For women has always been topical issue pregnancy prevention. Such an action must necessarily be reasonable and safe, therefore, the fair sex always meticulously study all the proposed contraceptive options.
Today we will look at how the Implanon is installed. - unique which is widely used abroad and is becoming more and more popular among our compatriots. We will listen to feedback from women using it and talk about side effects that may occur in those who use this contraceptive.
How is the contraceptive effect achieved when using the implant
The contraceptive drug "Implanon" is a contraceptive that contains etonogesrel in an amount of 68 mg and is not biodegradable. It comes in the form of a silicone-like rod, about four centimeters long and 2 mm in circumference, which is placed in an applicator. This drug provides continuous contraception for three years.
After administration, a contraceptive substance begins to be released from the described agent in very small quantities, similar in effect to substances in It inhibits ovulation, preventing the growth of eggs and their release from the ovaries, and also changes the viscosity of the cervical mucus, which greatly complicates the movement of spermatozoa.
This woman is enough for a stable contraceptive effect. It is 99%. This result corresponds to the effect of regular oral pills, but without many side effects observed in this case.
How can Implanon be inserted?
The contraceptive is usually administered from the first to the fifth day of the cycle, and after childbirth - from the 21st to the 28th day. In the case when the installation occurs later, the woman is recommended to use a barrier method as an additional contraception within a week after the administration of the drug. If the patient had sexual intercourse, then she should wait for the first menstruation before inserting the implant.
The duration of the manipulation is only a minute. The contraceptive is placed under the skin inside shoulder, which allows him to be invisible to others. After that, a bandage is applied to the wound surface. It can be removed within a few hours after the placement of the Implanon contraceptive.
Patient reviews claim that the drug can be detected later only with gentle pressure on the implantation site.
Provided that the instructions are followed, the risk of complications is low.
How to terminate the effect of a subdermal implant?
If you decide to stop contraception for any reason, then you do not have to wait three years for the expiration date of the Implanon drug. The instruction clarifies that its removal should be carried out only by a doctor familiar with the methodology of this process. This is done at a convenient time for you, on an outpatient basis, using
In the process of removal, the location of the implant is determined by palpation (by the way, it must be indicated in the patient's card), its distal end is found and a 3 mm incision is made on the skin, which does not require further suturing. This procedure takes only five minutes. It is important to ensure that the entire implant is removed: to do this, it must be measured (the length must remain the same: 40 mm).
The action of the described drug is reversible, and after its removal, the menstrual cycle and reproductive function are restored. female body for three weeks now.
Cases of deep injection of the drug
In rare cases, when the contraceptive was inserted too deeply, not in accordance with the instructions, or as a result of external influence (for example, when hitting the inside of the arm), it may migrate from the place of placement. It is rather difficult to determine its position, and extraction may require a strong dissection.
If the drug is never detected, then both the contraceptive effect and the risk of side effects may persist beyond the time desired by the patient.
The consequences of using a contraceptive
There is no in the world medicines with no side effects. In the described remedy, these may be migraines, small decreases or increases in body weight. Sometimes the side effects that appear after the administration of the drug "Implanon" are expressed in the form of menstrual-like discharge, the same as when taking other contraceptives. The nature of these secretions may change, but in most cases they are insignificant. One in five women stop having periods altogether.
If the listed signs are systemic, a medical consultation is necessary. And increased bleeding requires immediate medical attention.
But all this does not mean that this remedy is not suitable or that the contraceptive effect will not be achieved.
Information about the interaction of the drug with other drugs
It is important to remember the need to be especially careful in the use of drugs when using the contraceptive "Implanon"! Reviews of experts say that the doctor needs all the information about the medicines that a woman takes in this moment or intends to take in the near future, including herbal remedies.
And since some of them can reduce the effectiveness of the described contraceptive, the woman will have to additionally use barrier methods to prevent pregnancy. And for patients taking drugs for the induction of microsomal liver enzymes for a long time, it is necessary to use these methods for 28 days after stopping the course of treatment, or remove the contraceptive and use non-hormonal methods of preventing pregnancy.
Is the drug safe for health?
The contraceptive "Implanon", reviews of which are discussed here, is not recommended during pregnancy, venous thromboembolism, severe liver disease, breast cancer, bleeding from the vagina, as well as hypersensitivity to the components of the drug.
If the condition worsens after the introduction of the drug, it is necessary to consult a doctor who will decide on the rationality of using this contraceptive.
Please note that although this implant is a long-acting product, it is not recommended to leave it on for more than three years.
Contraceptive "Implanon": reviews
According to the reviews of gynecologists and women who used the drug "Implanon", this remedy is suitable for many of those who are contraindicated in conventional birth control pills- breastfeeding, patients with diseases of the cardiovascular system and women who smoke.
In addition, the drug, which is part of the described contraceptive, according to the observation of physicians, has not only a contraceptive effect. It can be used to treat a number of gynecological diseases such as endometriosis, uterine fibroids, etc.
When using this implant, there was also a normalization of the menstrual cycle and the disappearance of premenstrual syndrome, as well as discomfort and pain during menstruation.
In addition, women noted the convenience of using this remedy: after all, it is impossible to forget to take this contraceptive on time - it is always with you!
The price of the drug
When discussing the contraceptive "Implanon" its price plays an important role.
And here it should immediately be noted that, of course, the cheapest method of preventing pregnancy is a complete renunciation of sexual activity. and the benefit from the acquisition of the described contraceptive can be easily calculated.
The price of the named drug in Russian pharmacies fluctuates around 6,000 rubles. And contraceptives purchased by a woman for three years (the period for which the Implanon contraceptive is installed) cost her about 32,000 rubles. Do you think this drug is beneficial in terms of price, not to mention convenience? The answer suggests itself.
So if you do not have direct contraindications for the use of the Implanon contraceptive, its price should suit you. And the conveniences described above in the use of this drug - push to the right decision.
Feel great!
The role of women in modern society and the family. Poll results. New scheme taking hormonal contraception.
V.N. Prilepskaya, Scientific Center for Obstetrics, Gynecology and Perinatology (Dir. - Academician of the Russian Academy of Medical Sciences V.I. Kulakov) RAMS, Moscow.
In the second half of the last century, there was a significant revision of the role of women in modern society and the family. The significant changes in women's lifestyle associated with this require a corresponding transformation of the medical care system, not only in the field of obstetrics and gynecology, but also in healthcare in general. One of the reasons for this is the fact that some physiological features of the body, previously considered normal and natural, require a change in their medical interpretation and approach to them (WHO, 2000).
At the beginning of the 21st century, a group of famous scientists and doctors published the concept that monthly ovulation and menstruation are not necessary, and in certain cases, due to significant fluctuations in hormone levels, pose a risk to a woman's health. This is primarily due to the occurrence in women of reproductive age of anemia, arthritis, bronchial asthma, dysmenorrhea, endometriosis, uterine fibroids, premenstrual syndrome (PMS) and other diseases that may be caused or associated with the menstrual cycle.
It is well known that menstrual disorders and menstrual disorders are one of the leading causes of gynecological morbidity in the world.
Analysis of general population data indicates significant changes in the function of the female reproductive system over the past 30–35 years (WHO, 2001). For example, in the 70-80s of the last century, the average age of menarche was 15.5 years, girls began to have sex no earlier than 18 years old, and, as a rule, this coincided with marriage, and, accordingly, the first pregnancy occurred at the age of 19–20 years. In the modern population, the age of menarche is 12-13 years, there is an early onset of sexual activity - at the age of 14-15 years. Despite this, modern young women are in no hurry to get married and have children, the frequency of civil marriages is currently quite high, while most couples are in no hurry to have children, and in most cases the first pregnancy, usually planned, occurs at the age of 25-30 years and even later. Unfortunately, the percentage of lactating women has significantly decreased: if earlier up to 85% of women were breastfeeding, then at present this figure is no more than 20%. In addition, the average age of menopause has increased from 40–45 years a few decades ago to 50–55 years now. All this indicates that the reproductive period of their life has significantly lengthened in the modern population of women.
At present, to a certain extent, it is possible to consider a modern woman from the position of “yesterday” and the same woman from the position of “today”. From the point of view of an obstetrician-gynecologist, “a woman yesterday” is, first of all, 160 ovulations during her life, early marriage and, at the same time, practicallylack of abortions, high frequency of pregnancies and childbirth and, as a result, long-term, up to 3years, lactational amenorrhea. At the same time, the “woman of yesterday” was not assigned a role at all either in society, or in politics, or in business.
Considering “a woman today”, one can dwell on several aspects of her life and, first of all, on her reproductive history. Modern women have a long menstrual and ovulatory period - up to 450 ovulations in a lifetime, and even a new term "chronic ovulation" has been introduced. Unfortunately, in the modern population, the frequency of medical abortions is high, women give birth less and, at the same time, the period of breastfeeding is short.
The social status of women has also changed: average duration life of a woman (for example, in economically developed countries this figure is 86 years), our contemporary is active in the family, business, politics, always wants to look good, actively goes in for sports, tries to be financially independent.
Along with this, there are changes in the endocrine profile: monthly ovulation leads to large fluctuations in hormone levels and desynchronization of the hypothalamic-pituitary system. The consequence of this is a significantly increased frequency of various gynecological diseases, including menstrual disorders, the development of PMS, the formation of functional ovarian cysts, as well as hyperplastic processes of the endometrium and mammary glands, uterine fibroids, endometriosis, polycystic ovaries, etc.
Thus, “a woman yesterday” and “a woman today” are different women who differ from each other in a number of parameters: social status, reproductive history, morbidity, etc.
Given this, the approach to a woman and as a patient should change, in particular, in modern literature, the issue is currently being actively discussed: “Could monthly menstruation be optional?” . However, some researchers are of the opinion that "there is no equal sign between "regular" and "normal" menstrual cycle" , and according to K. Blanchard et al., "periods should be a woman's choice, not a disaster" .
Despite the fact that this issue is actively discussed in the medical community, it is first of all important to know the opinion of women themselves. For this purpose, in 1999, for the first time in Holland, a survey was conducted, in which 1,300 women took part. The results of the study showed that 1/3 of the women surveyed preferred monthly menstruation, 9% would not like to menstruate at all.
In 2002, the Association for Reproduction conducted a similar study. Of the 491 women surveyed, 44% preferred no menstruation, and 155 women were already using combined oral contraceptives to suppress or delay their next period.
In 2004, a study was conducted in Germany among 1195 women of reproductive ageand found the following: monthly menstrual bleeding prefer 26-35% of the samewomen, 16–27% of the respondents would like to have periods every 3.6 or 12 months, and 37–46% of women would not like to have menstrual bleeding at all. The main reasons for this were the desire of women to improve the quality of life, reduce the degree of blood loss and pain during menstruation. According to respondents, reducing the number of menstruation improves personal hygiene and even solves some of the sexual problems associated with a regular menstrual cycle.
Similar surveys were conducted not only among women, but also among medical workers, and, as their results show, the attitude to this issue in the professional environment is also ambiguous. For example, according to the results of a survey conducted by C. Linda et al. in 2005 among doctors and nurses, the following data were obtained. According to 11% of the respondents, it is important to menstruate monthly, 22% believe that monthly menstruation is unhealthy, 44% of medical professionals answered that suppression of menstruation is necessary only in certain cases, and 23% abstained from answering.
One of the first publications on practical application long-term contraception, were the results of a 7-year clinical study conducted by Sulak et al. in 2000 (26). The results of this study showed that almost all observed in the use of combined oral contraceptives (COCs) side effects are more pronounced during the 7-day break, and the authors called them "withdrawal symptoms". In order to prevent side effects, women were asked to increase their COC intake to 12 weeks and shorten the interval to 4–5 days. An increase in the duration of admission and a shortening of the interval reduced the frequency and severity of "withdrawal symptoms" by 4 times.
It has now been proven that during the 7-day interval when taking COCs from the 3-4th day of the cycle, an increase in the level of FSH is noted, which leads to the growth of follicles and increases the endogenous production of estradiol. By the 6-7th day, follicles with a diameter of 8 mm or more can be detected, which have aromatase activity, produce estradiol, and can develop into a dominant follicle.
Prolonged contraception has been proposed to regulate the menstrual cycle, treat a number of diseases and reduce the number of side effects observed with the traditional COC regimen. The use of COCs in continuous mode (prolonged contraception) determines the best suppression of FSH and the best suppression of ovarian follicular activity, against this background, stabilization of the function of the endocrine system is observed and thus has a positive effect on various hyperestrogenic states.
The idea of prolonged-dose contraception was proposed back in 1968 by the creator of the first contraceptive pill, Gregory Pincus.
Long-term contraception is an effective fertility control method that helps regulate the menstrual cycle, prevent unplanned pregnancy and protect againsta number of gynecological and extragenital diseases.
Prolonged contraception provides for an increase in the duration of the cycle from 7 weeks to several months. For example, it may include taking 30 mcg of ethinyl estradiol and 150 mcg of desogestrel (Marvelon) or any other COC continuously. There are several schemes of prolonged contraception. The short-term dosing scheme allows you to delay menstruation by 1-7 days and is practiced before the upcoming surgery, vacation, honeymoon, business trip, etc. The long-term dosing scheme allows you to delay menstruation from 7 days to 3 months, as a rule, it is used for medical reasons for menstrual irregularities, endometriosis, uterine fibroids, anemia, diabetes mellitus, etc.
Due to the urgency of the problem, in late 2003 the FDA (Food and Drug Administration) approved the use of the new COC Seasonale® with an extended dose regimen, specially designed to reduce the total number of menstruations from 13 to 4 per day. year. The composition of each tablet of the drug includes 30 mcg of ethinyl estradiol and 150 mcg of levonorgestrel, the regimen includes 84 days of admission + 7 days of placebo.
Long-term contraception can be used not only to delay menstruation, but also with therapeutic purpose. For example, there is evidence in the literature on the continuous use of oral
a contraceptive containing 30 mcg of ethinyl estradiol and 150 mcg of desogestrel (Marvelon®) after surgical treatment of endometriosis. According to the results of the study, the use of this drug in a continuous mode for 3-6 months significantly reduced the symptoms of dysmenorrhea, dyspareunia, improved the quality of life of patients and their sexual satisfaction.
The appointment of prolonged contraception is also justified in the treatment of uterine leiomyoma, since in this case the synthesis of estrogens by the ovaries is suppressed, the level of total and free androgens decreases, which, under the action of aromatase synthesized by the tissues of leiomyoma, can turn into estrogens. At the same time, there is no estrogen deficiency in the woman's body due to its replenishment with ethinyl estradiol, which is part of the COC.
Currently, experience is accumulating in the use of prolonged contraception in polycystic ovary syndrome. Studies have shown that continuous use of COCs for 3 cycles causes a more significant and persistent decrease in LH and testosterone.
In addition to the treatment of various gynecological diseases, the use of the method of prolonged contraception is justified in the treatment of dysfunctional uterine bleeding, hyperpolymenorrhea syndrome in perimenopause, as well as in order to relieve vasomotor and neuropsychiatric disorders of the climacteric syndrome. In addition, prolonged contraception enhances the onco-protective effect of hormonal contraception and helps prevent bone loss in women of this age group.
The main problem of the prolonged regimen is the high frequency of bleeding "breakthroughs".va” and “spotting” spotting compared to the traditional COC regimen. ByAccording to the results of clinical studies, intermenstrual bleeding, as a rule, is observed during the first 2 months of admission and is the reason for the refusal of further continuous medication in 10-12% of women. The data currently available indicate that the incidence of adverse reactions with extended cycle regimens is similar to those for conventional regimens.
The world clinical experience accumulated to date shows that today a woman, depending on her personal needs or for medical reasons, has the right to choose to use one or another COC regimen. An alternative to the standard regimen of oral contraceptives is prolonged contraception using COCs of various composition and dose. At the same time, it must be remembered that prolonged contraception is not suitable for all women, and before its appointment and in the process of its use, careful monitoring, dynamic monitoring and consideration of contraindications to the use of COCs in general are required.
Of course, further analysis of multicenter studies on this issue and a detailed study of the effect of the prolonged regimen on the woman's body are to be carried out.
A new hormonal contraceptive regimen in which hormonal preparations are taken continuously for several cycles, a seven-day break is taken, and the regimen is repeated. The most common regimen is to take hormonal contraceptives continuously for 63 days, then take a break for 7 days. Along with the 63+7 regime, a scheme is proposed - 126+7, which in terms of its portability does not differ from the 63+7 regime.
According to studies, against the background of prolonged intake, women practically cease to face such common PMS problems as naked pain, dysmenorrhea, tightness in the mammary glandspuffiness. When there is no break in taking hormonal contraceptives P there is a stable suppression of gonadotropic hormones, in the ovaries does not occurthe maturation of follicles and a monotonous m hormonal background. This explains the decrease or complete disappearance of menstrual symptoms and better tolerability of contraception in general.
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Contraception, which does not require regular and constant intake of contraceptive tablet forms and is designed for a long period of action, is called prolonged (from lat. prolongus - ongoing). Interest in this method of contraception and its use for medicinal purposes arose in the late 80s of the XX century, today it is very popular in many countries. The effectiveness of the method is beyond doubt and according to clinical studies is 99-99.7%.
What is the basis of prolonged contraception?
Prolonged contraception is based on the action of exclusively progestin drugs, which are analogues of the hormone progesterone, which is produced in the ovaries. The estrogen component, which often leads to disruption of metabolic processes, is absent. This means that the likelihood of such serious side effects as hypertension and thromboembolism is reduced or completely absent. Indicated in the presence of contraindications for the use of estrogen and the intrauterine device.
What is the choice?
Modern medicine offers two types of prolonged contraceptives, which differ in the way they are introduced into the female body:
- subcutaneous implants;
- injectable gestagens.
Both have the same principle of action for all progestin contraceptives: the susceptibility of the endometrium decreases and ovulation is suppressed, the penetration of spermatozoa is difficult due to thickening of the cervical mucus in the cervix.
Prolonged contraception with Norplant: pros and cons
Norplant is used as an implantable agent, which is able to continuously provide a pregnancy-preventing effect for 5 years. The active substance levonorgestrel is placed in a capsule (there are six in a set), from which it methodically (at a constant rate) penetrates into the blood. Externally, the capsule looks like a match 34 mm long. Norplant replanting is carried out surgically in the forearm area in the first 5-7 days after the onset of menstruation or immediately after an abortion. Being on the inside, the capsules are not visible from the outside and do not cause any discomfort. Novocaine is usually used as a local anesthetic. After implantation, you need to keep the place dry for several days and exclude pressure.
The advantages include:
- safety;
- high reliability;
- minimum complications;
- disappearance of PMS and menstrual pain;
- uncomplicated menopause in the future;
- reduction of exacerbations of chronic inflammatory diseases of the female genital area, including regression of myomatous and fibrocystic nodes;
- reduced risk of cancer, including endometrial cancer.
There are also disadvantages:
- the likelihood of a slight increase in weight;
- changes in the menstrual cycle (scanty periods or their absence);
- bloody issues.
These side effects gradually subside without causing harm to health. By the end of the five-year period, the capsules are removed by the doctor.
The method is aimed at women under 40 who are firmly convinced that they are not planning a child in the next few years.
Prolonged drug Depo-Provera: "pros" and "cons"
Prolonged contraception by intramuscular injection of depot medroxyprogesterone acetate is a good alternative to estrogen-containing forms. The drug should be administered at a dose of 150 mg, observing a three-month interval.
First of all, Depo-Provera is indicated for lactating women and those in the late reproductive period, as well as those at risk of developing cardiovascular complications.
endometriosis
Endometriosis is manifested by pain in the pelvic area, menometrorrhagia, dysmenorrhea, dyspareunia, and infertility. The clinical manifestations of endometriosis largely depend on the level of estrogen, so the suppression of steroid production by the ovaries leads to a decrease in the severity of symptoms. In endometrioid tissue, the expression of type 2 17p-hydroxysteroid dehydrogenase, which converts estradiol to estrone, is reduced, but is not involved in the metabolism of ethinyl-estradiol (Guillebaud J., 1987).
Suppression of estrogen synthesis in the ovaries under the action of oral contraceptives can reduce the estrogen effect in tissues, since ethinylestradiol stimulates proliferation less than estradiol (Wiegratz L., Kuhl H., 2004). Continuous treatment with a combination drug containing 20 μg of ethinyl estradiol and 150 μg of desogestrel, with recurrent pain in the pelvic area, after surgical treatment of endometriosis, accompanied by clinical manifestations, led to a significant decrease in the severity of dysmenorrhea (Wiegratz L. et al., 2004), dyspareunia , as well as to improve the quality of life and the degree of sexual satisfaction of patients. It is assumed that the progression of endometriosis during oral contraceptive therapy is suppressed, but after stopping treatment, its clinical manifestations may recur (Park VK et al., 1996). Therefore, continuous regimens with an extended cycle of oral contraceptives in endometriosis seem very promising and interesting for further study.
Leiomyoma of the uterus
In many patients, uterine leiomyoma is not accompanied by clinical symptoms, but in some cases it can be accompanied by pain and mennorrhagia. It has been shown that while taking oral contraceptives, the risk of developing uterine leiomyomas is reduced; these data were confirmed by pe-results of ultrasound examination and the results of hysterectomy (Marshall L.M. et al., 1997). With uterine leiomyomas
treatment with oral contraceptives did not have a statistically significant effect on the size or volume of the uterine cavity, but reduced the duration of menstrual bleeding and increased the hematocrit (Friedman A.J., Thomas P.P., 1995). However, prospective randomized clinical trials are needed to assess the efficacy and safety of continuous oral contraceptives in uterine leiomyomas.
Polycystic ovary syndrome (PCOS)
In PCOS, continuous treatment with monophasic oral contraceptives causes more pronounced suppression of ovarian androgen production than standard treatment regimens, and due to this, it can have a more pronounced therapeutic effect in diseases associated with androgen hyperproduction (Ruchhoft E. et al., 1996). While taking oral contraceptives according to the usual schemes, androgen synthesis during withdrawal intervals may increase again (Kuhl H. et al., 1985; Kistner R.W., 1956).
In a small study of patients with PCOS, the conventional combination regimen of ethinylestradiol 30 mcg and desogestrel 150 mcg resulted in a statistically significant decrease in LH and testosterone levels, which disappeared during hormone withdrawal intervals. In contrast, continuous use for 3 months. without 7-day breaks caused a pronounced and persistent decrease in LH and testosterone. This effect was compared with the results of monthly administration of deposited GnRH agonists (Ruchhoft E. et al., 1996). Although oral contraceptives are considered the traditional method of long-term treatment of PCOS, data on the health risks they induce in patients are still insufficient. Additional studies are required to evaluate the long-term effects of oral contraceptives on metabolism, given the possibility of PCOS being associated with various risk factors for cardiovascular diseases.
Iron deficiency and iron deficiency anemia Iron deficiency is detected in almost 10% of young women, and iron deficiency anemia in 2.2%, and the proportion of women with iron deficiency correlates with the severity and duration of menstruation (Milman N. et al., 1998). In both iron deficiency and iron deficiency anemia, reducing the frequency and intensity of menstruation or withdrawal bleeding may improve the overall clinical condition of patients.
Therefore, in case of pathological uterine bleeding, after the exclusion of organic causes of the disease, regimens with an extended cycle of oral contraceptives can be recommended (Chuong C.J., Brenner P.F. et al., 1996).
Premenstrual syndrome and dysmenorrhea Almost 30% of fertile women complain of pain in the lower abdomen and in the mammary glands, swelling, depressive states, increased irritability, which are fully manifested in the second phase of the menstrual cycle and disappear during menstruation (Svemdottir H., Backstrom T.J 2000). During the use of oral contraceptives in accordance with the standard "21/7" scheme, clinical manifestations develop more often during the 7-day intervals of hormone withdrawal than during the 21-day cycles of taking hormonal drugs (Oinonen K.A., Mazmanian D., 2002). A number of studies have shown that the continuous and uniform effect of sex steroids leads to a decrease in the clinical manifestations caused by the withdrawal of COCs: 74% of women noted a decrease in symptoms associated with hormone withdrawal. The extended regimen of oral contraceptives continued for 5 years, almost half of the women, and most of them noted a decrease in the original clinical manifestations of the menstrual cycle, as well as a significant improvement; quality of life (Sulak P. et al., 1996; Sulak P. et al., 1997).
Effect on the endometrium
A large number of studies have shown that the correct use of combined oral contraceptives reduces the incidence of hyperplasia and endometrial cancer by 50-60% and that the protective effect correlates with the duration of treatment (Stanford J.L. et al., 1993). Continuous treatment with oral contraceptives, which causes a permanent and significant suppression of ovarian estrogen production, enhances the inhibitory effect of the progestogen component on the endometrium. With continuous therapy with ethinyl estradiol at 20 μg and levonorgestrel at 100 μg for 336 days, histological examination of endometrial biopsies of 8 women in 7 of them revealed the absence of proliferative activity or atrophy of the endometrium (Miller L., Hughes J.P., 2003).
Impact on fertility
Although the significant suppression of ovarian activity caused by oral contraceptives can in many cases be |
teas lead to amenorrhea, hypoestrogenism does not develop, since the decrease in the level of estradiol is compensated by the presence of exogenous estradiol. Current data suggest that long-term use of oral contraceptives after its completion does not adversely affect fertility (Farrow A. et al, 2002).
The risk associated with long-term use of the drug
Although clinicians have empirically used cycles of extended oral contraceptive therapy to delay menstruation for many years, there are no data on the long-term risk of this regimen. The risk of developing cancer or cardiovascular disease in young women can only be assessed after courses of treatment in a large number pacintok for a sufficiently long period of time. However, in the Million Women Study, no difference was found between sequential and continuous estrogen and progesterone regimens in relation to breast cancer risk (Million Women Study Collaborators, 2003). On the other hand, the protective effect of oral contraceptives against benign breast diseases correlates with the duration of treatment and progestogen activity (Bunion L.A. et al., 1981). The question of the likelihood of developing thromboembolic diseases also remains unresolved, which increases 3-5 times when taking oral contraceptives (Bloemenkamp K.W.M. et al., 2000). This risk is highest during the first six cycles of therapy, due to the influence of predisposition to this disease, and the duration of treatment plays a less significant role (Bloemenkamp K.W.M. et al., 1999). Considering that the absolute number of women suffering from venous thromboembolic disease at a young age is very small (according to Rosendaal E, 1997 - 1-2 women per 10,000 women per year), in order to identify differences in increased risk between traditional and extended regimens the appointment of oral contraceptives will take a considerable time.
It is known that the metabolic effects of oral contraceptives largely depend on the composition of the drug and that various indicators of the blood count can both increase and decrease in this case. With the traditional treatment regimen, these changes are largely reversible during the hormone withdrawal interval, which lasts for 7 days (Kuhl H. et al., 1988; Jung-Hoff-
mann C. et al., 1998). In the future, it will be necessary to assess whether a stable level of these indicators is achieved with continuous therapy or with extended cycle regimens and over what period of time this occurs.
The main side effects caused by the prolonged regimen of oral contraceptives
Some studies of extended cycle regimens have found a high rate of discontinuation due to irregular uterine bleeding and spotting (Parazzini F. et al., 1994); therefore, it is necessary to evaluate the impact on these symptoms of different formulations of oral hormonal contraceptives. At the same time, some studies have shown that many women agree to the occurrence of these adverse reactions, provided that problems associated with menstruation and / or endometriosis disappear, as well as a decrease in the number of menstrual bleeding per year. (Vercellini P. et al, 1999; Back D J., Orme M.L.E., 1990).
Data from clinical trials comparing the side effects of conventionally used oral contraceptive regimens and extended-release regimens in which the same drugs were used did not reveal differences in the frequency and nature of developing side effects, for example, breast tenderness, nausea, anxiety, changes in body weight .
Thus, in recent decades, several major trends in the development of contraception have been observed: chemical composition combined contraceptives, aimed at creating new progestogenic components; development and implementation of new routes of entry of drug components into a woman's body (such as intrauterine releasing system, vaginal contraceptive ring and transdermal releasing system), as well as modernization of schemes for the use of existing combined oral contraceptives. The use of regimens with an extended regimen of oral contraceptives significantly suppresses ovarian function, which allows you to increase the effectiveness of contraception, reducing the likelihood of an unwanted pregnancy if you accidentally skip pills. In addition, regimens of prolonged use may be the therapy of choice when administered simultaneously with drugs that affect the effectiveness of oral contraceptives. The frequency and abundance of menstruation with this method of using COCs significantly reduce
Thus, it becomes possible to prevent the development of clinical symptoms associated both with the menstrual cycle itself and with periods of drug withdrawal.
Changes over the last decades
XX century in reproductive history, morbidity and social
real status of a woman, dictate to doctors the need for you
express the desires of patients in relation to the frequency of menstruation
bleeding, as well as the presence of withdrawal bleeding
and/or spotting spotting. Regulatory ability
to control these processes is another step towards autonomy
women. Some authors call drug ame
noreyu "menstrual nirvana" (Edelman A., 2002).
Existing evidence suggests that most women prefer extended cycle regimens, despite an increasing incidence of irregular bleeding, as a reduction in the frequency of menstruation and the clinical manifestations of premenstrual syndrome can improve quality of life. "Monthly cycles should be a woman's choice, not a disaster" (Blanchard K., 2003).
Active study and application of regimens for prolonged use of oral contraceptives will allow doctors to
XXI century to use contraceptives not only
for the purpose of contraception or treatment of a number of gynecological diseases
pain, but also pay more attention to subjective
women's feelings about their health and improved
quality of life.
Thus, today the trend towards the use of drugs not only for therapeutic purposes, but also from the standpoint of choosing a lifestyle is caused by a joint decision of the patient and the doctor. However, for the widespread introduction into clinical practice of regimens for prolonged use of oral contraceptives, further research is required on the effect of regimens for taking oral contraceptives in a prolonged mode on the general condition of patients, the menstrual cycle and its disorders (dysmenorrhea, hyperpolymenorrhea), changes in the hemostasis system, lipid- spectrum of blood, for the subsequent restoration of fertility after discontinuation of the drug. A significant role in the introduction of schemes for prolonged use of oral contraceptives in clinical practice will be played by the study of the attitude of women themselves and medical workers to this issue. At the same time, it must be remembered that prolonged contraception is not indicated for all women, and careful monitoring and dynamic monitoring is required before its appointment and during its use.
ORAL HORMONAL CONTRACEPTIVES CONTAINING ONLY PROGESTAGEN (PURE PROGESTIN PILLS OR MINI-PILS)
Pure progestin contraceptives are one of the types of hormonal contraception, which was created in connection with the need to exclude the estrogen component that causes most metabolic disorders: hypertension and, especially, thromboembolic conditions. Progestin-only methods of contraception include:
oral contraceptives containing only progestogen (purely progestin tablets, or mini-pills);
injectable gestagens (Depo-Provera);
subcutaneous implants (Norplant, Implanon);
intrauterine hormonal system (Mirena).
This chapter will only provide information about oral progestogen contraceptives - pure progestin tablets (POPs). Modern POPs contain 0.03-0.5 mg (30-500 mcg) of progestin, which is 1/10-1/2 (15-30%) of its share, which is part of the combined oral contraceptives. These include:
Exkluton - 500 mcg of linestrenol;
Microlut - 30 mcg of levonorgestrel;
Charozetta - 75 micrograms of desogestrel.
1. Increasing the viscosity of cervical mucus.
Progestogens reduce the volume of crypts, thicken the cervix
mucus, reduce the content of sialic acid in the mucus, reduce the activity of spermatozoa, narrow the cervical canal, thereby preventing the penetration of spermatozoa and some microorganisms into the cervical canal, uterus and tubes. This explains both the contraceptive and therapeutic effect of progestogens in pelvic inflammatory disease.
Reducing the contractile activity of the fallopian tubes by reducing the contractile activity and the excitability threshold of the muscle cell.
specific effect on the endometrium.
The mechanism of action on the endometrium determines both contraceptive efficacy and healing effect and depends on the dose of progestogen, its type and affinity for progesterone receptors.
4. Inhibitory effect on the secretion of gonadotropic pituitary hormones (especially luteinizing) and, as a result, inhibition of ovulation (depends on the dose of gestagens in the tablet).
Application scheme
POPs are taken on a continuous basis, starting from the 1st day of the menstrual cycle daily without a break for menstruation. The time of administration does not play a role, however, the subsequent administration of the drug should be made at the same selected hour, since the half-life of the drug is 22-24 hours. The contraceptive effect is fully manifested after 48 hours. Therefore, it is necessary to apply additional protective measures during this period . In case of missing the drug or taking the pill later than 24 hours, the forgotten pill should be taken as soon as possible and continue to adhere to the pill regimen, at the same time using other types of contraception for the first 48 hours.
The exception is Charozetta. These pure progestin tablets contain 75 micrograms of desogestrel, which allows 97% of women to suppress ovulation, and the elimination half-life is 36 hours, like COCs.
When switching from COC to CHPT reception of the latter should begin the next day after the end of the use of COCs. None additional measures precaution is not required.
After the abortion pills should be started immediately, preferably on the day of the abortion.
Purely progestin pills, like any other method of contraception, have indications and contraindications, advantages and disadvantages.
Progestin methods of contraception, as well as combined estrogen-progestin contraceptives, have contraindications for use. There is an opinion that absolute contraindications for the use of pure progestin-new and combined hormonal contraceptives are the same. However, gestagenic contraceptives do not affect blood pressure, blood coagulation, therefore, do not cause the development of thrombosis, slightly affect lipid metabolism and liver function. Therefore, medical contraindications to the use of contraceptives containing only
gestagens should be considered separately from contraindications to the use of COCs.
Contraindications to the use of progestogen-containing contraceptives
1. Confirmed and suspected pregnancy.
Progestogen contraceptives should not be used during
time of pregnancy. Current evidence suggests that low dose progestin injections, implants, tablets, and progestin IUDs do not significantly increase the risk of congenital malformations, miscarriage, or stillbirth. However, despite the low dose of progestin, it is best to avoid taking these drugs in early pregnancy.
2. Diseases of the liver with a violation of its function.
There is no evidence that progestogen contraceptives cause liver and biliary tract disease. However, impaired hepatic function may interfere with the metabolism of PPT. Therefore, it is not recommended to use POP in active viral hepatitis, benign and malignant liver tumors, severe uncompensated cirrhosis and concomitant use of drugs that affect its enzymatic function (rifampicin, phenytoin, carbamazepine, barbiturates, topiramate, etc.).
3. Lesions of the cerebral and coronary arteries.
Theoretically, POPs may have an effect on lipid
spectrum of blood, thereby contributing to the emergence and. progression of atherosclerosis, and hence the occurrence of myocardial infarctions and strokes. Also, their use in coronary heart disease in history or at the moment is not shown.
4. Malignant tumors of the reproductive system (according to
thoracic organs, mammary gland, etc.).
There is no evidence that low doses of progestin can cause breast cancer. However, breast cancer is a hormone-dependent tumor. Patients with seals in the mammary gland need a preliminary examination by a mammologist or oncologist. For women with current or past breast cancer (within the past 5 years), progestin-only contraceptives are not recommended. The use of this method of contraception in women with benign conditions
breast pressure or with a family history of breast cancer is not contraindicated.
5. Bleeding from the genital tract of unclear etiology.
The use of purely progestin contraceptives not only does not cause worsening of diseases, the symptom of which is bloody discharge from the genital tract (the threat of premature termination of uterine pregnancy, ectopic pregnancy, cervicitis, genital cancer, etc.), but often prevents their development. However, POPs can cause menstrual irregularities in the form of intermenstrual spotting and acyclic bleeding, which can lead to delayed diagnosis of diseases that have the same symptomatology. In connection with the foregoing, this method of contraception for bleeding of unclear etiology is not recommended.
Relative contraindications include functional ovarian cysts, since the use of progestogen contraceptives has a high incidence of their occurrence.
The same applies to a history of ectopic pregnancy, since gestagens slow down the transport of the egg through the tubes and the occurrence of a repeated ectopic pregnancy is not excluded.
Advantages
No estrogen-dependent adverse reactions.
Better portability.
Possibility of use during lactation. PPTs can be used for breastfeeding, since they do not affect the quantity and quality of mother's milk and the duration of lactation. There is evidence that preparations containing only progestogen even increase the amount of mother's milk and lengthen the lactation period. This type of contraception can be used after 6 weeks. postpartum (WHO, 2004).
Less, compared with combined estrogen-progestin contraceptives, systemic effects on the body.
Progestogens have little effect on carbohydrate, fat and protein metabolism, blood pressure.
A pronounced therapeutic and protective effect in algo-dysmenorrhea, ovulatory pain, inflammatory diseases of the pelvic organs, anemia, fibrocystic mastopathy, genital endometriosis.
Flaws
POPs, with the exception of Charosetta, are less effective than COCs.
High frequency of menstrual irregularities.
Annual control over the intake of tablets.
The most common side effect of progestogen contraceptives is menstrual irregularity:
intermenstrual bleeding,
shortening of the menstrual cycle,
oligomenorrhea,
menometrorrhagia.
As the duration of the use of progestogen contraceptives increases, the frequency of intermenstrual bleeding You- divisions decreases, and after 3-6 months. they usually stop.
Cases of severe uterine bleeding requiring therapeutic intervention are extremely rare (occur in approximately 0.5% of women). The need for estrogen therapy or curettage of the uterine cavity is rare. When using gestagens, amenorrhea may also develop. Women using progestogen methods of contraception should be prepared for the fact that in the first 6 months of using the drug they may experience irregular spotting, and then, in the next 6 months and beyond, rare bleeding or amenorrhea.
Menstrual irregularities in the form of a smearing nature of intermenstrual spotting and acyclic bleeding in women using pure progestin tablets are observed in 15-20% of cases. Amenorrhea is extremely rare.
Some women taking progestogen-only contraceptives cannot get used to menstrual irregularities, despite the explanations given to them during counseling. In this regard, various approaches can be used to reduce bleeding. In the absence of contraindications to the use of estrogens, combined oral contraceptives or estrogens in a small dose are prescribed for 1-3 weeks, which in most cases
tea temporarily reduces or even stops bleeding. It is not recommended to prescribe COCs in order to cause bleeding in case of amenorrhea resulting from the use of pure progestin contraceptives. The effectiveness of progestogen contraception increases the correct counseling.
Rarely, side effects such as:
increased appetite;
change in body weight;
decreased libido;
depression;
nausea;
vomit;
headache;
engorgement of the mammary glands;
acne.
The lower the dose of progestogen, the less often the above reactions occur. However, the lower the dose of progestogen, the lower the effectiveness of this method of contraception.
Contraceptive efficacy
Gestagens block ovulation if they are used in high doses. The contraceptive effect in this case is primarily due to the suppression of ovulation, as a result of which changes occur in the endometrium, cervical mucus, which leads to a decrease in fertility. Microdoses of gestagens also provide contraception in most women, but without the suppression of ovulation, but due to the ability of gestagens to increase the viscosity of cervical mucus and inhibit secretory changes in the endometrium. Anovulation is observed only in 25-40% of women when using Microlut and Exkluton, and when using Charosetta - in 97%. This explains the low effect of small doses of progestagens. The contraceptive efficacy of mini-pills ranges from 0.14 to 10 pregnancies per 100 women within 1 year.
The reasons for the low effectiveness of POPs, in addition, are their irregular intake, the development of vomiting and diarrhea within 2-4 hours after taking the pill, the simultaneous use of other drugs (antibiotics, tranquilizers, hypnotics, activated charcoal, anticonvulsants and
tuberculosis) and switching to various low-calorie and vegetarian diets.
Possible systemic effects on the body
Receptors for progesterone are found in many tissues of a woman's body, in particular, in the brain, bone system, vascular wall, uterus, cells of the cervical canal, bladder, breast tissues, etc. This is the reason for both the contraceptive effect of progestogens, and and their possible systemic effects on the body.
Progestogens have the ability influence neurohormones and neuropeptides, contained in the brain by binding to progesterone receptors in the CNS.
The normal functioning of the hypothalamic region and other parts of the brain is characterized by a certain ratio of dopamine, serotonin and acetylcholine. It is in the hypothalamic region of the brain that the central steroid-sensitive systems (receptors) involved in the feedback mechanism are concentrated.
Mood, sexual behavior, nutrition, pain and the state of the hypothalamic-pituitary-ovarian system are regulated by P-endorphins produced by the hypothalamus.
The use of progesterone, cyproterone, norethisterone and norgestimate increases the level of P-endorphins. Medroxyprogesterone and desogestrel do not have this ability. Androgens reduce the level of p-endorphins (Genazzani A.R. el al., 1992).
Gamma-aminobutyric acid (GABA) plays an important role in the activity of dopaminergic systems. In the hypothalamic region, in particular in the adenohypophysis, a change in the concentration of one mediator entails shifts in the concentration of other mediators. GABA is a natural mediator of brain tissue. Its largest amount is noted in the gray matter of the brain, in the hypothalamic region, the smallest - in the spinal cord, only traces - in other organs and tissues. A decrease in the level of GABA in the brain tissue in animals leads to the appearance of the phenomenon of arena running and seizures. An increase in the level of GABA is accompanied by ataxia, a decrease in motor activity, and an increase in the convulsive threshold.
Progesterone and its metabolites bind to GABA receptors and have a psychotropic effect on a woman's body, so they are used to treat certain forms of depression, aggression, migraine, emotional excitability.
ty Progesterone can have a hypnotic effect that is used to treat premenstrual syndrome and psychological stress. With a significant increase in the concentration of progesterone, drowsiness may occur.
IN Lately Researchers around the world are interested in the question of the effect of steroids on breast tissue. The mammary cycle differs significantly from the endometrial cycle. Although changes in the mammary glands occur during the cycle, however, the proliferative and secretory phases do not correspond to estrogenic and progestogenic activity, as in the endometrium. On the contrary, the peak of proliferation of mammary gland tissues is observed when the proliferative effect in the endometrium is minimal - when there is a maximum concentration of endogenous progesterone.
The effect of progestogens on the development of breast cancer is still unclear; in vivo progestogens in physiological concentrations simultaneously have both an inhibitory and an activating effect on the proliferation of breast cells. Progestogens reduce the concentration of estrogen receptors in breast tissues, the activity of 17p-hydroxysteroid dehydrogenase, which promotes the conversion of inactive estrogen into active, and the concentration of estradiol in breast tissues. Progestogens induce proliferation of epithelial cells and stimulate both apoptosis and mitosis. In phase II of the cycle, the volume of nuclei of epithelial cells is greater than in the proliferative phase, and an increase in mitotic activity is observed only in the secretory phase. The apoptosis index increases in the second phase of the cycle and is compensated by an increase in the mitosis index in the same phase. In the absence of this balancing mechanism, the mammary gland would be enlarged until menopause. Progestogens have the most pronounced proliferative effect on the mammary glands of nulliparous women.
Very important is effect of progestogens on the skeletal system women. They stimulate specific osteoblast receptors, block receptors for glucocorticoids, reduce the inhibitory effect of glucocorticoids on osteosynthesis, and have an antiresorptive effect.
Like all steroids progestogens affect metabolic processes. However, this effect is minimal. In particular, progestogens in high doses can affect carbohydrate metabolism, reducing glucose tolerance and increasing the concentration of insulin in the blood. There is a relationship between
the chemical structure of progestogen and the effect on glucose and insulin metabolism.
It should be noted that the effect of progestogens on carbohydrate metabolism depends not only on their chemical structure, but also on the type of animals on which the study is carried out. In experiments on monkeys, it has been shown that the use of progesterone and some synthetic progestins leads to an increase in insulin levels in response to intravenous glucose, and glucose tolerance is not impaired. According to researchers, progesterone causes the formation of metabolically inactive forms of insulin. With the introduction of exogenous insulin, the decrease in blood glucose is slower against the background of taking progesterone. This indicates a decrease in the rate of glucose utilization in the periphery. Mini-doses of progestogens do not affect carbohydrate metabolism in healthy women.
As with any active compounds, progestogens can affect blood lipid profile. Progestogens inhibit the synthesis of triglycerides in hepatocytes and cells of the small intestine, increasing the activity of lipoprotein lipase, accelerate the breakdown of HDL, thereby reducing their content in blood plasma, and contribute to an increase in LDL. In high doses, progestogens can lead to an increase in the atherogenic coefficient (CA) - the ratio of the amount of LDL and VLDL to HDL. An increase in CA during the use of hormonal contraception is prognostically unfavorable, as it predisposes to an increase in the relative risk of developing cardiovascular complications. The severity of the effect of progestogens on the concentration of HDL is due to the degree of androgenic activity of steroids (see the section "Comparative characteristics of progestogens that are part of modern COCs").
Progestogens do not cause significant changes in blood coagulation system and do not lead to an increased risk of thromboembolic complications in healthy women. If the parameters of hemostasis are already impaired before the start of hormonal contraception and there are other risk factors, then the risk of thromboembolic diseases may be increased.
The presence of estrogen and progestogen receptors in the endothelial and smooth muscle walls of blood vessels indicates the involvement of sex hormones in Metabo controllysm and vasoactive function of the vascular wall of veins and arteriy. It has been shown that sex hormones affect the activity of neurotransmitters and vasoactive peptides in the vascular
wall, promoting the synthesis and release of vasodilation and vasoconstriction factors from the endothelium, and have a direct effect on smooth muscle cell relaxation. On arteries progestogens in high doses can have a vasoconstrictive effect. The vasoconstrictive effect of progestogens is manifested only at the site of violation of the integrity of the vessel wall and damage to the epithelium, which can lead to platelet hyperaggregation, hypercoagulation and the development of arterial thrombosis. Therefore, women with a history of coronary heart disease, cerebrovascular accident, atherosclerosis should be observed more carefully. The effects of progestogens on veins not marked. Therefore, varicose veins are not a contraindication for the use of progestogens. Mini-doses of progestogens do not affect the vascular wall.
Fertility Restoration
After the end of the use of POP immediately or within 3 months. there is a normalization of the menstrual cycle and restoration of the regenerative function.
Any deviations during pregnancy and childbirth are not observed, a teratogenic effect has not been established.
Thus, compared with estrogen-containing contraceptives, POPs have a lesser systemic effect on the woman's body, do not cause estrogen-dependent effects, and can be used during lactation and in women with extragenital pathology and intolerance to estrogen-containing drugs. They have a pronounced therapeutic and protective effect in many estrogen-dependent diseases. Adverse reactions that occur with their use, as a rule, do not require any therapy. However, the effectiveness of POPs, with the exception of Charo-zetta, is inferior to that of COCs, and frequent intermenstrual bleeding reduces their acceptability. The safety of POP, like any other hormonal contraceptives, depends on careful consideration of contraindications, knowledge of the basics of clinical pharmacology, prediction and consideration of possible complications and adverse reactions, individual approach, as well as on age, health status, characteristics of intimate life, tolerability of the drug, the attitude of sexual partners to their appointment.
HORMONAL RELEASING SYSTEMS
Injectable contraception
The possibility of using long-acting contraceptives continues to attract the attention of scientists around the world. The most studied, widespread and well-proven injectable is depot med-] roxyprogesterone acetate (DMPA, Depo-Provera).
Description of the method
Depo-Provera is an aqueous suspension with the active ingredient medroxyprogesterone acetate (17-hydroxyprogesterone with a methyl group in position 6, Fig. 2.16) at a dose of 150 mg. The progestogenic activity of DMPA exceeds the activity of 17a-hydroxyprogesterone by 6-10 times. DMPA lacks the estrogenic and androgenic activity characteristic of some steroids used to prevent pregnancy.
Absolute contraindications(according to the medical "Criteria for the acceptability of the use of contraceptive methods", WHO, 2004):
deep vein thrombosis, thromboembolism, including history;
prolonged immobilization after surgery;
thrombogenetic mutations (Leiden factor, prothrombin mutations, etc.);
stroke, coronary artery disease (including history);
heart valve diseases (complicated by pulmonary hypertension, atrial fibrillation, etc.);
multiple risk factors for cardiovascular disease;
hypertension (BP system > 160 mm Hg or BP diast. > 100 mm Hg);
viral hepatitis;
malignant tumors of the liver;
pregnancy;
bleeding from the genital tract of unknown origin;
breast cancer (currently available).
The contraceptive effect of DMPA is due to various mechanisms, the most important of which are the suppression of ovulation and changes in the endometrium, in which the implantation of the egg is impossible. The contraceptive effect is carried out
Rice. 2.16. Chemical structure of medroxyprogesterone acetate.
It occurs at various levels of the hypothalamus-pituitary-ovaries-uterus system (for more details on the contraceptive effect of progestogens, see the relevant sections of the Guide).
Advantages:
prolonged prolonged contraception;
persistent protective effect against endometrial cancer;
lack of estrogen-dependent side effects;
no need for daily self-monitoring of use;
decrease in the volume of menstrual blood loss;
increased hemoglobin levels;
reducing the risk of inflammatory diseases;
reduction in the frequency of vulvovaginal candidiasis;
absence pronounced changes from blood coagulation factors and lipid metabolism.
1. Violations of the menstrual cycle.
Occur in most women while taking the drug and are more often characterized by non-abundant acyclic bleeding lasting 15 days or more, which are observed during the first months of using the drug. According to most researchers, in case of heavy bleeding, an effective treatment is a repeated injection of DMPA, produced against their background. The third and subsequent injections should
be carried out in the usual time, i.e. with an interval of 90 days (Prilepskaya V.N., Tagieva T.T., 1996; Gertig D. et al., 2004).
With an increase in the duration of DMPA use, the frequency and duration of bleeding are reduced, oligomenorrhea may occur, then amenorrhea, which is associated with changes in the endometrium, the cessation of cyclic processes in it as a result of continued contraception. With amenorrhea, it is recommended to exclude pregnancy using known methods. Treatment of amenorrhea is not required, since after the abolition of contraception, the cycle is restored by itself. independently (Bescrovniy S., Kira E., 2003; Gertig D., 2004).
2. Delayed restoration of fertility.
3 Bone resorption with long-term use.
4. The inability to quickly cancel this method of contraception.
Occasionally, side effects such as headache, decreased libido, swelling, weight gain. As a rule, adverse reactions are not pronounced and disappear on their own in the first months of contraception.
Considering that DMPA is a progestogen contraceptive, its use may be accompanied by the appearance spotting(of varying intensity), which usually occur during the first months of use and tend to decrease with further use drug. According to a study conducted at the State Institution Scientific Center of AGiP RAMS, against the background of the use of DMPA, 96.6% of women experienced menstrual irregularities in the form of acyclic bleeding (of varying intensity and duration) and amenorrhea. The duration of spotting did not exceed 8 days per month. In most patients, | after the first 3 months of contraception, the frequency, duration and intensity of bleeding decreased with the subsequent development of amenorrhea. So, by the 6th month of contraception, amenorrhea was observed in 20% of women, after 12 months. - every third (Prilepskaya V.N., Tagieva TT., 1996).
With light spotting, no therapy is required, as they tend to decrease with further use of the drug.
Excessive bleeding while taking DMPA is extremely rare, affecting less than 1 in 1,000 women.
In the case of heavy and / or prolonged bleeding, first of all, it is necessary to exclude a previously unrecognized organic pathology of the reproductive system. Compulsory
is to determine the level of hemoglobin. If iron deficiency anemia is detected, appropriate drugs should be recommended (Lamarque J.M., 2003).
With more abundant and prolonged bleeding, which is extremely rare, it is recommended to use estrogens (Microfolin) in a daily dose equivalent to 0.05-0.1 mg of ethinyl estradiol for 7-15 days for 1-2 cycles. However, no work has yet been carried out to study the effectiveness of estrogen therapy in the treatment of menstrual disorders associated with the use of injectable contraceptives.
Some women who use DMPA experience slight weight gain. Most studies report an increase in body weight from 0.5 to 2 kg by the end of the first year of use (Lamarque J., 2003; Truael J., 2004). According to a WHO study (1991), the average increase in body weight in 607 women who used DMPA was 1.5 g (Shirley S., 2001; Bescrovniy S. et al, 2003).
Filed by T.T. Tagiyeva (1996), in 48% of women, the use of DMPA was accompanied by rapidly passing adverse reactions in the form of weight gain, nausea, and minor edema.
The occurrence and disappearance of adverse reactions in the first 3 months of contraception confirm the concept of the existence of an adaptation period, after which the acceptability of the hormonal agent increases.
The results of the studies have shown that complications and adverse reactions are usually associated with uncontrolled and prolonged use of the drug without taking into account the characteristics of the female body and contraindications for use, which is observed in cases where a woman takes the drug without proper medical supervision or it is prescribed by a doctor, insufficiently familiar with the issues of contraception, pharmacological features of the drug, indications and contraindications for their appointment.
Application scheme
DMPA as a contraceptive is administered once every 90 days at a dose of 150 mg intramuscularly. The first injection is not
must be done within the first 7 days of the menstrual cycle. Compliance with this rule is extremely important, since it excludes the introduction of a hormonal contraceptive on early term not yet diagnosed pregnancy, as well as to obtain the maximum contraceptive effect during the first month. Subsequent injections of DMPA are carried out at 3-month intervals.
When administering the drug, in order to avoid incorrect dosage of the microcrystalline compound, it is necessary to shake the vial thoroughly before filling the syringe with the suspension. The solution is injected deep intramuscularly into the gluteal or deltoid muscle. The initial level of DMPA in plasma is high, and then gradually decreases. However, the high contraceptive effect of one injection persists for 3 months. and longer.
The introduction procedure is simple, not associated with sexual intercourse and, unlike most oral contraceptives, does not require daily self-monitoring.
Monitoring of patients is carried out in accordance with WHO recommendations (see Chapter 6).
Efficiency
One intramuscular injection of the drug provides a reliable contraceptive effect for 3 months. (99.7%).
The high contraceptive effectiveness of DMPA has been confirmed in more than 90 countries of the world, including the UK, Germany, Belgium, France, the USA, and about 3.5 million women around the world use this type of protection against unplanned pregnancy.
As a result of a multicenter study on the use of DMPA at a dose of 150 mg with an interval of 90 days in 3856 women, it was shown that the pregnancy rate was 0.25 per 100 women in 1 year (Selim A.G., 2002).
Studies have shown that preventing pregnancy with intramuscular injection of DMPA at a dose of 150 mg every 3 months is as effective as other methods of contraception and even surpasses many of them. Thus, the number of pregnancies within 1 year with the use of DMPA is 0.3-1%, oral contraceptives - 1-7%, bayer methods - up to 22% or more (Yasasever V. et al., 2003).
Thus, DMPA is a reliable contraceptive drug, comparable in effectiveness to surgical sterilization.
It has been established that the drug does not adversely affect the state of the gastrointestinal tract and liver function, thereby preventing the possibility of metabolic changes. It also does not cause precipitated changes in blood clotting factors and lipid metabolism, which can occur when taking certain oral contraceptives, which determines its advantages over them in relation to the risk of cardiovascular disorders.
Many researchers, analyzing data from epidemiological studies, found no relationship between an increase in the risk of coronary artery disease and the use of DMPA. It has been established that DMPA does not increase the frequency of thrombosis, since changes in the coagulation system occur mainly under the influence of the estrogenic component of hormonal contraceptives (Selim A., 2001).
Most researchers believe that DMPA does not affect the enzymatic and excretory functions of the liver, does not affect the activity of transaminases, alkaline phosphatase, and the level of bilirubin in the blood. According to the literature, even long-term use of DMPA does not have a significant effect on the levels of albumin and globulins in blood plasma. Also, there were no significant changes in the plasma concentrations of trace elements such as sodium, potassium, calcium, magnesium, zinc, phosphorus and copper (Sotaniemi E.A., 2003; Parkin D.M., 2004).
Restoration of fertility after DMPA withdrawal
After stopping the use of DMPA, most women experience a delayed restoration of fertility. The average duration of the period from the last injection to the restoration of ovulatory cycles is 5.5 months. For some women, this period is 1-2 years, while fertility is restored faster in younger women. A history of pregnancies and the total duration of DMPA use do not affect the rate of fertility recovery.
There is evidence that 1 year after the abolition of DMPA, the number of pregnancies ranged from 5 to 10%. Subsequently, by the 15th month of drug withdrawal, the pregnancy rate increases to 75%, and after 2 years - up to 95% (Ferguson D., 2003).
According to another large-scale study, during the first 12 months after stopping the use
DMPA planned pregnancy occurred in 70% of women (Triae1., 2004).
Thus, clinical studies conducted in several countries show that a delay in the restoration of fertility after the use of DMPA does not lead to subsequent infertility and fertility is restored, but, as a rule, it is delayed in time.
The use of DMPA reduces the risk of developing inflammatory diseases of the pelvic organs and the frequency of vulvovaginal candidiasis.
Due to the fact that the use of DMPA helps to reduce the volume of menstrual blood loss, in women using this drug, the level of hemoglobin and the life expectancy of red blood cells increase.
From our point of view, it is advisable to prescribe DMPA in cases where the drug will have not only a contraceptive, but also a therapeutic effect. We are talking about diseases such as hyperplastic processes of the endometrium, internal endometriosis, uterine fibroids. small sizes, in connection with which the use of DMPA seems to be especially promising in women over the age of 35 (Kulakov V.I. et al., 1998; Kulakov V.I., Prilepskaya V.N., 2002).
For 3 years, the effect of the drug on normal breast tissue (35 women) and on hyperplastic processes in the mammary glands (35 patients) was studied at the State Research Center of Anti-Agey and Psychiatry of the Russian Academy of Medical Sciences for 3 years. The state of the mammary glands was assessed on the basis of complaints of patients, examination, palpation every 3, 6, 9, 12 months. Non-contrast mammography was performed on the 8-10th day of the menstrual cycle. Control x-ray examination - after the end of contraception, but not earlier than in 1-2 years. As a result of the observation, it was revealed that under the influence of DMPA, the regression of diffuse hyperplastic processes of the mammary glands was observed in most women after 12 months. from the start of contraception. However, in a third of women, the x-ray picture remained the same as before the start of contraception.
Thus, DMPA is one of the effective contraceptives. In addition, in a number of diseases, the use of DMPA can also have a therapeutic effect.
IMPLANT CONTRACEPTION
In the 1980s, implanted contraception became very popular. This method continues to be improved to this day. The most famous of the implantation preparations is Norplant.
Development Norplant began in 1965. Norplant was first approved for clinical use in 1983. Currently, Norplant is registered and approved for use in more than 60 countries around the world.
Description of the method
The Norplant system consists of six cylindrical polymethylsiloxane (silastic) capsules containing a progestogen - levonorgestrel. Norplant capsules are installed subcutaneously, on the inner surface of the left shoulder in the form of a fan (Fig. 2.17) using a simple trocar.
Each capsule is 34 mm long, about 2.5 mm in diameter and contains 36 mg of levonorgestrel.
Rice. 2.17. Scheme of installation of Norplant capsules.
The hormone diffuses through the silastic wall at a constant rate. It should be noted that in the first few months after the introduction of Norplant, the rate of diffusion of levonorgestrel into the surrounding tissues and blood is 80 μg / day, but then gradually decreases and reaches 30-34 μg / day by the end of the first year of use.
Contraindications (in accordance with the "Criteria for the Acceptance of the Use of Contraceptive Methods", WHO, 2004). Absolute contraindications:
known or suspected pregnancy;
uterine bleeding of unknown etiology;
disorders of the blood coagulation system, including thrombosis, thrombophlebitis;
frequent headaches;
acute liver disease;
Relative contraindications:
taking rifampicin or anticonvulsants;
angina;
stroke;
circulatory disorders;
benign or malignant tumors of the liver.
The contraceptive action of Norplant is determined by several mechanisms. Ovulation suppression is one of the main mechanisms of the contraceptive action of levonorgestrel. It occurs as a result of an inhibitory effect on the hypothalamic-pituitary-ovarian system and, as a result, suppression of the secretion of gonadotropins LH and FSH. Reducing or suppressing the secretion of gonadotropins prevents the maturation of follicles in the ovary, inhibits ovulation and the preovulatory LH peak. The impact on the endometrium is characterized by inhibition of proliferative processes and the development of atrophic changes in the uterine mucosa, which prevents implantation. Cervical mucus under the influence of levonorgestrel becomes thicker and more viscous, which makes it difficult and disrupts the penetration of spermatozoa. Under the influence of levonorgestrel, the processes of maturation of the cells of the stratified squamous epithelium of the vagina change - the number of intermediate cells increases. It is also assumed that levonorgestrel may affect the activity of enzymes involved in the process of penetration of spermatozoa into the egg.
Thus, the mechanism of the contraceptive action of levonorgestrel is basically identical to all releasing systems, based on the blockade of ovulation, disruption of the implantation process and changes in the transport of gametes and the function of the corpus luteum.
Application scheme
Implantation is carried out in the first 5-7 days from the onset of menstruation or immediately after the abortion.
Norplant is recommended primarily for those who do not want to have children over the next few years, and for those who do not plan pregnancy and childbirth at all, or who have completed their reproductive function, but do not want to resort to irreversible methods of contraception, such as sterilization. In addition, Norplant can be offered to women who are deprived of a permanent source of contraceptives, and to patients immediately after an abortion.
Non-contraceptive therapeutic effects
Research recent years showed that hormonal contraceptives, including Norplant, not only prevent unwanted pregnancy, but also help reduce the risk of tumor diseases, which include ovarian cancer and endometrial cancer. Due to the fact that hormonal contraceptives are able to block ovulation, they have a protective effect against ovarian cancer, reducing the need for epithelial repair after repeated ovulations. By preventing proliferative processes, repetitive rejection and repair of the endometrium, hormonal contraceptives reduce the incidence of endometrial cancer.
Efficiency
According to I. Sivin (1980), during the first year after Norplant implantation, pregnancy occurs in only one woman out of 500, which is 0.2%. Population Council data, based on a study of 12,333 women, indicate that the percentage of failures is 1.2, 1.6 and 0.4% of pregnancies per year, respectively, for the second, third, fourth and fifth years of using Norplant.
Based on the results of a study of 10,710 women using Norplant, I. Sivin (1988) noted that the majority of pregnancies (Pearl index - 0.94) in the first year of Norplant use occurred even before implantation. Therefore, WHO since 1995 recommends Norplant implantation during the first 7 days of the menstrual cycle or immediately after the abortion.
Norplant capsules are subject to mandatory removal at the end of the fifth year of using the drug.
Thus, Norplant, subject to the recommendations on the timing of the introduction of the implant and its removal or replacement, is in a number of effective forms of reversible contraception.
Restoration of fertility after removal of Norplant
Restoration of fertility, regardless of the reason for the removal of the implanted drug, occurs quite quickly. Research conducted by J.C. Konje et al. (1992) showed that after the removal of Norplant, ovulation recovered gradually, but within 7 weeks. the restoration of ovulation occurred in all women, and already in the first cycle after the removal of Norplant, some women became pregnant.
Possible side effects and complications
One of the side effects of Norplant are menstrual irregularities. These disorders can manifest as prolonged menstrual-like bleeding, spotting, irregular menstruation, and amenorrhea. However, it should be noted that menstrual disorders are much more common in the first year of using Norplant, while the likelihood of amenorrhea increases with increasing duration of use of the drug.
Despite the lack of data on the adverse effects of irregular menstruation and amenorrhea on women's health, unpredictable episodes of bleeding or spotting of a spotting nature can cause discomfort to a woman, and prolonged amenorrhea raises the suspicion of an unplanned pregnancy.
Unfortunately no effective way diagnostics, on the basis of which it would be possible to predict in advance in which cases menstrual dysfunction should be expected. Some authors suggest that bleeding occurs more often in those women who in the past, even before the use of Norplant, had various menstrual irregularities.
In addition, some women experience headaches, nausea, nervousness, mastalgia, acne, weight gain. Very rarely, the introduction and removal of Norplant can be accompanied by an inflammatory process of the skin and subcutaneous tissue at the site of implantation. This is usually due to violations of the rules of asepsis.
Influence on metabolic processes
Based on the research of A. Benenson et al. (1995), J. Barbosa et al. (1995), Z.Haler et al. (1996) it can be concluded that the use of Norplant is not associated with
function of the liver, kidneys, adrenal glands, thyroid gland. However, J. Veigas et al. (1988) found a decrease in high-density lipoprotein in women using Norplant.
Norplant has only a minor effect on carbohydrate metabolism. The very weak effect of levonorgestrel on glucose tolerance has no clinical significance.
According to the literature, the drug changes the absorption of calcium by bone tissue and reduces its renal excretion.
The use of long-acting progestogens, such as injectable contraceptives and subcutaneous implants, is an effective and acceptable method of contraception for breastfeeding mothers. Norplant does not adversely affect lactation, the composition breast milk and child development.
An analysis of the observation of 100 women (50 in early reproductive age, 50 in late reproductive age) who were implanted with Norplant showed its high efficiency (not a single case of pregnancy was registered), good tolerance - 3% of implant removal before the end of the term actions (Gogaeva E.V., 2000).
Norplant, as already mentioned, consists of six capsules, which creates additional difficulties during administration and removal. It was to solve such problems in the early 90s of the last century that a single-capsule implantable contraceptive was proposed. Implanon, containing etonogestrel - a highly selective progestogen of the latest generation, a biologically active metabolite of desogestrel.
Description of the method
Etonogestrel is a derivative of 19-nortestosterone and has a high affinity for progesterone receptors in target tissues. The contraceptive effect of Implanon is due to the suppression of ovulation. Ovulation is absent during the first two years and is very rare in the third year of using Implanon. In addition to inhibiting ovulation, Implanon also causes a change in the viscosity of the cervical mucus, which prevents the penetration of spermatozoa.
Contraindications for the use of Implanon are the same as for Norplant.
Application scheme
Implanon is injected under the skin on the 1st-5th day of the menstrual cycle, immediately after the abortion or on the 21st-28th day after childbirth.
Implanon is a single silastic (evata-new) capsule 40 mm long, 2 mm in diameter, without a cavity and consisting of a system of membranes and the active substance etonogestrel, which is released at a constant rate along the biological gradient. The thickness of the outer membrane is 0.06 mm. The capsule shell consists of 100% ethylene vinyl acetate, the core is 28% ethylene vinyl acetate (46 mg) and 72% etonogestrel. Each capsule of Implanon contains 68 mg of etonogestrel.
After the introduction of Implanon, etonogestrel quickly enters the systemic circulation. A concentration sufficient to inhibit ovulation is achieved within 1 day.
Efficiency
In clinical studies, no pregnancies were reported in women using Implanon for a total of 73,429 cycles. The Pearl index for a three-year follow-up is 0.95 (confidence interval 0.00-0.07) (Affandi V., 1998).
Fertility Restoration
The contraceptive effect of Implanon is reversible, as evidenced by the rapid restoration of the normal menstrual cycle after the removal of the implant. Although Implanon inhibits ovulation, complete suppression of ovarian function does not occur. The average concentration of estradiol is maintained at a level above what is usually detected in the early follicular phase.
Influence on metabolic processes
In a two-year study, bone mineral density was determined in 44 patients using Implanon and compared with that of a control group of 29 women using intrauterine devices. There was no negative effect of the drug on bone mass (Beerthuizen R. et al, 2000). When using Implanon, there were no clinically significant abnormalities in lipid metabolism. However, acyclic spotting and amenorrhea occur quite often with its use.
With an increase in the time of use, data from retrospective and prospective studies on the use of implantable contraception are accumulating. It should be noted that Norplant is currently not supplied to Russia. Clinical trials are being conducted on the use of Implanon, but so far it has not been registered in Russia.
TRANSDERMAL RELEASE SYSTEM
The administration of drugs through a transdermal patch is a modern and non-invasive method that is easy to use and has a reversible effect. Transdermal systems have been used in various fields of medicine since the 90s of the last century, in particular in cardiology (for the purpose of stopping angina, antihypertensive), in oncology (pain relief for cancer), in gynecology (hormone replacement therapy), etc.
Progress in the improvement of transdermal systems using new technologies has led to the creation of polymers not only to improve the adhesive and functional properties of patches, but also to improve the possibility of their longer use, which, of course, was the impetus for their use for contraception.
The transdermal method of "delivery" of the active substance eliminates the effect of the primary passage through the liver, ensures a uniform concentration of the drug in the blood plasma during the day, gives additional confidence in the contraceptive effect: there is no need for additional use of contraception in case of diarrhea, vomiting, and also in cases where the woman forgot to replace the patch with a new one (the contraceptive effect persists for 48 hours).
Present on the Russian market transdermal contraceptive system EURA is a thin patch, the area of contact of which with the skin is 20 cm 2 . Each patch contains 600 micrograms of ethinylestradiol (EE) and 6 mg of norelgestromin (NG). Within 24 hours, the system releases 150 μg of NG and 20 μg of EE into the blood, which provides a contraceptive effect. According to the daily release of hormones, EVRA corresponds to combined microdosed oral contraceptives. The serum concentrations of norelgestromin and ethinylestradiol, which are released from the transdermal patch, remain within the appropriate limits for 7 days of use, regardless of its location (abdomen, buttocks, arm, torso). Norelgestromin is a highly selective gestagen of the latest generation, is a biologically active metabolite of norgestimate. It has been proven that norelgestromin has a high gestagenic activity, effectively suppresses ovulation, and increases the viscosity of cervical mucus (Abrams L.S. et al., 2002). Chemical formulas EE and NG are shown in Figure 2.18.
There are other methods of contraception. Probably, the method of contraception, which I will talk about in the article, is not known to everyone, so I will talk about it in detail. So, now let's look at, and for some women, get acquainted with prolonged contraception.
What is prolonged contraception?
Prolonged contraception means long-term contraception from the Latin word prolongus, which means "long, ongoing." Unlike those that need to be drunk regularly and constantly, prolonged preparations are injected into a woman's body with an injection and prevent pregnancy for a long time: from 3 months to 5 years.
The most common type of prolonged contraception is the injection of Depo-Provera. People usually call this procedure a "three-month" syringe, because one injection protects against pregnancy for three months. Also, many women use the hormonal drug Netoen. It is injected into the buttock once every two months by injection. The above drugs prevent the maturation of the egg and thus fertilization will not be able to occur. Such drugs are best used by women over 35 years of age.
Also now widespread is a prolonged contraceptive - "Norplant". It consists of six capsules that are injected into the skin of the forearm. The contraceptive effect is that the required dose of hormones is secreted from the capsules daily, and ovulation does not occur. Norplant has been operating for 5 years. Doctors advise administering the drug to a woman's body within a week from the onset of the menstrual cycle, after an abortion or after childbirth.
The pros and cons of long-acting contraception
Long-acting drugs can be taken with:
- obesity
- Liver diseases; drugs even treat some liver diseases: chronic cirrhosis, hepatitis
- hypertension
- Over 35 years of age
- Breastfeeding, but only 6-8 weeks after birth
After prolonged contraception, it takes time for fertilization to occur. On average, this will take about six months. Also with the menstrual cycle. He will recover in about 3 months.
