Information
Editors
Hormonal Contraception
- The majority of women using hormonal contraception use low-dose preparations (containing 20-30 µg ethinyloestradiol).
- There are usually two types of combined oral contraceptives (COCs) on the market:
- Monophasic pills, in which every pill contains the same amount of oestrogen and progestogen.
- Multiphasic (variable dose) pills, in which every pill contains both oestrogen and progestogen but the amounts vary in different phases of the menstrual cycle. There is no significant difference in efficacy or adverse effects between monophasic and biphasic pills.
- Unless there is some contraindication, a combined contraceptive is usually prescribed independent of the age of the woman.
- For a woman with acne Combined Oral Contraceptive Pills (Cocs) for Treatment of Acne or hirsutism select a product with cyproterone acetate Cyproterone Acetate for Hirsutism, desogestrel, drospirenone or dienogest as the progestogen.
- For a healthy normal-weight woman who doesn't smoke, any combined oral contraceptive on the market is usually suitable up until menopause, unless otherwise specified in the product instructions.
Contraindications of COCs
Cardiovascular risk associated with oral contraceptives
- Use of a COC containing 20-30 µg of ethinylestradiol by a non-smoking woman under 35 years of age does not seem to significantly increase her risk of arterial thromboembolism Ischaemic Stroke and Myocardial Infarction Risk with Combined Oral Contraceptives.
- As risk factors, the use of oral contraceptives, smoking and age (as well as elevated levels of blood pressure, glucose and cholesterol) are synergistic.
- The risk of cardiovascular death of a smoking woman under the age of 35 using COCs is about 1 per 100 000 woman-years (mainly stroke or myocardial infarction). The risk is increased by age, and in a smoking woman over 35 years of age, the risk is already tenfold Ischaemic Stroke and Myocardial Infarction Risk with Combined Oral Contraceptives.
- Smoking as such is always a more significant cardiovascular risk factor than the use of pills in any age group.
- High effectiveness
- Reduction in
- Reduced androgen production reduces greasiness of skin and acne
- Regular bleeding
- Less heavy bleeding
- Timing of bleeding can be controlled.
- A woman using a combined preparation and wanting less frequent menstruation can try extended cycles (2-3 cycles of pills taken without a break) Continuous or Extended Cycle Use of Combined Oral Contraceptives.
Skin patch
- Low dose combined contraceptive that releases ethinyloestradiol 20 µg/day and norelgestromin 150 µg/day.
- The product is a thin depot skin patch (size 45 mm × 45 mm).
- Has similar action, effectiveness and indications as combined contraceptive pills, with only minor differences in contraindications, advantages and disadvantages Skin Patch and Vaginal Ring Versus Combined Oral Contraceptives for Contraception.
- Easy to use: A new patch is attached to the skin once a week always on the same weekday during three weeks. Then follows one week without a patch, which leads to menstrual bleeding (the patch is started on the first day of the period).
- Skin patch is an alternative to combined contraceptive pills and is suitable for those who have difficulties in remembering or who do not wish daily pill-taking.
Vaginal ring
- A low dose combined hormone contaceptive that releases ethinyloestradiol 15 µg/day and etonogestrel 120 µg/day for three weeks.
- Flexible and translucent vaginal ring with a diameter of 54 mm and a cross diameter of 4 mm.
- Has similar action, effectiveness and indications as combined contaceptive pills, with only minor differences in contraindications, advantages and disadvantages Skin Patch and Vaginal Ring Versus Combined Oral Contraceptives for Contraception.
- The ring is inserted into the vagina for three weeks. This is followed by a week without the ring, then a new ring is inserted etc. Bleeding appears during the week without the ring.
- Vaginal ring is an alternative to combined pill. It is suitable for those who have difficulties in remembering or who do not wish daily pill-taking.
- Contraception with progestogen-only is available as pills or as injections, or as hormone-releasing products like subcutaneous implants and hormone-releasing intrauterine devices.
- Has not the contraindications of oestrogen and according to current knowledge is less frequently associated with severe side effects.
Contraindications to contraception with progestogen
- Suspicion of pregnancy
- Active hepatic diseases (relative contraindication)
- Undiagnosed genital tract bleeding
Progestogen-only pills
- Special indications for contraception with progestogen-only pills (POP)
- During the use of POP, bleeding disorders are quite common (the patient should be informed).
- Two different products are available
- A product with two implants releasing levonorgestrel effective for 5 years (4 years in women weighing more than 60 kg) .
- A product with one implant releasing etonogestrel effective, according to its manufacturer, for 3 years, but which may often be used for up to 5 years provided that the bleeding profile will not change.
- Implants are an effective method of contraception Subdermal Implants for Contraception, although the effect might be decreased in women weighing more than 75 kg. Women of any age who need long-term contraception and who do not have contraindications to progestogens can use implants.
- It is important to insert the implants directly under the skin and not into the subcutaneous fat where they are difficult to remove. Inserting the implants in a fan-shaped arrangement is easier if you put only one implant in the applicator at a time (not as advised in the instructions following the product).
- Removal is more difficult than insertion but is made easier by injecting local anaesthetic cautiously under the ends of the implants so that the implants are raised and can be easily seen. If the implants are not readily palpable under the skin at the attempt of removal, they can be localized by ultrasound.
- The most common side effects include bleeding disorders (amenorrhoea, spotting), which often resolve during the first year of use. Pregnancy is rare. If a pregnancy does occur, it can be continued but the implants must be removed.
Hormone releasing IUD
- The supply of products and their brand names may vary from country to country. In levonorgestrel-releasing IUDs, the amount of levonorgestrel and the duration of use differ between products.
- The duration of use of the product that contains 52 mg levonorgestrel (Mirena® ) is 8 years
- The duration of use of the product containing 19.5 mg (Kyleena® ) is 5 years
- The duration of use of the product containing 13.5 mg (Jaydess® ) is 3 years.
- The two latter ones have a thin insertion tube which makes the insertion easier.
- Hormone releasing IUD is a good alternative for a woman who wants an IUD, but has heavy bleeding or bleeding increases with a copper IUD Levonorgestrel Intrauterine System Vs. other Forms of Reversible Contraceptives. A hormone-releasing IUD decreases the menstrual bleeding, sometimes to amenorrhoea (in about 20%). Spotting occurs in one third of the patients and it may last some months (inform the patient). A hormone-releasing IUD is also a good alternative for a woman who has contraindications for combined oral contraceptives or who has difficulties in keeping in mind the regularity required when using contraceptive pills, skin patches or vaginal rings.
- Young age or nulliparity are not contraindications for a progestin-releasing IUD.
- The contraceptive effect of hormone-releasing IUDs is excellent.
Follow-up of hormonal contraception
- Many of the most common side effects occur only during the first months of use.
- Nausea
- A harmless side effect associated with oestrogen, usually only during the first months
- The pill is advised to be taken in the evenings or it is changed to a preparation with a lower oestrogen content.
- Abnormal bleeding
- Spotting is common in the initial phase when combination pills are used (in about 30% of users). It is important to continue with the use according to the instructions.
- If spotting continues after the initial phase, switch to a preparation that contains more oestrogen or a different progestogen 20 Mcg Versus over 20 Mcg Estrogen Combined Oral Contraceptives for Contraception.
- Smoking exposes to menstrual disturbances by increasing the metabolism of oestrogen.
- Infections (chlamydia!), cervical atypias or pregnancy may be the cause of abnormal bleeding.
- Forgotten pills? Forgetting one pill leads to 10% risk of menstrual disturbance.
- Switch to a pill containing more oestrogen if disturbing amenorrhoea occurs.
- Headache
- Check for hypertension or severe migraine.
- Switch to a pill with a different progestogen or to parenteral combined preparation. If this does not help, choose a pill with less oestrogen.
- If the headache appears only during the one-week pill-free interval advise the woman to use two or three (monophasic regimen) rounds after each other and then have a break for one week. Progestogen-only or non-hormonal contraception are the alternatives.
- Lost libido
- Is it associated with contraception or with the life situation?
- Switch to a different progestogen (e.g. a combined preparation containing levonorgestrel) or to progestogen-only contraception.
- If dryness of the vagina is the problem, try a pill with more oestrogen.
- Mood changes
- Try a pill with a different composition, or a vaginal ring, or a progestogen-only pill, or lenghten the cycle.
- Changes of the skin are rare.
- Swelling and tenderness of the breasts
- Switch to pills with less oestrogen or with drospirenone as the progestogen or to progestogen-only pills.
- Changes in body weight, oedema
- Both oestrogen and progestogen may expose to fluid retention.
- Progestogens may have an anabolic effect.
- The explanation may often be in the changed life style of the couple, and the COCs probably have no significant effect on the body weight Combination Contraceptives: Effects on Weight.
- Switch to another progestogen or to pills with less oestrogen.
- Switch to a pill containing drospirenone that is related to spironolactone.
- Elevated blood pressure
- If blood pressure is repeatedly > 140/90 mmHg, try pills containing drospirenone or switch to progestogen-only pills or to non-hormonal contraception.
- Risk for venous thromboembolism, see also Evaluation of Thrombophilia.