Hormonal Contraceptives

Question 1

Long-term Reversible Contraception

Answer 1

1. Contraceptive Implant
2. Intrauterine System (IUS)
3. Progesterone-only-injectable Contraception

Question 2

User-dependent Contraception

Answer 2

1. Combined Pill
2. Progesterone-only Pill
3. Combined Transdermal Patch
4. Combined Vaginal Ring

Question 3

Emergency Contraception

Answer 3

1. Levonorgestrel
   - A single dose for emergency contraception
2. Selective Progesterone Receptor Modulator Ulipristal Acetate (UPA)
   - A single dose within 120 hours of unprotected sex
   - More effective than levonorgestrel

Question 4

Drug Interactions

Answer 4

• Drugs which induce cytochrome p450 enzymes (e.g. Anti-convulsants - Carbamazepine, Phenytoin) may reduce the efficiency of hormonal contraception
• If long-term treatment with liver enzyme-inducing drugs (e.g. Epilepsy). a higher dose of OC pills / alternative contraceptive methods (e.g. Barrier contraception - condoms) should be used

Question 5

MOA of Hormonal Contraception

Answer 5

1. Combined hormonal contraception
   - Inhibits ovulation by acting on the hypothalmo-pituitary-ovarian axis to suppress luteinising hormone (LH) and follicle-stimulating hormone (FSH)
2. Progesterone Component
   - Thickens cervical mucus and prevent sperm entry, alters endometrium and make it inhospitable to implantation

Question 6

Administration of Hormonal Contraception

Answer 6

1. Combined Oestrogen and Progesterone Hormonal Contraceptive
   - Orally as the combined oral contraceptive (COC) pill
   - Trandermally as a patch
   - Intravaginally as a Vaginal Ring
2. Progesterone-Only
   - Oral Pill
   - Injection (IM/Subc)
   - Subdermal Implant
   - Intrauterine System

Question 7

Contraindications of Hormonal Contraception

Answer 7

1. Age >/= 35 years old
2. Smoking >/= 15 cigarettes per day
3. Migraine with AURA (any age)
4. Breastfeeding <6 weeks postpartum
5. Hypertension consistently >/= 160mmHg systolic and/or >/= 100mmHg diastolic
6. History of Thromboembolic Disease
7. History of Ischemic Heart Disease / Stroke
8. Current Breast Cancer

Question 8

Composition of Hormonal Contraception

Answer 8

• A combination of oestrogen and progesterone pills, patch and vaginal ring
• Synthetic Oestrogen (Ethinylestradiol)
• Synthetic Progesterone (Progestogen): Norethisterone (1st Gen), Levonorgestrel (2nd Gen), Desogestrel, Gestodene, Nergestimate (3rd Gen), Drospirenone, Dienogest, Nomegestrol Acetate (Newer)

Question 9

Clinical Use of Hormonal Contraception

Answer 9

1. OC Pill
   - Standard dosing one tablet daily for 21 days, with 7-day pill-free break
2. Combined Contraceptive Vaginal Ring
   - One ring inserted vaginally for 3 weeks of use per cycle with a new ring inserted after a 7-day ring-free break
3. Combined Contraceptive Patch
   - Wear one patch for 7 days, replace every week for 3 weeks, followed by a patch free week
4. IM Progesterone depot injection every 12 weeks
5. Progesterone-only Implant
   - Effective contraception for 3 years
6. Levonorgestrel-releasing Intrauterine System (LNG-IUS)
   - Effective contraception for 3-5 years

Question 10

Adverse Effects of Hormonal Contraception

Answer 10

1. Venous Thromboembolic Disease
2. Arterial Diesease
3. Hypertension
4. Focal Migraine
5. Oral Contraceptives & Cancer
6. Bone Mineral Density
7. Irregular Bleeding and Return to Fertility

• Others: Nausea, Vomiting, Mood Swings, Weight Gain, Skin disorders, Headaches, Changes in Libido

Question 11

Venous Thromboembolic Disease

Answer 11

1. Increased risk of Deep Vein Thrombosis and Pulmonary Embolism
2. Pathogenesis
   - Increased coagulation factors, decreased anticoagulant response
   - Increased fibrinolytic inhibitors
3. Risk increased by
   - High oestrogen content of the pill
   - Obesity
   - Major Surgical Procedures
   - Travel Associated with Immobilisation
4. Risk highest in the months after
   - Initiating
   - Restarting the pill after a break of > 1 month, thus is not recommended to take the OC pills immediately

Question 12

Arterial Disease

Answer 12

1. An increased risk of myocardial infraction and ischemic stroke
2. Pathogenesis
   - Increased coagulation factors
   - Decreased coagulant response
   - Increased fibrinolytic inhibitors
3. Risk is increased by
   - High oestrogen content of the pill
   - Obesity
   - Age
   - Smoking

Question 13

Hypertension

Answer 13

1. Tp check BP prior to starting OHC
2. Not recommended for a hypertensive individual to take OHC
3. If systolic BP >160mmHg / diastolic >95mmHg, stop OHC
4. Pathogenesis
   - Oestrogen stimulation of synthesis of angiotensinogen-aldosterone in the control of BP)

Question 14

Focal Migraine

Answer 14

• Women with focal migraine with AURA are additional risk for ischemic stroke, COC not advisable

Question 15

Oral Contraceptives & Cancer

Answer 15

• Decreased risk of ovarian and endometrial cancer by up to 50% after 10-15 years
• Decreased risk of colorectal cancer
• A small increase of breast cancer

Question 16

Bone Mineral Density

Answer 16

• Progesterone-only injectable contraceptive, leads to a small loss of bone marrow density
• Recovers after discontinuation

Question 17

Irregular Bleeding and Return to Fertility

Answer 17

• Progesterone only methods (Pills, INJ, Implants), causing irregular bleeding
• No delay in return to fertility with any form of contraception once discontinue using, except INJ progesterone contraception