Combined hormonal contraceptives (CHCs), consisting of an estrogen-progestin combination, are usually used for hormonal contraception. In the so-called “micropill,” the estrogen component is 15-35 μg of ethinyl estradiol (EE) or estradiovalerate. Ultra-low-dose pills contain as little as 20 µg of ethinyl estradiol or estradiol valerate. The mini-pills are progestogen-only preparations. They contain either desogestrel or levonorgestrel. They have a narrow intake window. In addition, hormonal IUDs, implants (contraceptive sticks), injections (three-month injections) are available for contraception. For details, see: Hormonal contraception/substancesThe contraceptive effect consists primarily of suppression (suppression) of gonadotropin secretion (sex hormones that stimulate the gonads).The ovulation-inhibiting effect of CHD depends primarily on the progestin component. During the period of taking CHD, changes in fibrinolysis and coagulation factors occur due to the hepatic effect of ethinylestradiol (EE)! At the beginning of an “initial pill prescription”, a detailed medical history and a gynecological examination, including a cytological smear (cancer smear) are required. At the initial presentation, the patient’s weight, height, onset of menarche (time of the first menstrual period) and cycle history (dysmenorrhea/regular pain?) are asked for as part of the anamnesis. In young girls, the physical development status is also assessed using the Tanner stages, as well as blood pressure. In young girls, monophasic combined contraceptives are considered the first choice.CHD should not be prescribed in the presence of the following diseases and health risks (= absolute contraindications):
- Family history
- Blood clotting disorders (clarification required if patient also has a blood clotting disorder).
- Familial breast carcinoma (breast cancer).
- History of thromboembolism: e.g., deep vein thrombosis (TBVT), pulmonary embolism, myocardial infarction (heart attack), transient ischemic attack (TIA; sudden circulatory disturbance of the brain leading to neurological disturbances that remit within 24 hours), apoplexy (stroke), angina pectoris (“chest tightness”; sudden onset of pain in the heart area)
- Blood clotting disorders?
- Diabetes mellitus with vascular damage?
- Hyperlipidemia (lipid metabolism disorder; high blood lipid levels?
- Hypertension (high blood pressure; systolic ≥ 160 or diastolic ≥ 100 mmHg)?
In the presence of one of the following diseases or permanent medication, a prescription of a CHD should be considered (= relative contraindications).
- Family history: a relative at a young age (<50 years) with a thromboembolism: eg, deep vein thrombosis (TBVT), pulmonary embolism, myocardial infarction, transient ischemic attack (TIA), angina).
- Age (> 35 years of age)
- Smoking [> 35 years + smoking → no hormonal contraception, i.e. use of non-hormonal contraception].
- Obesity (overweight; BMI > 30).
- Ulcerative colitis (inflammatory bowel disease)?
- Hemolytic uremic syndrome (HUS)?
- Hepatopathies (liver disease)?
- Heart valve disease
- Cardiac arrhythmia – atrial fibrillation (VHF)
- Hypertension (systolic 140-159 or diastolic 90-99 mmHg).
- Coronary artery disease (CAD; coronary artery disease)?
- Migraine with focal neurological symptoms (aura).
- Crohn’s disease (inflammatory bowel disease)
- Sickle cell anemia (genetic disease of the erythrocytes (red blood cells), which leads to anemia (anemia)).
- Systemic lupus erythematosus (SLE; autoimmune disease)?
- Tumor disease
- Vasculitis (vascular inflammation)
- Continuous medication that increases the risk of thrombosis:
- Antidepressants
- Antipsychotics (neuroleptics)
- Chemotherapeutic agents
- Corticoids
- Diuretics
- Et al
Options for contraindications to estrogens.
Estrogen-free contraceptive methods include:
- Estrogen-free pill (“progestin only pills”, POP; “mini-pill”).
- Intrauterine devices (IUS) containing levonorgestrel.
- Desogestrel-containing hormone implant (etonogestrel implant).
- Three-month injection
- copper-containing spiral or chain
Taking hormonal contraceptives (CHD) increases the risk of:
- Venous thrombosis (due toethinylestradiol (EE); see above. Risk factors for venous thrombosis).
- Myocardial infarction (heart attack) (marginal increase); to be considered in this context are other risk factors such as: Age, smoking, obesity (overweight), hypertension (high blood pressure), diabetes mellitus, and hyperlipidemia (hyperproteinemia/fatty metabolism disorder) [progestin monopreparations do not appear to increase myocardial infarction risk].
- Ischemic apoplexy when migraine with aura (visual, somatosensory, olfactory, motor, and speech disturbances) is present [risk increases sevenfold for female smokers!].
- Benign liver tumors (extremely rare; prevalence: 3-4 per 100,000); appears to be dependent on duration of use and EE dose; if under CHD this diagnosis is made, then use should be discontinued
- Mammary carcinoma (breast cancer) (CHD have a marginal effect on the risk of mammary carcinoma).
- Cervical intraepithelial neoplasia (CIN) (= precancerous lesions of cervical cancer/precancerous lesions of the cervix) [doubled risk after 5 years; quadrupled risk after 10 years].
- See also chapter: “Hormonal contraceptives in risk constellations”, “Hormonal contraceptives and carcinoma risk“, “Thromboembolism risk/cardiovascular risks associated with hormonal contraceptives”).
Cave!In familial breast carcinoma, hormonal contraception should not be used before the age of 20. Furthermore, the duration of use should not exceed 10 years.In case of thrombosis burden (thrombophilia), the following laboratory tests should be performed: APC resistance (mutation of factor V Leiden; prevalence: approx. 5%) and factor II (prothrombin gene mutation) (see below Thrombosis Diagnostics (Thrombophilia Screening)).
Part of the “first pill prescription” should be information about contraceptive safety. Reference should be made to factors that may adversely affect contraceptive safety:
- Medications (see Chapter: “Hormonal contraceptives: efficacy with medications”), e.g.:
- Analgesics (painkillers)/antirheumatics (oxyphenbutazone, phenacetin, phenylbutazone, pyrazolone derivatives, salicylic acid derivatives).
- Antiepileptic drugs (carbamazepine, oxcarbazepine, felbamate, lamotrignine, oxcarbazepine (Trileptal, Timox), phenobarbital, phenytoin, primidone, topiramate (Topamax)).
- Antibiotics (cephalosporins. Chloramphenicol, nitroimidazoles, penicillins, rifampicin, sulfonamides, tetracycline).
- Antifungals/antifungals (griseofulvin).
- Laxatives/purgatives
- Tuberculostatics such as rifabutin, etc.
- Gastrointestinal disorders/gastrointestinal disorders (e.g., vomiting, diarrhea/diarrhea).
- Gastrointestinal diseases (gastritis / gastritis, enteritis / small intestine inflammation, celiac disease, Crohn’s disease).
- Disorders of the enterohepatic circulation (antibiotics).
Other notes
- Intake start date:
- Default: start on the first day of the period. Safety is given from now on.
- Start 2nd – 5th day. In addition, contraception at least seven days necessary.
- So-called. Quickstart: start combined hormonal contraception at any time in the cycle,
- Prerequisite: certain exclusion of pregnancy. Additional compensation of at least seven days necessary. If these conditions are met, the contraceptive safety and side effect profile of this method does not differ from the classical application.
- Combined oral contraceptives (CHCs) may also adversely affect the effects of other medications (see Hormonal contraceptives: effectiveness with medications).
- Within six and twelve months after discontinuation of CHD, cumulative pregnancy rates (83% and 94%, respectively) are identical with barrier methods (e.g., condom).
- The mean menopausal age (52 years) should be assumed as the endpoint of contraception (= endpoint of the fertile life phase).
