Hormonal Contraception
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Case 1
• Mrs R, a 26-year-old married, nulliparous, wishes to
postpone her pregnancy as she is planning to advance
her career.
• She is in need of regular contraception.
• She has no known co-morbidities.
• Menstrual history reveals that her periods are regular,
but are heavy (bleeding) and painful for the past 6
months.
• She was treated for primary dysmenorrhoea with
Mefenamic acid and tranexamic acid but she continues
to have symptoms.
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Questions
1. What are the methods of contraception?
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2. Which is the most suitable contraceptive method for this
patient? Justify
Mrs R is apparently a healthy lady with no co-morbidities and
she needs regular contraception, but she also has heavy and
painful periods which are not relieved with first line drugs –
therefore, combination oral contraceptives (COC) are most
suitable option for her
COC pills reduce the duration and also amount of menstrual
bleeding by 50%.
It also reduces dysmenorrhoea – ovulation suppressed, reduces
the amount of prostaglandin produced by glands in the lining
of the uterus
She is also nulliparous so IUDs are contraindicated. 5
3. What are the non contraceptive health
benefits of COC?
1. Reduces heavy menstrual bleeding (HMB) and
menstrual pain
2. Benefits the symptoms associated with
Premenstrual syndrome (PMS)
3. Reduces risk of recurrence of endometriosis after
surgical management
4. Useful in the management of polycystic ovary
syndrome (PCOS) associated acne, hirsutism and
menstrual irregularities
5. Reduction in risk of endometrial, ovarian cancer and
colorectal cancer 6
4. Why emergency contraceptive pills are
not suitable in this case?
ECP is a rescue/ back up method for contraceptive
emergencies. It is not indicated for regular contraception
One dose of ECP protects that episode of UPSI (unprotected
sexual intercourse). It does not provide protection for the
entire cycle
Frequent administration of ECPs in the same cycle is likely to
disrupt the HPO axis
Failure rates with ECPs are high – It depends on which phase
of the menstrual cycle she had UPSI and whether it was taken
with in 72hrs or not
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• Note : Educate women about prevention of
STIs and HIV/ AIDS.
Inform her that COCs does not offer protection
against any sexually transmitted diseases
including HIV and Hepatitis B
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Case 2
• Mrs J, a 26yrs old married woman is on regular
contraception (COCs) as she is pursuing her post-
graduation and not planning for pregnancy in
immediate future.
• After finishing her year end assessments, she left
for a holiday with her husband to San Francisco.
• She had unprotected sexual intercourse and the
next day she realized that she had already missed 3
consecutive pills in the 1st week of the COC pill
pack as she was preoccupied with her assessments.
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1. What do you advise her? Justify
Emergency contraceptive pill –
Levonorgestrel 1.5mg single tablet or
Levonorgestrel 0.75mg 2 tablets.
Should be taken at the earliest (within 72 hrs.)
Since she has missed 3 consecutive pills in the 1st week of
her regular combined pill pack – there is risk of contraceptive
failure. In addition, it is less than 72hrs since UPSI, hence LNG
emergency contraceptive pill is indicated in this case.
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Week 1 Week 2 Week 3
(1-7 days) (8-14 days) (15 to 21 days)
Missed • EC not required* • EC not required**
1 Pill • Take the missed pill as soon as • Take the missed pill as soon as possible
possible • Continue the remaining pills at the usual time
• Continue the remaining pills at the • No additional contraceptive precaution
usual time required
• No additional contraceptive
precaution required
Missed • Consider EC if UPSI has taken • EC not required**
2-7 Pills place • Take the most recent missed pill as soon as
• Take the most recent missed pill as possible
soon as possible • If 2 or more pills missed in 7 days prior to a
• Continue the remaining pills at the scheduled HFI, omit the HFI
usual time • Barrier methods should be used or sex
• Barrier methods should be used or avoided until pills have been taken for 7
sex avoided until pills have been consecutive days
taken for 7 consecutive days
• Consider follow up pregnancy test
>7 • Consider EC
consecutive • Manage as new contraception
pills missed in • Consider immediate pregnancy test
any week of • Quick start new COC packet (or consider effective contraception)
pill taking • Barrier methods should be used or sex avoided until pills have been taken for 7
consecutive days
• Consider follow up pregnancy test 13
Emergency contraceptives
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2. What is emergency contraception? Enlist
different methods of emergency contraception
• Emergency contraception refers to back-up methods
for contraceptive emergencies which a women can use
within the first 72 hours – 120 hours after unprotected
vaginal intercourse to prevent an unwanted pregnancy
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3. Should she discontinue the pack? How
to proceed further?
1. She should take Levonorgestrel (LNG) 1.5mg
single tablet at the earliest.
2. Take the most recently missed pill as soon as
possible
3. Continue the remaining pills at the usual time
4. Condoms should be used or abstinence until she
takes the pills for 7 consecutive days
5. Consider follow up pregnancy test - 21 days after
the last UPSI 16
4. Does ECP offer protection for the
entire cycle?
• NO
• It is for a single act of unprotected sexual intercourse
• ECP will not provide continued protection against
pregnancy for the remainder of the menstrual cycle
• ECP is recommended for use more than once in a cycle
if there has been unprotected sexual intercourse earlier
(>12 hours after taking ECP) in the same cycle
• Taking ECP multiple times in a the cycle can cause
irregular periods 17
Case 3
• Mrs S, a 33-year-old married woman, P1L1
requires contraception.
• She gives history of severe migraine with aura
and family history of Breast Ca.
• Menstrual history reveals that her periods are
regular but heavy and prolonged.
• Her Hb is 9gm/dl. All other investigations found
to be normal.
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1. What is the contraception of choice in this
case? Justify
• Progesterone impregnated IUCD (Mirena) is the
choice.
• She is ineligible for COC as she has severe
migraine with aura and a family history of Breast
Ca.
• She needs contraception and treatment for heavy
menstrual bleeding.
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2. What is Mirena? How does it act
Mirena is a hormone releasing IUCD. It contains
Levonorgestrel (52 mg) and delivers up to 20 mcg
levonorgestrel per day
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Mechanism of Action :
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3. When it should be inserted?
• ‘ MIRENA’ can be inserted any time during the cycle
provided pregnancy is ruled out
• In women of fertile age, MIRENA should be inserted
ideally within 2-3 days of the onset of menstruation
• If insertion is more than seven days since menstrual
bleeding started, a barrier method of contraception
should be used or the patient should abstain from
vaginal intercourse for the next seven days to prevent
pregnancy
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4. What instructions should be given after
insertion of IUD?
She should regularly check the thread or tail to be sure
that the IUCD is in the uterus
• She should visit the clinic whenever she experiences
any side effects such as
– Fever
– Pelvic pain
– Bleeding
– Misses a period
– Can’t locate the thread or tail
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