Hormonal contraception. Secrets of choosing a combined oral contraceptive. How to choose birth control pills? How are hormonal contraceptives prescribed?

Last update 04/04/2019

Many women prefer protection with oral contraceptives, which is due to several factors: preventing unexpected pregnancy, improving the appearance of skin, hair and nails, and normalizing hormonal levels. Disadvantages include spotting between menstruation, lack of protection against sexually transmitted diseases, and difficulty in selecting according to individual characteristics. The latter factor is decisive in successful contraception and hormone replacement therapy.

Classification and types

Which ones are better to choose for reliable contraception? The pharmaceutical industry produces a sufficient number of new generation oral contraceptives. Contrary to prevailing opinions about the dangers of hormones for the female body, modern drugs do not increase weight (in some cases even reduce body weight), do not increase hair growth in unwanted places, and do not affect libido and women's health. Ease of use and benefits for the beauty of the body and face often become the determining condition for this particular type of contraception. Before choosing birth control pills, you need to know the existing types of tablets.

Single-phase (aka monophasic) tablets

A characteristic feature of such tablets is the same ratio of estrogen and progestogen hormones. The main drugs of the group are the following tablets:

The doctor selects single-phase oral contraceptives to correct hormonal levels after abortion, in case of menstrual irregularities.

Biphasic contraceptives

One tablet of biphasic drugs includes a certain constant concentration of estrogen and a variable dose of gestagen, which changes in the first and second periods of the menstrual cycle. The following types of tablets are distinguished:

This group of drugs is prescribed to women with particular sensitivity to gestagens, as well as with a history of hyperandrogenism. Treatment is carried out in accordance with the indications of the drug.

Contraception in three phases

Three-phase drugs contain a dose of hormones that changes three times during the menstrual cycle. The main drugs in this group are:

Tablets with three-phase action are prescribed to women over 35 years of age and girls under 18 years of age. Considering that the main contraindication to the use of tablets is smoking, triphasic hormones can be taken by women who smoke. The advantage is its high effectiveness for obesity at any stage of development. The main disadvantage is the complex application regimen and the frequency of bleeding between menstruation.

Minipill tablets

The active component of mini-pill tablets is only progestogen. The substance affects local areas of the woman’s reproductive system, normalizes cervical mucus and its biochemical composition. The volume of mucus under natural conditions decreases in the middle of the cycle, but with the use of the drug, the viscosity remains consistently high and interferes with the movement of sperm. Usually the choice falls on such effective tablets:

Lactinet, Charozetta (based on the drug desogestrel);

Microlut, Exluton, Orgametril (the drug is based on linestrenol).

Changes while taking the mini-pill occur at the level of biochemical processes, as well as in the endometrial layer. Implantation of a fertilized egg becomes difficult. For many women, ovulation is completely blocked. Even such pills are extremely difficult to choose without a doctor.

The basic principle of action of combined oral contraceptives is to completely block ovulation and implantation of the fertilized egg into the uterine wall. Oral contraception provides a kind of glandular regression in the mucous structures of the uterus. The mucous components in the cervical canal thicken, which prevents the penetration of sperm. These changes are responsible for the contraceptive effect of using the pills.

Classification by volume of hormonal components

Differences in tablet contraceptives are also due to the total concentration of hormones in one tablet. The information is presented in the following table:

attitude towards the group	destination features	pharmacy names
Microdosed preparations		Zoeli (single-phase); Qlaira (three-phase); Lindinet; Mercilon; Miniziston;
Low-dose products	The tablets have a pronounced antiandrogenic effect and are prescribed when androgens predominate in female hormones (increased hair growth, deepening of the voice, acne, oily skin). The drug is prescribed to healthy young women who have given birth to patients to prevent pregnancy, to reduce bleeding between menstruation when prescribing low-dose drugs.	Microgynon; Marvelon; Rigevidon; Miniziston;
High-dose drugs	Modern contraceptives with a high content of hormones are prescribed for diseases of the uterus (for example, endometriosis) or for hormonal disorders. The use of this group is possible only as prescribed by a doctor.	Non-Ovlon; Tri-Regol; Triquilar; Trizeston.

Features of choosing birth control pills

It is very difficult to choose pills on your own, so doctors recommend not to practice on your own health. In some cases, even after examinations and consultation with specialists It is impossible to choose the right drug perfectly the first time. Women are tormented by constant spotting between menstruation, there is a lack of effectiveness of therapeutic effects and an increase in symptoms of gynecological diseases. When prescribing a drug, a number of diagnostic criteria are taken into account:

general clinical history;

number of births and abortions;

living conditions (nutrition, bad habits, sexual contacts, the nature of menstruation);

test indicators (sampling from the cervical canal, urine and blood tests);

ultrasound of the peritoneal and pelvic organs;

mammological examination;

assessment of a woman’s type based on hormonal levels.

It is impossible to obtain all this data at home. Self-prescription leads not only to a decrease in contraceptive function, but also to a number of side effects.

Before appointment consultation with an endocrinologist or ophthalmologist is required. The choice of oral contraceptives is also based on other criteria for assessing general physiological parameters:

type of mammary glands;

the nature of menstruation;

the presence of chronic diseases of organs and systems, including gynecological pathologies;

general condition of the skin and hair;

type of pubic hair growth.

According to all clinical data, the woman’s phenotype is compiled, which is the main criterion for choosing suitable pills for contraception and the treatment of gynecological diseases, including infertility.

Women of this type are of medium or short stature, their hair and skin are dry. Femininity is defined. Menstruation is accompanied by severe blood loss and is prolonged. The duration of the menstrual cycle is more than 4 weeks. Such women are prescribed high-dose and normal-dose contraceptives. The main drugs are Milvane, Femoden, Tri-regol, Rigevidon, Lindinet, Microgynon, Logest, Triziston. Such remedies are not prescribed to oneself.

Balanced estrogen content

The type of woman is characterized by average height, medium-sized breasts, normal skin and hair condition. Signs of PMS are usually absent or moderate. The duration of menstruation does not exceed 5 days, and the total duration of the menstrual cycle is normal. Women can choose the following drugs:

Tri-mercy;

• Lindinet-30;

  Triquilar;

• Marvelon;

• Microgynon.

A balanced content of female hormones is accompanied by moderate femininity, normal hair growth in the pubic area and other parts of the body.

Predominance of gestrogens (aka androgens)

The women are predominantly tall and boyish in appearance. The mammary glands are poorly developed, and there is increased oiliness in the hair and skin. Androgenic manifestations are expressed in excess hair growth in the armpits and pubis. PMS is accompanied by depression and abdominal pain. The duration of the menstrual cycle is short, less than 28 days. The periods themselves last no more than 3-4 days. The following tablets are prescribed:

Yarina, Jess, Dimia, Jazz containing drospirenone and ethinyl estradiol;

Erica-35, Chloe and Diana-35 with ethinyl estradiol, cyproterones in the composition;

Siluet and Janine, which contain predominantly dienogest and ethinyl estradiol;

Zoely with estradiol and nomegestrol.

Each phenotype is distinguished by features and individual characteristics in clinical and life terms.

Contraception by age

It is impossible to independently assess age-related changes in the body without consequences for the body and ensuring normal contraceptive function. The benefits and harms of certain pills can only be assessed after adequate diagnosis. The selection of oral contraceptives is the task of professional gynecologists. The main goal is the prevention of unwanted pregnancy and additional therapeutic effects if necessary. The age characteristics of a woman are an important aspect of successful and effective prescription of drugs. Biochemical indicators of the female body change with age and are divided into several main periods:

teenage girl (from 11 to 18 years old);

early reproductive (from 19 to 33 years);

late reproductive (from 34 to 45 years);

postmenopausal (2-3 years after the cessation of menstruation).

Adequate contraception should begin during adolescence if necessary. According to statistics, the age of a woman giving birth is noticeably decreasing, and the frequency of abortions is increasing. Combined contraceptives are preferable in adolescence with low doses of hormones. The following drugs are indicated for young girls: Tri-regol, Triquilar, Triziston, Mercilon, Marvelon, Silest, Femoden. These drugs not only protect against unwanted pregnancy, but improve the appearance of the skin with juvenile acne, normalize the menstrual cycle, and prevent the development of gynecological diseases.

Appointment for women from 20 to 35 years old

At this age, all methods of protection against unwanted pregnancy are usually widely used. The use of combined oral tablets is especially effective during constant sexual contact. The main disadvantage of the drugs is the lack of complete protection against sexually transmitted diseases. Women in this age group are usually prescribed drugs with a minimum dosage of hormones or low-dose drugs that ensure stabilization of hormonal levels. Such products do not harm a woman’s reproductive health and normalize the menstrual cycle. The main drugs are Yarina, Regulon, Janine.

Women over 35 years old

Women over 30 years of age should be prescribed adequate contraception against unwanted pregnancy due to high perinatal risks. Usually at this age they don’t think about children; many women smoke and build a career. Diseases of the female genital organs, endocrine disorders, and varicose veins often occur. Hormones are prescribed here only after a thorough diagnosis and medical consultation.

The preferred agents are Triziston, Silest, Marvelon, Tri-regol, Triquilar. Contraceptives from the mini-pill group with a low content of hormonal components are suitable for women. After 35 years, it is important to prescribe drugs with a clear therapeutic effect, for example Femulen. The drug is suitable for many female diseases, chronic liver and kidney damage of any origin. Smoking and systemic chronic diseases greatly complicate the selection of tablet contraception for women at any age.

Appointment after 45 years

After 40 years, a woman’s reproductive function decreases significantly, and ovarian activity decreases. Many women go through menopause, and some continue to ovulate. The likelihood of pregnancy is greatly reduced, but protection is still necessary. There may be a risk of pregnancy, but full pregnancy is already problematic: existing diseases, aging of the tissues of the pelvic organs, and possible fetal pathologies have an effect. Another important aspect is raising a child - many women after 45 have their own grandchildren. When pregnancy occurs, they resort to abortion in 90% of cases, which has a particularly negative impact on the woman’s health, including the development of endometriosis and uterine cancer.

The presence of chronic diseases of organs and systems, sexual dysfunction, bad habits - all this can become a contraindication to the prescription of oral contraceptives. After 45 years, promising contraception is the use of hormonal pills, injectable implants, and mini-pills. At this age, oral contraception is contraindicated in case of obesity, severe forms of liver or kidney failure, and diabetes mellitus. The drug Femulen with a low likelihood of side effects may be ideal.

Basic rules for taking birth control pills

Traditional birth control pills taken on the first day of the active phase of the menstrual cycle, only then the tablets begin their active effect. For irregular periods, you can start taking the drug from the first day of the cycle, with the absolute exception of pregnancy. After childbirth, the tablets should be taken 3 weeks later (on day 21), provided there is no lactation. If you continue breastfeeding, taking oral contraceptives should be postponed for six months. After an abortion of any level of complexity, you should start taking contraceptives on the day of surgery.

Dosage regimen

Classic mode involves The duration of the course is 21 days, after which they take a break of 7 days. Then they continue to continuously receive new packaging. The appearance of spotting between menstruation occurs during the break between doses.

A complex regimen involves a special regimen where you take pills for 24 days, taking a 4-day break (24+4 regimen).

The prolonged regimen consists of continuous use of tablets with active hormones. So, 63 days of monophasic tablets with a 7-day break. With this scheme, the discharge between periods is reduced by up to 4 times.

Adequate contraception is of interest to girls from the moment of their first menstruation. The correct selection of hormonal pills not only protects against unplanned pregnancy, but also significantly improves a woman’s appearance. At the same time, when hormonal levels are normalized, the condition of hair, nails, facial skin and body improves. Modern drugs have virtually no effect on a woman’s weight, and in some cases, hormonal treatment can even reduce it.

Understanding the hormonal background on your own is a difficult task, so you need to trust specialists for comfortable contraception without consequences for health and life.

The first contraceptive pills appeared on the US pharmaceutical market in 1960. Until this moment, women had not used any means of protection. They used tampons soaked in vinegar, special ointments made from honey and cinnamon or lead. On the advice of Hippocrates, women douched with their own urine. Other famous doctors of antiquity, for example, Dioscorides, advised them to drink decoctions of pennyroyal, juniper or asafoetida.

Each of the famous doctors considered his method ideal and reliable, but in practice all these methods did not always work. Only with the advent of birth control pills did women receive a truly reliable method for preventing unplanned pregnancy.

Evolution and types of birth control pills

The first contraceptive, called Enovid, contained huge doses of hormones by modern standards. It contained 10 mg of norethinodrel acetate and 150 μg of mestranol. It is not surprising that it had many side effects. However, modern contraceptives have a gentle composition and very rarely cause negative consequences of use. Each drug contains two components: gestagen and estrogen. The modern classification of drugs looks like this:

• Monophasic drugs - the amount of hormones in each tablet is the same.
• Biphasic - tablets intended for use in the second phase of the cycle contain a larger amount of gestagen.
• Three-phase preparations - the content of estrogen in tablets intended for the first half of the cycle increases, and in the second, on the contrary, it decreases, and the amount of gestagens changes in the opposite direction.

Separately, it is worth highlighting a group of contraceptives called “mini-pills”, which contain only one hormone – gestagen.

How to choose oral contraceptives?

There are no bad or good birth control pills. There are no effective or ineffective. Most modern tools have a Pearl index below one. This means that with the correct use of birth control pills, out of a hundred women who were protected with this drug for a year, only one became pregnant. No other method of protection can boast of such reliability.

Depending on the duration of treatment

How to choose birth control pills? First of all, it will depend on whether you plan to take them for a long time or whether you only need the protection once. Depending on this, the whole variety of modern oral contraceptives can be divided into those that are used throughout the month and those that are taken once.

Coursework

It is quite easy to distinguish such contraceptive drugs. Their packaging is designed to be taken throughout the month and contains 21 or 28 tablets. Depending on the composition, oral contraceptives should be taken from the first, second or fifth day of menstruation. It is better to drink at the same time, so that the supply of hormones corresponds as much as possible to the natural, physiological rhythm of the woman’s body.

After the entire package has been consumed to the end, there is a break in taking it for seven days, when menstruation arrives. After which you can start drinking the next package. Modern oral contraceptives are so safe that if you choose them correctly, you can take them for several years.

Only a doctor can choose the oral contraceptive that is right for you, after an examination and a series of tests.

Emergency

Unlike long-term pills, emergency or postcoital contraceptives come in one or two pills. They contain a shock dose of a hormone aimed at preventing fertilization of the egg or, if this does happen, preventing its attachment to the wall of the uterus.

Such drugs are intended to prevent pregnancy in force majeure situations, for example, if a condom breaks. They are effective no later than 72 hours after unprotected sex has occurred.

High doses of hormones make such drugs quite dangerous for women's health, so they can be used rarely and only in exceptional situations.

Depending on hormonal levels

Hormones determine not only how a woman feels, but also how she looks. Doctors distinguish three types of appearance, depending on whether estrogen, progesterone predominate in her body, or whether both of these hormones have an equivalent effect. Using the table, it’s quite easy to determine which type you belong to.

Characteristic	Estrogen-dominant type	Estrogen- progesterone type	Progesterone-dominant type
Height	Mostly below average sometimes average	Average	Most often high
Features of the figure	The figure is feminine, with well-developed breasts and wide hips	Feminine, medium size	More like a boy's with small breasts and narrow hips
Skin and hair	Prone to dryness and brittleness	Normal	Hair may suffer from oiliness, skin is prone to acne
Volume and duration of menstruation	The cycle is usually more than 28 days, menstruation is heavy and prolonged	The cycle is 28 days, menstruation is moderate, lasting from three to five days	Short cycle, usually 21 days, scanty menstruation, lasting no more than three days.
Premenstrual symptoms	Breast engorgement, mood swings, nervousness.	Absent or mildly expressed, there are almost no mood swings.	Most often manifested by pain in the abdomen and lower back, fatigue, bad mood

Depending on the characteristics of the hormonal background, the doctor will select drugs with an enhanced estrogenic or gestagenic effect.

Depending on age

How to choose hormonal contraceptives depending on age? Preparations with minimal hormone content are prescribed to nulliparous girls under the age of 25. They do not have a significant effect on natural hormonal levels. After the end of treatment, you can plan a pregnancy after six months.

At the age of 25 to 40 years, the selection of contraceptives is carried out individually, depending on the woman’s hormonal characteristics, the presence of pregnancies or abortions in the past, how long she wants to take the drugs and whether she plans to soon become a mother. After some medications, pregnancy will have to be delayed for at least a year.

After 40 years, the production of hormones, and especially estrogens, in a woman’s body gradually decreases. Mood swings, skin and hair problems, and excess weight appear. As a rule, doctors prescribe drugs with high levels of estrogen, which, in addition to the contraceptive effect, help a woman get rid of the unpleasant symptoms associated with a lack of this hormone.

Any contraceptive drug should be taken only after consulting a doctor. Properly selected tablets will perform their main function and will not have side effects.

Selection rules

How to choose birth control pills so that their effect is maximum and side effects are minimal, only your doctor can answer. You can't handle this on your own. Despite the apparent simplicity of selection based on age or hormonal characteristics, it is possible to determine the drug that is right for you only after a series of tests. The selection pattern will be something like this:

1. Consultation with a gynecologist who will collect information about the characteristics of your cycle and lifestyle, the presence of pathologies and pregnancies in the past.
2. Analysis for oncocytology, which is a contraindication for most hormonal drugs.
3. Consultation with a mammologist.
4. Blood biochemistry analysis, which includes determining hormone levels.
5. Ultrasound of the pelvic organs on the fifth or seventh day of the cycle.

During the period of adaptation to a hormonal contraceptive, which usually lasts from one to three months, mild spotting may appear, mood swings, changes in taste preferences and other symptoms associated with hormonal changes may occur. As a rule, they go away on their own.

Dear friends, hello!

Why are there so many of them? Or rather, WHY? Was it really impossible to release 3-4 drugs and stop there?

Why fool women, obstetricians-gynecologists and, of course, first-city residents who are forced to answer the eternal question of customers “which is better”?

Moreover, often they, in the sense of buyers, want to know everything “here and now”, and categorically do not want to go to the doctor to get a prescription for a remedy for women’s “”.

But you will have to... You know better than me how many contraindications are indicated in the instructions for hormonal contraceptives, and how many side effects they can cause.

Let's try to understand the abundance of hormonal pills that leave the stork almost no chance of bringing a human baby in its beak to the couple.

But this article is not intended for you to choose a hormone on your own!

Always, when I start talking about prescription drugs, I am afraid that you will use this information in your own way and will recommend them left and right, as, unfortunately, happens.

As I begin this conversation, I set myself four goals:

And again about the menstrual cycle

We have already talked about the female reproductive system and the menstrual cycle.

Before we begin to analyze hormonal contraceptives, I will remind you of a story that happens in a woman’s body every month.

The hypothalamus and pituitary gland control the menstrual cycle.

It all starts with the hypothalamus instructing the pituitary gland to release follicle-stimulating hormone into the blood.

Under his strict guidance, several follicles with eggs inside begin to grow and mature in the ovaries, synthesizing estrogens, which are necessary for their maturation. After some time, one of the follicles breaks forward in its development, while the others resolve.

Meanwhile, in the uterus, under the influence of estrogens, the preparation of a “pillow” for the fertilized egg begins, so that it feels warm, cozy and well-fed there. The uterine mucosa thickens.

On average, after 2 weeks from the beginning of the cycle, the level of estrogen reaches its maximum, and the egg reaches its “coming of age.” The “signal signal” for its exit from its native nest is the release of luteinizing hormone by the pituitary gland (in response to an increase in estrogen levels). The follicle bursts, the egg is released (this is called “ovulation”), enters the fallopian tube and makes its way into the uterine cavity.

And in place of the burst follicle, a corpus luteum is formed, which produces progesterone.

Progesterone is enthusiastically involved in the process of preparing the uterus to welcome a fertilized egg. It loosens the endometrium, one might say, “fluffs the feather bed” for the newlyweds (if a fateful meeting takes place), reduces the tone of the uterus to preserve, changes the properties of cervical mucus to prevent infection, and prepares the mammary glands for a possible pregnancy.

If fertilization does not occur, the level of progesterone drops, and the overgrown functional layer of the endometrium is rejected as unnecessary. This is menstruation.

The maximum level of estrogen occurs during the period of ovulation, and progesterone - approximately on the 22-23rd day of the cycle.

Hormonal contraception for different target audiences

I divided all hormonal contraceptive drugs into 3 groups:

The first two groups are intended for those who have regular sex life with one partner, since they do not protect against sexually transmitted infections, which casual relationships are famous for. True, life with one partner does not always save you from them, but we will assume that everyone is faithful to each other, like swans, and none of the couple walks either to the left or to the right, or diagonally, or in a circle.

To the group "for those in charge"(according to my classification) includes drugs that need to be taken every day and preferably at the same time.

These include:

1. Combined oral contraceptives. They contain a COMBINATION of estrogen and gestagen, simulating the menstrual cycle. Hence the name.
2. Mini-drinks. This is the name given to products containing only gestagen.

Agree, not every woman (due to girlish memory) will be able to swallow pills every day, and even at the same time, often for several years.

In Group “for busy or “happy” There are medications that do not need to be taken every day, so the risk of missing a birth control pill is reduced.

“Happy” because, as the classic said, “happy people don’t watch the clock.”

Those who are very busy, overwhelmed with their problems beyond the roof, can remember about the pills after a few days, or even only in the absence of red days on the calendar. Therefore, the optimal thing for them is something that they stick on, insert, inject, and forget about for a few days/months/years.

The drugs of this group are especially convenient for conductors, flight attendants, for those who constantly travel on business trips, tours, competitions, and at the same time, as I said, manage to have a regular sex life.

It has 5 subgroups:

1. Transdermal therapeutic system Evra.
2. Vaginal ring NuvaRing.
3. Intrauterine devices.
4. Contraceptive implants.
5. Contraceptive injections.

To the group "For the irresponsible" I placed emergency contraception. Sorry if I offended anyone.

As a rule, they are taken by those who are in search of unearthly happiness, who like to “relax” on holidays and weekends, who lose the remnants of their sanity when heard in their ears with a breath: “Honey, having sex with a condom is like smelling a rose in a gas mask,” and hopes for “maybe.”

Total turned out total 8 subgroups, which we will analyze in order.

Combined oral contraceptives

Combined oral contraceptives (COCs) were invented by men in the 1960s. These were chemist Carl Djerassi, pharmacologists Gregory Pincus and John Rock. And the first oral contraceptive was called Enovid.

What prompted them to this invention, history, of course, is silent. Perhaps they were driven by the desire to save their loved ones from frequent “headaches.”

The first contraceptive contained just horse doses of estrogen and gestagen, so against the background of their use, women began to grow in the wrong places, acne appeared on the body, and some even died from a heart attack or stroke.

All subsequent research was aimed at improving the safety of oral contraceptives and reducing the number of side effects. Doses of estrogen and gestagen were gradually reduced. But it was important not to cross the line when the contraceptive effect was at risk.

This process continues to this day, since the ideal COC has not yet been invented, although colossal progress has been achieved in this direction.

You may have heard of the Pearl Index. This is the failure rate, which shows the number of pregnancies per 100 women using a particular method of contraception.

So that you understand: for modern COCs it is less than one, while for condoms it is 10, for spermicides and lovers of coitus interruptus - 20.

How do combined oral contraceptives work?

1. Since there are estrogens in the body (which come from outside), the hypothalamus understands that “everything is calm in Baghdad” and does not give the command to the pituitary gland to produce follicle-stimulating hormone.
2. Since follicle-stimulating hormone is not produced, the follicles in the ovaries are in a half-asleep state, they do not produce estrogen, and if they grow, they grow very sluggishly and reluctantly. Therefore, the egg does not mature.
3. If the egg cannot reach “coming of age,” it is deprived of the opportunity to leave its parental home and go in search of a soul mate. There is no ovulation.
4. Since estrogen levels do not increase, luteinizing hormone is not released, the corpus luteum is not formed, and progesterone is not produced. Why is it needed? After all, it comes from outside.
5. This same “foreign” progesterone thickens the mucus produced by the glands of the cervix, and no matter how fast the sperm are, they cannot penetrate the uterus.
6. There is another level of protection: since in a woman’s reproductive system, while taking COCs, what should be happening is not happening, the uterus cannot prepare a “cushion” to receive a fertilized egg. The functional layer of the endometrium grows quite a bit. Then it will come out in the form of menstrual-like bleeding. And even if, by some miracle, the egg matures in spite of all its enemies, comes out of the follicle, and the sperm overcomes all obstacles, and they merge in a fit of passion, then the fertilized egg will not be able to settle on the lining of the uterus.

So what happens?

It turns out that when a COC enters the body, the estrogen and gestagen that come in their composition signal the hypothalamus that everything is OK in the body, there are enough necessary hormones, everyone is happy and calm, in general, EVERYONE SLEEP!

And a sleepy kingdom begins in the female reproductive system...

So COC is a deep anesthesia for the hypothalamus, pituitary gland, and ovaries. Deception of nature. Everyone sleeps quietly, snoring and making timid attempts to rehabilitate themselves only on the rare days of a hormone-free interval.

Hormonal contraception: secrets of medical prescriptions

To be honest, until I delved into this topic, I thought that in order to select a contraceptive, a woman needs to be carefully examined for hormonal status, the presence of malignant tumors, condition, coagulation system, etc.

It turns out there is nothing like that!

The obstetrician-gynecologist questions the woman in detail to determine her health problems, lifestyle, readiness and ability to take pills daily.

The doctor finds out:

1. Is the woman breastfeeding her baby?
2. How long has it been since your last birth?
3. Is there a mass in the mammary gland of unknown origin?
4. Is there any damage to the heart valves?
5. Do migraines happen? With or without aura?
6. Whether there is a ? If so, is it compensated or not?
7. Have you had a heart attack or stroke in the past, or is there any ischemic heart disease?
8. Are there any serious problems with the liver and biliary tract?
9. Have you had thrombophlebitis or pulmonary embolism in the past?
10. Are you planning a major surgical operation in the near future, which in itself dramatically increases the risk of thrombosis and pulmonary embolism?

With love to you, Marina Kuznetsova

Hormonal type, or rather phenotype- this is the structure of the female body depending on the predominance of one or another sex hormone in the body. With this information, you can better understand the characteristics of your body, select hormonal contraception and calculate its side effects.

In total, 3 female phenotypes were previously identified, but I would still say that there are 5 of them.
Etrogen phentype(type 1), balanced phenotype(type 2), progesterone phenotype(type 3) was previously considered progesterone/androgenic, but based on clinical observations I would single out androgen phenotype in a separate form (type 4). Besides hypoestrogen type allocated to a separate group (with etrogen deficiency).

Estrogen phenotype (i.e. hyperestrogen phenotype): scientific fat type, endomorphic. The predominant hormone is estradiol.

These are women with a “pear” figure type, with pronounced development of the hips and mammary glands, which makes them prone to the phenomena of mastopathy and fibroadenomatosis of the breast. Prone to obesity, with the formation of gallstone disease. They are characterized by good skin, without acne, but a little dry, thin, sometimes curly hair on the head.

Hirsutism (hair growth is active on the face, abdomen, back, thighs) and hypertrichosis (hair growth is more active on the forearms and lower legs) are not typical for them - this applies to Russian women, for women of other nationalities - it depends on the severity of hair growth in the family - constitutional hypertrichosis may be present.

Women of this type are of average height, with a high timbre of voice and a “pretty appearance.” With a tendency to PMS (like “hysteria” and tearfulness). The menstrual cycle is often regular or delays do not exceed 60 days (that is, disorders such as progestron deficiency - hypoluteinism), the cycle can be heavy, with a tendency to endometrial hyperplasia in perimenopause - in the presence of obesity.

Taking Duphaston is well tolerated (they have a “classic type of reaction” to it - with the onset of menstruation 3-6 days after stopping the drug).
By nature, they are more “female lovers”, active (more choleric), in need of constant male attention.

Prone to uterine fibroids, the formation of follicular cysts and varicose veins. They get pregnant quickly, but pregnancy can be complicated by a lack of progesterone and threats of miscarriage. COCs with gestodene, desogestrel, levonogestrel (Mikrogynon, Lindinet-20, etc.) are well suited for them. They may have hot flashes for a long time after menopause, sometimes all their lives.

Balanced Phenotype, a kind of “Ideal Woman”. Estradiol/progesterone are balanced according to the phases of the cycle.

The body structure is proportional, the skin is clean, with normal moisture and oil content. The hair is thick and dense. Menstruation is regular, PMS is not typical or is only slightly expressed. Soprano voice. Hirsutism is uncharacteristic, there may be slight hypertrichosis - more constitutional. They get pregnant and carry to term without problems.

The most suitable COCs are three-phase COCs with desogestrel and gestodene. (Tri-Mercy, Marvelon, Lindinet-20, etc.)

Progesterone phenotype. Scientifically also called bone, ectomorphic. Progesterone predominates.

These are women with the following body type: both shoulders and hips are developed evenly, “sports body type”, subcutaneous tissue is distributed evenly, sometimes according to the android (male) type (this is for obesity, that is, the deposition of fat masses in the upper abdomen and back ). Skin prone to oiliness (oily seborrhea) of both the face and scalp. Acne happens, sporadically.

Height is usually above average (more dependent on genetic characteristics), the mammary glands are moderately developed, with a predominance of adipose rather than glandular tissue. Therefore, they are less prone to mastopathy. Menstruation is often scanty or very. short or long, up to 7 days. PMS happens, but with a tendency to melancholy and tearfulness, swelling.

Taking duphaston (according to indications) can increase the manifestations of PMS and swelling. The reaction to Duphaston may be “non-classical” - menstruation does not begin 7 days after the course of the drug (caused by a preliminary lack of estrogen). By nature, they are more sanguine, the type of “woman-mother” - with the need to care for others.

She often shows sexual activity only in the presence of a love object; in her absence, she can be sexually inactive, which distinguishes her from women of the estrogen type. Therefore, the menstrual cycle is often irregular in women of the progesterone type; sometimes there is a tendency that if there is regular sexual intercourse, the menstrual cycle is regular (the production of estrogen is stimulated), if not, the cycle is irregular. Therefore, she does not get pregnant right away - after a certain time of regular sexual relations, she bears without threats (this is, of course, theoretically, based on the activity of the hormone progesterone), but she is prone to large weight gains!

Prone to insulin resistance and weight gain, also after childbirth. COCs with dienogest and drospirenone are good options. (Yarina, Jess, Bonade, etc.)

Androgenic phenotype. Muscular or mesomorphic.
A woman's appearance depends on the predominance of androgens (male hormones) from the ovaries or adrenal glands.

Adrenal hyperandrogenism (17-OH progesterone, androstenedione or DHA-S predominates) is a tall woman, asthenic (thin), “muscular type”, with poorly developed subcutaneous tissue. “Boyish body type”, the mammary glands are poorly developed, the skin tends to be oily, and acne is not pronounced. An example is modern super-models.

Sexually moderately active, does not get pregnant right away, and carries threats of miscarriage. The menstrual cycle is often irregular. The voice is low.

A woman with a predominance of ovarian androgens (or with mixed secretion, a predominance of total/free testosterone) is short in stature, with a pronounced shoulder girdle, oily skin and acne, hirsutism and hypertrichosis. The mammary glands are moderately developed. The voice is low, mezzo-soprano type. They get pregnant with difficulty and carry threats. Sexually very active (testosterone is the basis of the hormone of sexual activity). We are not prone to PMS because of irregular ovulation, which is the “key” to PMS.

If they are obese, often with the phenomenon of hyperinsulenism and impaired carbohydrate metabolism, they can lose weight well with properly selected physical activity, but there is a risk of “pumping up” the muscles. Behavior of women like “their boyfriend”.

An example is women with PCOS syndrome. COCs with cyproterone acetate, drospirenone and dienogest are good options. (Diana-35, Yarina, Klaira... etc.).

Hypoestrogenic phenotype– these are women who are either tall or short (depending genetically), of an infantile structure – small breasts, disproportionately long arms and legs, thin, “parchment” skin, easily tired. PMS is not typical. The menstrual cycle is disrupted up to amenorrhea - delays of up to 6-12 months. Menstruation is painful. Behavior of a “teenage girl”. The voice is high, poor in overtones. Libido is sharply reduced or absent if there is also a lack of androgens. Getting pregnant is problematic. An example is girls with anorexia.

Indicated: hormone replacement therapy, triphasic COCs, COCs with levonogestrel.

A combination of several phenotypes is possible.

By 2011-2015, information appeared that during perimenopause a 6th phenotype can also form: androgen deficiency (according to Apetov S.S.) the level of androgens in the adrenal glands decreases, which also has its consequences - a decrease in muscle strength and endurance, scarcity of axillary and pubic hair , hair loss on the head, gradual disproportionate weight gain in the waist area. A sharp decrease in libido. Correction of these phenomena may require hormone replacement therapy.

According to information obtained from a clinical study that included 300 women, type 1 of women predominates.

*During the writing process, 6 classifications were analyzed.

Important! Message from the site administration about questions on the blog:

Dear readers! By creating this blog, we set ourselves the goal of giving people information on endocrine problems, diagnostic methods and treatment. And also on related issues: nutrition, physical activity, lifestyle. Its main function is educational.

Within the framework of the blog, in answering questions, we cannot provide full-fledged medical consultations; this is due to both the lack of information about the patient and the doctor’s time spent in order to study each case. Only general answers are possible in the blog. But we understand that not everywhere it is possible to consult with an endocrinologist at your place of residence; sometimes it is important to get another medical opinion. For such situations, when a deeper dive and study of medical documents is needed, at our center we have a format for paid correspondence consultations on medical documentation.

How to do it? Our center’s price list includes a correspondence consultation on medical documentation, costing 1,200 rubles. If this amount suits you, you can send scans of medical documents, a video recording, a detailed description, everything that you consider necessary regarding your problem and questions that you want answered to the address patient@site. The doctor will see if the information provided can give a full conclusion and recommendations. If yes, we will send the details, you will pay, and the doctor will send a report. If, based on the documents provided, it is impossible to give an answer that could be considered as a doctor’s consultation, we will send a letter stating that in this case, absentee recommendations or conclusions are impossible, and, of course, we will not take payment.

Sincerely, Administration of the Medical Center "XXI Century"

Video version:

At first glance, it may seem strange that, despite the fact that in recent years mortality in Russia has prevailed over birth rates, the problem of contraception remains one of the most important problems in gynecology. But this situation can only be strange for those who consider contraception only from the standpoint of preventing pregnancy.

An obvious fact is that preventing unwanted pregnancy and, as a consequence, abortion is a factor in preserving a woman’s reproductive health.

Modern hormonal contraception has gone beyond its original properties. The therapeutic and preventive effect of these drugs, in fact, can dramatically change the structure of gynecological morbidity as a whole, since taking hormonal contraceptives has been shown to reduce the risk of most gynecological and general diseases. Contraception “preserves” a woman’s reproductive system, providing her with a comfortable personal life, preventing diseases and the consequences of abortion. Thus, effectively reducing the number of unwanted pregnancies is the leading driving force for increasing the reproductive potential of women.

I don’t presume to say for sure, but most likely it is in our country that women live who have set a kind of record for the number of abortions they have undergone. The most depressing fact is that the most common “method of contraception” in Russia was and remains to this day – abortion.

Of course, recently there has been a positive trend, and more and more, mainly young women, are starting to use oral contraceptives. Oddly enough, this is largely facilitated by fashionable women's magazines, which with a sufficient degree of competence talk about all sorts of aspects of a healthy lifestyle and hygiene, paying great attention to the problems of contraception. Apparently, it is to these printed publications that we owe the debunking of the prevailing myth about the harmfulness of “hormonal pills.” But at the same time, even a quick glance at the advertising spreads of popular magazines and newspapers in the “medicine” section shows that the prevailing service offered to the population remains: “Abortion on the day of treatment. Any terms,” and, as you know: demand creates supply.

Several points about contraception

• There is no perfect method of contraception. All currently available contraceptives are safer than the consequences that may result from terminating an unwanted pregnancy due to non-use of contraception. At the same time, it is impossible to create a contraceptive that would be 100% effective, easy to use, ensure full return of reproductive function and have no side effects. For every woman, any method of contraception has its advantages and disadvantages, as well as both absolute and relative contraindications. An acceptable method of contraception means that its benefits substantially outweigh the risks of its use.
• Women using contraception should visit a gynecologist at least once a year. Problems associated with the use of contraception can be direct and indirect. Increased frequency of sexual intercourse or more frequent changes of sexual partners may necessitate a change in contraceptive method.
• The effectiveness of most contraceptive methods depends on the motivation of the person using the method. For some women, a more adequate method of contraception may be a spiral, ring or patch, since they, for example, do not have the desire to take pills every day, which can lead to incorrect use and a decrease in the contraceptive properties of the method. The contraceptive effect of the so-called calendar method, in addition to other factors, largely depends on the attitude of the couple to calculate and observe days of abstinence from sexual intercourse.
• Most women wonder about the need for contraception after having already had one or more abortions. It often happens that the onset of sexual activity, apparently as a result of some strong emotional experience, is not accompanied by proper care for contraception. In our country, there is a practice of “voluntary-compulsory” prescription of contraception to women coming for an abortion, instead of an “explanatory and recommendatory” approach to all women who are or are just planning to begin sexual activity.

Oral hormonal contraception

Oral contraceptives (OCs) belong to the most studied class of drugs. More than 150 million women worldwide take oral contraceptives daily, and most experience no serious side effects. In 1939, gynecologist Pearl proposed an index for numerical expression of fertility:

Pearl Index = number of conceptions * 1200 / number of months of observation

This indicator reflects the number of pregnancies in 100 women during the year without the use of contraceptives. In Russia, this figure is on average 67-82. The Pearl index is widely used to assess the reliability of a contraceptive method - the lower this indicator, the more reliable this method is.

Pearl index for different types of contraception

Sterilization for men and women 0.03-0.5
Combined oral contraceptives 0.05-0.4
Pure progestins 0.5-1.2
IUD (spiral) 0.5-1.2
Barrier methods (condom) 3-19 (3-5)
Spermicides (local preparations) 5-27 (5-10)
Coitus interruptus 12-38 (15-20)
Calendar method 14-38.5

The Pearl index for OK ranges from 0.03 to 0.5. Thus, OCs are an effective and reversible method of contraception; in addition, OCs have a number of positive non-contraceptive effects, some of which continue for several years after stopping taking the drugs.

Modern OCs are divided into combined (COC) and pure progestins. Combined OCs are divided into monophasic, biphasic and triphasic. At the moment, biphasic drugs are practically not used.

How to understand the variety of drugs?

The combination drug contains two components - two hormones: estrogen and progesterone (more precisely, their synthetic analogues). Ethinyl estradiol is usually used as estrogen, it is designated as “EE”. Progesterone analogues have been around for several generations and are called “progestins.” There are now drugs on the market that contain 3rd and 4th generation progestins.

The drugs differ from each other in the following respects:

• Estrogen content (15,20,30 and 35 mcg)
• Type of progestin (different generations)
• To the manufacturer (the same drug composition may have different names)

Oral Contraceptives are:

• High- (35 µg), low- (30 µg) and micro- (15-20 µg) dosed (depending on estrogen content) - now low- and micro-dosed drugs are mainly prescribed.
• Monophasic and triphasic - in the vast majority of cases, monophasic is prescribed, since the level of hormones in these tablets is the same and they provide the necessary “hormonal monotony” in the woman’s body
• Containing only progestins (analogues of progesterone), there are no estrogens in such preparations. Such tablets are used in nursing mothers and in those who are contraindicated in taking estrogen.

How is contraception actually chosen?

If a woman is generally healthy and needs to choose a drug for contraception, then only a gynecological examination with ultrasound and the exclusion of all contraindications is sufficient. Hormonal tests in a healthy woman do not indicate in any way which drug to choose.

If there are no contraindications, it is clarified which type of contraception is preferable: tablets, patch, ring or Mirena system.

You can start taking any of the drugs, but it’s easiest to start with the “classic” Marvelon - since this drug is the most studied, and is used in all comparative studies of new drugs, as a standard with which the new product is compared. The patch and the ring come in one version, so there is no choice.

Next, the woman is warned that the normal period of adaptation to the drug is 2 months. During this period, various unpleasant sensations may occur: chest pain, spotting, changes in weight and mood, decreased libido, nausea, headache, etc. These phenomena should not be severe. As a rule, if the drug is suitable, all these side effects quickly disappear. If they persist, then the drug must be changed - reduce or increase the dose of estrogen or change the progestin component. This is chosen depending on the type of side effect. That's all!

If a woman has concomitant gynecological diseases, then initially you can choose a drug that has a more pronounced therapeutic effect on the existing disease.

Other forms of hormone administration for contraception

Currently, there are two new options for administering hormones for contraception - the patch and the vaginal ring.

Evra contraceptive patch

“Evra” is a thin beige patch with a skin contact area of ​​20 cm2. Each patch contains 600 mcg ethinyl estradiol (EE) and 6 mg norelgestromin (NG).

During one menstrual cycle, a woman uses 3 patches, each of which is applied for 7 days. The patch should be replaced on the same day of the week. This is followed by a 7-day break, during which a menstrual-like reaction occurs.

The mechanism of contraceptive action of Evra is similar to the contraceptive effect of COCs and consists of suppressing ovulation and increasing the viscosity of cervical mucus. Therefore, the contraceptive effectiveness of the Evra patch is similar to that when using oral contraception.

The therapeutic and protective effects of Evra are the same as those of the combined oral contraception method.

The effectiveness of the Evra patch does not depend on the location of application (stomach, buttocks, upper arm or torso). The exception is the mammary glands. The properties of the patch are practically not affected by increased ambient temperature, air humidity, physical activity, or immersion in cold water.

Vaginal ring Novo-Ring

A fundamentally new, revolutionary solution was the use of the vaginal route for administering contraceptive hormones. Thanks to the abundant blood supply to the vagina, the absorption of hormones occurs quickly and constantly, which allows them to be distributed evenly into the blood throughout the day, avoiding daily fluctuations, as when using COCs.

The size and shape of the vagina, its innervation, rich blood supply and large epithelial surface area make it an ideal site for drug administration.

Vaginal administration has significant advantages over other methods of administering contraceptive hormones, including oral and subcutaneous methods.

The anatomical features of the vagina ensure successful use of the ring, ensuring its comfortable location and reliable fixation inside.

Since the vagina is located in the pelvis, it passes through the urogenital diaphragm muscle and the pubococcygeus muscle of the pelvic diaphragm. These muscle layers form functional sphincters that narrow the entrance to the vagina. In addition to the muscular sphincters, the vagina consists of two sections: a narrow lower third, which passes into a wider upper part. If a woman is standing, the upper region is almost horizontal, as it lies on the horizontal muscular structure formed by the pelvic diaphragm and the levator anus muscle.

The size and position of the upper part of the vagina, the muscular sphincters at the entrance, make the vagina a convenient place for inserting a contraceptive ring
The innervation of the vaginal system comes from two sources. The lower quarter of the vagina is innervated mainly by peripheral nerves, which are highly sensitive to tactile influences and temperature. The upper three-quarters of the vagina are mainly innervated by autonomic nerve fibers, which are relatively insensitive to tactile stimulation and temperature. This lack of sensation in the upper vagina explains why a woman cannot feel foreign objects such as tampons or a contraceptive ring.

The vagina is abundantly supplied with blood from the uterine, internal genital and hemorrhoidal arteries. Abundant blood supply ensures that vaginally administered drugs quickly enter the bloodstream, bypassing the first-pass effect through the liver.

NuvaRing is a very flexible and elastic ring, which, when inserted into the vagina, “adjusts” as much as possible to the contours of the body, taking the shape that is necessary. At the same time, it is securely fixed in the vagina. There is no right or wrong position of the ring - the position that NuvaRing takes will be optimal

The starting point for the ring to start working is a change in the concentration gradient when it is inserted into the vagina. A complex membrane system allows the constant release of a strictly defined amount of hormones during the entire time the ring is used. The active ingredients are evenly distributed inside the ring in such a way that they do not form a reservoir inside it.

In addition, a necessary condition for the ring to work is body temperature. At the same time, changes in body temperature during inflammatory diseases do not affect the contraceptive effectiveness of the ring.

NuvaRing is easily inserted and removed by the woman herself.

The ring is squeezed between the thumb and index finger and inserted into the vagina. The position of NuvaRing in the vagina should be comfortable. If a woman feels it, then she must carefully move the ring forward. Unlike a diaphragm, the ring does not need to be placed around the cervix, as the position of the ring in the vagina does not affect effectiveness. The round shape and elasticity of the ring ensure good fixation in the vagina. Remove the NuvaRing by grasping the rim of the ring with your index finger or middle and index fingers and gently pulling the ring out.

Each ring is designed for one cycle of use; one cycle consists of 3 weeks of using the ring and a week break. After insertion, the ring should remain in place for three weeks, then removed on the same day of the week on which it was inserted. For example, if NuvaRing was introduced on Wednesday at 10:00 p.m., then the ring must be removed after 3 weeks on Wednesday at about 10:00 p.m. A new ring needs to be inserted next Wednesday.

Most women never or very rarely feel the ring during intercourse. The opinion of partners is also very important; Although 32% of women noted that their partners sometimes felt the ring during intercourse, the majority of partners in both groups did not object to women using NuvaRing.

According to the results of the All-Russian research project conducted in 2004, NuvaRing has a positive effect on the sexual life of women:

• 78.5% of women believe that NuvaRing has a positive effect on their sex life
• 13.3% believe that NuvaRing provides additional positive sexual sensations
• Almost 60% of women have never felt NuvaRing during sexual intercourse. Women who felt NuvaRing said it was a neutral (54.3%) or even pleasant sensation (37.4%)
• There was an increase in the frequency of sexual activity and the frequency of achieving orgasm.

Mirena

Mirena is a polyethylene T-shaped system (similar to a regular intrauterine device) containing a container that contains levonorgestrel (progestin). This container is coated with a special membrane that provides a continuous, controlled release of 20 mcg of levonorgestrel per day. The contraceptive reliability of Mirena is much higher than that of other intrauterine contraceptives and is comparable to sterilization.

Due to the local action of levonorgestrel in the uterus, Mirena prevents fertilization. Unlike Mirena, the main mechanism of the contraceptive effect of conventional intrauterine devices is an obstacle to the implantation of a fertilized egg, that is, fertilization occurs, but the fertilized egg does not attach to the uterus. In other words, when using Mirena, pregnancy does not occur, but with conventional IUDs, pregnancy occurs but is immediately terminated.

Studies have shown that the contraceptive reliability of Mirena is comparable to that of sterilization, however, unlike sterilization, Mirena provides reversible contraception.

Mirena provides a contraceptive effect for 5 years, although the real contraceptive resource of Mirena reaches 7 years. After the expiration of the period, the system is removed, and if a woman wants to continue using Mirena, simultaneously with the removal of the old system, a new one can be introduced. The ability to become pregnant after Mirena removal is restored in 50% after 6 months and in 96% after 12 months.

Another important advantage of Mirena is the ability to quickly return to the ability to become pregnant. So, in particular, Mirena can be removed at any time at the woman’s request; pregnancy can occur already in the first cycle after its removal. As statistical studies have shown, from 76 to 96% of women become pregnant within the first year after Mirena removal, which generally corresponds to the fertility level in the population. Also noteworthy is the fact that all pregnancies in women who used Mirena before their onset proceeded and ended normally. In women who are breastfeeding, Mirena, introduced 6 weeks after birth, does not have a negative effect on the development of the child.

For most women, after installing the Mirena, the following changes are noted in the menstrual cycle: in the first 3 months, irregular spotting between menstrual bleeding appears; in the next 3 months, menstruation becomes shorter, weaker and less painful. A year after Mirena installation, 20% of women may not have menstruation at all.

Such changes in the menstrual cycle, if the woman is not informed about them in advance, can cause anxiety in the woman and even a desire to stop using the Mirena; therefore, detailed counseling of the woman is recommended before installing the Mirena.

Non-contraceptive effects of Mirena

Unlike other intrauterine contraceptives, Mirena has a number of non-contraceptive effects. The use of Mirena leads to a decrease in the volume and duration of menstruation and, in some cases, to their complete cessation. It was this effect that became the basis for the use of Mirena in patients with heavy menstruation caused by uterine fibroids and adenomyosis.

The use of Mirena leads to significant pain relief in women with painful menstruation, especially due to endometriosis. In other words, Mirena is an effective treatment for pain caused by endometriosis and, in addition, leads to the reverse development of endometrial formations or, at least, has a stabilizing effect on them. Mirena has also proven itself as a component of hormone replacement therapy in the treatment of menopausal symptoms.

New regimens for hormonal contraception

As a result of many years of research into hormonal contraception, it became possible to change the pattern of use of these drugs, which reduced the incidence of side effects and relatively increased their contraceptive effect.

The fact that with the help of hormonal contraception you can prolong your menstrual cycle and delay menstruation has been known for a long time. Some women successfully used this method in cases where they needed it, for example, on vacation or sports competitions. However, there was an opinion that this method should not be abused.

Relatively recently, a new regimen for taking hormonal contraception was proposed - a prolonged regimen. With this regimen, hormonal contraception is taken continuously for several cycles, after which a 7-day break is taken and the regimen is repeated again. The most common regimen is 63+7, that is, hormonal contraceptives are taken continuously for 63 days and only after that there is a break. Along with the 63+7 mode, a 126+7 scheme is proposed, which in its portability does not differ from the 63+7 mode.

What is the advantage of a prolonged regimen of hormonal contraception? According to one study, in more than 47% of women, during a 7-day break, the follicle matures to a perovulatory size, the further growth of which is suppressed by the start of taking the next pack of the drug. On the one hand, it is good that the system does not turn off completely and the function of the ovaries is not impaired. On the other hand, a break in taking hormonal contraceptives leads to a disruption of the monotony established during their use, which ensures the “preservation” of the reproductive system. Thus, with the classic dosage regimen, we “tug” the system, actually turning it on and off, not allowing the body to completely get used to the new monotonous hormonal model of functioning. This model can be compared to operating a car, in which the driver would turn off the engine every time he stopped on the road and then start it again. The prolonged mode allows you to turn off the system and start it less often - once every three months or once every six months. In general, the duration of continuous use of hormonal contraception is largely determined by psychological factors.

The presence of menstruation in a woman is an important factor in her sense of herself as a woman, a guarantee that she is not pregnant, and that her reproductive system is healthy. Various sociological studies have confirmed the fact that most women, in general, would like to have the same menstrual rhythm that they have. Those women for whom the period of menstruation is associated with severe physiological experiences - severe pain, heavy bleeding, and generally severe discomfort - wanted to menstruate less often. In addition, the preference for one or another rhythm of menstruation varies between residents of different countries and strongly depends on social status and race. Such data are quite understandable.

Women's attitude towards menstruation has evolved over centuries, and only a small part of women can correctly imagine what this physiological phenomenon is and what it is needed for. There are many myths that attribute cleansing functions to menstruation (it’s funny, but most of our compatriots use the term “cleaning” in relation to curettage of the uterine cavity; they often say “I was cleaned”). In such a situation, it is quite difficult to offer a woman long-term contraception, while the benefits of prolonged use are greater and this regimen is better tolerated.

In 2000 Sulak et al. showed that almost all side effects encountered when using COCs are more pronounced during a 7-day break in use. The authors called these “withdrawal symptoms.” Women were asked to increase their COC intake to 12 weeks and shorten the interval to 4-5 days. Increasing the duration of use and shortening the interval between taking pills reduces the frequency and severity of “withdrawal symptoms” by 4 times. Although the study lasted 7 years, only 26 of 318 women (8%) were lost to follow-up.

According to other studies, with prolonged use, women practically cease to encounter such common problems as headache, dysmenorrhea, tension in the mammary glands, and swelling.

When there is no break in taking hormonal contraceptives, a stable suppression of gonadotropic hormones occurs, follicles do not mature in the ovaries, and a monotonous hormonal pattern is established in the body. This is what explains the reduction or complete disappearance of menstrual symptoms and better tolerability of contraception in general.

One of the most striking side effects of a prolonged hormonal contraceptive regimen is intermenstrual spotting. Their frequency increases in the first months of taking the drugs, but by the third cycle their frequency decreases and, as a rule, they disappear completely. In addition, the total duration of spotting against the background of the prolonged regimen is less than the sum of all days of bleeding with the classic dosage regimen.

About the prescription of contraceptives

The drug that the patient takes is of no small importance. As noted above, the drug should suit the woman and this can actually be assessed in the first cycles of use. It happens that a woman already has prolonged spotting during the first cycle or she generally does not tolerate the drug well. In such a situation, we must replace it with another one: either with a different dose of estrogen or change the progestogen component. Therefore, in practice, there is no need to immediately advise a woman to buy three packs of hormonal contraceptives. She should start with the drug you suggested and then evaluate how she tolerates it. If the frequency of side effects is adequate to the period of starting to take hormonal contraceptives, then she can continue to take them in a prolonged mode; if not, then she should take the drug to the end, and after a 7-day break, start taking another one. As a rule, in most cases it is possible to select a drug on which a woman feels comfortable, even though she has experienced many side effects with other drugs.

It is very important to properly prepare a woman who has never taken hormonal contraceptives, or who has taken them according to the classical regimen, for starting to take hormonal contraceptives in a prolonged mode. It is important to correctly and clearly convey to her the principle of functioning of the reproductive system, explain why menstruation occurs and what its true meaning is. Many fears in patients arise from a banal ignorance of anatomy and physiology, and ignorance actually gives rise to the mythologization of consciousness. Objectively speaking, not only in relation to contraception, but also in relation to other situations, educating patients significantly increases their adherence to treatment, taking medications and preventing subsequent diseases.

The most common question that women ask when talking about hormonal contraception, and especially about its long-term use, is the question of the safety and reversibility of this method of birth control. In this situation, much depends on the doctor, his knowledge and ability to clearly explain what happens in the body when taking hormonal contraception. The most important thing in this conversation is the emphasis on the non-contraceptive effect of hormonal contraception and the negative impact of abortion on a woman’s body. A woman’s negative experience of using contraceptives in the past is usually due to an incorrect approach to their prescription. Quite often, negative experiences are associated with situations where a woman was prescribed a drug only for therapeutic purposes and only of a certain composition for a short period. It was clearly not suitable for the woman; she experienced many side effects, but continued to take it, stoically putting up with difficulties for the sake of cure. In such a situation, an actual change in the drug (and their variety allows this to be done) would neutralize the side effects and would not create a negative attitude in the woman’s mind. This is also important to convey.

On the reversibility of contraception

A very pressing issue among gynecologists is the problem of reversibility of hormonal contraception, and it became especially acute when long-term drug regimens were proposed.

Many gynecologists, summarizing their experience, claim that quite often, while taking hormonal contraceptives, hyperinhibition syndrome of the hypothalamic-pituitary-ovarian system (hypothalamic-pituitary-ovarian system - the system of regulation of the menstrual cycle) occurs, which leads to prolonged amenorrhea (lack of menstruation), which is very difficult to cope with .

This problem, like many other problems of contraception, is largely mythologized. The incidence of amenorrhea after discontinuation of hormonal contraception has been greatly exaggerated. This is a phenomenon of personal analysis of one’s clinical experiences, which quite often breaks down against impartial statistical data. It happens that within a week several patients with the same pathology may come for an appointment, or the same side effect occurs with a drug used for a long time and you may get the feeling that the incidence of a certain disease has recently increased or that a drug you know has become counterfeit by unscrupulous people. But these are just sensations, a series of coincidences that cannot form a pattern. In statistics, there are rules that describe patterns, determining the degree of their reliability depending on the sample and various errors. Thanks to statistics, it is possible to prove whether this fact is reliable or not, and with an increase in the sample, that is, the number of cases, the reliability may change.

Why do we have to deal with the problem of amenorrhea relatively more often after taking hormonal contraceptives? Among the women to whom we most often recommend using contraception, most are our patients, that is, women who already have gynecological disorders. Much less often, healthy women come to an appointment with the sole purpose of choosing hormonal contraception for her. If a woman has already had menstrual dysfunction, then the likelihood of these disturbances continuing after discontinuation of the drug is higher than in a healthy woman. Here it can be argued that hormonal contraception is used to treat dysfunctional conditions of the reproductive system and there is a “withdrawal effect”, when the HPA axis after a “reboot” should begin to work normally, however, disorders in the HPA axis are different and the reason for their development has not yet been clearly established.

For one situation, temporary suppression of the production of gonadotropins is a positive factor that eliminates disruption in their impulse work, and for another, suppression of the function of the hypothalamic-pituitary system can cause disturbances in their production. This is probably due to various subtle functional disorders, in which either only the cyclicity program is disrupted, or the pathology is much more serious. The most interesting thing is that these nuances in dysfunction of the hypothalamic-pituitary system are described quite generally - there is hypofunction, hyperfunction, dysfunction and complete absence of function, although the concept of dysfunction must be deciphered and classified.

As a rule, women whose dysfunction is more serious are in a state of subcompensation and for them any tangible stimulus can become a trigger factor leading to decompensation of this system. Serious illness, stress, pregnancy, abortion and, oddly enough, taking hormonal contraceptives - all of these can be considered effective factors that can cause disturbances in the system.

We can compare two groups of women - those for whom multiple abortions do not affect the reproductive system in any way and those for whom one abortion becomes the cause of persistent infertility and reproductive dysfunction in general. Some women are affected by stress so significantly that amenorrhea develops, while other women in more difficult situations maintain a regular menstrual cycle. Illnesses and childbirth also divide women into two groups. These comparisons can be continued for a long time, but the conclusion suggests itself - the normal operation of the GGJ has a large supply of compensatory capabilities and can adequately adapt to various situations occurring in the body. If the work of compensatory mechanisms is disrupted, sooner or later the system will fail, and it does not matter what leads to this - taking hormonal contraception or an abortion that occurs in its absence. Therefore, the duration of contraception does not play a crucial importance, since the HGYS is completely suppressed already at the end of the first cycle of taking the drugs.

Is it possible to know in advance what the state of the GGJ is and whether taking hormonal drugs can permanently disrupt its work? Not yet. Various hormonal studies are not able to fully reflect the true state of the GGJ, and even less so to predict the likelihood of disorders. Studies of gonadopropin levels are informative in cases of severe disorders (amenorrhea, PCOS, stimulation protocols, etc.). Since pituitary hormones are produced in impulses, their values ​​during a single measurement are generally not informative, since you do not know at what point in the impulse you did the study at the peak of concentration or at the end.

It will be possible in the future to solve the problem of predicting possible disorders while taking hormonal contraception, in the postpartum or post-abortion period. Nowadays, there are tools that allow us to evaluate the features of subtle disorders differently and highlight the patterns of individual conditions. At the moment, hormonal contraceptives can be prescribed if there are no established contraindications to their use. The problem of amenorrhea, if it arises, can be solved with the use of drugs to induce ovulation.

Contraception for various medical conditions

One of the most controversial issues regarding contraception is the problem of its use in women with various diseases and in various conditions of the body.

Contraception in the postpartum period

The postpartum period is characterized by hypercoagulable (increased clotting) characteristics of the blood, and therefore the use of drugs containing estrogens is not recommended. Three weeks after birth, when the coagulation properties of the blood return to normal, women who are not breastfeeding can be prescribed combined contraceptives without any restrictions. As for contraceptives containing only progestins, their use is acceptable from any day, since they do not affect the blood coagulation system, however, it is still not advisable to use them in the first 6 weeks after birth - explanation below. Intrauterine devices and the Mirena system can also be installed without time restrictions, but it is preferable to do this in the first 48 hours after birth, since in this case the lowest frequency of their expulsions is observed.

Lactation period (breastfeeding period)

During the lactation period, the choice of contraception is determined by its type and the time elapsed since birth. According to WHO recommendations, the use of combined hormonal contraceptives in the first 6 weeks after birth can have a negative effect on the liver and brain of the newborn, so the use of such drugs is prohibited. From 6 weeks to 6 months, hormonal contraceptives containing estrogens may reduce the amount of milk produced and impair its quality. 6 months after birth, when the baby begins to eat solid food, combined contraceptives can be taken.

Breastfeeding in the first 6 months after childbirth in itself prevents the possibility of pregnancy if a woman does not menstruate. However, according to updated data, the frequency of pregnancies due to lactational amenorrhea reaches 7.5%. This fact indicates the obvious need for adequate and reliable contraception during this period.

During this period, contraceptives containing only progestins (progesterone analogues) are usually prescribed. The most famous drug is the mini-pill. These tablets are taken every day without a break.

Post-abortion period

In the post-abortion period, regardless of the form in which it was performed, immediately starting to use hormonal contraception is safe and useful. In addition to the fact that a woman in this case does not need to use additional methods of contraception in the first week of taking the drug, hormonal contraception, if we are talking about monophasic combined contraceptives, can neutralize the effects of hypothalamic stress, which can lead to the development of metabolic syndrome, we will talk about this in more detail will go lower. Also, immediately after an abortion, an intrauterine device or the Mirena system can be installed.

Migraine

Migraine is a fairly common disease among women of reproductive age. Tension headaches do not in any way affect the risk of strokes, while migraines can lead to such a severe complication, so the differential diagnosis of headaches is important when deciding whether to take hormonal contraception.

Some women note relief of migraine symptoms while taking COCs and use these drugs on a long-term basis to avoid menstrual exacerbation during the seven-day break. At the same time, others experience increased symptoms of this disease.

COCs are known to increase the risk of ischemic stroke in women with migraine, while simply having migraine in a woman increases the risk of ischemic stroke by 2-3.5 times compared to women of the same age who do not have this disease.

It is extremely important to distinguish between migraine with aura and regular migraine, since migraine with aura is significantly more likely to lead to ischemic stroke. The risk of ischemic stroke while taking COCs in women with migraine increases by 2-4 times compared with women with migraine but not taking COCs and 8-16 times compared with women without migraine and not taking COCs. Regarding progestin-containing contraceptives, the WHO has concluded that “the benefits of use outweigh the risks” regarding their use in women with migraine.

Therefore, women suffering from migraine should not take COCs. For contraception, it is possible to use intrauterine devices, barrier methods, and possibly progestin-containing contraceptives.

Obesity

Excess body weight can significantly affect the metabolism of steroid hormones through increased basal metabolic rate, increased liver enzyme activity and/or excess fermentation in adipose tissue.

Some studies indicate that low-dose COCs and progestin-containing contraceptives may be less effective in overweight women. The risk of pregnancy has been shown to be 60% higher in women with a BMI (body mass index) > 27.3 and 70% higher in women with a BMI > 32.2 compared to women with normal BMI values. Despite this, the effectiveness of COCs is recognized to be better than barrier methods of contraception, while the effectiveness of COCs increases with weight loss and proper medication use.

It is known that overweight women are at risk for developing venous thrombosis.

Taking COCs itself increases the risk of venous thrombosis, and in women with increased body weight this risk increases. At the same time, no reliable evidence has been obtained of the effect of progestin-containing contraceptives on increasing the risk of venous thrombosis. In addition, when using the Mirena system, there were no changes in the metabolism of progestins in women with increased body weight. Thus, given the described risks, obese women should be recommended progestin-containing contraceptives or, preferably, the Mirena system, which in turn will prevent endometrial hyperplastic processes, often observed in overweight women.

Diabetes

As a result of comparative studies, the following data were obtained: All types of hormonal contraceptives, with the exception of high-dose COCs, do not have a significant effect on carbohydrate and fat metabolism in patients with type I and type II diabetes. The most preferred method of contraception is the Mirena intrauterine hormonal system. Miro- and low-dose COCs can be used by women with both types of diabetes who do not have nephro- or retinopathy, hypertension or other cardiovascular risk factors such as smoking or age over 35 years.

Non-contraceptive effects of oral contraceptives

Correct use of hormonal birth control pills can provide both contraceptive and non-contraceptive benefits of this method. From the list of advantages of this method given below, in addition to the contraceptive effect, some therapeutic effects are also noted.

• almost 100% reliability and almost immediate effect;
• reversibility of the method and providing the woman with the opportunity to independently control the onset of pregnancy. Fertility in nulliparous women under 30 years of age who took combined OCs is restored within 1 to 3 months after discontinuation of the drug in 90% of cases, which corresponds to the biological level of fertility. During this time interval, there is a rapid rise in FSH and LH levels. Therefore, it is recommended to stop taking OCs 3 months before the planned pregnancy.
• sufficient knowledge of the method;
• low incidence of side effects;
• comparative ease of use;
• does not affect the sexual partner and the course of sexual intercourse;
• impossibility of poisoning due to overdose;
• reduction in the incidence of ectopic pregnancy by 90%;
• reduction in the incidence of inflammatory diseases of the pelvic organs by 50-70% after 1 year of use due to a decrease in the amount of lost menstrual blood, which is an ideal substrate for the proliferation of pathogens, as well as less expansion of the cervical canal during menstruation due to the specified reduction in blood loss. Reducing the intensity of uterine contractions and peristaltic activity of the fallopian tubes reduces the likelihood of developing an ascending infection. The progestogen component of OC has a specific effect on the consistency of cervical mucus, making it difficult to pass not only for sperm, but also for pathogenic pathogens;
• preventing the development of benign neoplasms of the ovaries and uterus. Taking OCs is strongly associated with a reduced risk of ovarian cancer. The mechanism of protective action of OCs is probably related to their ability to inhibit ovulation. As is known, there is a theory according to which “continuous ovulation” throughout life, accompanied by trauma to the ovarian epithelium with subsequent repair (restoration), is a significant risk factor for the development of atypia, which, in fact, can be considered as the initial stage of the formation of ovarian cancer. It has been noted that ovarian cancer develops more often in women who have had a normal (ovulatory) menstrual cycle. Physiological factors that “turn off” ovulation are pregnancy and lactation. The social characteristics of modern society determine a situation in which a woman, on average, experiences only 1-2 pregnancies in her life. That is, physiological reasons for limiting ovulatory function are not enough. In this situation, taking OCs seems to replace the “lack of physiological factors” limiting ovulation, thus realizing a protective effect against the risk of developing ovarian cancer. Using COCs for about 1 year reduces the risk of developing ovarian cancer by 40% compared with non-users. The purported protection against ovarian cancer associated with OCs continues to exist 10 years or more after stopping their use. For those who have used OCs for more than 10 years, this figure decreases by 80%;
• positive effect on benign breast diseases. Fibrocystic mastopathy is reduced by 50-75%. An unresolved issue is whether COCs cause an increased risk of breast cancer in young women (under 35-40 years of age). Some studies claim that COCs may only accelerate the development of clinical breast cancer, but overall the data seems encouraging for most women. It is noted that even in the case of breast cancer development while taking OCs, the disease most often has a localized nature, a more benign course and a good prognosis for treatment.
• reduction in the incidence of endometrial cancer (uterine lining) with long-term use of OCs (the risk decreases by 20% per year after 2 years of use). The Cancer and Steroid Hormone Study, conducted by the Centers for Disease Control and the National Institutes of Health, showed a 50% reduction in the risk of endometrial cancer associated with OC use for at least 12 months. The protective effect lasts up to 15 years after stopping OC use;
• relief of symptoms of dysmenorrhea (painful menstruation). Dysmenorrhea and premenstrual syndrome occur less frequently (40%).
  reduction of premenstrual tension;
• positive effect (up to 50% when taken for 1 year) in iron deficiency anemia by reducing menstrual blood loss;
• positive effect on endometriosis - a positive effect on the course of the disease is associated with pronounced decidual necrosis of the hyperplastic endometrium. The use of OCs in continuous courses can significantly improve the condition of patients suffering from this pathology;
• According to a study that included a large group of women, long-term use of oral contraceptives was shown to reduce the risk of developing uterine fibroids. In particular, with a five-year duration of taking OCs, the risk of developing uterine fibroids is reduced by 17%, and with a ten-year duration - by 31%. A more differentiated statistical study, which included 843 women with uterine fibroids and 1557 women in the control group, found that with increasing duration of continuous OC use, the risk of developing uterine fibroids decreases.
• reduction in the frequency of development of retention formations of the ovaries (functional cysts - read about ovarian cysts in the corresponding section) (up to 90% when using modern hormonal combinations);
• reduced risk of developing rheumatoid arthritis by 78%
• positive effect on the course of idiopathic thrombocytopenic purpura;
• reducing the risk of developing colorectal cancer (colon and rectal cancer) by 40%
• therapeutic effect on the skin for acne (pimples), hirsutism (increased hair growth) and seborrhea (when taking third-generation drugs);
• preservation of higher bone density in those who used OCs in the last decade of childbearing age.
• A large number of studies have been devoted to the relationship between COCs and cervical cancer. The conclusions from these studies cannot be considered unambiguous. It is believed that the risk of developing cervical cancer increases in women who have taken COCs for a long time - more than 10 years. At the same time, the establishment of a direct connection between cervical cancer and human papillomavirus infection partly explains this trend, since it is obvious that women using oral contraceptives rarely use barrier methods of contraception.
• Other types of contraception

Condoms, like other methods of barrier contraception, are unlikely to lose their relevance in the near future, since only these means of preventing pregnancy combine both the contraceptive effect and the possibility of protection against sexually transmitted infections. Combined use of spermicides with condoms or diaphragms is known to improve their reliability. Obviously, this method of birth control is especially indicated for women who do not have a stable monogamous relationship, are prone to promiscuity, and also in cases where, for one reason or another, the contraceptive effect of oral contraceptives is reduced. The routine use of barrier methods or spermicides is essentially indicated only in the case of absolute contraindications to the use of OCs or IUDs, irregular sexual activity, and also in the case of a woman’s categorical refusal of other methods of contraception.

The calendar method of birth control is known to be one of the least reliable methods, however, this method has a unique advantage: it is the only method of birth control accepted by both the Catholic and Orthodox churches.

Sterilization is an irreversible method of contraception, although if desired, fertility can be restored either through tubal surgery or assisted reproductive technology. The contraceptive effect of sterilization is not absolute; in some cases, pregnancy develops after this procedure, and in most cases such pregnancy is ectopic.

Although there are clear indications for whom this method of contraception is indicated, that is, women who have achieved reproductive function, it is still necessary to take into account the fact that sterilization is an abdominal surgical intervention requiring general anesthesia. The question is: does it make sense to achieve a contraceptive effect at such a price? Obviously, for this category of women, Mirena may be the optimal method of contraception. Considering the fact that it is in this age group that diseases such as uterine fibroids and endometriosis are most common, the use of Mirena will have not only a contraceptive, but also a therapeutic and/or preventive effect. A doctor should never forget that a woman’s choice of a contraceptive method is largely determined by her ability to clearly and convincingly explain the advantages and disadvantages of each type of contraception.

In our opinion, injectable contraceptives occupy a completely separate place and, probably, this is primarily due to a certain degree of inconvenience in their use. In addition to the method of their administration (injections, sewing in capsules), negative emotions in women are caused by frequently observed spotting. In general, it is difficult to precisely identify the group of women who would be most suitable for this method of contraception.

Thus, the problem of contraception at the moment can be successfully solved using oral contraceptives, patches and rings, intrauterine devices or Mirena and barrier methods. All of the listed methods of birth control are quite reliable, extremely safe, reversible and easy to use.