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Hormonal contraceptives

Last updated: December 18, 2020

Summary

Hormonal contraceptives involve the use of estrogen and progestin analogs to prevent pregnancy. The contraceptive effect is mediated by negative feedback at the hypothalamus, ultimately leading to reduced pituitary follicle-stimulating hormone (FSH) and luteinizing hormone (LH) secretion. Without an LH surge, ovulation does not occur. Progestin also makes implantation less likely, as it causes a thickening of cervical mucus, a decrease in tubal motility, and the inhibition of endometrial proliferation. Oral contraceptives (OCs) are the most common form of hormonal contraception, but other forms of hormone delivery, including patches, injections, and implants, also exist. In combination monophasic OCs, the dose of estrogen and progestin remains constant, while in combination multiphasic OCs it varies over the course of one cycle. The decreased total hormone doses of multiphasic OCs mitigate certain associated side effects and risks. These include bothersome symptoms such as breast tenderness, nausea, bloating, and breakthrough bleeding as well as medical emergencies such as venous thromboembolism. Because of the complications associated with hormonal contraceptives, their use is contraindicated in patients with certain medical conditions and histories, e.g., significant hypertension, ischemic heart disease, venous thromboembolism, and stroke.

Overview

Types of oral contraceptives

Overview of different types of hormonal contraceptives
Type Description Pregnancy rate in first year with typical use (with perfect use) [1] Indications
Oral contraceptive pill Combined oral contraceptive (COC)
  • 7% (< 1%)
Progestin-only contraceptive pills (minipill)
  • 7% (< 1%)
Contraceptive patch
  • 7% (< 1%)
  • Patches are considered as effective as COC pills
  • Only require application to the skin once a week
  • Similar indications as for COC
Vaginal ring
  • 7% (0.3%)
  • Similar indications as for COC
Injectable progestin
  • Intramuscular or subcutaneous injection administered every 3 months.
  • 4% (0.2%)
  • Long-term and reversible
Intrauterine device with progestin
  • Need to be replaced every 3 to 5 years (varies with type of device).
  • 0.7% (0.5%)
Subdermal progestin implant
  • The device (flexible plastic rod) is usually inserted subdermally in the upper arm and lasts 3 years.
  • 0.1%

Emergency contraception

  • Non-hormonal methods: copper-containing intrauterine devices
    • Added benefit of long-term contraception
    • Requires brief, clinical procedure
  • Hormonal methods
    • Most effective when taken within 3 days of intercourse
    • Typically administered as a single dose or as two doses over one day
    • Significantly less effective in patients who are obese or overweight
    • Types

The rate of pregnancy is ≤ 3.0% if emergency contraception is taken within 72 hours after unprotected sexual intercourse. The earlier it is taken, the lower the likelihood of pregnancy!

References:[2][3][4]

Pharmacodynamics

Mechanisms of action depend on the hormones used in the formulation.

Adverse effects

Common side effects

Indications for immediate discontinuation

Studies have shown that women taking estrogen-progestin combination OCPs before menopause have an increased risk of cervical carcinoma but a decreased risk of endometrial and ovarian carcinoma.

References:[6][7]

We list the most important adverse effects. The selection is not exhaustive.

Indications

Contraceptive indications

Non-contraceptive indications

Contraindications

Absolute contraindications for estrogen-containing OCPs

Women who smoke and are > 35 years old should not be prescribed OCPs because of increased risk of cardiovascular side effects!

Relative contraindications for estrogen-containing OCPs

We list the most important contraindications. The selection is not exhaustive.

Special patient groups

Minors

In the United States, laws allowing minors to consent to contraceptive health care are determined by individual states. Most states allow adolescents to receive medical care related to pregnancy prevention without parental consent.

References

  1. World Health Organization Department of Reproductive Health and Research (WHO/RHR) and Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP), Knowledge for Health Project.. Family Planning - A global handbook for providers. WHO ; 2018
  2. Cerel-Suhl SL, Yeager BF. Update on oral contraceptive pills. Am Fam Physician. 1999; 60 (7): p.2073-2084.
  3. Allen RH, Cwiak CA, Kaunitz AM. Contraception in women over 40 years of age. CMAJ. 2013; 185 (7): p.565-573. doi: 10.1503/cmaj.121280 . | Open in Read by QxMD
  4. Choosing a Birth Control Method. http://www.arhp.org/Publications-and-Resources/Quick-Reference-Guide-for-Clinicians/choosing/Progestin-Only-OCs. Updated: June 1, 2014. Accessed: June 17, 2017.
  5. Trenor CC, Chung RJ, Michelson AD et al. Hormonal contraception and thrombotic risk: a multidisciplinary approach. Pediatrics. 2011; 127 (2): p.347-357. doi: 10.1542/peds.2010-2221 . | Open in Read by QxMD
  6. Martin KA, Douglas PS, Barbieri RL, Crowley WF, Martin KA. Risks and Side Effects Associated with Estrogen-Progestin Contraceptives. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/risks-and-side-effects-associated-with-estrogen-progestin-contraceptives.Last updated: August 22, 2016. Accessed: June 17, 2017.
  7. Morbidity and Mortality Weekly Report (MMWR) - Appendix L - Summary of Classifications for Hormonal Contraceptive Methods and Intrauterine Devices. https://www.cdc.gov/Mmwr/preview/mmwrhtml/rr59e0528a13.htm. Updated: May 28, 2010. Accessed: June 17, 2017.