4. Types of OCP
Hormonal
• COC (Combined
oral
contraceptives)
• POP
(Progesterone
Only Pills)
Non-Hormonal
• Centchroman
(Saheli)
5. What’s in “The Pill”
• 15-50 micrograms estrogen (ethinyl estradiol
is a synthetic form of estrogen, which is used
most commonly)
• Varying amounts of progestagen component
(commonly levonorgestrel)
• Types of Regimens
– 21-day or 28-day pack
5
9. Mechanism of anovulation
• Inhibit ovulation: Both hormones
acts synergistically on the HPO
axis.
• The release of GnRH from the
hypothalamus is prevented
through a negative feedback
mechanism.
10. Mechanism of anovulation
• So, no peak release of FSH & LH
from the anterior pituitary occurs.
• So, follicular growth is either not
initiated or if initiated –recruitment
doesn’t occur.
• Resulting Anovulation.
11. The 21 day pack
• The first seven pills in a packet inhibit
ovulation.
• The remaining 14 pills maintain
anovulation.
12. Estrogen
• Primary female sex hormone
• Roles of estrogen:
–To develop secondary female
sex characteristics
–Thicken the endometrium
–Regulate menstrual cycle
12
16. Functions of estrogen in
OCP
1. Improves the efficacy over
progesterone only pills.
2. Inhibits FSH rise & prevents
follicular growth.
3. It provides better cycle control
than progesterone only pills
4. It prevents Break through
bleeding. 16
17. Progesterone
• Produced by
– Adrenal glands
– Gonads
– Brain
– Placenta (only during pregnancy)
Primary Effect- prepares uterus for
implantation by the proliferation of
endometrium; prepares body for
pregnancy 17
18. Progesterone
• Natural progesterone- destroyed by
digestive system when consumed
orally
ALL oral contraceptives
contain progestin, synthetic
form of progesterone
18
19. Different progestogens can be
classified
According to their
steroid structure
1. -PREGNANES
(derived from
the
progesterone
molecule),
2. -ESTRANES
(derivatives of
testosterone),
and
3. -GONANES
Timing of their
introduction into
the market.
1st, Generation
2nd, Generation
3rd, Generation
4th, Generation
24. Role of progestins in COC
• Primarily inhibits LH surge &
thereby ovulation.
• Counteract the adverse effects of
estrogen on the endometrium
(Hyperplasia)
• Thickens cervical mucosa &
thereby sperm penetration difficult.24
25. Advantages of 3rd
generations of progestins
• Lipid friendly progestogens.
• to minimize androgenic side effects
such as acne, hirsutism, nausea, and
lipid changes while
• increasing progestational effects
25
26. Advantages of 4th
generations of progestins
• Drospirenone.
• Dienogest,
• Nomegestrol
• All three progestogens have
antiandrogenic activity;
• drospirenone has antimineralocorticoid
activity.
26
28. Commonly available COCs
in the market
28
Brand Name Progestin Estrogen Pack
Mala-D ,
Mala-N
Levonorgestrel
150 mcg
Ethinyl Estradiol
30 mcg
21+7 tab pack
Loette,
Femilon
Desogestrel
150mcg
Ethinyl Estradiol
20 mcg
21 tab pack
Yasmin,
Dronis
Drospirenone 3
mg
Ethinyl Estradiol
30 mcg
21 tab pack
29. What to do before
prescribing COC
• A proper history and general
examination is important before
prescribe.
• H/O headache, migraine,
• H/O amenorrhoea
• Family H/O Breast cancer
29
30. What to do before
prescribing COC
• Breast examination for any nodule
• Weight and BP
• Pelvic examination to rule out any
cervical pathology
• Pregnancy must be excluded
• A cervical smear should be taken
before.
30
31. Instruction for pill use
New user
• New users should normally start
their pill pack on Day 1 of their
menstrual cycle.
• 1 tab daily preferably at the same
time (e.g. bed time)
• Continue upto 21 days and then a
7 days gap.
31
32. Instruction for pill use
New user
• During this 7 days period there will
be withdrawl bleeding.
• Then start new pack on the 8th day
(irrespective of the withdrawl
bleeding)
• 3 wks & 1 wk off
• Pill which contains 28 tabs have 7
placebo tablets, so no need to
give a gap. 32
33. What if she did not started
on Day1
• She can start upto day 5.
• But has to take additional
precaution (condom) for next 7
days.
33
34. Special situations
• After abortion: the day after
abortion
• After delivery:
• If non-lactating after 6 wk (WHO) ?
• Lactating: no COC.
34
35. Follow up
• Check the patient after 3 months,
6 month and then once every
yearly.
• More frequent check if >35 yr.
• Ask for any adverse effects
• Examine breasts, weight, BP.
• Pelvic examination if required.
35
36. Miss pill
• If forgets to take one pill (late upto
24 hr).
• She should take the missed pill at
once and continue the rest as
schedule.
• There is nothing to worry.
36
37. If one pill has been missed (more than
24 hours and up to 48 hours late)
Next pill
on usual
time
Keep
taking
active pills
as usual
Take a pill
as soon you
remember
39. If two pills have been missed
(more than 48 hours late)
• Return to next day active pill
• Avoid sex or use extra method
next 7 days.
• EC if already had sex.
If pills are
missed in week
1
(Day 1-7)
• Finish the active pills
• Start a new pack from day
22 with no PFI
• EC if already had sex
• Extra method next 7 days
If pills are
missed in week
3
(Day 15-21)
40. If two pills have been missed
in 2nd wk (Day 8-14)
• No indication for EC if the pills in
the preceding 7 days have been
taken consistently and correctly
• Take 2 tab as soon remembers &
continue the rest as usual.
• Condoms should be used or sex
avoided until 7 consecutive active
pills have been taken.
41. Any time >2 miss pills
• The most recent missed pill should
be taken as soon as possible,
leave any earlier missed pills.
• Condoms should be used or sex
avoided until 7 consecutive active
pills have been taken.
• EC according to the situation
• Start a new pack from day 22 with
no PFI
42. Missed inactive pills
• Discard the missed pill
• Nothing to worry
• Continue the rest as usual.
42
43. Efficacy
• As a contraceptive.
• Failure rates are 0.1 per 100
women year.
43
46. WHO MEC Cat4
Circulatory disease (present or Past)
• Arterial/venous thrombosis
• Severe Htn
• H/O stroke
• Heart disease (valvular,
ischaemic)
• Diabetes with vascular
involvement
• Migraine with aura
46
47. WHO MEC Cat4
Liver disease
• Active liver disease
• Liver adenoma
• Liver carcinoma
47
48. WHO MEC Cat4
Others
• Pregnancy
• Breast feeding (post partum upto 6
wk)
• Major surgery or prolonged
immobilization
• Estrogen dependent cancers
(Breast cancer)
48
49. WHO MEC Cat3
• Benign liver tumour
• Breast feeding (post partum from
6 wk to 6 month)
• Heavy smoker (>20 cig/day)
• Past H/O breast cancer
• Hyperlipidaemia
• Unexplained vaginal bleeding
49
50. WHO MEC Cat2
• Age ≥40 yr
• Smoker <35yr
• H/O jaundice
• Mild Htn
• Gallbladder disease
• Diabetes
• Sickle cell ds
• Headache
• Cancer cervix or CIN
50
51. Ideal candidates
• Age: menarche to 40 yr
• Newly married/ frequent sexual
activity
• Non obese
• Normotensive
• Can take pills regularly without
missing.
• No contraindications.
51
52. Drug interaction
Reduces the efficacy of
• Aspirin
• Oral anticoagulants
• Oral hypoglycaemics
Increases the efficacy of
• Beta blockers
• Cortico-steroids
• Diazepam
52
53. Additional contraceptives
if:
• Using broad spectrum antibiotics
(ampicillin, tetracycline)
• Using enzyme inducing drugs
(Burbiturates, Anti-epileptics,
Nevirapine).
53
54. Minor adverse effects of
COCs
• Nausea, vomiting
• Mastalgia
• Weight gain
• Cholasma & acne
• Menstrual abnormalities (Break-
through bleed, Hypomenorrhoea,
Menorrhagia, Post pill amenorrhoea)
• Loss of libido
• White vaginal discharge (leukorrhoea)
54
56. Caution if develop
• Severe migraine
• Visual or speech disturbance
• Sudden chest pain
• Unexplained fainting attack
• Severe cramps & pain in legs
• Excessive weight gain
• Severe depression
56
57. COC & neoplasia
Protects against:
• Endometrial Ca
• Epithelial ovarian Ca
• Colorectal Ca
No direct relation with Breast cancer
& cervical cancer with low dose
estrogen COCs.
57
58. Advantages
• Highly effective
• Good cycle control
• Convenient to use
• Not intercourse related
• Reversible
• Additional non-contraceptive
benefits.
58
59. Non-contraceptive benefits.
Improvement of menstrual
abnormality:
• Cycle regulation
• ↓Dysmenorrhoea
• ↓Menorrhagia
• ↓ PMS
• ↓ Mittelsmerz’s syndrome
• Protect against anemia
• In patients with PCOS. 59
62. Dis-advantages
• Requires education & motivation
• Requires initial check-up & follow-
up
• Risk of drug interaction & failure
• Side effects may develop
• Many contra-indications are there.
• Miss pill problems.
62
64. Triphasic pills
• Estrogen & progesterone dosage
vary over the course of the cycle.
• Minimum dosage in the 1st half of
the cycle for contraceptive
purpose.
• Maximum dosage given in later
part of cycle to prevent Break
through bleeding.
64
69. If you vomit
• Take another pill as soon as
possible.
• If you do not vomit this second
pill and it is taken on the same
day, then nothing to worry.
within 2-3
hours of
taking a pill
• Then follow the same
as missing pills .
If you
continue to
vomit
70. Diarrhoea
•No affect on the
absorption of the
pill.
Mild
diarrhoea
•consider this as the
same as missing
pills.
Severe
diarrhoea
72. No withdrawal bleed between packs
• It is quite common for there to be no bleeding
between pill packs.
• You are not likely to be pregnant if you have
taken the pill correctly and have not vomited
or taken any medicines that can interfere with
the pill.
• Start the next pack after the usual seven-day
break and continue to take pill as usual.
73. See your doctor or nurse if:
1. You don't have any bleeding after the next
pack (two packs in total); or
2. You have not taken the pill correctly; or
3. You have any reason to think that you may be
pregnant.
A pregnancy test may be advised, considering
the circumstances.
75. Bleeding whilst on the pill
(breakthrough bleeding)
• During the first few months, while your body
is adjusting to the pill, you may have some
vaginal bleeding in addition to the usual
bleeding between packs.
• This is not serious but more of a nuisance. It
may vary from spotting to a heavier loss like a
light period.
• Do not stop taking your pill. This usually
settles after the first 2-3 months.
76. Can I delay or
skip a withdrawal
bleed (period)?
???
77. Can I delay or skip a
withdrawal bleed (period)?
• There are times when it is useful not to have
vaginal bleeding, for example, during exams or
holidays or any ceremony.
• Bicycling/Tricycling may be done- using
monophasic pills (most commonly used), you
can go straight into your next pack without a
break. Have the usual seven-day break at the
end of the second /third packet.
