HORMONAL METHODS OF

CONTRACEPTION
&
EMERGENCY CONTRACEPTION

URVASHI GOEL
M.Sc (N)
PREVIOUS
HORMONAL CONTRACEPTIVES
 Hormonal contraceptives refers to birth
control methods that act on the endocrine
system.

 Action varies from one type to another

 Uses synthetic progesterone and estrogen

CLASSIFICATION
A. Oral pills
 1. Combined pill

 2. Progestrogen only pill (POP)

 3. Post-coital pill

 4. Once-a-month (long-acting) pill

 5. Male pill

 B. Depot (slow release} formulations

 1. Injectables
 2. Subcutaneous implants
 3. Vaginal rings
Oral pills :
 a) Combined pills
 Content: Contains estrogen and progesterone
 Mode of action: Inhibits ovulation of ovum by

blocking the gonadotropin from pituitary

gland.
 The progestrogen alters the cervical mucosa

which prevents entry of sperms into genital

canal makes the uterine inner lining unsuitable
for implantation of fertilized egg.
 Duration: 21 or 28 days

 Taken for 21 consecutive days beginning from

5th day of menstruation.

 Effects: “withdrawal bleeding”

 When the bleeding occurs, this is considered

the first day of the next cycle. The bleeding

which occurs is not like normal menstruation,
but is an episode of uterine bleeding from an
incompletely formed endometrium caused by
the withdrawal of exogenous hormones
 Example: Mala-N and Mala - D

 It is supplied by the government of India

Content: Contains levonorgesterol 0.15 mg
and ethinil estrodiol 0.003 mg

Mala- D: 21 OCP and 7 iron tablets (60 mg

ferrous fumarate tablet) available at the cost
of Rs. 3
 Mala-N: 21 OCP, supplied free of cost

through PHC, Urban health centers.

 Progesterone only pills (Mini
pill/ micro pill )
 Content: Contains only progesterone

 Mode of action:  The progestrogen alters the

cervical mucosa which prevents entry of sperms
into genital canal makes the uterine inner lining
unsuitable for implantation of fertilized egg.
 Duration: throughout the menstrual cycle
 Commonly used progesterone are

Norethirsterone and levonorgesterol

 Disadvantage: Increased pregnancy rate and

poor cycle control.

 Advantage: can be used in older women with

cardiovascular risks
 Post coital pill

 Post coital method is advocated as an

emergency method eg. Contraceptives failure,
rape, unprotected sex

 Duration: To be taken within 72 hours of

unprotected intercourse

 Content: Contains hormone progesterone

 Action: It prevents ovary from releasing egg or

prevents fertilization or implantation
 (a) IUD : The simplest technique is to insert an
IUD, if acceptable, especially a copper device
within 5 days.

 (b) Hormonal : More often a hormonal method

may be preferable.

 In India Levonorgestrel 0. 75 mg tablet is

approved for emergency contraception. It is
used as one tablet of 0.75 mg within 72 hours
of unprotected sex and the 2nd tablet after 12
hours of 1st dose.
 Once a month pill
 Its a long acting pill

 Combination of long acting estrogen

(quinestrol) with short acting progesterone

 High pregnancy rate

 Irregular menstrual cycle

 Male pill
 An ideal male contraceptive pill should
decrease sperm count but does not affect
testosterone levels.

Eg. Gossypol- derivation of cotton seed oil

 Produces oligospermia or azoospermia
 Not on practice
 Advantage of oral pills
 Prevents pregnancy
 Eases menstrual cramps
 Regular period
 Decreases incidence of ovarian and uterine

cancer
 Decreases acne
 Provides protection against at least 6

disease: benign breast disorder, ovarian

cysts, iron deficiency anemia, pelvic
inflammatory disease, ectopic pregnancy,
ovarian cancer
 CONTRAINDICATIONS
Absolute
 Cancer of breast and genital
 History of thromboembolism
 Cardiac abnormality
 Abnormal uterine bleeding
 Congenital hyperlipidemia

Relative
 Age above 40 years
 Smoking
 Mild hypertension
 Epilepsy
 Migraine
 Lactating mother
 Adverse effects
 Cardiovascular disease
 Risk of breast cancer
 Risk of cervical cancer
 Risk of thromboembolism
 Risk of liver adenoma
 Lipid metabolism disorder
 Nausea
 Depression
 Post-pill amenorrhea
 Weight gain
 Headache
 Migraine
 Breast tenderness
 Injectable contraceptives
 
PROGESTOGEN-ONLY INJECTABLES

They offer more reliable

 protection against unwanted pregnancies

than the older barrier techniques.

 a. DMPA (Depot-medroxyprogesterone
acetate)
 b. NET-EN (Norethisterone enantate)
 c. DMPA-SC
 Depo metroxyprogesterone
acetate (DMPA)
Safe, effective and acceptable contraceptive
that needs minimum motivation.
 Good use among multipara women>35 years

who have completed family

 Administration: IM injection of 150 mg every 3

months
 Duration: Given at 1st 5 days of menstrual

cycle, timing is to rule out pregnancy

 Effectiveness: 99% protection from pregnancy

 Mode of action: Stops ovulation and thickens

cervical mucus

 Side effects: weight increase, irregular

menstrual bleed, prolonged infertility

Points to remember :
 Given deep IM in the gluteus maximus
 Injection site should never be massaged
 Norethisterone enantate (NET-EN)

 Less extensively used than DMPA

 Administration: IM injection of 200 mg every

2 months
 Duration: Given deep at 1st 5 days of

menstrual cycle

 Mode of action: Inhibition of ovulation and

thickening of cervical mucus
 Effectiveness: Higher pregnancy rate than
DMPA (0.4%)

Points to remember : Given deep IM in

gluteus maximus
 Injection site should never be massaged
 Combined injectable
 Content: Contains progesterone and
estrogen

 Duration: Given at monthly intervals

 Mode of action: Action mainly ovulation

suppression
 • Ex: Cyclo provera
ADVANTAGES :

 Very effective
 Maintains privacy
 Reversible
 Suitable for breast feeding in women
 Best for gastritis or peptic ulcer diseases
 Protects against ectopic pregnancy
SIDE EFFCETS OF INJECTABLE CONTRACEPTIVES:

 Irregular menstrual bleeding

 Termination of periods
 Bone density loss
 Weight gain
 Delayed return of fertility
 Abdominal pain and discomfort
 Headache
 Weakness/fatigue
 nervousness
Contraindications for injectable
contraceptives
Cancer of breast, genitals
 Undiagnosed abnormal uterine bleeding
 Deep vein thrombosis
 History of stroke, heart attack
 High BP>160/100 mm of hg
 Sub dermal implants
 Administration: Implants are placed in the
body filled with hormone that prevents
pregnancy .

Physically inserted in simple 15 minute

outpatient procedures
 Plastic capsules, the size of paper

matchsticks inserted under the skin in the

arm
 Effectiveness: 99.95% effectiveness rate
 NORPLANT 1=
 Six capsules
 Five years effectiveness

 NORPLANT 2 =
 Two capsules
 Three years
CONTRAINDICATIONS OF IMPLANT:

 Women with liver diseases

 Breast cancer
 Pregnancy
 Hypertensive
SIDE EFFECTS:

 Irregular menstrual periods

 Weight gain
 Nervousness
 Anxiety
 Nausea and vomiting
 Dermatitis, rash
 Scalp hair loss
 Headache depression
 acne
 Vaginal rings
 Vaginal rings containing levonorgesterol have
been found to be effective
 Hormone is slowly absorbed through vaginal

mucosa
 Rings is worn 3weeks of the cycle and

removed
ADVANTAGES OF VAGINAL RING:

 Protects against acne and PMS

 Protection against:
 Pelvic inflammatory disease
 Iron deficiency anemia
 Irregular heavy periods
 Ovarian and endometrial cancer
 Ectopic pregnancy
 Bone thinning
 Cyst in ovary and breast
SIDE EFFCETS:

 Nausea, vomiting
 Breast tenderness
 Vaginal irritation
 Increase vaginal discharge
 Infection
EMERGENCY CONTRACEPTION
 Emergency contraception refers to methods
of contraception that can be used to prevent
pregnancy after sexual intercourse.
IN WHAT SITUATIONS CAN EMERGENCY
CONTRACEPTION BE USED?
 no contraceptive has been used.

 Sexual assault

 possible contraceptive failure, from improper or

incorrect use
◦ condom breakage, slippage, or incorrect use
◦ 3 or more consecutively missed combined oral contraceptive
pills;
◦ dislodgment, breakage, tearing, or early removal of a
diaphragm or cervical cap;
◦ failed withdrawal (e.g. ejaculation in the vagina or on
external genitalia);
◦ failure of a spermicide tablet or film to melt before
intercourse;
◦ more than 2 weeks late for the norethisterone
enanthate (NET-EN) progestogen-only injection;

◦ more than 4 weeks late for the depot-

medroxyprogesterone acetate (DMPA) progestogen-
only injection;

◦ more than 7 days late for the combined injectable

contraceptive (CIC);

◦ miscalculation of the abstinence period, or failure to

abstain or use a barrier method on the fertile days of
the cycle when using fertility awareness based methods;
or
◦ expulsion of an intrauterine contraceptive device (IUD)
or hormonal contraceptive implant.
METHODS OF EMERGENCY
CONTRACEPTION
 High doses of progestogen only
pill containing levonorgestrel
(LNG)

 High doses of combined oral

contraceptive containing
ethylestradiol and levonorgestrol
(Yuzpe regimen)

 Copper releasing intrauterine

devices (IUCD) such as CuT 380A
 EMERGENCY CONTRACEPTION PILLS (ECPS)
AND COMBINED ORAL CONTRACEPTIVE PILLS
(COCS)
 WHO recommends any of the following drugs
for emergency contraception:
◦ ECPs with LNG taken as a single dose of 1.5 mg, or
alternatively, LNG taken in 2 doses of 0.75 mg each,
12 hours apart.

◦ COCs, taken as a split dose, one dose of 100 μg of

ethinyl estradiol plus 0.50 mg of LNG, followed by a
second dose of 100 μg of ethinyl estradiol plus 0.50
mg of LNG 12 hours later. (Yuzpe method)
MODE OF ADMINISTRATION

 The emergency contraceptive pills must be

preferably taken within 72 hours of an
unprotected act of intercourse, the earlier the
better.
 Best if taken as soon as possible after the

unprotected act and as a single dose of 1

tablet of 1.5mg or 2 tablets of 0.75mg each.
CALCULATION OF THE 72 HOURS
(THREE-DAY) INTERVAL
 The calculation of 72 hours or 3 days should
start from the first unprotected penetrative
vaginal intercourse the woman has had
during that particular menstrual cycle.
HOW DO EMERGENCY
CONTRACEPTIVE PILLS WORK?
 work by delaying ovulation and hence
preventing the eggs to be released from the
ovary for fertilization.
 Some pills prevent a fertilized egg to implant

itself in the uterus

 some inhibit fertilization
emergency contraceptive pills do not protect against
sexually transmitted diseases and nor do they cause
abortions if a pregnancy has already happened
EFFECTIVENESS OF EMERGENCY
CONTRACEPTIVE PILLS
 impossible to predict correctly who would
become pregnant after an unprotected
intercourse.
◦ ECPs taken within 72 hours of unprotected vaginal
intercourse are 85% effective. ECP is more effective
if used within 12-24 hours of unprotected
intercourse

◦ The delay in taking the pills decreases the efficacy

of ECP
SIDE EFFECTS OF ECP'S
 sideeffects generally do not last
more than one to two days.
◦ about 20%: nausea
◦ 6%: vomiting

 Overall ECPs are well tolerated.

MANAGEMENT OF SIDE EFFECTS
 vomiting occurs within two hours- repeat the
full dose.
 Women with irregular bleeding and spotting

after taking with ECPs should be counseled that

this is normal.
 If menstruation is delayed beyond one week

from scheduled date, tests should be

conducted to exclude the possibility of
pregnancy
 Side effects such as breast tenderness,

headache, dizziness, and fatigue are not

common and do not generally last more than 24
hours.
LIMITATIONS
 The closer a woman is to ovulation at the
time of unprotected intercourse, higher is the
pregnancy risk and lower is the efficacy of the
ECPs.
 Failure of EC to prevent pregnancy beyond

the time frame of efficacy window (72-120

hours) following unprotected intercourse may
limit its use in clients who usually report later
than this interval.
BENEFITS OF EMERGENCY
CONTRACEPTIVE PILLS
 Safe and effective
 Easy to use and widely available
 Can be taken at any time during the monthly cycle
 A physical examination is not required
 It is available without a prescription from

registered medical practitioner

 Can be given to women for whom use of

hormonal contraceptive pills are contraindicated

 Can be used as many times as needed; although

not a substitute for regular contraceptives