2.

Hormonal contraceptive methods

Definition
Hormonal contraceptives consist of synthetic
compounds made to resemble actual hormones
within a woman’s body(oestrogen, progesterone)

Types of hormonal contraceptives

1. Combine oral contraceptives(COCs)
2. Progesterone only pills(pops)
3. Emergency hormonal contraceptives
4. Injectables
5. implants
 1. COCs oral contraceptives
Definition
The combined oral contraceptives are made of
synthetic oestrogen and progesterone which are
similar to the natural hormones produced in a
woman's body

Types of COCs
 The pill comes in a packet of 21 or 28 pills. In the 28
pill packet, only the first 21 pills are active i.e. they
contains hormones.

 The remaining seven pills are not active and usually

contains iron
 Low dose pill
Types
a. Monophasic
 Each active pills contains the same amount of oestrogen
and progesterone e.g. microgynon, Nordette,
Neogynon, Eugynon( have high levels of oestrogen

b. Triphasic
 The active pill contains three different dose
combination of oestrogen and progesterone out of a
cycle of 21 active pill. 6 might contain one combination,
5 pills contains another combination, while10 pills
contain other combination e.g. Logynon, Trinordial
 ct

NB.
 Low oestrogen content pill are preferred for
teenagers and women over 35years and those
with acne

c. Biphasic
 The active pills in the packet contains two
different dose combination of oestrogen and
progesterone e.g.in a cycle of active pills, 10
may contain one combination while 11
contain another e.g. Biphasil
 Mechanism of action
 Slows done the motility of the fallopian tubes
delaying implantation

 Delay or inhibit ovulation as the follicles

stimulating hormone(FSH) production is
suppressed, which inhibits maturation of ovarian
follicles

 Mucus is too thick to be penetrated by the sperms

 Endometrium is not well prepared for fertilized

ovum due to low oestrogen levels
 Indication or who can use COCs
 Sexually active women of reproductive age

 Women of any parity, nulliparous included breast

feeding mothers after six months postnatal
whose LAM criteria applies

 Women who can follow daily routine of pill taking

 Women with anemia

 Women with severe dysmenorrhoea

 Contradiction. Those can not use COCs check (MEC)

 Breastfeeding mothers before six months post-

partum

 Women who are pregnant or suspected to be

pregnant

 Women with history of blood clothing disorders

 Women with history of heart disease

 Women with active liver disease

 ..ct..
 Women with hypertension, BP of 160/100 or
over

 Women with diabetes mellitus complicated by

vascular diseases

 Women over 35years and they smoke

 Women with sickle cell

 Instructions for COCs to the Client
 Pills should be taken at about the same time
each day preferable at night after meals

 If one pill is missed, it should be taken as soon

as it is remembered even if it means taking two
pills next day

 If a client has missed two or more pills in any

7day period. She should take the pill at once and
continue as usual. However she should use also
condoms, spermicides or avoid sex for 7 days.
 ..ct..
 If on a 21 day packet pill, the client should rest
for 7 days on completion of a packet. On the
8th day, start a new packet. If on 28th day
packet, pill should be taken continuously

 The client should come to the clinic for a

follow up , annual checkup and for pap smear
 Common side effects of COCs

 Irregular bleeding
 Missed periods or no monthly periods
 Ordinary headache
 Nausea or dizziness
 Breast tenderness
 Weight changes
 Mood change or changes in sex drive
 Acne
NB
students to write short notes on management
of the above side effects
 Danger signs of COCs
 Health provider should ensure the clients is
aware of complications associated with COCs.

 If the client has the following signs should stop

the method and use backup, report immediately
to the clinic:-

I. A- Abdominal pains
II. C- Chest pain or shortness of breath
III. H- Headache, frontal in nature
IV. E- Eye disturbance such us blurring or flashes
V. S- Severe calf muscle pain
 Advantages of COCs
Contraceptive benefits
 COCs are highly effective and are effective
immediately when started within the first five
days of the menstrual periods
 COCs are safe for the majority women
 COCs are easy to use
 COCs can be provided by untrained non-clinical
service provider
 Pelvic exam is not required to initiate use of
COCs
Non-contraceptives health benefits
 Reduction of menstrual flow (lighter, shorter
periods)
 Decrease in dysmenorrhoea (painful periods)
 Reduction of symptoms of endometriosis
 Protection against ovarian and endometrial
cancer
 Possible protection from symptomatic pelvic
inflammatory diseases
 Treatment for acne
 Characteristic of COCs
Monophasic pill
Eugynon
oestrogen - Ethinyl-estradiol 0.05mg
Progesterone- Norgestral 0.5mg
Neogynon
Oestrogen Ethinyl-estradiol 0.05mg
progesterone levonorgestral 0.25mg
Microgynon
Oestrogen Ethinyl-estradiol 0.03mg
progesterone levonorgestral 0.15mg
Nordette
Oestrogen Ethinyl-estradiol 0.03mg
progesterone levonorgestral 0.15mg
 ct
Triphasic
Logynon
6 brown Ethinyl-estradiol 0.05mg levonorgestral 0.5mg
5 white Ethinyl-estradiol 0.04mg levonorgestral 0.75mg
10 yellow Ethinyl-estradiol 0,03mg levonorgestral 0.125
Trinordial
6 brown Ethinyl-estradiol 0,03mg levonorgestral 0.5mg
5 white Ethinyl-estradiol0.04mg levonorgestral 0.75mg
10 yellow Ethinyl-estradiol 0.03mg levonorgestral 0.125
 Progestin only pills(POPs)
 Pops are pills that contains low doses of
synthetic progestin
Mechanism of action
 The cervical mucus is thickened, which impairs
penetration by spermatozoa
 Inhibits ovulation(suppression of ovulation)
 Regresses endometrium(thinning of the
endometrial lining making implantation
unlikely
 Types of POPs

1. Microlutte
2. Levonorgestral
3. Microval
4. Ovrette
Contraceptive benefits of POPs
• Highly effective if correctly used
• Immediate return of fertility on discontinuation
• Pelvic examination is not required to initiate use
Non-contraceptive benefits
• Does not affect breast-feeding
• Lighter, shorter periods
• Decrease in breast tenderness
 ct
• Does not increase blood clotting
• Decreases dysmenorrhoea
• Protect against endometrial cancer
• Protects against benign breast disease
Those who can not use POPs
• Breast mothers less then 4wks post-partum
• Women who are pregnant or suspected of being
pregnant
• Women with abnormal unexplained vaginal bleeding
• Women with active liver problems and tumors
 ct
• On concurrent drugs e.g. anti-tuberculosis, that
is Rifampicin, anti-fungal, anti-epileptic
• Women with recurrent DVT
When to initiate use of POPs
• If the woman is breastfeeding and has not
resumed her menses any time between 6wks
and 6months after child birth
• After child birth and non breastfeeding, any time
within the first 3wks
• After miscarriage within the first 7days method
can be initiated without needs for backup
 ct
• Having menstrual cycle. Any time if reasonably sure that
she is not pregnant. If initiated within 5 days after
menstrual cycle, no backup method needed
Clients instruction
• POPs are usually started on the first day of menses
• Take pills daily at the same time until packet is finished
(35 days)
• After you finish the packet of mini pills, state the next
packet the next day. NEVER MISS A PILL, AND NEVER
REST in between the packet
• Take pills every day without stopping
• If you forget a pill, take it as soon as you remember and
take you next pill at the regular time
 ct
• If forget to take two pills in a packet, take one pill
twice a day for 2 days, then one pill daily. But use a
backup method such as condoms and foaming tablets
• If you do not have a menstrual period within 45days
of your last periods, you should go to the clinic for
pregnancy test
• Some women get spotting, continue taking the pills
during the spotting and bleeding periods according to
your routine
• Report to the clinic immediately if any of the warning
signs are noted
 Common side effects of POPs
• Irregular spotting or bleeding, frequent or infrequent bleeding
• Prolonged bleeding, amenorrhea. Bleeding changes are
common but not harmful
• Headache , dizziness, nausea
• Breast tenderness
• Mood changes

Eligibility for using POPs

• Women of any parity and nulliparous women
• Women immediately postpartum, if they are not
breastfeeding
• Breastfeeding mothers from four weeks postpartum
 Ct
• Women of any age who are cigarette smokers
• Women who cannot use COCs as a results of oestrogen
related contra-indications
• Post abortion clients is initiated within five days after
abortion
Conditions that require extra care when taking POPS
• History of ectopic pregnancy
• Diagnosis of systemic lupus erythematosus with or
without severe thrombocytopenia
• Migraine without aura at any age
• History of DVT and pulmonary, embolism
 ct
• Gall bladder disease, asymptomatic, medical
treated or after cholecytectomy
• At risk of cardiovascular disease history of
ischaemic heart disease
• Women with irregular, heavy or un exaplained
vaginal bleeding
• Women with diabetes and vascular
complications
• Un-complicated breast lumps
 Advantages of POPS

• They are effective

• They are safe
• women return to fertility immediately upon
discontinuation
• A pelvic exam is not required to imitate
• They can be given to a woman at any time to
start later
• Taking POPs does not affect milk productions
or breast feeding
• Taking POPs does not increase blood clotting
 Disadvantages of POPs
• The provide a slightly lower level of
contraceptives protection than COCs
• They require strict daily pill-taking, preferably at
the same time each day
• They do not protect against STIs Hepatitis and
HIV. So at risk individual should use a barrier
method to ensure protection against STIs and HIV
• They may lower effectiveness when certain drugs
are taken concurrently e.g. certain anti-
tuberculosis, anti-retroviral and anti-epileptic
drugs
 When POPs can be initiated
• If a woman is breastfeeding and has not resumed her
menses
• After childbirth and she is not breastfeeding, initiate
within the first four weeks(no back method is required)
or any other time if she is sure she is not pregnant
• After miscarriage or abortion, initiate within the first 5
days. POPs can be initiate without need of backup
protection
• If client is having menstrual cycle, initiate any time if it
is reasonably certain that she is not pregnant. If the
method is initiate within the first days of her
menstruation , client does not need a backup method
 Emergency hormonal contractive pill (ECPs)
 Emergency hormonal contraceptive pill refer
to the use of certain contraceptive methods
by woman to prevent pregnancy after
unprotected sexual intercourse.

 Hormonal ECPs must be taken within

120hours of intercourse, however, the sooner
they are taken, the more effective they are
 ..ct..
• ECPs provide a second chance for preventing
pregnancy after unprotected sex, either
accidental, coerced sex or rape

• It should be emphasized that EC should not be

used on a regular basis because it is less effective
then other methods

• ECPs seem to prevent between 75-95% of

pregnancies that would otherwise have occurred
 ct
How ECPs prevent pregnancy
 Preventing or delaying ovulation

 Inhibiting or slowing down transportation of the

egg and sperm through the fallopian tubes, which
prevents fertilization and implantation

NB
 ECPs do not cause abortion because they work
before implantation. Any woman who is
pregnant should not take ECPs thinking that the
pills will cause abortion
 ..ct..
The success of ECPS depend on knowledge,
and awareness of its availability and
efficacy prior to an unprotected,
unplanned act.
Types of ECPs
Combined oral contraceptives
 Contain the hormones oestrogen and
progestin and they prevent about 75% of
expected pregnancies. Two standard
dosage options:
 ..ct..
 50mcg oestrogen pill e.g. Eugynon. Two
tablets to be taken as soon as unprotected
intercourse , but within 120hrs. Repeat the
same dose in 12hrs. Total of four pills are
required

 30mcg oestrogen pills e.g. microgynon. Four

tablets to be taken as soon as possible after
unprotected intercourse, but before 120hrs.
Repeat the same dose in 12hrs. Total of eight
pills is required
 ct
Progesterone only pill
 Contains the same levonorgestral in high dose.
They are mare effective than COCs preventing up
to 95 % of expected pregnancy
e.g. Postinor 2, Pregnon, Smart lady and Truston2

Standard dosage
 One 750mcg levonorgestral pill to be taken as
soon as possible after unprotected intercourse,
but with 120hrs. Repeat the same dose in 12hrs.
A total of 2pills are required
 ..ct..
 Two 750mcg levonorgestral to be taken as
soon as possible after unprotected sex, but
within 120 hours

 Regular POPs may be used:20 tablets taken

within 120 hours after unprotected
intercourse. Repeat the same dose in 12
hours. A total of 40 pill are required
 Advantages and benefits of ECPs
• Provide protection against pregnancy for about 75-
95% of those at risk

• It is effective, and easy to use

• No medical examination or pregnancy test are

necessary or required

• It can be used at any time during the menstrual cycle

• ECPs are available in government, private, and NGOs

health facilities
Disadvantages or limitation of ECPs
 ECPs are only effective if used within 120
hours of unprotected intercourse
 They are not to be used as regular method
 ECPs do not protect against STIs HIV
 They can cause nausea(more common for the
COC regimen
Eligibility for using EC
 Sex took place without contraception and the
woman wants to avoid pregnancy
 ..ct..
 A woman has run out of oral contraceptives
has missed two or more POPOs or is more
then four weeks late for DMPA injectables,
and has had unprotected intercourse

 A woman has had coerced sexual intercourse

 A condom has broken

 An IUCD has come out of place

 Common side effects
• Nausea and vomiting which is very common in
COCs regimen

• Slight irregular bleeding

• Change in timing of next monthly bleeding

Assignment :
Students to manage common side effects of ECPs
 Medical eligibility criteria(MEC) categories
for COCs
• Women who should not use COCs includes
MEC categories 3 and 4.

• This means circumstances that would

absolutely prohibit a woman from using
COCs(category 4).
• In category 3, a women may use if no other
method is available under strict clinical
judgment and follow up.
 ..ct..

Conditions MEC category

• Breast feeding before six weeks postpartum
(4)

• Breastfeed before six months postpartum or

non-breastfeeding mothers before 3weeks
postpartum (3)

• Women with recurrent ischaemic, valvular

heart diseased (4)
 ….MEC….
 Blood pressure 140/90 to 159/99mmHg (3)

 Severe hypertension 160/100mmHg higher (4)

 Diabetes mellitus that is complicated or longer then 20years in

duration (4)

 Women who smoke more than 15 cigarettes a day and over

35years or older (4)

 History of current breast cancer (4)

 Symptoms of gall bladder disease or under medical treatment

(3)
 ..MEC..

 Women with current or previous history of DVT,

embolism, on anticoagulant therapy (4)

 Women with acute viral hepatitis (3 or 4)

 Women with liver cirrhosis ( 4)

 Women with ARV therapy who are receiving ritonavir

or ritonavir- boasted protease inhibitors
( 3)

 Women on TB therapy who are on Rifampicin (3)

 Injectables contraceptives
Description
• Injectable contraceptives contains one or two
contraceptive hormones and provide protection
from pregnancy for one, two or three months
(depending on the type) following an injection

• About 61% of Kenyan women who use modern

contraceptive method choose Injectable
 ..ct..
 Widely used injectables methods contain only progestin
and less common methods are those that contain both
progestin and oestrogen

Progestin only injectables (POICs)

Types of injectables
1. Depo provera (Depot medroxyprogesterone acetate)
DMPA, three months interval 150mg

2. Noristerat (Norethisterone enanthate)NET-EN interval of

two month 200mg

These injections are given by an intramuscular

 ..ct..
Mechanism of action
1. Progestin only injectables prevent pregnancy
by suppressing ovulation

2. Thickening cervical mucus preventing the

sperms to penetrate through

3. Thinning the endometrium which could

prevent implantation
Combined injectables contraceptives (CICs)
 The method consist of a natural oestrogen
plus progesterone. They prevent pregnancy
mainly through the inhibition of ovulation

Types of CICs

 Cyclofem and cyclo- provera which contains

medroxyprogesterone actate and estradiol
valerate
 Advantages of injectables
Contraceptives benefits:-

 They are highly effectives and safe

 A pelvic exam is not required to initiate use

 They contain no oestrogen, so they do not have the

cardiac and blood-clotting effects

 They are long acting method

 Provide confidentiality
 Non-contraceptives health benefits
 Amenorrhea. Prevent iron deficiency anaemia

 Decrease in sickle cell crises

 Reduction of symptoms of endometriosis

 Protection against endometrial cancer

 Protection against uterine fibroids

 Possible prevention of ectopic pregnancy

 Mechanism of action
 Suppression of ovulation
 Thinning of endometrium which interferes with
implantation
 Thickening of cervical mucus
Clients instruction
 Clients should return to clinic every three
months for an injection.
 If using Noristerat, return to clinic every two
months for an injection. After 6months(3
injection) on Noristerat, you will get injection
every 3months
 ..ct..
Client will notice the following changes:-

I. Less regular periods

II. Spotting between periods

III. Amenorrhoea

IV. Breast tenderness or discomfort

 Common side effects
1. Spotting or light bleeding between monthly
periods.

 Common during use of injectables the first 6-

8months.

 If continues bleeding plus spotting, assess for

pregnancy or incomplete abortion, exclude
gynaecological problems
 ..ct..
2. Heavy or prolonged bleeding lasting more
than eight days or twice as long as her usual
menstrual periods.
 Explain that it is common for women using
injectables.

 Discontinue the injectables if bleeding

continues to prevent anaemia, provides
haematinics and advice on diet, also you can
give a pill with oestrogen to regulate her
menses1-3 cycle
 ct

 Give ibuprofen and mefenamic acid

3. Amenorrhoea.
 By the end of the first year on Injectable, amenorrhea
develops in the majority of clients counsel and reassure
the client

 If client is bothered by lack of menses, discontinue the

Injectable
4. Headache or dizziness.
 If mild, treat with analgesic and reassure.

 Check the blood pressure. If it is normal and headache

persist, discontinue Injectable, refer for evaluation, help
client choose another method
 Implants

Description
They are small rods that are inserted under the skin of a
woman upper arm to release the hormone progestin
slowly and prevent pregnancy.
They do not contain oestrogen, therefore they are free
from side effects associated with that hormone

Mechanism of action
Make cervical mucus too thick for sperms to pass through

Suppresses ovulation

Thinning the endometrium thus inhibiting implantation

 .. Ct..
Types
1. Jadelle 2rods levonorgestral 2x75mgs for 5years

2. Implanon 11rods etonogestral 68mg for 3years

3. Implanon NXT I rod etonogestral 68mg 4years

4. Sino-implant 2rods levonorgestral 2x75mg for
4yrs

5. Norplant 6 plastic capsules 36mgsx6 for

5yrs(levanogestral)
 Benefits of implant
• No delay in return of fertility after removal

• Highly effective

• Effective within 24hours after insertion pelvic examination not

needed

Non-contraceptives
• Reduce menstrual flow

• Protects against ectopic pregnancy

• Do not affects breast feeding

• Protects against iron deficiency anaemia

 Implants ct
Limitation
• Must only be inserted and removed by trained providers

• Involves minor surgical procedure

• Removal services are done by trained person only

Instruction to women
• Keep inserted area dry for four to five days

• Remove the gauze bandage after one or two days but

leave the adhesive plaster in place for additional five
days
 ct
• Return to the clinic if the rods come out or if
soreness develops after the removal of the
adhesive plaster

• Return to the clinic if she experience pain,

heat, pus or redness at the insertion site, or if
she seas a rod come out or swelling and pain
develops

• Rest the arm for at least 3days

 Warning signs in implants
• D—Delayed menses
• I---Infection on the site
• S—Severe lower abdominal pains
• C –Capsule expelled
• U –Unexplained abnormal vaginal bleeding
• S—Severe headache
• S –Severe arm pain
 5. Intra-uterine contraceptives devices(IUCD)
Definition
• The IUCD is a flexible device that is inserted into
the uterine cavity by a trained services provider.
• It is a safe effective, long acting contraceptive
method
Types of IUCD
Two categories of IUCD:-
• Copper based
• Hormone releasing device(levonogestral for 5yrs)
 ct
Copper based device
1. Copper T 380A for 12years
2. Multiload 375 for 5years
3. Nova T 200-5years
4. Gynaaefix for 8years
5. Lippes loop
 ..ct..
2. Hormone releasing device( levonorgestral for 5yrs)
1. Mirena (LNG-20IUS)
2. Lingus (LNG-IUS)
• They are less widely used and they releases
hormone
• They are device made of plastic and they work by
releasing a progesterone (levonorgestral)
• They suppresses ovulation
• Thickening cervical mucus
• Making the endometrium thin
 Mechanism of action
• S-Sperm immobilization (prevent movement)

• O- Ova transportation acceleration

• F-Fertilization interference

• I –Implantation prevention
Who should not use IUCD
• Post partum women after 48hrs and before 4wks
• Women with puerperal sepsis or immediately post septic
abortion
• Unexplained vaginal bleeding
• Benign or malignant
• Pelvic cancer
 ct
• Recurrent PID
• Congenital uterine abnormality
• Women with fibroids distorting the uterine
cavity
Warning signs
• P –Periods late
• A –Abdominal pains lower
• I –Infections
• N –Not feeling well
• S –Strings missing
 Common side effects
1. Cramping pains.
 Rule out PID, perforation of the uterus or
cervix or ectopic pregnancy
2.Amenorrhoea.
 Do speculum and pelvic exam to check for
strings and rule out pregnancy

 Doctor remove IUCD if pregnant

 ..ct..
3.Missing strings.
 Do a speculum and bimanual exam.

 Strings may be high up to the vaginal

 Check for pregnancy. If not pregnant refer for x-ray

 Rule out perforation of the uterus

4. Irregular bleeding.
 Check for anaemia

 Do bimanual exam to rule out fibroids, endometrial

hyperplasic of menopause
 Instruction for use of IUCD
1. You are not likely to became pregnant because IUCD
is inserted

2. Copper 380A can remain in the uterus for 12 years

3. Check threads once after a monthly periods

4. Maintain good personal hygiene to prevent

infections

5. While using IUCD, do not use tampons to avoid

dislodging of IUCD
 Other instructions
1. Experience lower abdominal pains, back pains, and if
it happens ,it will take a period of 2 months

2. Increased menstrual periods and more vaginal

discharge

3. She should check for sanitary pads during period

before throwing it away because IUCD can come out,
so she come to clinic immediately because she is not
protected

4. Report to clinic immediately she notice warning signs

 When to initiate IUCD
 Day 1-7 during menses

 During any time in menstrual cycle when sure she is

not pregnant

 When changing from another method to IUCD

 4-6wks after normal delivery

 When pregnancy test is negative

 7 days after post abortion