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Hormonal contraception
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Permanent temporary
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Hormonal contraception Intrauterine devices Barrier contraception
Temporary contraceptives Hormonal contraception Intrauterine devices Barrier contraception Natural family planning methods
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ORAL CONTRACEPTIVES
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ORAL CONTRACEPTIVES Oral contraceptives are medicines taken by mouth to help prevent pregnancy. They are also known as “birth control pills”. Birth control (contraceptive) medications contain hormones (estrogen and progesterone, or progesterone alone). Efficacious Low cost Overall safety Complete return of fertility on discontinuation
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Primary action is inhibition of ovulation
MECHANISM OF ACTION Primary action is inhibition of ovulation
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Mechanism of oral contraceptives
Hormonal birth control medications prevent pregnancy through the following ways: By blocking ovulation (release of an egg from the ovaries), thus preventing pregnancy By altering mucus in the cervix, which makes it hard for sperm to travel further By changing the endometrium (lining of the uterus) so that it cannot support a fertilized egg By altering the fallopian tubes (the tubes through which eggs move from the ovaries to the uterus) so that they cannot effectively move eggs toward the uterus
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FSH Progestogen- LH
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mode of action Inhibition of Gn release from pituitary by reinforcement of normal feedback inhibition. estrogen inhibits secretion of FSH via negative feedback on the anterior pituitary, and thus suppresses development of the ovarian follicle progestogen inhibits secretion of LH and thus prevents ovulation; it also makes the cervical mucus less suitable for the passage of sperm oestrogen and progestogen act in concert to alter the endometrium in such a way as to discourage implantation. They may also interfere with the coordinated contractions of cervix, uterus and fallopian tubes that facilitate fertilisation and implantation.
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Ovulation
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ORAL CONTACEPTIVE VIDEO
..\..\VIDEOS\ORAL CONTRACEPTIVE VIDEO\Birth Control Pills.mp4 ..\..\VIDEOS\PARTURATION PROCESS\Parturition - Pregnancy, Hormones, Giving Birth.mp4
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Types ORAL Combined pill- Efficacy 98-99.9% Estrogen+Progestin
2nd generation pills- ↓estrogen+progestins 3rd generation pills- newer progestins-desogestrel COURSE 1 tablet daily(starting on 5th day of menstruation)-21 days Next course after gap of 7 days
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2. Phased regimens Reduction in total steroid dose without compromising efficacy -Biphasic -Triphasic Estrogen - Constant(or varied b/w 30-40µg) Progestin- Low in 1st phase-progressively higher in 2nd and 3rd phase 3. Minipill Low dose Progestin only pill Taken continuously without any gap Efficacy %
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4. Postcoital (emergency) contraception
3 regimens Levonorgestrel 0.5mg- Ethinylestradiol 0.1mg within 72 hrs & repeated after 12 hrs ‘YUZPE method’ Levonorgestrel 0.75mg Twice with 12 hr gap within 72 hrs WHO essential drug list(2001)- recommended replacement of YUZPE method by this regimen c) Mifepristone 600mg- single dose within 72 hrs
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COMBINED ORAL CONTRACEPTIVE PILLS
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The combined pill This is the most popular and most efficacious method. It contains an estrogen and a progestin in fixed dose for all the days of a treatment cycle (monophasic). With accumulated experience It has been possible to reduce the amount of estrogen and progestin in the ‘second generation’ oc pills Without compromising efficacy, but reducing side effects and complications. ‘Third generation’pills containing Newer progestins like desogestrel with improved profile of action. Ethinylestradiol 30 µg daily is considered threshold but can be reduced to 20 µg/day if a progestin with potent antiovulatory action is included. The progestin is a 19-nortestosterone because these have potent antiovulatory action.
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The combined pill The estrogen in most combined preparations (second-generation pills) Ethinylestradiol, although a few preparations contain mestranol instead. The progestogen may be Norethisterone, levonorgestrel, ethynodiol, or In 'third-generation' pills-desogestrel or gestodene Are more potent But which probably cause a greater risk of thromboembolism than do second- generation preparations. Well tolerated and gives good cycle control in the individual woman. This combined pill is taken for 21 consecutive days followed by 7 pill-free days, which causes a withdrawal bleed. Normal cycles of menstruation usually commence fairly soon after discontinuing treatment.
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First generation:- 50 μg ethinyl estradiol and Progesterone (Norethynodrel, norethisterone acetate and lynestrenol) :ovral Second generation:- 20-30μg ethinyl estradiol and Progesterone (Norgestrel, levonorgestrel) Without compromising efficacy, but reducing side effects and complications. :ovral –L, malaN , malaD Third generation: Containing newer progestins with improved profile of action. Ethinylestradiol 30 μg and progesterone (Desogestrel, gestodene, norgestimate) :novelon , femilon
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Phased regimens These have been introduced to permit reduction in total steroid dose withaut Compromising efficacy. These are biphasic or Triphasic. The estrogen dose is kept constant (or Varied slightly between µg), while the Amount of progestin is low in the first phase and Progressively higher in the second and third Phases. Phasic pills Particularly recommended for Women over 35 years of age or when other risk Factors are present.
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Phased regimens Biphasic (each tablet contains a fixed amount of estrogen, while the amount of progestin increases in the second half of the cycle); or Estrogen - constant(or varied b/w 30-40µg) Progestin- low in 1st phase-progressively higher in 2nd and 3rd phase Triphasic (the amount of estrogen may be fixed or variable, while the amount of progestin increases in 3 equal phases).
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Minipill (progestin only pill)
It has been devised to eliminate the estrogen, because many of the long-term risks have been ascribed to this component. A low-dose progestin only pill is taken daily continuously without any gap. The menstrual cycle tends to become irregular and ovulation occurs in 20-30% women, but other mechanisms contribute to the contraceptive action. The efficacy is lower (96-98%) compared to % with combined pill. This method is less popular.
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Postcoital (emergency) contraception
3 regimens Levonorgestrel 0.5mg+ethinylestradiol 0.1mg within 72 hrs & repeated after 12 hrs ‘YUZPE method’ Levonorgestrel 0.75mg twice with 12 hr gap within 72 hrs WHO essential drug list(2001)- recommended replacement of YUZPE method by this regimen Mifepristone 600mg- single dose within 72 hrs Emergency postcoital contraception should be reserved For unexpected or accidental exposure (rape, condom rupture) only Because all emergency regimens have higher failure rate and side effects than regular low-dose combined pill.
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Adverse effects A. Nonserious side effects
These are frequent, Specially in the first 1-3 cycles and then disappear Gradually. Nausea and vomiting, Headache, migraine, bleeding or spotting, Amenorrhoea, Breast discomfort. B. Side effects that appear later 1. Weight gain, acne and increased body hair 2. Chloasma: pigmentation of cheeks, nose and Forehead 3. Pruritus vulvae 4. Carbohydrate intolerance and precipitation Of diabetis 5. Mood swings, abdominal distention
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Adverse effects 1 . Leg vein and pulmonary thrombosis
C. Serious complications 1 . Leg vein and pulmonary thrombosis 2. Coronary and cerebral thrombosis 3. Rise in BP 4. raise plasma HDL/LDL ratio 5. Genital carcinoma 6. Benign hepatomas 7. Gallstones
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Other health benefits lower probability of developing endometrial and ovarian carcinoma; probably colorectal cancer as well. Reduced menstrual blood loss and associated anaemia; cycles if irregular become regular endometriosis and pelvic inflammatory disease are improved. reduced incidence of fibrocystic breast disease .
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Contraindications The combined oral contraceptive
Absolutely contraindicated in: Thromboembolic, coronary and cerebrovascular disease or a history of it. 2. Moderate-to-severe hypertension; hyperlipidaemia. 3. Active liver disease, hepatoma or jaundice during past pregnancy 4. Suspected malignancy of genitals/breast. 5. Prophyria. 6. Impending major surgery—to avoid excess risk of postoperative thromboembolism. Relative contraindications (requiring avoidance/cautious use under supervision) 1. Diabetes 2. Obesity 3. Smoking 4. Undiagnosed vaginal bleeding 5. Mentally ill 6. Age above 35 years 7. Mild hypertension 8. Migraine 9. Gallbladder disease
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Interaction With Drugs…
Contraceptive failure may occur if the following drugs are used concurrently: Enzyme inducers: Phenytoin, phenobarbitone, primidone, carbamazepine, rifampin, ritonavir. Metabolism of estrogenic as well as progestational component is increased. Suppression of intestinal microflora: Tetracyclines, ampicillin, etc. Deconjugation of estrogens excreted in bile fails to occur → their enterohepatic circulation is interrupted → blood levels fall.
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Indications of Withdrawal :
Severe migraine Visual or speech disturbances Sudden chest pain Unexplained fainting attack or acute vertigo Severe leg cramps Excessive weight gain Severe depression Prior to surgery ( Atleast 6 weeks ) Patient wants pregnancy …
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THANK YOU - PHARMA STREET
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