Hormonal contraceptives contain: Everything you need to know about hormonal contraception

Each tablet combined oral contraceptives (COCs) contains estrogen and progestogen. Synthetic estrogen - ethinyl estradiol - is used as an estrogenic component of COCs, and various synthetic progestogens (synonym - progestins) are used as a progestogen component.

Mechanism of contraceptive action of COCs:

suppression of ovulation;
thickening of cervical mucus;
changes in the endometrium that prevent implantation.

Contraceptive effect of COCs provides a progestogen component. Ethinyl estradiol in COCs supports endometrial proliferation and provides cycle control (lack of intermediate bleeding when taking COCs).

In addition, ethinyl estradiol is necessary to replace endogenous estradiol, since when taking COCs there is no follicle growth and, therefore, estradiol is not produced in the ovaries.

The main clinical differences between modern COCs are: individual tolerance, frequency adverse reactions, features of the effect on metabolism, medicinal effects and so on - are determined by the properties of the progestogens included in their composition.

CLASSIFICATION AND PHARMACOLOGICAL EFFECTS OF COCs

Chemical synthetic progestogens - steroids; they are classified by origin.

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 PR. In addition to their effect on the endometrium, synthetic progestogens also act on other organs that are the targets of progesterone. The antiandrogenic and antimineralocorticoid effects of progestogens are favorable for oral contraception; the androgenic effect of progestogens is undesirable.

The residual androgenic effect is undesirable, since it can be clinically manifested by the appearance of acne, seborrhea, changes in lipid spectrum blood serum, changes in carbohydrate tolerance and an 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 (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). The androgenic properties of these progestogens are detected only in pharmacological tests, clinical significance in most cases they don't. WHO recommends the use of COCs with low androgenic progestogens. Studies have found that desogestrel (active metabolite - 3ketodesogestrel, etonogestrel) has high progestogenic and low androgenic activity and the lowest affinity for SHBG, therefore, even in high concentrations does not displace androgens from their connection with it. These factors explain the high selectivity of desogestrel compared to other modern progestogens.

Cyproterone, dienogest and drospirenone, as well as chlormadinone, have an antiandrogenic effect.

Clinically, the antiandrogenic effect leads to 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 PCOS, idiopathic androgenization and some other conditions.

SIDE EFFECTS OF COMBINED ORAL CONTRACEPTIVES (COCs)

Side effects most often 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 mechanism-dependent.

Excessive estrogen influence:

headache;
increased blood pressure;
irritability;
nausea, vomiting;
dizziness;
mammalgia;
chloasma;
deterioration of tolerability contact lenses;
increase in body weight.

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;
deterioration of varicose veins;
increase in body weight.

Insufficient progestogenic effect:

heavy menstruation;
intermenstrual bleeding in the second half of the cycle;
delay of menstruation.

If side effects persist longer than 3–4 months after starting treatment and/or intensify, then the contraceptive drug should be changed or discontinued.

Serious complications when taking COCs are extremely rare. These include thrombosis and thromboembolism (deep vein thrombosis, thromboembolism pulmonary artery). For women's health, the risk of these complications when taking COCs with a dose of ethinyl estradiol 20–35 mcg/day is very small - lower than during pregnancy. Nevertheless, the presence of at least one risk factor for the development of thrombosis (smoking, diabetes mellitus, high degrees of obesity, arterial hypertension, etc.) serves as a relative contraindication to taking COCs. A combination of two or more of these risk factors (for example, 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; APS). In this regard, it should be emphasized that routine determination of prothrombin in the blood does not give an idea of the hemostatic system and cannot be a criterion for prescribing or discontinuing COCs. When selected latent forms thrombophilia, a special study of hemostasis should be performed.

CONTRACEPTIONS TO THE USE OF COMBINED ORAL CONTRACEPTIVES

Absolute contraindications to taking COCs:

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 mm Hg. or more and/or diastolic blood pressure 100 mm Hg. and more 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 for the development of 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 the age of 35;
lactation in the first 6 weeks after birth;
pregnancy.

RESTORATION OF FERTILITY

After stopping taking COCs normal functioning 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. Taking COCs before conception does not have any effect negative influence on the fetus, course and outcome of pregnancy. Accidental use of COCs on early stages pregnancy is not dangerous and does not serve as a basis 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 hypothalamus-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 the treatment of some forms of anovulation. In rare cases, amenorrhea may be observed after discontinuation of COCs. Amenorrhea 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 (hyperinhibition syndrome) can be observed. The frequency 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 women strictly individually, taking into account the characteristics of their somatic and gynecological status, individual and family history. The selection of COCs is carried out 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 COC method.

decision to change or cancel COCs.

Clinical observation of the woman during the entire period of use of COCs.

In accordance with the WHO conclusion, COCs are not relevant to assessing the safety of use following methods examinations:

examination of the mammary glands;
gynecological examination;
examination for the presence of atypical cells;
standard biochemical tests;
tests for PID, 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.

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, you should take into account the characteristics of the patient’s health condition (Table 12-2).

Table 12-2. Selection of combined oral contraceptives

Clinical situation	Recommendations
Acne and/or hirsutism, hyperandrogenism	Drugs with antiandrogenic progestogens
Menstrual irregularities (dysmenorrhea, dysfunctional uterine bleeding, oligomenorrhea)	COCs with a pronounced progestogenic effect (Marvelon©, Microgynon©, Femoden©, Janine©). When dysfunctional uterine bleeding is combined with recurrent hyperplastic processes of the endometrium, the duration of treatment should be at least 6 months
Endometriosis	Monophasic COCs with dienogest, levonorgestrel, desogestrel or gestodene, as well as progestin COCs are indicated for long-term use. The use of COCs can help restore generative function
Diabetes mellitus without complications	Preparations with a minimum estrogen content - 20 mcg/day
Initial or re-prescription of COCs in a smoking patient	If you smoke under the age of 35, use COCs with minimal estrogen content. For smoking patients over 35 years of age, COCs are contraindicated
Previous use of COCs was accompanied by weight gain, fluid retention in the body, and mastodynia	Yarina©
Poor control of the menstrual cycle has been observed with previous COC use (in cases where other causes other than COC use have been excluded)	Monophasic or three-phase COCs (Tri-Mercy©)

The first months after starting to take COCs serve as a period of adaptation of the body to hormonal changes. At this time, intermenstrual spotting bleeding or, less commonly, “breakthrough” bleeding (in 30–80% of women), as well as other side effects associated with hormonal imbalance (in 10–40% of women), may occur.

If these adverse events do not go away within 3–4 months, this may be a reason to change the contraceptive (after excluding other causes - organic diseases reproductive system, missed pills, drug interactions) (Table 12-3).

Table 12-3. Selection of second-line COCs

Problem	Tactics
Estrogen-dependent side effects	Reducing the dose of ethinyl estradiol Switching from 30 to 20 mcg/day ethinyl estradiol Switching from triphasic to monophasic COCs
Progestin-dependent side effects	Reducing the progestogen dose Switching to a three-phase COC Switching to a COC with another progestogen
Decreased libido	Switching to a three-phase COC - Switching from 20 to 30 mcg/day ethinyl estradiol
Depression
Acne	Switching to COCs with an antiandrogenic effect
Breast engorgement	Switching from triphasic to monophasic COCs Switching to ethinyl estradiol + drospirenone Switching from 30 to 20 mcg/day ethinyl estradiol
Vaginal dryness	Switching to a three-phase COC Switching to a COC with another progestogen
Pain in the calf muscles	Switching to 20 mcg/day ethinyl estradiol
Scanty menstruation	Switching from monophasic to triphasic COC Switching from 20 to 30 mcg/sutethinyl estradiol
Heavy menstruation	Switching to a monophasic COC with levonorgestrel or desogestrel Switching to 20 mcg/day ethinyl estradiol
Intermenstrual bloody issues at the beginning and middle of the cycle	Switching to a three-phase COC Switching from 20 to 30 mcg/day ethinyl estradiol
Intermenstrual bleeding in the second half of the cycle	Switching to COC from higher dose progestogen
Amenorrhea while taking COCs	Pregnancy must be excluded Together with COC ethinyl estradiol throughout the entire cycle Switching to COC with a lower dose of progestogen and a higher dose of estrogen, for example triphasic

The basic principles for monitoring women using COCs are as follows:

in an annual gynecological examination, including colposcopy and cytological examination;
in examining the mammary glands every six months (in women with a history of benign tumors breast and/or breast cancer in the family), mammography once a year (in perimenopausal patients);
in regular blood pressure measurement: when diastolic blood pressure increases to 90 mm Hg. and more - stopping taking COCs;
in a special examination according to indications (if side effects develop, complaints arise).

In case of menstrual dysfunction - exclude pregnancy and transvaginal ultrasound scanning uterus and its appendages.

RULES FOR TAKEN 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”). In this case, the packs should be taken without interruption, which reduces the likelihood that the woman will forget to start taking the next pack on time.

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.

Women who are breastfeeding:

COCs are not prescribed earlier than 6 weeks after birth;
in the period from 6 weeks to 6 months after childbirth, if a woman is breastfeeding, use COCs only if absolutely necessary (the method of choice is minipills);
more than 6 months after birth, COCs are prescribed:
♦for amenorrhea - see the section “Women with amenorrhea”;
♦with a restored menstrual cycle - see the section “Women with a regular menstrual cycle.”

PROLONGED REGIMEN OF PRESCRIPTION OF COMBINED ORAL CONTRACEPTIVES

Prolonged contraception provides for an increase in cycle duration from 7 weeks to several months. For example, it may consist of taking 30 mcg ethinyl estradiol and 150 mcg desogestrel or any other COC in a continuous regimen. There are several long-acting contraceptive regimens. The short-term dosing regimen allows you to delay menstruation for 1–7 days; it is practiced before an upcoming surgical intervention, vacation, honeymoon, business trip, etc. The long-term dosing regimen allows you to delay menstruation from 7 days to 3 months. As a rule, it is used for medical reasons for menstrual irregularities, endometriosis, MM, anemia, diabetes mellitus etc.

Long-acting contraception can be used not only to delay menstruation, but also for therapeutic purposes. For example, after surgical treatment endometriosis in a continuous manner for 3–6 months, which significantly reduces the symptoms of dysmenorrhea, dyspareunia, and helps improve the quality of life of patients and their sexual satisfaction.

The prescription of long-acting contraception is also justified in the treatment of MM, since in this case the synthesis of estrogen by the ovaries is suppressed, the level of total and free androgens, which under the influence of aromatase synthesized in the fibroid tissues, can be converted into estrogens, decreases. At the same time, women do not observe estrogen deficiency in the body due to its replenishment with ethinyl estradiol, which is part of the COC. Studies have shown that in PCOS, continuous use of Marvelon© for 3 cycles causes a more significant and persistent decrease in LH and testosterone, comparable to that with the use of GnRH agonists, and contributes to a much greater reduction in these indicators than when taken in the standard regimen.

In addition to the treatment of various gynecological diseases, the use of the method of prolonged contraception is possible in the treatment of dysfunctional uterine bleeding, hyperpolymenorrhea syndrome in perimenopause, as well as for the purpose of relieving vasomotor and neuropsychic disorders of menopausal syndrome. In addition, prolonged contraception enhances the cancer-protective effect of hormonal contraception and helps prevent bone loss in women of this age group.

The main problem with the prolonged regimen was the high frequency of breakthrough bleeding and spotting, which was observed during the first 2–3 months of use. Currently available data indicate that the incidence of adverse reactions with extended cycle regimens is similar to those for conventional dosing regimens.

RULES FOR FORGOTTEN AND MISSED PILLS

If 1 tablet is missed:
♦less than 12 hours late in taking the dose - take the missed pill and continue taking the drug until the end of the cycle according to the previous regimen;
♦delay in appointment more than 12 hours - the same actions 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 to 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 taking them into your regular schedule, plus use additional methods of contraception for 7 days. If spotting begins after missing tablets, it is better to stop taking tablets from the current package and start new packaging after 7 days, counting from the start of missing pills.

RULES FOR PRESCRIPTION OF COMBINED ORAL CONTRACEPTIVES

Primary appointment - from the 1st day of the menstrual cycle. If reception is started later (but no later than the 5th day of the cycle), then in the first 7 days it is necessary to use additional methods of contraception.
Post-abortion appointment - immediately after the abortion. Abortion in the first and second trimesters, as well as septic abortion, are classified as category 1 conditions (there are no restrictions on the use of the method) for prescribing COCs.
Prescription after childbirth - in the absence of lactation - no earlier than the 21st day after birth (category 1). If there is lactation, do not prescribe COCs; use minipills no earlier than 6 weeks after birth (category 1).
Switching from high-dose COCs (50 mcg ethinyl estradiol) to low-dose ones (30 mcg ethinyl estradiol or less) - without a 7-day break (so that the hypothalamic-pituitary system does not become activated due to dose reduction).
Switching from one low-dose COC to another after the usual 7-day break.
Switching from a minipill to a COC on the first day of the next bleeding.
Switching from an injection drug to a COC on the day of the next injection.
Switching from a combined vaginal ring to a COC on the day the ring was removed or on the day a new one was supposed to be inserted. Additional contraception is not required.

Choosing the right drug for a particular patient can be very difficult. There is no simple way - to see what is missing and fill it up - so we will have to figure out what and where we are introducing in order to ensure not only effective contraception, but also good tolerability.

	progestogenic	androgenic	antiandrogenic	antimineralkorticoid	glucocorticoid
Progesterone	+	-	(+)	+	-
Dienogest	+++	-	++	-	-
Drospirenone	+	-	+	++	-
Levonorgestrel	++	+	-	-	-
Gestoden	+	+	-	(+)	-
IPA	+	+	-	-	++
Norgestimate	++	+	-	-	-
Norethisterone	+++	+	-	-	-
Cyproterone acetate	+	-	+++	-	+++
Desogestrel	+	+	-	-	+

Alas, to individually select a contraceptive combination, it is not enough to simply hold a sign in front of your eyes. What scientists obtained in an experiment does not always coincide with what will happen in the body of a particular patient.

Attempts to systematize the methodology for selecting COCs based on phenotype have been and are being made. The idea sounds very tempting. Breasts are large and lush - which means there is a lot of estrogen. The bust “takes after my father” means there is not enough estrogen. It would seem that they have already decided which drug to prescribe.

Various phenotypes have been identified in women - with a predominance of the estrogenic, androgenic or progesterone component. Depending on what type the patient belongs to, it is proposed to select the starting dosage of estrogen and the optimal gestagen.

Perhaps this makes some sense (although this point of view does not have serious evidence: all the work was carried out on relatively small groups of patients). But it is much more important for a practicing doctor to understand what exactly a particular drug contains and why a particular patient needs this content.

This is why we have many doctors who prefer to prescribe the same 2-3 drugs. They have studied them sufficiently, are confident in their knowledge and have accumulated decent experience in their own observations.

Selection of a drug based on individual problems

While talking with the patient and conducting an examination, the doctor “catches” small details, problems, features that can be eliminated, smoothed out or leveled out by using a specific drug.

If the patient has heavy and prolonged menstruation without apparent reason(idiopathic menorrhagia), Klaira is perfect for her.
For patients with PCOS, we will offer Yarina or Diana-35, depending on the severity of hyperandrogenism.
Jess is perfect for patients with PMS.
For patients with endometriosis - Janine.
For young girls, it is better to recommend drugs with a minimal estrogen content and a formula that can “withstand the blow” of possible omissions and errors.
For women 35+, it is preferable to offer drugs with estrogens identical to endogenous ones (Klaira and Zoeli).
If obvious signs of estrogen deficiency are evident, you can try to start with multiphase drugs containing different dosages hormones.
Women under 35 years of age who smoke (and have recently quit smoking) should be offered a drug with minimum dose estrogens.
If a detailed conversation and examination do not reveal any peculiarities, the drug of first choice should be a monophasic COC with an estrogen content of no more than 30 mcg/day. and low androgenic gestagen.

Unfortunately, Before starting to take COCs, it is impossible to predict exactly how a woman’s body will react to a specific combination. Neither phenotypic tables nor deep knowledge of biochemistry, biophysics and clinical pharmacology, nor the disciplined donation of blood “for all hormones.” Armed with knowledge, you can only avoid very serious mistakes and correct them in time by analyzing the tolerability of previously used drugs. Therefore, the reality is that the best person to select COCs is the doctor who knows which 15 combinations were not suitable for the patient.

It is important to understand that this is not about the lack of qualifications of your gynecologist and, of course, no one is experimenting on you. In any case, the doctor tries to find the optimal contraceptive option as soon as possible. And with high probability his search will be crowned with success.

Oksana Bogdashevskaya

Photo thinkstockphotos.com

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Many modern women are interested in the answer to the question, how do hormonal contraceptives act on the body? The most effective in the modern world are considered combined agents(COCs) created on the basis of progestogens and estrogens. They differ in composition, dosage of active components and generation. But here is the mechanism of action hormonal contraceptives combined type (COC) will be the same:

Suppression (blockade) of ovulation. Taking the tablet has a slowing (inhibiting) effect on the hypothalamic-pituitary system. Initially active substances suppress the release of certain releasing hormones by the hypothalamus. A reduction in their numbers leads to inhibition of the pituitary gland. The result of this is the absence of a peak in estradiol, LH and FSH in the middle of the menstrual cycle, and the attenuation of the postovulatory increase in progesterone in the blood. This effect of hormonal contraceptives blocks the production of endogenous hormones by the ovaries, but does not suppress their formation. The amount of estrogen when taking COCs corresponds to the follicular phase, which completely eliminates ovulation.
Thickening of cervical mucus. This secretion has many purposes, but the most important of them is to promote the movement of sperm into the uterine cavity. If the quality of mucus does not meet the norm (viscosity, thickness), then the biological material cannot achieve its goal. Taking COCs changes the biochemical properties of this secretion. The mucus becomes too thick and viscous, which prevents the penetration of biomaterial into the cervix.
Effect on implantation (fixation of the fetus in the uterus). The mechanism of action of hormonal contraceptives is such that even if ovulation and then fertilization have occurred, the mature and fertilized egg will still not be able to attach to the wall of the uterus. Taking COCs changes the quality of the endometrium - it becomes thinner (transformation).

The mechanism of action on the body of the mini-drink

More gentle drugs are mini-drink tablets based on synthetic gestagens. The gentle principle of action of hormonal contraceptives of this class is based on the minimum content (low dose) of gestagens, which leads to:

Increased viscosity of mucus (cervical). The progestogens included in the composition reduce the volume of crypts, reduce the amount of sialic acid, narrow the cervical canal - all this makes it difficult for sperm to move through the woman’s genitals.
Inhibition of the activity of the uterine tubes.
Changes in the endometrium, which prevents the attachment of the fetus.
Impact on the formation of gonadotropic hormones. The main effect of low-dose hormonal contraceptives on the reproductive system is to suppress the secretion (production) of gonadotropic hormones from the pituitary gland, which prevents ovulation.
Changes in ovarian function.

Such effects of COCs and mini-drinks on the female body can in rare cases cause stress (slight weight gain, depression), but in contrast to this side effects the pills protect a woman from ovarian cancer, mastitis and infections.

remember, that contraception may have fundamental differences that must be taken into account when prescribing. Therefore, the most important thing when choosing is to visit a specialist who, based on the individual characteristics of the woman’s body, will select the right drug.

Gynecology: textbook / B. I. Baisova et al.; edited by G. M. Savelyeva, V. G. Breusenko. - 4th ed., revised. and additional - 2011. - 432 p. : ill.

Chapter 20. MODERN METHODS OF CONTRACEPTION

Medicines used to prevent pregnancy are called contraceptives. Contraception is an integral part of the family planning system and is aimed at regulating the birth rate, as well as preserving the health of women. Firstly, use modern methods Pregnancy protection reduces the frequency of abortions as the main cause of gynecological pathology, miscarriage, maternal and perinatal mortality. Secondly, contraceptives serve to regulate the onset of pregnancy depending on the health of the spouses, compliance with the interval between births, the number of children, etc. Third, some contraceptives have protective properties in relation to malignant neoplasms, inflammatory diseases of the genital organs, postmenopausal osteoporosis, they serve as a powerful aid in the fight against a number of gynecological diseases - infertility, ovarian apoplexy, menstrual irregularities, etc.

An indicator of the effectiveness of any contraceptive method is the Pearl index - the number of pregnancies occurring within 1 year in 100 women who used one or another method of contraception.

Modern methods of contraception are divided into:

Intrauterine;

Hormonal;

Barrier;

Natural;

Surgical (sterilization).

20.1. Intrauterine contraception

Intrauterine contraception (IUD)- this is contraception using means introduced into the uterine cavity. The method is widely used in Asian countries (primarily China), Scandinavian countries, and Russia.

The history of intrauterine contraception dates back to ancient times. However, the first such remedy was proposed in 1909 by the German gynecologist Richter: a ring made from the intestines of a silkworm, fastened with metal wire. Then they offered gold or silver ring with an internal disk (Ott ring), but since 1935 the use of IUDs has been prohibited

due to the high risk of developing inflammatory diseases of the internal genital organs.

Interest in this method of contraception was revived only in the 60s of the 20th century. In 1962, Lipps used flexible plastic in the form of a double Latin letter “S” to create a contraceptive, which allowed it to be inserted without significant expansion cervical canal. A nylon thread was attached to the device to remove the contraceptive from the uterine cavity.

Types of intrauterine contraceptives. IUDs are divided into inert (non-medicinal) and medicinal. The first include plastic IUDs of various shapes and designs, including the Lipps loop. Since 1989, WHO has recommended the abandonment of inert IUDs as ineffective and often causing complications. Medicinal IUDs have a plastic base of various configurations (loop, umbrella, number “7”, letter “T”, etc.) with the addition of metal (copper, silver) or a hormone (levonorgestrel). These supplements increase contraceptive effectiveness and reduce the number of adverse reactions. In Russia the most commonly used are:

Copper-containing Multiload- Si 375 (numbers indicate the surface area of the metal, in mm 2), designed for 5 years of use. It has an F-shape with spike-like protrusions for retention in the uterine cavity;

-Nova-T- T-shaped with a copper winding area of 200 mm 2 for 5 years of use;

Cooper T 380 A - T-shaped with high content copper; period of use - 6-8 years;

Hormonal intrauterine system"Mirena" *, which combines the properties of intrauterine and hormonal contraception, is a T-shaped contraceptive with a semi-permeable membrane through which levonorgestrel is released from a cylindrical reservoir (20 mcg/day). The period of use is 5 years.

Mechanism of action. The contraceptive effect of the IUD ensures a decrease in the activity or death of sperm in the uterine cavity (the addition of copper enhances the spermatotoxic effect) and an increase in the activity of macrophages that absorb sperm that enter the uterine cavity. When using an IUD with levonorgestrel, thickening of the cervical mucus under the influence of gestagen creates an obstacle to the passage of sperm into the uterine cavity.

In case of fertilization, the abortive effect of the IUD is manifested:

Increased peristalsis fallopian tubes, which leads to the penetration of the fertilized egg into the uterine cavity, which is not yet ready for implantation;

The development of aseptic inflammation in the endometrium as a reaction to a foreign body, which causes enzyme disorders (the addition of copper enhances the effect) that prevents the implantation of a fertilized egg;

Promotion contractile activity the uterus itself as a result of increased synthesis of prostaglandins;

Endometrial atrophy (for an intrauterine hormone-containing system) makes the process of implantation of the fertilized egg impossible.

The hormone-containing IUD, having a local effect on the endometrium due to the constant release of gestagen, inhibits proliferation processes and causes atrophy of the uterine mucosa, which is manifested by a decrease in the duration of menstruation or amenorrhea. At the same time, levo-norgestrel does not have a noticeable effect systemic influence on the body while maintaining ovulation.

The contraceptive effectiveness of IUDs reaches 92-98%; The Pearl index ranges from 0.2-0.5 (when using a hormone-containing IUD) to 1-2 (when using an IUD with copper additives).

An intrauterine contraceptive can be inserted on any day of the menstrual cycle if you are sure there is no pregnancy, but it is more advisable to do this on the 4-8th day from the start of menstruation. An IUD can be inserted immediately after an artificial termination of pregnancy or 2-3 months after childbirth, and after a cesarean section - no earlier than 5-6 months. Before inserting an IUD, the patient should be interviewed to identify possible contraindications and gynecological examination and bacterioscopic examination of smears from the vagina, cervical canal, urethra for microflora and degree of purity. An IUD can be inserted only with smears of I-II degree of purity. When using a contraceptive, you should carefully follow the rules of asepsis and antisepsis.

For 7-10 days after IUD insertion, it is recommended to limit physical activity, not take hot baths, laxatives and uterotonics, and avoid sex life. A woman should be informed about the timing of using the IUD, as well as about the symptoms of possible complications that require urgent medical attention. A repeat visit is recommended 7-10 days after insertion of the IUD, then at in good condition- after 3 months Clinical examination of women using an IUD involves visiting a gynecologist twice a year with microscopy of smears from the vagina, cervical canal and urethra.

The IUD is removed at the request of the patient, as well as due to the expiration of the period of use (when replacing an old IUD with a new one, there is no need to take a break), if complications develop. The IUD is removed by pulling the “antennae”. In the absence or breakage of the “antennae” (if the period of use of the IUD has been exceeded), it is recommended to carry out the procedure in a hospital setting. It is advisable to clarify the presence and location of the contraceptive using ultrasound. The IUD is removed after dilation of the cervical canal under hysteroscopy control. The location of the IUD in the uterine wall, which does not cause complaints from the patient, does not require removal of the IUD, since this can lead to serious complications.

Complications. When inserting an IUD, perforation of the uterus is possible (1 in 5000 insertions) up to the location of the contraceptive in abdominal cavity. Perforation is manifested by acute pain in the lower abdomen. The complication is diagnosed using pelvic ultrasound and hysteroscopy. In case of partial perforation, you can remove the contraceptive by pulling on the “antennae”. Complete perforation requires laparoscopy or laparotomy. Cha-

Strict perforation of the uterus often goes unnoticed and is detected only after an unsuccessful attempt to remove the IUD.

Most frequent complications ICH are pain, bleeding like menometrorrhagia, inflammatory diseases internal genital organs. Constant intense pain most often indicates a discrepancy between the sizes of the contraceptive and the uterus. Cramping pain in the lower abdomen and blood discharge from the genital tract are a sign of ex-pulsion of the IUD (spontaneous expulsion from the uterine cavity). The frequency of expulsions (2-9%) can be reduced by prescribing one of the NSAIDs (indomethacin, diclofenac - voltaren*, etc.) after insertion of the IUD.

The combination of pain with increased body temperature, purulent or purulent vaginal discharge indicates the development of inflammatory complications (0.5-4%). The diseases are particularly severe, with pronounced destructive changes in the uterus and appendages and often require radical surgical interventions. To reduce the incidence of such complications, prophylactic antibiotics are recommended for 5 days after IUD insertion.

Uterine bleeding is the most common (1.5-24%) complication of intrauterine contraception. These are menorrhagia, less often - metrorrhagia. An increase in menstrual blood loss leads to the development of iron deficiency anemia. Prescribing NSAIDs in the first 7 days after IUD insertion increases the acceptability of this method of contraception. A positive effect is achieved by prescribing combined oral contraceptives (COCs) 2-3 months before the introduction of an IUD and in the first 2-3 months after it, which facilitate the adaptation period. If menstruation remains heavy, the IUD must be removed. When metrorrhagia occurs, hysteroscopy and separate diagnostic curettage are indicated.

Pregnancy when using an IUD occurs rarely, but is not excluded. The frequency of spontaneous miscarriages when using an IUD increases. However, if desired, such a pregnancy can be maintained. The question of the need and timing of IUD removal remains controversial. There is an opinion about the possibility of removing the IUD for early stages, but this can lead to termination of pregnancy. Other experts consider it acceptable not to remove the contraceptive during pregnancy, believing that the IUD does not have a negative effect on the fetus due to its extra-amniotic location. Typically, the IUD is released along with the placenta and membranes in the third stage of labor. Some authors suggest terminating a pregnancy that occurs while using an IUD, since its prolongation increases the risk of septic abortion.

An IUD significantly reduces the possibility of pregnancy, including ectopic pregnancy. However, the frequency ectopic pregnancy in these cases higher than in the population.

In most cases, fertility is restored immediately after removal of the IUD. When using an IUD, there was no increase in the risk of developing cervical, uterine, or ovarian cancer.

Contraindications. TO absolute contraindications relate:

Pregnancy;

Acute or subacute inflammatory diseases of the pelvic organs;

Chronic inflammatory diseases of the pelvic organs with frequent exacerbations;

Malignant neoplasms of the cervix and uterine body. Relative contraindications:

Hyperpolymenorrhea or metrorrhagia;

Hyperplastic processes of the endometrium;

Algomenorrhea;

Hypoplasia and developmental anomalies of the uterus that interfere with the insertion of an IUD;

Cervical canal stenosis, cervical deformation, isthmic-cervical insufficiency;

Anemia and other blood diseases;

Submucous uterine fibroids (small nodes without deformation of the cavity are not a contraindication);

Severe extragenital diseases of inflammatory etiology;

History of frequent IUD expulsions;

Allergy to copper, hormones (for medicated IUDs);

No history of childbirth. However, some experts allow the use of IUDs in nulliparous women with a history of abortion, provided there is only one sexual partner. In nulliparous patients, the risk of complications associated with the use of IUDs is higher.

It must be emphasized that many contraindications for the use of conventional IUDs become indications for the use of hormone-containing IUDs. Thus, ♠ levonorgestrel contained in Mirena has a therapeutic effect in hyperplastic processes endometrium after establishing a histological diagnosis, with uterine fibroids, with menstrual irregularities, reducing menstrual blood loss and eliminating pain.

The advantages of intrauterine contraception include:

High efficiency;

Possibility of long-term use;

Immediate contraceptive effect;

Rapid restoration of fertility after removal of the IUD;

Lack of connection with sexual intercourse;

Low cost (except for the hormonal intrauterine system);

Possibility of use during lactation;

Therapeutic effect for certain gynecological diseases (for the hormonal intrauterine system).

The disadvantages are the need for medical manipulation during insertion and removal of the IUD and the possibility of complications.

20.2. Hormonal contraception

Hormonal contraception has become one of the most effective and widespread methods of birth control.

The idea of hormonal contraception arose at the beginning of the 20th century, when the Austrian physician Haberland discovered that the administration of ovarian extract causes temporary sterilization. After the discovery of sex hormones (estrogen in 1929 and progesterone in 1934), an attempt was made to synthesize artificial hormones, and in 1960 the American scientist Pincus et al. created the first contraceptive pill, Enovid. Hormonal contraception developed along the path of reducing the dose of steroids (estrogens) and along the path of creating selective (selective action) gestagens.

At the 1st stage, drugs were created with a high estrogen content (50 mcg) and many serious side effects. At the 2nd stage, contraceptives with a low content of estrogens (30-35 mcg) and gestagens with selective action appeared, which made it possible to significantly reduce the number of complications when taking them. To medications III generation include products containing low (30-35 mcg) or minimal (20 mcg) doses of estrogens, as well as highly selective gestagens (norgestimate, desogestrel, gestodene, dienogest, drospirenone), which have an even greater advantage over their predecessors.

Composition of hormonal contraceptives. All hormonal contraceptives (HCs) consist of estrogen and progestogen or only progestogen components.

Ethinyl estradiol is currently used as estrogen. Along with the contraceptive effect, estrogens cause proliferation of the endometrium, prevent the rejection of the uterine mucosa, providing a hemostatic effect. The lower the dose of estrogen in the drug, the higher the possibility of “intermenstrual” bleeding. Currently, GCs are prescribed with an ethinyl estradiol content of no more than 35 mcg.

Synthetic gestagens (progestogens, synthetic progestins) are divided into progesterone derivatives and nortestosterone derivatives (norsteroids). Progesterone derivatives (medroxyprogesterone, megestrol, etc.) when taken orally do not provide a contraceptive effect, since they are destroyed under the influence of gastric juice. They are used primarily for injectable contraception.

Norsteroids of the first generation (norethisterone, ethynodiol, linestrenol) and more active norsteroids of the second generation (norgestrel, levonorgestrel) and third generation (norgestimat, gestodene, desogestrel, dienogest, drospirenone) after absorption into the blood bind to progesterone receptors, exerting a biological effect. The gestagenic activity of norsteroids is assessed by the degree of binding to progesterone receptors; it is significantly higher than that of progesterone. In addition to the gestagenic effect, norsteroids produce androgenic, anabolic and mineralocorticoid effects expressed to varying degrees.

effects due to interaction with relevant receptors. Third generation gestagens, on the contrary, have an antiandrogenic effect on the body as a result of increased synthesis of globulin, which binds free testosterone in the blood, and high selectivity (the ability to bind to progesterone receptors to a greater extent than to androgen receptors), as well as an antimineralocorticoid effect (drospirenone ). Group classification:

Combined estrogen-progestin contraceptives:

Oral;

Vaginal rings;

Plasters;

Progestin contraceptives:

Oral contraceptives containing microdoses of gestagens (mini-pills);

Injectable;

Implants.

Combined oral contraceptives(KOK) - these are tablets containing estrogen and progestogen components (Table 20.1).

Mechanism of action COC is diverse. Contraceptive effect is achieved as a result of blockade of the cyclic processes of the hypothalamic-pituitary system in response to the administration of steroids (the principle feedback), as well as due to the direct inhibitory effect on the ovaries. As a result, follicle growth, development and ovulation do not occur. In addition, progestogens, by increasing the viscosity of cervical mucus, make it impenetrable for sperm. Finally, the gestagenic component slows down the peristalsis of the fallopian tubes and the movement of the egg through them, and in the endometrium causes regressive changes up to atrophy, as a result of which implantation of the fertilized egg, if fertilization does occur, becomes impossible. This mechanism of action ensures high reliability of COCs. At correct use contraceptive effectiveness reaches almost 100%, the Pearl index is

0,05-0,5.

Based on the level of ethinyl estradiol, COCs are divided into high-dose (more than 35 mcg; currently not used for contraceptive purposes), low-dose (30-35 mcg) and micro-dose (20 mcg). In addition, COCs are monophasic, when all the tablets included in the package have the same composition, and multiphase (two-phase, three-phase), when the package, designed for a dosage cycle, contains two or three types of tablets of different colors, differing in the amount of estrogenic and gestagenic components. Stepped dosage causes cyclic processes in target organs (uterus, mammary glands), reminiscent of those during a normal menstrual cycle.

Complications when taking COCs. Due to the use of new low- and micro-dose COCs containing highly selective gestagens, side effects when using GCs are rare.

Table 20.1. Currently used COCs, indicating the composition and dose of their components

A small percentage of women taking COCs may experience discomfort during the first 3 months of use due to the metabolic effects of sex steroids. Estrogen-dependent effects include nausea, vomiting, swelling, dizziness, heavy menstrual-like bleeding, and gestagen-dependent effects include irritability, depression, increased fatigue, decreased libido. Headache, migraine, engorgement of the mammary glands, and bleeding can be caused by the action of both components of the COC. Currently, these signs are

are seen as symptoms of adaptation to COCs; usually they do not require the prescription of corrective agents and disappear on their own by the end of the 3rd month of regular use.

The most serious complication when taking COCs is the effect on the hemostatic system. It has been proven that the estrogen component of COCs activates the blood coagulation system, which increases the risk of thrombosis, primarily coronary and cerebral, as well as thromboembolism. The possibility of thrombotic complications depends on the dose of ethinyl estradiol included in the COC and risk factors, which include age over 35 years, smoking, hypertension, hyperlipidemia, obesity, etc. It is generally accepted that the use of low or micro-dose COCs does not have a significant effect on the hemostatic system in healthy people women.

When taking COCs, blood pressure increases, which is due to the influence of the estrogen component on the renin-angiotensin-aldosterone system. However, this phenomenon was noted only in women with an unfavorable history (hereditary predisposition, obesity, hypertension in the present, OPG-gestosis in the past). Clinically significant change Blood pressure was not detected in healthy women taking COCs.

When using COCs, a number of metabolic disorders are possible:

A decrease in glucose tolerance and an increase in its level in the blood (estrogenic effect), which provokes the manifestation of latent forms of diabetes mellitus;

The adverse effect of gestagens on lipid metabolism (increased levels of total cholesterol and its atherogenic fractions), which increases the risk of developing atherosclerosis and vascular complications. However, modern selective gestagens included in third-generation COCs do not have a negative effect on lipid metabolism. In addition, the effect of estrogens on lipid metabolism is directly opposite to the effect of gestagens, which is regarded as a factor protecting the vascular wall;

Increased body weight due to the anabolic effect of gestagens, fluid retention due to the influence of estrogens, and increased appetite. Modern COCs with low estrogen content and selective gestagens have virtually no effect on body weight.

Estrogens may have a slight toxic effect on the liver, manifested in a transient increase in transaminase levels, cause intrahepatic cholestasis with the development of cholestatic hepatitis and jaundice. Progestins, increasing the concentration of cholesterol in bile, contribute to the formation of stones in the bile ducts and bladder.

Acne, seborrhea, hirsutism are possible when using gestagens with a pronounced androgenic effect. The highly selective gestagens currently used, on the contrary, have an antiandrogenic effect, and they provide not only a contraceptive, but also a therapeutic effect.

A sharp deterioration in vision when using COCs is a consequence of acute retinal thrombosis; in this case, immediate discontinuation of the drug is required. It should be taken into account that COCs when using contact lenses cause swelling of the cornea with a feeling of discomfort.

Rare but concerning complications include amenorrhea that occurs after discontinuation of COCs. There is an opinion that COCs do not cause amenorrhea, but only hide hormonal disorders due to regular menstrual-like bleeding. Such patients must be examined for a pituitary tumor.

Long-term use of COCs changes the microecology of the vagina, promoting the occurrence of bacterial vaginosis, vaginal candidiasis. In addition, the use of COCs is considered a risk factor for the transition of existing cervical dysplasia to carcinoma. Women taking COCs should undergo regular cytological studies cervical smears.

Any component of the COC may cause an allergic reaction.

One of the most common side effects is uterine bleeding when using COCs (from spotting to breakthrough). The causes of bleeding are a lack of hormones for a particular patient (estrogens - when bleeding appears in the 1st half of the cycle, gestagens - in the 2nd half), impaired absorption of the drug (vomiting, diarrhea), missed pills, competitive effect of those taken with COCs medications (some antibiotics, anticonvulsants, β-blockers, etc.). In most cases, intermenstrual bleeding disappears on its own during the first 3 months of taking COCs and does not require discontinuation of contraceptives.

COCs do not have a negative effect on fertility in the future (it is restored in most cases within the first 3 months after discontinuation of the drug) and do not increase the risk of fetal defects. Incidental use of modern hormonal contraceptives in early pregnancy does not produce mutagenic, teratogenic effect and does not require termination of pregnancy.

Towards the contraceptive benefits of COCs include:

Highly effective and almost immediate contraceptive effect;

Reversibility of the method;

Low incidence of side effects;

Good fertility control;

Lack of connection with sexual intercourse and influence on the sexual partner;

Eliminating the fear of unwanted pregnancy;

Easy to use. Non-contraceptive benefits of COCs:

Reducing the risk of developing ovarian cancer (by 45-50%), endometrial cancer (by 50-60%), benign breast diseases (by 50-75%), uterine fibroids (by 17-31%), postmenopausal osteoporosis (increased mineralization bone tissue), colorectal cancer (by 17%);

Reduced incidence of inflammatory diseases of the pelvic organs (by 50-70%) as a result of increased viscosity of cervical mucus, ectopic pregnancy, retention tumors

ovarian cysts (up to 90%), iron deficiency anemia due to less blood loss during menstrual-like discharge than during normal menstruation;

Relieving symptoms of premenstrual syndrome and dysmenorrhea;

Therapeutic effect for acne, seborrhea, hirsutism (for third-generation COCs), endometriosis, uncomplicated cervical ectopia (for triphase COCs), for some forms of infertility accompanied by ovulation disorders (rebound effect after discontinuation

COOK);

Increasing the acceptability of ICH;

Positive effect on the course of rheumatoid arthritis. The protective effect of COCs appears after 1 year of use, increases with increasing duration of use and persists for 10-15 years after discontinuation.

Disadvantages of the method: the need for daily administration, the possibility of errors during administration, lack of protection against sexually transmitted infections, decreased effectiveness of COCs when taking other medications simultaneously.

Indications. Currently, according to WHO criteria, hormonal contraception is recommended for women of any age who wish to limit their reproductive function:

In the post-abortion period;

IN postpartum period(3 weeks after birth, if the woman is not breastfeeding);

With a history of ectopic pregnancy;

Having suffered from inflammatory diseases of the pelvic organs;

With menometrorrhagia;

With iron deficiency anemia;

With endometriosis, fibrocystic mastopathy (for monophasic

COOK);

With premenstrual syndrome, dysmenorrhea, ovulatory syndrome;

With retention formations of the ovaries (for monophasic COCs);

With acne, seborrhea, hirsutism (for COCs with third generation gestagens). Contraindications. Absolute contraindications to the use of COCs:

Hormone dependent malignant tumors(tumors of the genital organs, breast) and liver tumors;

Severe dysfunction of the liver and kidneys;

Pregnancy;

Heavy cardiovascular diseases, vascular diseases of the brain;

Bleeding from the genital tract of unknown etiology;

Severe hypertension (blood pressure above 180/110 mm Hg);

Migraines with focal neurological symptoms;

Acute deep vein thrombosis, thromboembolism;

Prolonged immobilization;

A period including 4 weeks before abdominal surgery and 2 weeks after it (increased risk of thrombotic complications);

Smoking and age over 35 years;

Diabetes mellitus with vascular complications;

Obesity III-IV degree;

Lactation (estrogens pass into breast milk).

The possibility of using oral contraception for other diseases, the course of which may be affected by COCs, is determined individually.

Conditions requiring immediate discontinuation of GC:

Sudden severe headache;

Sudden loss of vision, coordination, speech, loss of sensation in the limbs;

Acute chest pain, unexplained shortness of breath, hemoptysis;

Acute abdominal pain, especially prolonged;

Sudden pain in the legs;

Significant increase in blood pressure;

Itching, jaundice;

Skin rash.

Rules for taking COCs. COCs are started to be taken from the 1st day of the menstrual cycle: 1 tablet daily at the same time of day for 21 days (as a rule, the drug package contains 21 tablets). It should be remembered that multiphase drugs must be taken in a strictly specified sequence. Then they take a 7-day break, during which a menstrual-like reaction occurs, after which they begin a new cycle of administration. When performing an artificial abortion, you can start taking COCs on the day of the operation. If a woman does not breastfeed, the need for contraception arises 3 weeks after birth. If it is necessary to delay menstrual-like bleeding, you can not take a break in taking the drugs, continuing to take the tablets of the next package (for multiphase contraceptives, only the tablets of the last phase are used for this).

For microdosed COC Jess*, containing 28 tablets per pack, the dosage regimen is as follows: 24 active tablets followed by 4 placebo tablets. Thus, the effect of hormones is extended for another 3 days, and the presence of placebo tablets makes it easier to comply with the contraceptive regimen.

There is another scheme for using monophasic COCs: taking 3 cycles of tablets in a row, then a 7-day break.

If the interval between taking pills is more than 36 hours, the reliability of the contraceptive effect is not guaranteed. If a pill is missed in the 1st or 2nd week of the cycle, then the next day you need to take 2 tablets, and then take the pills as usual, using additional contraception for 7 days. If you missed 2 tablets in a row on the 1st or 2nd week, then in the next 2 days you should take 2 tablets, then continue taking the tablets according to the usual regimen, using additional methods of contraception until the end of the cycle. If you miss a pill last week cycle, it is recommended to start taking the next package without interruption.

When used correctly, COCs are safe. The duration of use does not increase the risk of complications, so you can use COCs for as many years as necessary, until the onset of postmenopause. It has been proven that taking breaks from taking medications is not only unnecessary, but also risky, since during this period the likelihood of an unwanted pregnancy increases.

Vaginal ring "NovaRing" ♠ refers to estrogen-gestagen contraception with parenteral supply of hormones to the body. "No-Varing" * is a flexible plastic ring that is inserted deep into the vagina from the 1st to the 5th day of the menstrual cycle for 3 weeks and then removed. After a 7-day break, during which bleeding appears, a new ring is introduced. While in the vagina, NuvaRing* daily releases a constant small dose of hormones (15 mcg ethinyl estradiol and 120 mcg of the gestagen etonogestrel), which enter the systemic circulation, which provides reliable contraception (Pearl index - 0.4). "NovaRing" * does not interfere with active Lifestyle, play sports, swim. There were no cases of the ring falling out of the vagina. Any discomfort The vaginal ring does not cause problems in partners during sexual intercourse.

Using transdermal contraceptive system "Evra" * a combination of estrogen and progestogen enters the body from the surface of the patch through the skin, blocking ovulation. 20 mcg of ethinyl estradiol and 150 mcg of norelgestramine are absorbed daily. One package contains 3 patches, each of which is applied alternately for 7 days on the 1st, 8th, 15th days of the menstrual cycle. The patches are attached to the skin of the buttocks, abdomen, and shoulders. On the 22nd day, the last patch is removed, and the next package begins to be used after a week's break. The patch is securely attached to the skin and does not interfere with active image life, does not come off even during water procedures, nor under the influence of the sun.

Transvaginal and transdermal routes of entry of contraceptive hormones into the body have a number of advantages over the oral route. Firstly, a smoother flow of hormones throughout the day provides good control of the cycle. Secondly, due to the absence of the primary passage of hormones through the liver, a smaller daily dose is required, which reduces the negative side effects of hormonal contraception to a minimum. Thirdly, there is no need to take a pill every day, which eliminates the possibility of violating the correct use of the contraceptive.

Indications, contraindications, negative and positive effects"NovaRinga" ♠ and "Evra" patches ♠ are the same as those used by COCs.

Oral progestin contraceptives (OGC) contain small doses of gestagens (mini-pills) and were created as an alternative to COCs. OGK is used in women for whom drugs containing estrogens are contraindicated. The use of pure gestagens, on the one hand, reduces the number of complications of hormonal contraception, and on the other, reduces the acceptability of this type of contraception. Due to the lack of estrogens, which prevent the endometrium from being rejected, intermenstrual discharge is often observed when taking OGK.

OGKs include demoulene * (ethinodiol 0.5 mg), microlute * (levonor-gestrel 0.03 mg), exluton * (linestrenol 0.5 mg), charosette * (desogestrel

0.075 mg).

ActionOGK is caused by an increase in the viscosity of cervical mucus, the creation in the endometrium of conditions unfavorable for the implantation of a fertilized egg, and a decrease in the contractility of the fallopian tubes. The dose of steroids in the minipill is not sufficient to effectively suppress ovulation. More than half of women taking OGCs have normal ovulatory cycles, so the contraceptive effectiveness of OGCs is lower than COCs; The Pearl index is 0.6-4.

Currently, only a few women use this method of contraception. These are mainly breastfeeding women (OGCs are not contraindicated during lactation), smokers, women in the late reproductive period, with contraindications to the estrogen component of COCs.

Mini-pills are taken from the 1st day of menstruation, 1 tablet per day continuously. It should be remembered that the effectiveness of OGK decreases if a dose is missed for 3-4 hours. Such a violation of the regimen requires the use additional methods contraception for at least 2 days.

To the above contraindications caused by gestagens, it is necessary to add a history of ectopic pregnancy (gestagens slow down the transport of the egg through the tubes) and ovarian cysts (gestagens often contribute to the occurrence of retention formations of the ovary).

OGK advantages:

Less systemic effect on the body compared to COCs;

No estrogen-dependent side effects;

Possibility of use during lactation. Disadvantages of the method:

Less contraceptive effectiveness compared to COCs;

High probability of bleeding.

Injectable contraceptives used for prolonged contraception. Currently, Depo-Provera * containing medroxyprogesterone is used for this purpose. The Pearl index of injection contraception does not exceed 1.2. The first intramuscular injection is given in any of the first 5 days of the menstrual cycle, the next - every 3 months. The drug can be administered immediately after an abortion, after childbirth if the woman is not breastfeeding, and 6 weeks after birth if she is breastfeeding.

Mechanism of action and contraindications to the use of Depo-Provera * are similar to those for OGK. Advantages of the method:

High contraceptive effectiveness;

No need to take the drug daily;

Duration of action;

Few side effects;

Absence of estrogen-dependent complications;

The ability to use the drug for therapeutic purposes in case of hyperplastic processes of the endometrium, benign diseases of the mammary glands, uterine fibroids, adenomyosis.

Disadvantages of the method:

Delayed restoration of fertility (from 6 months to 2 years after discontinuation of the drug);

Frequent bleeding (subsequent injections lead to amenorrhea).

Injection contraception is recommended for women who need long-term reversible contraception during lactation, who have contraindications to the use of estrogen-containing drugs, and who do not want to take hormonal contraceptives daily.

Implants provide a contraceptive effect as a result of the constant long-term release of a small amount of gestagens. In Russia, Norplant * is registered as an implant, containing levonorgestrel and consisting of 6 silastic capsules for subcutaneous administration. The level of levonorgestrel required for contraception is achieved within 24 hours after administration and is maintained for 5 years. Capsules are introduced under the skin of the inner side of the forearm in a fan-shape through a small incision under local anesthesia. The Pearl index for norplant is 0.2-1.6. The contraceptive effect is achieved as a result of suppression of ovulation, increased viscosity of cervical mucus and the development of atrophic changes in the endometrium.

Norplant is recommended for women who need long-term (at least 1 year) reversible contraception, with estrogen intolerance, and who do not want to take hormonal contraceptives daily. Upon expiration or at the request of the patient, the contraceptive is removed surgically. Fertility is restored within a few weeks after the capsules are removed.

In addition to Norplant, there is a single-capsule implantation contraceptive Implanon p* containing etonogestrel - a highly selective gestagen of the latest generation, a biologically active metabolite of deso-gestrel. Implanon is administered and removed four times faster than a multicapsule drug; complications are observed less frequently (less than 1%). Implanon provides long-term contraception for 3 years, high efficiency, lower incidence of adverse reactions, rapid restoration of fertility and therapeutic effects inherent in progestin contraceptives.

Advantages of the method: high efficiency, duration of contraception, safety (few side effects), reversibility, absence of estrogen-dependent complications, no need to take the drug daily.

Disadvantages of the method: Frequent bleeding, need surgical intervention for insertion and removal of capsules.

* This drug is currently being registered with the Ministry of Health and social development RF in the Department of State Regulation of Medicines Circulation.

20.3. Barrier methods of contraception

Currently, due to the increase in the number of sexually transmitted diseases, the number of people using barrier methods has increased. Barrier methods of contraception are divided into chemical and mechanical.

Chemical methods of contraception (spermicides) - These are chemicals that are harmful to sperm. The main spermicides included in the finished forms are nonoxynol-9 and benzalkonium chloride. They destroy cell membrane sperm. The contraceptive effectiveness of spermicides is low: the Pearl index is 6-20.

Spermicides are produced in the form of vaginal tablets, suppositories, pastes, gels, creams, films, foams with special nozzles for intravaginal administration. Benzalkonium chloride (pharmatex *) and nonoxynol (patentex oval *) deserve special attention. Suppositories, tablets, films with spermicides are inserted into the upper part of the vagina 10-20 minutes before sexual intercourse (the time required for dissolution). Cream, foam, gel immediately after administration exhibit contraceptive properties. Repeated sexual intercourse requires additional administration of spermicides.

There are special polyurethane sponges impregnated with spermicides. Sponges are inserted into the vagina before sexual intercourse (can be a day before sexual intercourse). They have the properties of chemical and mechanical contraceptives, since they create a mechanical barrier to the passage of sperm and secrete spermicides. It is recommended to leave the sponge in for at least 6 hours after sexual intercourse to ensure a reliable contraceptive effect, but no later than 30 hours later it should be removed. If a sponge is used, then additional spermicide is not required for repeated sexual intercourse.

In addition to the contraceptive effect, spermicides provide some protection against sexually transmitted infections, since the chemicals have bactericidal and viruscidal properties. However, the risk of infection still remains, and for HIV infection it even increases due to the increased permeability of the vaginal wall under the influence of spermicides.

Advantages of chemical methods: short duration of action, no systemic effect on the body, few side effects, protection against sexually transmitted infections.

Disadvantages of methods: the possibility of developing allergic reactions, low contraceptive effectiveness, connection of use with sexual intercourse.

TO mechanical methods of contraception These include condoms, cervical caps, and vaginal diaphragms, which create a mechanical barrier to the penetration of sperm into the uterus.

Condoms are the most widely used. There are male and female condoms. The male condom is a thin, cylindrical pouch made of latex or vinyl; some condoms are treated with spermicides. The condom is put on

erect penis before sexual intercourse. The penis should be removed from the vagina before the erection stops in order to avoid the condom slipping and sperm entering the woman’s genital tract. Cylindrical female condoms are made of polyurethane film and have two rings. One of them is inserted into the vagina and put on the cervix, the other is taken outside the vagina. Condoms are disposable products.

Pearl index for mechanical methods ranges from 4 to 20. The effectiveness of a condom is reduced if it is used incorrectly (use of fatty lubricants that destroy the surface of the condom, repeated use of the condom, intense and prolonged sexual intercourse leading to microdefects of the condom, improper storage, etc.). Condoms are good protection against sexually transmitted infections, but infection with viral diseases and syphilis is still possible through contact between damaged skin sick and healthy partner. Side effects include latex allergy.

This type of contraception is indicated for patients who have casual sex, with a high risk of infection, and who are rarely and irregularly sexually active.

For reliable protection against pregnancy and sexually transmitted infections, use “double Dutch method" - a combination of hormonal (surgical or intrauterine) contraception and a condom.

The vaginal diaphragm is a dome-shaped device made of latex with an elastic rim around the edge. The diaphragm is inserted into the vagina before sexual intercourse so that the dome covers the cervix and the rim fits closely to the walls of the vagina. The diaphragm is usually used with spermicides. If sexual intercourse is repeated after 3 hours, repeated administration of spermicides is required. After sexual intercourse, you should leave the diaphragm in the vagina for at least 6 hours, but no more than 24 hours. The removed diaphragm is washed with soap and water and dried. Using a diaphragm requires special training. It is not recommended to use a diaphragm for prolapse of the vaginal walls, old perineal ruptures, large sizes vagina, cervical diseases, inflammatory processes of the genital organs.

Cervical caps are metal or latex cups that are placed over the cervix. The caps are also used together with spermicides, administered before sexual intercourse, removed after 6-8 hours (maximum after 24 hours). After use, wash the cap and store it in a dry place. Contraindications to birth control using this method include diseases and deformities of the cervix, inflammatory diseases of the genital organs, prolapse of the vaginal walls, and the postpartum period.

Unfortunately, neither diaphragms nor caps protect against sexually transmitted infections.

TO benefits mechanical means of contraception include the absence of a systemic effect on the body, protection against sexually transmitted infections (for condoms), to shortcomings- connection between the use of the method and sexual intercourse, insufficient contraceptive effectiveness.

20.4. Natural methods of contraception

The use of these methods of contraception is based on the possibility of pregnancy in the days close to ovulation. To protect against pregnancy, abstain from sexual activity or use other methods of contraception on the days of the menstrual cycle with the highest probability of conception. Natural methods of birth control are ineffective: the Pearl index ranges from 6 to 40. This significantly limits their use.

To calculate the fertile period use:

Calendar (rhythmic) Ogino-Knaus method;

Rectal temperature measurement;

Examination of cervical mucus;

Symptothermal method.

Application calendar method is based on determining the average timing of ovulation (on average on the 14th day ± 2 days with a 28-day cycle), the lifespan of sperm (on average 4 days) and the egg (on average 24 hours). With a 28-day cycle, the fertile period lasts from the 8th to the 17th day. If the duration of the menstrual cycle is variable (the duration of at least the last 6 cycles is determined), then fertile period determined by subtracting from the short cycle 18 days, of the longest - 11. The method is acceptable only for women with a regular menstrual cycle. With significant fluctuations in duration, almost the entire cycle becomes fertile.

Temperature method based on determining ovulation by rectal temperature. The egg survives for a maximum of three days after ovulation. The fertile period is considered to be the period from the beginning of menstruation to the expiration of three days from the moment the rectal temperature rises. The long duration of the fertile period makes the method unacceptable for couples who are sexually active.

Cervical mucus During the menstrual cycle, it changes its properties: in the preovulatory phase, its quantity increases, it becomes more extensible. The woman is taught to evaluate cervical mucus over several cycles to determine when she ovulates. Conception is likely within two days before the mucus leaves and 4 days after. This method cannot be used for inflammatory processes in the vagina.

Symptothermal method based on monitoring rectal temperature, properties of cervical mucus and ovulatory pain. The combination of all methods allows you to more accurately calculate your fertile period. The symptothermal method requires scrupulousness and perseverance from the patient.

Interrupted sexual intercourse - one of the options for a natural method of contraception. Its advantages can be considered simplicity and lack of ma-

material costs. However, the contraceptive effectiveness of the method is low (Pearl index - 8-25). Failures are explained by the possibility of pre-ejaculatory fluid containing sperm entering the vagina. For many couples, this type of contraception is unacceptable because self-control reduces the feeling of satisfaction.

Natural methods of birth control are used by couples who do not want to use other means of contraception, fear side effects, or for religious reasons.

20.5. Surgical methods of contraception

Surgical methods of contraception (sterilization) are used in both men and women (Fig. 20.1). Sterilization in women causes obstruction of the fallopian tubes, making fertilization impossible. During sterilization in men, the vas deferens is ligated and crossed (vasectomy), after which sperm cannot enter the ejaculate. Sterilization is the most effective method of preventing pregnancy (Pearl index is 0-0.2). Pregnancy, although extremely rare, is explained by technical defects in the sterilization operation or recanalization of the fallopian tubes. It should be emphasized that sterilization is an irreversible method. Existing options for restoring the patency of the fallopian tubes (microsurgical operations) are complex and ineffective, and IVF is an expensive procedure.

Before the operation, a consultation is carried out, during which the essence of the method is explained, they are informed about its irreversibility, and the details of the history are clarified.

Rice. 20.1. Sterilization. Coagulation and division of the fallopian tube

problems that prevent sterilization, and also conduct a comprehensive examination. All patients are required to obtain written informed consent for the operation.

In our country it is voluntary surgical sterilization allowed since 1993. According to the Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens (Article 37), medical sterilization as a special intervention with the aim of depriving a person of the ability to reproduce offspring or as a method of contraception can be carried out only upon a written application from a citizen who is at least 35 years old or has at least 2 children, and if available medical indications and with the consent of the citizen - regardless of age and presence of children.

For medical indications These include diseases or conditions in which pregnancy and childbirth pose a health risk. Is the list of medical indications for sterilization determined by order? 121n dated 03/18/2009 Ministry of Health and Social Development of Russia.

Contraindications sterilization are diseases in which the operation is impossible. As a rule, these are temporary situations; they only cause the postponement of surgical intervention.

The optimal timing for the operation is the first few days after menstruation, when the likelihood of pregnancy is minimal, and the first 48 hours after childbirth. Sterilization during caesarean section is possible, but only with written informed consent.

The operation is performed under general, regional or local anesthesia. Laparotomy, mini-laparotomy, and laparoscopy are used. Laparotomy is used when sterilization is performed during another operation. The other two accesses are most often used. With a mini-laparotomy, the length of the skin incision does not exceed 3-4 cm; it is performed in the postpartum period, when the uterine fundus is high, or in the absence of appropriate specialists and laparoscopic equipment. Each access has its own advantages and disadvantages. The time required to perform the operation, regardless of the approach (laparoscopy or mini-laparotomy) is 10-20 minutes.

The technique for creating occlusion of the fallopian tubes is different - ligation, cutting with ligatures (Pomeroy method), removal of a segment of the tube (Parkland method), coagulation of the tube (see Fig. 20.1), application of titanium clamps (Filshi method) or silicone rings compressing the lumen of the tube .

The operation is associated with the risk of anesthetic complications, bleeding, hematoma formation, wound infections, inflammatory complications of the pelvic organs (during laparotomy), injuries of the abdominal organs and great vessels, gas embolism or subcutaneous emphysema (during laparoscopy).

In addition to the abdominal method of sterilization, there is a transcervical method, when occlusive substances are injected into the mouths of the fallopian tubes during hysteroscopy. The method is currently considered experimental.

Vasectomy in men is a simpler and less dangerous procedure, but in Russia few resort to it due to the false fear of adverse effects on sexual function. Inability to conceive occurs in men 12 weeks after surgical sterilization.

Advantages of sterilization: a one-time intervention that provides long-term protection against pregnancy and no side effects.

Disadvantages of the method: the need for surgery, the possibility of complications, irreversibility of the intervention.

20.6. Postcoital contraception

Postcoital, or emergency, contraception is a method of preventing pregnancy after unprotected intercourse. The purpose of this method is to prevent pregnancy at the stage of ovulation, fertilization, and implantation. The mechanism of action of postcoital contraception is diverse and manifests itself in desynchronization of the menstrual cycle, disruption of the processes of ovulation, fertilization, transport and implantation of the fertilized egg.

Emergency contraception cannot be used regularly, it should be used only in exceptional cases (rape, condom rupture, diaphragm displacement, if the use of other methods of birth control is impossible) or in women who have rare sexual intercourse.

The most common methods of post-coital contraception are the introduction of an IUD or the use of sex steroids after intercourse.

With the aim of emergency protection against pregnancy, an IUD is administered no later than 5 days after unprotected sexual intercourse. In this case, possible contraindications for using an IUD should be taken into account. This method can be recommended to patients who wish to continue using permanent intrauterine contraception, in the absence of a risk of infection of the genital tract (contraindicated after rape).

For hormonal postcoital contraception, COCs (Yuzpe method), pure gestagens or antiprogestins are prescribed. The first dose of COCs according to the Yuzpe method is necessary no later than 72 hours after unprotected sexual intercourse, the 2nd - 12 hours after the 1st dose. The total dose of ethinyl stradiol should not be less than 100 mcg at each dose. The drugs postinor ♠, containing 0.75 mg of levonorgestrel, and escapelle ♠, containing 1.5 mg of levonorgestrel, have been created specifically for postcoital gestagenic contraception. Postinor ♠ should be taken 1 tablet 2 times according to a scheme similar to the Yuzpe method. When using escapelle * 1 tablet must be used no later than 96 hours after unprotected sexual intercourse. The antiprogestin mifepristone in a dose of 10 mg binds progesterone receptors and prevents or interrupts the process of preparing the endometrium for implantation, caused by the action of progesterone. A single dose of 1 tablet is recommended within 72 hours after sexual intercourse.

Before prescribing hormones, it is necessary to exclude contraindications.

The effectiveness of various methods of this type of contraception ranges from 2 to 3 according to the Pearl index ( average degree reliability). High doses of hormones can cause side effects - uterine bleeding, nausea, vomiting, etc. A failure should be considered pregnancy, which, according to WHO experts, must be terminated due to the danger of the teratogenic effect of high doses of sex steroids. After using emergency contraception, it is advisable to conduct a pregnancy test; if the result is negative, choose one of the methods of planned contraception.

20.7. Teenage contraception

According to WHO definition, adolescents are young people aged 10 to 19 years. Early onset of sexual activity puts teenage contraception in one of the first places, since the first abortion or childbirth at a young age can seriously affect health, including reproductive health. Sexual activity among adolescents increases the risk of sexually transmitted diseases.

Contraception for young people should be highly effective, safe, reversible and affordable. Several types of contraception are considered acceptable for adolescents.

Combined oral contraception - microdosed, low-dose COCs with the latest generation of gestagens, triphasic COCs. However, estrogens contained in COCs can cause premature closure of the growth centers of the epiphyses of bones. Currently, it is considered acceptable to prescribe COCs with a minimum content of ethinyl estradiol after a teenage girl has completed her first 2-3 menstruation.

Postcoital contraception with COCs or gestagens is used for unplanned sexual intercourse.

Condoms combined with spermicides provide protection against sexually transmitted infections.

The use of pure gestagens in view frequent occurrence bleeding is not acceptable, and the use of an IUD is relatively contraindicated. Natural methods of birth control and spermicides are not recommended for adolescents due to their low effectiveness, and sterilization is unacceptable as an irreversible method.

20.8. Postpartum contraception

Most women in the postpartum period are sexually active, so contraception after childbirth remains relevant. Several types of postpartum contraception are currently recommended.

Method lactational amenorrhea(MLA) is a natural method of birth control, based on the inability to conceive when

regular breastfeeding. Prolactin released during lactation blocks ovulation. The contraceptive effect is ensured for 6 months after birth if the baby is breastfed at least 6 times a day, and the intervals between feedings are no more than 6 hours (the “three sixes” rule). During this period there are no menstruation. The use of other natural methods of contraception is excluded because the timing of the resumption of menstruation after childbirth cannot be predicted, and the first menstruation is often irregular.

Postpartum sterilization is currently performed even before discharge from the maternity hospital. Progestin-based oral contraception is allowed to be used during lactation. Prolonged progestin contraception (Depo-Provera *, Norplant *) can be started from the 6th week after birth while breastfeeding.

Condoms are used in combination with spermicides.

In the absence of lactation, it is possible to use any method of birth control (COCs - from the 21st day, IUD - from the 5th week of the postpartum period).

The creation of contraceptive vaccines based on the achievements of genetic engineering is promising. HCG, sperm, egg, and fertilized egg antigens are used as antigens.

A search is underway for contraceptives that cause temporary sterilization in men. Gossypol, isolated from cotton, when taken orally, caused the cessation of spermatogenesis in men for several months. However, many side effects did not allow this method to be put into practice. Research into developing hormonal contraception for men continues. It has been proven that the production of male germ cells can be stopped by introducing androgen and progestogen in the form of an injection or implant. After stopping the effect of the drug, fertility is restored within 3-4 months.

Text: Anastasia Travkina

Using hormonal contraception, of course, it’s already difficult to surprise anyone, but it’s easy to get lost in the myths that surround this topic. In the United States, up to 45% of women 15–44 years old prefer hormonal contraception, while in Russia only 9.5% of women have ever used it. With the help of gynecologist-endocrinologist Valentina Yavnyuk, we figured out how it works, what medicinal properties it has, whether it poses a danger to women’s health, and what feminism has to do with it.

What is hormonal contraception

Distinctive feature modern world- a large-scale movement to free the individual from various cultural, religious and social stereotypes. A significant part of this process is related to women gaining reproductive freedom. This means that a woman regains the right to control her own body: to live like this sex life which suits her, and independently make a decision about readiness to become pregnant or terminate an unwanted pregnancy. In many ways, it was the emergence and development of hormonal contraception that allowed women to take control of their bodies.

Hormonal contraception is a method of protection against unwanted pregnancy that a woman can completely regulate independently. Moreover, its effectiveness is higher than all other options for protection - subject to the rules of use, of course. So, possible pregnancy becomes something that partners can consciously choose. True, such contraceptives do not protect against sexually transmitted infections - here the only way The only way to protect yourself is to use a condom.

All hormonal contraceptives generally work on the same principle: they suppress ovulation and/or prevent the egg from attaching to the surface of the uterine mucosa. This occurs due to the fact that a small amount of synthetic sex hormones constantly enters the body. Suppression of ovulation puts the ovaries into an artificially induced, controlled “sleep”: they decrease in size and the follicles stop releasing eggs in vain.

How do hormones work?

Hormones are substances that actively influence all functions of the human body. Yes, in most cases they help improve the quality of skin and hair, stabilize weight and have many non-contraceptive benefits. However, you should never take hormones on your own without consulting your doctor. In addition, these drugs should not be prescribed by a cosmetologist or gynecologist without a referral for consultation with a gynecologist-endocrinologist.

Sex hormones are biologically active substances in our body that are responsible for the development of male or female sexual characteristics. We have two types: estrogens are produced by the ovaries and form from the beginning of puberty female characteristics body, are responsible for libido and menstruation. Progestogens are produced yellow body ovaries and adrenal cortex and provide the possibility of conception and continuation of pregnancy, which is why they are called “pregnancy hormones”.

It is these two types of hormones that provide our monthly cycle, during which the egg matures in the ovary, ovulation occurs (when the egg leaves the ovary) and the uterus prepares for gestation. If fertilization does not occur, then after ovulation the egg dies, and the endometrium, that is, the mucous lining of the uterus, begins to be rejected, which leads to the onset of menstruation. Despite the opinion that menstruation is a “bursting egg,” in fact, bleeding is caused by mucosal rejection. An unfertilized egg does come out with it, but it is too small to see.

Primary estrogen female body- the hormone estradiol, produced in the ovaries. A high concentration of estradiol in the blood in the middle of the cycle leads to the pituitary gland actively “turning on” in the brain. The pituitary gland triggers ovulation and the production of the main gestagen - progesterone - in case of pregnancy. Hormonal contraceptives work like this: they suppress the ovulatory activity of the pituitary gland, which controls it all complex process“from above”, and maintain a stable level of the pregnancy hormone progesterone. Thus, the pituitary gland takes a break from reproductive concerns, and the female body experiences a state of so-called false pregnancy: there is no monthly fluctuation in hormones, the eggs quietly “sleep” in the ovary, so fertilization becomes impossible.

There is another type of hormonal drugs. The gestagens in their composition change the quantity and quality of vaginal mucus, increasing its viscosity. This makes it more difficult for sperm to enter the uterus, and changes in the thickness and quality of its coating prevent egg implantation and reduce the mobility of the fallopian tubes.

How to start using hormonal contraceptives

You can take hormonal contraceptives from late puberty, when monthly cycle(on average from 16–18 years), and until the cessation of menstruation and the onset of menopause. In the absence of complaints and with regular preventive diagnostics, women are recommended to take a break from taking hormones only if necessary to become pregnant, during pregnancy and lactation. If there are no contraindications, hormonal contraception can be taken the rest of the time.

Remember that a gynecologist-endocrinologist must collect information about the condition of your body as carefully as possible in order to effectively select a drug and avoid unnecessary risks. This information includes a history—gathering information about thromboembolic diseases, diabetes, hyperandrogenism, and other diseases in your family—and an examination. The examination should include a general gynecological examination, examination of the mammary glands, measurement blood pressure, taking a smear from the cervix, donating blood for coagulation and sugar, and assessing risk factors based on the results.

What are the types of hormonal contraception?

There are several types of hormonal contraception: they differ in the method of use, regularity, composition and dosage of hormones. Oral contraceptives are one of the most popular. For example, in the States it accounts for about 23% of all methods of contraception. These are tablets that are taken every day with a break, depending on the properties of the particular drug. There are two types of tablets: mini-pills contain only synthetic gestagen (they can be used by nursing mothers), and combined oral contraceptives (COCs) contain synthetic estrogen and one type of synthetic gestagen - depending on the indications and condition of the body, you may need certain substances.

Oral contraceptives have the lowest dosages of hormones and are highly effective in protecting against unwanted pregnancy. Recently, a natural analogue of estrogen was found - estradiol valerate. The drug based on it has the lowest concentration of the hormone to date while maintaining the contraceptive effect. The only downside to the pills is the need to take them at the same time every day. If this condition seems difficult, then you should choose a method that requires less care, since violation of the rules of administration leads to an increased risk of pregnancy and possible complications.

The lifestyle of a modern woman often not only does not imply constant pregnancy, but also requires her to withstand a large social burden

Mechanical contraceptives are placed on or under the skin or inside the vagina or uterus. They constantly secrete small concentration hormones, and they need to be changed periodically. The patch is fixed on any part of the body and is changed once a week. The ring is made of an elastic transparent material and is inserted into the vagina for a month, almost like a tampon. There is also a hormonal intrauterine system or IUD, which is inserted only by a doctor - but it lasts up to five years. Hormonal implants are installed under the skin - and can also last for almost five years.

There are also hormonal injections, which are also introduced for a long period of time, but in Russia they are practically not used: they are mainly popular in poor countries where women do not have access to other methods - injections are highly effective and not too expensive. The disadvantage of this method is that it cannot be reversed: you can remove the patch, take out the ring, remove the coil, and stop taking the pills - but it is impossible to stop the effect of the injection. At the same time, implants and spirals are also inferior to rings, tablets and patches in mobility, since they can only be removed with the help of a doctor.

What is treated with hormonal contraceptives

It is precisely because hormonal contraceptives help stabilize the hormonal levels of the female body that they have not only contraceptive, but also. that modern women suffer from ecological-social reproductive dissonance - simply put, from the dramatic difference between the way we live and the way our ancient biological mechanism works. Lifestyle modern woman often not only does not imply permanent pregnancy, but also requires her to withstand a large social load. Since the advent of contraception, the number of monthly cycles a woman has in her life has increased significantly. Monthly hormonal changes are not only associated with a monthly risk of symptoms of premenstrual syndrome or dysphoric disorder, but also deplete the body as a whole. A woman has the right to spend these energy resources at her discretion on any other type of constructive activity - and hormonal contraceptives help with this.

Due to the action described above, hormonal contraceptives treat the symptoms of premenstrual syndrome and are even able to cope with the manifestation of its more severe form - premenstrual dysphoric disorder. And through combined estrogen-gestagen contraceptives, endocrinologists correct hyperandrogenism - an excess of male hormones in a woman’s body. This excess can lead to cycle disruption, infertility, heavy menstruation and its absence, obesity, psycho-emotional problems and other serious conditions. Due to hyperandrogenism, other problems may also bother us: hirsutism ( enhanced growth hair by male type), acne (inflammation sebaceous glands, acne) and many cases of alopecia (hair loss). The effectiveness of COCs in the treatment of these diseases is quite high.

After consulting with your doctor, some tablets can be taken in such a mode that even withdrawal bleeding will not occur

Hormonal contraceptives treat abnormal uterine bleeding - this is general designation any deviations of the menstrual cycle from the norm: changes in frequency, irregularity, bleeding that is too heavy or too long, and so on. The reasons for such failures and the severity of the condition may vary, but often include complex treatment hormonal contraceptives are prescribed. In the absence of contraindications, the IUD will most likely be chosen: it daily releases progestogen into the uterine cavity, which effectively causes changes in the lining of the uterus, due to which it corrects heavy menstrual bleeding. The risk of developing ovarian cancer and uterine cancer with the use of hormonal contraceptives is reduced, since the ovaries decrease in size and “rest”, as during pregnancy. Moreover, the longer the reception lasts, the lower the risk.

Hormonal medications are designed primarily to mimic a monthly cycle, so there is a monthly withdrawal bleed—a “period”—with a few days between drug cycles. Good news for those who hate periods: after consulting with your doctor, some pills can be taken in such a way that there will be no bleeding.

Who should not take hormonal contraceptives

According to WHO, there is an impressive list of contraindications that cannot be ignored. Combined contraceptives should not be taken by pregnant, non-breastfeeding mothers earlier than three weeks after childbirth and nursing mothers - earlier than six months after childbirth, smokers after thirty-five years of age, hypertensive patients with thromboembolic diseases or their risk, diabetics with vascular disorders or experience of more than twenty years, and also for breast cancer, gallbladder diseases, coronary heart disease or complications with the valve apparatus, hepatitis, liver tumors.

There are fewer restrictions on taking progestogen contraceptives. They should not be taken again by pregnant women, breastfeeding women earlier than six weeks after birth, or those with cancer. mammary gland, hepatitis, tumors or cirrhosis of the liver. Combining some antibiotics, sleeping pills, and anticonvulsants with hormonal contraception may also be undesirable: tell your doctor if you are taking other medications.

Are hormonal contraceptives dangerous?

Hormones have an effect not only on the reproductive system, but also on the entire body as a whole: they change some metabolic processes. Therefore, there are contraindications for taking hormones based on possible side effects. Since the time of the first and second generations of high-dose hormonal contraceptives, there have been many horror stories about weight gain, hair growth, strokes, chemical dependence and others. sad consequences taking high concentrations of hormones. In new generations of products, the concentration of hormones is reduced tenfold and often different substances are used than before. This allows them to be used even for non-contraceptive medicinal purposes - therefore, transferring stories about the first generations of drugs to them is incorrect.

The most common side effect of hormonal contraception is increased blood clotting, which can lead to a risk of thromboembolic disease. Women who smoke and women whose relatives have had any thromboembolic complications are at risk. Since smoking itself increases the risk of blood clots, smoking women After age thirty-five, most doctors will refuse to prescribe hormonal contraceptives. The risk of thrombosis is usually higher in the first year of taking and in the first six months after stopping hormones, which is why, contrary to popular belief, you should not take frequent breaks in taking hormones: it is not recommended to take them for less than a year and return to them earlier than after a year's break, so as not to damage your health. health. Prevention of thrombosis, in addition to quitting smoking, is an active lifestyle, drinking enough liquid and an annual blood test for homocysteine and coagulogram.

While taking hormones, other types of intoxication can also have a negative effect: drinking alcohol and various psychoactive substances, including marijuana, psychedelics and amphetamines, can cause problems with blood pressure, blood vessels in the heart and brain. If you are not going to reduce your intake of toxic substances while taking hormonal contraception, you should inform your endocrinologist about your habits to avoid unnecessary risks.

The risks of cervical cancer when taking contraceptives increase when a woman has human papillomavirus, chlamydia, or a high risk of contracting sexually transmitted infections - that is, neglect barrier contraception with unstable partners. The pregnancy hormone progesterone suppresses the body's immune response, so women who fall into this risk group can take hormonal contraceptives, but they must undergo a cytological examination more often - if there are no complaints, once every six months. There is no convincing evidence that modern contraceptives increase the risk of liver cancer, although the first generations of drugs due to high dosage had a bad effect on her health. Many women are afraid that taking medications will cause breast cancer. Most studies have failed to make a reliable connection between the use of hormonal contraceptives and the occurrence of breast cancer. Statistics show that women with a history of breast cancer, late menopause, giving birth after forty, or who have never given birth are at risk. In the first year of using GC, these risks increase, but disappear as you take them.

There is no evidence to suggest that a woman taking hormonal contraceptives has a reduced egg supply

There is an opinion that taking hormonal contraceptives can lead to depression. This can happen if the ingredient in the product does not suit you. combined contraceptive gestagen: with this problem you need to consult a doctor in order to change combination drug- most likely, this will help. But in general, depression and even observation by a psychiatrist is not a contraindication for taking birth control pills. However, be sure to tell both doctors about the medications you are using because some may reduce the effects of each other.

There is a myth that hormonal contraceptives, due to inhibition of the reproductive system, lead to infertility, subsequent miscarriage and fetal pathologies. This is wrong . The so-called ovarian sleep, or hyperinhibition syndrome, is reversible. At this time, the ovaries are resting, and the entire body is in a hormonally balanced state of “false pregnancy.” There is no evidence to show that a woman taking hormonal contraceptives has a reduced egg supply. Moreover, hormone therapy used to treat infertility, because after discontinuation of the drug and recovery, the ovaries work more actively. Taking hormonal contraceptives in the past does not affect the course of pregnancy and fetal development. In most cases, the risks and side effects of taking hormonal contraceptives are significantly lower than those of terminating an unwanted pregnancy.

Also, hormonal contraceptives do not cause amenorrhea, the pathological cessation of menstruation. After stopping the drug, it often takes at least three months for menstruation to return (if it has not been there for more than six months, it is better to see a doctor). Hormonal contraceptive withdrawal syndrome is a condition that occurs after stopping taking hormones, when the body returns to constant monthly hormonal changes. In the first six months after withdrawal, the body may experience storms, and therefore during this period it is better to be observed by an endocrinologist. Without medical necessity, you should not interrupt taking hormones in the middle of the cycle: sudden breaks contribute to uterine bleeding and cycle disorders.

In the endocrinological environment, there is a poetic phraseology that characterizes the status of “balanced” women's health: harmony of hormones. Modern hormonal contraceptives still have contraindications and side effects, but with proper selection, adherence to rules of administration and a healthy lifestyle, they can not only eliminate the risk of unwanted pregnancy, but also significantly improve the quality of life of a modern woman - freeing her energy for desired activities.