Cook action. Birth control pills

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

Chapter 20

Chapter 20

Drugs used to prevent pregnancy are called contraceptive. Contraception is an integral part of the family planning system and is aimed at regulating the birth rate, as well as maintaining the health of a woman. Firstly, the use of modern methods of contraception 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. Thirdly, some of the contraceptives have protective properties against malignant neoplasms, inflammatory diseases of the genital organs, postmenopausal osteoporosis, and serve as a powerful tool in the fight against a number of gynecological diseases - infertility, ovarian apoplexy, menstrual irregularities, etc.

An indicator of the effectiveness of any contraceptive is the Pearl index - the number of pregnancies that occurred 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 with the help of funds introduced into the uterine cavity. The method is widely used in Asian countries (primarily in China), Scandinavian countries, and Russia.

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

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

Interest in this method of contraception revived only in the 60s of the XX century. In 1962, Lipps used a flexible plastic in the form of a double Latin letter "S" to create a contraceptive, which made it possible to insert it without significant expansion of the 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-drug) and drug-induced. The former include plastic IUDs of various shapes and designs, including the Lipps loop. Since 1989, WHO has recommended abandoning inert IUDs as ineffective and often causing complications. Medical IUDs have a plastic base of various configurations (loop, umbrella, number "7", letter "T", etc.) with the addition of a metal (copper, silver) or a hormone (levonorgestrel). These additives increase contraceptive effectiveness and reduce the number of adverse reactions. In Russia, the most commonly used:

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 a high copper content; term of use - 6-8 years;

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

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

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

Increased peristalsis of the fallopian tubes, which leads to the penetration into the uterine cavity of the ovum, 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;

Increased contractile activity of the uterus itself as a result of an increase in the synthesis of prostaglandins;

Atrophy of the endometrium (for the intrauterine hormone-containing system) makes it impossible for the process of implantation of the fetal egg.

The hormone-containing IUD, having a local effect on the endometrium due to the constant release of progestogen, 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 systemic effect on the body while maintaining ovulation.

The contraceptive effectiveness of the IUD 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 that there is no pregnancy, but it is more expedient to do this on the 4-8th day from the onset of menstruation. IUD can be inserted immediately after abortion or 2-3 months after childbirth, and after caesarean section - not earlier than 5-6 months. Before the introduction of the IUD, the patient should be interviewed to identify possible contraindications, a gynecological examination and a bacterioscopic examination of smears from the vagina, cervical canal, and urethra for microflora and purity should be carried out. IUD can only be administered with smears of I-II purity. When using a contraceptive, you should carefully follow the rules of asepsis and antisepsis.

Within 7-10 days after the introduction of the IUD, it is recommended to limit physical activity, do not take hot baths, laxatives and uterotonics, and exclude sexual activity. A woman should be informed about the timing of the use of the IUD, as well as symptoms of possible complications that require urgent medical attention. A second visit is recommended 7-10 days after the introduction of the IUD, then in a normal state - after 3 months. Medical examination of women using IUDs includes 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 the used IUD with a new break, you can not do), with the development of complications. The IUD is removed by sipping on the "antennae". In the absence or breakage of the "antennae" (if the period of use of the IUD is exceeded), it is recommended to carry out the procedure in a hospital. 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. With the introduction of the IUD, perforation of the uterus is possible (1 in 5000 injections) up to the location of the contraceptive in the abdominal cavity. Perforation is manifested by acute pain in the lower abdomen. The complication is diagnosed using ultrasound of the pelvic organs, hysteroscopy. With partial perforation, you can remove the contraceptive by pulling on the "antennae". Complete perforation requires laparoscopy or laparotomy. Cha-

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

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

The combination of pain with fever, purulent or suicidal-purulent discharge from the vagina indicates the development of inflammatory complications (0.5-4%). The disease is especially severe, with severe destructive changes in the uterus and appendages, and often requires radical surgical interventions. To reduce the frequency of such complications, prophylactic antibiotics are recommended for 5 days after the introduction of the IUD.

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. The appointment of NSAIDs in the first 7 days after the introduction of the IUD increases the acceptability of this method of contraception. A positive effect is given by the appointment of combined oral contraceptives (COCs) 2-3 months before the introduction of the IUD and in the first 2-3 months after it, which facilitate the adaptation period. If periods remain heavy, the IUD should be removed. With the appearance of metrorrhagia, hysteroscopy and separate diagnostic curettage are indicated.

Pregnancy with the use of IUDs is rare, but still not excluded. The frequency of spontaneous miscarriages with the use of IUDs increases. However, if desired, such a pregnancy can be saved. The question of the need and timing of removal of the IUD remains controversial. There is an opinion about the possibility of removing the IUD in the 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 adversely affect the fetus due to its extra-amniotic location. Usually, the IUD is released along with the placenta and fetal membranes in the third stage of labor. Some authors suggest terminating a pregnancy that occurs with the use of an IUD, since its prolongation increases the risk of septic abortion.

IUD significantly reduces the possibility of pregnancy, including ectopic. However, the incidence of ectopic pregnancy in these cases is higher than in the general population.

Fertility after removal of the IUD in most cases is restored immediately. With the use of IUDs, there was no increase in the risk of developing cancer of the cervix and body of the uterus, ovaries.

Contraindications. Absolute contraindications include:

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 body of the uterus. Relative contraindications:

Hyperpolymenorrhea or metrorrhagia;

Hyperplastic processes of the endometrium;

Algomenorrhea;

Hypoplasia and anomalies in the development of the uterus that prevent the introduction of the IUD;

Stenosis of the cervical canal, deformity of the cervix, isthmic-cervical insufficiency;

Anemia and other blood diseases;

Submucosal uterine myoma (small nodes without deformation of the cavity are not a contraindication);

Severe extragenital diseases of inflammatory etiology;

Frequent expulsions of the IUD in history;

Allergy to copper, hormones (for medical IUDs);

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

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

The advantages of intrauterine contraception include:

High efficiency;

Possibility of long-term use;

Immediate contraceptive action;

Rapid restoration of fertility after removal of the IUD;

Lack of connection with sexual intercourse;

Low cost (with the exception of the hormonal intrauterine system);

Possibility of use during lactation;

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

The disadvantages are the need for medical manipulations during the introduction and removal of the IUD and the possibility of complications.

20.2. Hormonal contraception

One of the most effective and widespread methods of birth control has become hormonal contraception.

The idea of ​​hormonal contraception arose at the beginning of the 20th century, when the Austrian physician Haberland discovered that the administration of an 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 has 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, preparations were created with a high content of estrogens (50 micrograms) and many serious side effects. At the 2nd stage, contraceptives with a low content of estrogens (30-35 μg) and progestogens with a selective effect appeared, which made it possible to significantly reduce the number of complications when taking them. Third-generation drugs include agents containing low (30-35 mcg) or minimal (20 mcg) doses of estrogen, as well as highly selective progestogens (norgestimate, dezogestrel, gestodene, dienogest, drospirenone), which have an even greater advantage over their predecessors.

Composition of hormonal contraceptives. All hormonal contraceptives (HC) consist of an estrogen and a progestogen or only a progestogen component.

Ethinyl estradiol is currently used as an estrogen. Along with the contraceptive effect, estrogens cause endometrial proliferation, prevent rejection of the uterine mucosa, providing a hemostatic effect. The lower the dose of estrogens in the preparation, the higher the possibility of the appearance of "intermenstrual" bleeding. Currently, HA is prescribed with an ethinylestradiol content of not more than 35 μg.

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

Norsteroids of the 1st generation (norethisterone, etinodiol, linestrenol) and more active norsteroids of the 2nd (norgestrel, levonorgestrel) and 3rd (norgestimate, gestodene, desogestrel, dienogest, drospirenone) generations 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 much higher than that of progesterone. In addition to the gestagenic, norsteroids give expressed to varying degrees androgenic, anabolic and mineralocorticoid

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

Combined estrogen-progestin contraceptives:

Oral;

vaginal rings;

plasters;

Gestagen contraceptives:

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

Injectable;

Implants.

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

Mechanism of action COC is diverse. The contraceptive effect is achieved as a result of the blockade of cyclic processes of the hypothalamic-pituitary system in response to the administration of steroids (feedback principle), and also due to the direct inhibitory effect on the ovaries. As a result, there is no growth, development of the follicle and ovulation. In addition, progestogens, by increasing the viscosity of cervical mucus, make it impassable for spermatozoa. 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 the implantation of the fetal egg, if fertilization does occur, becomes impossible. This mechanism of action ensures the high reliability of COCs. When used correctly, contraceptive efficacy reaches almost 100%, the Pearl index is

0,05-0,5.

According to the level of ethinylestradiol, COCs are divided into high-dose (more than 35 mcg; currently not used for contraceptive purposes), low-dose (30-35 mcg) and microdosed (20 mcg). In addition, COCs are monophasic, when all the tablets included in the package have the same composition, and multi-phase (two-phase, three-phase), when the package, designed for a cycle of administration, contains two or three types of tablets of different colors, differing in the amount of estrogen and progestogen components. Gradual dosage causes cyclic processes in the target organs (uterus, mammary glands), reminiscent of those during a normal menstrual cycle.

Complications when taking COCs. In connection with the use of new low- and micro-dose COCs containing highly selective progestogens, side effects with the use of HA are rare.

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

In a small percentage of women taking COCs, in the first 3 months of use, discomfort associated with the metabolic action of sex steroids is possible. Estrogen-dependent effects include nausea, vomiting, edema, dizziness, heavy menstrual-like bleeding, and gestagen-dependent effects include irritability, depression, fatigue, decreased libido. Headache, migraine, breast engorgement, bleeding may be due to the action of both components of the COC. At present, these signs are

are seen as symptoms of adaptation to COCs; usually they do not require the appointment 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 hemostasis 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 COCs and risk factors, which include age over 35 years, smoking, hypertension, hyperlipidemia, obesity, etc. It is generally accepted that the use of low or microdose COCs does not significantly affect the hemostasis system in healthy people. women.

When taking COCs, blood pressure rises, 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 anamnesis (hereditary predisposition, obesity, hypertension in the present, OPG-preeclampsia in the past). Clinically significant changes in blood pressure in healthy women taking COCs have not been identified.

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

Decreased 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 atherosclerosis and vascular complications. However, modern selective gestagens, which are part of third-generation COCs, do not adversely affect 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 in the protection of the vascular wall;

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

Estrogens can have a slight toxic effect on the liver, manifested in a transient increase in the level of transaminases, cause intrahepatic cholestasis with the development of cholestatic hepatitis and jaundice. Gestagens, by increasing the concentration of cholesterol in bile, contribute to the formation of stones in the bile ducts and bladder.

Acne, seborrhea, hirsutism are possible with the use of gestagens with a pronounced androgenic effect. The currently used highly selective progestogens, 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 withdrawal of the drug is required. It should be borne in mind that COCs when using contact lenses cause swelling of the cornea with the appearance of a feeling of discomfort.

A rare but worrying complication is amenorrhea following discontinuation of COCs. It is believed that COCs do not cause amenorrhea, but only hide hormonal disorders due to regular menstrual bleeding. Such patients should definitely be examined for a pituitary tumor.

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

Any of the components of COCs can 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 the lack of hormones for a particular patient (estrogens - with the appearance of blood discharge in the 1st half of the cycle, gestagens - in the 2nd half), malabsorption of the drug (vomiting, diarrhea), missed pills, competitive action taken together with COCs drugs (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 the abolition 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), do not increase the risk of fetal defects. Accidental use of modern hormonal contraceptives in early pregnancy does not give a mutagenic, teratogenic effect and does not require termination of pregnancy.

To the contraceptive benefits of COCs include:

High efficiency and almost immediate contraceptive effect;

Reversibility of the method;

Low frequency of side effects;

Good fertility control;

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

Eliminate the fear of unwanted pregnancy;

Ease of 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%);

Reducing the incidence of inflammatory diseases of the pelvic organs (by 50-70%) as a result of an increase in the viscosity of cervical mucus, ectopic pregnancy, retention

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

Relief of symptoms of premenstrual syndrome and dysmenorrhea;

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

COOK);

Increasing the acceptability of IUDs;

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

Disadvantages of the method: the need for daily intake, the possibility of errors in admission, the lack of protection against sexually transmitted infections, a decrease in the effectiveness of COCs while taking other drugs.

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

With a history of ectopic pregnancy;

Those who have undergone 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 III generation progestogens). Contraindications. Absolute contraindications to the appointment of COCs:

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

Severe violations of the liver and kidneys;

Pregnancy;

Severe cardiovascular disease, cerebrovascular disease;

Bleeding from the genital tract of unknown etiology;

Severe hypertension (BP 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 them (increased risk of thrombotic complications);

Smoking and age over 35;

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 COCs can affect, is determined individually.

Conditions requiring immediate cancellation of the GC:

sudden severe headache;

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

Acute chest pain, unexplained shortness of breath, hemoptysis;

Acute pain in the abdomen, especially prolonged;

sudden pain in the legs;

Significant increase in blood pressure;

Itching, jaundice;

Skin rash.

Rules for taking COCs. COCs begin 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 a new cycle of administration begins. When performing an artificial abortion, you can start taking COCs on the day of the operation. If a woman is not breastfeeding, the need for contraception occurs 3 weeks after birth. If it is necessary to delay menstrual-like bleeding, a break in taking the drugs can be avoided by continuing to take the tablets of the next package (for multi-phase contraceptives, only tablets of the last phase are used for this).

For microdosed COC jess* containing 28 tablets per pack, the regimen is as follows: 24 active tablets followed by 4 placebo tablets. Thus, the action of hormones is extended for another 3 days, and the presence of placebo tablets facilitates adherence to the contraceptive regimen.

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

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

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

Vaginal ring "NovaRing" ♠ refers to estrogen-progestin contraception with parenteral delivery of hormones to the body. The No-Varing* is a flexible plastic ring that is inserted deep into the vagina from day 1 to day 5 of the menstrual cycle for 3 weeks and then removed. After a 7-day break, during which bleeding occurs, a new ring is introduced. Being in the vagina, "NovaRing" * daily releases a constant small dose of hormones (15 μg of ethinyl estradiol and 120 μg of the progestogen etonogestrel), which enter the systemic circulation, which provides reliable contraception (Pearl index - 0.4). "NovaRing" * does not interfere with an active lifestyle, playing sports, swimming. There were no cases of prolapse of the ring from the vagina. The vaginal ring does not cause any discomfort in partners during sexual intercourse.

Using transdermal contraceptive system "Evra" * the combination of estrogen and progestogen enters the body from the surface of the patch through the skin, blocking ovulation. 20 micrograms of ethnylestradiol and 150 micrograms of norelgestramine are absorbed daily. One package contains 3 patches, each of which is alternately glued for 7 days on the 1st, 8th, 15th days of the menstrual cycle. The patches are attached to the skin of the buttocks, abdomen, shoulders. On the 22nd day, the last patch is removed, and the next pack is started after a week break. The patch is securely attached to the skin, does not interfere with an active lifestyle, does not peel off either during water procedures or under the influence of the sun.

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

Indications, contraindications, negative and positive effects of NovaRing ♠ and Evra patches ♠ are the same as for COCs.

Oral progestogen contraceptives (OGCs) contain small doses of progestogens (mini-pills) and were created as an alternative to COCs. OGK is used in women who are contraindicated in drugs containing estrogens. The use of pure gestagens, on the one hand, reduces the number of complications of hormonal contraception, and on the other hand, reduces the acceptability of this type of contraception. Due to the lack of estrogens to prevent endometrial rejection, intermenstrual bleeding is often observed when taking OGK.

OGKs include Demulene* (ethinodiol 0.5 mg), Microlut* (levonorgestrel 0.03 mg), Exluton* (linestrenol 0.5 mg), Charosetta* (desogestrel

0.075 mg).

ActionWGC due to an increase in the viscosity of cervical mucus, the creation of unfavorable conditions for the implantation of a fertilized egg in the endometrium, and a decrease in the contractility of the fallopian tubes. The dose of steroids in the minipill is insufficient to effectively suppress ovulation. More than half of women taking OGKs have normal ovulatory cycles, so the contraceptive effectiveness of OGKs 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 (OGCs are not contraindicated in 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 in continuous mode. It should be remembered that the effectiveness of OGK decreases when a dose is missed, which is 3-4 hours. Such a violation of the regimen requires the use of additional methods of contraception for at least 2 days.

To the above contraindications due to 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 ovarian retention formations).

Advantages of OGK:

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 efficacy compared to COCs;

High chance of bleeding.

Injectable contraceptives used for prolonged contraception. Currently, Depo-Provera * containing medroxyprogesterone is used for this purpose. The Pearl Index of injectable contraception does not exceed 1.2. The first intramuscular injection is made on 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 childbirth when breastfeeding.

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

High contraceptive efficiency;

No need for daily intake of the drug;

Duration of action;

Few side effects;

Absence of estrogen-dependent complications;

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

Disadvantages of the method:

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

Frequent bleeding (subsequent injections lead to amenorrhea).

Injectable 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 constant long-term release of a small amount of gestagens. In Russia, Norplant * is registered as an implant, containing levonorgestrel and representing 6 silastic capsules for subcutaneous injection. The level of levonorgestrel required for contraception is reached within 24 hours after administration and persists for 5 years. Capsules are injected under the skin of the inner side of the forearm fan-shaped through a small incision under local anesthesia. The Pearl Index for norplant is 0.2-1.6. The contraceptive effect is provided by suppressing ovulation, increasing the 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, who do not want to take hormonal contraceptives daily. After the expiration date 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 implantable contraceptive Implanon p * containing etonogestrel, a highly selective progestogen of the latest generation, a biologically active metabolite of desogestrel. Implanon is inserted and removed four times faster than a multi-capsule preparation; complications are less common (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 progestogen contraceptives.

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

Disadvantages of the method: frequent occurrence of bleeding, the need for surgical intervention for the introduction and removal of capsules.

* This drug is currently undergoing registration at the Ministry of Health and Social Development of the Russian Federation in the Department of State Regulation of the Circulation of Medicines.

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 spermatozoa. The main spermicides that are part of the finished forms are nonoxynol-9 and benzalkonium chloride. They destroy the cell membrane of spermatozoa. The effectiveness of the contraceptive action of spermicides is low: the Pearl index is 6-20.

Spermicides are available 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. Candles, tablets, films with spermicides are injected 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. With repeated sexual intercourse, additional administration of spermicides is required.

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

In addition to the contraceptive effect, spermicides provide some protection against sexually transmitted infections, since the chemicals have a bactericidal, virocidal property. However, the risk of infection still remains, and for HIV infection it even increases due to the increase in the 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 efficacy, the relationship of use with sexual intercourse.

TO mechanical methods of contraception include condoms, cervical caps, vaginal diaphragms, which create a mechanical obstacle to the penetration of spermatozoa into the uterus.

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

erect penis before intercourse. The penis should be removed from the vagina before the erection ceases to prevent the condom from slipping off and semen from 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 neck, the other is taken out of the vagina. Condoms are single use.

The Pearl Index for mechanical methods ranges from 4 to 20. The effectiveness of a condom is reduced if it is used incorrectly (use of grease that destroys 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 a good protection against sexually transmitted infections, but infection with viral diseases, syphilis is still possible when the damaged skin of the patient and a healthy partner come into contact. Side effects include an allergy to latex.

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

For reliable protection against pregnancy and sexually transmitted infections, use the "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 is closely adjacent to the walls of the vagina. The diaphragm is usually used with spermicides. With repeated sexual intercourse after 3 hours, repeated administration of spermicides is required. After intercourse, 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. The use of the diaphragm requires special training. It is not recommended to use the diaphragm for prolapsed vaginal walls, old perineal ruptures, large vaginal sizes, diseases of the cervix, inflammatory processes of the genital organs.

Cervical caps are metal or latex cups that are placed over the cervix. Caps are also used together with spermicides, injected before sexual intercourse, removed after 6-8 hours (maximum - after 24 hours). The cap is washed after use and stored in a dry place. Contraindications to protection from pregnancy in this way are diseases and deformity of the cervix, inflammatory diseases of the genital organs, prolapse of the walls of the vagina, 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), shortcomings- the 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 on days close to ovulation. To prevent 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 contraception are ineffective: the Pearl index ranges from 6 to 40. This significantly limits their use.

To calculate the fertile period use:

Calendar (rhythmic) method of Ogino-Knaus;

Measurement of rectal temperature;

The study of cervical mucus;

symptothermal method.

Application calendar method is based on the determination of the average timing of ovulation (average day 14 ± 2 days for a 28-day cycle), spermatozoa (average 4 days) and egg (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 not constant (the duration of at least the last 6 cycles is determined), then the fertile period is determined by subtracting 18 days from the shortest cycle and 11 days from the longest. 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 the determination of ovulation by rectal temperature. The egg survives for a maximum of three days after ovulation. Fertile is the period from the onset 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 have an active sex life.

cervical mucus during the menstrual cycle, it changes its properties: in the preovulatory phase, its amount increases, it becomes more extensible. A woman is trained to evaluate the cervical mucus over several cycles to determine the time of ovulation. Conception is likely within two days before the discharge of mucus and 4 days after. This method cannot be used for inflammatory processes in the vagina.

Symptothermal method based on the control of rectal temperature, properties of cervical mucus and ovulatory pain. The combination of all methods allows you to more accurately calculate the fertile period. The symptomatic method requires the patient to be thorough and persistent.

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

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

Natural methods of contraception are used by couples who do not want to use other methods of contraception for fear of side effects, as well as 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 provides obstruction of the fallopian tubes, as a result of which fertilization is impossible. During sterilization in men, the vas deferens are tied up and crossed (vasectomy), after which spermatozoa cannot enter the ejaculate. Sterilization is the most effective method of contraception (Pearl index is 0-0.2). The onset of pregnancy, although extremely rare, is due to technical defects in the sterilization operation or recanalization of the fallopian tubes. It should be emphasized that sterilization refers to irreversible methods. The 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 they explain the essence of the method, report its irreversibility, find out the details of the anam-

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

neza, interfering with the implementation of sterilization, as well as conduct a comprehensive examination. All patients must provide written informed consent for the operation.

In our country, voluntary surgical sterilization has been allowed since 1993. According to the Basic Laws of the Russian Federation on protecting the health of citizens (Article 37), medical sterilization as a special intervention to deprive a person of the ability to reproduce offspring or as a method of contraception can only be carried out upon a written application of a citizen at least 35 years of age or having at least 2 children, and if there are medical indications and with the consent of the citizen - regardless of age and the presence of children.

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

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

The optimal timing of the operation is the first few days after menstruation, when the likelihood of pregnancy is minimal, 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, laparoscopy are used. Laparotomy is used when sterilization is performed during another operation. The two most commonly used are the other two. 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 access (laparoscopy or mini-laparotomy) is 10-20 minutes.

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

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

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

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

Sterilization benefits: a one-time intervention that provides long-term protection against pregnancy, no side effects.

Disadvantages of the method: the need for a surgical operation, the possibility of complications, the irreversibility of the intervention.

20.6. Postcoital contraception

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

Emergency contraception should not be used regularly and should only be used in exceptional cases (rape, condom rupture, diaphragmatic displacement if no other method of contraception is available) or in women who have infrequent sexual intercourse.

The most common methods of postcoital contraception should be considered the introduction of an IUD or the use of sex steroids after intercourse.

For the purpose of emergency protection against pregnancy, the IUD is administered no later than 5 days after unprotected intercourse. At the same time, possible contraindications for the use of IUDs should be taken into account. This method can be recommended to patients who wish to continue to use permanent intrauterine contraception, in the absence of the 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 COC intake according to the Yuzpe method is necessary no later than 72 hours after unprotected intercourse, the 2nd - 12 hours after the 1st dose. The total dose of ethinyl-stradiol should not be less than 100 micrograms per dose. Postinor ♠ containing 0.75 mg of levonorgestrel and escapel ♠ containing 1.5 mg of levonorgestrel have been created specifically for postcoital progestational 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 intercourse. The antiprogestin mifepristone at a dose of 10 mg binds progesterone receptors and prevents or interrupts the process of preparation of the endometrium for implantation, due to the action of progesterone. A single dose of 1 tablet is recommended within 72 hours after sexual intercourse.

Before prescribing hormones, contraindications must be excluded.

The effectiveness of various methods of this type of contraception is on the Pearl index from 2 to 3 (medium reliability). High doses of hormones can cause side effects - uterine bleeding, nausea, vomiting, etc. A pregnancy should be considered a failure, which, according to WHO experts, must be interrupted due to the risk of teratogenic effects 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

The WHO defines adolescents as young people between the ages of 10 and 19. 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 in adolescents increases the risk of sexually transmitted diseases.

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

Combined oral contraception - microdosed, low-coded COCs with the latest generation of progestogens, three-phase COCs. However, the estrogens that are part of COCs can cause premature closure of the growth centers of the epiphyses of the bones. Currently, it is considered acceptable to prescribe COCs with a minimum content of ethnylestradiol after the first 2-3 menstruations have passed in a teenage girl.

Postcoital contraception COCs or gestagens are used for unplanned sexual intercourse.

Condoms combined with spermicides provide protection against sexually transmitted infections.

The use of pure gestagens is unacceptable due to the frequent occurrence of blood discharge, and the use of IUDs is relatively contraindicated. Natural methods of contraception, 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. Currently, several types of postpartum contraception are recommended.

The lactational amenorrhea method (LAM) is a natural method of contraception based on the inability to conceive when

regular breastfeeding. Prolactin released during lactation blocks ovulation. The contraceptive effect is provided within 6 months after childbirth if the child 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, menstruation is absent. The use of other natural methods of contraception is ruled out because it is impossible to predict the time of the resumption of menstruation after childbirth, and the first menstruation is often irregular.

Postpartum sterilization is currently performed even before discharge from the maternity hospital. Gestagen oral contraception is allowed to be used during lactation. Prolonged progestogen contraception (depo-provera *, norplant *) can be started from the 6th week after childbirth while breastfeeding.

Condoms are used in combination with spermicides.

In the absence of lactation, it is possible to use any method of contraception (COC - 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. As antigens, CG, antigens of sperm, egg, fetal egg are used.

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 prevented the introduction of this method into practice. Research into the creation of hormonal contraception for men is ongoing. It has been proven that the production of male germ cells can be stopped by the administration of androgen and progestogen in the form of an injection or implant. After the termination of the drug, fertility is restored after 3-4 months.

Contraceptives are drugs used to prevent pregnancy. The purpose of contraception is family planning, the preservation of the health of a woman, and partly her sexual partner, the realization of a woman's right to a free choice: to become pregnant or refuse to do so.

Why are all types of contraception necessary:

• any method of contraception reduces the number of abortions - the causes of gynecological diseases, premature birth, maternal and infant mortality;
• protection helps to plan the appearance of a child, depending on the living conditions of the family, the health of the parents and many other factors;
• some effective methods of contraception at the same time help fight gynecological diseases, osteoporosis, and infertility.

The effectiveness of contraceptives is assessed by the Pearl index. It shows how many women out of a hundred who used the method during the year became pregnant. The smaller it is, the higher the protection efficiency. Modern methods of contraception have a Pearl index close to 0.2-0.5, that is, pregnancy occurs in 2-5 women out of 1000.

Classification of contraceptive methods:

• intrauterine;
• hormonal;
• barrier;
• physiological (natural);
• surgical sterilization

Consider the listed types of contraception, the principle of their action, effectiveness, indications and contraindications.

intrauterine methods

Use foreign objects placed in the uterine cavity. Intrauterine contraception is widespread in China, Russia, Scandinavian countries.

The method was proposed at the beginning of the 20th century, when it was proposed to introduce a ring of different materials into the uterine cavity to prevent pregnancy. In 1935, intrauterine contraception was banned due to the large number of infectious complications.

In 1962, Lipps proposed the famous device made of curved plastic with an attached nylon thread for removing a contraceptive, the Lipps loop. Since then, intrauterine contraception has been constantly evolving.

Intrauterine devices are divided into inert and medical. Inert ones are not currently used. Only medical contraceptives containing metal supplements or hormones are recommended, including:

• MultiloadCu-375 - F-shaped coil, copper-plated and designed for 5 years;
• Nova-T - a device in the form of the letter T, covered with a copper winding;
• CooperT 380 A - T-coil, designed for 6 years;
• - the most popular spiral to date, gradually releasing levonorgestrel into the uterine cavity - a progesterone derivative that has a contraceptive and therapeutic effect.

Mechanism of action

The intrauterine contraceptive has the following effects:

• the death of spermatozoa that have penetrated the uterus due to the toxic effect of the metal;
• increased viscosity of cervical mucus due to the hormone, which prevents spermatozoa;
• endometrial atrophy under the influence of levonorgestrel; ovulation and the effect of estrogen on the female body is preserved, and menstruation becomes shorter, less frequent or completely disappears;
• abortive action.

The abortion mechanism includes:

• active movement of the tubes and entry into the uterine cavity of an immature egg;
• local inflammatory process in the endometrium, preventing the attachment of the embryo;
• activation of uterine contractions that eject the egg from the genital tract.

The Pearl index for spirals with a copper content is 1-2, for the Mirena system 0.2-0.5. Thus, this hormonal system is the best method of intrauterine contraception.

The introduction of a contraceptive

The intrauterine device is installed after an abortion or removal of an old one, 1.5-2 months after the birth of a child, or six months after a cesarean section. Before this, the patient is examined, paying attention to signs of infection.

After 7 days, the woman visits the gynecologist. If all went well, she should see a doctor at least once every 6 months.

The contraceptive is removed at the request of the patient, with the development of complications or at the end of the period of use, by pulling on the "antennae". If the "antennae" broke off, the removal is carried out in a hospital. It happens that the spiral grows into the thickness of the myometrium. If a woman does not have any complaints, she is not removed, and the woman is advised to use other methods of protection.

Complications and contraindications

Possible complications:

• perforation of the myometrium (1 case per 5000 injections);
• pain syndrome;
• bloody issues;
• infectious diseases.

If you experience severe pain in the abdomen, cramping sensations with bleeding, heavy menstruation, fever, heavy discharge, "falling out" of the spiral, you should immediately consult a doctor.

The introduction of the spiral is absolutely contraindicated in pregnancy, infection or tumors of the genital organs. It is better not to use it if the menstrual cycle is disturbed, there is endometrial hyperplasia, anatomical features of the genital organs, blood diseases, large ones, allergies to metals, severe concomitant conditions. Women who have not given birth can use intrauterine contraception, but the risk of pregnancy pathology in the future is higher.

The advantages of this method of contraception are the possibility of using during lactation, the absence of side effects caused by estrogens, and less impact on body systems. Disadvantages - less efficiency and the likelihood of metrorrhagia.

Injectable contraceptives and implants

This method is used for long-term protection against unwanted pregnancy. The Depo-Provera preparation is used, containing only the progestogen component, it is injected into the muscle 1 time per quarter. Pearl index 1.2.

Benefits of injectable contraception:

• fairly high efficiency;
• duration of action;
• good tolerance;
• no need for daily pills;
• you can take the drug for uterine fibroids, and other contraindications for drugs with an estrogen component.

Disadvantages of the method: the ability to conceive is restored only after 6 months - 2 years after the last injection; a tendency to the development of uterine bleeding, and subsequently to their complete cessation.

This method is recommended for women who need long-term contraception (which is, however, reversible), while breastfeeding, with contraindications to estrogenic drugs, and for patients who do not want to take daily tablet forms.

According to the same indications, it is possible to install the implantable drug Norplant, which is 6 small capsules. They are sutured under local anesthesia under the skin of the forearm, the effect develops during the first day and lasts up to 5 years. The Pearl Index is 0.2-1.6.

barrier methods of contraception

One of the advantages of barrier methods is protection against sexually transmitted diseases. Therefore, they are widely distributed. They are divided into chemical and mechanical methods of contraception.

Chemical methods

Spermicides are substances that kill sperm. Their Pearl Index is 6-20. Such drugs are produced in the form of vaginal tablets, suppositories, creams, foams. Solid forms (candles, films, vaginal tablets) are inserted into the vagina 20 minutes before sexual intercourse so that they have time to dissolve. Foam, gel, cream act immediately after application. With repeated coitus, it is necessary to re-introduce spermicidal agents.

The most common means are Pharmatex and Patentex Oval. Spermicides slightly increase protection against sexually transmitted diseases, since they have a bactericidal effect. However, they increase the permeability of the vaginal walls, which increases the likelihood of contracting HIV infection.

The advantages of chemical methods of contraception are the short duration of their action and the absence of systemic effects, good tolerance, and protection against sexually transmitted diseases. The disadvantages that significantly limit the use of such drugs include low efficiency, the risk of allergies (burning, itching in the vagina), as well as the direct connection of the use with coitus.

Mechanical methods of contraception

Such methods hold the spermatozoa, creating a mechanical obstacle on their way to the uterus.

The most common are condoms. They are for men and for women. Men's should be worn during an erection. Female condoms consist of two rings connected by a latex film forming a cylinder closed at one end. One ring is put on the neck, and the other is brought out.

The Pearl Index for condoms ranges from 4 to 20. To maximize their effectiveness, you must use these accessories correctly: do not use oil-based lubricants, do not reuse the condom, avoid prolonged intense acts during which the latex can break, and pay attention to expiration date and storage conditions of the contraceptive.

Condoms protect quite well against sexually transmitted diseases, but do not completely protect against infection with syphilis and some viral diseases transmitted by skin contact.

This type of contraception is most indicated for women with infrequent or promiscuous sexual intercourse.

Which method of contraception to choose for the most complete protection against pregnancy and sexually transmitted diseases? In this case, a combined method is recommended - taking hormonal contraceptives and using a condom.

Vaginal diaphragms and caps are not widely used. These devices are worn on the cervix before sexual intercourse, and are removed 6 hours after it. They are usually used together with spermicides. They are washed, dried, stored in a dry place and reused if necessary. The use of these tools requires training. They are not used for deformation of the neck, vagina, inflammatory diseases of the genital organs. The undoubted advantage of such devices is their reusable use and low cost.

Mechanical methods of contraception have the following advantages: safety, protection against sexually transmitted diseases (for condoms). Cons associated with insufficient effect and the relationship between application and coitus.

Natural Ways

Natural methods involve abstaining from sexual intercourse on days close to ovulation. The Pearl index reaches 40. To determine the fertile ("dangerous" period), the following methods are used:

• calendar;
• measurement of temperature in the rectum;
• examination of cervical mucus;
• symptothermal.

calendar method of contraception

It is used only in women with a regular cycle. It is believed that ovulation occurs on the 12-16th day of the cycle with a duration of 28 days, the sperm cell lives 4 days, the egg cell - 1 day. Therefore, the "dangerous" period lasts from 8 to 17 days. These days you need to use other methods of protection.

Each tablet combined oral contraceptives (COCs) contains estrogen and progestogen. Synthetic estrogen, ethinyl estradiol, is used as the estrogenic component of COCs, and various synthetic progestogens (synonymous with progestins) are used as progestogenic components.

Mechanism of contraceptive action of COC:

• suppression of ovulation;
• thickening of cervical mucus;
• change in the endometrium that prevents implantation.

The contraceptive action of COCs provides a progestogenic component. Ethinylestradiol as part of COCs supports endometrial proliferation and provides cycle control (no intermittent bleeding when taking COCs).

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

The main clinical differences between modern COCs - individual tolerance, the frequency of adverse reactions, the characteristics of the effect on metabolism, therapeutic effects, etc. - are due to the properties of their progestogens.

CLASSIFICATION AND PHARMACOLOGICAL EFFECTS OF COCs

Chemical synthetic progestogens - steroids; they are classified according to their origin.

Like natural progesterone, synthetic progestogens induce secretory transformation of the estrogen-stimulated (proliferative) endometrium. This effect is due to the interaction of synthetic progestogens with endometrial PR. In addition to affecting the endometrium, synthetic progestogens also act on other target organs of progesterone. The antiandrogenic and antimineralocorticoid effects of progestogens are favorable for oral contraception, and 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 the lipid spectrum of blood serum, changes in carbohydrate tolerance and an increase in body weight due to anabolic action.

According to the severity of androgenic properties, progestogens can be divided into the following groups:

• High androgenic progestogens (norethisterone, linestrenol, ethinodiol).
• Progestogens with moderate androgenic activity (norgestrel, levonorgestrel in high doses, 150-250 mcg / day).
• Progestogens with minimal androgenicity (levonorgestrel at a dose of not more than 125 mcg / day, including triphasic), ethinylestradiol + gestodene, desogestrel, norgestimate, medroxyprogesterone). The androgenic properties of these progestogens are found only in pharmacological tests, in most cases they have no clinical significance. WHO recommends the use of COCs with low-androgenic progestogens. In studies, it was found that desogestrel (active metabolite - 3-ketodesogestrel, etonogestrel) has high progestogenic and low androgenic activity and the lowest affinity for SHBG, therefore, even at high concentrations, it does not displace androgens from its connection. 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 decrease 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 often occur in the first months of taking COCs (in 10-40% of women), in the subsequent time their frequency decreases to 5-10%. Side effects of COCs are usually divided into clinical and mechanism-dependent.

Excessive influence of estrogens:

• headache;
• increase in blood pressure;
• irritability;
• nausea, vomiting;
• dizziness;
• mammalgia;
• chloasma;
• worsening tolerance to contact lenses;
• weight gain.

Insufficient estrogenic effect:

• headache;
• depression;
• irritability;
• reduction in the size of the mammary glands;
• decreased libido;
• dryness of the vagina;
• intermenstrual bleeding at the beginning and middle of the cycle;
• scanty menses.

Excessive influence of progestogens:

• headache;
• depression;
• fatigue;
• acne;
• decreased libido;
• dryness of the vagina;
• deterioration of varicose veins;
• weight gain.

Insufficient progestogenic effect:

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

If side effects persist longer than 3-4 months after the start of treatment and / or increase, 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, pulmonary embolism). For women's health, the risk of these complications when taking COCs with a dose of ethinylestradiol 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.) is a relative contraindication to taking COCs. A combination of two or more of the listed risk factors (for example, smoking over the age of 35) excludes the use of COCs altogether.

Thrombosis and thromboembolism, both when taking COCs and during pregnancy, can be manifestations of hidden 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 the routine determination of prothrombin in the blood does not give an idea of ​​the hemostasis system and cannot be a criterion for prescribing or canceling COCs. When identifying latent forms of thrombophilia, a special study of hemostasis should be carried out.

CONTRAINDICATIONS TO THE USE OF COMBINED ORAL CONTRACEPTIVES

Absolute contraindications to taking COCs:

• deep vein thrombosis, pulmonary embolism (including history), high risk of thrombosis and thromboembolism (with extensive surgery associated with prolonged immobilization, with congenital thrombophilia with pathological levels of coagulation factors);
• ischemic heart disease, stroke (presence of a history of cerebrovascular crisis);
• arterial hypertension with systolic blood pressure of 160 mm Hg. and more and / or diastolic blood pressure of 100 mm Hg. and more and / or with the presence of angiopathy;
• complicated diseases of the valvular apparatus of the heart (hypertension of the pulmonary circulation, atrial fibrillation, history of septic endocarditis);
• a combination of several factors in 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 the use of COCs, the normal functioning of the hypothalamus-pituitary-ovaries 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 adversely affect the fetus, the course and outcome of pregnancy. Accidental use of COCs in the early stages of 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 (within 3 months) causes an increase in the sensitivity of the receptors of the "hypothalamus-pituitary-ovaries" system, therefore, when COCs are canceled, tropic hormones are released and ovulation is stimulated.

This mechanism is called the "rebound effect", it is used in the treatment of certain forms of anovulation. In rare cases, after the abolition of COCs, amenorrhea can be observed. Amenorrhea may be the result 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. Approximately 2% of women, especially in the early and late periods of fertility, after stopping the use of COCs, amenorrhea can be observed lasting more than 6 months (hyperinhibition syndrome). The frequency and causes of amenorrhea, as well as the response to therapy in women using COCs, do not increase the risk, but may mask the development of amenorrhea with regular menstrual bleeding.

RULES FOR INDIVIDUAL SELECTION OF COMBINED ORAL CONTRACEPTIVES

COCs are selected for women strictly individually, taking into account the characteristics of the somatic and gynecological status, individual and family history data. The selection of COCs is carried out according to the following scheme:

• Targeted interview, assessment of somatic and gynecological status and determination of the acceptability category of the combined oral contraceptive method for this woman in accordance with the WHO acceptance criteria.
• The choice 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.

• Dispensary observation of a woman during the entire period of COC use.

In accordance with the WHO conclusion, the following examination methods are not related to the assessment of the safety of the use of COCs:

• 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 not more than 35 mcg / day and a low-androgenic progestogen.

Three-phase COCs can be considered as reserve drugs when signs of estrogen deficiency appear against the background of monophasic contraception (poor cycle control, dryness of the vaginal mucosa, decreased libido). In addition, triphasic drugs are indicated for primary use in women with signs of estrogen deficiency.

When choosing a drug, one should take into account the characteristics of the patient's health status (Table 12-2).

Table 12-2. Choice of combined oral contraceptives

Clinical situation	Recommendations
Acne and/or hirsutism, hyperandrogenism	Drugs with antiandrogenic progestogens
Menstrual disorders (dysmenorrhea, dysfunctional uterine bleeding, oligomenorrhea)	COCs with a pronounced progestogenic effect (Marvelon ©, Microgynon ©, Femoden ©, Jeanine ©). With a combination of dysfunctional uterine bleeding with recurrent endometrial hyperplastic processes, 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 content of estrogen - 20 mcg / day
Primary or repeated administration of COCs to a smoking patient	When smoking under the age of 35 - COC with a minimum content of estrogen. Smoking patients older than 35 years COCs are contraindicated
Previous COC use was accompanied by weight gain, fluid retention in the body, mastodynia	Yarina©
Poor menstrual control has been observed with previous COC use (in cases where causes other than COC use are ruled out)	Monophasic or three-phase COCs (Three-Mercy ©)

The first months after the start of taking COCs serve as a period of adaptation of the body to hormonal changes. At this time, intermenstrual spotting bleeding or, less often, 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 disappear within 3–4 months, this may be the basis for changing the contraceptive (after excluding other causes - organic diseases of the reproductive system, missing pills, drug interactions) (Table 12-3).

Table 12-3. Selection of COCs of the second line

Problem	Tactics
Estrogen dependent side effects	Reducing the dose of ethinylestradiol Switching from 30 to 20 mcg / day of ethinylestradiol Switching from triphasic to monophasic COCs
Gestagen-dependent side effects	Dose reduction of progestogen Switching to a three-phase COC Switching to COC with another progestogen
Decreased libido	Switching to a three-phase COC- Switching from 20 to 30 mcg / day of ethinylestradiol
Depression
Acne	Switching to COCs with antiandrogenic effect
Breast engorgement	Switching from a triphasic to a monophasic COC Switching to ethinylestradiol + drospirenone Switching from 30 to 20 mcg/day of ethinylestradiol
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 of ethinyl estradiol
Scanty menstruation	Switching from monophasic to triphasic COCs Switching from 20 to 30 mcg/sutetinylestradiol
Abundant menstruation	Switching to a monophasic COC with levonorgestrel or desogestrel Switching to ethinylestradiol 20 mcg/day
Intermenstrual spotting at the beginning and middle of the cycle	Switching to a three-phase COC Switching from 20 to 30 mcg / day of ethinylestradiol
Intermenstrual spotting in the second half of the cycle	Switching to COCs with a higher dose of progestogen
Amenorrhea while taking COCs	Pregnancy must be ruled out Together with COC ethinylestradiol throughout the 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 the annual gynecological examination, including colposcopy and cytological examination;
• in the examination of the mammary glands every six months (in women with a history of benign tumors of the mammary glands and / or breast cancer in the family), mammography once a year (in patients in perimenopause);
• in the regular measurement of blood pressure: with an increase in diastolic blood pressure up to 90 mm Hg. and more - stop taking COCs;
• in a special examination according to indications (with the development of side effects, the appearance of complaints).

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

RULES FOR RECEPTION OF COMBINED ORAL CONTRACEPTIVES

All modern COCs are produced in "calendar" packages designed for one cycle of administration (21 tablets - one per day). There are also packs of 28 tablets, in which case the last 7 tablets do not contain hormones ("pacifiers"). 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. In the first 7 days, an additional method of contraception is required.

Women who are breastfeeding:

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

PROLONGED REGIME OF COMBINED ORAL CONTRACEPTIVES

Prolonged contraception provides for an increase in the duration of the cycle from 7 weeks to several months. For example, it may consist of taking 30 micrograms of ethinyl estradiol and 150 micrograms of desogestrel or any other COC continuously. There are several schemes of prolonged contraception. The short-term dosing scheme allows you to delay menstruation by 1-7 days, it is practiced before the upcoming surgery, 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, etc.

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

The appointment of prolonged contraception is also justified in the treatment of MM, since in this case the synthesis of estrogens by the ovaries is suppressed, the level of total and free androgens decreases, which, under the action of aromatase synthesized by fibroid tissues, can turn into estrogens. 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 GnRH agonists, and contributes to a much greater decrease in these indicators than when taken in a 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, and also for the purpose of stopping vasomotor and neuropsychiatric disorders of the climacteric syndrome. In addition, prolonged contraception enhances the oncoprotective effect of hormonal contraception and helps prevent bone loss in women of this age group.

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

RULES OF FORGOTTEN AND MISSED PILLS

• If 1 tablet is missed:
  ♦ delay in taking less than 12 hours - take the missed pill and continue taking the drug until the end of the cycle according to the previous scheme;
  ♦ being late for more than 12 hours - the same actions plus:
  - if you miss a tablet in the 1st week, use a condom for the next 7 days;
  - if you miss a pill on the 2nd week, there is no need for additional contraceptives;
  - if you miss a tablet on the 3rd week, after finishing one package, start the next one without a break; there is no need for additional protective equipment.
• If 2 or more tablets are missed, take 2 tablets per day until regular intake, plus use additional methods of contraception for 7 days. If bleeding occurs after the missed tablets, it is better to stop taking the tablets from the current package and start a new package after 7 days, counting from the start of the missed tablets.

RULES FOR PRESCRIBING COMBINED ORAL CONTRACEPTIVES

• Primary appointment - from the 1st day of the menstrual cycle. If the 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.
• Appointment after abortion - immediately after the abortion. Abortion in the I, II trimesters, as well as septic abortion are classified as category 1 conditions (there are no restrictions on the use of the method) for the appointment of COCs.
• Appointment after childbirth - in the absence of lactation - not earlier than the 21st day after childbirth (category 1). In the presence of lactation, do not prescribe COCs, use minipill no earlier than 6 weeks after birth (category 1).
• The transition from high-dose COCs (50 micrograms of ethinylestradiol) to low-dose (30 micrograms of ethinylestradiol or less) - without a 7-day break (so that the hypothalamic-pituitary system does not activate due to dose reduction).
• Switching from one low-dose COC to another - after the usual 7-day break.
• The transition from minipili to COC - on the first day of the next bleeding.
• Switching from an injectable to a COC is 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 to be introduced. Additional contraception is not required.

In recent years combined oral contraceptives widely used to prevent unwanted conception. It is hormonal contraceptives that are rightfully considered one of the most effective and at the same time reliable means. In addition, this has a positive effect on the female body, strengthening reproductive health.

To understand the mechanism of action of such contraceptives, one should turn to the physiology of the woman's body. All changes that occur in it are cyclical and repeat after a clear period of time. A cycle is the time from the first day of menstruation to the start of the next bleeding. The cycle can last from 21 to 35 days, but for most women it is 28 days. Ovulation occurs in the middle of the cycle. At this time, a mature egg is released from the ovary. If it is combined with a spermatozoon, conception occurs. All these processes are regulated and. During the cycle, the ratio of these sex hormones changes several times.

How do COCs work?

The action of combined oral contraceptives is based on the effect of sex hormones on the body. Combined oral contraceptives (COCs for short) consist of synthetic analogues of the hormones estrogen and progesterone. Depending on the amount of active substances in the preparation and their ratio, such agents are divided into single-phase , two-phase And three-phase drugs. These are the best oral contraceptives for modern women, as they can be selected depending on the individual characteristics of the body.

Three-phase COCs contain an amount of hormones that is as close as possible to the natural fluctuation of estrogen and progesterone in a woman's body. In biphasic oral contraceptives, the ratio of sex hormones changes twice, and this already has a certain difference with the natural processes of the female body. But, when determining which means to choose, a woman must take into account that single-phase contraceptives are the least consistent with natural processes. But in general, all COCs affect the woman's body in the same way, preventing unwanted ones.

Therefore, when recommending a woman to take these drugs, the doctor pays special attention to the individual tolerance of such drugs. In some cases, the body, which normally perceives single-phase combined contraceptives, reacts negatively to three-phase means. But in general, modern COCs are so positively perceived by the female body that their use is allowed from the beginning of sexual life to the period. During menopause, oral contraceptives can be used as a hormone replacement treatment to prevent pathological changes in bone and cartilage tissue that occur due to calcium loss.
COCs have several routes of exposure to the body, resulting in a contraceptive effect. First of all, under their influence, ovulation is suppressed, so the egg does not mature and does not go into the fallopian tube. Also, drugs of this type change the composition cervical secretion . Under normal conditions, this secret facilitates the penetration of spermatozoa into the uterus, and due to the action of COCs, it turns into a thicker and more viscous mass. As a result, spermatozoa cannot penetrate inside, and besides, they become practically unviable when they enter the cervix. In addition, when taking such contraceptives, the structure of the uterine mucosa changes markedly: the membrane becomes noticeably thinner. Therefore, even if the fertilization process does occur, the egg with the embryo will not be able to attach to the wall of the uterus. Thus, the triple level of COC exposure guarantees a high level of protection against unwanted conception. According to statistical information, when taking oral contraceptives, 0.1 pregnancies are recorded per 100 women.

Hormonal contraceptives are also an effective prophylactic for preventing a number of gynecological diseases, hormonal imbalance . Also, taking these drugs facilitates the course of menstruation, reducing the amount of blood released.

Types of COCs

As mentioned above, hormonal contraceptives are divided into several varieties. Single phase oral contraception contains the same amount of synthetic analogues of progesterone and estrogen in all tablets of the package. This type of COC includes drugs, , Silest , Ovidon , Non-Ovolon , . Such contraceptives are an appropriate method of contraception for young nulliparous women. The fundamental difference between these drugs are the doses of hormones that they contain. Therefore, an important condition is the individual selection of such means, which necessarily takes into account the general state of the woman's health, the presence of chronic ailments and pathologies, and, finally, the ability to purchase more expensive contraceptives.

Speaking of biphasic drugs, it should be noted that this category includes fewer drugs. In the preparation Anteovin contained And . Biphasic contraceptives, in addition to the main effect, contribute to the cure for acne , . The fact is that these ailments are often provoked by too high a content androgens in the body, contraceptives allow you to balance the content of hormones. Specialists define biphasic COCs as intermediate preparations between single-phase and triphasic agents.

Three-phase hormonal contraception allows you to simulate the natural menstrual cycle, because the preparation contains hormones in a ratio as close as possible to the physiological one. This group includes drugs Trinovum , . These drugs contain hormones in different proportions. Such funds have a positive effect on the body in the presence of initial ovarian dysfunction and other diseases. Three-phase COCs are recommended for women over 27 years of age.

How to take COC?

Hormonal contraceptives from modern manufacturers are produced in plates containing 21 tablets or 28 tablets. In order for a woman to easily navigate the order of taking the drug, new three-phase and two-phase tablets have special designations on the packaging in the form of arrows or days of the week. COCs should be started on the first day of the menstrual cycle, after which the drug should be taken every day. Doctors advise, if possible, to take the tablets at the same time. The latest research shows that with such a clear intake of COCs, hormonal substances are absorbed better. If there are 21 tablets in the plate, the drug should be taken from the first day of menstruation, after which there is a break for seven days. On days when pills are not taken, the use of other methods of protection is not required, since the contraceptive effect remains. If there are 28 tablets in the plate, the drug is taken continuously. After one year of taking COCs, a woman should take a break for three months so that ovarian function can fully recover and unwanted side effects do not occur. These days, it is necessary to protect yourself from conception using other methods.

A woman taking such pills should be clearly aware that COCs are categorically not combined with certain drugs. These are anticonvulsants, a number of antibiotic preparations, medicines for lung diseases. But even if a woman is prescribed treatment with any other drug, then she must definitely warn her doctor about taking oral contraceptives.

How to choose COC?

Contraceptives for women, like male contraceptives, must be chosen by carefully weighing all the individual pros and cons. Before you start using any drugs, you need to consult a gynecologist. For the correct selection of COCs, it is necessary to undergo a number of studies. So, initially a routine gynecological examination is performed, a smear is taken. This allows you to exclude a number of diseases, among which - oncological pathologies. Twice during the menstrual cycle, an ultrasound examination of the pelvic organs is performed. Ultrasound should be performed immediately after menstruation and before the start of the next menstruation. Such a study will allow you to learn about the growth and condition of the uterine mucosa, about the features of ovulation. A woman is also assigned a consultation with a mammologist, an ultrasound of the mammary glands. Sometimes it is also necessary to determine the level of hormones in the blood of the patient.

About three months after the woman began taking the pills regularly, she needs to visit the doctor again in order to control the effects of hormonal substances on the body.

In general, oral contraceptives for women have many visible advantages, including a high level of reliability, rapid onset of effect, ease of use, and good body tolerance. In addition, such female contraceptives provide a normal level of reversibility, that is, after stopping taking such pills, a woman can become pregnant in 1-12 months. Such pills are also suitable for young girls, as they allow you to adjust the monthly cycle, eliminate pain during menstruation, get a certain therapeutic effect in certain diseases, and reduce the manifestation of inflammatory processes.

COCs reduce the risk of cysts , oncological diseases , benign breast tumors , and also avoid iron deficiency anemia . Their use is advisable for women who have a high level of male hormones.

Due to the inhibition of ovulation, the tablets also provide protection against development. In some cases, they also allow you to eliminate some of the provoking factors. Therefore, after stopping treatment with such drugs, pregnancy occurs with a higher probability.

By the way, monophasic COCs allow, if necessary, to “postpone” the next menstruation. To achieve this effect, you should start taking pills from the next package of single-phase contraceptives immediately after the previous one has ended. In addition, COCs provide emergency contraception.

Flaws

In addition to the described number of advantages, these contraceptives have some disadvantages. First of all, this is the likelihood of a decrease in the contraceptive effect in the case of interaction with certain medications. For some women, it is quite difficult to ensure the accuracy and regularity of taking pills. At the same time, skipping pills increases the risk of unwanted pregnancy. As side effects when taking the same drugs, there may be amenorrhea , intermenstrual bleeding , decreased sex drive , headache , mood swings , soreness in the chest , weight gain , vomit , nausea . However, all of these phenomena occur, as a rule, in the first months of taking the pills, and later they disappear immediately after the body has fully adapted to COCs.

A significant disadvantage when taking such drugs as contraceptives is the lack of protection during sexual intercourse, both from and from diseases that are sexually transmitted .

Contraindications

There are several absolute contraindications in which oral contraceptives are not used categorically. This is pregnancy or the suspicion that conception has already occurred; the period after childbirth, when a woman is breastfeeding, or the first six months after childbirth; diseases and tumors of the liver; pituitary tumors; cardiovascular diseases; mammary cancer; progressive forms; a number of mental disorders.

Relative contraindications are hypertension , active smoking , tendency to depression . The intake of such contraceptive pills is stopped for one month before planned surgical operations, as well as before taking some. In all these cases, women are advised to use non-hormonal contraceptives .

What if the woman did not take the pill on time?

Despite the fact that if you miss a timely pill, the risk of conception immediately increases, a woman should not panic in this case. The tablet should be taken as soon as possible. If the missed dose happened just on the days of the expected ovulation, then the best way out would be to use an additional method of contraception until the day of the next menstruation. However, modern COCs act on the body in such a way that skipping one tablet for 12 hours does not affect the contraceptive effect. If you miss two tablets, you should take two forgotten tablets as soon as possible, and two more the next day. In this case, it is important to apply an additional method of protection. Such changes can provoke the appearance of spotting, which occurs as a result of a high concentration of hormones. After a few days, this side effect disappears.

If three or more pills were missed, then in this case, you should switch to additional methods of contraception, and start taking COCs again, from the first day of menstruation. Therefore, every woman, before starting to take such contraceptives, should carefully analyze whether she can ensure regular intake of the drug, since the irregular and indiscriminate use of such pills can adversely affect the woman's health.

Combination pills (combined oral contraceptives - COCs) are the most widely used form of hormonal contraception.

According to the content of the estrogen component in the form of ethinylestradiol (EE) in the tablet, these drugs are divided into high-dose, containing more than 40 meg EE, and low-dose - 35 meg or less EE. In monophasic preparations, the content of the estrogen and progestin components in the tablet is unchanged throughout the entire menstrual cycle. In biphasic tablets in the second phase of the cycle, the content of the progestogen component increases. In three-phase COCs, the increase in the dose of progestogen occurs stepwise in three stages, and the dose of EE increases in the middle of the cycle and remains unchanged at the beginning and at the end of administration. The variable content of sex steroids in two- and three-phase preparations throughout the cycle made it possible to reduce the total course dose of hormones.

Combined oral contraceptives are highly effective reversible means of contraception. The Pearl Index (IP) of modern COCs is 0.05-1.0 and depends mainly on compliance with the rules for taking the drug.

Each combined oral contraceptive (COC) tablet contains estrogen and a progestogen. Synthetic estrogen - ethinyl estradiol (EE) is used as the estrogenic component of COCs, and various synthetic progestogens (synonymous with progestins) as the progestogenic component.

Gestagen contraceptives contain in their composition only one sex steroid - a progestogen, due to which a contraceptive effect is provided.

Benefits of combined oral contraceptives

contraceptives

• High efficiency with daily intake IP = 0.05-1.0
• Quick effect
• Lack of connection with sexual intercourse
• Few side effects
• The method is easy to use
• The patient can stop taking

Non-contraceptive

• Reduce menstrual bleeding
• Reduce menstrual pain
• May reduce anemia
• May help establish a regular cycle
• Prevention of ovarian and endometrial cancer
• Reduce the risk of developing benign breast tumors and ovarian cysts
• Protect against ectopic pregnancy
• Provides some protection against pelvic inflammatory disease
• Provides prevention of osteoporosis

Currently, COCs are very popular all over the world due to the benefits listed below.

• High contraceptive reliability.
• Good tolerance.
• Availability and ease of use.
• Lack of connection with sexual intercourse.
• Adequate control of the menstrual cycle.
• Reversibility (complete restoration of fertility within 1-12 months after discontinuation).
• Safe for most healthy women.
• Healing effects:
  • regulation of the menstrual cycle;
  • elimination or reduction of dysmenorrhea;
  • reduction of menstrual blood loss and, as a result, treatment and prevention of iron deficiency anemia;
  • elimination of ovulatory pain;
  • reduction in the frequency of inflammatory diseases of the pelvic organs;
  • therapeutic effect in premenstrual syndrome;
  • therapeutic effect in hyperandrogenic conditions.
• Preventive effects:
  • reduced risk of endometrial and ovarian cancer, colorectal cancer;
  • reducing the risk of benign neoplasms of the breast;
  • reducing the risk of developing iron deficiency anemia;
  • reducing the risk of ectopic pregnancy.
• Removal of "fear of unwanted pregnancy".
• The possibility of "postponing" the next menstruation, for example, during exams, competitions, rest.
• emergency contraception.

Types and composition of modern combined oral contraceptives

According to the daily dose of the estrogen component, COCs are divided into high-dose, low-dose and microdose:

• high-dose - 50 mcg EE / day;
• low-dose - no more than 30-35 mcg EE / day;
• microdosed, containing microdoses of EE, 15-20 mcg / day.

Depending on the combination scheme of estrogen and progestogen, COCs are divided into:

• monophasic - 21 tablets with a constant dose of estrogen and progestogen for 1 cycle of administration;
• biphasic - two types of tablets with a different ratio of estrogen and progestogen;
• three-phase - three types of tablets with a different ratio of estrogen and progestogen. The main idea of ​​the triphasic is to reduce the total (cyclic) dose of progestogen due to a three-stage increase in its dose during the cycle. At the same time, in the first group of tablets, the dose of progestogen is very low - approximately from that in monophasic COCs; in the middle of the cycle, the dose increases slightly and only in the last group of tablets corresponds to the dose in the monophasic preparation. The reliability of ovulation suppression is achieved by increasing the dose of estrogen at the beginning or middle of the cycle. The number of tablets of different phases varies in different preparations;
• multi-phase - 21 tablets with a variable ratio of estrogen and progestogen in tablets of one cycle (one pack).

Currently, for the purpose of contraception, low- and micro-dose drugs should be used. High-dose COCs can be used for planned contraception only for a short time (if it is necessary to increase the dose of estrogen). In addition, they are used for medicinal purposes and for emergency contraception.

The mechanism of contraceptive action of combined oral contraceptives

• Ovulation suppression.
• Thickening of cervical mucus.
• Changes in the endometrium that prevent implantation. The mechanism of action of COCs is generally the same for all drugs, it does not depend on the composition of the drug, the dose of the components and phase. The contraceptive effect of COCs is provided mainly by the progestogen component. EE as part of COCs supports endometrial proliferation and thus provides cycle control (no intermittent bleeding when taking COCs). In addition, EE is necessary to replace endogenous estradiol, since there is no follicle growth when taking COCs and, therefore, estradiol is not secreted in the ovaries.

Classification and pharmacological effects

Chemical synthetic progestogens are steroids and are classified by origin. The table shows only progestogens that are part of hormonal contraceptives registered in Russia.

Classification of progestogens

Like natural progesterone, synthetic progestogens induce secretory transformation of the estrogen-stimulated (proliferative) endometrium. This effect is due to the interaction of synthetic progestogens with endometrial progesterone receptors. In addition to affecting the endometrium, synthetic progestogens also act on other target organs of progesterone. The differences between synthetic progestogens and natural progesterone are as follows.

• Higher affinity for progesterone receptors and, as a result, a more pronounced progestogenic effect. Due to the high affinity for progesterone receptors in the hypothalamic-pituitary region, synthetic progestogens in low doses cause a negative feedback effect and block the release of gonadotropins and ovulation. This underlies their use for oral contraception.
• Interaction with receptors for some other steroid hormones: androgens, gluco- and mineralocorticoids - and the presence of corresponding hormonal effects. These effects are relatively weakly expressed and therefore are called residual (partial or partial). Synthetic progestogens differ in the spectrum (set) of these effects; some progestogens block receptors and have a corresponding antihormonal effect. For oral contraception, the antiandrogenic and antimineralocorticoid effects of progestogens are favorable, androgenic effect is undesirable.

Clinical significance of individual pharmacological effects of progestogens

A pronounced residual androgenic effect is undesirable, as it can cause:

• androgen-dependent symptoms - acne, seborrhea;
• a change in the spectrum of lipoproteins towards the predominance of low-density fractions: low-density lipoproteins (LDL) and very low-density lipoproteins, since the synthesis of apolipoproteins and the destruction of LDL are inhibited in the liver (an effect opposite to the influence of estrogen);
• deterioration of tolerance to carbohydrates;
• weight gain due to anabolic action.

According to the severity of androgenic properties, progestogens can be divided into the following groups.

• High androgenic progestogens (norethisterone, linestrenol, etinodiol diacetate).
• Progestogens with moderate androgenic activity (norgestrel, levonorgestrel in high doses - 150-250 mcg / day).
• Progestogens with minimal androgenicity (levonorgestrel at a dose of not more than 125 mcg / day, gestodene, desogestrel, norgestimate, medroxy-progesterone). The androgenic properties of these progestogens are found only in pharmacological tests, in most cases they have no clinical significance. WHO recommends the use of predominantly oral contraceptives with low androgenic progestogens.

The antiandrogenic effect of cyproterone, dienogest and drospirenone, as well as chlormadinone is of clinical importance. Clinically, the antiandrogenic effect is manifested in a decrease 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 polycystic ovary syndrome (PCOS), idiopathic androgenization, and some other conditions.

The severity of the antiandrogenic effect (according to pharmacological tests):

• cyproterone - 100%;
• dienogest - 40%;
• drospirenone - 30%;
• chlormadinone - 15%.

Thus, all progestogens that are part of COCs can be arranged in a row in accordance with the severity of both their residual androgenic and antiandrogenic effects.

COCs should be started on the 1st day of the menstrual cycle, after taking 21 tablets, a break of 7 days is taken or (with 28 tablets per pack) 7 placebo tablets are taken.

Missed Pill Rules

The following rules are currently adopted regarding missed pills. In cases where less than 12 hours have passed, it is necessary to take a pill at the time when the woman remembered the missed dose, and then the next pill at the usual time. This does not require any additional precautions. If more than 12 hours have passed since the pass, you must do the same, but within 7 days apply additional measures of protection against pregnancy. In cases where two or more tablets are missed in a row, take two tablets per day until the intake enters the usual schedule, using additional methods of contraception for 7 days. If bleeding occurs after the missed pills, it is better to stop taking the pills and start a new pack after 7 days (counting from the start of missing the pills). If you miss even one of the last seven hormone-containing pills, the next pack should be started without a seven-day break.

Rules for changing drugs

The transition from higher-dose drugs to low-dose ones is carried out with the start of taking low-dose COCs without a seven-day break on the day after the end of the 21st day of taking high-dose contraceptives. The replacement of low-dose drugs with high-dose ones occurs after a seven-day break.

Symptoms of possible complications when using COCs

• Severe chest pain or shortness of breath
• Severe headaches or blurred vision
• Severe pain in the lower extremities
• Complete absence of any bleeding or discharge during the pill-free week (pack of 21 pills) or while taking 7 inactive pills (from a 28-day pack)

If you experience any of the symptoms listed above, an urgent consultation with a doctor is required!

Disadvantages of combined oral contraceptives

• Method depends on users (requires motivation and discipline)
• Nausea, dizziness, breast tenderness, headaches, and spotting or moderate spotting from the genital tract and mid-cycle may occur.
• The effectiveness of the method may decrease with the simultaneous administration of certain drugs.
• Thrombolytic complications are possible, although very rare.
• The need to replenish the supply of contraceptives
• Does not protect against STDs, including hepatitis and HIV infection

Contraindications to the use of combined oral contraceptives

Absolute contraindications

• Deep vein thrombosis, pulmonary embolism (including history), high risk of thrombosis and thromboembolism (with extensive surgery associated with prolonged immobilization, with congenital thrombophilia with abnormal levels of coagulation factors).
• Ischemic heart disease, stroke (presence of a history of cerebrovascular crisis).
• Arterial hypertension with systolic blood pressure of 160 mm Hg. Art. and above and / or diastolic blood pressure of 100 mm Hg. Art. and above and / or with the presence of angiopathy.
• Complicated diseases of the valvular apparatus of the heart (hypertension of the pulmonary circulation, atrial fibrillation, history of septic endocarditis).
• The combination of several factors in the development of arterial 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.
• Pregnancy. Relative contraindications
• Arterial hypertension with systolic blood pressure below 160 mm Hg. Art. and / or diastolic blood pressure below 100 mm Hg. Art. (a single increase in blood pressure is not the basis for the diagnosis of arterial hypertension - the primary diagnosis can be established with an increase in blood pressure to 159/99 mm Hg during three visits to the doctor).
• Confirmed hyperlipidemia.
• Headache of a vascular nature or migraine that appeared while taking COCs, as well as migraine without focal neurological symptoms in women over 35 years of age.
• Gallstone disease with clinical manifestations in history or at present.
• Cholestasis associated with pregnancy or COC use.
• Systemic lupus erythematosus, systemic scleroderma.
• History of breast cancer.
• Epilepsy and other conditions requiring the use of anticonvulsants and barbiturates - phenytoin, carbamazepine, phenobarbital and their analogues (anticonvulsants reduce the effectiveness of COCs by inducing microsomal liver enzymes).
• Reception of rifampicin or griseofulvin (for example, in tuberculosis) due to their effect on microsomal liver enzymes.
• Lactation from 6 weeks to 6 months after childbirth, the postpartum period without lactation up to 3 weeks.
• Smoking less than 15 cigarettes per day over the age of 35. Conditions requiring special control while taking COCs
• Increased blood pressure during pregnancy.
• Family history of deep vein thrombosis, thromboembolism, death from myocardial infarction under the age of 50 years (I degree of relationship), hyperlipidemia (assessment of hereditary factors of thrombophilia and lipid profile is necessary).
• Upcoming surgery without prolonged immobilization.
• Thrombophlebitis of superficial veins.
• Uncomplicated diseases of the valvular apparatus of the heart.
• Migraine without focal neurological symptoms in women under 35 years of age, headache that began while taking COCs.
• Diabetes mellitus without angiopathy with a disease duration of less than 20 years.
• Gallstone disease without clinical manifestations; condition after cholecystectomy.
• Sickle cell anemia.
• Bleeding from the genital tract of unknown etiology.
• Severe dysplasia and cervical cancer.
• Conditions that make it difficult to take pills (mental illness associated with impaired memory, etc.).
• Age over 40 years.
• Lactation more than 6 months after childbirth.
• Smoking before the age of 35.
• Obesity with a body mass index of more than 30 kg / m 2.

Side effects of combined oral contraceptives

Side effects are most often slightly pronounced, occur in the first months of taking COCs (in 10–40% of women), and subsequently their frequency decreases to 5–10%.

Side effects of COCs are usually divided into clinical and dependent on the mechanism of action of hormones. Clinical side effects of COCs, in turn, are divided into general and causing menstrual disorders.

• headache;
• dizziness;
• nervousness, irritability;
• depression;
• discomfort in the gastrointestinal tract;
• nausea, vomiting;
• flatulence;
• biliary dyskinesia, exacerbation of gallstone disease;
• tension in the mammary glands (mastodynia);
• arterial hypertension;
• change in libido;
• thrombophlebitis;
• leucorrhea;
• chloasma;
• leg cramps;
• weight gain;
• worsening tolerance to contact lenses;
• dryness of the mucous membranes of the vagina;
• increase in the overall coagulation potential of the blood;
• an increase in the transition of fluid from the vessels into the intercellular space with a compensatory delay in the body of sodium and water;
• change in glucose tolerance;
• hypernatremia, increased osmotic pressure of blood plasma. Menstrual irregularities:
• intermenstrual spotting spotting;
• breakthrough bleeding;
• amenorrhea during or after taking COCs.

If side effects persist longer than 3-4 months after the start of treatment and / or increase, the contraceptive drug should be changed or discontinued.

Serious complications when taking COCs are extremely rare. These include thrombosis and thromboembolism (deep vein thrombosis, pulmonary embolism). For women's health, the risk of these complications when taking COCs with a dose of EE 20-35 mcg / day is very small - lower than during pregnancy. Nevertheless, at least one risk factor for the development of thrombosis (smoking, diabetes mellitus, high obesity, hypertension, etc.) is a relative contraindication to taking COCs. The combination of two or more of the listed risk factors (for example, the combination of obesity with smoking over the age of 35) excludes the use of COCs altogether.

Thrombosis and thromboembolism, both when taking COCs and during pregnancy, can be manifestations of hidden genetic forms of thrombophilia (resistance to activated protein C, hyperhomocysteinemia, deficiency of antithrombin III, protein C, protein S, antiphospholipid syndrome). In this regard, it should be emphasized that the routine determination of prothrombin in the blood does not give an idea of ​​the hemostasis system and cannot be a criterion for prescribing or canceling COCs. If latent forms of thrombophilia are suspected, a special study of hemostasis should be carried out.

Fertility Restoration

After stopping the use of COCs, the normal functioning of the hypothalamus-pituitary-ovarian system is quickly restored. More than 85-90% of women are able to become pregnant within 1 year, which corresponds to the biological level of fertility. Taking COCs before the start of the conception cycle does not adversely affect the fetus, the course and outcome of pregnancy. Accidental use of COCs in the early stages of pregnancy is not dangerous and is not a reason for abortion, but at the first suspicion of pregnancy, a woman should immediately stop taking COCs.

Short-term use of COCs (within 3 months) causes an increase in the sensitivity of the receptors of the hypothalamus-pituitary-ovarian system, therefore, when COCs are canceled, tropic hormones are released and ovulation is stimulated. This mechanism is called the "rebound effect" and is used in some forms of anovulation.

In rare cases, after the abolition of COC, amenorrhea is observed. It 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 strogen therapy. Approximately 2% of women, especially in the early and late periods of fertility, after stopping the use of COCs, amenorrhea lasting more than 6 months (the so-called post-pill amenorrhoea - hyperinhibition syndrome) is observed. The nature and causes of amenorrhea, as well as the response to therapy in women using COCs, do not increase the risk, but may mask the development of amenorrhea with regular menstrual bleeding.

Rules for the individual selection of combined oral contraceptives

COCs are selected for a woman strictly individually, taking into account the characteristics of the somatic and gynecological status, individual and family history data. The selection of COCs is carried out according to the following scheme.

• Targeted interview, assessment of somatic and gynecological status and determination of the acceptability category of the combined oral contraceptive method for this woman in accordance with the WHO acceptance criteria.
• The choice of a specific drug, taking into account its properties and, if necessary, therapeutic effects; counseling a woman about the method of combined oral contraception.
• Observation of a woman for 3-4 months, assessment of tolerability and acceptability of the drug; if necessary, a decision to change or cancel the COC.
• Dispensary observation of a woman during the entire period of COC use.

The survey of women is aimed at identifying possible risk factors. It necessarily includes the following number of aspects.

• The nature of the menstrual cycle and gynecological history.
  • When was the last menstruation, whether it proceeded normally (current pregnancy should be excluded).
  • Is the menstrual cycle regular? Otherwise, a special examination is necessary to identify the causes of an irregular cycle (hormonal disorders, infection).
  • The course of previous pregnancies.
  • abortion.
• Previous use of hormonal contraceptives (oral or otherwise):
  • were there any side effects; if so, which ones;
  • Why did the patient stop using hormonal contraceptives?
• Individual history: age, blood pressure, body mass index, smoking, medication, liver disease, vascular disease and thrombosis, diabetes mellitus, cancer.
• Family history (diseases in relatives that developed before the age of 40): arterial hypertension, venous thrombosis or hereditary thrombophilia, breast cancer.

In accordance with the conclusion of the WHO, the following examination methods are not related to the assessment of the safety of the use of COCs.

• Examination of the mammary glands.
• Gynecological examination.
• Examination for the presence of atypical cells.
• Standard biochemical tests.
• Tests for inflammatory diseases of the pelvic organs, AIDS. The drug of first choice should be a monophasic COC with an estrogen content of not more than 35 mcg / day and a low-androgenic progestogen. These COCs include Logest, Femoden, Janine, Yarina, Mercilon, Marvelon, Novinet, Regulon, Belara, Minisiston, Lindinet, Silest ".

Triphasic COCs can be considered as reserve drugs when signs of estrogen deficiency appear against the background of monophasic contraception (poor cycle control, dryness of the vaginal mucosa, decreased libido). In addition, triphasic drugs are indicated for primary use in women with signs of estrogen deficiency.

When choosing a drug, the patient's health status should also be taken into account.

In the first months after the start of taking COCs, the body adapts to hormonal changes. During this period, intermenstrual spotting or, less commonly, breakthrough bleeding may occur (in 30-80% of women), as well as other side effects associated with hormonal imbalance (in 10-40% of women). If adverse events do not disappear within 3–4 months, the contraceptive may need to be changed (after excluding other causes - organic diseases of the reproductive system, missing pills, drug interactions). It should be emphasized that at present the choice of COCs is large enough to fit them to the majority of women who are indicated for this method of contraception. If a woman is not satisfied with the first choice drug, the second choice drug is selected taking into account the specific problems and side effects that the patient has experienced.

Choice of COC

Clinical situation	Preparations
Acne and/or hirsutism, hyperandrogenism	Preparations with antiandrogenic progestogens: "Diana-35" (for severe acne, hirsutism), "Zhanin", "Yarina" (for mild to moderate acne), "Belara"
Menstrual disorders (dysmenorrhea, dysfunctional uterine bleeding, oligomenorrhea)	COCs with a pronounced progestogenic effect ("Mikroginon", "Femoden", "Marvelon", "Zhanin"), when combined with hyperandrogenism - "Diana-35". When DMC is combined with recurrent hyperplastic processes of the endometrium, the duration of treatment should be at least 6 months.
endometriosis	Monophasic COCs with dienogest (Janine), or levonorgestrel, or gestodene, or progestogen oral contraceptives are indicated for long-term use. The use of COCs can help restore generative function
Diabetes mellitus without complications	Preparations with a minimum content of estrogen - 20 mcg / day (intrauterine hormonal system "Mirena")
Initial or re-prescribing oral contraceptives to a patient who smokes	For smokers under 35 years of age, COCs with minimal estrogen content; for smokers over 35 years of age, COCs are contraindicated.
Previous use of oral contraceptives was accompanied by weight gain, fluid retention in the body, mastodynia	"Yarina"
Poor menstrual control has been observed with previous oral contraceptives (in cases where causes other than oral contraceptives are ruled out)	Monophasic or triphasic COCs

Basic principles for monitoring patients using COCs

• Annual gynecological examination, including colposcopy and cytological examination.
• Once or twice a year examination of the mammary glands (in women with a history of benign breast tumors and / or breast cancer in the family), mammography once a year (in patients in perimenopause).
• Regular measurement of blood pressure. With an increase in diastolic blood pressure up to 90 mm Hg. Art. and above, COCs are stopped.
• Special examinations according to indications (with the development of side effects, the appearance of complaints).
• In case of menstrual dysfunction - exclusion of pregnancy and transvaginal ultrasound scanning of the uterus and its appendages. If intermenstrual spotting persists for more than three cycles or appears with further COC use, the following recommendations should be followed.
  • Eliminate an error in taking COCs (missing pills, non-compliance with the regimen).
  • Exclude pregnancy, including ectopic.
  • Exclude organic diseases of the uterus and appendages (myoma, endometriosis, hyperplastic processes in the endometrium, cervical polyp, cancer of the cervix or body of the uterus).
  • Rule out infection and inflammation.
  • If these reasons are excluded, the drug should be changed in accordance with the recommendations.
  • In the absence of withdrawal bleeding, the following should be excluded:
    • taking COCs without 7-day breaks;
    • pregnancy.
  • If these causes are excluded, then the most likely cause of the absence of withdrawal bleeding is endometrial atrophy due to the influence of progestogen, which can be detected by ultrasound of the endometrium. This condition is called "silent menstruation", "pseudoamenorrhea". It is not associated with hormonal disorders and does not require the abolition of COCs.

Rules for taking COCs

Women with regular menstrual cycles

• The initial intake of the drug should be started within the first 5 days after the onset of menstruation - in this case, the contraceptive effect is provided already in the first cycle, additional measures of protection against pregnancy are not needed. Taking monophasic COCs begins with a tablet marked with the corresponding day of the week, multiphasic COCs - with a tablet marked "start taking". If the first tablet is taken later than 5 days after the start of menstruation, an additional method of contraception for a period of 7 days is needed in the first COC cycle.
• Take 1 tablet (pellets) daily at approximately the same time of day for 21 days. If you miss a pill, follow the Forgotten and Missed Pill Rule (see below).
• After taking all (21) tablets from the package, a 7-day break is taken, during which withdrawal bleeding ("menstruation") occurs. After a break, start taking the tablets from the next package. For reliable contraception, the interval between cycles should not exceed 7 days!

All modern COCs are produced in "calendar" packages designed for one cycle of administration (21 tablets - 1 per day). There are also packs of 28 tablets; in this case, the last 7 tablets do not contain hormones ("pacifiers"). In this case, there is no break between packs: it is replaced by taking a placebo, since in this case, patients are less likely to forget to start taking the next pack on time.

Women with amenorrhea

• Start taking at any time, provided pregnancy is reliably excluded. Use an additional method of contraception for the first 7 days.

Women who are breastfeeding

• Do not prescribe COCs earlier than 6 weeks after delivery!
• The period from 6 weeks to 6 months after childbirth, if the woman is breastfeeding, use COCs only if absolutely necessary (method of choice - mini-pill).
• More than 6 months after childbirth:
  • with amenorrhea in the same way as in the section "Women with amenorrhea";
  • with a restored menstrual cycle.

"Forgotten and Missed Pill Rules"

• If 1 tablet is missed.
  • Delay in taking less than 12 hours - take the missed pill and continue taking the drug until the end of the cycle according to the previous scheme.
  • Being late for more than 12 hours - the same actions as in the previous paragraph, plus:
    • if you miss a pill on the 1st week, use a condom for the next 7 days;
    • if you miss a pill on the 2nd week, there is no need for additional contraception;
    • if you miss a tablet on the 3rd week, after finishing one package, start the next one without interruption; there is no need for additional protective equipment.
• If 2 tablets or more are missed.
  • Take 2 tablets per day until regular use, plus use additional methods of contraception for 7 days. If bleeding occurs after the missed tablets, it is better to stop taking the tablets from the current package and start a new package after 7 days (counting from the start of the missed tablets).

Rules for the appointment of COCs

• Primary appointment - from the 1st day of the menstrual cycle. If the 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.
• Appointment after abortion - immediately after the abortion. Abortion in the I, II trimesters, as well as septic abortion, belong to category 1 conditions (there are no restrictions on the use of the method) for the appointment of COCs.
• Appointment after childbirth - in the absence of lactation, start taking COCs no earlier than the 21st day after childbirth (category 1). In the presence of lactation, do not prescribe COCs, use mini-pills no earlier than 6 weeks after delivery (category 1).
• The transition from high-dose COCs (50 μg EE) to low-dose (30 μg EE or less) - without a 7-day break (so that the hypothalamic-pituitary system does not activate due to dose reduction).
• Switching from one low-dose COC to another - after the usual 7-day break.
• The transition from mini-pill to COC - on the 1st day of the next bleeding.
• Switching from an injectable to a COC is on the day of the next injection.

• It is advisable to reduce the number of cigarettes smoked or quit smoking altogether.
• Observe the regimen of taking the drug: do not skip taking the pills, strictly adhere to the 7-day break.
• Take the drug at the same time (in the evening before going to bed), drinking it with a small amount of water.
• Have the Rules for Forgotten and Missed Pills handy.
• In the first months of taking the drug, intermenstrual bleeding of varying intensity is possible, as a rule, disappearing after the third cycle. With ongoing intermenstrual bleeding at a later date, you should consult a doctor to determine their cause.
• In the absence of a menstrual-like reaction, you should continue taking the tablets as usual and immediately consult a doctor to exclude pregnancy; upon confirmation of pregnancy, you should immediately stop taking COCs.
• After stopping the drug, pregnancy can occur already in the first cycle.
• The simultaneous use of antibiotics, as well as anticonvulsants, leads to a decrease in the contraceptive effect of COCs.
• If vomiting occurs (within 3 hours after taking the drug), you must additionally take 1 more tablet.
• Diarrhea lasting for several days requires the use of an additional method of contraception until the next menstrual-like reaction.
• With a sudden localized severe headache, migraine attack, chest pain, acute visual impairment, shortness of breath, jaundice, increased blood pressure above 160/100 mm Hg. Art. immediately stop taking the drug and consult a doctor.

ICD-10

Y42.4 Oral contraceptives