Contraception- hormonal

Question 1

Hormonal contraception (oestrogens and progestrogens)

Common indications

Answer 1

• For hormonal contraction in women who require highly effective and reversible contraception
• HRT in women with early menopause (when it is given until 50 years of age) and those who have distressing monpausal symptoms

Question 2

Hormonal contraception

oestrogens (ethinylestradiol) and progestrogens (Desogestrel)

MOA

Answer 2

• Lutenising hormone (LH) and follicle-stimulating hormone (FSH) control ovulation and ovarian production of oestrogen and progesterone
• In turn, oestrogen and progesterone exert predominantly negative feedback on LH and FSH release
• In hormonal contraception, oestrogen and/or progestogen are given to Suppress LH/FSH release and hence ovulation
• Oestrogens and progestogens also have many effects outside the ovary
• Effects on cervix and endometrium contribute to the contraceptive effect
• Others include reduce menstrual pain and bleed as well as improvements in acne.
• At the menopause, they can reduce vaginal dryness and vasomotor instability (hot flushes)

Question 3

Hormonal contraception

oestrogens (ethinylestradiol) and progestrogens (Desogestrel)

Important adverse effects

Answer 3

• Irregular bleeding
• Mood changes
• Increased risk of VTE
• Increase the risk of CVD and stroke, but only in women with other risk factors
• Increase risk of breast and cervical cancers

Question 4

Hormonal contraception

oestrogens (ethinylestradiol) and progestrogens (Desogestrel)

Warnings

Answer 4

• All forms of oestrogens and progestrogens are contraindicated in breast cancer
• CHC should be avoided in those with an increased risk of VTE or CVD (>35, CV risk factors, migraine with aura, heavy smoker)
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Question 5

Hormonal contraception

oestrogens (ethinylestradiol) and progestrogens (Desogestrel)

Interactions

Answer 5

• Correct use of CYP P450 inducers (rifampicin) can reduce the efficacy of hormonal contraception, particularly progestrogen only forms

Question 6

Hormonal contraception

oestrogens (ethinylestradiol) and progestrogens (Desogestrel)

Adminstration

Answer 6

• COC pills can be started on any day of the cycle
• If this is within the first 6 days, no additional contraception is needed
• If it is beyond day 6, a barrier method should be used for the first 7 days
• Most CHC are designed to be take for 21 days with a 7 days free interval to be taken while bleeding
• Missing 1 COC pill is okay, but missing 2 or more pills necessitates the use of additional contraception for the next 7 days.

Question 7

Hormonal contraception

oestrogens (ethinylestradiol) and progestrogens (Desogestrel)

Communication

Answer 7

• Hormonal contraception should be offered only after a discussion of the risks and benefits of the various contraceptive measures.
• Explain that the usually method of taking the pill results in a bleed each month, although irregular bleeding may occur initially
• Explain the rules for missed pills and provide information and support

Question 8

Hormonal contraception

oestrogens (ethinylestradiol) and progestrogens (Desogestrel)

Monitoring

Answer 8

• Baseline assessment should include a relevant history, BP check and BMI
• Women starting CHC should be seen again at 3 months to check her BP and discuss any issues
• Thereafter, she should be seen yearly to discuss health changes and to check her BP and BMI