Oral Contraceptive Pills

Most widely used form of hormonal contraception

(easy to use and efficient)
Action: Suppress ovulation, change cervical
mucus, and alter the endometrium
The current formulations are made from synthetic
estrogens and progestins
Estrogen component ethinyl estradiol or
mestranol, which is metabolized to ethinyl estradiol
Multiple synthetic progestins are used
Norethindrone and its derivatives are used in many
formulations
Low-dose norgestimate and the more recently developed
progestins (desogestrel, gestodene, drospirenone) have a
less androgenic profile
Levonorgestrel appears to be the most androgenic of the
progestins (avoid in patients with hyperandrogenic symptoms)
Harrison's Principles of Internal Medicine, 18th
Ed.
The 3 major formulations of oral contraceptives
1. fixed-dose estrogen-progestin combination,
2. phasic estrogen-progestin combination, and
3. progestin only
Each of these formulations is administered daily for 3 weeks
followed by a week of no medication during which menstrual
bleeding generally occurs
Current doses of ethinyl estradiol range from 20 to
50 g (majority 35 g; 50-g is rare)
2
nd
and 3
rd
generation pills has reduced estrogen
and progestin content (mostly to decrease both side
effects and risks associated with oral contraceptive
use)
At the currently used doses, patients must be
cautioned not to miss pills due to the potential for
ovulation
Side effects, including breakthrough bleeding,
amenorrhea, breast tenderness, and weight gain,
often respond to a change in formulation
Harrison's Principles of Internal Medicine, 18th
Ed.
Harrison's Principles of Internal Medicine, 18th
Ed.
The microdose progestin-only minipill is less
effective as a contraceptive, having a pregnancy
rate of 27 per 100 women-years
May be appropriate for women with cardiovascular
disease or for women who cannot tolerate synthetic
estrogens
Harrison's Principles of Internal Medicine, 18th
Ed.
New Methods
A weekly contraceptive patch (Ortho Evra)
Similar efficacy to oral contraceptives but may be
associated with less breakthrough bleeding
Approximately 2% of patches fail to adhere, and a
similar percentage of women have skin reactions
Efficacy is lower in women weighing >90 kg
Harrison's Principles of Internal Medicine, 18th
Ed.
The amount of estrogen
delivered may be comparable to
that of a 40-g ethinyl estradiol oral
contraceptive, raising the
possibility of increased risk of
venous thromboembolism (used
must be balanced against potential
benefits for women not able to
successfully use other methods)
A monthly contraceptive
estrogen/progestin injection
(Lunelle)
Highly effective, with a first-year
failure rate of <0.2%, but it may be
less effective in obese women
Its use is associated with bleeding
irregularities that diminish over time
Fertility returns rapidly after
discontinuation

Harrison's Principles of Internal Medicine, 18th
Ed.
A monthly vaginal ring
(NuvaRing)
A monthly vaginal ring
(NuvaRing) that is
intended to be left in
place during
intercourse is also
available for
contraceptive use
Highly effective, with a
12-month failure rate
of 0.7%
Ovulation returns
within the first
recovery cycle after
discontinuation

Harrison's Principles of Internal Medicine, 18th
Ed.
Long-Term Contraceptives
Acts primarily by inhibiting ovulation and causing
changes in the endometrium and cervical mucus
that result in decreased implantation and sperm
transport.
Irregular bleeding, amenorrhea, and weight gain
are the most common side effects.
This form of contraception may be particularly
good for women in whom an estrogen-containing
contraceptive is contraindicated (e.g., migraine
exacerbation, sickle-cell anemia, fibroids).
Harrison's Principles of Internal Medicine, 18th
Ed.