in 10–40% of women), may occur.
If these adverse events do not go away within 3–4 months, this may be a reason to change the contraceptive (after excluding other causes - organic diseases of the reproductive system, missed pills, drug interactions) (Table 12-3).
Table 12-3. Selection of second-line COCs
| Problem | Tactics |
| Estrogen-dependent side effects | Reducing the dose of ethinyl estradiol Switching from 30 to 20 mcg/day ethinyl estradiol Switching from triphasic to monophasic COCs |
| Progestin-dependent side effects | Reducing the progestogen dose Switching to a three-phase COC Switching to a COC with another progestogen |
| Decreased libido | Switching to a three-phase COC - Switching from 20 to 30 mcg/day ethinyl estradiol |
| Depression | |
| Acne | Switching to COCs with an antiandrogenic effect |
| Breast engorgement | Switching from triphasic to monophasic COCs Switching to ethinyl estradiol + drospirenone Switching from 30 to 20 mcg/day ethinyl estradiol |
| Vaginal dryness | Switching to a three-phase COC Switching to a COC with another progestogen |
| Pain in the calf muscles | Switching to 20 mcg/day ethinyl estradiol |
| Scanty menstruation | Switching from monophasic to triphasic COC Switching from 20 to 30 mcg/sutethinyl estradiol |
| Heavy menstruation | Switching to a monophasic COC with levonorgestrel or desogestrel Switching to 20 mcg/day ethinyl estradiol |
| Intermenstrual bleeding at the beginning and middle of the cycle | Switching to a three-phase COC Switching from 20 to 30 mcg/day ethinyl estradiol |
| Intermenstrual bleeding in the second half of the cycle | Switching to COCs with a higher dose of progestogen |
| Amenorrhea while taking COCs | Pregnancy must be excluded Together with COC ethinyl estradiol throughout the entire cycle Switching to COC with a lower dose of progestogen and a higher dose of estrogen, for example triphasic |
The basic principles for monitoring women using COCs are as follows:
- in an annual gynecological examination, including colposcopy and cytological examination;
- examining the mammary glands every six months (in women with a history of benign tumors of the mammary glands and/or breast cancer in the family), performing mammography once a year (in perimenopausal patients);
- in regular blood pressure measurement: when diastolic blood pressure increases to 90 mm Hg. and more - stopping taking COCs;
- in a special examination according to indications (if side effects develop, complaints arise).
In case of menstrual dysfunction, exclude pregnancy and transvaginal ultrasound scanning of the uterus and its appendages.
RULES FOR TAKEN COMBINED ORAL CONTRACEPTIVES
All modern COCs are produced in “calendar” packages designed for one administration cycle (21 tablets - one per day). There are also packs of 28 tablets, in which case the last 7 tablets do not contain hormones (“dummy”). In this case, the packs should be taken without interruption, which reduces the likelihood that the woman will forget to start taking the next pack on time.
Women with amenorrhea should start taking it at any time, provided that pregnancy has been reliably excluded. An additional method of contraception is required for the first 7 days.
Women who are breastfeeding:
- COCs are not prescribed earlier than 6 weeks after birth;
- in the period from 6 weeks to 6 months after childbirth, if a woman is breastfeeding, use COCs only if absolutely necessary (the method of choice is minipills);
- more than 6 months after birth, COCs are prescribed:
♦for amenorrhea - see the section “Women with amenorrhea”;
♦with a restored menstrual cycle - see the section “Women with a regular menstrual cycle.”
PROLONGED REGIMEN OF PRESCRIPTION OF COMBINED ORAL CONTRACEPTIVES
Prolonged contraception provides for an increase in cycle duration from 7 weeks to several months. For example, it may consist of taking 30 mcg ethinyl estradiol and 150 mcg desogestrel or any other COC in a continuous regimen. There are several long-acting contraceptive regimens. The short-term dosing regimen allows you to delay menstruation by 1–7 days; it is practiced before an upcoming surgical intervention, vacation, honeymoon, business trip, etc. The long-term dosing regimen allows you to delay menstruation from 7 days to 3 months. As a rule, it is used for medical reasons for menstrual irregularities, endometriosis, MM, anemia, diabetes, etc.
Long-acting contraception can be used not only to delay menstruation, but also for therapeutic purposes. For example, after surgical treatment of endometriosis in a continuous manner for 3–6 months, which significantly reduces the symptoms of dysmenorrhea, dyspareunia, helps to improve the quality of life of patients and their sexual satisfaction.
The prescription of long-acting contraception is also justified in the treatment of MM, since in this case the synthesis of estrogen by the ovaries is suppressed, the level of total and free androgens, which under the influence of aromatase synthesized in the fibroid tissues, can be converted into estrogens, decreases. At the same time, women do not observe estrogen deficiency in the body due to its replenishment with ethinyl estradiol, which is part of the COC. Studies have shown that in PCOS, continuous use of Marvelon© for 3 cycles causes a more significant and persistent decrease in LH and testosterone, comparable to that with the use of GnRH agonists, and contributes to a much greater reduction in these indicators than when taken in the standard regimen.
In addition to the treatment of various gynecological diseases, the use of the method of prolonged contraception is possible in the treatment of dysfunctional uterine bleeding, hyperpolymenorrhea syndrome in perimenopause, as well as for the purpose of relieving vasomotor and neuropsychic disorders of menopausal syndrome. In addition, long-acting contraception enhances the cancer-protective effect of hormonal contraception and helps prevent bone loss in women of this age group.
The main problem with the prolonged regimen was the high frequency of breakthrough bleeding and spotting, which was observed during the first 2–3 months of use. Currently available data indicate that the incidence of adverse reactions with extended cycle regimens is similar to those for conventional dosing regimens.
RULES FOR FORGOTTEN AND MISSED PILLS
- If 1 tablet is missed:
♦less than 12 hours late in taking the dose - take the missed pill and continue taking the drug until the end of the cycle according to the previous regimen;
♦delay in appointment more than 12 hours - the same actions plus:
– if you miss a pill in the 1st week, use a condom for the next 7 days;
– if you miss a pill in the 2nd week, there is no need for additional means of protection;
– if you miss a pill in the 3rd week, after finishing one pack, start the next one without a break; There is no need for additional means of protection. - If 2 or more tablets are missed, take 2 tablets per day until taking them into your regular schedule, plus use additional methods of contraception for 7 days. If bleeding begins after missing tablets, it is better to stop taking tablets from the current package and start a new package 7 days later, counting from the start of missing tablets.
RULES FOR PRESCRIPTION OF COMBINED ORAL CONTRACEPTIVES
- Primary appointment - from the 1st day of the menstrual cycle. If reception is started later (but no later than the 5th day of the cycle), then in the first 7 days it is necessary to use additional methods of contraception.
- Post-abortion appointment - immediately after the abortion. Abortion in the first and second trimesters, as well as septic abortion, are classified as category 1 conditions (there are no restrictions on the use of the method) for prescribing COCs.
- Prescription after childbirth - in the absence of lactation - no earlier than the 21st day after birth (category 1). If there is lactation, do not prescribe COCs; use minipills no earlier than 6 weeks after birth (category 1).
- Switching from high-dose COCs (50 mcg ethinyl estradiol) to low-dose ones (30 mcg ethinyl estradiol or less) - without a 7-day break (so that the hypothalamic-pituitary system does not become activated due to dose reduction).
- Switching from one low-dose COC to another after the usual 7-day break.
- Switching from a minipill to a COC on the first day of the next bleeding.
- Switching from an injection drug to a COC on the day of the next injection.
- Switching from a combined vaginal ring to a COC on the day the ring was removed or on the day a new one was supposed to be inserted. Additional contraception is not required.
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