Hormonal Contraceptives

COCs: Basics & MOA - Pill Power Intro

Combined Oral Contraceptives (COCs) are widely used hormonal pills containing synthetic estrogen and progestin. They offer highly effective, reversible contraception when used correctly.

• Core Mechanism of Action (MOA):
  • Ovulation Inhibition (Primary): Estrogen suppresses FSH (↓ follicle development); Progestin suppresses LH surge (prevents ovulation). Both act on hypothalamus-pituitary-ovarian axis.
  • Cervical Mucus Thickening: Progestin makes mucus viscous, ↑ impenetrability to sperm.
  • Endometrial Alteration: Endometrium becomes thin, atrophic, and unreceptive to blastocyst implantation.
• Estrogen Component: Typically Ethinyl Estradiol (EE), common doses range 20-35 µg.

⭐ Ethinyl estradiol (EE) is the most common synthetic estrogen in COCs; newer COCs may use estradiol valerate or estetrol (E4).

COCs: Benefits, Risks & Combined Methods - Perks, Perils, Combos

• Benefits (Non-Contraceptive):
  • Significant ↓ Ovarian & Endometrial cancer risk.

    ⭐ Combined hormonal contraceptives significantly reduce the risk of ovarian and endometrial cancers.

  • Menstrual cycle regulation: ↓dysmenorrhea, ↓menorrhagia.
  • Other: ↓Pelvic Inflammatory Disease (PID), ↓ectopic pregnancy, ↓benign breast disease, ↓acne, ↓hirsutism.
• Risks & Contraindications (CI):
  • VTE (Venous Thromboembolism): Estrogen-dependent; highest risk in 1st year.
  • Cardiovascular: ↑MI/Stroke (CI: smokers >35yrs, uncontrolled HTN, migraine with aura).
  • HTN, Gallbladder disease, Hepatic adenoma (rare).
  • Cancer: Slight ↑Breast Ca risk (normalizes 10 yrs post-cessation); ↑Cervical Ca risk with >5 yrs use.
• Other Combined Hormonal Methods:
  • Transdermal Patch (e.g., Evra): Weekly; higher systemic estrogen exposure.
  • Vaginal Ring (e.g., NuvaRing): Monthly; lower systemic estrogen.
• Missed COC Pill Management:

Progestin-Only Contraceptives - Solo Hormone Hits

• Mechanism: Thicken cervical mucus, suppress ovulation (variably), endometrial changes.

• Ideal for: Breastfeeding, estrogen contraindications (e.g., VTE risk, smokers >35 yrs, migraine with aura).

• Types:

  • Progestin-Only Pills (POPs / Mini-pills):
    • E.g., Norethindrone, Levonorgestrel.
    • Strict 3-hour intake window (traditional); 12-hour for desogestrel. 📌 POP In Time!
    • Common: Irregular bleeding.
  • Injectables (DMPA):
    • Depot Medroxyprogesterone Acetate: 150 mg IM / 104 mg SC every 3 months.
    • Side effects: Menstrual changes (amenorrhea common), weight gain.
    • Delayed fertility return (~9-10 months).
    • ⭐ > DMPA (Depo-Provera) use is associated with a potential reversible decrease in bone mineral density, particularly with long-term use.
  • Implants (e.g., Etonogestrel - Nexplanon):
    • Long-acting (up to 3 years).
    • Highly effective.
    • Common: Irregular bleeding.

Emergency Contraception & Comparisons - Backup & Best Bets

• Top ECP Choices (Post-Coitus):
  • Copper IUD (Cu-IUD): Most effective, up to 120 hrs.
  • Ulipristal Acetate (UPA): 30mg dose, up to 120 hrs.
  • Levonorgestrel (LNG): 1.5mg dose, up to 72 hrs (some efficacy up to 120 hrs).
• Mechanisms:
  • UPA/LNG: Primarily delay/inhibit ovulation.
  • Cu-IUD: Prevents fertilization; inhibits implantation.
• Key Note: High BMI may ↓ hormonal ECP efficacy; Cu-IUD often preferred.

⭐ Ulipristal acetate (UPA) is more effective than Levonorgestrel for emergency contraception, especially closer to ovulation and up to 120 hours post-coitus.

High‑Yield Points - ⚡ Biggest Takeaways

• OCPs primarily inhibit ovulation; progestins thicken cervical mucus & alter endometrium.
• Combined OCPs ↓ risk of ovarian & endometrial cancer, regulate cycles, and improve acne.
• Progestin-only pills (POPs) are preferred during lactation & for women with estrogen contraindications (e.g., VTE history).
• Emergency Contraception: Levonorgestrel (LNG) within 72 hours, Ulipristal acetate (UPA) within 120 hours; Copper IUD is most effective.
• Absolute COCP Contraindications: History of VTE, stroke, migraine with aura, current breast cancer, severe liver disease, uncontrolled hypertension.
• DMPA (injectable): Associated with delayed return to fertility and potential ↓ bone mineral density with long-term use.
• Hormonal IUDs (LNG-IUS): Provide long-acting reversible contraception and can significantly reduce menstrual bleeding, treating menorrhagia.