Combined Contraceptive

Combined Contraceptive

Combined contraceptives are hormonal contraceptive methods that contain both estrogen (usually ethinyl estradiol) and a progestin. They are available in various forms, including oral pills, transdermal patches, and vaginal rings.

Types of combined contraceptives

1. Combined Oral Contraceptive Pills (COCPs)

COCP's contain estrogen in the form of ethinyl estradiol and one progestin. These are to be taken continuously daily at the same time starting from day 2-3 of a period. These are freely available as part of the national family planning mission. eg- Mala-D, Femilon, Novelon

1. Transdermal Patch

Patches ethinyl estradiol and progestin. These patches are to be applied to the shoulder / upper arm or inner thigh. The patches are to be started on day 2-3 of cycle and replaced weekly. Once 3 patches are completed, a drug free period is observed during which period occurs. These patches are not readily available in India.

1. Vaginal Ring

A flexible vaginal ring made of silicone containing ethinyl estradiol and progestin. The ring is inserted vaginally once every month after periods and remains in place for 3 weeks. Once removed, period occurs and a new ring is reinserted after 1 week of ring free period. e.g. Nuva ring.

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HOW DOES IT WORK

Combined contraceptives prevent pregnancy through multiple mechanisms:

Inhibition of ovulation – They suppress the mid-cycle LH (luteinizing hormone) surge, preventing follicular maturation and ovulation. Thickening of cervical mucus – High amount of progesterone thickens the cervical mucus making it difficult for sperm to penetrate. Endometrial alterations – Hormonal contraceptive makes the endometrium thin and unreceptive. This reduces the likelihood of implantation.

Indication

Contraception- most common method used by women in reproductive age group (mainly women <35 yrs ) with no medical contraindication.

Menstrual regulation- the combination of estrogen and progesterone regulate hormonal imbalances and help with menstrual regularity.

Management of PCOS- PCOS is characterized by hormonal imbalance which causes anovulation. Correction of hormonal imbalance which lead to improvement of PCOS symptoms including hirsutism, anovulation and period regularity.

Treatment of acne and hirsutism

Dysmenorrhea and endometriosis- Both these conditions are due to excessive estrogen or increased sensitivity to estrogen. High estrogen levels leads to increased prostaglandin release which worsens dysmenorrhea.

Premenstrual syndrome (PMS/PMDD)-Increased hormonal fluctuation which causes PMS /PMDD is made better by constant levels of estrogen ad progesterone provided by COC.

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Selection Criteria

Age: Generally suited for women <35 years who are nonsmokers.

Medical history: Avoid in history of thromboembolism, migraine with aura, uncontrolled hypertension, liver disease.

Lifestyle: Consider compliance and ease of use.

Preferences: Desire for cycle regulation or acne benefits may guide choice.

WHO Medical Eligibility Criteria (WHO MEC) is used to guide safe use.

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Advantages

1. Highly effective with consistent use- Simple and easy to use.

2. Easily reversible-fertility return within 1-2 months of stopping contraceptive. This is highly useful for couples /women planning for pregnancy within a shot duration.

3. Regulates menstrual cycles.

4. Reduces menstrual pain and bleeding.

5. Lowers risk of endometrial and ovarian cancer.

6. Improves acne and symptoms of PCOS as it helps to regulate the ovarian hormone production and thus reduces the testosterone levels.

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Disadvantages

1. Daily compliance needed (for COCPs)- As it has to be take daily and preferably at the same day every day, it is easy to forget /miss a dose which brings down the efficacy.

2. As hormones are administered, these can cause nausea, breast tenderness, headache which are aa side effects of excessive estrogen and progesterone.

3. Risk of thromboembolism (especially in smokers >35 years) due to the excessive estrogen which increases the formation blood clots, which in turn can cause a stroke, DVT (deep vein thrombosis), heart attack.

4. Combined contraceptives do not offer protection against STIs.

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Efficacy:

Efficacy of a contraceptive depends on consistent and regular use of the same

Perfect use: 99.7% effective

Typical use: 91% effective (due to missed pills)

Cost:

Combined hormonal contraceptives are highly affordable and easily available

Mala -D (Govt supply) -Free/nominal and are available at all government facilities

Femilon - Rs 130–180

Novelon - Rs 200–250

Ovral-G -Rs 60–100

Nuva ring - 700 Rs per ring

Evra patches (rarely available in India)- 6800 Rs for a box of 9 patches (have to be imported from Europe / UK)

References

1. WHO Medical Eligibility Criteria for Contraceptive Use, 5th Edition.

1. Indian Ministry of Health and Family Welfare Guidelines on Family Planning.

1. Curtis et al., Contraceptive Technology (21st Ed.)