1) Oral contraceptive pills are widely used worldwide for contraception and have many non-contraceptive health benefits. They contain a combination of synthetic estrogen and progestin and work primarily by suppressing ovulation. 2) Oral contraceptives are effective in treating conditions like dysmenorrhea, menorrhagia, premenstrual syndrome, acne, and hirsutism. They may also help prevent endometriosis, ovarian cysts, and some cancers. 3) Different oral contraceptive formulations contain varying doses and types of estrogen and progestin. Monophasic pills contain the same dose each day while triphasic pills have graduating doses. Extended regimen pills allow fewer menstrual

1. ORAL CONTRACEPTIVE AND
BEYOND…….
Dr.bharti singh D.G.O
Bharti women’s clinic

2. • 100 Million worldwide ( WHO1998)
• NFHS II 1999, India
– 34% female sterilisation
– OC use 2.19%
– 30% girls have first child before age 19 years
Pearl index - 0.25 per HWYears
Failure rate - 0.3% to 8% ( Perfect versus Typical Use)

3. What are oral contraceptive
pills?

4. COMPONENTS
• ESTROGEN:
ETHINYL ESTRADIOL
MESTRANOL-3 methyl ester derivative
(mestranol causes increased risk of
tromboembolism;TINDALL)
50 ug
standard dose
30-35ug
low dose
20ug
ultra low dose
Study-15ug EE /60 ug GESTODENE-24/4.good efficacy and
cycle control(BARBOSA ,CONTRACEPTION 2006)

6. A comparison of various
progestinsANTIANDRO ANTIMINER
PROGESTINS
ESTRO ANTIEST ANDROGENI
GENIC
ROGENIC C
GENIC
ELOCORTIC
OID
-
-
-
+
+
•MPA
-
-
+
-
-
•NORETHISTERONE
-
+
+
-
-
•LNG
-
+
+
-
-
NEWER PROGESTINS
-
-
-
-
-
CYPROTERONE
ACETATE
-
-
-
+
+
•DROSPIRENONE
-
-
-
+
+
PROGESTERONE
OLDER PROGESTINS
•DESOGESTREL

7. NEWER PROGESTIN
• dienogest a norethindrone-like structure that acts as an
antiandrogen
• three 19-norprogesterone derivatives nestorone
nomegestrol acetate
trimegestone
(sitruk and ware 2006)
Speroff and decherny

8. MECHANISM OF ACTION

9. SPIRONOLACTONE
Property
Clinical benefit
Progestogenic
Antigonadotrophic- inhibits ovulation
Inhibits endometrial proliferation- ↓ menstrual bleeding
Cervical mucus thickening
ANTIMINERELOCORTIC
OID
Promotes salt & water excretion: ↓ wt gain, bloating, BP,
mood changes, breast tenderness
ANTIANDROGENIC
Effective against acne & hirsutism
↑HDL & ↓ LDL Cholesterol
No androgenic action
No adverse effect on lipid or glucose tolerance
No wt gain/ acne/ oily skin
No antiestrogenic
action
Does not ↓ SHBG, does not ↑ free androgen levels

10. MONOPHASIC PILLS
Type
Estrogen
PROGESTERONE
Mala N
EE 30 ug
Norgestrel 300 ug
Mala D
EE 30 ug
Levonorgestrel 150 ug
Ovral L
EE 30 ug
Levonorgestrel 150 ug
Ovral G
EE 50 ug
Levonorgestrel 250 ug
Novelon
EE 30 ug
Desogestrel 150 ug
Femilon
EE 20 ug
Desogestrel 150 ug
Loette
EE 20 ug
Levonorgestrel 100 ug
Yasmin
EE 30 ug
Drospirenone 3 mg
GINNETE 35,KRIMSON 35,
EE 35ug
Cyperoterone acetate 2mg

11. TIRPHASIC PILLS
TRIQILAR
•
.05mg LNG/30 ug EE -5DAYS
•
.075mg LNG/40 ug EE-NEXT5 DAYS
•
.125mg LNG/30ug EE-LAST 10 DAYS
• Triphasic preparations have been shown to
reduce acne, decrease the incidence of
ectopic pregnancy, reduce menstrual blood
loss, and lower the frequency of irregular
bleeding and menorrhagia.

12. Extended regimen COC
•
•
•
•
Also reffered as menstrual suppression
Shorter hormone free interval , similar efficacy.
Decreased escape ovulation , decreased ovarian activity.
Decreased mid cycle break through bleeding.
• Decreased pelvic pain ,breast tenderness ,bloating , swelling.
• Useful in perimenopausal women with vasomotor symptoms
• Eg-seasonale,sesonique,(30ug EE/150ug LNG)for 84 days
Lybrel(20ug EE/90ug LNG)
• Comparision study shows similar efficacy and side effects with
decreased break through bleeding and intermenstrual
spotting (ALEXANDER T,2006)

13. benefits of extended use regimen
• Reduction in risk of ovarian and endometrial
cancer
• Relief of dysmenorrhea
• Prevention and treatment of menorrhagia
• Prevention and treatment of anemia in women
with bleeding diatheses

14. • Prevention and treatment of excessive bleeding
related to uterine leiomyoma or adenomyosis —
Somewomen with heavy menstrual bleeding
associated with leiomyomas respond to
contraception
• Treatment of pain related to endometriosis
• Prevention of menstrual migraine
• Management of symptoms related to
premenstrual syndrome

15. POTENTIAL BENEFITS OF COC
ACOG practical bulletin no 10
•
•
•
•
•
•
•
Menstrual cycle regularity
Treatment of acne
Treatment of dysmenorrhea
Treatment of hirsutism
Treatment of menorrhagia
Treatment of pelvic pain from endometriosis
Treatment of premenstrual syndrome

16. Continued……
• Treatment of bleeding from leiomyoma
• Prevention of menstrual migraines
• Improved bone mineral density in older women
• Decreased risk of endometrial, ovarian, and
colorectal cancers
• Induction of amenorrhea for lifestyle considerations

17. DYSMENORRHEA

18. • Most common menstrual disorder in 50-90% women.
• Due to prostaglandins PGF2ALPHA and PGE2 causing increase myometrial
contractility(primary dysmenorrhea).
• 80% decrease in symptoms in primary dysmenorrhea . (ACOG2005)
• Decreases severity in secondary dysmenorrhea of endometriosis
(haukesson et al)
•
can be used as FIRST LINE TREATMENT(1-A)
• 4 cross-sectional surveys-improvement in pain irrespective of
progestational component,estrogen dose,monophasic or multiphasic
pill.(lippinccott andwilkins 2007)
• Extended cycle regimens are better.(1-A).(ACOG 2005)
• Not FDA approved.

19. MENORRHAGIA

20. • 10% fertile women suffer from menorrhagia.
• Prescribe if no structural or histological abnormality is
present or fibroid>3 cm not distorting the cavity (NICE 07)
• Can be used as first line or second line drug specially in
women who want to preserve fetility .(ACOG 10)
• 50% decrease in symptoms with both high dose (nilson and
solvel 93) and low dose COC.(larsson et al,fraser and mc carron)
• Extended cycle regimen more effective (ACOG 10)
• Can be used in perimenopausal age group after proper
evaluation but comes after LNG-IUD(86% after 3 months
),TRANEXEMIC ACID in efficacy(A)

21. PRE MENSTRUAL SYNDROME
PRE MENSTRUAL DYSPHORIC
DISORDER

22. • Premenstrual symptoms,PMS,PMDD-same
spectrum with varying severity.
PMS is defined as ‘the cyclic recurrence in the luteal
phase of the menstrual cycle of a combination of
distressing physical, psychological and/or
behavioural changes of sufficient severity to
result in deterioration of interpersonal
relationships and/or interference with normal
activities’ (Reid and Yen, 1981).

23. • Considered to be the result of complex
interaction between ovarian steroids and central
neurotransmitters.(Neng/Jmed 1998) .
• 24/4 regimen of 30ug EE/3mg drospirenone is
effective in decreasing some physical effects like
bloating,breast tenderness,headache and some
psychological manifestations by its
minerelocorticoid activity and ovarian
suppresion.
ACOG 2010

24. POLYCYSTIC OVARIAN DISEASE
• Usually is the first line treatment
• Normalize androgen levels in 18-21 days
• Non androgenic OCP’s preferred
• Suitable for contraception
• Favorable effect on CHO and lipid metabolism
• Corrects menstrual cycle disturbances
•
incidence of anaemia
• Frequency of dysmenorrhoea & pelvic inflammatory disease will
be lowered
•
in risk of endometrial and ovarian cancer

25. ROLE IN ACNE TREATMENT
• FDA approval to three preparation
• EE WITH
•
norgestimate(orthotricyclen)
•
norethindrone(estrostep)
•
drospirenone (yasmin)
• Acts by decreasing the androgens level by GnRH
suppresion and increased SHBG.
• Used along with retenoids.
• 5 clinical trials-decreases lesion no. in mod to
severe acne.

26. ROLE IN HIRSUITISM
• OCP are first-line treatment for hirsutism,
particularly in those women desiring
contraception.
• OCP with DROSPIRENONE(acts as androgen
blocker,decreased androgen production and
increase SHBG) CYPROTERONE ACETATE(anti
androgenic) are used.
• Long term use recommended(A)

27. ENDOMETRIOSIS
• “symptom relief with COC is as good 6 months after
treatment is ended”
chochrane review
• ”contraceptive steroidal preparations must therefore be
considered drugs of choice and are currently the only safe
and economic alternative to surgery”
(The Royal College of Obstetricians and Gynaecologists, 2000).
• “COC reduces menstrual flow,cause
decidualisation,decrease cell proliferation and increase
apoptosis”
MERESMAN GF 2002
Upto 70% relief in symptoms of endometriosis
Vercellini et al., 2003c

28. CONCLUSION
• OCP can be used as first line drugs along
with GnRH agonist and danazole.
• gives good symptom relief and helps to cure
the disease to some extent.(more in mild to
moderate cases)
• Extended therapy is recommended..

29. OVARIAN CYST
• Ever use of the combined pill was associated with
a decreased risk of nonfollicular benign tumours,
including serous and mucinous adenoma,
teratoma and endometrioma (OR 0.79, 95% CI
0.6–1.05) (Westhoff et al., 2000).
• The reduction in risk was associated with
duration of use.
• combined oral contraceptives should not be
used to treat existing functional ovarian
cysts.(ACOG 10)
• Can be given to prevent future cyst formation.

30. OTHER BENEFITS..
• BONE MINERAL DENSITY
• Beneficial effect in women above 40 yrs using COC for
more than 5 yrs (vessey m ’98)
• younger women who use combined oral
contraceptives have a lower BMD compared with
nonusers.(ACOG 10)
• LEIOMYOMAS
• Case-control studies have reported no effect or
reduced risk of leiomyomas in women who use
combined oral contraceptives.
• Can be used to control menstrual pain and flow.

31. • BENIGN BREAST DISEASE
• Includes mainly fibrocystic diesease and
fibroadenoma.
• High-dose oral contraceptives may reduce the
risk of BBD (Burkman et al., 2004)
• Degree of risk reduction depends on duration
of use (7 yrs reduce by 40%)(ROHAN TE ‘99)

32. • Protects against ectopic pregnancy.
• Prevent menstrual migraine- used as
continuous prophylactic therapy
• Prevents progression of reumatoid arthritis
but not a protective factor (spector and
hochberg’90)

33. PID
• Barriers are better for STD/HIV protection
• 50% reduction in PID with OC users versus
non-users of any method
• Mechanism
– Effect on cervical mucus
– Preventing unwanted pregnancies
and deliveries
– Reducing unsafe abortions

34. • Ovarian Cancer
– 1.5 to 2 times less in pill users
– CASH Study : effect within 6 months, increased to 5 times
by 10 years use
– Mechanism
–
chronic suppression of ovulation
–
chronic gonadotropin suppression
– COC with high progestin have greater protective affect
(schildkraut et al)
– Protective effect againsy BRCA MUTATION) also (ACOG 10)
– Ex-use effect last for 15 years

35. • Endometrial Cancer
– 50% less risk
– Effect even with 1 year use
– Ex-use effect lasts 15 years
-
CASH study N. Engl. J. Med 1987
- COLORECTAL CANCER
- 18% risk reduction ,more in recent users
(ACOG 10)

36. Special groups
Used in women with disabilities for
hygienic improvement.
In perimenopausal women to control AUB.
Nowadays used for decreasing the frequency
of menstruation to increase quality of life.

37. Take home message……
ACOG RECOMMENDATIONS 2010
• The following recommendations are based on
good and consistent scientific evidence (Level A):
• Combined oral contraceptives (OCs) should not be used to treat
existing functional ovarian cysts.
• Use of combined hormonal contraception has been shown to
decrease the risk of endometrial and ovarian cancer.
• Combined OCs have been shown to regulate and reduce menstrual
bleeding, treat dysmenorrhea, reduce premenstrual dysphoric
disorder symptoms, and ameliorate acne.
• Continuous combined hormonal contraception, depot
medroxyprogesterone acetate (DMPA), and the levonorgestrel
intrauterine system may be considered for long-term menstrual
suppression.

38. • The following recommendations are based
on limited or inconsistent scientific evidence
(Level B):
• Based on the limited data available, it appears
overall that combined OCs do not increase the
risk of development of uterine leiomyomas.
• Hormonal contraception should be considered
for the treatment of menorrhagia in women
who may desire further fertility.

39. • Grades of Evidence
•
•
•
•
•
Definitions:
I: Evidence obtained from at least one properly designed randomized controlled
trial.
II-1: Evidence obtained from well-designed controlled trials without
randomization.
II-2: Evidence obtained from well-designed cohort or case–control analytic studies,
preferably from more than one center or research group.
II-3: Evidence obtained from multiple time series with or without the intervention.
Dramatic results in uncontrolled experiments also could be regarded as this type of
evidence.
III: Opinions of respected authorities, based on clinical experience, descriptive
studies, or reports of expert committees.
• Levels of Recommendations
•
•
•
Level A —Recommendations are based on good and consistent scientific evidence.
Level B —Recommendations are based on limited or inconsistent scientific
evidence.
Level C —Recommendations are based primarily on consensus and expert opinion.

40. THANK YOU..