Method of contraception: combined oral contraceptive (COC). Hormonal contraception - indications for use

Combined oral contraceptives are tablet preparations containing female sex hormones synthesized in a laboratory. The main objectives of these funds are to create protection against unwanted pregnancy by creating a special hormonal background, as well as to normalize the menstrual cycle. However, these drugs do not protect against sexually transmitted viruses and bacteria that cause disease. They are taken at a certain time for 21-28 days, after which menstruation should occur. If you miss a pill, it is important to take a number of steps, which we will cover.

There are several different classifications of oral contraceptives (COCs), based on both the dosage of the hormones contained and their percentage. Considering this fact, as well as the fact that the drugs contain hormones, they should be selected by a gynecologist.

Composition of drugs and classification

Combined type contraceptives consist of two main components:

1. Estrogenic: it is provided by ethinyl estradiol (EE). The task of this component is to replace your own estrogens, the synthesis of which is inevitably suppressed when taking COCs. In addition, EE is needed for the growth of the functional layer of the uterus - the endometrium.
2. Progesterone, or more precisely, progestogen: it can be provided by various progestins (progestogens).

It is the progestogen component of the drugs that helps avoid pregnancy. The essence of its action is to suppress the maturation of the egg, and without ovulation it is impossible to conceive.

According to the amount of ethinyl estradiol contained in the preparations, they are:

• Highly dosed, containing more than 40 µg EE.
• Low-dose, when they contain less than 35 µg of estrogens. Can be used regardless of a history of childbirth. Especially indicated for the purpose of normalizing the cycle during heavy periods or the appearance of intermenstrual bleeding. These are drugs such as Lindinet 30, Marvelon, Silest, Regulon, Belara
• Microdosed: their ethinyl estradiol content is below 20 µg. Have a minimal number of side effects; are prescribed either to young girls who have not had childbirth, or to women over 35 years of age who have already given birth. Examples of such drugs are Logest, Lindinet 20, Novinet, Mercilon.

There are also COCs that further reduce elevated levels of male sex hormones. They can also be low- and micro-dosed. The first include: Jeannine, Chloe, Diane-35; to the second - Klaira, Zoely.

The drugs are also divided according to the estrogen/progesterone ratio in each tablet:

• if this ratio does not change during the cycle, it is called a monophasic drug;
• if in the second “portion” of tablets, which should be used in the second half of the cycle, the level of gestagens increases (by analogy with the natural cycle);
• The essence of three-phase tablets: gestagens increase in three stages, in the middle of the cycle there is a peak concentration of EE, then it decreases to the level that was at the very beginning (this is the most physiological ratio). The essence of such drugs is to reduce the total dose of progestogen entering the body.

If a contraceptive pill contains only progestogens, it is not called “combined”.

There is also a classification of COCs based on the chemical structure of progestogens. So, there are contraceptives containing:

• desogestrel;
• cyproterone acetate;
• gestodene;
• dienogest;
• levonorgestrel;
• chlormadione acetate;
• norgestimate and others.

Effects of contraceptives

The contraceptive effect is achieved by suppressing ovulation. This is due to the fact that synthetic progestogen binds to its receptors better than natural ones, which suppresses the production of those hormones of the hypothalamus and pituitary gland that “command” the work of the ovaries.

In addition, there are other effects:

1. the secretion secreted by the cervical glands thickens;
2. the structure of the endometrium changes so much that implantation of an embryo into it becomes impossible;
3. the menstrual cycle is normalized.

Some contraceptives have additional effects:

• treat acne, seborrhea, the growth of excess black hair in special areas (above the lip, around the nipple, on the stomach, thighs);
• normalize cholesterol metabolism;
• reduce body weight;
• prevent the development of edema.

Indications for use

Combined-action contraceptives are indicated for the prevention of pregnancy - uterine and ectopic. In addition, a gynecologist can also recommend them for:

• irregular cycle;
• dysfunctional uterine bleeding;
• painful menstruation and/or ovulation;
• heavy blood loss during menstruation;
• pathological premenstrual syndrome;
• when an increased amount of male hormones is detected in the blood;

Pros of oral contraceptives

The positive aspects of COCs are as follows:

• low probability of pregnancy (about 0.05%);
• the effect begins quickly;
• well tolerated;
• no need to choose a time before sexual intercourse to take the pill;
• there are few side effects, they quickly disappear when you stop taking it;
• used to normalize the menstrual cycle;
• reduce abdominal pain associated with menstruation;
• the amount of blood loss during menstruation is reduced;
• when taken for a period of 5 years or less, reduce the risk of developing tumors of the mammary glands and ovaries;
• after stopping treatment, pregnancy may occur within 1-12 months;
• you can “delay” the arrival of the next menstruation for a short period (5-7 days);
• treat conditions in which testosterone levels are elevated;
• can be used for emergency contraception;
• there is a proven preventive effect on the development of intestinal cancer and ectopic pregnancy.

Disadvantages of contraceptives

Oral combined contraceptive drugs also have disadvantages:

• must be taken at the same time every day;
• can cause thrombosis, especially when taking pills in combination with smoking;
• there is no protection against sexually transmitted diseases;
• may cause side effects: swelling of the mammary glands, headaches, nausea, metrorrhagia in the middle of the cycle;
• Long-term use increases the likelihood of breast and ovarian cancer.

How are contraceptives used?

They start taking medications on the 1st day of the cycle, choosing a time convenient for themselves, at which the woman will not forget to take them. If you had to start taking pills later than the 5th day of your cycle, additional contraception is required.

Take according to labeling with water only. Concomitant use with other drugs should be discussed with your doctor. In total you need to take 21 tablets, and then take a week break during which your period should begin.

There are drugs where the package contains 28 tablets. In this case, a new pack is opened the very next day after taking the last pill from the old one, that is, without a break.

If COCs are prescribed in the absence of menstruation (and pregnancy too!), you can start taking them on any day, and you need to take additional protection for a week.

If you need to take it during lactation, you can start only with a mini-pill and only from the 6th week of the postpartum period.

If vomiting occurs in the first 3 hours after taking the tablet, you need to take an additional tablet. If diarrhea develops, you need to additionally protect yourself from pregnancy.

Contraindications to COCs

You should absolutely not use contraceptives if:

1. thrombosis of any veins;
2. a history of pulmonary embolism;
3. IHD (coronary heart disease);
4. a history of stroke or micro-stroke;
5. high blood pressure;
6. heart rhythm disturbances;
7. septic endocarditis;
8. a combination of such factors: smoking (this is considered more than 15 cigarettes per day), hypertension, age 35 years and older, obesity;
9. liver diseases: cirrhosis, hepatitis, native or metastatic liver cancer;
10. migraine, which manifests itself with some focal symptoms;
11. breast cancer;
12. breastfeeding;
13. lipid metabolism disorders;
14. simultaneous use of Phenytoin, Phenobarbital, Carbamazepine, Griseofulvin, Rifampicin;
15. upcoming surgery that will require long-term immobilization;
16. cervical carcinoma.

What to do if you miss a pill

The algorithm of actions depends on how much time has passed since the woman remembered the pass:

1. If 12 hours or less have passed, you should take the missed tablet immediately, and the next one on the same day, at the appointed time.
2. If more than half a day has passed, then you need to proceed as in point 1, but during this week additionally protect yourself from pregnancy with contraceptives, interrupted intercourse or spermicides.
3. When 2 or more tablets are missed, then take 2 tablets per day for as many days as possible until the woman “catch up” with her dosing schedule. In this case, additional contraception is needed.
4. If you missed taking tablet contraceptives, which caused the development of menstruation, then you need to count 7 days from the last pill you took, and after this period of time start taking a new package of such contraceptives.
5. If one of the last seven tablets is missed, then you need to start taking the next package without a pause.

If you need to change the drug

When switching to a lower-dose contraceptive, the interval after taking the last tablet of a higher dosage is not necessary - take the new medicine immediately. If the doctor decides to change the drug to one in which the dosage of EE is higher, you need to take a break for a week.

Side effects

Typically, undesirable effects develop only in the first months of drug use, later they decrease - from 10-40% to 5-10%. These are the following symptoms:

• headache (cephalgia);
• flatulence;
• abdominal pain;
• nausea or vomiting;
• irritability;
• change in sexual desire;
• exacerbation of cholelithiasis;
• increased blood pressure;
• copious whitish vaginal discharge;
• leg muscle cramps;
• vaginal dryness;
• swelling;
• bleeding from the vagina.

The lower the dosage of the estrogen component, the lower the chance of side effects. They are also high in the presence of diabetes, obesity, smoking, and hypertension.

If side symptoms persist longer than 3-4 months, the drug requires discontinuation.

When you need to see a doctor urgently

If you experience at least one of the symptoms described below, immediately visit a gynecologist or call him by phone:

• dyspnea;
• chest pain;
• severe pain in the legs;
• visual impairment;
• if there is no menstruation during a week's break (when there are 21 tablets in a pack) or when taking the last seven (when there are 28 tablets in a pack).

In 85-90% of cases, fertility is restored within a year. There are also episodes of no menstrual bleeding for six months or more after stopping the medication. This may require the use of estrogen medications.

How the drug is selected

To correctly determine which group of COCs is needed in this case, the gynecologist must know:

• Is the cycle regular?
• whether there were abortions;
• How were previous pregnancies?
• what diseases the woman has (it is especially important to know about the presence of hypertension, atherosclerosis, blood clotting disorders, liver diseases). To obtain more accurate data, he must refer the woman to appropriate laboratory or instrumental examinations.

Also, the gynecologist should know the results or, take a smear from the cervical canal and vagina, prescribe an ultrasound of the uterus and appendages, and blood tests for HIV.

If there are no contraindications, they start with high-dose monophasic COCs; if there are signs of a lack of estrogen in the blood (dry mucous membranes of the vulva and vagina, decreased libido), triphasic contraceptives are prescribed.

If a woman has elevated testosterone, the drugs of choice for her are Diane-35, Zhannine or Yarina. There are also recommendations for choice in case of existing diabetes mellitus, endometriosis, and severe cycle disorders. Doctors also have recommendations for the use of COCs after childbirth, abortion, and also for menorrhagia associated with drug withdrawal.

Monitoring while taking COCs

If a woman uses contraceptives, she needs to undergo the following examinations:

1. - Every year;
2. – annually;
3. measure blood pressure once a month ();
4. other studies - according to indications.

If a woman did not pay attention to the absence of menstruation in the interval between taking pills, and it turned out that she took COCs in the first 2 months of pregnancy, most likely she will have to terminate it, since there is a high risk of fetal development abnormalities. If pregnancy was detected immediately and it was desired, you need to cancel the COC and save the life of the child.

Oral contraceptives are birth control pills taken orally to prevent pregnancy. They contain synthetic analogues of two hormones produced in the body, and are called COCs (combined oral contraceptives). Estrogen and progestin (gestagen) regulate a woman’s menstrual cycle, so taking them in the required dosages on a specific schedule is an effective method of preventing pregnancy. Research shows that less than 1% of women taking oral contraceptives become pregnant within the first year of using them. That is, the efficiency of the PDA is more than 99%.

Birth control pills come in a wide range of estrogen and progestin combinations. The drugs used today contain lower doses of estrogen than were available in the past, greatly reducing the likelihood of serious side effects.

The essence of birth control pills and the mechanism of action of PDAs

For conception to occur, the egg must mature in the ovary and move into the fallopian tube. When the sperm reaches the fallopian tubes, fertilization of the egg occurs. The fertilized egg then passes into the uterus, where the embryo develops. Oral contraceptives do not allow the egg to mature completely: the progestins contained in the tablets block the release of statins (releasing factors), the secretion of gonadoliberin is inhibited, which inhibits. An unripe egg cannot be fertilized. In addition, birth control pills thicken the mucus in the cervical canal, preventing sperm from passing through. Oral contraceptives also change the structure of the endometrium, which prevents the fertilized egg from attaching to the uterine wall and developing. The estrogenic component of the PDA stabilizes the menstrual cycle.

Classification of combined oral contraceptives

According to dosage regimen, oral contraceptives are divided into:

• monophasic,
• two-phase,
• three-phase.

Monophasic ones (non-ovlon, rigevidon, ovidone) include estrogen and gestagen in certain quantities. Reception scheme: daily for 21 days.

Two- and three-phase (anteovin, triziston, tri-regol, triquilar) are taken according to the same scheme, but they are produced in sets/containers, which include tablets with different concentrations of estrogen and gestagen, corresponding to the physiological cycle. This packaging helps a woman “track” her daily intake of birth control pills. The tablets have different colors, indicating the amount of hormones contained.

Some drugs are produced with additional dummy tablets (without active substance). They are designed to develop a “conditioned reflex” - the habit of taking a contraceptive every day, and not just on certain days of the menstrual cycle. Since the amount of hormones in two- and three-phase preparations is smaller, they have a weaker effect on metabolic processes without reducing the contraceptive effect.

Based on the estrogen component, COCs are divided into: ethinyl estradiol-containing and NOC (natural oral contraceptives) based on estradiol valerate . Ethinyl estradiol (EE)-containing COCs are divided into:

1. High-dose doses - 50 mcg of EE (anteovin, non-ovlon) - are not currently used due to the high risk of side effects.
2. Low-dose - 30–35 mcg EE (Yarina, Marvelon, Zhanin, Diane-35) with high contraceptive reliability.
3. Microdosed – 15–20 mcg EE (Jess, Mercilon, Logest).

A drug based on estradiol valerate (EV) – claira. EV is chemically identical to the natural hormone of the female body, so it has a milder effect than EE, hence the name - NOC.

There is no clear division according to the gestagenic component. First, testosterone derivatives with residual androgenic activity were used as progestins. Next came drugs containing levonorgestrel, desogestrel, and gestodene. Then progestins with antiandrogenic action were created: dienogest, drospirenone, cyproterone acetate.

Advantages of a PDA

In addition to the 99% effectiveness of drugs containing progestin and estrogen, they have the following advantages:

• reduction of symptoms of dysmenorrhea, menorrhagia;
• reliability, reversibility of action;
• reducing the incidence of unpleasant nagging premenstrual pain;
• “safety net” against the occurrence of benign neoplasms of the mammary glands;
• reducing the risk of inflammatory processes in the pelvis (as opposed to the use of intrauterine devices);
• reducing the risk of endometrial cancer (by 50%), ovarian cancer (by 80%).

Method of use of COCs

Important: The dosage regimen depends on the type of oral contraceptives. For a 21-day schedule: take one tablet daily for 21 days, then skip 7 days and repeat the cycle. For a 28-day schedule: take one tablet for 28 days, then repeat the cycle. Carefully studying the instructions included with the drug will help you avoid mistakes.

Missing a dose by more than 24 hours increases not only the risk of conception, but also the likelihood of side effects. It is advisable to take PDA at the same time “automatically”, then a habit will appear: we don’t forget to brush our teeth. If a dose is missed, follow the instructions in the instructions or consult the doctor who prescribed the medicine for recommendations. It is better to take birth control pills with food or before bed. This will help prevent nausea that sometimes occurs during the first few weeks.

Side effects of hormonal contraception

Serious side effects are more likely to occur in women over 35 who smoke and in patients with specific health problems (hypertension, diabetes, a history of breast or uterine cancer). All risks and benefits of this type of contraception should be discussed with a gynecologist, taking into account your health condition.

Side effects are rare in healthy women, but it is still better to be aware of them. Oral contraceptives may cause:

• liver tumors, including malignant ones;
• increased blood pressure;
• stroke;
• nausea/vomiting;
• cramping abdominal pain;
• chest pain;
• swelling of the legs (ankles);
• fatigue;
• acne;
• menstrual changes, including mid-cycle bleeding;
• headache;
• vaginal infections;
• itching/irritation of the external genitalia;
• heaviness in the chest;
• change in libido;
• venous thromboembolism;
• depression;
• skin reactions;
• fluid retention, weight gain;
• increased blood sugar levels.

Birth control pills cause photosensitivity - sensitivity to sunlight, so you should avoid prolonged exposure to the sun and avoid tanning beds. Sometimes age spots appear, disappearing a few months after the COC is discontinued. Oral contraceptives can cause bleeding gums and irritation of the cornea when wearing contact lenses.

The side effects of oral contraceptives are described in more detail in the video review:

Mini-pill – progestogen contraception

Mini-pills are oral contraceptives that contain only the hormone progesterone (without estrogen). Mini-pills (Exluton, Microlut, Ovrette) are prescribed to women who cannot use COCs: over 35 years old, suffering from hypertension, with a tendency to thrombosis, and overweight.

Mini-pills can be used:

• for heart disease;
• liver diseases;
• breast cancer;
• vaginal bleeding of unknown etiology;
• ovarian cyst.

The tablets are safe to take while breastfeeding: a small amount of gestagen may pass into breast milk, but this is not harmful to the baby.

The minipills are generally well tolerated and side effects are rare. The first few months may include:

• acne;
• soreness, swelling of the breast;
• increased/decreased sexual desire;
• mood changes;
• headache/migraine;
• nausea, vomiting;
• small ovarian cysts (disappear without treatment);
• stomach upset;
• weight gain.

Oral contraceptives: pros and cons

COCs have been used for 55 years. The “horror stories” associated with the side effects of the “pioneers” of hormonal contraception are gradually being forgotten: “a mustache will grow,” “you will get fat,” and others. Birth control pills not only help women control their reproductive function, they are prescribed for hormonal imbalances, hirsutism, acne, dysmenorrhea, and PMS. But we must not forget that these are still hormonal drugs that have a number of contraindications, so they must be prescribed by a doctor.

You will receive more useful information about the advantages and disadvantages of oral contraceptives by watching the video.

« Graviora quae dam sunt remedia periculis»
(“Some medicines are worse than the disease,” lat.)

Hormonal contraception is currently one of the most common family planning methods worldwide. Millions of women have been using these “peace pills” very successfully for a long time - convenient, reliable, practically safe when used correctly.
However, against the background of long-term (months and years) hormonal contraception, quite often there is a need to use (for a variety of indications) medications of many pharmacological groups. This is where certain difficulties often arise: issues of compatibility, pharmacological interactions, complications, side effects, etc. are, in many ways, terra incognita. Therefore, we have made a modest attempt to “dispel the fog.”

As is known, hormonal contraceptive drugs most often have a combined composition (estrogens, mainly represented by ethinyl estradiol (EES), and gestagens of various generations and chemical modifications) and are called COCs.
A variety of medications prescribed concomitantly with COCs can alter their contraceptive activity. COCs, in turn, quite often significantly affect the pharmacodynamics, bioavailability and other important aspects of the action of many drugs. In the processes of interaction of COCs, their estrogenic component plays a special role. Previously, it was believed that the progestogen component in drug interactions was not significant. However, according to Shenfield (1993), relatively recently developed gestagens of the third generation, in particular desogestrel, also undergo sulfate conjugation in the gastrointestinal tract, resulting in the potential for their interaction with many drugs.

The metabolism of exogenous ethinyl estradiol is as follows. 65% of the dose of EES taken orally undergoes conjugation in the intestinal wall, 29% is hydroxylated in the liver with the participation of the microsomal enzymatic system; the remaining 6% forms glucuronic and sulfate conjugates in the liver. Conjugated EES derivatives are excreted in the bile and enter the intestine, where they are exposed to bacteria to produce active hormone, which is then reabsorbed (so-called hepatoenteric recirculation).
COCs have an effect on the microsomal enzyme system of the liver, as a result of which the hydroxylation activity of these enzymes decreases, metabolism slows down andconcentration increasesin the plasma of some concomitantly taken drugs. Therefore, the therapeutic dose of these drugs is necessarydecreaseto avoid complications of drug therapy. With an increase in the degree of glucuronide conjugation, an inducing effect is observed, and therefore it is shownincreasetherapeutic dose to prevent a decrease in the effectiveness of treatment (see Table 1)
One of the mechanisms of pharmacological interaction is a possible induced increase in globulin that binds sex hormones in plasma, and in connection with this, a decrease in the amount of biologically active free steroids.

Table 1. Interaction of COCs with other drugs

Due to frequently occurring side effects and complications, the simultaneous use of COCs and bromocriptine (parlodel), ergot alkaloids (ergotamine), dopegite (methyldopa, aldomet), antipyrine, ketoconazole (orally only) is not recommended.
In addition to the possible influence of COCs on the effectiveness of various concomitantly taken medications, it is imperative to take into account the effect of various drugs on the main and main property of COCs -contraceptive activity.This data is constantly being supplemented, modified and improved, but it has now been established that the effectiveness of hormonal contraceptivessignificantly reduce:

1. Antacids containing magnesium;
2. Anticonvulsants and antiepileptic drugs (hexamidine, carbamazepine, tegretol, diphenin, ethosuximide, etc.);
3. Barbiturates (in particular phenobarbital);
4. Meprobamate (meprotan, andaxin);
5. Nitrofurans (furadonin);
6. Imidazoles (metronidazole, flagyl, Klion, trichopolum, tinidazole, etc.);
7. Sulfonamides and trimethoprim (in particular, their combination - Biseptol, Bactrim);
8. Some anti-tuberculosis drugs (in particular, isoniazid);
9. Phenylbutazone (butadione), indomethacin;
10. Butamide.

Particular caution must be observed when coadministeringCOCs and antibiotics, in particular, having an effect on the intestinal microflora, since the latter can reduce the absorption of estrogens from the intestine, preventing them from achieving their effective concentrations in the blood. There is a fairly original recommendation (Boroyan R. G., 1999) to increase the dose of COCs for the entire period of taking antibiotics and for two weeks after the end of the course of therapy
Antibiotics that significantly reduce the contraceptive effectiveness of COCs include: rifampicin and its analogs, penicillin and semisynthetic penicillins (phenoxymethylpenicillin, ampicillin, amoxicillin, augmentin, etc.), griseofulvin, the entire group of tetracyclines (doxycycline, vibramycin, metacycline), chloramphenicol (levomycetin) . To a lesser extent, cephalexin and other cephalosporins, clindamycin (Dalacin), macrolide antibiotics (in particular, erythromycin), neomycin and its analogs have a lesser effect on the contraceptive effectiveness of COCs.
The occurrence of intermenstrual bleeding observed during the simultaneous use of COCs and other drugs may actually reflect a decrease in contraceptive activity

Remembering the well-known saying about “God-protected” and “the frightened crow that is afraid of the bush” (in our context - pregnancy), in our practical activities we are guided by the principle set out in the above sayings, recommending the so-called “safety net contraception”. Its meaning is that the patient’s taking any drug (except for one-time use, for example, paracetamol for headaches) simultaneously with a COC should be accompanied byindispensableusing barrier (condom, cap, diaphragm), spermicidal or even generally not recommended (coitus interruptus) methods of contraception until the end of a given menstrual cycle.
This recommendation is especially relevant due to the current availability of a myriad of drugs from new pharmacological groups, their synonyms, analogues, etc., the interaction of which with COCs has not yet been sufficiently studied or is completely unknown...

Issues of drug interactions are very relevant, but, unfortunately, have not been sufficiently studied and covered in the medical literature. We absolutely agree with the opinion of S. N. Panchuk and N. I. Yabluchansky (2002) that “the key link in ensuring drug safety is the practicing physician. His awareness of these issues, concern and active life position are important components of safe pharmacotherapy.”

LITERATURE

1. Bagdan Sh. Modern pregnancy prevention and family planning, trans. from Hungarian, Graphite Pencil, Budapest, 1998.
2. Boroyan R. G. Clinical pharmacology for obstetricians and gynecologists, Medical Information Agency, Moscow. 1999.
3. Derimedved L.V., Pertsev I.M., Shuvanova E.V., Zupanets I.A., Khomenko V.N.. Interaction of drugs and the effectiveness of pharmacotherapy, Kharkov, Megapolis, 2002.
4. Mayorov M.V. Some aspects of hormonal contraception // Pharmacist, 2002, No. 1, January, p. 43-44.
5. Mayorov M.V. Contraception: modern principles, methods, drugs // Medicine and..., 1999, No. 2 (5), p. 8-14.
6. Panchuk S.N., Yabluchansky N.I., Drug safety // Medicus Amicus, 2002, No. 6, p. 12-13.
7. Guide to contraception / Russian international publication, Bridging The Gap Communications. Inc. Decatur, Georgia, U.S.A., 1994.
8. Darcy P. F. Drug interactions with oral contraceptives // Drug. Intel. Clin. Pharm., 1986, 20:353-62.
9. Miller D. M, Helms S. E, Brodell R. T A practical approach to antibiotic treatment in women taking oral contraceptives // J. Am. Acad. Dermatol 1998, 30:1008-11.
10. 10. Shenfield G. M. Drug interactions with oral contraceptive preparations // Med. J Aust. 1986, 144:205-211.
11. 11. Shenfield G. M. Oral Contraceptives. Are drug interactions of clinical significance? //Drug. Safety, 1998, 9(1):21-37.

Each tablet combined oral contraceptives (COCs) contains estrogen and progestogen. Synthetic estrogen - ethinyl estradiol - is used as an estrogenic component of COCs, and various synthetic progestogens (synonym - progestins) are used as a progestogen component.

Mechanism of contraceptive action of COCs:

• suppression of ovulation;
• thickening of cervical mucus;
• changes in the endometrium that prevent implantation.

Contraceptive effect of COCs provides a progestogen component. Ethinyl estradiol in COCs supports endometrial proliferation and provides cycle control (no intermediate bleeding when taking COCs).

In addition, ethinyl estradiol is necessary to replace endogenous estradiol, since when taking COCs there is no follicle growth and, therefore, estradiol is not produced in the ovaries.

The main clinical differences between modern COCs - individual tolerability, frequency of adverse reactions, features of the effect on metabolism, therapeutic effects, etc. - are due to the properties of the progestogens they contain.

CLASSIFICATION AND PHARMACOLOGICAL EFFECTS OF COCs

Chemical synthetic progestogens - steroids; they are classified by origin.

Like natural progesterone, synthetic progestogens cause secretory transformation of the estrogen-stimulated (proliferative) endometrium. This effect is due to the interaction of synthetic progestogens with endometrial PR. In addition to their effect on the endometrium, synthetic progestogens also act on other organs that are the targets of progesterone. The antiandrogenic and antimineralocorticoid effects of progestogens are favorable for oral contraception; the androgenic effect of progestogens is undesirable.

The residual androgenic effect is undesirable, as it can be clinically manifested by the appearance of acne, seborrhea, changes in the lipid spectrum of the blood serum, changes in carbohydrate tolerance and weight gain due to anabolic effects.

Based on the severity of androgenic properties, progestogens can be divided into the following groups:

• Highly androgenic progestogens (noethisterone, linestrenol, ethynodiol).
• Progestogens with moderate androgenic activity (norgestrel, levonorgestrel in high doses, 150–250 mcg/day).
• Progestogens with minimal androgenicity (levonorgestrel in a dose of no more than 125 mcg/day, including triphasic), ethinyl estradiol + gestodene, desogestrel, norgestimate, medroxyprogesterone). The androgenic properties of these progestogens are detected only in pharmacological tests; in most cases they have no clinical significance. WHO recommends the use of COCs with low androgenic progestogens. Studies have found that desogestrel (active metabolite - 3-ketodesogestrel, etonogestrel) has high progestogenic and low androgenic activity and the lowest affinity for SHBG, therefore, even in high concentrations, it does not displace androgens from its connection. These factors explain the high selectivity of desogestrel compared to other modern progestogens.

Cyproterone, dienogest and drospirenone, as well as chlormadinone, have an antiandrogenic effect.

Clinically, the antiandrogenic effect leads to a reduction in androgen-dependent symptoms - acne, seborrhea, hirsutism. Therefore, COCs with antiandrogenic progestogens are used not only for contraception, but also for the treatment of androgenization in women, for example, with PCOS, idiopathic androgenization and some other conditions.

SIDE EFFECTS OF COMBINED ORAL CONTRACEPTIVES (COCs)

Side effects most often occur in the first months of taking COCs (in 10–40% of women); subsequently, their frequency decreases to 5–10%. Side effects of COCs are usually divided into clinical and mechanism-dependent.

Excessive estrogen influence:

• headache;
• increased blood pressure;
• irritability;
• nausea, vomiting;
• dizziness;
• mammalgia;
• chloasma;
• deterioration of tolerance to contact lenses;
• increase in body weight.

Insufficient estrogenic effect:

• headache;
• depression;
• irritability;
• reduction in the size of the mammary glands;
• decreased libido;
• vaginal dryness;
• intermenstrual bleeding at the beginning and middle of the cycle;
• scanty menstruation.

Excessive influence of progestogens:

• headache;
• depression;
• fatigue;
• acne;
• decreased libido;
• vaginal dryness;
• deterioration of varicose veins;
• increase in body weight.

Insufficient progestogenic effect:

• heavy menstruation;
• intermenstrual bleeding in the second half of the cycle;
• delay of menstruation.

If side effects persist longer than 3–4 months after starting treatment and/or intensify, then the contraceptive drug should be changed or discontinued.

Serious complications when taking COCs are extremely rare. These include thrombosis and thromboembolism (deep vein thrombosis, pulmonary embolism). For women's health, the risk of these complications when taking COCs with a dose of ethinyl estradiol 20–35 mcg/day is very small - lower than during pregnancy. Nevertheless, the presence of at least one risk factor for the development of thrombosis (smoking, diabetes mellitus, high degrees of obesity, arterial hypertension, etc.) serves as a relative contraindication to taking COCs. A combination of two or more of these risk factors (for example, smoking over the age of 35 years) generally excludes the use of COCs.

Thrombosis and thromboembolism, both when taking COCs and during pregnancy, can be manifestations of latent genetic forms of thrombophilia (resistance to activated protein C, hyperhomocysteinemia, deficiency of antithrombin III, protein C, protein S; APS). In this regard, it should be emphasized that routine determination of prothrombin in the blood does not give an idea of ​​​​the hemostatic system and cannot be a criterion for prescribing or discontinuing COCs. When identifying latent forms of thrombophilia, a special study of hemostasis should be performed.

CONTRACEPTIONS TO THE USE OF COMBINED ORAL CONTRACEPTIVES

Absolute contraindications to taking COCs:

• deep vein thrombosis, pulmonary embolism (including a history), high risk of thrombosis and thromboembolism (with extensive surgery associated with prolonged immobilization, with congenital thrombophilia with pathological levels of coagulation factors);
• coronary heart disease, stroke (history of cerebrovascular crisis);
• arterial hypertension with systolic blood pressure 160 mm Hg. or more and/or diastolic blood pressure 100 mm Hg. and more and/or with the presence of angiopathy;
• complicated diseases of the valvular apparatus of the heart (hypertension of the pulmonary circulation, atrial fibrillation, history of septic endocarditis);
• a combination of several factors for the development of cardiovascular diseases (age over 35 years, smoking, diabetes, hypertension);
• liver diseases (acute viral hepatitis, chronic active hepatitis, liver cirrhosis, hepatocerebral dystrophy, liver tumor);
• migraine with focal neurological symptoms;
• diabetes mellitus with angiopathy and/or disease duration of more than 20 years;
• breast cancer, confirmed or suspected;
• smoking more than 15 cigarettes per day over the age of 35;
• lactation in the first 6 weeks after birth;
• pregnancy.

RESTORATION OF FERTILITY

After stopping taking COCs, the normal functioning of the hypothalamus-pituitary-ovarian system is quickly restored. More than 85–90% of women are able to become pregnant within one year, which corresponds to the biological level of fertility. Taking COCs before conception does not have a negative effect on the fetus, the course or outcome of pregnancy. Accidental use of COCs in the early stages of pregnancy is not dangerous and does not serve as a basis for abortion, but at the first suspicion of pregnancy, a woman should immediately stop taking COCs.

Short-term use of COCs (for 3 months) causes an increase in the sensitivity of the receptors of the hypothalamus-pituitary-ovarian system, therefore, when COCs are discontinued, tropic hormones are released and ovulation is stimulated.

This mechanism is called the “rebound effect” and is used in the treatment of some forms of anovulation. In rare cases, amenorrhea may be observed after discontinuation of COCs. Amenorrhea may be a consequence of atrophic changes in the endometrium that develop when taking COCs. Menstruation appears when the functional layer of the endometrium is restored independently or under the influence of estrogen therapy. In approximately 2% of women, especially in the early and late periods of fertility, amenorrhea lasting more than 6 months (hyperinhibition syndrome) can be observed after stopping taking COCs. The frequency and causes of amenorrhea, as well as the response to therapy in women who used COCs, do not increase the risk, but may mask the development of amenorrhea with regular menstrual-like bleeding.

RULES FOR INDIVIDUAL SELECTION OF COMBINED ORAL CONTRACEPTIVES

COCs are selected for women strictly individually, taking into account the characteristics of their somatic and gynecological status, individual and family history. The selection of COCs is carried out according to the following scheme:

• A targeted interview, assessment of somatic and gynecological status and determination of the category of acceptability of the combined oral contraceptive method for a given woman in accordance with WHO eligibility criteria.
• Selection of a specific drug, taking into account its properties and, if necessary, therapeutic effects; counseling a woman about the COC method.

decision to change or cancel COCs.

• Clinical observation of the woman during the entire period of use of COCs.

In accordance with the WHO conclusion, the following examination methods are not relevant to assessing the safety of COC use:

• examination of the mammary glands;
• gynecological examination;
• examination for the presence of atypical cells;
• standard biochemical tests;
• tests for PID, AIDS.

The drug of first choice should be a monophasic COC with an estrogen content of no more than 35 mcg/day and a low androgenic gestagen.

Three-phase COCs can be considered as reserve drugs when signs of estrogen deficiency appear against the background of monophasic contraception (poor cycle control, dry vaginal mucosa, decreased libido). In addition, three-phase drugs are indicated for primary use in women with signs of estrogen deficiency.

When choosing a drug, you should take into account the characteristics of the patient’s health condition (Table 12-2).

Table 12-2. Selection of combined oral contraceptives

The first months after starting to take COCs serve as a period of adaptation of the body to hormonal changes. At this time, intermenstrual spotting bleeding or, less commonly, “breakthrough” bleeding (in 30–80% of women), as well as other side effects associated with hormonal imbalance (in 10–40% of women), may occur.

If these adverse events do not go away within 3–4 months, this may be a reason to change the contraceptive (after excluding other causes - organic diseases of the reproductive system, missed pills, drug interactions) (Table 12-3).

Table 12-3. Selection of second-line COCs

The basic principles for monitoring women using COCs are as follows:

• in an annual gynecological examination, including colposcopy and cytological examination;
• examining the mammary glands every six months (in women with a history of benign tumors of the mammary glands and/or breast cancer in the family), performing mammography once a year (in perimenopausal patients);
• in regular blood pressure measurement: when diastolic blood pressure increases to 90 mm Hg. and more - stopping taking COCs;
• in a special examination according to indications (if side effects develop, complaints arise).

In case of menstrual dysfunction, exclude pregnancy and transvaginal ultrasound scanning of the uterus and its appendages.

RULES FOR TAKEN COMBINED ORAL CONTRACEPTIVES

All modern COCs are produced in “calendar” packages designed for one administration cycle (21 tablets - one per day). There are also packs of 28 tablets, in which case the last 7 tablets do not contain hormones (“dummy”). In this case, the packs should be taken without interruption, which reduces the likelihood that the woman will forget to start taking the next pack on time.

Women with amenorrhea should start taking it at any time, provided that pregnancy has been reliably excluded. An additional method of contraception is required for the first 7 days.

Women who are breastfeeding:

• COCs are not prescribed earlier than 6 weeks after birth;
• in the period from 6 weeks to 6 months after childbirth, if a woman is breastfeeding, use COCs only if absolutely necessary (the method of choice is minipills);
• more than 6 months after birth, COCs are prescribed:
  ♦for amenorrhea - see the section “Women with amenorrhea”;
  ♦with a restored menstrual cycle - see the section “Women with a regular menstrual cycle.”

PROLONGED REGIMEN OF PRESCRIPTION OF COMBINED ORAL CONTRACEPTIVES

Prolonged contraception provides for an increase in cycle duration from 7 weeks to several months. For example, it may consist of taking 30 mcg ethinyl estradiol and 150 mcg desogestrel or any other COC in a continuous regimen. There are several long-acting contraceptive regimens. The short-term dosing regimen allows you to delay menstruation by 1–7 days; it is practiced before an upcoming surgical intervention, vacation, honeymoon, business trip, etc. The long-term dosing regimen allows you to delay menstruation from 7 days to 3 months. As a rule, it is used for medical reasons for menstrual irregularities, endometriosis, MM, anemia, diabetes, etc.

Long-acting contraception can be used not only to delay menstruation, but also for therapeutic purposes. For example, after surgical treatment of endometriosis in a continuous manner for 3–6 months, which significantly reduces the symptoms of dysmenorrhea, dyspareunia, helps to improve the quality of life of patients and their sexual satisfaction.

The prescription of long-acting contraception is also justified in the treatment of MM, since in this case the synthesis of estrogen by the ovaries is suppressed, the level of total and free androgens, which under the influence of aromatase synthesized in the fibroid tissues, can be converted into estrogens, decreases. At the same time, women do not observe estrogen deficiency in the body due to its replenishment with ethinyl estradiol, which is part of the COC. Studies have shown that in PCOS, continuous use of Marvelon© for 3 cycles causes a more significant and persistent decrease in LH and testosterone, comparable to that with the use of GnRH agonists, and contributes to a much greater reduction in these indicators than when taken in the standard regimen.

In addition to the treatment of various gynecological diseases, the use of the method of prolonged contraception is possible in the treatment of dysfunctional uterine bleeding, hyperpolymenorrhea syndrome in perimenopause, as well as for the purpose of relieving vasomotor and neuropsychic disorders of menopausal syndrome. In addition, long-acting contraception enhances the cancer-protective effect of hormonal contraception and helps prevent bone loss in women of this age group.

The main problem with the prolonged regimen was the high frequency of breakthrough bleeding and spotting, which was observed during the first 2–3 months of use. Currently available data indicate that the incidence of adverse reactions with extended cycle regimens is similar to those for conventional dosing regimens.

RULES FOR FORGOTTEN AND MISSED PILLS

• If 1 tablet is missed:
  ♦less than 12 hours late in taking the dose - take the missed pill and continue taking the drug until the end of the cycle according to the previous regimen;
  ♦delay in appointment more than 12 hours - the same actions plus:
  – if you miss a pill in the 1st week, use a condom for the next 7 days;
  – if you miss a pill in the 2nd week, there is no need for additional means of protection;
  – if you miss a pill in the 3rd week, after finishing one pack, start the next one without a break; There is no need for additional means of protection.
• If 2 or more tablets are missed, take 2 tablets per day until taking them into your regular schedule, plus use additional methods of contraception for 7 days. If bleeding begins after missing tablets, it is better to stop taking tablets from the current package and start a new package 7 days later, counting from the start of missing tablets.

RULES FOR PRESCRIPTION OF COMBINED ORAL CONTRACEPTIVES

• Primary appointment - from the 1st day of the menstrual cycle. If reception is started later (but no later than the 5th day of the cycle), then in the first 7 days it is necessary to use additional methods of contraception.
• Post-abortion appointment - immediately after the abortion. Abortion in the first and second trimesters, as well as septic abortion, are classified as category 1 conditions (there are no restrictions on the use of the method) for prescribing COCs.
• Prescription after childbirth - in the absence of lactation - no earlier than the 21st day after birth (category 1). If there is lactation, do not prescribe COCs; use minipills no earlier than 6 weeks after birth (category 1).
• Switching from high-dose COCs (50 mcg ethinyl estradiol) to low-dose ones (30 mcg ethinyl estradiol or less) - without a 7-day break (so that the hypothalamic-pituitary system does not become activated due to dose reduction).
• Switching from one low-dose COC to another after the usual 7-day break.
• Switching from a minipill to a COC on the first day of the next bleeding.
• Switching from an injection drug to a COC on the day of the next injection.
• Switching from a combined vaginal ring to a COC on the day the ring was removed or on the day a new one was supposed to be inserted. Additional contraception is not required.

The problem of protection from unwanted pregnancy is very relevant. According to statistics, more than half of all conceptions are unplanned. This situation can sometimes result in the birth of a healthy child, but more often it is followed by artificial termination of pregnancy or other undesirable outcomes. Case decides a lot. However, in the modern world you should not rely on fate in the matter of prolongation of the family. The pharmaceutical industry produces different types of contraceptives that have several mechanisms of action and fairly high efficiency. The leading place belongs to hormonal drugs.

Pills, implants, injectables and transdermal releasing systems have the greatest ability to prevent ovulation, fertilization of a mature egg and its implantation. All this makes an unwanted pregnancy almost impossible. The most widely used tablets are hormonal contraceptives, popularly called “birth control pills.” The choice of this dosage form is associated with traditional preferences, wide availability, and ease of use.

Combined oral contraceptives

Combined oral contraceptives (COCs), so beloved by gynecologists, are pills to prevent unwanted pregnancy, including two active hormonal components (estrogens and gestagens). The introduction of birth control pills in the 60s of the 20th century led to profound social changes in society. In fact, for the first time, a woman was able to have an active sex life without the danger of an unwanted pregnancy and plan the birth of her children. Historians consider the advent of COCs to be responsible for the sexual revolution in the Western world. What are these pills? How have they changed over the past decades?

Mechanism of action of birth control pills

The mechanism of action of COCs is realized at the level of cellular receptors. Estrogens and gestagens in tablets block receptors in the organs of the female reproductive system.

As a result of this, firstly, ovulation is inhibited. The growth and maturation of eggs is suppressed due to a decrease in the concentration and normal rhythm of secretion of pituitary hormones - luteinizing and follicle-stimulating.

Birth control pills also affect the inner lining of the uterus. “Glandular regression” occurs in it. This means that the endometrium practically atrophies and if suddenly the egg still manages to mature and is fertilized, it will be impossible for it to be implanted in the uterus.

Another important effect of COCs is a change in the structure of mucus in the cervix. The viscosity of this secretion increases and the entrance to the uterine cavity for sperm is actually blocked.

Fourthly, birth control pills also affect the uterine adnexa - the fallopian tubes. Their contractile activity decreases, which means that the movement of the egg along them becomes almost impossible.

The contraceptive effect of COCs is largely associated with inhibition of ovulation (ovule maturation). The pills create an artificial cycle in a woman’s body, suppressing the normal menstrual cycle. The physiology of the reproductive system is based on the principle of “feedback”. That is, the pituitary gland produces tropic hormones (in this case, follicle-stimulating hormones) in response to a decrease in the level of hormones in target organs (in this case, estrogens and gestagens in the ovaries). If a sufficiently large amount of estrogens and gestagens enters a woman’s body from outside, then tropic hormones in the pituitary gland cease to be produced. This leads to a lack of growth and development of eggs in the ovaries.

The level of hormones in the blood when taking COCs is quite individual. Specific numbers depend on the woman’s weight, the percentage of adipose tissue in her body, and the level of sex-binding globulin in the blood. Studies of progesterone and estrogen are considered inappropriate while taking pills. Theoretically, the concentration of estrogens and gestagens after taking high-dose COCs is comparable to the hormonal background of pregnancy. When taking low- and micro-dose drugs, these levels are lower than during pregnancy, but higher than in the normal menstrual cycle.

Types of combined oral contraceptives

COCs are divided into groups depending on the concentration of hormones and division into phases.

As estrogens The tablets usually contain estradiol. Currently, ethinyl estradiol is used. As for estrogen concentrations, over five decades of COC use, they have progressively decreased. In 1960, estradiol was 150 mcg per tablet. Currently, its dose is much lower and can be as low as 15-20 mcg. Tablets are divided into high-dose (more than 35 mcg), low-dose (30-35 mcg), microdose (less than 30 mcg).

The negative effects of large doses of estrogen (more than 50 mcg per day) made the use of first-generation COCs quite unsafe in a number of women. The most severe complications are considered to be disorders in the blood clotting system - thrombosis and embolism. Modern low-dose and micro-dose birth control pills are much less likely to cause such complications. However, disturbances in the hemostatic system are a contraindication to the use of even modern COCs.

As gestagens synthetic derivatives of norsteroids and progesterone are used. The dose of gestagens also gradually decreased from the 60s to the present (from 9.85 to 0.15-0.075 mg).
The first generation of gestagens norsteroids: norethinodrel, linesterenol, norgesterel, ethynodiol diacetate, norgestimate, norgestrel.
First generation progesterone: medroxyprogesterone acetate, cyproterone acetate, chlormadinone acetate. The improvement of this component of COCs followed the path of reducing unwanted glucocorticoid and androgenic effects.
Modern norsteroyl derivatives– these are levonorgestrel, desogestrel, gestodene, norgestimate. The new gestagen drospirenone is a derivative of spirolactone.

Old gestagens increase the atherogenic properties of the blood and can contribute to the development of arterial hypertension, decreased glucose tolerance, fluid retention, the appearance of seborrhea and hirsutism. Modern gestagens do not affect metabolism (lipids, glucose).

Cyproterone acetate and drospirenone have an antiandrogenic effect. They can be used to treat hirsutism, acne, seborrhea, and hair loss. COCs with these components are Diane-35 (35 mcg ethinyl estradiol and 2 mg cyproterone acetate) and Yarina (30 mcg ethinyl estradiol and 3 mg drospirenone), Jess (20 mcg ethinyl estradiol and 3 mg drospirenone). Other modern gestagens in combination with estrogens also have a positive effect on the condition of a woman’s skin and hair. These drugs are Femoden, Marvelon, Regulon, Silest, Janine, Mercilon, Logest, Novinet, Mirelle, Lindinet, Tri-Mercy.

Drospirenone helps reduce fluid retention in the body. Yarina and Jess are successfully used to treat premenstrual syndrome, as it is mainly caused by hidden tissue swelling.

COC tablets are divided into three types: one-, two-, three-phase. This classification is based on the concentration of substances in tablets.

IN single-phase birth control pills the dose of components is constant. In two-phase and three-phase COCs, an attempt is made to imitate a woman’s normal menstrual cycle - its follicular and luteal phases. In the natural cycle of women after ovulation, the level of gestagens in the blood increases sharply.

IN biphasic COCs the first 11 tablets contain estrogens and gestagens in a ratio of 1:1, the next 10 - 1:2.5. An example is Anteovin (ethinyl estradiol 50 mcg and levonorgestrel 0.05 mg-0.125 mg). The high dose of estrogen makes these drugs unattractive.

Triphasic birth control pills are used more often. Phases may have different numbers of tablets. In Tri-Mercy, each phase is 7 days (ethinyl estradiol 35-30-30 mcg and desogestrel 0.05-0.1-0.15 mg). Examples of three-phase COCs are also Triquilar, Tri-regol, Triziston.

The most common COCs are single-phase. They do not imitate the natural menstrual cycle, but consistently suppress ovulation with a relatively small estrogen requirement.

Examples of high-dose single-phase COCs– Ovidon, Non-Ovlon; low-dose– Rigevidon, Microgynon, Miniziston, Femoden, Marvelon, Regulon, Silest, Diane-35, Janine, Yarina; microdosed- Mercilon, Logest, Novinet, Mirelle, Lindinet, Jess.

Choosing birth control pills

The doctor decides which COCs will be prescribed. Choosing pills on your own is dangerous to your health. Side effects of drugs and contraindications to their use can only be assessed by a gynecologist during a face-to-face consultation and after an appropriate examination.

Modern drugs are considered optimal today - low- and micro-doses containing 20-30 mcg of ethinyl estradiol and modern gestagens.

Low-dose three-phase COCs (Tri-Mercy) are recommended for young women without children. Teenage girls with acne and seborrhea can be prescribed this particular drug - its effect on the pituitary gland and the entire functional activity of the reproductive system is minimal, which is especially important at a young age and before the first birth. It is also acceptable to use microdosed COCs in girls before childbirth (ethinyl estradiol 15-20 mcg).

For women who have given birth, single-phase COCs can be recommended. They are chosen depending on the clinical situation.
For symptoms of increased androgens (acne, seborrhea, hirsutism), Diana-35, Yarina, Jess are prescribed.
For symptoms of premenstrual syndrome, choose a COC with drospirenone (Yarina, Jess).
For diabetes mellitus, only low- and micro-dose COCs are permissible. Preference should be given to single-phase microdosed tablets (Mersilon, Logest, Novinet, Mirelle, Lindinet, Jess).
In the presence of intermenstrual bloody (ovulatory) discharge, single-phase contraceptives are chosen - the first 2-3 cycles are high-dose (Non-Ovlon, etc.), and then low-dose (Regulon, Rigividon, etc.)
For functional ovarian cysts, microdose contraceptive pills (Logest, Lindinet, Jess) are selected for 21 days with a 7-day break for a period of at least 6 months.
In case of cervical erosion, a thorough examination of the defect in the mucous membrane is carried out. Hormone therapy is carried out when ectopia of columnar epithelium of dishormonal nature is detected using micro- and low-dose single-dose COCs. Some gynecologists prefer three-phase drugs.
Mastopathy in a woman under 45 years of age before her first birth and lactation should be a reason to refrain from long-term (more than 5 years) use of COCs. Modern low- and micro-dose tablets are considered a prophylactic agent for the prevention of fibrocystic mastopathy.

Before the doctor selects a COC, you must undergo an appropriate examination. Most likely, colposcopy and cytological examination of the endocervix, cervix, ultrasound examination of the pelvic organs and mammary glands will be required. Women over 35 years of age are additionally prescribed a blood test for the lipid spectrum (cholesterol and its fractions, triglycerides), analysis of the hemostatic system (prothrombin, fibrinogen, plasmin, antithrombin III), glycosylated hemoglobin or oral glucose tolerance test, ultrasound examination of the liver and gall bladder. The examination must be repeated annually.

Contraindications to taking birth control pills

COCs are absolutely contraindicated for women with thrombophlebitis, thromboembolism, vascular diseases of the brain, heart attack, stroke previously and currently. Severe liver disease, kidney disease with impaired function, and severe cardiovascular failure are also considered an absolute contraindication to the use of COCs. Birth control pills are not allowed for breastfeeding mothers.

The use of COCs is undesirable for migraines, epilepsy, gastric ulcers, hypertension, complications during a previous pregnancy such as diabetes or jaundice.

Sometimes situations may arise when COCs need to be immediately discontinued. These include: increased blood pressure, sudden visual disturbances, significant weight gain, planned surgery, a long period of inactivity (for example, due to injury).

Side effects of combined oral contraceptives

Microdosed COCs rarely lead to fatigue, weight gain, increased appetite, or decreased libido. With high-dose tablets, these phenomena can be quite pronounced. Nausea, tenderness of the mammary glands, intermenstrual bleeding may occur within 2-3 months from the start of taking the pills and these are NOT indications for stopping the drug.

A doctor should recommend switching to other COCs. Breakthrough bleeding causes a transfer to higher-dose birth control pills. The appearance of symptoms of fluid retention in the body makes one prefer COCs with drospirenone as a gestagen (Jess, Yarina).

In women with an initially irregular cycle, long-term (more than 2-3 years) use of COCs can lead to the development of amenorrhea. Menstrual-like bleeding disappears and after discontinuation of COCs, the cycle does not recover on its own. This is associated with ovarian hyperinhibition syndrome due to dysfunction of the pituitary gland. In this case, treatment is necessary.

Modern data on the use of low- and micro-dose COCs demonstrate their safety in relation to the development of oncology of the reproductive system. There is no definitive answer to the question about the effect of birth control pills on the risk of breast cancer. Most likely, after 45 years of age, the risk of breast cancer when taking COCs is no higher than with other types of contraception.
When taking COCs, the incidence of endometrial cancer is reduced by 50%. The incidence of epithelial malignant ovarian tumors is reduced by at least 40% (up to 80% when taken for more than 5 years). In women with initially disturbed hormonal balance, the preventive role of COCs is higher.

How to take COC tablets?

A package of tablets for a month contains 21 (24) active tablets, that is, COCs with hormones. Some of the drugs also include placebos - “empty tablets” that do not contain hormones, but are included for ease of administration. Single-phase COCs (21 tablets) are taken from days 5 to 25 or from days 1 to 21 of the cycle. Multiphase tablets must be taken from day 1 of the cycle. Then take a break of 7 days. If COCs contain a placebo, then the tablets are taken without interruption.

The tablets are taken at the same time with a small amount of water. If the delay in taking the drug is less than 12 hours, the contraceptive effect is not reduced. The woman should take the missed pill as soon as possible, and the next one should be taken at the usual time.

If the delay in taking the next pill is more than 12 hours, contraceptive effectiveness may be reduced.

If a woman has vomiting or diarrhea within the first 4 hours after taking the active tablets, absorption may be incomplete and the woman should take additional contraceptive measures. As an additional measure, a barrier method - a condom - is usually recommended.

Other hormonal contraceptives in tablets

In addition to COCs, there are also single-component hormonal tablets. They contain only gestagen. Currently, the area of ​​​​use of these drugs is mainly during breastfeeding in women who are sexually active. Gestagens do not affect the quality and quantity of breast milk and do not have a negative effect on the baby. While estrogens have a pronounced effect on both lactation and the health of the child. Traditionally, mini-pills are used. The problem with their use is the dependence on the time of administration - a delay of 3 hours already increases the risk of pregnancy. Of the modern drugs, Desogestrel (75 mcg) is recommended. It can be taken without fear even 11-12 hours later than due.

Hormonal pills "after" (for postcoital contraception)

Emergency (postcoital) contraception is a method of preventing pregnancy after unprotected intercourse.
Emergency contraception is worse for a woman's health and less effective. The sooner measures are taken, the greater the chances of avoiding an unwanted pregnancy. The proximity of ovulation, that is, the day of the cycle, also matters. On the day of ovulation, such contraception is less effective.
Postinor is used most often. It contains 0.75 mg levonorgestrel. There are two tablets in the package. They must be taken sequentially with an interval of 12 hours on the first day after sexual intercourse. Further efficiency decreases.

High-dose COCs can be used as emergency contraception "after". Non-Ovlon (or another similar COC) is taken in the amount of 2 tablets immediately after sexual intercourse and 2 more tablets after 12 hours.

Another substance, the antiprogestogen mifepristone, is increasingly used as a means of emergency contraception. It is recommended 600 mg once within 72 hours after intercourse, or 200 mg on days 23-27 of the cycle, or: 25 mg 12 hours 2 times after intercourse. Now the drug in a dose of 10 mg has appeared on the market as a means of post-coital contraception. It has been proven to be highly effective with few side effects. It is possible to use 10 mg of the drug once within 120 hours after unprotected intercourse with a very high contraceptive effect. The advantage of the drug is its activity even in relation to a pregnancy that has already occurred at short stages.

Endocrinologist Tsvetkova I.G.