Therapeutics of
hormonal contraceptives

Pharmacology

estrogen & progestin work primarily before fertilization to prevent contraception

PROGESTIN

block LH surge

thickening cervical mucus

alters endometrial lining

ESTROGEN

suppress FSH release

stabilize endometrial lining

provide cycle control

in obesity

2-4 x more pregnancies

due to decreased serum
concentrations of OCs

POPs (progestin-only pills) recommended

due to increased risk
of VTE in obesity

effectiveness

perfect use

99% effective

typical use

93% effective

OC's
CLASSIFICATION

hormones

combined hormonal contraceptives

progestin only

dosing

low dose

high dose

day supply

28 days

84 days (extended cycle)

reduce # of periods/year by
increasing # of active tablets

consider in patients w/ PMS, premenstrual
dysphoric disorder, menstrual migraines, or
dysmenorrhea

can take continuously for up to 1 year

phases

monophasic

easier to initiate

easier to manipulate
packs and skip periods

triphasic

most common

multiphasic

estrogen and progestin levels vary

other ingredients

hormones only

iron

B vitamins

ESTROGENS

Ethinyl estradiol (EE)

most common

doses range from
10-50 mcg

ULTRA LOW DOSE:
< 20 MCG

LOW DOSE:
20-35 MCG

HIGH DOSE:
≥ 50 MCG

Mestranol

Necon

must be activated by the liver

50% less effective than EE

Estradiol Valerate

Dienogest

natural estrogen

Initiating
OCs

..........

start date

1st day of bleeding

1st Sunday after
cycle begins

"Sunday Starter"

5th day after
cycle begins

..........

backup

must be used for ≥ 7 days

backup first cycle due to user error

..........

postpartum use

concerns

postpartum women
are hypercoaguable

OCs may interfere
w/ lactation

avoid ESTROGEN for
21 days after birth

consider progestin only pills (POPs)

DOSING
CONDIDERATIONS

healthy women

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≤ 25 mcg of EE

≤ 0.5 mcg norethindrone
or equivalent

consider lower doses if

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adolescent?

underweight

age > 35 years

perimenopausal

overweight/obese

≥ 30/35 mcg EE recommended

Progestins

..........

..........

Progestin
SE

ESTROGENIC

bloating
N/V
breakthrough bleeding
irritability
HA
HTN

PROGESTATIONAL

HA
breast pain/
tenderness
HTN

ANDROGENIC

acne/oily skin
weight gain
hirsutism
fatigue
depression

ADVANTAGES

decreased menstrual cramps

decreased ovulation pain (mittelschmerz)

menstrual regularity

decreased menstrual blood loss

decreased iron-deficiency anemia

reduced ovarian cancer rates

reduced endometrial cancer rates

Think "dinos" are naturally
in the VALley

In a situation where the tablets that were missed were the last week of active pills

omit the hormone free interval by finishing active drug tablets and then starting a new pack