The effectiveness of birth control pills and factors that reduce their effectiveness. The Newest Birth Control Pills: Freedom of Choice

When taken correctly, the tablets provide protection against unwanted pregnancy by more than 99%. The tablet must be taken every day for 21 days, then stopping for seven days, during which the discharge occurs, as during menstruation. After seven days, taking the pills is resumed.

You should take the tablet at the same time every day. Lack of a schedule can lead to pregnancy, and a missed dose can lead to vomiting or diarrhea.

The combination tablet may help relieve severe, painful menstruation. Minor side effects include mood swings, breast tenderness, and headaches.

There is no evidence that the pill is associated with weight gain.

The pills offer a very low risk for serious side effects such as thick blood and cervical cancer.

Combined birth control pills are not suitable for women over 35 who smoke, or for women with certain medical conditions.

The pill does not protect against sexually transmitted infections (STIs).

Combined oral contraceptives: principle of action

• suppress ovulation (maturation and release of the egg)
• promotes thickening of mucus in the cervix, making it impassable for sperm
• change the lining of the uterus, making it impossible for a fertilized egg to attach to it
• reduce the motor ability of sperm in the fallopian tubes

There are many manufacturers of pills, but the main thing you need to know is that combined oral contraceptives come in three types:

• monophasic 21 day : the most common type - each tablet contains the same amount of hormone. The dose includes 21 tablets, and then a break for 7 days. Representatives of this type are Microgynon, Brevinor, Cileste
• phase 21 day : The tablets contain two or three sections of different colored tablets per package. Each section contains different amounts of hormones. One tablet is taken every day for 21 days, then a break for 7 days. Phase tablets must be taken in the correct order. Examples are Binovum and Loginon.
• daily tablets: The package contains 21 active tablets and seven inactive (dummy) tablets. The two types of pills look different. One tablet is taken every day for 28 days without a break between packs. The tablets must be taken in the correct order. Representatives of this type are Microgynon ED and Loginon ED.

Follow the instructions that come inside the package. If you have any questions about how to take the tablet, consult your doctor or pharmacist. It is important to take the tablets as directed because taking the tablets on the wrong schedule or taking them at the same time as another medication may reduce the effectiveness of the drug.

How to take combined oral contraceptives

• Take the first tablet from the pack marked with the correct day of the week, or the first tablet of the first color (phase tablets).
• Continue taking the tablets at the same time each day until the pack runs out.
• Stop taking the tablets for 7 days (you will bleed during these seven days).
• Start the next pack of tablets on the eighth day, regardless of whether there is discharge. This should be on the same day of the week that you took your first tablet.

How to take the daily tablet:

• Take the first tablet from the section of the package marked "start". This will be the active tablet.
• Continue to take the tablets every day, in the correct order and preferably at the same time, until the pack runs out (28 days).
• During the seven days you take the inactive pills, you will have discharge.
• Start the next pack of tablets, regardless of the end of the discharge.

Most women can start taking the pill at any time during their menstrual cycle. There are special rules for those who have had a childbirth, abortion or miscarriage.

You may need to use additional contraception during the first few days on the pill, depending on what phase of your menstrual cycle you start taking it.

If you start taking the combination pill on the first day of your cycle (menstruation), you will immediately receive protection against unwanted pregnancy and will not need additional contraception.

Only in the case of a short cycle (over 23 days), if you start taking the pill before the 5th day of the cycle, protection against pregnancy also occurs immediately.
If the cycle is short, up to 23 days, you will need additional protection until the period of taking the pills is 7 days.

If you start taking the pill on any other day of your cycle, protection will not occur immediately, so you will need additional contraception until you have taken the pill for 7 days.

Taking pills without interruption

For monophasic combination pills (pills that are the same color and have the same hormone levels), it is normal to start new packaging pills immediately after the previous one has ended - for example, if you want to delay your menstruation for a trip.

However, you should not take more than two packs without a break unless recommended by your doctor. This is because you may experience unexpected bleeding because the uterine lining does not retain fluid. Some women complain of a feeling of swelling after taking several packs of pills one after another.

What to do if you miss a birth control pill

If you miss one or two tablets, or start the pack too late, this may reduce the effectiveness of the drug in preventing pregnancy. The likelihood of getting pregnant after missing a pill or pills depends on:

• when they are missed
• how many pills missed

The pill is considered "late" if you forget to take it at the usual time.

A pill is “missed” if more than 24 hours have passed since you were supposed to take it. One forgotten pill in the pack or starting a new pack a day early is not catastrophic, since you will still be protected from pregnancy (you have what is called contraceptive coverage).

However, if you miss two or more tablets, or start a new pack two or more days late (more than 48 hours), your protection may be affected.

In particular, if you extend your 7-day break by two more days, forgetting about the pill, your ovaries may release an egg and you will have a very real risk of becoming pregnant. This happens because the ovaries do not get any effect from the pill during the seven-day break.

If you miss a pill, follow the tips below. If you are unsure what to do, continue taking the pills and use another method of contraception, seeking professional advice as soon as possible.

If you miss one tablet, anywhere in the package:

• continue to take the rest of the pack at normal mode
• you do not need to use additional contraception such as condoms
• keep a seven-day break as usual

If you miss two or more tablets (you are taking next pill more than 48 hours) anywhere in the package:

• accept the last one the right pill even if it means taking two tablets in one day
• leave all the previously missed pills
• continue to take the rest of the package as usual, using an additional method of contraception for the next seven days
• you may need emergency contraception
• you may have to start the next pack without interruption

You may need it if you have had unprotected sex in the last seven days and you have missed two or more tablets in the first week of the pack.

Starting a new pack of tablets after missing two or more tablets: If there are seven or more tablets left in the pack after the last missed tablet, you should:

• finish packing
• take a regular seven-day break

If there are less than seven tablets left in the pack after the last missed tablet, you need to:

• finish the pack and start a new one the next day, without interruption

If you vomit within two hours of taking combined birth control pills, the drug is not completely absorbed into your bloodstream. Take another tablet immediately and the next one at your usual time.

If you still feel unwell, continue using another form of contraception while you feel discomfort and illness, and for two days after you have recovered.

Very severe diarrhea (six to eight watery stools in 24 hours) may also mean that the pill is not working properly. Continue to take the pills as usual, but use additional contraception such as , and for two days after recovery.

For more information, or if your symptoms continue, it is best to talk to your doctor.

Combined oral contraceptives: contraindications

• pregnant
• smoke and you are over 35 years old
• Quit smoking less than a year ago and you are now 35 or older
• are extremely overweight
• are taking certain medications (consultation with a doctor is required)
• thrombosis (thick blood)
• cardiac pathology or heart disease, including high blood pressure
• severe migraines, especially with aura (alarming symptoms)
• mammary cancer
• gallbladder or liver disease
• diabetes mellitus with complications or diabetes within the last 20 years

Taking combined oral contraceptives after childbirth

If you have just given birth and are not breastfeeding, you can start taking the pill on the 21st day after giving birth. Protection against pregnancy occurs immediately. If you start taking the pill later than 21 days after giving birth, you will need additional contraception (such as a condom) for the next seven days.

If you are breastfeeding a baby less than 6 months old, taking the pills may reduce your milk flow. It is recommended to use another method of contraception until you stop breastfeeding.

Taking combined oral contraceptives after miscarriage or abortion

If you have had a miscarriage or abortion, you can start taking the pills after up to five days for immediate protection. If you start taking the pill more than five days after a miscarriage or abortion, you will need to use additional contraception until you have been on the pill for seven days.

Combined oral contraceptives: benefits

• The pill does not interrupt sex
• Installs regular cycle, menstruation becomes lighter and less painful
• Reduces the risk of developing ovarian, uterine and colon cancer
• May reduce PMS symptoms
• May sometimes have an effect on reducing rashes and acne
• Can protect against inflammatory diseases pelvic organs
• May reduce the risk of fibroids and non-cancerous breast diseases

Combined oral contraceptives: disadvantages

• May cause side effects such as headaches, nausea, breast tenderness and mood swings - if these do not go away after a few months, you may need to change your medication
• May increase blood pressure
• Does not protect against sexually transmitted infections
• Causes sudden bleeding and bloody issues which often occur during the first few months of using the tablet
• The pill has been linked to an increased risk of developing certain serious illnesses, such as thrombosis (thick blood) and breast cancer.

Combined oral contraceptives: combination with medications

Some medications interact with the combination pill in such a way that it may not continue to work properly. You should always ask your doctor about the compatibility of the drug with other drugs, and also carefully read the instructions in the package yourself.

Antibiotics

The antibiotics rifampicin and rifabutin (which may be used to treat diseases such as tuberculosis and meningitis) may cause the combination pills to be less effective. Other antibiotics do not have this effect.

If you are prescribed rifampicin or rifabutin, you may need additional contraception (such as condoms).

Epilepsy, HIV medications and St. John's wort

Combination tablets may interact with enzyme-inducing drugs. These drugs speed up the breakdown of progestogen in the liver, reducing the effectiveness of the pill.

Examples of such drugs are:

• drugs used in the treatment of epilepsy - carbamazepine, oxcarbazepine, phenytoin, phenobarbital, primidone and topiramate
• St. John's wort (herbal remedy)

• antiretroviral drugs used to treat HIV infection (research suggests that interactions between these drugs and progestogen-only pills may affect the safety and effectiveness of both)

Your doctor may prescribe an alternative or additional form of contraception while taking any of these medications.

Combined oral contraceptives: dangers

There are some risks associated with using combined birth control pills. However, these risks are small and, for most women, the benefits of the pill outweigh the possible risks.

Thick blood

The estrogen in the pill may make the blood more willing to clot. If thick blood disease develops, it can cause deep vein thrombosis (blood clots in the leg), embolism pulmonary artery(blood clots in the lung), stroke or heart attack.

The risk of getting a blood clot is very small, but before prescribing, your doctor should check if you have certain risk factors that make you more vulnerable to this disease.

The tablets should be taken with caution if you have one of the risk factors listed below. If you have more than two risk factors, you should not take the pills at all.

• You are over 35 years old
• Do you smoke or quit smoking in the past year?
• you have excessive overweight(in women with a BMI of 35 or more, the risks of using the pill usually outweigh the benefits)
• Having migraines (you should not take the tablets if you have severe or regular migraines, especially if they have an aura or warning sign before the attack)
• High blood pressure
• Medical history: blood clot or stroke
• Availability close relative, who had a blood clot before age 45
• Being immobile for long periods of time - such as sitting in a wheelchair or with a leg in a cast

Research to establish a connection between and the tablet is still ongoing. Today they show that users of all types hormonal contraception are slightly more likely to be diagnosed with breast cancer compared to women who do not use them.

However, 10 years after you stop taking the pill, your risk of developing breast cancer returns to normal.

Research is also trying to establish or disprove a link between the pills and the risk of cervical cancer and a rare form of liver cancer. However, the tablets do provide some protection against the development of endometrial (lining of the uterus) cancer, ovarian cancer and colon cancer.

57. Hormonal methods contraception. Mechanism of action. Classification by composition and methods of application. Contraindications. Complications.

Classification of hormonal methods of contraception

Combined estrogen-progestin contraceptives:

Oral: Monophasic , Two-phase , Three-phase

Parenteral: NovaRing vaginal ring, Evra transdermal contraceptive system

Purely progestogen contraceptives:

Oral: Mini-pills (Microlut, Exluton, Charozetta)

Parenteral: Levonorgestrel implants Normplant, Medroxyprogesterone injections, Intrauterine hormonal system with levonorgestrel Mirena

COMBINED ORAL CONTRACEPTIVES

Each tablet contains estrogen (ethinyl estradiol) and progestogen (synthetic progestins).

Mechanism of contraceptive action of COCs:

●suppression of ovulation; ●thickening of cervical mucus;

●changes in the endometrium that prevent implantation.

Contraceptive effect - progestogen component. Ethinyl estradiol - supports

proliferation of the endometrium and ensures cycle control (no intermediate bleeding when taking COCs), is necessary for replacing endogenous estradiol, because When taking COCs, there is no follicle growth and estradiol is not produced in the ovaries.

pharmacological effects

Synthetic progestogens cause secretory transformation estrogen-stimulated (proliferative) endometrium.

Have antiandrogenic and antimineralocorticoid effects

Progestogens. Based on the severity of androgenic properties, progestogens can be divided into:

●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).

Clinically, the antiandrogenic effect leads to a reduction in androgen-dependent symptoms - acne, seborrhea, hirsutism.

Side effects of combined oral contraceptives.

More often - in the first months of taking COCs (in 10–40% of women)

Excessive estrogen influence: headache, increased blood pressure, irritability, nausea, vomiting, dizziness, mastodynia, chloasma, deterioration of varicose veins, deterioration of tolerance to contact lenses, weight gain.

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, worsening varicose veins, weight gain.

Insufficient progestogenic effect: heavy menstruation, intermenstrual bleeding in the second half of the cycle, delayed menstruation.

Serious complications are thrombosis and thromboembolism.

Contraindications to the use of combined oral contraceptives

●deep vein thrombosis, pulmonary embolism (including history), ●coronary heart disease, stroke; ●arterial hypertension.

●a combination of factors for the development of cardiovascular diseases (age over 35 years, smoking, diabetes, hypertension); ●liver diseases; ●lactation in the first 6 weeks after birth

●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;●pregnancy.

Fertility restoration

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.

Rules for taking 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”). 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.

ORAL CONTRACEPTIVES CONTAINING PROGESTAGEN ONLY (MINIPILES) contain only microdoses of progestogens (300–500 mcg), which is 15–30% of the progestogen dose in combined estrogen-progestogen preparations.

Mechanism:

●cervical factor ●uterine factor ●tubal factor ●central factor.

The main drugs of the class include Microlut©, Exluton©, Charozettau©. Take continuously at the same time of day, starting from the 1st day of the menstrual cycle.

After childbirth, if a woman is breastfeeding, the drug should be taken 6–8 weeks after the birth of the child.

Contraindications the same as when prescribing COCs.

Side effects:

●menstrual cycle disorders; ●nausea, vomiting; ●depression; ●increase in body weight;

●decreased libido; ●headache, dizziness ●breast engorgement.

PARENTERAL DRUGS

Classification

●Injections - medroxyprogesterone. ●Implants - desogestrel.

●Transdermal contraceptive system.

●Intrauterine hormonal system that secretes levonorgestrel (Mirena©).

●Vaginal ring - etonogestrel + ethinyl estradiol (NovaRing©).

INJECTION DRUGS (DEPO DRUGS)

Mechanism of action:

●suppression of ovulation; ●thickening of cervical mucus

●changes in the structure of the endometrium, which complicates implantation;

●decreased contractile activity of the fallopian tubes.

Advantages of injectable contraceptives:

●long action; ●ease of use;

●high reliability (no user errors).

Disadvantages of injectable contraceptives:

●delayed restoration of fertility;

●impossibility to stop contraceptive protection at any time desired by the patient;

●the need for regular visits to the clinic for repeated injections.

SUBCUTANEOUS IMPLANTS (CAPSULES)

Mechanism of action: ●suppression of ovulation ●effect on the endometrium

●change in the consistency of cervical mucus

●suggest the possibility of levonorgestrel influencing the activity of enzymes involved in the process of sperm penetration into the egg.

TRANSDERMAL CONTRACEPTIVE SYSTEM EURA

The Evra transdermal contraceptive system is a combined estrogen-progestogen contraceptive. Evra is a thin beige patch, each patch contains 600 mcg ethinyl estradiol and 6 mg norelgestromin. 150 mcg of norelgestromin and 20 mcg of ethinyl estradiol enter the systemic circulation per day.

During one menstrual cycle - 3 patches, each for 7 days. The patch must be replaced on the same day of the week. Then there is a 7-day break, during which a menstrual-like reaction occurs. The mechanism is similar to that of COCs.

Advantages of the patch:

●ease of use; ●release of minimal doses of hormones;

●lack of the effect of primary passage through the liver and gastrointestinal tract;

●quick restoration of fertility after withdrawal;

●possibility of use in women of different ages;

●possibility of independent use (without the participation of medical personnel);

●small number of side effects.

Disadvantages of the patch:

●sometimes the patch may come off, it can be washed off with water, etc.;

●if the loss of the patch is not noticed by the woman within 48 hours, pregnancy may occur;

●limited number of body areas to which the patch can be applied;

●possibility of local adverse reactions.

HORMONE-CONTAINING IUDs

Mirena is a levonorgestrel-releasing system that combines high contraceptive effectiveness and the therapeutic properties of hormonal contraceptives (COCs and subcutaneous implants). The shelf life of Mirena is 5 years.

Mechanism of action - a combination of the mechanisms of action of the IUD and levonorgestrel, due to which:

●the functional activity of the endometrium is suppressed: endometrial proliferation is inhibited, atrophy of the endometrial glands develops, pseudodecidual transformation of the stroma and vascular changes, which prevents implantation;

●motility of sperm in the uterine cavity and fallopian tubes decreases.

Advantages of the method:

●reliable contraceptive effect; ●high safety;

●reversibility of the contraceptive effect (fertility is restored after 6–24 months);●lack of connection with sexual intercourse and the need for self-control;

●reduction of menstrual blood loss (in 82–96% of patients);

●therapeutic effect for idiopathic menorrhagia;

●possibility of use for small MMs.

Contraindications to the use of Mirena © :

●acute thrombophlebitis or thromboembolic conditions;●breast cancer;

●acute hepatitis;●severe liver cirrhosis, liver tumors;

●ischemic heart disease; ●general contraindications to the use of IUDs.

Side effects and complications when using Mirena ©:

●during the first 3–4 months - systemic effects - changes in mood, headache, mastalgia, nausea, acne; ●possible development of functional ovarian cysts

●possible menstrual cycle disorders: ♦acyclic uterine bleeding

♦oligo and amenorrhea develop in 20% of cases

HORMONE-CONTAINING VAGINAL CONTRACEPTIVE RING NOVARING The vaginal route of hormone administration is used.

15 mcg of ethinyl estradiol and 120 mcg of etonogestrel, which are the active metabolite of desogestrel, are released from the ring per day.

The vaginal route of administration allows you to achieve significant advantages: stable hormonal levels; lack of primary passage through the liver and gastrointestinal tract.

mechanism of action - suppression of ovulation. In addition, it causes an increase in the viscosity of cervical mucus.

Each ring is intended for use during one menstrual cycle. The woman inserts and removes it herself, insert it from the 1st to the 5th day of the menstrual cycle, for 3 weeks into the vagina, then remove it and take a 7-day break, then the next ring. During the first 7 days of using the vaginal ring, you must use a condom. Adverse reactions and contraindications similar to COCs and transdermal systems.

EMERGENCY CONTRACEPTION

a method of preventing pregnancy after unprotected intercourse.

Mechanism - suppression or delay of ovulation, disruption of the fertilization process, egg transport and blastocyst implantation.

The effect is possible when used within the first 24–72 hours after unprotected sexual intercourse.

Currently used for emergency contraception:

●KOK; ●progestogens; ●copper-containing VMC.

USPE METHOD

Twice doses of 100 mcg ethinyl estradiol and 0.5 mg levonorgestrel. The first dose must be taken within 72 hours after unprotected sexual intercourse. The second - 12 hours after the first dose.

For the purpose of emergency contraception, almost all modern contraception can be used. COOK in appropriate doses: 8 tablets of a low-dose COC (containing 30-35 mcg ethinyl estradiol), taken in two doses with a 12-hour interval, or 4 tablets of a high-dose COC (containing 50 mcg ethinyl estradiol), also taken in two doses with a 12-hour interval.

Contraindications- pregnancy, as well as conditions in which estrogens are contraindicated (history of thromboembolism, severe liver disease, bleeding of unknown etiology, breast and endometrial cancer).

Side effects : nausea (51%), vomiting (19%), mastalgia, bleeding.

EMERGENCY CONTRACEPTION WITH PROGESTAGENS they use the drug postinor©, containing 0.75 mg of levonorgestrel in one tablet, and escapelle©, containing 1.5 mg of levonorgestrel in one tablet.

Use 2 tablets of Postinor©: the first tablet within 48 hours after unprotected sexual intercourse, the second - after 12 hours. Escapelle© - once no later than 72 hours after unprotected sexual intercourse.

EMERGENCY CONTRACEPTION USING COPPER-CONTAINING INTRAUTERINE DEVICES

For this purpose, an IUD is inserted into the uterus within 5 days after unprotected sexual intercourse. This method not indicated for nulliparous women, as well as for patients with a high risk of developing inflammatory diseases of the genital organs, primarily STIs, increased risk which occurs when there are a large number of sexual partners and casual sexual relationships.

Today, every couple can plan to have children and control their sex life thanks to the pharmaceutical industry. A huge selection of contraceptives allows you to choose suitable method protection against pregnancy and/or sexually transmitted infections.

Coitus interruptus

The most unreliable options for preventing pregnancy are interrupted sexual intercourse and the calendar method. In general, PPA can hardly be called a method of contraception. The essence of the method is to remove the penis before ejaculation begins.

In 60% of couples who use PPA protection, pregnancy occurs in the first year of using the method. And according to statistics, 80% of women who became pregnant “accidentally” were protected by interrupted sexual intercourse. The problem is that not all men feel the onset of ejaculation. One “wrong” move, and the likelihood of getting pregnant increases significantly.

Calendar method

The method is slightly more effective than the previous one - 65%. For every hundred women who take the risk of using this method, there are 10-15 pregnancies per year. This method becomes more relevant after 30 than for young girls. Only girls and women with a regular menstrual cycle can afford to protect themselves in this way.

The essence of the method is to calculate the so-called dangerous days and do not have sex during this period. In general, from the 16th day until the expected start of the next period, the probability of conception is greatest. The most dangerous days fall in the middle of the cycle - from the 12th to the 18th day of the cycle (with a 28-day cycle).

Cons: errors, irregular cycle, in which it is almost impossible to accurately calculate the day of ovulation, hormonal imbalances. There are other nuances - if sexual intercourse occurred several days before the expected ovulation, sperm can live in the genital tract for several days and fertilize the egg even after such a seemingly long time. To increase the reliability of this method of contraception, you need to learn how to correctly calculate dangerous days. Besides calendar method you can use ovulation test strips or monitor basal temperature charts.

Spermicides and non-hormonal tablets

Another not very effective method (70% reliability) is spermicides. These are special substances that are introduced into the vagina and negatively affect sperm, after which they can no longer fertilize. female egg. Products with a similar mechanism of action are sold in pharmacies in the form of suppositories, creams, capsules or tablets, which are administered directly orally before sex.

Such non-hormonal ones (which ones are better to choose, reviews of different types below) are used by many women who, for one reason or another, are afraid to take conventional OCs (oral contraceptives). Such non-hormonal tablets are recommended for use in premenopausal women and patients with impaired functioning endocrine system, individual sensitivity and adverse reactions to conventional OCs. What is important, these can be used during breastfeeding (breastfeeding).

How to choose non-hormonal contraceptives? The ranking of the best is presented by the following tablets:

1. "Pharmatex". Available in the form of tablets, cream and suppositories. The average price of a package of 12 tablets is 250 rubles.
2. "Gynekotex". The same release form, price - 100 rubles for the same 12 tablets.
3. "Benatex". The cost of 10 tablets is 250-300 rubles.
4. "Erotex". Price 5 pcs. - 110 rubles.
5. "Contratex".

How to choose tablets? It is advisable to consult a doctor; otherwise, you should rely on your personal feelings when using it. Some pills, for example, cause itching in some women, which goes away when they switch to a different brand of medication.

Barrier contraception

Barrier methods protect not only from conception and unwanted pregnancy, but also from infections transmitted through sexual contact. But the reliability of such means is not 100% (moreover, no contraceptive means is 100% reliable, except complete abstinence from any sexual intercourse), but is only about 85%. Barrier methods include the use of condoms, but they can also break, and then all efforts will go in vain and blur the sensations of sexual intercourse.

Hormonal patches and ring

Other non-invasive methods include patches and hormonal rings. The effectiveness of such products reaches 92%. The patch adheres to the skin, but it is noticeable, requires regular replacement and is not suitable for use by women weighing more than 90 kg. The ring is inserted into the vagina, but also has disadvantages: in some cases it can cause a change in character menstrual bleeding and disrupt the regularity of menstruation. These methods do not have additional contraceptive effects, such as treating acne, relieving PMS symptoms or preventing seborrhea.

Implants and injections

Hormonal implants and injections are essentially the same oral contraceptives, i.e. birth control pills, only with a different mechanism of action. If substances from tablets are absorbed through digestive tract, then injectable contraceptives are administered intramuscularly. The frequency of injections is once a month or every three months. Implants are inserted into the shoulder and require replacement only once every five years. The effectiveness of the methods is 90-99%.

Such contraception, however, can cause migraines, changes in the menstrual cycle, hormonal imbalances, decreased sex drive or weight gain. Injections and implants, as a rule, are not used by young women who have not yet given birth; this method of contraception is more suitable for women between thirty and forty years old who do not plan to have a child in the near future.

Intrauterine device

The second most effective method of contraception after birth control pills is the intrauterine device. The method also refers to the barrier method, only the spiral is installed in the uterine cavity, preventing the embryo from fixing. But installing an IUD can cause changes in the nature of menstruation, sometimes causes pain, and increases the risk of developing various inflammations and the occurrence of an ectopic pregnancy.

Oral contraceptives

Oral contraceptives protect against unwanted pregnancy, but not against diseases transmitted through sexual contact. The newest birth control pills also have an additional effect: many drugs contain the active form of folic acid, so they relieve PMS symptoms, have an antidepressant effect, help fight acne, and improve the condition of the skin and hair. The reliability of OCs is 99.7%, but this method of contraception requires prior consultation with a gynecologist and the woman’s attentiveness and organization when taking it. It is this method of planned contraception that will be discussed further.

Classification of OK according to hormone content

All birth control pills are divided into 2 large groups: combined oral contraceptives (COCs) and mini-pills. COCs contain an estrogen analogue and a progestogen. The mechanism of action of such tablets is that they block the onset of ovulation (the maturation of the egg and its readiness for conception), make implantation of the egg into the uterine cavity impossible due to “glandular regression” and thicken the mucus, which disrupts the movement of sperm to the female reproductive cell.

COCs are divided into groups according to the variation of hormones and their content. Thus, there are monophasic, two- and three-phase tablets (more about them below), as well as micro-dose, low-dose and high-dose COCs. Microdosed OCs are suitable for young girls, since the content of active substances in the tablets is minimal. The rating of birth control pills of this type is presented as follows:

1. "Jess."
2. "Marvelon".
3. "Klayra" (the only three-phase tablets in the list of microdosed ones).
4. "Dimia."
5. "Zoeli."
6. "Logest".
7. "Mersilon".
8. "Lindynet."
9. "Novinet."

Low-dose OCs are suitable for both young and more mature women; they can be used by those patients who experience intermenstrual bleeding when using microdosed tablets. These birth control pills are suitable for women who have given birth. In addition, low-dose OCs prevent hair growth in unwanted places, eliminate increased fat content skin and acne, reduce the manifestations of seborrhea.

1. "Yarina.
2. Tablets "Janine".
3. "Silhouette".
4. "Diana."
5. Femoden tablets.
6. "Tri-mercy."
7. "Lindynet."
8. Tablets "Silest".
9. "Miniziston" and others.

High-dose OCs can be taken only on the recommendation of a gynecologist. Such drugs are generally used for therapeutic purposes (for the treatment of endometriosis, hormonal disorders and other diseases). In the rating of birth control pills with a high concentration of hormones, the following are OK:

1. "Non-Ovlon."
2. "Trikivlar."
3. "Ovidon".
4. "Triseston".
5. "Tri-Regol."

Another type of contraceptives - mini-pills - contains only progestogen. On reproductive system mini-pills have an effect only at the local level:

• increase the viscosity and amount of cervical mucus, which interferes with the free movement of sperm;
• change the biochemical and morphological structure of the uterine endometrium, which makes it impossible for the embryo to attach even in the event of fertilization.

Mini-pills completely block ovulation in only half of women, but this does not affect the reliability of the pills as a method of birth control.

1. "Charozetta" (800 rubles per package).
2. "Laktinet" (530 rub.).
3. "Orgametril" (1100 rub.).
4. "Exluton" (1250 rub.).

There is also emergency contraception, which is used if unprotected sex occurs, which can lead to pregnancy. These birth control pills are taken within 72 hours after sex. A common example of this type of OC is Postinor. You need to take birth control pills within 72 hours after sexual intercourse, otherwise emergency contraception will not have any effect. Such drugs cannot be used constantly.

Monophasic, two- and three-phase drugs

COCs also differ in variations in hormone content, being divided into monophasic, biphasic and triphasic. In monophasic tablets, the percentages of substances do not change in each tablet; in biphasic tablets, the ratio of active components changes in the first and second halves of the cycle; in three-phase tablets, percentage substances are changed three times per package.

Monophasic birth control pills:

• "Regulon";
• "Rigevidon";
• "Janine";
• "Silhouette";
• "Lindynet";
• "Logest";
• "Femoden";
• "Mikrogynon" and others.

Two-phase OK:

• "Femoston";
• "Binovum";
• "Bifazil";
• "Adepal";
• "Anteovin" and others.

Three-phase are represented by the drugs "Tri-Mercy", "Triziston", "Tri-Regol" and others.

How to choose the right birth control pills

You cannot choose birth control pills on your own or even with the help of a pharmacist at a pharmacy. To pick up suitable remedy contraception, you should definitely go to the doctor. The gynecologist will interview the patient, find out if there are any diseases (whether they were in the past) and which ones, and conduct an examination. During the examination, the gynecologist will measure the patient’s weight, blood pressure, assess the condition of the skin, palpate the breasts and prescribe tests. You may also need to visit an ophthalmologist, since long-term use of OCs increases the risk of various eye diseases.

The doctor chooses the tablets that are best suited for the patient depending on the phenotype. The phenotype takes into account the woman’s height and appearance, mammary glands, degree of hair growth, condition of the skin, hair, existing chronic diseases, the nature and frequency of menstruation, the presence and severity of PMS, and so on.

There are three main phenotypes:

1. Women of short or medium height whose skin and hair are prone to dryness. Menstruation is heavy and prolonged, the cycle is more than 28 days. Medium- and high-dose COCs are suitable for such patients, for example, Milvane, Triziston, Femoden and others.
2. Women of average height, with hair and skin of normal oil content, with medium-sized breasts. This type of woman does not have PMS symptoms or they do not cause negative, painful feelings. The menstrual cycle is standard - 5 days, every 28 days. Suitable tablets are Marvelon, Regulon, Tri-Mercy, Silest, Logest, Tri-Regol and others (most COCs on the market).
3. Women who are different tall, underdeveloped mammary glands, oily hair and skin. Menstruation is frequent and painful, but scanty, and PMS symptoms are often severe. Tablets "Yarina", "Jess", "Zoeli", "Dimia" are suitable.

Rating of oral contraceptives

Oral contraceptives are too diverse to form an overall rating. But still, the recommendations of gynecologists and reviews of patients allow us to identify several of the best COCs of the new generation. The rating of birth control pills is represented by the following drugs:

1. "Jess." They not only perform a direct function, i.e. they protect against unwanted pregnancy, but also treat a number of gynecological diseases, hormone dependence, improve the condition of the skin and hair, reduce the symptoms of PMS and ease painful periods. How to take birth control pills "Jess"? According to the instructions, you need to start taking it on the first day of your period, pink pills need to be taken every day, and on the 28th day - take white (placebo). After the end of the cycle, start the next package.
2. "Jess Plus". The same "Jess", only it also includes active form folic acid, which normalizes the psycho-emotional state and allows you to avoid unpleasant consequences if pregnancy does occur: the body will be ready to bear a child, despite taking pills. If the patient decides to stop taking OCs in order to become pregnant, planning can begin already in the next cycle after discontinuation. In addition, "Jess Plus" is a birth control pill that does not make you fat. The latter is confirmed by patient reviews.
3. Tablets "Janine". According to girls and women who took "Zhanine", this drug somewhat reduces sexual desire, but is reliable. In addition, "Janine" is a birth control pill that does not make you fat, as proven by many reviews.
4. "Marvelon". OK are recommended for use by women after 25-35 years of age who are in childbearing age, but have already given birth. The hormone content is minimal, but the tablets are suitable for patients who are active sex life. Like other OCs, Marvelon improves the appearance, condition of the skin and hair, and normalizes hormonal balance and reduces hair growth in unwanted places.
5. "Regulon", instructions for use, price, reviews of which are of interest to many women, costs about 1,150 rubles (63 tables). You need to take the pills daily, from the first to the twenty-first day of the cycle. This is followed by a seven-day break. After the break, you need to start taking Regulon again, even if your periods have not stopped yet. Instructions for use, price, reviews must be studied before purchasing. The opinions of patients are contradictory: some women became irritable and gained weight, noted a significant deterioration in their health and disruption of the menstrual cycle, others were completely satisfied with the drug, while other OCs were not suitable for them.
6. "Depo-Provera". The tablets are recommended for women over forty years of age and can be used in the treatment of various gynecological diseases. There are injections - doctors say that Depo-Provera is much more effective this way than in tablet form.
7. "Pharmatex". This is a non-hormonal contraceptive that is inserted directly into the vagina in the form of suppositories. It is recommended to use Pharmatex for women over 45 years of age who are sexually active.
8. "Yarina". The drug is low-dose and has an antiadrogenic effect. Some patients claim that they managed to get pregnant while taking Yarina strictly according to the instructions. How to take birth control pills "Yarina"? You need to drink OK every day, starting from the 1st day of the cycle, in the order indicated on the blister.
9. "Laktinet" is not combined agents, but mini-pills, which have a number of contraindications, so you should definitely consult a doctor before you start taking them. The tablets are suitable for women over 45 years of age, patients with diabetes mellitus, varicose veins, smokers, and breastfeeding patients.
10. Birth control pills "Silhouette". Many patients note a visible improvement in the appearance of their skin and hair, stabilization of the menstrual cycle, and a decrease in pain during menstruation and PMS symptoms. But Silhouette birth control pills can cause weight gain - about half of women complain about this side effect.

Side effects of taking contraception

A reliable, safe (if you consult a gynecologist before taking it) and convenient method of contraception is birth control pills. There are, however, side effects too. Among them:

• nausea;
• absence of menstruation;
• lack of appetite;
• weight gain;
• uncharacteristic discharge between periods;
• dizziness, headaches;
• decreased libido;
• swelling of the legs;
• painful sensations in the chest.

If side effects occur, contraceptive pills are discontinued.

Contraindications for use

Contraindications to taking OCs include:

• hypertension;
• kidney pathologies;
• pregnancy;
• serious diseases of the cardiovascular system;
• migraine of unknown origin;
• preparation for surgical intervention;
• overweight (more than 30%);
• smoking after 35 years (for some tablets this fact is not a contraindication - a mandatory consultation with a doctor is required);
• diabetes mellitus (you can use some OCs) and so on.

Whether to take birth control pills is a personal choice for each woman. This is a reliable means of contraception that is convenient to use for those who are sexually active. At the same time, there are a number of side effects that occur if you choose the wrong remedy. So, the main thing to be guided by when choosing and taking birth control pills is the recommendations of a gynecologist.

Combination pills (combined oral contraceptives - COCs) are the most widely used form of hormonal contraception.

Based on the content of the estrogen component in the tablet in the form of ethinyl estradiol (EE), these drugs are divided into high-dose, containing more than 40 meg of EE, and low-dose - 35 meg or less of EE. In monophasic preparations, the content of estrogen and gestagen components in the tablet remains unchanged throughout the menstrual cycle. IN biphasic tablets in the second phase of the cycle, the content of the gestagen component increases. In three-phase COCs, the dose of gestagen is increased stepwise in three stages, and the dose of EE increases in the middle of the cycle and remains unchanged at the beginning and end of the dose. The variable content of sex steroids in two- and three-phase preparations throughout the cycle made it possible to reduce the total course dose of hormones.

Combined oral contraceptives are highly effective reversible means of preventing pregnancy. The Pearl index (IP) of modern COCs is 0.05-1.0 and depends mainly on compliance with the rules for taking the drug.

Each combined oral contraceptive (COC) tablet contains estrogen and progestogen. Synthetic estrogen, ethinyl estradiol (EE), is used as the estrogenic component of COCs, and various synthetic progestogens (synonymous with progestins) are used as progestogen components.

Progestin contraceptives contain only one sex steroid - gestagen, which provides a contraceptive effect.

Benefits of combined oral contraceptives

Contraceptive

• High efficiency when taken daily IP = 0.05-1.0
• Quick effect
• Lack of connection with sexual intercourse
• Few side effects
• The method is easy to use
• The patient can stop taking it herself.

Non-contraceptive

• Reduce menstrual bleeding
• Reduce menstrual pain
• May reduce the severity of anemia
• May help establish a regular cycle
• Prevention of ovarian and endometrial cancer
• Reduce the risk of developing benign breast tumors and ovarian cysts
• Protects against ectopic pregnancy
• Provide some protection against pelvic inflammatory disease
• Provides prevention of osteoporosis

Currently, COCs are very popular all over the world due to the benefits that are listed below.

• High contraceptive reliability.
• Good tolerance.
• Availability and ease of use.
• Lack of connection with sexual intercourse.
• Adequate control of the menstrual cycle.
• Reversibility ( full recovery fertility for 1–12 months after discontinuation).
• Safe for most somatically healthy women.
• Therapeutic effects:
  • regulation of the menstrual cycle;
  • elimination or reduction of dysmenorrhea;
  • reduction of menstrual blood loss and, as a result, treatment and prevention of iron deficiency anemia;
  • elimination of ovulatory pain;
  • reducing the incidence of inflammatory diseases of the pelvic organs;
  • therapeutic effect for premenstrual syndrome;
  • therapeutic effect in hyperandrogenic conditions.
• Preventive effects:
  • reducing the risk of developing endometrial and ovarian cancer, colorectal cancer;
  • reducing the risk of benign breast tumors;
  • reducing the risk of developing iron deficiency anemia;
  • reducing the risk of ectopic pregnancy.
• Removing the “fear of unwanted pregnancy.”
• Possibility of “delay” next menstruation, for example, during exams, competitions, rest.
• Emergency contraception.

Types and composition of modern combined oral contraceptives

Based on the daily dose of the estrogen component, COCs are divided into high-dose, low-dose and micro-dose:

• high-dose - 50 mcg EE/day;
• low-dose - no more than 30–35 mcg EE/day;
• microdosed, containing microdoses of EE, 15–20 mcg/day.

Depending on the combination regimen of estrogen and progestogen, COCs are divided into:

• monophasic - 21 tablets with a constant dose of estrogen and progestogen for 1 cycle of administration;
• biphasic - two types of tablets with different ratios of estrogen and progestogen;
• triphasic - three types of tablets with different ratios of estrogen and progestogen. The main idea of ​​three-phase is a reduction in the total (cyclic) dose of progestogen due to a three-step increase in its dose during the cycle. Moreover, in the first group of tablets the dose of progestogen is very low - approximately the same as in a monophasic COC; in the middle of the cycle the dose increases slightly and only in last group tablets corresponds to the dose in a monophasic preparation. Reliable suppression of ovulation is achieved by increasing the dose of estrogen at the beginning or middle of the dosing cycle. Number of tablets different phases varies between drugs;
• multiphase - 21 tablets with a variable ratio of estrogen and progestogen in tablets of one cycle (one package).

Currently, low- and micro-dose drugs should be used for contraception. High-dose COCs can be used for routine contraception only for a short time (if it is necessary to increase the dose of estrogen). In addition, they are used for medicinal purposes and for emergency contraception.

Mechanism of contraceptive action of combined oral contraceptives

• Suppression of ovulation.
• Thickening of cervical mucus.
• Endometrial changes that prevent implantation. The mechanism of action of COCs is generally the same for all drugs; it does not depend on the composition of the drug, the dose of components and phase. The contraceptive effect of COCs is provided mainly by the progestogen component. EE contained in COCs supports endometrial proliferation and thereby ensures cycle control (no intermediate bleeding when taking COCs). In addition, EE is necessary to replace endogenous estradiol, since when taking COCs there is no follicular growth and, therefore, estradiol is not secreted in the ovaries.

Classification and pharmacological effects

Chemical synthetic progestogens are steroids and are classified according to their origin. The table shows only progestogens included in hormonal contraceptives registered in Russia.

Classification of progestogens

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 progesterone receptors. In addition to their effect on the endometrium, synthetic progestogens also act on other target organs of progesterone. The differences between synthetic progestogens and natural progesterone are as follows.

• Higher affinity for progesterone receptors and, as a result, a more pronounced progestogenic effect. Due to their high affinity for progesterone receptors in the hypothalamic-pituitary region, synthetic progestogens in low doses cause a negative effect feedback and block the release of gonadotropins and ovulation. This underlies their use for oral contraception.
• Interaction with receptors for some other steroid hormones: androgens, gluco- and mineralocorticoids - and the presence of corresponding hormonal effects. These effects are relatively weakly expressed and are therefore called residual (partial or partial). Synthetic progestogens differ in the spectrum (set) of these effects; some progestogens block receptors and have a corresponding antihormonal effect. For oral contraception, the antiandrogenic and antimineralocorticoid effects of progestogens are favorable; the androgenic effect is undesirable.

Clinical significance of individual pharmacological effects of progestogens

A pronounced residual androgenic effect is undesirable, as it can cause:

• androgen-dependent symptoms - acne, seborrhea;
• a change in the spectrum of lipoproteins towards the predominance of low-density fractions: low-density lipoproteins (LDL) and very low-density lipoproteins, since the synthesis of apolipoproteins and the destruction of LDL are inhibited in the liver (an effect opposite to the influence of estrogens);
• worsening carbohydrate tolerance;
• increase in body weight due to anabolic effects.

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

• Highly androgenic progestogens (norethisterone, linestrenol, ethynodiol diacetate).
• 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, gestodene, desogestrel, norgestimate, medroxy-progesterone). The androgenic properties of these progestogens are detected only in pharmacological tests and in most cases have no clinical significance. WHO recommends the use of oral contraceptives with low androgenic progestogens.

The antiandrogenic effect of cyproterone, dienogest and drospirenone, as well as chlormadinone, is of clinical significance. Clinically, the antiandrogenic effect is manifested in 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 polycystic ovary syndrome (PCOS), idiopathic androgenization and some other conditions.

Severity of antiandrogenic effect (according to pharmacological tests):

• cyproterone - 100%;
• dienogest - 40%;
• drospirenone - 30%;
• chlormadinone - 15%.

Thus, all progestogens included in COCs can be ranked in accordance with the severity of their residual androgenic and antiandrogenic effects.

Taking COCs should start on the 1st day of the menstrual cycle; after taking 21 tablets, take a 7-day break or (with 28 tablets per package) take 7 placebo tablets.

Rules for missed pills

Currently accepted following rules regarding missed pills. In cases where less than 12 hours have passed, it is necessary to take the tablet at the time when the woman remembered to miss the dose, and then the next tablet at the usual time. This does not require additional measures precautions. If more than 12 hours have passed since the missed date, you must do the same, but within 7 days take additional measures to prevent pregnancy. In cases where two or more tablets are missed in a row, you should take two tablets per day until you return to your regular schedule, using additional methods of contraception for 7 days. If bleeding begins after missing pills, it is better to stop taking the pills and start a new pack after 7 days (counting from the start of missing pills). If you miss even one of the last seven hormone-containing tablets, the next package must be started without a seven-day break.

Rules for changing medications

The transition from higher-dose drugs to low-dose drugs is carried out with the start of taking low-dose COCs without a seven-day break on the day after the end of the 21st day of taking high-dose contraceptives. Replacement of low-dose drugs with high-dose ones occurs after a seven-day break.

Symptoms of possible complications when using COCs

• Severe chest pain or shortness of breath
• Severe headaches or blurred vision
• Severe pain in the lower extremities
• Complete absence of any bleeding or discharge during a pill-free week (pack of 21 tablets) or while taking 7 inactive pills (from a 28-day pack)

If any of the above symptoms occur, urgent consultation with a doctor is required!

Disadvantages of combined oral contraceptives

• The method depends on the users (requires motivation and discipline)
• Possible nausea, dizziness, breast tenderness, headaches, as well as spotting or moderate bleeding from the genital tract and mid-cycle
• The effectiveness of the method may decrease if simultaneous administration some medications
• Thrombolytic complications are possible, although very rare.
• The need to replenish the contraceptive supply
• Does not protect against STDs, including hepatitis and HIV infection

Contraindications to the use of combined oral contraceptives

Absolute contraindications

• 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 mmHg. Art. and above and/or diastolic blood pressure 100 mmHg. Art. and higher and/or with the presence of angiopathy.
• Complicated diseases of the heart valve apparatus (pulmonary hypertension, atrial fibrillation, septic endocarditis in the anamnesis).
• A combination of several factors in the development of arterial 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 35 years of age.
• Lactation.
• Pregnancy. Relative contraindications
• Arterial hypertension with systolic blood pressure below 160 mmHg. Art. and/or diastolic blood pressure below 100 mm Hg. Art. (a single increase in blood pressure is not a basis for diagnosing arterial hypertension - the primary diagnosis can be established when blood pressure increases to 159/99 mm Hg during three visits to the doctor).
• Confirmed hyperlipidemia.
• Vascular headache or migraine that appeared while taking COCs, as well as migraine without focal neurological symptoms in women over 35 years of age.
• Gallstone disease with clinical manifestations in history or currently.
• Cholestasis associated with pregnancy or COC use.
• Systemic lupus erythematosus, systemic scleroderma.
• History of breast cancer.
• Epilepsy and other conditions requiring the use of anticonvulsants and barbiturates - phenytoin, carbamazepine, phenobarbital and their analogues (anticonvulsants reduce the effectiveness of COCs by inducing microsomal liver enzymes).
• Taking rifampicin or griseofulvin (for example, for tuberculosis) due to their effect on liver microsomal enzymes.
• Lactation from 6 weeks to 6 months after birth, postpartum period without lactation for up to 3 weeks.
• Smoking less than 15 cigarettes per day over 35 years of age. Conditions requiring special monitoring while taking COCs
• Increased blood pressure during pregnancy.
• Family history of deep vein thrombosis, thromboembolism, death from myocardial infarction before the age of 50 years (1st degree of relationship), hyperlipidemia (assessment of hereditary factors of thrombophilia and lipid profile is necessary).
• Upcoming surgery without prolonged immobilization.
• Thrombophlebitis of superficial veins.
• Uncomplicated heart valve diseases.
• Migraine without focal neurological symptoms in women under 35 years of age, headache that began while taking COCs.
• Diabetes mellitus without angiopathy with a disease duration of less than 20 years.
• Gallstone disease without clinical manifestations; condition after cholecystectomy.
• Sickle cell anemia.
• Bleeding from the genital tract of unknown etiology.
• Severe dysplasia and cervical cancer.
• Conditions that make it difficult to take pills (mental illnesses associated with memory impairment, etc.).
• Age over 40 years.
• Lactation more than 6 months after birth.
• Smoking under 35 years of age.
• Obesity with a body mass index of more than 30 kg/m2.

Side effects of combined oral contraceptives

Side effects are most often mild and 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 dependent on the mechanism of action of hormones. Clinical side effects of COCs are in turn divided into general and those causing menstrual irregularities.

• headache;
• dizziness;
• nervousness, irritability;
• depression;
• discomfort in the gastrointestinal tract;
• nausea, vomiting;
• flatulence;
• bile duct dyskinesia, exacerbation of cholelithiasis;
• tension in the mammary glands (mastodynia);
• arterial hypertension;
• change in libido;
• thrombophlebitis;
• leukorrhea;
• chloasma;
• leg cramps;
• weight gain;
• deterioration of tolerance to contact lenses;
• dryness of the vaginal mucous membranes;
• increasing the overall coagulation potential of the blood;
• an increase in the transition of fluid from vessels to the intercellular space with a compensatory delay in the body of sodium and water;
• changes in glucose tolerance;
• hypernatremia, increased osmotic pressure of blood plasma. Menstrual irregularities:
• intermenstrual spotting;
• breakthrough bleeding;
• amenorrhea during or after taking COCs.

If side effects persist longer than 3–4 months after starting treatment and/or intensify, 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 an EE dose of 20–35 mcg/day is very small - lower than during pregnancy. However, at least one risk factor for the development of thrombosis (smoking, diabetes, high degree obesity, hypertension, etc.) is a relative contraindication to taking COCs. A combination of two or more of these risk factors (for example, a combination of obesity and 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, antiphospholipid syndrome). In this regard, it should be emphasized that routine determination of prothrombin in the blood does not provide insight into the hemostatic system and cannot be a criterion for prescribing or discontinuing COCs. If latent forms of thrombophilia are suspected, a special study hemostasis.

Fertility restoration

After stopping the use of COCs, the normal functioning of the hypothalamic-pituitary-ovarian system is quickly restored. More than 85–90% of women are able to become pregnant within 1 year, which corresponds to the biological level of fertility. Taking COCs before the start of the conception cycle does not have any effect negative influence on the fetus, course and outcome of pregnancy. Accidental use of COCs in early stages pregnancy is not dangerous and is not a reason 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 hypothalamic-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 some forms of anovulation.

In rare cases, amenorrhea is observed after discontinuation of COCs. It 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 fertility, after stopping taking COCs, amenorrhea lasting more than 6 months is observed (the so-called post-pill amenorrhoea - hyperinhibition syndrome). The nature 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 a woman strictly individually, taking into account the characteristics of her somatic and gynecological status, individual and family history. The selection of COCs occurs 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 method of combined oral contraception.
• Observation of the woman for 3–4 months, assessment of tolerability and acceptability of the drug; if necessary, a decision to change or cancel the COC.
• Clinical observation of the woman during the entire period of use of COCs.

The woman's survey is aimed at identifying possible risk factors. It necessarily includes the following number of aspects.

• The nature of the menstrual cycle and gynecological history.
  • When was your last menstruation, did it proceed normally (pregnancy should be ruled out at this time).
  • Is your menstrual cycle regular? Otherwise, a special examination is necessary to identify the causes. irregular cycle(hormonal disorders, infection).
  • The course of previous pregnancies.
  • Abortion.
• Previous use of hormonal contraceptives (oral or other):
  • were there any side effects; if so, which ones;
  • for what reasons did the patient stop using hormonal contraceptives?
• Individual history: age, blood pressure, body mass index, smoking, taking medications, liver disease, vascular disease and thrombosis, diabetes mellitus, cancer.
• Family history (diseases in relatives that developed before the age of 40): arterial hypertension, venous thrombosis or hereditary thrombophilia, breast cancer.

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

• Breast examination.
• Gynecological examination.
• Examination for the presence of atypical cells.
• Standard biochemical tests.
• Tests for pelvic inflammatory diseases, 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. Such COCs include Logest, Femoden, Zhanin, Yarina, Mercilon, Marvelon, Novinet, Regulon, Belara, Miniziston, Lindinet, Silest "

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, the patient's health status should also be taken into account.

In the first months after starting to take COCs, the body adapts to hormonal changes. During this period, intermenstrual spotting or, less commonly, breakthrough bleeding may appear (in 30–80% of women), as well as other side effects associated with the disorder. hormonal balance(in 10–40% of women). If adverse events do not go away within 3–4 months, the contraceptive may need to be changed (after excluding other causes - organic diseases of the reproductive system, missing pills, drug interactions). It should be emphasized that currently the choice of COCs is large enough to suit most women who are indicated for this method of contraception. If a woman is not satisfied with the first choice drug, the second choice drug is selected taking into account the specific problems and side effects encountered by the patient.

Selecting a COC

Basic principles of monitoring patients using COCs

• Annual gynecological examination, including colposcopy and cytological examination.
• Once or twice a year, examination of the mammary glands (in women with a history of benign tumors mammary glands and/or breast cancer in the family), mammography once a year (in perimenopausal patients).
• Regular blood pressure measurement. When diastolic blood pressure increases to 90 mm Hg. Art. and above, stop taking COCs.
• Special examinations 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. If intermenstrual bleeding persists for more than three cycles or appears with further use of COCs, you must adhere to the following recommendations.
  • Eliminate errors in taking COCs (skipping pills, non-compliance with the dosage regimen).
  • Rule out pregnancy, including ectopic.
  • Exclude organic diseases of the uterus and appendages (fibroids, endometriosis, hyperplastic processes in the endometrium, cervical polyp, cancer of the cervix or uterine body).
  • Rule out infection and inflammation.
  • If the above reasons are excluded, change the drug in accordance with the recommendations.
  • In the absence of withdrawal bleeding, the following should be excluded:
    • taking COCs without 7-day breaks;
    • pregnancy.
  • If these reasons are excluded, then the most likely reason for the absence of withdrawal bleeding is endometrial atrophy due to the influence of progestogen, which can be detected by endometrial ultrasound. This condition is called “silent menstruation”, “pseudoamenorrhea”. It is not associated with hormonal disorders and does not require discontinuation of COCs.

Rules for taking COCs

Women with regular menstrual cycles

• The initial dose of the drug should be started within the first 5 days after the start of menstruation - in this case, the contraceptive effect is ensured already in the first cycle, additional measures to protect against pregnancy are not necessary. Taking monophasic COCs begins with a tablet marked with the corresponding day of the week, multiphasic COCs with a tablet marked “start of use”. If the first pill is taken later than 5 days after the start of menstruation, an additional method of contraception is required in the first cycle of taking COCs for 7 days.
• Take 1 tablet (dragée) daily at approximately the same time of day for 21 days. If you miss a pill, follow the “Rules for Forgotten and Missed Pills” (see below).
• After taking all (21) tablets from the package, take a 7-day break, during which withdrawal bleeding (“menstruation”) occurs. After the break, begin taking tablets from the next package. For reliable contraception, the break between cycles should not exceed 7 days!

All modern COCs are produced in “calendar” packages designed for one cycle of administration (21 tablets - 1 per day). There are also packs of 28 tablets; in this case, the last 7 tablets do not contain hormones (“pacifiers”). In this case, there is no break between packs: it is replaced by taking a placebo, since in this case patients are less likely to forget to start taking the next pack on time.

Women with amenorrhea

• Start taking it at any time, provided that pregnancy has been reliably excluded. Use an additional method of contraception for the first 7 days.

Women breastfeeding

• Do not prescribe COCs earlier than 6 weeks after birth!
• The period from 6 weeks to 6 months after birth, if a woman is breastfeeding, use COCs only if absolutely necessary (the method of choice is mini-pills).
• More than 6 months after birth:
  • with amenorrhea, the same as in the section “Women with amenorrhea”;
  • with a restored menstrual cycle.

“Rules for forgotten and missed pills”

• If 1 tablet is missed.
  • If you are less than 12 hours late in taking the pill, take the missed pill and continue taking the drug until the end of the cycle according to the previous regimen.
  • Delay in appointment by more than 12 hours - the same actions as in the previous paragraph, 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, you need additional funds there is no 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 regular dosing, 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 after 7 days (counting from the start of missing tablets).

Rules for prescribing COCs

• Primary purpose - from the 1st day of the menstrual cycle. If treatment is started later (but no later than the 5th day of the cycle), then additional methods of contraception must be used in the first 7 days.
• Post-abortion appointment - immediately after the abortion. Abortion in the first and second trimesters, as well as septic abortion, belong to category 1 conditions (there are no restrictions on the use of the method) for prescribing COCs.
• Prescription after childbirth - in the absence of lactation, start taking COCs no earlier than the 21st day after birth (category 1). If there is lactation, do not prescribe COCs; use mini-pills no earlier than 6 weeks after birth (category 1).
• Switching from high-dose COCs (50 mcg EE) to low-dose ones (30 mcg EE or less) - without a 7-day break (so that the hypothalamic-pituitary system does not become activated due to a dose reduction).
• Switching from one low-dose COC to another after the usual 7-day break.
• Switch from a mini-pill to a COC on the 1st day of the next bleeding.
• Switching from an injection drug to a COC on the day of the next injection.

• It is advisable to reduce the number of cigarettes you smoke or quit smoking altogether.
• Follow the regimen of taking the drug: do not skip taking pills, strictly adhere to the 7-day break.
• Take the drug at the same time (in the evening before bed), with a small amount of water.
• Have the “Rules for Forgotten and Missed Pills” on hand.
• In the first months of taking the drug, intermenstrual bleeding is possible. varying intensity, usually disappearing after the third cycle. If intermenstrual bleeding continues at a later date, you should consult a doctor to determine its cause.
• In the absence of a menstrual-like reaction, you should continue taking the pills as usual and immediately consult a doctor to exclude pregnancy; If pregnancy is confirmed, you should immediately stop taking COCs.
• After stopping the drug, pregnancy may occur in the first cycle.
• Concomitant use of antibiotics, as well as anticonvulsants leads to a decrease in the contraceptive effect of COCs.
• If vomiting occurs (within 3 hours after taking the drug), you must additionally take 1 more tablet.
• Diarrhea that continues for several days requires the use of an additional method of contraception until the next menstrual reaction occurs.
• For sudden localized severe headache, migraine attack, chest pain, acute visual impairment, difficulty breathing, jaundice, increased blood pressure above 160/100 mmHg. Art. Immediately stop taking the drug and consult a doctor.

ICD-10

Y42.4 Oral contraceptives

More than 55 years have passed since the appearance of the first hormonal contraceptive - Enovida. Today, drugs have become lower-dose, safer and more varied in form.

Combined oral contraceptives (COCs)

Most drugs use the estrogen ethinyl estradiol at a dosage of 20 mcg. The following is used as a gestagen:

• norethindrone;
• levonorgestrel;
• norgestrel;
• norethindrone acetate;
• norgestimate;
• desogestrel;
• Drospirenone is the most modern progestin.

A new trend in the production of COCs is the release of drugs that increase the level of folate in the blood. These COCs contain drospirenone, ethinyl estradiol and calcium levomefolate (a metabolite of folic acid) and are indicated for women planning a pregnancy in the near future.

Monophasic COC contraceptives have a constant dose of estrogen and progestin. Biphasic COCs contain two, three-phase - three, and four-phase - four combinations of estrogen and progestogen. Multiphasic drugs have no advantages over monophasic combined oral contraceptives in terms of effectiveness and side effects.

About three dozen COCs are available on the pharmaceutical market, the vast majority of which are monophasic. They are available in the form of 21+7:21 hormonally active tablets and 7 placebo tablets. This facilitates consistent daily monitoring of regular COC use.

Combined oral contraceptives (COCs) list: types and names

Mechanism of action

The main principle of operation of COCs is to inhibit ovulation. The drugs reduce the synthesis of FSH and LH. The combination of estrogen and progestin gives a synergistic effect and increases their antigonadotropic and antiovulatory properties. In addition, COC contraceptives change the consistency of cervical mucus, cause endometrial hypoplasia and reduce contractility of the fallopian tubes.

Efficiency largely depends on compliance. The pregnancy rate during the year ranges from 0.1% with correct use to 5% with violations of the dosage regimen.

Advantages

Combined hormonal contraceptives are widely used to treat menstrual irregularities and reduce or eliminate ovulatory syndrome. Taking COCs reduces blood loss, so it is advisable to prescribe them for menorrhagia. COCs can be used to adjust the menstrual cycle — if necessary, delay the onset of the next menstruation.

COCs reduce the risk of developing benign breast formations, inflammatory diseases of the pelvic organs, and functional cysts. Taking COCs if you already have functional cysts contributes to their significant reduction or complete resorption. The use of COCs helps reduce the risk of malignant ovarian diseases by 40 %, endometrial adenocarcinoma by 50 %. The protective effect lasts up to 15 years after discontinuation of the drug.

Flaws

Side effects: nausea, breast tenderness, breakthrough bleeding, amenorrhea, headache.

Estrogen, which is part of COCs, can activate the blood clotting mechanism, which can lead to the development of thromboembolism. The risk group for developing such complications while taking COCs includes women with high level LDL and low blood HDL levels, severe diabetes accompanied by arterial damage, uncontrolled arterial hypertension, obesity. In addition, the likelihood of developing blood clotting disorders increases in women who smoke.

Contraindications for the use of combined oral contraceptives

• thrombosis, thromboembolism;
• angina pectoris, transient ischemic attacks;
• migraine;
• diabetes mellitus with vascular complications;
• pancreatitis with severe triglyceridemia;
• liver diseases;
• hormone-dependent malignant diseases;
• bleeding from the vagina of unknown etiology;
• lactation.

COCs and breast cancer

The most comprehensive analysis of cases of breast cancer development while taking COCs was presented in 1996 by the Collaborative Group on Hormonal Factors in Breast Cancer. The study assessed epidemiological data from more than 20 countries. The study results showed that women who are currently taking COCs, as well as those who have taken them in the past 1–4 years, have a slightly increased risk of developing breast cancer. The study highlighted that women participating in the experiment were much more likely to undergo breast examinations than women not taking COCs.

Today it is assumed that the use of COCs may act as a cofactor that only interacts with the underlying cause of breast cancer and possibly potentiates it.

Transdermal Therapeutic System (TTS)

The transdermal therapeutic system patch is applied for 7 days. The used patch is removed and immediately replaced with a new one on the same day of the week, on the 8th and 15th days of the menstrual cycle.

TTS appeared on the market in 2001 (“Evra”). Each patch contains a week's supply of norelgestromin and ethinyl estradiol. TTC is applied to dry, clean skin of the buttocks, abdomen, outer surface of the upper arm or torso with minimal hair growth. It is important to monitor the density of TTC attachment every day and not apply cosmetics nearby. Daily release of sex steroids (203 mcg norelgestromin + 33.9 mcg ethinyl estradiol) is comparable to that of low-dose COCs. On the 22nd day of the menstrual cycle, the TTS is removed and a new patch is applied 7 days later (on the 29th day).

The mechanism of action, effectiveness, disadvantages and advantages are the same as those of COCs.

Vaginal ring

The hormonal vaginal ring (NovaRing) contains etonogestrel and ethinyl estradiol (daily release 15 mcg + 120 mcg, respectively). The ring is installed for three weeks, after which it is removed and a week-long break is maintained. On day 29 of the cycle, a new ring is inserted.

The dosage of ethinyl estradiol in the vaginal ring is lower than that of COCs, due to the fact that absorption occurs directly through the vaginal mucosa, bypassing the gastrointestinal tract. Due to complete suppression of ovulation and regular release independent of the patient, the effectiveness is higher than that of COCs (0.3–6 %). Another advantage of the ring is the low likelihood of dyspeptic side effects. Some patients experience vaginal irritation and discharge. In addition, the ring may accidentally slip out.

The effect of hormonal contraceptives on libido has not been sufficiently studied; research data are contradictory and depend on the average age in the sample and gynecological diseases, the drugs used, and methods for assessing the quality of sexual life. In general, 10-20 percent of women may experience a decrease in libido while taking medications. In most patients, the use of GC does not affect libido.

Acne and hirsutism usually have low levels of sex hormone binding globulin (SHBG). COCs increase the concentration of this globulin, having a beneficial effect on the condition of the skin.

Subtleties of application

Estrogen in COCs helps eliminate LDL and increase HDL and triglyceride levels. Progestins counteract estrogen-induced changes in lipid levels in the body.

1. For acne, medications containing cyproterone acetate, drospirenone or desogestrel are prescribed as a progestin. COCs containing cyproterone acetate and ethinyl estradiol are more effective for acne than the combination of ethinyl estradiol and levonorgestrel.
2. For hirsutism, medications containing progestogens with antiadrogenic properties are recommended: cyproterone acetate or drospirenone.
3. Combinations of estradiol valerate and dienogest are more effective in reducing menstrual blood loss than ethinyl estradiol and levonorgestrel. In addition, the intrauterine system is indicated for the treatment of menorrhagia.
4. Preparations containing drospirenone 3 mg and ethinyl estradiol 20 mcg are recognized as the most effective combination for correcting PMS symptoms, including those of a psychogenic nature.
5. Taking oral contraceptives increases systolic blood pressure (BP) by 8 mmHg. Art., and diastolic by 6 mm Hg. Art. . There is evidence of an increased risk of cardiovascular events in women taking COCs. Due to the increased likelihood of developing myocardial infarction and stroke in patients with arterial hypertension, when prescribing COCs, the benefit/risk ratio must be carefully weighed.
6. In non-smoking women under 35 years of age with compensated hypertension, COCs can be prescribed with careful monitoring of blood pressure during the first months of use.
7. In case of increased blood pressure while taking COCs or in women with severe hypertension intrauterine system or DMPA are indicated.
8. The selection of a contraceptive for patients with dyslipidemia must be carried out taking into account the effect of the drugs on lipid levels (see Table 5).
9. Because the absolute risk of cardiovascular events in women with controlled dyslipidemia is low, COCs containing 35 mcg or less of estrogen can be used in most cases. For patients with LDL levels above 4.14 mmol/L, alternative means of contraception are indicated.
10. The use of COCs in women with diabetes mellitus accompanied by vascular complications is not recommended. A suitable option for hormonal contraception for diabetes mellitus is the intrauterine levonorgestrel-releasing system, and, as a rule, no dose adjustment of hypoglycemic drugs is required.
11. results epidemiological studies studying the risk of myocardial infarction when prescribing oral contraceptives smoking women, are contradictory. Due to limited convincing data, COCs are recommended to be prescribed with caution to all women over 35 years of age who smoke.
12. Obesity with a body mass index of 30 kg/m2 or higher reduces the effectiveness of COCs and transdermal GCs. In addition, the use of COCs in obesity is a risk factor for venous thromboembolism. Therefore, the method of choice for such patients is mini-pills (gestagen-containing tablet contraceptives) and intrauterine contraceptives(levonorgesterelreleasing system).
13. The use of COCs with estrogen dosages of less than 50 mcg in nonsmoking, healthy women over 35 years of age may have a beneficial effect on density bone tissue and vasomotor symptoms in perimenopause. This benefit must be considered in light of the risk of venous thromboembolism and cardiovascular factors. Therefore, women of the late reproductive period are prescribed COCs individually.

List of sources

1. Van Vliet H. A. A. M. et al. Biphasic versus triphasic oral contraceptives for contraception //The Cochrane Library. - 2006.
2. Omnia M Samra-Latif. Contraception. Available from http://emedicine.medscape.com
3. Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and hormonal contraceptives: collaborative reanalysis of individual data on 53,297 women with breast cancer and 100,239 women without breast cancer from 54 epidemiological studies. Lancet 1996; 347(9017):1713–1727.
4. Carlborg L. Cyproterone acetate versus levonorgestrel combined with ethinyl estradiol in the treatment of acne. Results of a multicenter study. Acta Obstetricia et Gynecologica Scandinavica 1986;65:29–32.
5. Batukan C et al. Comparison of two oral contraceptives containing either drospirenone or cyproterone acetate in the treatment of hirsutism. Gynecol Endocrinol 2007;23:38–44.
6. Fruzzetti F, Tremollieres F, Bitzer J. An overview of the development of combined oral contraceptives containing estradiol: focus on estradiol valerate/dienogest. Gynecol Endocrinol 2012;28:400–8.
7. Lopez LM, Kaptein AA, Helmerhorst FM. Oral contraceptives containing drospirenone for premenstrual syndrome. Cochrane Database Syst Rev 2012.
8. Armstrong C, Coughlin L. ACOG releases guidelines on hormonal contraceptives in women with coexisting medical conditions. - 2007.
9. Carr BR, Ory H. Estrogen and progestin components of oral contraceptives: relationship to vascular disease. Contraception 1997; 55:267–272.
10. Burrows LJ, Basha M, Goldstein AT. The effects of hormonal contraceptives on female sexuality: a review. The journal of sexual medicine 2012; 9:2213–23.