In harmony with hormones. Combined oral contraceptives. Side effects of hormonal contraception

Contraception is not only protection against unwanted pregnancy, but also a way to maintain health and the opportunity to give birth to the desired healthy child.

Family planning is a contraceptive priority. Currently, the choice of modern contraceptive methods is very large. It is best to seek advice from a specialist on choosing a contraceptive method, rather than trying to choose them yourself, since each method has its own contraindications and side effects, which depend on the woman’s age.

Incorrectly selected methods of contraception can not only be useless, but also cause complications in the hormonal, genitourinary, cardiovascular systems, as well as the gastrointestinal tract and other systems and organs of a woman. The essence hormonal contraception consists of using synthetic estrogen and gestagen or only gestagen components, which are an analogue of a woman’s natural sex hormones. Hormonal contraception is an effective and most common method of birth control.

There is the following classification hormonal contraceptives:

• combined estrogen-progestogen oral contraceptives;
• progestin contraceptives:
• oral contraceptives containing microdoses of gestagens (mini-pills);
• injection;
• implants;
• vaginal rings with estrogens and gestagens.

As a result of the action of these contraceptives, growth, development of follicles and ovulation are simply not possible. Progestogens increase the viscosity of cervical mucus, making it impassable for sperm, and gestagens slow down the peristalsis of the fallopian tubes and the movement of the egg through them, as a result of which implantation of the fertilized egg, if fertilization does occur, becomes impossible.

Combined contraceptives, depending on the level of ethinyl estradiol, are divided into high-dose (they are not used now), low-dose, micro-dose.

Side effects and complications.
A small percentage are women who, when taking these contraceptives in the first months of use, experience nausea, vomiting, swelling, dizziness, heavy bleeding during menstruation, irritability, depression, increased fatigue, decreased libido. Now such symptoms are considered in the form of the body’s adaptation to the drugs; they usually disappear by the end of the third month of constant use.

A more serious side effect of taking combined oral contraceptives is the effect on the hemostatic system. The estrogen component included in COCs increases the risk of coronary and cerebral thrombosis. However, this applies only to women at risk, namely women over 35 years of age, smokers, obesity, arterial hypertension, etc. It has been proven that the use of these contraceptives does not affect the hemostatic system of healthy women.

Under the influence of estrogen, blood sugar levels increase, resulting in latent forms of diabetes. Gestagens have a negative effect on fat metabolism, as a result, with an increase in cholesterol levels, the risk of developing atherosclerosis and vascular diseases increases. The effect of modern third-generation COCs, which contain gestagens, is exactly the opposite, that is, it does not disrupt lipid metabolism, but protects the vascular walls. An increase in body weight under the influence of gestagens is not observed when taking modern COCs. Acne and various rashes are possible when taking gestagens with a pronounced androgenic effect. The modern highly selective gestagens used, on the contrary, have not only contraceptive, but also healing effect. Remember that combined oral contraceptives cause swelling of the cornea of ​​the eye, which causes some discomfort for those who use contact lenses.

With long-term use of combined oral contraceptives, the vaginal microflora changes, which contributes to the development of bacterial vaginosis and vaginal candidiasis. The use of these contraceptives is a risk factor for the transition of cervical dysplasia (if any) to carcinoma. Women taking COCs must undergo cervical smears for medical examination. Any component included in the COC may cause an allergic reaction. The most common and frequent side effect of COC use is uterine bleeding.

The causes of bleeding may be a lack of hormones for a particular patient (estrogens - when bleeding in the first half of the cycle, gestagens - in the second half). In most cases, such bleeding disappears on its own within the first 3 months of taking COCs and does not require their discontinuation. COCs do not have any adverse effect on a woman's fertility. It recovers within the first three months, from the day you stop taking contraceptives. In case of accidental use of COCs on early stages No side effects were identified during pregnancy, and no negative effects on the fetus were observed.

Hormonal contraceptives are one of the most convenient ways to prevent pregnancy. There are many methods of hormonal contraception: birth control pills, IUD or implants, birth control patches or injections. However, hormones affect the entire woman’s body. Therefore, it is so important to fully understand the mechanism of action and consequences of use.

Hormonal contraception contains specially selected doses of synthetic sex hormones, which, according to the principle of negative feedback, suppress the secretion of gonadotropins (FSH and LH) in a woman’s body, which inhibits, in particular, ovulation.

Mechanism of action of hormonal contraception

Hormonal contraceptives are a method of preventing pregnancy that is based on the introduction of artificial hormones into the body. These substances, although produced artificially, work in the same way as natural feminine sex hormones. The presence of artificial hormones in the body is associated with high efficiency, but also with the possibility of developing systemic (affecting the entire body) side effects. Hormonal contraception uses a hormone from the estrogen group (ethinyl estradiol) and a hormone from the progestin group. Most drugs contain both of these hormones, some drugs contain only a hormone from the progestin group.

There are several mechanisms of action of hormonal contraception. Together they determine the high efficiency of this method preventing pregnancy:

• Inhibition of ovulation– artificial hormones “deceive” the body and, in particular, the ovaries, which go into sleep mode and do not release eggs every month. In such a situation, despite the presence of sperm in the woman’s genital tract, fertilization cannot occur.
• Thickening of mucus occurs in the woman’s genital tract– sperm cannot move, they get stuck in mucus, so even if ovulation occurred, the meeting of male and female gametes is very unlikely.
• Hormones interfere with transport through the fallopian tubes(the egg, when released from the ovaries, cannot meet the sperm).
• Changes occur in the endometrium, preventing implantation (the embryo is rejected, even if it has reached fertilization).

The above mechanisms are triggered mainly through gestagen. Estrogens cause inhibition of ovulation, and in addition, enhance the effect of progestins. This allows the use of lower doses of hormones needed to achieve the same effect.

Types of hormonal contraception

Hormonal contraceptives are:

• contraceptive pills, two-component and one-component;
• contraceptive patches;
• vaginal rings;
• implants;
• hormonal injections;
• “72 hours after” tablets;
• IUD with hormone release.

Some hormonal contraceptives contain two components (estrogen and progestogen). Other drugs are single-component (containing gestagen).

These include:

• a one-component tablet that can be used by breastfeeding women;
• contraceptive patches;
• vaginal rings;
• implants;
• hormonal injections;
• “72 hours after” tablet;
• insert with hormones.

Another difference is how hormones enter the body:

• through the gastrointestinal tract (birth control pills);
• through the skin (contraceptive patches);
• through the vaginal mucosa (vaginal inserts);
• through the mucous membrane of the uterus and cervix (hormone release spiral);
• through small vessels under the skin (hormonal injections, implants).

Single-component tablets

“Mini” tablets include only one type of hormones - progestin. Thanks to this, they can be taken by breastfeeding women. During their use, the natural course of the ovulation cycle can be maintained, including ovulation. The mechanism of action of “mini” tablets is to increase the density of cervical mucus, which significantly complicates the path of sperm to the egg.

They should be taken daily, at the same time, without a 7-day break (28 tablets per package). About 4 hours after taking the pills, the cervix produces the most effective barrier to sperm, so it is worth adapting your sexual habits to this feature of the pills.

If one or more tablets are missed, or there is a delay in taking a tablet for more than 3 hours, additional contraceptive protection must be used for 7 days. You can start taking the drug as early as 3 weeks after birth.

Their effectiveness is less than in the case of “regular” birth control pills, the Pearl index is about 3 (in the case of two-component pills, the Pearl index is less than 1).

The disadvantage of this method is the fact that the tablets must be taken within an hour! A delay of more than 3 hours increases the risk of pregnancy! When using them, cycle disturbances and sometimes bloody intermonthly discharge may occur. Other side effects include an increase in body weight at the beginning of using the drug, the possibility of developing depression in women who are predisposed to it, the appearance of acne, an increase in the volume of all types of hair, and a decrease in libido.

Two-component tablet

This pill contains two types of hormones - estrogen And progestogen. Its use consists of taking tablets daily for 21 days. After finishing a package that contains only 21 tablets, you should take a 7-day break and then start a new package.

There are various types of birth control pills:

• single-phase– the most common (all tablets have the same composition, so the order during their use is not important),
• two-phase– two types of tablets, the order of use is very important;
• three-phase– three types of tablets, the order of use is very important;
• multiphase.

The first tablet from the first package should be taken on the first day of menstruation. You must take the tablets from the package every day at a certain time. Then you should take a 7-day break (then the effectiveness of contraception remains). On the 2-4th day of the break, menstruation should occur. After a 7-day break, start a new pack, regardless of whether the bleeding has stopped or not. After each package, take a 7-day break.

To birth control pill was effective, it is necessary to take it regularly, daily at a certain time. Missing one or more tablets can lead to unwanted pregnancy; starting the pill on a day other than the first day of menstruation or extending the 7-day break also increases the risk. Certain medications, as well as vomiting and diarrhea within 3-4 hours after taking the tablet, may reduce the effectiveness of the method.

Birth control pills affect the entire body, so side effects may occur while taking them. In this case, you need to try to select other pills individually, and if this does not help, you should look for another method of contraception.

A woman who wants to start using birth control pills should contact her gynecologist and ask for a prescription from the pharmacy. During this visit, the doctor must conduct a detailed conversation and examine the patient. It is necessary to exclude pregnancy and conduct an interview in the direction of familial thromboembolism. This is important because not all women want this form of contraception!

Contraceptive patches

Birth control patches work by continuously releasing hormones into the body from a patch placed on bare skin. This method of administration, unlike oral administration, reduces the effect of hormones on the liver. The package contains three records. Each of them contains a dose of hormones sufficient for one week. They are used for three weeks in a row. Then you need to take a week off.

The patch should always be changed on the same day of the week. Places where the patch can be placed are the abdomen, upper outer shoulder, buttock, upper arm, or shoulder blade.

There are numerous benefits of using birth control patches. They provide stable concentrations of hormones in the blood. Unlike birth control pills, they do not burden the liver.

This contraceptive method It also allows the use of lower doses of hormones than would be the case with internal administration. The transdermal patch system is very convenient, you don’t need to worry about taking pills, they don’t interfere with your activity. It is also very important that you can stop therapy at any time by peeling off the patch.

Vaginal ring

It has several small barriers that are imperceptible to the woman or her partner; in addition, the ring releases progestins for 21 days.

The vaginal ring is inserted into the woman's vagina and removed after 21 days. After seven days, the woman inserts a new ring into the vagina (it is important that this happens on the same day of the week as in the previous cycle).

Other methods of hormonal contraception

Tablet “72 hours after”

This emergency contraception method, that is, contraception, which is used immediately after intercourse.

In fact, this measure can hardly be called a method of contraception and should not be perceived as such. It is used in “emergency situations”, for example, when the means used failed (for example, a condom burst), when it came to rape, when, under the influence of excitement, the couple forgot to take precautions.

The 72 Hours After Pill works after fertilization but before implantation, so it is not an illegal abortion pill. When an “emergency situation” occurs, a woman has 72 hours to protect herself from an unwanted pregnancy. To do this, you need to contact your gynecologist and ask for a prescription for such a pill.

Contraceptive injections

Contraceptive injections involve the intramuscular injection (for example, into the buttock) of progestins, which suppress ovulation, thicken the cervical mucus, and prevent implantation into the uterine mucosa.

Depending on the type of progestogen, the procedure must be repeated every 8 or 12 weeks. The first injection is administered 1-5 days from the start of the cycle. If the first injection is given from the first day of the cycle, then the effect is achieved immediately, otherwise, within 8 days it is necessary to use additional means of protection, for example, mechanical or chemical.

The effectiveness of a contraceptive injection is even higher than the effect of birth control pills, since a woman does not have to remember to use the drug every day. The disadvantage of injections is that if any side effects appear after the administration of the drug (irregular and prolonged bleeding, headaches, dizziness, acne, nausea, ovarian cysts, weight gain), then it is impossible to cancel the drug - it is already in the body! You will have to suffer until the end of its effect, that is, 2-3 months. Another disadvantage is that it may take a while for fertility to return after you stop using the method.

Contraceptive implant

With this method, a twig is implanted under the skin of the forearm, releasing progestins throughout the entire time (on average 40 mcg). The contraceptive effect of the implant lasts for 5 years. After this time you should remove it and possibly install a new one. If unwanted side effects occur, the implant can be removed earlier (this is done by the doctor).

Hormonal contraception inhibits ovulation. In addition, it covers all those drugs that inhibit the endocrine function of the ovaries and adrenal cortex, increase the viscosity of cervical mucus (that is, make it difficult for sperm to penetrate). In addition, they cause changes in the lining of the uterus.

Advantages and disadvantages of hormonal contraception

Women using hormonal contraception regain their ability to bear children immediately after discontinuation of use. Children who were born to women who previously used hormonal contraception are just as healthy as the children of other women. You can try to conceive a child in the first cycle after stopping hormonal contraception.

Benefits of hormonal contraception are:

• contraceptive effectiveness – Pearl index 0.2-1;
• the method is easy to use - does not interfere with sexual intercourse;
• Immediately after completion of the method, conception is possible;
• reduction menstrual cycle, as well as diseases associated with premenstrual tension syndrome;
• increasing the regularity of cycles;
• reducing the risk of ectopic pregnancy and ovarian cysts;
• reducing the risk of ovarian cancer and endometrial cancer;
• reducing the incidence of pelvic inflammation.

There is a possibility of numerous side effects. It must be remembered that birth control pills are not indifferent to a woman’s health.

Side effects of hormonal contraception

It must be remembered that regardless of the method of administration, hormonal contraception affects the entire body, which can lead to systemic side effects. Women using hormonal methods should be aware of possible side effects, such as:

• acyclic bleeding and spotting;
• acne, seborrhea (oily hair);
• headaches;
• nausea, vomiting;
• bloating;
• increased blood pressure;
• body weight gain;
• nipple pain;
• vaginal fungus;
• decreased libido (decreased desire to have sex),
• worsening mood, irritability;
• increase in varicose veins lower limbs;
• thromboembolic complications (can be life threatening);
• fat balance disorders (more bad LDL cholesterol);
• coronary heart disease in women over 35 years of age, smoking cigarettes;
• increases the risk of breast and cervical cancer.

These diseases can occur, but not necessarily! This is a very individual matter. It often happens that the severity of side effects is greatest at the beginning of using hormonal contraception, and after 3-4 cycles it decreases significantly.

Topic: Hormonal contraception. History of the issue. Types of hormonal contraceptives. Prevalence, advantages and disadvantages, complications, effectiveness. Indications and contraindications for use

The range of modern contraceptive methods includes various hormonal contraceptives, intrauterine, surgical, barrier contraception, spermicides and natural methods of family planning.

When selecting a method of contraception, many criteria are taken into account: effectiveness, safety for a particular patient, side effects, non-contraceptive effects, reversibility of the method, accessibility, cost and other criteria, including social and personal ones.

Such highly effective and reversible means, which often also have a therapeutic effect for a number of gynecological diseases, are hormonal contraceptives.

Due to its effectiveness and ease of use, hormonal contraception is widespread throughout the world.

According to WHO, it is used annually by 100 to 120 million women. In Russia, about 5-7% of women use hormonal contraception.

Background

In the 50s of our century, it was shown that large doses of sex hormones (estrogens and/or gestagens) block ovulation and thereby have a contraceptive effect. The first synthetic combined contraceptives (COCs) contained high doses of estrogen (150 mcg mestranol) and progestogen (9.8 mg norethinodrel) components. The use of these drugs increased the risk of developing cardiovascular diseases, mainly due to the effect of high doses of estrogens on the blood coagulation system.

Subsequently, by the 70s, the dose of estrogen in drugs was reduced to 50 mcg, and in modern low-dose COCs it is 20-35 mcg.

All modern drugs contain ethinyl estradiol as an estrogenic component.

The progestogen components in various drugs differ from each other in their affinity for progesterone, estrogen and androgen receptors in various tissues and organs. In this regard, they can only have a progesterone effect (desogestrel, gestodene); mild androgenic effect (levonorgestrel), antimineralocorticoid effect (drospirenone). One of the new generation progestogens is dienogest, a highly selective progestogen with antiproliferative activity.

There are monophasic, biphasic and triphasic COCs. In monophasic preparations, the content of estrogen and progestogen components is the same throughout the entire cycle. In two-phase and three-phase cycles, the progestogen content in the second phase of the cycle increases.

Mechanism of action of COCs

The mechanism of action of all COCs is the same and does not depend on the structure of the drug, dosage and type of progestogen included in the tablet. The contraceptive effect of drugs is achieved through direct and indirect effects on parts of the reproductive system. The main effect of COCs is to suppress the synthesis of FSH and LH by the pituitary gland and eliminate the ovulatory LH peak, resulting in blocked ovulation. If ovulation does occur, the main mechanisms in preventing pregnancy are changes in the cervical mucus and endometrium: the mucus becomes more viscous and impenetrable for sperm, and regression is observed in the endometrium up to pseudoatrophic changes, due to which implantation of a fertilized egg becomes unlikely.

When taking COCs for 21 days, there is no increase in the levels of endogenous estrogens and progesterone, as well as FSH and LH.

Benefits of using COCs

The advantages of COCs are high efficiency, ease of use, reversibility, and the presence of favorable therapeutic effects.

According to numerous epidemiological studies, it has been noted that taking COCs leads to a significant reduction in the number of gynecological diseases. In particular, the relative risk of developing endometrial cancer (by an average of 60%), ovarian cancer (by an average of 40%), benign ovarian tumors, uterine fibroids, endometriosis, algomenorrhea, premenstrual syndrome, pelvic inflammatory diseases, mastopathy, iron deficiency anemia.

These positive effects are due to the fact that:

– COCs suppress the functional activity of the ovaries (growth of the epithelium in the follicles, ovulation) and thereby sometimes prevent “uncontrolled growth of the epithelium, leading to neoplasms;

– the use of COCs prevents the formation of hyperplastic formations and endometrial cancer;

– when using COCs, the level of prostaglandins in the endometrium before menstruation increases slightly, so premenstrual pain does not occur;

– the use of COCs facilitates the course of premenstrual syndrome by reducing the production of endogenous sex steroids and reducing the local production of prostaglandins in the endometrium;

– thickening of cervical mucus, associated with the influence of progesterone, reduces the risk of developing acute bacterial diseases of the pelvic organs;

– COCs with third-generation progestogens (cyproterone acetate, desogestrel, gestodene) can be used to treat acne.

Side effects of COCs

Side effects that occur when using COCs are minimal when using low-dose drugs with progestogens that are highly selective for progesterone receptors.

The most typical side effects are: nausea, vomiting, breast engorgement, slight weight gain, decreased or increased libido, headache, intermenstrual discharge. These symptoms are observed, as a rule, in the first cycles of taking the drugs, in the future their frequency does not exceed 5-10%.

Side effects should be distinguished from complications that may occur when using COCs. They differ in that the side effects do not pose a risk to a woman's health and usually do not require treatment.

Combined hormonal contraceptives are contraindicated:

if pregnancy is suspected;

with uterine bleeding of unknown origin;

smoking women over 35 years old;

women suffering from hypertension (with blood pressure above 160/90 mmHg)

women with severe diabetes with vascular disorders;

women who have or have had: coronary heart disease or stroke, angina pectoris;

women who have breast cancer (or have had it before);

women with active liver or gallbladder disease in the acute stage;

women suffering from migraines;

nursing mothers.

Progestogenic contraceptives:

Progestogen-based methods of birth control combine hormonal contraceptives that contain only progestogens. This group includes:

– oral progestogen contraceptives (OPC), called “mini-pills”;

– injectable drugs (the drug Depo-Provera is registered in Russia);

– Norplant subcutaneous implant.

Progestogen contraceptives are modern, highly effective and safe means of preventing pregnancy.

The composition of the drugs determines a number of advantages of this group of contraceptives:

– possibility of use in the presence of contraindications to the use of estrogens;

– possibility of use during lactation;

– the presence of non-contraceptive effects, the most important of which are the prevention of the pathology of endometriosis, including endometrial cancer; reducing the risk of inflammatory diseases of the pelvic organs; benign diseases of the mammary glands; can reduce pain during menstruation;

– use of Depo-Provera and Norplant for prolonged contraception.

Contraception using a mini-pill is suitable for women with estrogen intolerance, smokers over the age of 35 years, during lactation, with diabetes mellitus, arterial hypertension, sickle cell anemia and focal migraine.

The disadvantage of mini-pills is their lower effectiveness compared to COCs. In this regard, progestogen oral contraceptives are not the method of choice for patients who have a history of ectopic pregnancy or are at risk for this pathology. While taking the mini-pill, you may experience longer periods, intermenstrual bleeding, and amenorrhea.

The injectable contraceptive Depo-Provera contains 150 mg of medroxyprogesterone acetate, administered intramuscularly once every 3 months.

The advantages are:

– high efficiency;

– safety (the use of Depo-Provera does not affect the blood coagulation system, blood pressure, lipid and carbohydrate metabolism);

– prolonged effect for 3 months;

– possibility of use during lactation;

– confidentiality;

– amenorrhea, which often develops after 9-12 months of using the method, is considered by some women as an advantage of the method.

Disadvantages of this method:

1. Irregular, prolonged spotting or heavy bleeding is possible.

2. Most women develop amenorrhea after a few months.

3. Does not protect against STDs and HIV.

4. Restoration of fertility after stopping the use of Depo-Provera in an average of 9-10 months.

5. If side effects occur, it is impossible to interrupt the action of the drug.

The hormonal contraceptive Norplant consists of six plastic capsules, each containing 36 mg of levonorgestrel, injected under the skin for 5 years.

Advantages of this method:

– Norplant is the most effective of the reversible methods of contraception;

– long-term contraception is provided for 5 years;

– ease of use of the method;

– confidentiality;

– safety of the method;

– possibility of use in the presence of contraindications to estrogens;

– causes positive contraceptive effects.

Disadvantages of the method:

1. The nature of menstrual bleeding often changes.

2. The introduction and removal of capsules is accompanied by surgery.

3. Operations for the introduction and removal of Norplant require special training of doctors.

4. A woman cannot stop using the method on her own.

5. The method does not protect against STDs and HIV.

Of particular value for clinicians and patients are the therapeutic and preventive, oncoprotective properties of hormonal contraceptives: reducing the risk of ectopic pregnancy (by 90%), the risk of ovarian and endometrial cancer (by 40-80% depending on the duration of use), the risk of developing benign breast diseases (by 40%).

Monophasic COCs reduce the risk of developing ovarian follicular cysts by more than 2 times (40-60%), the positive effect of COCs is pronounced with the risk of developing corpus luteum cysts (up to 78%). These effects are based on the main mechanism of action of COCs - suppression of ovulation, resulting in the absence of unwanted peak estrogen concentrations and excessive estrogenic stimulation of target organs.

The therapeutic and prophylactic effects of hormonal contraceptives, as well as contraceptives, are determined by the same mechanism of action: suppression of ovulation as a result of a decrease in the cyclic secretion of gonadotropins. It should be taken into account that the mechanism of action of hormonal contraceptives on individual parts of the reproductive system is ambiguous and depends on the type and dose of drugs, therefore the clinical aspects of their use are also different. When using synthetic progestins for contraceptive purposes, the central mechanism of their action, expressed in the suppression of ovulation, is mainly taken into account. Regarding their use for therapeutic purposes, an important mechanism is their peripheral action, expressed in the suppression of endometrial proliferation, necrosis of hyperplastic endometrial glandular tissue (endometrial hyperplasia and cancer, endometriosis)..

The use of monophasic COCs in women with premenstrual syndrome (PMS), especially if they require contraception, is considered first-line therapy. The effectiveness of these drugs has been proven, both in relation to psycho-emotional manifestations and, especially, somatic symptoms of PMS. With the correct selection of patients, serious complications are extremely rare, the half-life of the components included in their composition is short, so if necessary, treatment can be quickly discontinued.

Additional therapeutic and preventive effects, as well as unwanted side effects, depend on the dosage of estrogen, the progestin component and individual tolerance.

Conditions for which therapeutic and prophylactic effects are used combined oral contraceptives:

• 
  Endometrial, ovarian, colorectal cancer
• 
  Menstrual irregularities and dysfunctional uterine bleeding.
• 
  Dysmenorrhea
• 
  Premenstrual syndrome
• 
  Functional ovarian cysts (prescription of combined oral contraceptives with a dose of EE 50 mcg/day for 3-6 months is indicated)
• 
  Perivulatory syndrome
• 
  Some forms of anovulation to achieve a rebound effect
• 
  Oligo- or amenorrhea due to chronic anovulation in polycystic ovary syndrome and/or hyperandrogenism
• 
  Some forms of acne, seborrhea, androgenetic alopecia
• 
  Uterine fibroids, endometriosis, endometrial hyperplastic processes
• 
  Diffuse mastopathy
• 
  Anemia, rheumatoid arthritis, peptic ulcer

COC and uterine fibroids

The development and growth of uterine fibroids, like other hormone-dependent tumors, are largely determined by the endogenous level and ratio of sex steroids in a woman’s body, as well as the expression and dominance of their corresponding receptors in target organs. Unlike normal biometry, tumor nodes contain a significantly higher number of estrogen receptors per unit volume of tissue and are therefore extremely sensitive to estrogens. In myometrial tissue, the number of estrogen receptors changes during the menstrual cycle, their number increases during the follicular phase in the absence of the counteracting influence of progesterone. The “progesterone” hypothesis has been recognized, according to which not only 17-estradiol, but also to a greater extent progesterone, plays a key role in initiating a cascade of molecular genetic disorders that occur during tumor growth. During the luteal phase of the cycle, mitotic activity and the number of progesterone receptors (A and B) simultaneously increase in uterine fibroid tissue in comparison with normal myometrium. Confirmation of the “progesterone” concept is the inhibitory effect of antiprogestins (mefiprestone) on tumor development. A combined interaction between estrogens and progesterone has been established to stimulate the proliferative potential of cellular elements of uterine fibroids due to the induction of epidermal growth factor and its receptors. Mitogenic growth factors for uterine fibroids also include prolactin, insulin-like growth factor (IGF), aromatase and Ki-67 antigen.

The largest studies that studied the effect of COCs on uterine fibroids include the work of Parassini P. et al., which was carried out in two stages: from 1986 to 1990, and then continued until 1997 and included 843 women with uterine fibroids. The control group consisted of 1557 women without genital pathology (the results of the work were published in Br.J.Obstet.Gynecol., 1999; 106: 857-60). The relative risk of developing uterine fibroids in women using COCs was 0.3 (95% CI 0.2-0.6) compared with the control group. At the same time, the risk of developing uterine fibroids decreased with increasing duration of COC use: from 1.4 after 1 year of use to 0.5 after 7 years of treatment. The second study was conducted by the Oxford Family Planning Association and lasted 30 years. 17 thousand women were observed; by the end of the study, 535 were diagnosed with uterine fibroids and underwent hysterectomy. The control group consisted of women who did not have uterine pathology. It was found that the risk of developing uterine fibroids decreased with long-term (more than 12 years) use of COCs, by approximately 17% for every 5 years of treatment.

The results of most studies that were conducted using both high-dose COCs and modern low-dose drugs indicate the absence of their adverse effect on uterine fibroids, however, this is not about the treatment of uterine fibroids using COCs, but only about the possible use of this method of contraception in such patients .

COCs and benign ovarian tumors

By “functional” cysts we mean follicular and luteal ovarian cysts. Epidemiological studies using high-dose first-generation COCs have revealed a decrease in the incidence of functional ovarian cysts, especially luteal cysts, while taking them. Subsequently, when using triphasic or low-dose COCs, this effect was less pronounced or absent. Reducing the dose of steroid hormones in COCs resulted in decreased suppression of gonadotropin and sex steroid levels. It should be borne in mind that the degree of suppression is determined not only by the dose of hormones, but also by the type of progestogen. It is generally accepted that the higher the level of gonadotropins, the higher the potential for follicular persistence, especially when using low-dose and triphasic COCs. Follicle growth can be observed before starting to take COCs, if the drug is not used from the first day of the cycle, in case of skipping pills and during the interval. Since the release of gonadotropins is suppressed, ovulation does not occur, but the follicle continues to persist. Cystic formations are transient and, as a rule, disappear within 1-2 menstrual cycles. A WHO expert group in 1991 concluded that such “follicle-like” formations are not classified as “cysts” if their size does not exceed 35 mm and they persist for less than 4 weeks.

The results of epidemiological studies have demonstrated that functional ovarian cysts occur more often than when taking combined, including triphasic, contraceptive drugs when using drugs containing only progestogens (mini-pills).

The most common true ovarian tumors are teratomas, or dermoid cysts, epithelial tumors (serous or mucinous cystadenomas), and endometrioid ovarian cysts. The results of the studies showed that the use of COCs does not affect the incidence of cystadenomas.

In some studies, the risk was lower in women who used these drugs for a long time or who had previously used them, but these differences were not always statistically significant. As for endometrioid ovarian cysts, one study (114 cases) revealed a statistically significant increase in the risk of endometrioid cysts in women who had ever used COCs, while another (311 cases) found a significant decrease in the risk of their formation against the background of COCs.

Treatment of ovarian cysts in most cases is surgical, while the ultrasonographic characteristics of the identified formation largely determine the treatment tactics, allowing in some cases to observe the patient for some time or use COCs. In 90-95% of cases, the identified thin-walled liquid formation is benign. The formation of a complex structure requires surgical treatment, since there is a high probability that it is malignant. Regardless of whether the patient receives a COC, the identification of a thin-walled liquid formation requires a differential diagnosis between a “functional” and a true ovarian cyst. .

Functional cysts, as mentioned above, are transient. If such a cyst is detected during COCs, they should not be discontinued. A functional cyst should disappear within 1-2 menstrual cycles. If such a formation is detected in a woman who does not use COCs, they can be prescribed in order to more quickly regress the “cyst”. However, the results of several randomized studies have shown that expectant management for 1-2 menstrual cycles and the use of COCs are equally effective. Thus, in contrast to high-dose first-generation COCs, against the background of modern drugs, especially mini-pills, “cysts” may appear, which are persistent follicles that spontaneously disappear and therefore do not require surgical treatment. True ovarian formations persist and “do not respond” to COCs. Even if the formation is thin-walled, liquid, but persistent, it must be removed surgically.

COCs and hyperandrogenic conditions in women

COCs containing progestins, devoid of a pronounced androgenic effect in the doses used, in many cases have demonstrated a certain positive effect on acne and seborrhea (except for severe forms). This is explained by the antigonadotropic effect (with low LH levels, androgen synthesis is significantly reduced) and the influence of the estrogen component (EE) of the drugs, which increases the level of SHBG and inactivates free testosterone.

However, even the residual androgenic activity of norsteroid progestins in many cases reduces the positive effect of EE on SHB levels. Therefore, speaking about hyperandrogenic conditions, it is important to highlight COCs containing antiandrogen progestins: cyproterone acetate (CPA), dienogest (DNG), drospirenone (DRSP), chlormadinone (CMA), the mechanism of action of which, in addition to the above pathogenetic links, includes a direct antiandrogenic effect . Due to competitive binding to androgen receptors, antiandrogen progestins prevent the negative effects of the most active androgen, dihydrotestosterone, which is formed even from a small amount of testosterone in target tissues under the influence of 5α-reductase. In addition, experimental studies have demonstrated the absence of any negative effect of antiandrogen progestins on SHB levels.

It is for these reasons that the contraceptives of first choice for women with cosmetic problems, as well as with polycystic ovary syndrome, are, first of all, COCs with progestin-antiandrogens (Fig. 1).

Diane-35 is recognized as the gold standard for the treatment of acne, seborrhea (including severe forms), hirsutism and androgenetic alopecia in women. In severe forms, it is necessary to additionally use cyproterone acetate (Androcur) in a daily dose of 10-100 mg during the first 10 days of taking Diane-35. The effectiveness of the combination of Diane-35 and Androcur has been demonstrated in clinical studies. Treatment should be carried out long-term - for at least 6–9 cycles for acne and seborrhea and at least 9–12 cycles for hirsutism. It is not recommended to interrupt treatment when the first positive results are obtained, since breaks in taking antiandrogen drugs lead to progression of symptoms and some loss of the achieved result. To obtain a lasting effect and reduce the risk of relapse, it is recommended to continue taking the drugs for a long time, at least for several cycles after achieving the desired result.

As for the treatment of hormone-dependent acne, the effectiveness of the combination of EE and CPA has been well studied and approved throughout the world. Recent studies have shown that the combination of EE 30 mcg + DRSP 3 mg (Yarina) is as effective when used in women with mild to moderate acne requiring contraception as a product containing EE 35 mcg + CPA 2 mg (Diane -35) . The positive effect of the drug is due not only to the antiandrogenic activity of DRSP, but also to its antimineratocorticoid effect, due to which patients experience a decrease in skin swelling in the second phase of the menstrual cycle, thereby helping to prevent the progression of the inflammatory reaction during the premenstrual and menstrual periods.

It is important to note that in the above comparative studies, only the drugs Diane-35 and Yarina were used; the clinical effectiveness of other CPA-containing COCs still requires study.

COCs and premenstrual disorders

In women with premenstrual disorders, including premenstrual syndrome (PMS), the use of monophasic COCs is effective, which are prescribed according to traditional provisions and temporarily eliminate cyclic ovarian activity, restoring the balance of sex hormones and, as a result, normalizing the metabolism of neurosteroids in the brain. Taking into account the need for contraception in the vast majority of women suffering from premenstrual disorders (PMS does not occur in the absence of cyclic ovarian activity), COCs should be considered as pharmacological agents of first choice for this category of patients.

In most cases, COCs are effective for psychopathological or cutaneous manifestations of PMS. But at the same time, experience shows that traditional combinations are less effective in the presence of symptoms caused by fluid retention and water-electrolyte imbalance, which significantly intensify on the eve of the menstrual period (peripheral edema, including swelling of the skin, weight gain, impaired diuresis, bloating, changes in blood pressure, constipation, etc.). Estrogens (both natural and synthetic) lead to activation of the renin-angiotensin-aldosterone system, while progestins, which are part of traditional COCs, unlike endogenous progesterone, do not have anti-aldosterone properties and have virtually no effect on symptoms caused by fluid retention and electrical imbalance. In connection with the above, COCs containing drospirenone (DRSP) deserve special attention. Among all synthetic progestins, only DRSP has a pronounced clinical antialdosterone effect.

DRSP is a 17-spirolactone derivative, like the well-known aldosterone antagonist spironolactone. DRSP is characterized by a mild diuretic effect (in terms of antialdosterone activity, 3 mg of drospirenone is equivalent to approximately 25 mg of spironolactone). Therefore, in combination with the estrogen component, DRSP only neutralizes fluid retention caused by the estrogen component and in clinical practice does not demonstrate an increase in diuresis in the absence of estrogen-dependent fluid retention or an effect on blood pressure in women with normotension and hypotension. At the same time, DRSP has more pronounced progestogenic properties and therefore, unlike spironolactone, it is classified as a progestin.

Thus, DRSP-containing COCs not only eliminate the cyclic activity of the ovaries, but also stabilize the renin-angiotensin-aldosterone system, increasing natriuresis and helping to get rid of the symptoms of fluid retention in premenstrual disorders. The antiandrogenic properties of DRSP additionally provide a positive effect on the skin and its derivatives during skin manifestations of PMS.

During PMS, the world has accumulated sufficient experience in the use of COCs in a continuous mode. The use of DRSP-containing COCs with a reduced dose of estrogen (20 mcg EE) in women with the most severe premenstrual disorders (including dysphoric) is very promising. This is the first estrogen-progestogen combination to receive official approval from US regulatory authorities for use in a 24+4 mode in this category of patients (the break in taking tablets is reduced to 4 days, and each blister contains 24 tablets).

^ COCs and endometriosis

Chronic pelvic pain and endometriosis are among the most common disorders in women of reproductive age. About 10% of his patients consult a gynecologist about chronic pelvic pain. Most common cause chronic pelvic pain is endometriosis (in 70-90%). Endometriosis affects 15-50% of women of reproductive age, 30-40% of whom experience infertility. Every second woman with endometriosis has a stable course of the disease or its regression, while the remaining 50% have a slow progression of pathological changes.

According to experts, today, if endometriosis is suspected in women with chronic pelvic pain, laparoscopic confirmation of the diagnosis is not required, in contrast to controlled studies for this pathology, in which verification of the diagnosis has a decisive role.

Various low-dose COCs have demonstrated high efficacy as first-line treatment for dysmenorrhea in women with chronic pelvic pain and endometriosis in several studies that included patients with chronic pelvic pain, and the diagnostic methods used included clinical laboratory tests, ultrasound, and laparoscopic confirmation of endometriosis According to the research protocol, it was not required.

In a randomized controlled 6-month study in laparoscopically confirmed endometriosis, the effectiveness of low-dose COCs in a cyclic regimen was found to be comparable to the effect of gonadotropin-releasing hormone agonists (GnRH-a): COCs were slightly less effective against dysmenorrhea, without differing in the degree of reduction in non-related pain. with menstruation (nonmenstrual pain), and effectiveness in dyspareunia.

American experts consider the use of low-dose COCs to be the first line of medical treatment for chronic pelvic pain and suspected endometriosis. Yes, according to clinical guidelines and treatment algorithms developed by the American Society for Reproductive Medicine (ASRM), therapy should begin with nonsteroidal anti-inflammatory drugs, COCs, or a combination thereof. The course of anti-inflammatory therapy is usually relatively short. If there is improvement, taking COCs should be continued for up to 6 months, and if there is no planning for pregnancy in the near future, for a longer period.

If first-line therapy fails, second line treatment is considered, which includes two therapeutic approaches:

• 
  Advanced medical therapy:
  • 
    Danazol
  • 
    GnRH-a
  • 
    Progestins*, causing a decidualizing effect and inducing acyclicity of the endometrium and endometrioid tissue

• 
  Surgical treatment (radical) and conservative surgical therapy (laparoscopy or laparotomy)**

*according to the criteria of evidence-based medicine (analysis of 27 studies, 4 of which were randomized), to date, medroxyprogesterone acetate (MPA) has been proven effective among progestin drugs for endometriosis, while dydrogesterone therapy (two dosages) has been found to be no more effective than placebo. The effectiveness of other progestins still requires high-quality randomized studies, despite a sufficient number of studies with the most promising progestins of the 19-norsteroid series in terms of their effect on endometrioid tissue: norethisterone acetate, levonorgestrel (for intrauterine administration to patients with genital endometriosis) and dienogest.

** There are no published results of comparative studies of the effectiveness of conservative and non-conservative therapy for chronic pelvic pain and endometriosis; The laparoscopic method is justified in the case of the presence of endometriotic formations in the ovaries or in the pelvis in order to exclude neoplasia.

European experts (ESHRE) believe that conservative surgery is an acceptable method of treating endometriosis, but incomplete relief from pain and recurrence of the process are often observed. COCs and progestins are recognized as highly effective against dysmenorrhea.

COCs and progestins, when used in appropriate dosages, cause anovulation and amenorrhea (“pseudopregnancy”), provoking significant decidualization of the eutopic and ectopic endometrium, its acyclicity and atrophy, and also contribute to a decrease in intraperitoneal inflammatory process.

Considering the above facts, COCs and progestins are recognized by European experts as “...the optimal choice for long-term treatment of endometriosis symptoms in women who do not plan to have a child in the near future.” Due to the fact that pain symptoms in endometriosis are more often associated with episodes of uterine bleeding, a continuous regimen of COCs is more justified than a cyclic regimen.

In Ukraine, the most extensive clinical experience has been accumulated with the use of progestins. Currently, with genital endometriosis, the approaches of Ukrainian specialists are practically no different from the recommendations of American and European experts.

According to the Methodological Recommendations developed in 2005 by experts from the Institute of Pediatrics, Obstetrics and Gynecology of the Academy of Medical Sciences of Ukraine in collaboration with experts from the Odessa State Medical University of the Ministry of Health of Ukraine and the Lvov National Medical University named after D. Galitsky, according to Protocol of the Ministry of Health of Ukraine No. 582, COCs as in cyclic, and in a prolonged mode are recommended as first-line therapy for genital endometriosis (Article 24).

^ 6. Long-term use of COCs: rationale, indications, advantages

IN lately a new approach to prescribing COCs has emerged. For patients who do not want monthly menstruation, who have severe dysmenorrhea, and who are suspected of having a minor form of external endometriosis, we can recommend the so-called “seasonal” regimen (continuous use of the drug for 12 weeks, a break of 1 week) (Fig. 2).

As for 7-day breaks in taking COCs when used in a cyclic mode, on the one hand, in the presence of hormonal fluctuations, the severity of some non-contraceptive benefits decreases. On the other hand, the presence of a short-term break in the supply of exogenous hormones provides changes in homeostasis that resemble those at the end of the physiological menstrual cycle and contribute to better control of the cycle from the first months of COC use.

According to some literature data, along with the occurrence of side effects (nausea, headache, mood changes), which most often occur during the first months of taking COCs (adaptation period), in women taking COCs for more than one year, the same side effects are recorded precisely during the 7-day interval of taking tablets, while during the 21-day period of taking COCs, practically no side effects are observed.

Experts in the field of hormonal contraception emphasized that after an adaptation period, women often report better overall health during the period of taking the pills than during the break period. According to the literature, the main argument in favor of prolonged use of COCs was a significant reduction in the frequency of headaches, dysmenorrhea, hypermenorrhea and premenstrual symptoms.

Rice. 2. Regimens for taking COCs.

• 
  Endometriosis
• 
  Premenstrual syndrome
• 
  Hyperpolymenorrhea
• 
  Dysfunctional uterine bleeding
• 
  Anemia
• 
  Polycystic ovary syndrome
• 
  Hemophilia
• 
  "Menstrual" migraine
• 
  Dysmenorrhea
• 
  Hyperandrogenic conditions
• 
  Hemorrhagic diathesis
• 
  Against the background of surgical treatment of cervical diseases (diathermocoagulation, laser vaporization, cryodestruction)

However, there are no epidemiological data on the effect of continuous COC dosing regimens on post-treatment fertility or the risk of cancer and cardiovascular disease.

^ 7. Combined oral contraceptives and cancer risk: new research

In August 2005 The Lancet published a report from the International Agency for Research on Cancer (IARC, International Agency for Research on Cancer), which outlines a new assessment of the carcinogenicity of sex steroids. There is still no full publication, so serious scientific processing of the IARC data remains to be done. The new data should influence scientific conclusions in five areas: breast cancer, cervical cancer, liver cancer, endometrial carcinoma, and ovarian cancer.

Breast carcinoma

In 2002, Marchbanks conducted a controlled study involving a large number of subjects (9257 women, of which 4575 patients with breast cancer, 4682 patients in the control group). This study is one of the largest controlled studies on this issue. As a result, a relative risk of breast cancer was found to be 1.0 (Cl 0.8 – 1.0) for women currently taking POCs and a risk of 0.9 (Cl 0.9 – 1.0) for women who have taken these drugs previously. This study did not examine the relationship with duration of POC use or women's ethnicity. The moment of initiation of GC administration was also not taken into account.

In women with a familial risk of breast cancer, GC use had no effect on disease risk, although the use of GC in women with a familial risk of breast cancer has been the subject of heated debate. There has been concern that the risk of developing breast cancer may increase when chemically modified steroids are administered. New research shows that taking GC does not increase the risk of breast cancer. On the contrary, there is a tendency to associate long-term use of POCs with a lower risk of disease. Some studies have provided evidence that the use of GCs had a positive effect, primarily in carriers of the BRCA - 1 gene mutation. Therefore, based on the currently known data, it is impossible to conclude that there is an increased risk of developing breast cancer during and after taking GC. In this aspect, refusal to use GCs seems unjustified for all patients, including women with a hereditary risk of breast cancer.

Cervical cancer

Due to the numerous risk factors for cervical cancer, it is difficult to clearly identify the main one. However, infection with certain types of human papillomaviruses (HPV 16-18) is considered a major risk factor for the development of squamous epithelial carcinoma of the cervix. Infection with Clamydia trachomatis further increases the risk of cancer. On the other hand, the risk increases due to smoking. A higher risk of morbidity is observed in women who use GCs, but there is no complete certainty as to whether this fact is an independent risk factor or the real reason is an increased risk of infection due to more frequent sexual intercourse. Therefore, annual preventive bacteriological and cytological examinations of all women, and not just those using GCs, are mandatory. To prevent infections, women who frequently change partners are recommended to use condoms in addition to GC.

In order to understand the mechanism of action of hormonal contraceptives, let us turn to the origins - the physiology of the female body. All changes occurring in it are cyclical, i.e. repeat after a certain time. A cycle is usually called the period of time from the first day of menstrual bleeding to the onset of the next. On average, the cycle is 28 days, but it can be shortened to 21 days or increased to 35, which is also the norm. In the middle of the menstrual cycle (approximately on the 14th day of a 28-day cycle), ovulation occurs - the release of a mature egg from the ovary, and if at this moment it “meets” a sperm, then pregnancy occurs. This entire complex process is regulated by female sex hormones - estrogen and progesterone, the ratio of which changes three times during each cycle.

Combined oral contraceptives (COCs) are pills that consist of synthetic analogues of estrogen and progesterone. COCs differ in the ratio of active ingredients in the drug and are divided into types: single-phase, two-phase and three-phase. The ratio of hormones in triphasic COCs is closest to the physiological fluctuations of estrogen and progesterone in female body. In biphasic COCs, the hormone ratio changes twice, which is somewhat different from natural processes. Most of all, single-phase contraceptives “do not correspond” to the flow of internal female hormonal processes. However, the mechanism of action of all COCs is the same and does not depend on the dosage of the components. And this does not mean that three-phase contraceptives are better. Individual tolerability and effectiveness of the drug depends on many characteristics, and there are often cases when single-phase drugs are well tolerated by the body, but three-phase drugs, on the contrary, cause negative symptoms (nausea, headache, etc.).

You can use COCs from the moment you become sexually active until menopause. For menopausal women after menopause, the use of oral contraceptives is indicated as hormone replacement therapy to prevent changes in bone and cartilage tissue associated with calcium leaching.

Mechanism of action of COCs

The contraceptive effect when using COCs is achieved in several ways. Firstly, combined contraceptives suppress ovulation and, therefore, make it impossible for the egg to mature and exit into the fallopian tube. Secondly, they change the composition of the cervical secretion, which normally should promote the movement of sperm into the uterus. Under the influence of COCs, the secretion becomes more viscous, thick, almost impenetrable, which reduces not only the motility, but also the viability of sperm. And finally, thirdly, combined contraceptives change the structure of the uterine mucosa (it becomes very thin) so that even in the case of fertilization, the attachment of an egg with an embryo to it is simply impossible. This “triple effect” of combined oral contraceptives guarantees their high effectiveness in preventing unwanted pregnancy - 0.1 pregnancies per 100 women.

Also, the effect of COCs on the uterine cavity is the reason that when they are taken, the amount of “menstrual” blood decreases. Taking combined oral contraceptives prevents the development of many gynecological diseases caused by hormonal disorders, such as uterine fibroids (benign tumors).

Types of COCs

Single-phase (monophasic) drugs contain the same amount of synthetic analogues of estrogen and progesterone in a constant ratio in all tablets of one package. For example, one MERSILON tablet contains 20 mcg of ethinyl estradiol and 150 mcg of desogestrel. Monophasic drugs also include: MARVELON, NOVINET, REGULON, OVIDON, RIGEVIDON, DIANE-35, NON-OVOLON, LOGEST, FEMODEN, SILEST, MINIZISTON. Monophasic drugs are recommended as the optimal means of contraception for nulliparous young women under 23–25 years of age. MERSILON has the ability to restore the regularity of the menstrual cycle. Recently, new drugs have appeared containing synthetic analogs of estrogen and progesterone of the third generation: LOGEST contains 20 mcg of ethinyl estradiol and 75 mcg of gestodene. FEMODEN consists of 30 mcg ethinyl estradiol and 75 mcg gestodene. The difference between the drugs lies in the dose of hormones contained in them. The lower the dose of ethinyl estradiol in COCs, the fewer side effects the drug has, such as increased blood clotting, which threatens the formation of blood clots and blockage of blood vessels, and weight gain (see below). But the effect of low-dose COCs on the mucous membrane of the uterus - the endometrium is insufficient, which leads to intermenstrual bleeding. Any oral contraceptive is selected individually, taking into account the state of health, concomitant pathologies, the woman’s preferences, her financial possibilities(low-dose drugs are more expensive). In this group, special mention should be made of the drug SILEST, which contains norgestimate (closer to the natural progesterone produced in a woman’s body). This is the only remedy recommended by the World Health Organization for young girls starting to take COCs for the first time. The group of single-phase drugs includes the oral contraceptive DIANE-35, which has a high degree of antiandrogenic activity. It is recommended to be taken by women who have increased levels of androgens (male sex hormones). DIANE-35 has a therapeutic effect on excess male pattern body hair growth, seborrhea and acne.

The group of biphasic drugs is not so numerous. It is represented by the drug ANTEOVIN. It contains ethinyl estradiol and levonorgestrel, and their ratio varies: the first 11 tablets of one package contain 50 mcg ethinyl estradiol and 50 mcg levonorgestrel, and the other 10 tablets contain 50 mcg ethinyl estradiol and 125 mcg levonorgestrel. The positive effect of biphasic COCs is observed in the treatment of acne and seborrhea, which are often a consequence of the increased content of androgens in a woman’s body. Biphasic COCs can be called an intermediate link between single-phase and three-phase drugs.

Three-phase drugs imitate the real menstrual cycle, because... the ratio of the hormones included in the drug is closest to the physiological fluctuations of female sex hormones during the menstrual cycle. Representatives of this group are: TRIZISTON, TRIKVILAR, TRINOVUM and TRI-REGOL. The ratio of components in these drugs varies. For example, in TRI-REGOL, the first six tablets of one package contain 30 mcg of ethinyl estradiol and 50 mcg of levonorgestrel, the next five tablets contain 40 mcg of ethinyl estradiol and 75 mcg of levonorgestrel, and the last 10 tablets contain 30 mcg of ethinyl estradiol and 125 mcg of levonorgestrel. Three-phase drugs are more suitable for therapeutic purposes, for example, for initial ovarian dysfunction.

Features of taking COCs

Modern oral contraceptives are available in the form of strips containing 21 or 28 tablets. For convenience, manufacturers usually put arrows on the plate corresponding to the order of taking the tablets (this is especially important when using two- or three-phase drugs) or the days of the week are indicated on the packaging (for monophasic drugs). Combined oral contraceptives begin to be taken from the first day of the cycle, i.e. on the day of the start of menstruation. In the future, they must be taken daily, preferably at the same time (it is very convenient to set an alarm clock while using COCs mobile phone). If you follow the schedule, hormonal substances are easier and better absorbed by the body. If the doctor has prescribed you a drug whose tablet contains 21 tablets, take them from the first day of the cycle, one tablet per day, after which they take a seven-day break, and then start a new tablet. During this week, the contraceptive effect of hormones remains the same, and additional methods of protection are not required. In addition, a menstrual-like reaction occurs during this period. If the oral contraceptive contains 28 tablets, they are taken without any breaks (a menstrual-like reaction will occur between 21 and 28 days).

After a year of continuous use of COCs, a three-month break is required to restore ovarian function. During this period, other methods of birth control are preferred.

A feature of COCs is their incompatibility with certain medications. These include anticonvulsants and some antibiotics, as well as a number of medications aimed at treating lung diseases. Studies have shown that the combination of these drugs with COCs leads to a decrease in the contraceptive properties of the latter and to the appearance of malaise. In any case, if you are prescribed any medicinal product, you must notify your doctor about taking COCs. In most cases, you will need additional contraception, such as a condom, or you will need to change to one that contains more hormones.

For the right choice hormonal contraceptives require consultation with a gynecologist who, in accordance with diagnostic data, will prescribe the drug that is most suitable for you.

When choosing a hormonal contraceptive, the following studies are necessary:

1. Gynecological examination, taking smears from the vagina and cervix to determine the microbial flora and exclude cancer (based on the structure of the cells in the smear);

2. Ultrasound examination (ultrasound) of the pelvic organs 2 times per cycle - after menstruation and before the next menstruation. The growth and maturation of the mucous membrane of the uterine cavity, the presence of ovulation, etc. are assessed. Excluded possible diseases pelvic organs.

3. Consultation with a mammologist (a doctor who treats diseases of the mammary glands), ultrasound of the mammary glands.

4. Determination of the level of hormones in the blood - as prescribed by the attending physician, if necessary.

A second consultation with a gynecologist is recommended approximately three months after starting to take the pills. This is necessary in order to monitor the effect of hormonal substances, as well as to determine the general state of health. In the future, you need to visit the gynecologist as standard, once every six months, and undergo a routine examination.

Advantages of combined oral contraceptives:

high contraceptive reliability (0.1 pregnancy per 100 women);

quick effect;

good tolerance;

accessibility and ease of use;

lack of connection with sexual intercourse;

adequate control of the menstrual cycle;

reversibility (full restoration of the ability to become pregnant within 1–12 months after stopping use, depending on the characteristics of the body). It has been proven that 30% of healthy married couples become pregnant in the first three months life together, in another 60% - over the next seven, in the remaining 10% - eleven to twelve months after the start of sexual activity. During one menstrual cycle, the chance of pregnancy is only 20%.

safe for most healthy women;

medicinal effects:

regulation of the menstrual cycle;

elimination or reduction of dysmenorrhea (pain during menstruation);

reduction of menstrual blood loss and, as a result, treatment and prevention of iron deficiency anemia (decreased hemoglobin in the blood);

elimination of ovulatory pain (may occur during egg maturation);

reducing the activity of inflammatory diseases of the pelvic organs;

therapeutic effect with increased levels of androgens (male sex hormones) in women;

preventive effects:

reducing the risk of developing cysts (hollow formations filled with liquid contents) of the ovaries;

reducing the risk of developing endometrial (uterine lining) and ovarian cancer, as well as colon cancer;

reducing the risk of benign breast tumors;

reducing the risk of developing iron deficiency anemia;

removing the fear of unwanted pregnancy;

the possibility of “delaying” the next menstrual-like reaction, for example, during exams, competitions, or rest. To do this, you need to start the next package of COCs immediately after finishing the previous one, without a break. Only monophasic COCs have these properties.

emergency contraception.

Disadvantages of COCs:

possible decrease in contraceptive effect when interacting with certain drugs;

the need to take pills constantly, without skipping, preferably at the same time; Each missed pill increases the risk of pregnancy;

side effects – amenorrhea (absence of menstrual-like bleeding at the end of the cycle); intermenstrual bleeding and spotting; mood changes, decreased sex drive; headache, increased blood pressure; soreness of the mammary glands; weight gain; nausea, vomiting. Most often, side effects occur in the first months of taking the pills and may be associated with the body’s adaptation to synthetic hormones. Later they disappear.

lack of protection against sexually transmitted diseases and AIDS;

Contraindications to the use of COCs

Absolute contraindications for the use of COCs (not used under any conditions) are:

pregnancy (or even suspicion of it; before you start taking contraceptives, you must undergo a gynecological examination); postpartum period (about six months or until the end of breastfeeding; after cessation of lactation, you should consult a specialist regarding the use of COCs);

liver diseases, liver tumors;

cardiovascular diseases;

benign pituitary tumors;

breast cancer;

diabetes mellitus (only progressive forms);

some mental disorders (for example, epilepsy).

Relative contraindications for taking COCs (their use is not recommended until the cause of the contraindication is eliminated or until an appropriate examination):

hypertension (high blood pressure); varicose veins; obesity; active smoking (more than 20 cigarettes per day) after the age of 35 years; susceptibility to neuroses and/or depression;

before planned surgical interventions, stop taking COCs 1 month in advance (in order to prevent postoperative thrombophlebitis);

when taking PHENYTHIONINE, PHENOBARBITAL, antibiotics – AMPICILLIN, drugs from the tetracycline group, GRISEOFULVIN.

Who can use COC:

women of reproductive age;

women who want highly effective protection against pregnancy;

nursing mothers (6 months or more after giving birth);

postpartum women who are not breastfeeding;

women who have not given birth;

teenagers;

women after abortion;

women suffering from menstrual irregularities;

women suffering from anemia;

women experiencing severe pain during menstruation;

women who have an excess amount of male sex hormones;

women with ectopic pregnancy in the past;

women whose relatives suffer from ovarian cysts or ovarian cancer or have previously had similar diseases.

When it is necessary to urgently consult a gynecologist while taking hormonal contraceptives: severe pain in the abdominal area; general weakness for a long time (more than a month); severe chest pain throughout the menstrual cycle; visual or speech disturbances; severe pain in the legs. All these symptoms can indicate both individual intolerance to the drug and the presence of some disease, not necessarily gynecological, which requires serious treatment.

If you forget to take your pill...

We have already said that for effective contraception it is necessary to take COCs daily. Missing a pill increases the risk of pregnancy, but in any case there is no need to panic. If you forget to take one tablet, take it as soon as you remember, regardless of the time, and take the next one as usual. In this case, the risk is minimal, but if this happened during expected ovulation, it is better to use an additional means of contraception (condom, etc.) until the next menstruation. In general, the peculiarities of the action of modern COCs are such that skipping a pill for less than 12 hours does not in any way affect the contraceptive effect of the drug. However, if you are in doubt, it is better to consult with the gynecologist who prescribed the drug.

If you forget to take two pills, it is highly advisable to use an additional method of protection. To restore the effect of the COC, you need to take two forgotten tablets immediately, and two more the next day, for example, in the morning and in the evening. In this case, COCs are used in the mode emergency contraception regardless of the days of the week on the package. In this case, bloody discharge from the vagina may occur, associated with a high concentration of hormones, but this symptom lasts no more than two to three days. If this phenomenon continues for a longer time, consult a gynecologist.

If three or more pills have been missed, you should start using an additional contraceptive immediately, regardless of what phase of the menstrual cycle you are in, and interrupt further pill taking. You can resume using this drug only with the onset of your next menstruation, i.e. you'll have to start all over again. If you are not sure that you can regularly take COCs, it is better to choose another method of contraception, since periodic, intermittent use of hormonal drugs may not be the best in the best possible way affect your well-being and cause menstrual dysfunction.

Elena Popenko, Gynecologist-endocrinologist, Ph.D. honey. Sciences, Tyumen