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Overview of Oral Contraceptives

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medical information in this presentation is provided as an information resource only, and is not

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PP-NXM-IND-0252 9th Apr 2019

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Table of Contents

• Choice of contraception

• Types of Oral Contraceptives

• Combined oral contraceptives: Myths and Facts

• Progestin-only pills

• When and how to use oral contraceptives

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Choice of Contraception

NICHD. What are the different types of contraception? Available from:

Hormonal

Combined oralcontraceptives

Progestin-only pills

Contraceptivepatch

Vaginal rings

Barrier

Condoms

Diaphragms and cervical caps

Contraceptivesponges and spermicides

Intrauterine

Copperintrauterine

device

Hormonal intrauterine

device

Sterilization

Implant

Tubal ligation

Vasectomy

https://www.nichd.nih.gov/health/topics/contraception/conditioninfo/Pages/types.aspx. Accessed on 6 April 2019

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What are Oral Contraceptives (Birth Control Pills)?

75545366974405.Accessed on 6 April 2019. 2. Jin J. Oral contraceptives. JAMA. 2014;311:321.

• Most common form of contraception1

• Used for prevention of unwanted pregnancy2

• Safe and reliable method2

• Highly effective: chance of pregnancy is 0.1% (if takenperfectly)2

• Real-world scenario: chance of pregnancy is about 8% per year2

1. NICE Guidelines, 2016. Contraception. Available from: https://www.nice.org.uk/guidance/qs129/resources/contraception-

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Types of Oral Contraceptives

Oral contraceptives(Birth control Pills)

Combined oralcontraceptives

(contains both estrogenand progestin)

Progestin-only pills (also known as the

“mini-pill”)

Jin J. Oral contraceptives. JAMA. 2014;311:321.

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COMBINED ORAL CONTRACEPTIVES

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What are Combined Oral Contraceptives?

• Contains both estrogen and progestin1

• Multiple formulations are available1

• Formulations vary by2

– Type and amount of hormones

– Patterns of those amount throughout the cycle

– Number of active pills in the packet

1. U.S. Selected Practice Recommendations for Contraceptive Use, 2013. Available from: https://www.cdc.gov/mmwr/pdf/rr/rr62e0614.pdf. Accessed on 6 April 2019. 2. Borgelt LM and Martell CW. Estradiolvalerate/dienogest: a novel combined oral contraceptive. Clin Ther. 2012;34:37-55.

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What are the Benefits/Risks of Combined OralContraceptives?

Benefits

• Improved cycle control and relief

from menstrual symptoms

• Reduced acne and hirsutism

• Improved bone health

• Prevention of ovarian / endometrial

and colorectal cancers

Risks

• Blockage of blood vessel by a

blood clot (venous

thromboembolism)

• Heart attack (myocardial infarction)

• Reduced blood supply to brain

(stroke)

Dragoman MV. The combined oral contraceptive pill - recent developments, risks and benefits. Best Pract Res Clin Obstet Gynaecol. 2014;28:825-34.

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Different Types of Combined Oral ContraceptivesRegimens

Combined oralcontraceptives

Traditionalregimen

28-day (21/7) regimen: 21 active

(contains hormones) and 7 inactive (placebo) pills

24/4 or 26/2 regimen:

28-day regimen with<7 hormone-free

days

Extendedregimen

More than 28 days of active hormones use

followed by hormone-free or -decreased interval

Continuousregimen

Regimen taken in an uninterrupted

manner with no hormone-free

interval

Benson LS and Micks EA. Why Stop Now? Extended and Continuous Regimens of Combined Hormonal Contraceptive Methods.Obstet Gynecol Clin North Am. 2015;42:669-81.

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Extended and Continuous Combined Oral Contraceptives

Benson LS and Micks EA. Why Stop Now? Extended and Continuous Regimens of Combined Hormonal Contraceptive Methods.Obstet Gynecol Clin North Am. 2015;42:669-81.

Benefits of extended and continuous combined oral contraceptives are

• High user acceptability

• Improved control of medical

conditions

• Likely improved efficacy

due to consistent ovulation

suppression

• Decreased frequency of

scheduled bleeding

• Decrease in estrogen-

withdrawal symptoms

• Unscheduled bleeding

lessens over time

COMBINED ORAL CONTRACEPTIVES:MYTHS AND FACTS

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Myths and Facts: Birth Defects

1. Myths and facts about... Contraceptive Pill. Available from: http://www.ippf.org/blogs/myths-and-facts-about-contraceptive-pill. Accessed on 6 April 2019. 2. Charlton BM, et al. Maternal use of oral contraceptives and risk of birth defects in Denmark: prospective, nationwide cohort study. BMJ. 2016;352:h6712.

• Combined oral contraceptives cause birth defects in babies1

MYTH

• Oral contraceptive use beforeor during pregnancy does notincrease the risk of birthdefects2

FACT

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Myths and Facts: Cancer

• Studies revealed a smallincrease in the risk of breastcancer, which, however,disappeared 5–10 years afterdiscontinuation of the COCs 2

MYTH FACT

COCs: Combined oral contraceptives1. Myths and facts about... Contraceptive Pill. Available from: http://www.ippf.org/blogs/myths-and-facts-about-contraceptive-pill. Accessed on 6 April 2019. 2. Küçük M, et al. Misconceptions about the side effects of combined oral contraceptive pills. Gynecol Endocrinol. 2012;28:282-5. 3. Bhupathiraju SN, et al. Exogenous Hormone Use: Oral Contraceptives, Postmenopausal Hormone

• Use of COCs increases the risk for cancers1

• Use of COCs reduces the riskfor endometrial,2 ovarian, andcolon cancers3

Therapy, and Health Outcomes in the Nurses’ Health Study. Am J Public Health. 2016;106:1631-7.

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Myths and Facts:

General Health Problems

• Combined oral contraceptivesasthma, andcause headaches,

hairloss1

MYTH

• Combined oral contraceptive use may cause minor and less frequentside effects such as headache,bloating and fluid retention, mood changes, and irregular bleeding2

• There are several reported healthbenefits of COCs as well such asreduction in menstrual blood loss,acne, hirsutism, and premenstrualsyndrome2

FACT

COCs: Combined oral contraceptives1. Myths and facts about... Contraceptive Pill. Available from: http://www.ippf.org/blogs/myths-and-facts-about-contraceptive-pill.Accessed on 6 April 2019. 2. Stewart M and Black K. Choosing a combined oral contraceptive pill. Aust Prescr. 2015;38:6-11.

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Myths and Facts:

Infertility/Delay in Conceiving

1. Myths and facts about... Contraceptive Pill. Available from: http://www.ippf.org/blogs/myths-and-facts-about-contraceptive-pill. Accessed on 6 April 2019. 2. Küçük M, et al. Misconceptions about the side effects of combined oral contraceptive pills. Gynecol Endocrinol. 2012;28:282-5. 3. Benson LS and Micks EA. Why Stop Now? Extended and Continuous Regimens of Combined Hormonal

• Combined oral contraceptiveuse may cause infertility or adelay in conceiving1

MYTH

• No correlation has been foundbetween the use of oral contraceptives and infertility2

• Return to fertility is observedwith the use of oralcontraceptives if you decide tobecome pregnant3

FACT

Contraceptive Methods. Obstet Gynecol Clin N Am. 2015;42:669-81.

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Myths and Facts: Sexual Desire

.COCs: Combined oral contraceptive1. Myths and facts about... Contraceptive Pill. Available from: http://www.ippf.org/blogs/myths-and-facts-about-contraceptive-pill. Accessed on 6 April 2019.2. Pastor Z, et al. The influence of combined oral contraceptives on female sexual desire: a systematic

• Combined oral contraceptivesreduce interest in sex (loss oflibido) and sexual pleasure1

MYTH

• Combined oral contraceptiveuse does not cause change insexual activity. Majority ofCOCs users reported no change in libido2

FACT

review. Eur J Contracept Reprod Health Care. 2013;18:27-43.

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Myths and Facts: Weight Changes

COCs: Combined oral contraceptives1. Myths and facts about... Contraceptive Pill. Available from: http://www.ippf.org/blogs/myths-and-facts-about-contraceptive-pill.Accessed on 6 April 2019. 2. Küçük M, et al. Misconceptions about the side effects of combined oral contraceptive pills. Gynecol

• Combined oral contraceptive use may cause weight changes1

MYTH

• Overweight issues may berelated to negative self-esteem and anxiety. There isno evidence of weight gain bylow-dose COCs2

• No difference in weight isreportedCOCs asusers2

in women takingnon-compared to

FACT

Endocrinol. 2012;28:282-5.

Special Considerations: Combined Oral Contraceptives

COCs: Combined oral contraceptives; VTE: Venous thromboembolism1. U.S. Selected Practice Recommendations for Contraceptive Use, 2013. Available from: http://www.cdc.gov/mmwr/pdf/rr/rr62e0614.pdf. Accessed on 6 April 2019. 2. WHO Press. Medical eligibility criteriafor contraceptive use. 5th ed. 2015. Available from: http://apps.who.int/iris/bitstream/10665/181468/1/9789241549158_eng.pdf?ua=1. Accessed on 6 April 2019

Absence of menstruation

(not post-partum)

• Combined oral contraceptives can be

started at any time if the woman is

not already pregnant

• Abstain from sex or use additional

contraceptive protection for the next 7

days

Post-abortion (spontaneous or

induced)

• Combined oral contraceptives can be

started within first 7 days after first or

second trimester abortion, including

immediately post abortion

• Abstain from sex or use additional

contraceptive protection for the next 7

days

After childbirth

• Breastfeeding women should not use

COCs till 6 weeks after childbirth and

usually should avoid use up to 6

months

Switching from another

contraceptive method

• Combined oral contraceptives can be

started immediately if it is reasonably

certain that the woman is not

pregnant

• Abstain from sex or use additional

contraceptive protection for the next 7

days (if >5 days since menstrual

bleeding started)

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PROGESTIN-ONLY PILLS

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What are Progestin-Only Pills?

• Also known as the “mini-pills”1

• Contains only synthetic progestogens1,2

• Reversible and can be used by women of all ages2

• Effective for women with contraindications to use of estrogen1

• Progestin pills can be used as emergency contraception1

• – Levonorgestrel is the most popular form for emergency contraception1

• Can be started at any time provided the woman is not pregnant2

http://www.cdc.gov/mmwr/pdf/rr/rr62e0614.pdf. Accessed on 6 April 2019.

1. Christin-Maitre S. History of oral contraceptive drugs and their use worldwide. Best Pract Res Clin Endocrinol Metab. 2013;27:3-12.2. U.S. Selected Practice Recommendations for Contraceptive Use, 2013. Available from:

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How do Progestin-Only Pills Prevent Pregnancy?

Preventsovulation

(release of eggfrom the ovaries)

Causes thickening of

cervical mucus

Reduce spermmotility andpenetration

Christin-Maitre S. History of oral contraceptive drugs and their use worldwide. Best Pract Res Clin Endocrinol Metab. 2013;27:3-12.

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What are the Benefits/Risks of Progestin-Only Pills?

Benefits

• Improvedsymptoms

• Can be

menstrual

used inbreastfeeding women

• Improvementmenstrual premenstrual and anemia

in heavyperiods,

syndrome,

Risks

• Breast cancer

• Cirrhosis of liver• Reduced blood supply to

brain (stroke)

Am J Obstet Gynecol. 2011;205:S14-7.

• Acute or recurrent vein thrombosis

• Liver tumors

deep

Burke AE. The state of hormonal contraception today: benefits and risks of hormonal contraceptives: progestin-only contraceptives.

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What are the Benefits/Risks of Progestin-Only Pills?

Risks

• Breast cancer

• Cirrhosis of liver

• Reduced blood supply to brain

(stroke)

• Acute or recurrent deep vein

thrombosis

• Liver tumors

Benefits

• Improved menstrual symptoms

• Can be used in breast-feeding

women

• Improvement in heavy menstrual

bleeding, pre-menstrual syndrome

and anemia

Am J Obstet Gynecol. 2011;205:S14-7.

Burke AE. The state of hormonal contraception today: benefits and risks of hormonal contraceptives: progestin-only contraceptives.

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What are the Side Effects of Progestin-Only Pills?

Primary Side effect

• Irregular bleeding1,2

• Amenorrhea2

• Shortened cycles2

Less Common side effects

• Headache2

• Breast tenderness2

• Dizziness2

OCs. Accessed on 6 April 2019.

1. Burke AE. The state of hormonal contraception today: benefits and risks of hormonal contraceptives: progestin-only contraceptives. Am J Obstet Gynecol. 2011;205:S14-7. 2. Choosing a Birth control Method: Progestin-Only Oral Contraceptives.Available from: http://www.arhp.org/Publications-and-Resources/Quick-Reference-Guide-for-Clinicians/choosing/Progestin-Only-

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How are Progestin-Only Pills Used?

• Can be taken every day

• No placebo or pill-free interval required

• Helps in maintaining a regular pill schedule

Burke AE. The state of hormonal contraception today: benefits and risks of hormonal contraceptives: progestin-only contraceptives.Am J Obstet Gynecol. 2011;205:S14-7.

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What to Do if a Dose of Progestin-Only Pills is Missed?

http://www.cdc.gov/mmwr/pdf/rr/rr62e0614.pdf. Accessed on 6 April 2019.

A dose is considered missed if it has been more than 3 hours since its scheduled time.

• One pill should be taken as soon as possible

• Continue taking pills daily (one each day, at the same timeeach day, even if two pills required on the same day)

• Back-up contraception should be used (e.g., condoms) oravoidance of sexual intercourse until pills have been takencorrectly on time for 2 consecutive days

• If the woman has had unprotected sexual intercourse,emergency contraception should be considered

U.S. Selected Practice Recommendations for Contraceptive Use, 2013. Available from:

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When Not to Take Combined Oral Contraceptives?

Combined oral contraceptives may be avoided in the following cases:– After delivery

• If breastfeeding, no use before 6 weeks and avoid use up to 6 months• If not breastfeeding, no use before 42 days without doctor ’s advice

– Smokers over 35 years– Higher than normal BP (systolic 140–159 mm Hg; diastolic 90–99 mm Hg)– History of loss/reduced blood supply to heart (ischemic heart disease) or

brain (stroke)– Severe headache (migraine with auras)

– History of blood clots in arms or legs (DVT/PE); prolonged immobilizationafter surgery

– Breast cancer (current or in the past)– Long-term severe diabetes

• While some conditions may rule out oral contraceptives, medicaladvice is always best in assessing individual cases

BP: Blood pressure; DVT: Deep vein thrombosis; PE: Pulmonary embolismWHO Press. Medical eligibility criteria for contraceptive use. 5th ed. 2015. Available from: http://apps.who.int/iris/bitstream/10665/181468/1/9789241549158_eng.pdf?ua=1. Accessed on 6 April 2019.

.

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