COLLEGE OF MEDICINE AND HEALTH SCIENCE DEP’T

OF PHARMACY

Seminar On
hormonal contraception
BY : Siraj Muhammed..................0422/20
Adisu birhan…..……………1248/20
Smegnew melak……………..1437/20
 OUTLINE

 Meaning of contraception
 Type of contraception
 Classification of hormonal methods
 Oral contraceptives
 Non-contraceptive benefits of OCP
 Possible adverse effects of OCP
 Injectable contraceptives
 Implants
 Contraceptive patch
 Vaginal ring
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 Objectives

 Describe meaning of contraception

 Explain type of contraception
 Classification of hormonal methods
 Explain oral contraceptives
 Describes non-contraceptive benefits of OCP
 Describe possible adverse effects of OCP
 Describe injectable contraceptives
 Describe about implants
 Explain contraceptive patch
 Explain vaginal ring
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 Introduction

Contraception :The prevention of pregnancy following

sexual intercourse by Inhibiting viable sperm from
coming into contact with a mature ovum or Preventing a
fertilized ovum from implanting successfully in the
endometrium (i.e., mechanisms that create an unfavorable
uterine environment)

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 Introduction

 Factors that influence the appropriateness of any

contraceptive choice include:
The safety & effectiveness of the method
The frequency & acceptability of side effects,
The willingness and ability to use the method consistently
and correctly,

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 Introduction

Cost and Societal attitudes as well as religious or cultural

beliefs regarding method
The frequency of coitus
The length of time that intended pregnancy is to be
delayed
The impact on lactation and the breast-fed infant

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 Introduction

Contraceptive Effectiveness: is a measure of reduction

in the probability of conception with use of a
contraceptive method over a defined period.
Contraceptive failure Determined by “Pearl Index
 It is defined as no. of contraceptive failures per 100
women years of exposure i.e, Pearl Index = Total no. of
accidental pregnancies*100 divided byTotal months of
exposure seminar on hormonal contraception 7
 Introduction

 Reversible contraceptive methods are best grouped by efficacy into

three major groups
 The highly effective methods (failure rates <3%), includes implants,
IUDs, and long-acting injections.
 Very effective methods (failure rates 3% -10%), include all the other
hormonal methods, such as contraceptive pills, patches, and rings.
 Effective methods(>10%) - includes all the barrier and behavioural
methods.
• The only 100% is abstinence/ postpone sexual intercourse

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 Types of contraceptives

I. Spacing methods
– Barrier method
– Intra-uterine devices
– Hormonal method of contraceptive
– Post-conceptional methods
– Miscellaneous
II. Terminal methods
– Male sterilization
– Female sterilization

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 Hormonal Contraceptives

I. Oral contraceptives
 Oral contraceptives are a combination of estrogen and
progestin (pill) or Progestin only (mini-pill).
 Unfortunately, no reliable reversible male hormonal
contraceptives have been developed.

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 Cont...

 Combination of estrogen and progestin typically consist of

a combination of an estrogen and a progestational agent
taken daily for 3wks and then placebo for 1wk, during
which there is withdrawal uterine bleeding.
 MOA: prevent ovulation by suppression of hypothalamic
gonadotropin-releasing factors, which in turn prevents
pituitary secretion of FSH and LH.

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 Cont...

 Progestin prevents ovulation by suppressing luteinizing

hormone.
 In addition, they render the endometrium unfavourable to
implantation & also thicken cervical mucus.
 Estrogen prevents ovulation by suppressing the release of
FSH.
A second effect is to stabilize the endometrium, which
prevents breakthrough bleeding.

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 Cont...

 The net effect of estrogen and progestin is extremely

effective ovulation suppression, inhibition of sperm
migration through cervical mucus, and creation of an
unfavourable endometrium for implantation.
 Thus, estrogen plus progestin containing combined oral
contraceptives provide virtually absolute protection
against conception when taken daily for 3 out of every 4
weeks(99%). seminar on hormonal contraception 13
 Cont...

 Pharmacology
 Estrogens
 Available are ethinyl estradiol and a prodrug mestranol
 Progestin:
Available progestins are 19-nortestosterone derivatives.
Has androgenic effect: Norgestrel, Levonorgestrel, Norethindrone,
Norethindroneacetate, Norgestimate, Desogestres, Drospirenone
Ethynodiol diacetate.
Has estrogenic effect: Ethynodiol(high)
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 Cont...

 COC can be
 Monophasic: contain the same amounts of estrogen and progestin
for 21 days, followed by 7- day placebo phase
 Multiphasic: contain variable amounts of estrogen and progestin for
21 days, also followed by a 7-day placebo phase
 Extended-cycle: increases number of hormone-containing pills From
21 to 84 days, followed by a 7-day placebo phase or
 Continuous cycle:Hormone-containing pills daily throughout the
year
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 Recommendation for use of COC

Ideally, women should begin taking combination oral

contraceptives on the first day of a menstrual cycle.
The more traditional "Sunday start" refers to initiation on
first Sunday after menses but may need back-up methods.

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 Recommendation for use of COC..

COCs, if one tablet is missed or late then it should be

taken as soon as remembered, and the rest of the tablets
should be continued as prescribed . Typically no
additional nonhormonal contraception methods are
warranted.

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 Recommendation for use of COC..

 If two or more consecutive tablets are missed then take one missed
tablet as soon as remembered and discard the other missed tablets.
Continue taking the OC tablets as scheduled which means two tablets
may need to be taken on the same day
 If tablets were missed in the last week of hormonal tablets, finish the
remaining active tablets (tablets with hormone) and then omit the
hormone-free interval (skip taking the placebo tablets) and start a new
pack of tablets.

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 Recommendation for use of COC..

 For both of these scenarios, counsel patients to use additional no

hormonal contraception until active hormone tablets have been taken
for seven consecutive days.
 For all scenarios when two or more consecutive tablets are missed,
consider counseling on EC use if warranted.

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 When to start COC

• Ask if LNMP is not more than 5 days

– If < 5 days: start today with backup for 1 week
– If > 5 days: do HCG test
• If positive link to ANC

• If negative start today with back up to next menses and repeat HCG in
2 weeks
• Start new cycle on 1st day of new menses

• What if the patent want to start new method at any time:

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 Drug Interactions of COC

COC interfere with the actions of some drugs and, some

drugs decrease the contraceptive effectiveness of COCs.
Anticonvulsants, sedatives and rifampin are believed to
reduce contraceptive effectiveness of pills
Many antiretrovirals decrease contraceptive efficacy,
therefore barrier contraceptive methods are recommended.

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 Possible Adverse Effects of OCP…

• Most minor S/E are raised at the first 3 cycles

• The most common causes of discontinuation pills.
– Nausea
– Wt. gain
– Mood change
– Breast tenderness
– Headach
• Reassurance and adequate advise is important to improve
adherence

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 Possible Adverse Effects of OCP…

1. Metabolic Effects
The changes associated with the current low-dose COCs
have little clinical significance.
a. Lipids:
Estrogens generally alter lipid metabolism in a fashion
that is considered beneficial, slightly increasing levels of
HDL and decreasing LDL.
Most changes are within the normal range and not
clinically relevant.

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 Possible Adverse Effects of OCP…

b. Glucose
 High-dose progestin associated with higher rates of peripheral insulin
resistance( elevated glucose and insulin levels)
 But low-dose COCs have no clinically significant effects on glucose
metabolism.
c. Proteins
 Estrogens increase hepatic production of a variety of
globulins(angiotensinogen) and then angiotensin I has been associated
with a pill-induced hypertension and coagulopathy
 d. Increase bile formation to cause gall stone

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 Possible Adverse Effects of OCP…

2. Cardiovascular Diseases
Epidemiologic research confirms that the overall risk of
serious CVS complications attributable to COC use is
extremely low for the vast majority of users of the current
low dose ethinyl estradiol preparations.
Cardiovascular complications associated with COC use
occur while the pill is being used; once pills are
discontinued, risk levels
seminar onreturn to baseline.
hormonal contraception 25
 Possible Adverse Effects of OCP…

a. Hypertension
 COC use may slightly increase blood pressure among
normotensive women and is reversible if discontinued.
 From increased plasma renin activity, angiotensin levels,
aldosterone section, and renal retention of sodium.
 The length of OCP use appears to relate to the development
of hypertension, which develops in approximately 5% of
users after 5 years of use.
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 Possible Adverse Effects of OCP…

b. Thromboembolism (PTE and VTE)

The incidence of VTE in COC using women is three to
four times higher than non-COC users and the risk
increases as estrogen dose increases.
The risk is higher during the 1st year of use
Increased with: obesity, age>35y, post partem, smokers.

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 Possible Adverse Effects of OCP…

c. Arterial embolism (Ischemic stroke and MI)

In healthy, non-smoking, reproductive age women with
normal B/P, the risk of MI and stoke is extremely low
For women on higher dose progestin with risk factors
CVD, risk for MI and stroke increases by 3 fold relative to
none user .
Thus, women with multiple major risk factors for CVD
generally should not use COCs.

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 Possible Adverse Effects of OCP…

3. Neoplasia
a. Breast cancer
A small but statistically significant increase in risk of
breast carcinoma exists in current and recent users of
OCPs, but not in past users.
b. Cervical cancer
Cervical hypertrophy and eversion are seen in OCP users.
There may be a small increased risk of cancer of the
cervix especially with use of more than 5 years.

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 Possible Adverse Effects of OCP…

c. Liver Tumors
Long-term use of high-dose oral contraceptives has been
associated with the development of benign liver tumors
such as focal nodular hyperplasia and adenomas.

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 Contraindications of COC

Age >35 years and smoking >15 cigarettes per day.

Multiple risk factors for arterial cardiovascular disease
(e.g., older age, smoking, DM with complication,
hypertension, migraine headach with aura)
Elevated B/P of 160mmHg systolic or 100 mm Hg
diastolic hypertension with vascular disease.
IHD
Current or previous VTE
Liver tumor/adenoma, or cirrhosis

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Return to Fertility after Discontinuing COC

Women who discontinue COCs have no overall reduction

in fertility.
At least 90 per cent of women who previously ovulated
regularly will do so within 3 months after discontinuance
of oral contraceptives.

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 Progestin-only “minipills”

 Progestin-only “minipills”
28 days of active hormone per cycle
If taken more than 3 hours late: use a backup
contraception for 48 hours
Less effective than combination OCs
Associated with irregular and unpredictable menstrual
bleeding
Risk of ectopic pregnancy is higher: doesn’t prevent
ovulation

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 Cont...

A small daily quantity of a progestin alone, usually

norethindrone or levonorgestrel, provides reasonably good
protection against pregnancy without suppressing
ovulation.
The method has several advantages: the side effects
attributable to the estrogen component of conventional
oral contraceptives are eliminated, and no special
sequence of pill-taking is necessary because the mini pill
is taken every day.

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 Cont...

MOA: the cervical mucus becomes less permeable to

sperm and that endometrial activity goes out of phase.
Progestin-only oral contraceptives result in a pregnancy
rate of 2–7 pregnancies per 100 woman-yrs.
 Progestin-only contraceptives are ideal for women for
whom estrogen is contraindicated.

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 When to choose POP?

Ideal candidates include older women who smoke; mental

retardation, migraine headache, hypertension, or systemic
lupus erythematosus; or women who are breastfeeding.
Unlike COCs, they do not reliably inhibit ovulation.
There is a relative increase in the proportion of ectopic
pregnancies on contraceptive failures.

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 DI/CI

 DI:
Their effectiveness is decreased by medications that
include
– Anticonvulsants (phenytoin, carbamazepine)
– Anti-tuberculous agents (rifampicin)
Women taking any of these medications should not use
this form of contraception.
 CI:
Progestin-only pills, are contraindicated in women with
unexplained uterine bleeding or breast cancer.

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 II. INJECTABLE CONTRACEPTIVES

 Sustained progestin exposure

Blocks the LH surge (inhibiting ovulation)
Reduce ovum motility in the fallopian tubes
Thin the endometrium, reducing the chance of
implantation
Thicken the cervical mucus (barrier to sperm penetration)

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 II. INJECTABLE CONTRACEPTIVES
 A. Injectable Progestin Contraceptives-IM
Depot medroxyprogesterone acetate (Depo-Provera) used
effectively worldwide.
Started for women on menses(no pregnancy), postpartum,
post abortion or after delivery.

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 INJECTABLES…

It is injected deeply into;

• Upper outer quadrant of the buttock or

• Into the deltoid muscles without massage

The usual dose is 150 mg every 90 days.

• An additional contraceptive method should be used for at least 2wks
after the initial injection.

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 INJECTABLES…

 Advantage:
Injected progestins have :
• contraceptive effectiveness better than COCs,
• a long duration of action, and
• no impairment of lactation.
Iron-deficiency anemia is less likely in long-term users
Amenorrhea develops in 80% of women after 5years.

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 INJECTABLES…

 Disadvantage:
The principal disadvantages of depot includes:
• irregular menstrual bleeding and
• prolonged anovulation after discontinuation resulting in delayed
fertility resumption./Median time to conception 10 month(12-18
month)
• Wt. gain
• Breast tenderness
• depression
After the injections are stopped, ¼ of women will not
resume regular menses for up to a year.

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 III. Implants

 Progestin Implants
A systems in which a progestin is delivered by a
subdermally implanted device containing the drug
Small plastic rods or capsules, each about the size of a
matchstick, release a progestin.
A specifically trained provider performs a minor surgical
procedure to place the implants under the skin on the
inside of a woman’sseminar
upper arm.contraception
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 Types of Implants…

Jadelle: 2 rods, effective for 5 years, contains 75mg levonorgestrel

Implanon: 1 rod, effective for 3 years, contains 68mg of etonogestrel
– Implanon rod is radio opaque so it can be detected by x-ray
 After ruling out pregnancy, timing of insertion is based on the
patient's contraceptive history:
 Insertion: between days 1 through 5 of menstruation by skilled
provider, even if woman is still bleeding
 Removal: no later than 3 years after the date of insertion.

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 Types of Implants…

 Norplant:
 6 capsules, labelled for 5 years, each capsule
containing 36mg of levonorgestrel.
 Is currently not in use for S/E and difficulty to
remove.
 Sinoplant: 2 rods, effective for 5 years.

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 MOA

Thickening cervical mucus (this blocks sperm from

meeting an egg)
Preventing the release of eggs from the ovaries (ovulation)
Return of fertility after implants are removed: No delay
Initiation, Indication and contraindications are similar
with other progestin contraceptives

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 Side Effects

prolonged or irregular bleeding, amenorrhea

Headaches
Acne (can improve or worsen)
Weight change
Breast tenderness
Dizziness
Mood changes.

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 IV. Contraceptive Patch

The transdermal contraceptive patch is designed to deliver

norgestimate, and ethinyl estradiol daily for a 7-day
period.
It delivers 150µg of the progestin, and 20µg of ethinyl
estradiol daily.
After 7 days, the patch is removed and a new patch is
applied to another skin site.
Three consecutive 7-day patches are applied in a typical
cycle, followed by a 7-day patch-free period to allow
withdrawal bleeding.

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 V. Vaginal Ring

Most steroid hormones are absorbed through the vaginal

epithelium and can be released from vaginal rings made
out of polymers.
It releases ethinyl estradiol and etonogestrel
The ring is initially placed within 5dys of the onset of
menses & is worn for 3wks/month.
The ring may be removed for coitus, but should be
replaced within 3hrs.

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 Side effect

Rates of serious side effects and minor side effects are similar
to those seen in users of COC.
10–15% of users report slight discomfort, a sensation of a
foreign body, leukorrhea, vaginitis, or coital problems.

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 Intrauterine device

 An intrauterine device (IUD) is a small, T-shaped

contraceptive device inserted into the uterus by a
healthcare provider to prevent pregnancy. It is a form of
long-acting reversible contraception (LARC) that can last
from 3 to 10 years, depending on the type

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 💊 Examples of IUDs

Active
Type Brand Names Duration
Component

Copper IUD ParaGard® Copper wire Up to 10 years

Mirena®, 3–8 years

Levonorgestrel (a
Hormonal IUDs Kyleena®, depending on
progestin)
Skyla®, Liletta® brand

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 ⚙️Mechanism of Action

 Copper IUD (ParaGard):

Releases copper ions, which are toxic to sperm, impairing
motility and viability.
Induces a local inflammatory response in the endometrium,
making it hostile to sperm and implantation.
 Hormonal IUDs (e.g., Mirena):
Release levonorgestrel, which:
• Thickens cervical mucus, blocking sperm entry.
• Thins the endometrial lining, reducing implantation likelihood.
• Suppresses ovulation in some users

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 Side Effects

Common Less Common Rare but Serious

Irregular bleeding or Uterine perforation
Cramping after insertion
spotting (<0.7%)

Heavier periods (copper Acne, breast tenderness

Expulsion (2–10%)
IUD) (hormonal IUDs)

Pelvic inflammatory
Lighter or no periods
Mood changes disease (within 20 days
(hormonal IUDs)
of insertion

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 Emergency contraception

Emergency contraception refers to methods used after

unprotected sexual intercourse to prevent pregnancy. It
is not intended for regular use and does not terminate
an existing pregnancy.
According to the CDC, EC methods vary in effectiveness
depending on the type and timing of administration

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 Examples of EC

Type Example Active Ingredient Time Window

Plan B One-Step, Levonorgestrel Within 72 hours

Progestin-only pill
My Way 1.5 mg (best within 24)

Selective
progesterone Ulipristal acetate Up to 120 hours
ella®
receptor 30 mg (5 days)
modulator

Within 5 days;
Copper IUD ParaGard Copper ions
most effective

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 Mechanism of Action

 Levonorgestrel (LNG):
Delays or inhibits ovulation by suppressing the LH surge.
May thicken cervical mucus to hinder sperm movement.
Does not prevent implantation or affect an established pregnancy.
 Ulipristal Acetate (UPA):
Delays ovulation even after LH surge has begun.
May alter endometrial receptivity, though not conclusively proven.
 Copper IUD:
Releases copper ions toxic to sperm.
Prevents fertilization and may inhibit implantation.

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 ⚠️Side Effects

 Common side effects include:

Nausea or vomiting
Headache
Dizziness
Breast tenderness
Fatigue
Menstrual irregularities (early, delayed, or heavier
bleeding)
 If vomiting occurs within 2 hours of taking LNG or 3
hours after UPA, a repeat dose may be needed
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 Reference

1. Standard treatment guideline for general hospitals in ethiopia ,

4th edition, 2020

2. Cunningham, F. G., Leveno, K. J., Bloom, S. L., Dashe, J. S.,

Hoffman, B. L., Casey, B. M., & Spong, C. Y. (2018). Williams
obstetrics (25th ed.). Mcgraw-hill education.

3. Medstar obstetrics and gynecology clinical guide (2nd edition,

2022/23)

4. Dipiro pharmacotherapy 12 edition

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THANK YOU

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