COMBINED ORAL CONTRACEPTIVES (PILLS)

• The combined oral steroidal contraceptives is the most effective

reversible method of contraception.
• In the combination pill, the commonly used progestins are either
levonorgestrel or norethisterone or desogestrel and the estrogens
are principally confined to either ethinyl-estradiol or menstranol (3
methylether of ethinyl-estradiol).

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 • Mode of action COC: {Mechanism}
• The primary mechanism is inhibition of the LH surge.

• 1. Suppression of ovulation {inhibition of ovulation}.

• 2. Thickening of the cervical mucus, so as to prevent sperm penetration.
• 3. Alteration of tubal motility {probably interferes with tubal motility and
alters tubal transport}.
• 4. Endometrium becomes atrophic, preventing blastocyst implantation.

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 • Selection of the patient COC:
• 1. History and examinations to exclude any contraindication of COC
(headache, migraine).
• 2. Examination of the breasts for any nodules, weight and blood
pressure are to be noted.
• 3.Pelvic examination to exclude cervical pathology.
• 4. Pregnancy must be excluded.
• 5. Cervical cytology to exclude abnormal cells, is to be done.
• 6. Any woman of reproductive age group without any systemic disease
and contraindications listed, is a suitable candidate for COC

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 • How to prescribe a pill:
• Instruction:
• Normally start their pill packet on day one of their cycle.
• One tablet is to be taken daily at bed time for consecutive 21 days.
• It is continued for 21 days and then have a 7 days break.
• Next pack should be started on the eighth day, irrespective of bleeding
(same day of the week, the pill finished).
• 3 weeks on and 1 week off.
• Packing of 28 tablets, there should be no break.
• However, a woman can start the pill up to day 5 of the bleeding.
• Advised to use a condom for the next 7 days.
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 • Drug interactions of COC:
• Effectiveness of some drugs
• (Aspirin, oral anticoagulants, oral hypoglycemics) are decreased
and that for some other drugs (beta blockers, corticosteroids,
diazepam, aminophylline) are increased by oral contraceptives.

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 • Disadvantages and common side effects
• Nausea, vomiting, headache
• Menstrual abnormalities.
• Mastalgia
• Weight gain
• Missed period.
• Mood changes
• Breast tenderness
• Suppresses lactation
• Libido
• Menorrhagia, amenorrhea

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 • Complications of COC
• Severe headaches,
• Blurred vision
• Hypertension
• Depression
• Vascular complications, Cholestatic jaundice
• Severe abdominal pain
• Chest pain plus dyspnoea (pulmonary embolism)
• Swelling or pain in calf muscle (Deep vein thrombosis}

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• BENEFITS OF COMBINED ORAL CONTRACEPTIVES (COCs)
• Contraceptive benefits of COC:
• (i) Protection against unwanted pregnancy (failure rate – 0.1 per
100 women year)
• (ii) Convenient to use
• (iii) Not intercourse related
• (iv) Reversibility
• (v) Improving maternal and child health care.

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 Non.contraceptive benefits of COC.
• 1. Ovarian cancer. • 9. Fibroid uterus
• 2. Endometrial cancer. • 10. Functional ovarian cysts
• 3. Benign breast disease. • 11. Autoimmune disorders
• 4. Ectopic pregnancy. • 12. Rheumatoid arthritis.
• 5. Iron deficiency anemia. • 13. Endometriosis
• 6. Pelvic inflammatory disease (PID). • 14. Regulation of menstrual cycle
• 7. Dysmenorrhea.
• 8. Hirsutism and acne

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PROGESTIN ONLY CONTRACEPTION (POP/MINI
PILL) {POC}
• POP is devoid of any estrogen compound.
• It contains very low dose of a progestin in any one of the following form
Levonorgestrel 75 µg, norethisterone 350 µg, desogestrel 75 µg,
lynestrenol 500 µg or norgestrel 30 µg.
• It has to be taken daily from the first day of the cycle.

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 •Mode of action POP:
• 1. Suppression of ovulation {inhibition of ovulation}. Prevents
ovulation by LH suppression.
• 2. Thickening of the cervical mucus, so as to prevent sperm
penetration.
• 3. Endometrium becomes atrophic, preventing blastocyst
implantation {Endometrial thinning}.

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 •How to prescribe mini pill:
• Instruction:
• The first pill has to be taken on the first day of the cycle and then continuously.
• It has to be taken regularly and at the same time of the day.
• There must be no break between the packs.
• Delay in intake for more than 3 hours, the woman should have missed pill immediately
and the next one as schedule.
• Extra precaution has to be taken for next 2 days.

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 Indications.
Women with sickle cell disease.
Women who cannot use COCs due to estrogen content.
Women awaiting surgical contraception.
Women who don not want more children but do not
Known HIV positive or Suspected women who need
Breastfeeding postpartum women.
Women more than 40 yrs.
Have a history of anemia with heavy menstrual bleeding.
Intend to breastfeed for a year or two.
Have chronic illnesses, in which health will be threatened by pregnancy.

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 • Contraindications of POP.
• Either Relative or absolute contraindications.
• Pregnancy
• Arterial disease
• Thromboembolic disease.
• Breast or genital malignancy (known or suspected)
• Undiagnosed vaginal bleeding
• Breast cancer >5 years ago, and it has not recurred
• Severe liver disease, infection, or tumor
• Taking barbiturates, carbamazepine, oxcarbazepine, phenytoin, primidone,
topiramate, rifampicin, rifabutin, or ritonavir or ritonavir-boosted protease inhibitors.
• Systemic lupus erythematosus with positive (or unknown) antiphospholipid
antibodies
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Benign or malignant liver tumors.
Known or suspected breast cancer.
Heavy cigarette smoking (15 or more daily)
Women older than 35 years.
History of ectopic pregnancy.
Diabetes mellitus.
Hypercholesterolemia.
Hypertension.
History of cardiovascular disease,
Gallbladder disease
Chronic disease, such as immunocompromised patients

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 • Advantages of POP.
• 1. Reduces the risk of PID.
• 2. It may be prescribed in patient having (medical disorders)
hypertension, fibroid, diabetes, epilepsy, smoking and history of
thromboembolism.
• 3. Easy to take.
• 4. No adverse effect on lactation.
• 5. No estrogen related side effects
• 6. Menstrual symptoms, e.g. menorrhagia, dysmenorrhea are reduced.
• 7. Protective against endometrial cancer.
• 8. Reduction in ectopic pregnancy
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• 9. Minimal drug-drug interactions
• 10. Reduction of menstrual bleeding and lower risk of
anemia.
• 11. Injections can be stopped at anytime.
• 12. Protective against endometrial cancer and ovarian
cancer

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 • Disadvantages:
• 1. Simple cysts of the ovary may be seen, but they do not
require any surgery
• 3. Failure rate is about 0.5–2 per 100 women years of use.
• 4. There may be acne, mastalgia, headache, breakthrough
bleeding.
• 5. Weight gain and headache.
• 6. No protection against STDs

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• 7. Bleeding irregularity; amenorrhea progressively more common
• 8. Can cause heavy prolonged vaginal bleeding during first 1-2
months after injection
• 9. Depression may occur, but overall rates not increased
• 10. Bone density decreases
• 11. Delay to return to fertility
• 12. Some risk of cancer breast, cervical cancer.

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• Side Effects.
• Irregular bleeding, spotting, break through bleeding, etc.
• Heavy or prolonged bleeding,
• Depression, headache, migraine.
• Weight gain and ectopic pregnancy.
• Mastalgia.
• Breast tenderness.
• Mood swings.
• Abdominal cramps.

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loss of Libido
Difficulty in removal is felt occasionally.
Infection at the Insertion Site,
Surgical application Pain, redness, sensitivity in the area of application
Weight gain 3-12%
Amenorrhea
Metroharrgia

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