Transcript oral contraceptive

Hormonal contraception
• Permanent
• temporary
1.
2.
3.
4.
Hormonal contraception
Intrauterine devices
Barrier contraception
Natural family planning
methods
• Oral contraceptives are medicines taken by mouth to
help prevent pregnancy.
• They are also known as “birth control pills”.
• Birth control (contraceptive) medications
• contain hormones (estrogen and progesterone, or
progesterone alone).
• Efficacious
• Low cost
• Overall safety
• Complete return of fertility on discontinuation
Primary action is inhibition of
ovulation
Mechanism of oral contraceptives
• Hormonal birth control medications prevent pregnancy
through the following ways:
• By blocking ovulation (release of an egg from the ovaries), thus
preventing pregnancy
• By altering mucus in the cervix, which makes it hard for sperm to
travel further
• By changing the endometrium (lining of the uterus) so that it
cannot support a fertilized egg
• By altering the fallopian tubes (the tubes through which eggs
move from the ovaries to the uterus) so that they cannot
effectively move eggs toward the uterus
FSH
Progestogen- LH
mode of action
• Inhibition of Gn release from pituitary by reinforcement of normal feedback
inhibition.
• estrogen
• inhibits secretion of FSH via negative feedback on the anterior pituitary, and
thus suppresses development of the ovarian follicle
• progestogen
• inhibits secretion of LH and thus prevents ovulation; it also makes the
cervical mucus less suitable for the passage of sperm
• oestrogen and progestogen
• act in concert to alter the endometrium in such a way as to discourage
implantation.
• They may also interfere with the coordinated contractions of cervix, uterus
and fallopian tubes that facilitate fertilisation and implantation.
Ovulation
ORAL CONTACEPTIVE VIDEO
• ..\..\VIDEOS\ORAL CONTRACEPTIVE VIDEO\Birth Control Pills.mp4
• ..\..\VIDEOS\PARTURATION PROCESS\Parturition - Pregnancy,
Hormones, Giving Birth.mp4
Types
ORAL
1. Combined pill- Efficacy 98-99.9%
Estrogen+Progestin
2nd generation pills- ↓estrogen+progestins
3rd generation pills- newer progestins-desogestrel
COURSE
1 tablet daily(starting on 5th day of menstruation)-21 days
Next course after gap of 7 days
2. Phased regimens
Reduction in total steroid dose without compromising
efficacy
-Biphasic
-Triphasic
Estrogen - Constant(or varied b/w 30-40µg)
Progestin- Low in 1st phase-progressively higher in 2nd and
3rd phase
3. Minipill
Low dose Progestin only pill
Taken continuously without any gap
Efficacy- 96-98%
4. Postcoital (emergency) contraception
3 regimens
a) Levonorgestrel 0.5mg- Ethinylestradiol 0.1mg
within 72 hrs & repeated after 12 hrs
‘YUZPE method’
b) Levonorgestrel 0.75mg
Twice with 12 hr gap within 72 hrs
WHO essential drug list(2001)- recommended
replacement of YUZPE method by this regimen
c) Mifepristone 600mg- single dose within 72 hrs
The combined pill
• This is the most popular and most efficacious method.
• It contains an estrogen and a progestin in fixed dose for all the days of a
treatment cycle (monophasic).
• With accumulated experience
• It has been possible to reduce the amount of estrogen and progestin in the ‘second
generation’ oc pills
• Without
compromising
efficacy,
but
reducing
side
effects
and
complications.
• ‘Third generation’pills containing
• Newer progestins like desogestrel with improved profile of action.
• Ethinylestradiol 30 µg daily is considered threshold but can be reduced to 20 µg/day if
a progestin with potent antiovulatory action is included.
• The progestin is a 19-nortestosterone because these have potent antiovulatory
action.
The combined pill
• The estrogen in most combined preparations (second-generation pills)
• Ethinylestradiol, although a few preparations contain mestranol instead.
• The progestogen may be
• Norethisterone, levonorgestrel, ethynodiol, or
• In 'third-generation' pills-desogestrel or gestodene
• Are more potent
• But which probably cause a greater risk of thromboembolism than do secondgeneration preparations.
• Well tolerated and gives good cycle control in the individual woman.
• This combined pill is taken for 21 consecutive days followed by 7 pill-free
days, which causes a withdrawal bleed.
• Normal cycles of menstruation usually commence fairly soon after
discontinuing treatment.
First generation:•50 μg ethinyl estradiol and Progesterone (Norethynodrel,
norethisterone acetate and lynestrenol)
:ovral
Second generation:•20-30μg ethinyl estradiol and Progesterone (Norgestrel,
levonorgestrel)
•Without compromising efficacy, but reducing side effects and
complications.
• :ovral –L, malaN , malaD
Third generation:
•Containing newer progestins with improved profile of action.
•Ethinylestradiol 30 μg and
progesterone (Desogestrel,
gestodene, norgestimate)
:novelon , femilon
Phased regimens
• These have been introduced to permit reduction in total
steroid dose withaut Compromising efficacy.
• These are biphasic or Triphasic.
• The estrogen dose is kept constant (or Varied slightly
between 30-40 µg), while the Amount of progestin is low
in the first phase and Progressively higher in the second
and third Phases.
• Phasic pills
• Particularly recommended for Women over 35 years of age
or when other risk Factors are present.
Phased regimens
1.
1.
Biphasic (each tablet contains a fixed amount of estrogen, while
the amount of progestin increases in the second half of the
cycle); or
•
Estrogen - constant(or varied b/w 30-40µg)
•
Progestin- low in 1st phase-progressively higher in 2nd and 3rd phase
Triphasic (the amount of estrogen may be fixed or variable,
while the amount of progestin increases in 3 equal phases).
Minipill (progestin only pill)
• It has been devised to eliminate the estrogen, because many of
the long-term risks have been ascribed to this component.
• A low-dose progestin only pill is taken daily continuously without
any gap.
• The menstrual cycle tends to become irregular and ovulation
occurs in 20-30% women, but other mechanisms contribute to
the contraceptive action.
• The efficacy is lower (96-98%) compared to 98-99.9% with
combined pill.
• This method is less popular.
Postcoital (emergency) contraception
3 regimens
a) Levonorgestrel 0.5mg+ethinylestradiol 0.1mg
• within 72 hrs & repeated after 12 hrs
• ‘YUZPE method’
b) Levonorgestrel 0.75mg
• twice with 12 hr gap within 72 hrs
•
WHO essential drug list(2001)•
recommended replacement of YUZPE method by this regimen
c) Mifepristone 600mg- single dose within 72 hrs
•
Emergency postcoital contraception should be reserved
•
•
For unexpected or accidental exposure (rape, condom rupture)
only
Because all emergency regimens have higher failure rate and side
effects than regular low-dose combined pill.
Adverse effects
A. Nonserious side effects
• These are frequent, Specially in the first 1-3 cycles and then
disappear Gradually.
• Nausea and vomiting, Headache, migraine, bleeding or spotting,
Amenorrhoea, Breast discomfort.
B. Side effects that appear later
1. Weight gain, acne and increased body hair
2. Chloasma: pigmentation of cheeks, nose and Forehead
3. Pruritus vulvae
4. Carbohydrate intolerance and precipitation Of diabetis
5. Mood swings, abdominal distention
Adverse effects
C. Serious complications
1 . Leg vein and pulmonary thrombosis
2. Coronary and cerebral thrombosis
3. Rise in BP
4. raise plasma HDL/LDL ratio
5. Genital carcinoma
6. Benign hepatomas
7. Gallstones
Other health benefits
• lower probability of developing endometrial and ovarian
carcinoma; probably colorectal cancer as well.
• Reduced menstrual blood loss and associated anaemia;
cycles if irregular become regular
• endometriosis and pelvic inflammatory disease are
improved.
• reduced incidence of fibrocystic breast disease .
Contraindications
• The combined oral contraceptive
• Absolutely contraindicated in:
1. Thromboembolic, coronary and
cerebrovascular disease or a
history of it.
2. Moderate-to-severe hypertension;
hyperlipidaemia.
3. Active liver disease, hepatoma or
jaundice during past pregnancy
4.
Suspected
malignancy
of
genitals/breast.
5. Prophyria.
6. Impending major surgery—to avoid
excess risk of postoperative
thromboembolism.
• Relative contraindications
(requiring avoidance/cautious use
under supervision)
1. Diabetes
2. Obesity
3. Smoking
4. Undiagnosed vaginal bleeding
5. Mentally ill
6. Age above 35 years
7. Mild hypertension
8. Migraine
9. Gallbladder disease
Interaction With Drugs…
• Contraceptive failure may occur if the following drugs are used
concurrently:
(a) Enzyme inducers:
• Phenytoin, phenobarbitone, primidone, carbamazepine, rifampin,
ritonavir.
Metabolism of estrogenic as well as progestational component is
increased.
(a) Suppression of intestinal microflora:
• Tetracyclines, ampicillin, etc.
• Deconjugation of estrogens excreted in bile fails to occur → their
enterohepatic circulation is interrupted → blood levels fall.
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Indications of Withdrawal :
 Severe migraine
Visual or speech disturbances
Sudden chest pain
Unexplained fainting attack or acute vertigo
Severe leg cramps
Excessive weight gain
Severe depression
Prior to surgery ( Atleast 6 weeks )
Patient wants pregnancy …

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- PHARMA STREET