Has always been for women topical issue pregnancy prevention. Such an action must be reasonable and safe, so representatives of the fair sex always meticulously study all the proposed contraceptive options.
Today we will look at how Implanon is installed. - unique, which is widely used abroad and is becoming increasingly popular among our compatriots. We will listen to reviews from women who use it and talk about the side effects that may occur in those who use this contraceptive.
How is the contraceptive effect achieved when using an implant?
The contraceptive drug "Implanon" is a contraceptive that contains etonogesrel in the amount of 68 mg and does not undergo biological degradation. It comes in the form of a silicone-like rod, about four centimeters long and 2 mm in circumference, which is placed in the applicator. This drug provides continuous contraception for three years.
After administration, a contraceptive substance begins to be released from the described product in very small quantities, similar in effect to the substances in it. 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 impedes the movement of sperm.
This is enough for a woman to have a lasting contraceptive effect. It is 99%. This result corresponds to the effect of regularly taking oral tablets, but without many side effects observed in this case.
How can Implanon be administered?
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 cases where installation occurs later, the woman is recommended to use a barrier method as additional contraception for a week after administration of the drug. If the patient has had sexual intercourse, then she should wait until her first menstruation before inserting the implant.
The duration of the manipulation is only a minute. The contraceptive is placed under the skin, with inside shoulder, which allows him to be invisible to others. After which a bandage is applied to the wound surface. It can be removed within a few hours after placement of the Implanon contraceptive.
Reviews from patients claim that the drug can be detected later only with gentle pressure on the implantation site.
If you follow the instructions, the risk of complications is low.
How to stop the action of a subcutaneous implant?
If you decide for any reason to interrupt contraception, then you do not need to wait three years for the Implanon drug to expire. The instructions specify that its removal should only be carried out by a doctor familiar with the methodology of this process. This is done at a time convenient for you, on an outpatient basis, using
During the removal process, 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 3mm incision is made in 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, you need to measure it (the length must remain the same: 40 mm).
The effect of the described drug is reversible, and after its removal the menstrual cycle and reproductive function are restored female body for three weeks already.
Cases of deep administration 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, a blow to the inside of the arm), it may migrate from its place of placement. It is quite difficult to determine its position, and removal may require strong dissection.
If the drug cannot be detected, then both the contraceptive effect and the risk of side effects may persist beyond the time desired by the patient.
Consequences of using contraception
In the world there is no medicines without side effects. For the described remedy, these may include migraines, slight 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 discharges may change, but in most cases they are minor. One in five women stop menstruating altogether for some time.
If these symptoms are systemic in nature, medical consultation is necessary. 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 on the interaction of the drug with other drugs
It is important to remember the need to be especially careful when using medications when using the Implanon contraceptive! Reviews from experts say that the doctor needs all the information about the medications that a woman takes in this moment or is going to take it in the near future, including herbal remedies.
And since some of them may reduce the effectiveness of the described contraceptive, the woman will have to additionally use barrier methods to prevent pregnancy. And patients taking medications for a long time to induce microsomal liver enzymes must 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 the use of which are discussed here, is not recommended during pregnancy, venous thromboembolism, severe liver disease, breast cancer, vaginal bleeding, as well as hypersensitivity to the components of the drug.
If the condition worsens after the administration of the drug, it is necessary to consult a doctor who will decide on the rationality of using this contraceptive.
Remember that although this implant is a long-acting drug, it is not recommended to leave it in place for longer than three years.
Contraceptive "Implanon": reviews
According to reviews of gynecologists and women who have used the drug "Implanon", this remedy is suitable for many of those for whom conventional birth control pills- breastfeeding women, patients with cardiovascular diseases and women who smoke.
In addition, the drug included in the described contraceptive, according to medical observations, 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, normalization of the menstrual cycle and the disappearance of premenstrual syndrome, as well as feelings of discomfort and pain during menstruation, were also observed.
In addition, women noted the convenience of using this product: after all, it is impossible to forget to take this contraceptive on time - it is always with you!
Price for the drug
When discussing the Implanon contraceptive, 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 benefits of purchasing the contraceptive described 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 approximately 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 have no direct contraindications for using the Implanon contraceptive, its price should suit you. And the conveniences described above in using this drug will push you to the right decision.
Feel great!
The role of women in modern society and family. Survey results. New scheme taking hormonal contraception.
V.N. Prilepskaya, State Institution Scientific Center of Obstetrics, Gynecology and Perinatology (Dir. - Academician of the Russian Academy of Medical Sciences V.I. Kulakov) Russian Academy of Medical Sciences, 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 associated significant changes in a woman’s lifestyle 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 characteristics of the body, previously considered normal and natural, need to change their medical interpretation and approach to them (WHO, 2000).
At the beginning of the 21st century, a group of renowned scientists and doctors published the concept that monthly ovulation and menstruation are unnecessary 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 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 menstruation-related disorders and menstrual irregularities 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 sexual activity 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, and early onset of sexual activity is noted – at the age of 14–15 years. Despite this, modern young women are in no hurry to get married and have children; currently the frequency of civil marriages is quite high, while most couples are in no hurry to have children, and in most cases the first pregnancy, usually planned, occurs at age 25–30 years and even later. Unfortunately, the percentage of lactating women has decreased significantly: if previously up to 85% of women breastfed, currently this figure is no more than 20%. In addition, the average age at menopause has increased from 40–45 years several decades ago to 50–55 years now. All this indicates that in the modern population of women, the reproductive period of their lives has significantly extended.
Currently, 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, “the woman of yesterday” is, first of all, 160 ovulations during her life, early marriage and, at the same time, practicallyabsence of abortions, high frequency of pregnancies and childbirths and, as a consequence, long-term, up to 3years, lactational amenorrhea. At the same time, the “woman of yesterday” was not assigned a role at all, neither in society, nor in politics, nor in business.
When considering a “woman today,” we can focus 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 during their lives, 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 often, and the period of breastfeeding is short.
The social status of women has also changed: it has increased average duration a woman’s life (for example, in economically developed countries this figure is 86 years), our contemporary woman is active in the family, business, politics, always wants to look good, is actively involved in sports, and tries to be financially independent.
Along with this, changes in the endocrine profile occur: monthly ovulations lead to large fluctuations in hormone levels and desynchronization of the hypothalamic-pituitary system. The consequence of this is a significantly increased incidence of various gynecological diseases, including menstrual irregularities, 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, “the woman of yesterday” and “the woman of today” are different women who differ from each other in a number of parameters: social status, reproductive history, morbidity, etc.
Taking this into account, the approach to a woman as a patient must change; in particular, in modern literature the issue is currently being actively discussed: “Can monthly menstruation be optional?” . However, a number of researchers are of the opinion that “there is no equal sign between a “regular” and a “normal” menstrual cycle” , and according to K. Blanchard et al., “menstrual cycles 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 the women themselves. It was for this purpose that 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 not to have periods, 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 1,195 women of reproductive ageand the following was established: monthly menstrual bleeding is preferred by 26–35%Of women, 16–27% of respondents would like to have menstruation 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 their quality of life, reduce the degree of blood loss and pain during menstruation. According to respondents, reducing the number of periods allows you to improve personal hygiene and even solve some 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 towards 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 respondents, it is important to menstruate monthly, 22% believe that monthly menstruation is harmful to health, 44% of health workers responded that suppressing menstruation is necessary only in certain cases, and 23% abstained from answering.
One of the first publications dedicated to practical application long-acting 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 with 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. Increasing the duration of use and shortening the interval reduced the frequency and severity of “withdrawal symptoms” by 4 times.
It has now been proven that during a 7-day interval when taking COCs from the 3rd–4th day of the cycle, there is an increase in the level of FSH, 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 may be detected, possessing aromatase activity, producing estradiol, and capable of developing into a dominant follicle.
Long-acting 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 regimen of taking COCs. The use of COCs in a continuous mode (long-term contraception) determines better FSH suppression and better suppression of ovarian follicular activity; against this background, stabilization of the function of the endocrine system is observed and thereby has a positive effect on various hyperestrogenic conditions.
The idea of long-term contraception was proposed back in 1968 by the creator of the first contraceptive pill, Gregory Pincus.
Long-acting contraception is an effective method of fertility control 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 cycle duration from 7 weeks to several months. For example, it may include taking 30 mcg ethinyl estradiol and 150 mcg desogestrel (Marvelon) or any other COC in a continuous regimen. There are several long-acting contraceptive regimens. The short-term dosing regimen allows you to delay menstruation by 1–7 days and is practiced before an upcoming surgical intervention, vacation, honeymoon, business trip, etc. A long-term dosing regimen 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, etc.
Due to the urgency of the problem, at the end of 2003, the FDA (Food and Drug Administration) approved the use of a new extended-release COC, Seasonale®, specifically designed to reduce the total number of menstrual periods from 13 to 4 per day. year. Each tablet of the drug contains 30 mcg of ethinyl estradiol and 150 mcg of levonorgestrel; the regimen includes 84 days of administration + 7 days of placebo.
Long-acting contraception can be used not only to delay menstruation, but also with therapeutic purpose. For example, there is evidence in the literature of continuous use of oral
a contraceptive containing 30 mcg ethinyl estradiol and 150 mcg desogestrel (Marvelon®), after surgical treatment of endometriosis. According to the results of the study, the use of this drug continuously for 3–6 months significantly reduced the symptoms of dysmenorrhea, dyspareunia, and improved the quality of life of patients and their sexual satisfaction.
The prescription of prolonged contraception is also justified in the treatment of uterine leiomyoma, since in this case the synthesis of estrogen by the ovaries is suppressed, the level of total and free androgens, which under the influence of aromatase synthesized by the tissues of leiomyoma, can be converted into estrogens, decreases. 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 long-acting contraception for 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 for the purpose of relieving vasomotor and neuropsychic disorders of menopausal syndrome. In addition, prolonged contraception enhances the cancer-protective effect of hormonal contraception and helps prevent bone loss in women of this age group.
The main problem with the prolonged regimen is the high frequency of bleeding.va" and "spotting" bloody discharge compared to the traditional regimen of taking COCs. ByAccording to the results of clinical studies, intermenstrual bleeding is usually observed during the first 2 months of use and is the reason for refusal of further continuous use of drugs in 10–12% of women. Currently available data indicate that the incidence of adverse reactions with extended cycle regimens is similar to those for conventional dosing regimens.
The global 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 regimen for taking COCs. An alternative to the standard regimen of oral contraceptives is long-acting contraception using COCs of varying composition and dosage. At the same time, it must be remembered that long-acting contraception is not suitable for all women, and before its prescription and during 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 problem and a detailed study of the effect of a prolonged regimen on a woman’s body is necessary.
A new regimen of hormonal contraception, in which hormonal drugs 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 7-day break. Along with the 63+7 mode, a 126+7 scheme is proposed, which in its portability does not differ from the 63+7 mode.
According to studies, against the background of prolonged use, women practically cease to encounter such common PMS problems as headache, dysmenorrhea, tension in the mammary glandsswelling. When there is no break in taking hormonal contraceptives P stable suppression of gonadotropic hormones occurs, but does not occur in the ovariesmaturation of follicles and a monotonous state is established in the body model of hormonal background. This is what explains the reduction 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 use of contraceptive tablet forms and is designed for a long period of action, is called prolonged (from the Latin prolongus - ongoing). Interest in this method of preventing pregnancy and its use for medicinal purposes arose in the late 80s of the 20th 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 long-acting contraception?
Prolonged contraception is based on the action of exclusively progestin preparations, which are analogues of the hormone progesterone, which is produced in the ovaries. The estrogenic 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 intrauterine device.
What choice do you have?
Modern medicine offers two types of long-acting contraceptives, differing in the method of administration to the female body:
- subcutaneous implants;
- injectable gestagens.
Both have the same principle of action for all gestagenic contraceptives: the receptivity of the endometrium is reduced and ovulation is suppressed, the penetration of sperm is difficult due to the thickening of cervical mucus in the cervix.
Long-term contraception with Norplant: pros and cons
Norplant is used as an implantable agent, which is capable of continuously providing pregnancy-preventing effects for 5 years. The active substance levonorgestrel is placed in a capsule (there are six in the set), from which it methodically (at a constant speed) penetrates into the blood. Externally, the capsule resembles a 34 mm long match. Norplant is transplanted surgically into the forearm area in the first 5-7 days after the onset of menstruation or immediately after an abortion. Being located on the inside, the capsules are not visible from the outside and do not cause any discomfort. Novocaine is usually used as a local anesthesia. After implantation, you need to keep the area dry for several days and avoid 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;
- reducing the risk of cancer, including endometrial cancer.
There are also disadvantages:
- the likelihood of slight weight gain;
- changes in the menstrual cycle (scanty or absent periods);
- bloody issues.
These side effects gradually subside without causing harm to health. At the end of the five-year period, the capsules are removed by a 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.
Long-acting 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 women who are breastfeeding and 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. Clinical manifestations of endometriosis largely depend on the level of estrogen, so suppression of ovarian steroid production leads to a decrease in the severity of symptoms. In endometrioid tissue, the expression of 17β-hydroxysteroid dehydrogenase type 2, which converts estradiol to estrone, but is not involved in the metabolism of ethinyl-estradiol, is reduced (Guillebaud J., 1987).
Suppression of estrogen synthesis in the ovaries under the influence of oral contraceptives can reduce the estrogenic effect in tissues, since ethinyl estradiol stimulates proliferation less than estradiol (Wiegratz L., Kuhl H., 2004). Continuous treatment with a combination drug containing 20 mcg ethinyl estradiol and 150 mcg desogestrel for recurrent pelvic pain after surgical treatment of endometriosis, accompanied by clinical manifestations, led to a significant reduction 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 therapy with oral contraceptives is suppressed, but after cessation of treatment its clinical manifestations may recur (Park V.K. et al., 1996). Therefore, continuous regimens with an extended cycle of oral contraceptives for 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 the results of ultrasound examination and the results of hysterectomy (Marshall L.M. et al., 1997). For 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, to evaluate the effectiveness and safety of continuous use of oral contraceptives for uterine leiomyomas, prospective randomized clinical trials are necessary.
Polycystic ovary syndrome (PCOS)
In PCOS, continuous treatment with monophasic oral contraceptives causes a more pronounced suppression of androgen production in the ovaries than standard treatment regimens, and due to this, it can have a more pronounced therapeutic effect in diseases associated with androgen overproduction (Ruchhoft E. et al., 1996). When taking oral contraceptives according to regular regimens, androgen synthesis may increase again during withdrawal intervals (Kuhl H. et al., 1985; Kistner R.W., 1956).
A small study of patients with PCOS showed that a conventional combination regimen of ethinylest-radiol 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 depot GnRH agonists (Ruchhoft E. et al., 1996). Although oral contraceptives are considered a traditional method of long-term treatment for PCOS, there is still insufficient data on the health risks they pose to patients. Additional studies are required to evaluate the long-term effect of oral contraceptives on metabolism, given the possibility of combining PCOS 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 can improve the overall clinical condition of patients.
Therefore, in case of pathological uterine bleeding, after excluding organic causes of the disease, regimens with an extended cycle of oral contraceptives may 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 mammary glands, swelling, depression, increased irritability, which fully manifest themselves in the second phase of the menstrual cycle and disappear during menstruation (Svemdottir H., Backstrom T.J 2000). When using oral contraceptives in accordance with the standard “21/7” regimen, clinical manifestations develop more often during 7-day hormone withdrawal intervals than during 21-day cycles of taking hormonal drugs (Oinonen K.A., Mazmanian D., 2002). A number of studies have shown that continuous and uniform exposure to sex steroids leads to a decrease in clinical manifestations caused by COC withdrawal: 74% of women noted a decrease in symptoms associated with hormone withdrawal. Almost half of the women continued the extended regimen of oral contraceptives for 5 years, and most of them noted a decrease in the initially existing 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 correct use of combined oral contraceptives reduces the incidence of endometrial hyperplasia and 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 constant and significant suppression of ovarian estrogen production, enhances the suppressive effect of the progestogen component on the endometrium. With continuous therapy with ethinyl estradiol 20 mcg and levonorgestrel 100 mcg, carried out for 336 days, a histological examination of endometrial biopsies from 8 women revealed a lack of proliferative activity or endometrial atrophy in 7 of them (Miller L., Hughes J.P., 2003).
Effect on fertility
Although the significant suppression of ovarian activity caused by oral contraceptives may in many cases |
teas lead to amenorrhea, hypoestrogenism does not develop, since the decrease in estradiol levels is compensated by the presence of exogenous estradiol. Current evidence suggests that long-term use of oral contraceptives, once discontinued, does not have an adverse effect on fertility (Farrow A. et al, 2002).
Risk associated with long-term use of the drug
Although clinicians have empirically used extended cycles of oral contraceptives to delay menstruation for many years, data on the long-term risks of this treatment regimen are lacking. The risk of developing cancer or cardiovascular disease in young women can only be assessed after courses of treatment have been completed. large quantity patsintok for a fairly long period of time. However, the Million Women Study found no difference between sequential and continuous estrogen and progesterone regimens in terms of 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 also remains unresolved about the likelihood of developing thromboembolic diseases, which increases 3-5 times when taking oral contraceptives (Bloemenkamp K.W.M. et al., 2000). This risk appears to be 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). Given 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), to identify differences in the increased risk between traditional and extended regimens Prescribing oral contraceptives will require considerable time.
It is known that the metabolic effects of oral contraceptives largely depend on the composition of the drug and that various blood counts can either increase or decrease. With traditional treatment regimens, these changes are largely reversible during the 7-day hormone withdrawal interval (Kuhl H. et al., 1988; Jung-Hoff-
Mann C. et al., 1998). In the future, it will be necessary to evaluate whether stable levels of these indicators are achieved with continuous therapy or with extended cycle regimens and over what period of time this occurs.
Main side effects associated with prolonged oral contraceptive regimens
Some studies of extended cycle regimens have revealed a high rate of treatment refusal due to the presence of irregular uterine bleeding and spotting (Parazzini F. et al., 1994); therefore, it is necessary to evaluate the effect of different formulations of oral hormonal contraceptives on these symptoms. At the same time, some studies have shown that many women are willing to accept these adverse reactions as long as problems associated with menstruation and/or endometriosis disappear and the number of menstrual bleedings per year decreases. (Vercellini P. et al, 1999; Back D J., Orme M.L.E., 1990).
Data from clinical trials comparing the side effects of traditionally used oral contraceptive regimens and long-acting regimens that used the same drugs did not reveal differences in the frequency and nature of side effects that developed, for example, breast tenderness, nausea, anxiety, weight changes .
Thus, in recent decades, several main trends in the development of contraception have been observed: improvement chemical composition combined contraceptives, aimed at creating new progestogen components; development and implementation of new ways of entering drug components into a woman’s body (such as the intrauterine releasing system, vaginal contraceptive ring and transdermal releasing system), as well as modernizing the use of existing combined oral contraceptives. The use of extended-dose regimens of oral contraceptives significantly suppresses ovarian function, which makes it possible to increase the effectiveness of contraception, reducing the likelihood of unwanted pregnancy if pills are accidentally missed. In addition, long-acting regimens may be the treatment of choice when coadministered with drugs that interfere with the effectiveness of oral contraceptives. The frequency and abundance of menstruation with this method of using COCs is significantly reduced -
This makes it possible to prevent the development of clinical symptoms associated both with the menstrual cycle itself and with periods of drug withdrawal.
Changes over recent decades
XX century in reproductive history, morbidity and social
al status of a woman, dictate to doctors the need for you
express the wishes of patients regarding menstrual frequency
significant bleeding, as well as the presence of withdrawal bleeding
and/or spotting. Reguli ability
mastering these processes is another step towards autonomy
women. Some authors call drug ame
norea “menstrual nirvana” (Edelman A., 2002).
Existing evidence suggests that most women prefer extended cycle regimens, despite the increasing incidence of irregular bleeding, because the reduction in menstrual frequency and clinical manifestations of premenstrual syndrome can improve quality of life. “Menstrue cycles should be a woman’s choice, not a disaster” (Blanchard K., 2003).
Active study and use of long-acting oral contraceptive regimens will allow physicians
In the 21st century, the use of contraceptives is not only
for the purpose of contraception or treatment of a number of gynecological problems
diseases, but also pay more attention to subjective
women's feelings about their health and improve
quality of life.
Thus, today the trend towards the use of drugs not only for therapeutic purposes, but also in terms of lifestyle choices is caused by a joint decision of the patient and the doctor. However, for the widespread introduction into clinical practice of regimens of prolonged use of oral contraceptives, further research is required regarding the effect of regimens of oral contraceptives in a prolonged mode on the general condition of patients, the menstrual cycle and its disorders (dysmenorrhea, hyperpolymenorrhea), changes in the hemostatic system, lipid- blood spectrum, for the subsequent restoration of fertility after stopping the use of the drug. A significant role in the introduction of long-term use of oral contraceptives into clinical practice will be played by studying the attitudes of women themselves and medical workers to this issue. At the same time, it must be remembered that long-acting contraception is not indicated for all women, and careful monitoring and follow-up are required before its use and during its use.
ORAL HORMONAL CONTRACEPTIVES CONTAINING PROGESTAGEN ONLY (PROGESTIN PURE TABLETS, OR MINI-PILS)
Progestin-only contraceptives are one of the types of hormonal contraception, which was created due to the need to exclude the estrogenic component, which causes most metabolic disorders: hypertension and, especially, thromboembolic conditions. Progestin-only methods of contraception include:
oral contraceptives containing only progestogen (pure progestin tablets, or mini-pills);
injectable gestagens (Depo-Provera);
subcutaneous implants (Norplant, Implanon);
intrauterine hormonal system (Mirena).
This chapter will provide information only about oral progestin contraceptives - progestin-only tablets (PPP). Modern PPTs contain 0.03-0.5 mg (30-500 mcg) of progestin, which is 1/10-1/2 (15-30%) of its share included in combined oral contraceptives. These include:
Excluton - 500 mcg linestrenol;
Microlut - 30 mcg of levonorgestrel;
Charozetta - 75 mcg desogestrel.
1. Increased viscosity of cervical mucus.
Progestogens reduce the volume of crypts, thicken the cervical
fecal mucus, reduce the content of sialic acid in the mucus, reduce the activity of sperm, narrow the cervical canal, thereby preventing the penetration of sperm and some microorganisms into the cervical canal, uterus and tubes. This explains both the contraceptive and therapeutic effect of progestogens in inflammatory diseases of the pelvic organs.
Reduced contractile activity of the fallopian tubes due to a decrease in contractile activity and the threshold of excitability of the muscle cell.
Specific effect on the endometrium.
The mechanism of action on the endometrium determines both contraceptive effectiveness 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 hormones of the pituitary gland (especially luteinizing) and, as a consequence, inhibition of ovulation (depending on the dose of gestagens in the tablet).
Application diagram
PPTs are taken continuously, starting from the 1st day of the menstrual cycle, every day without a break for menstruation. The time of administration does not matter, however, subsequent doses of the drug should be taken 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 . If you miss a drug or take a pill later than 24 hours later, the forgotten pill should be taken as soon as possible and continue to adhere to the pill regimen, while using other types of contraception for the first 48 hours.
The exception is Charosetta. These progestin-only tablets contain 75 mcg of desogestrel, which suppresses ovulation in 97% of women, and has a half-life of 36 hours, similar to COCs.
When switching from COC to ChPT taking the latter should begin the very next day after stopping use of COCs. None additional measures no precautions required.
After an abortion Taking the pills must be started immediately, preferably on the day of the abortion.
Progestin-only pills, like any other method of contraception, have indications and contraindications, advantages and disadvantages.
Progestin methods of contraception, as well as combined estrogen-gestagen contraceptives, have contraindications for use. There is an opinion that the absolute contraindications for the use of progestin-only and combined hormonal contraceptives are the same. However, progestin contraceptives do not affect blood pressure, blood clotting indicators, therefore, do not cause the development of thrombosis, and have a slight effect on lipid metabolism and liver function. Therefore, there are 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 gestagen-containing contraceptives
1. Confirmed and suspected pregnancy.
Progestin-only contraceptives should not be used during
pregnancy time. Current evidence shows that low-dose progestin in injections, implants, tablets, and progestin IUDs does not significantly increase the risk of birth defects, spontaneous miscarriage, or stillbirth. However, despite the low dose of progestin, it is best to avoid taking these drugs in early pregnancy.
2. Liver diseases with impaired liver function.
There is no evidence that progestin contraceptives cause liver and bile duct diseases. However, impaired liver function may make it difficult for PPT to metabolize. Therefore, it is not recommended to use PPT for active viral hepatitis, benign and malignant liver tumors, severe uncompensated cirrhosis and simultaneous use of drugs that affect its enzymatic function (rifampicin, phenytoin, carbamazepine, barbiturates, topiramate, etc.).
3. Lesions of the cerebral and coronary arteries.
Theoretically, PPTs may have an effect on lipid
blood spectrum, thereby contributing to the emergence of and. progression of atherosclerosis, and hence the occurrence of myocardial infarction and stroke. Their use is also not indicated for patients with a history of or current coronary heart disease.
4. Malignant tumors of the reproductive system (according to
genital 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 lumps 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 diseases
breast tenderness or with a family history of breast cancer is not contraindicated.
5. Bleeding from the genital tract of unknown etiology.
The use of purely progestin contraceptives not only does not cause worsening of diseases, the symptom of which is bleeding from the genital tract (threat of premature termination of intrauterine pregnancy, ectopic pregnancy, cervicitis, oncological diseases of the genital organs, etc.), but often prevents their development. However, PPTs can cause menstrual irregularities in the form of intermenstrual spotting and acyclic bleeding, which can lead to delayed diagnosis of diseases with the same symptoms. In connection with the above, this method of contraception for bleeding of unknown etiology is not recommended.
Relative contraindications include functional ovarian cysts, since a high incidence of their occurrence has been noted when using progestin-based contraceptives.
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 repeat ectopic pregnancy cannot be excluded.
Advantages
No estrogen-dependent adverse reactions.
Better portability.
Possibility of use during lactation. CPT can be used when breastfeeding, since they do not affect the quantity and quality of mother’s milk and the duration of lactation. There is evidence that drugs containing only gestagen even increase the amount of mother's milk and lengthen the lactation period. This type of contraception can be used after 6 weeks. after childbirth (WHO, 2004).
Less systemic effect on the body compared to combined estrogen-gestagen contraceptives.
Progestogens have a slight effect on carbohydrate, fat and protein metabolism, and blood pressure.
Pronounced therapeutic and protective effect for algo-dysmenorrhea, ovulatory pain, inflammatory diseases of the pelvic organs, anemia, fibrocystic mastopathy, genital endometriosis.
Flaws
POTs, with the exception of Charozetta, have less pronounced effectiveness compared to COCs.
High incidence of menstrual irregularities.
Annual monitoring of pill intake.
The most common side effect of progestin contraceptives is menstrual irregularities:
intermenstrual bleeding,
shortening of the menstrual cycle,
oligomenorrhea,
menometrorrhagia.
As the duration of use of progestin contraceptives increases, the frequency of intermenstrual bleeding You- divisions decrease, and after 3-6 months. they usually stop.
Cases of severe uterine bleeding requiring therapeutic intervention are extremely rare (occurring in approximately 0.5% of women). The need for estrogen therapy or curettage of the uterine cavity rarely occurs. When using gestagens, amenorrhea may also develop. Women using gestagen methods of contraception should be prepared for the fact that in the first 6 months of using the drug they may experience irregular bleeding, and then, in the next 6 months and beyond, rare bleeding or amenorrhea.
Menstrual irregularities in the form of spotting, intermenstrual spotting and acyclic bleeding in women using purely 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 explanations given to them during counseling. Therefore, 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 stops bleeding altogether. It is not recommended to prescribe COCs to induce bleeding in cases of amenorrhea resulting from the use of progestin-only contraceptives. The effectiveness of progestin contraception is enhanced by proper counseling.
Rarely, side effects may occur 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 gestagen, the less common the above reactions occur. However, the lower the dose of gestagen, the less effective this method of contraception is.
Contraceptive effectiveness
Progestins block ovulation if they are used in large 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 and cervical mucus, which leads to a decrease in fertility. Microdoses of gestagens also provide contraception in most women, but without suppressing 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 Excluton, and in 97% when using Charozetta. This explains the low effect of small doses of progestogens. The contraceptive effectiveness of minipills ranges from 0.14 to 10 pregnancies per 100 women over 1 year.
The reasons for the low effectiveness of PPTs, in addition, are their irregular use, the development of vomiting and diarrhea within 2-4 hours after taking the tablet, the simultaneous use of other medications (antibiotics, tranquilizers, sleeping pills, activated carbon, anticonvulsants and
anti-tuberculosis) and the transition to various low-calorie and vegetarian diets.
Possible systemic effects on the body
Receptors for progesterone are present in many tissues of a woman’s body, in particular, in the brain, skeletal system, vascular wall, uterus, cells of the cervical canal, bladder, breast tissue, etc. This is what is associated with both the contraceptive effect of progestogens and and their possible systemic effect on the body.
Progestogens have the ability influence neurohormones and neuropeptides, contained in the brain by binding to progesterone receptors in the central nervous system.
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 neurotransmitter of brain tissue. Its greatest amount is observed 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 of animals leads to the appearance of the phenomenon of manege running and seizures. An increase in GABA levels is accompanied by ataxia, decreased motor activity, and an increased seizure threshold.
Progesterone and its metabolites bind to GABA receptors and have a psychotropic effect on the woman’s body, therefore they are used to treat some forms of depression, aggression, migraines, emotional excitability.
ty Progesterone may have a hypnotic effect, which is used to treat premenstrual syndrome and psychological stress. With a significant increase in progesterone concentration, drowsiness may occur.
IN Lately researchers around the world are interested in the question of the effect of steroids on breast tissue. The maternal cycle is significantly different from the endometrial cycle. Although changes in the mammary glands occur during the cycle, the proliferative and secretory phases do not correspond to estrogenic and progestational activity, as in the endometrium. On the contrary, the peak of breast tissue proliferation 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 activating effect on the proliferation of mammary gland cells. Progestogens reduce the concentration of estrogen receptors in breast tissue, the activity of 17p-hydroxysteroid dehydrogenase, which promotes the conversion of inactive estrogen into active, and the concentration of estradiol in breast tissue. Progestogens cause proliferation of epithelial cells and stimulate both apoptosis and mitosis. In phase II of the cycle, the volume of epithelial cell nuclei is greater than in the proliferative phase, and increased mitotic activity is observed only in the secretory phase. The apoptosis index increases in phase II 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 increase in volume until menopause. Progestogens have the most pronounced proliferative effect on the mammary glands of nulliparous women.
It is very important effect of progestogens on the skeletal system women. They stimulate specific osteoblast receptors, block glucocorticoid receptors, reduce the inhibitory effect of glucocorticoids on osteosynthesis, and have an antiresorptive effect.
Like all steroids, progestogens affect metabolic processes. However, this impact is minimal. In particular, progestogens in large 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 the metabolism of glucose and insulin.
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 animal on which the study is conducted. Experiments on monkeys have shown that the use of progesterone and some synthetic progestins leads to an increase in insulin levels in response to intravenous glucose, while glucose tolerance is not impaired. According to researchers, progesterone causes the formation of metabolically inactive forms of insulin. When exogenous insulin is administered, the decrease in blood glucose occurs more slowly when 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.
Like any active compounds, progestogens can have an effect on blood lipid spectrum. Progestogens suppress the synthesis of triglycerides in hepatocytes and colon cells, increasing the activity of lipoprotein lipase, accelerate the breakdown of HDL, thereby reducing their content in the blood plasma, and contribute to an increase in LDL. In large doses, progestogens can lead to an increase in the atherogenic coefficient (AC) - the ratio of the sum of LDL and VLDL to HDL. An increase in KA 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 gestagens on the concentration of HDL is due to the degree of androgenic activity of steroids (see section “Comparative characteristics of progestogens included in 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 hemostatic parameters are already impaired before starting hormonal contraception and there are other risk factors, then the risk of thromboembolic diseases may be increased.
The presence of receptors for estrogens and progestogens in the endothelial and smooth muscle walls of blood vessels indicates the involvement of sex hormones in Metabo controllism and vasoactive function of the vascular wall of veins and arteriesriy. It has been shown that sex hormones influence 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 the relaxation of smooth muscle cells. On arteries progestogens in large doses can have a vasoconstrictor effect. The vasoconstrictor effect of progestogens manifests itself only at the site of disruption 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, and atherosclerosis should be monitored more carefully. The effects of progestogens on veins not noted. 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 CPT immediately or within 3 months. the menstrual cycle is normalized and regenerative function is restored.
No deviations during pregnancy and childbirth are observed, no teratogenic effect has been established.
Thus, PPTs, compared to estrogen-containing contraceptives, have a lesser systemic effect on a 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 PPT, with the exception of Charozetta, is inferior to the effectiveness of COCs; frequent intermenstrual bleeding reduces their acceptability. The safety of using PPT, like any other hormonal contraceptives, depends on careful consideration of contraindications, knowledge of the basics of clinical pharmacology, prediction and accounting of possible complications and adverse reactions, individual approach, as well as on age, health status, characteristics of intimate life, drug tolerance, and the attitude of sexual partners towards their prescription.
HORMONAL RELEASING SYSTEMS
Injection 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 drug 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 at 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 is devoid of estrogenic and androgenic activity characteristic of some steroids used to prevent pregnancy.
Absolute contraindications(according to the medical “Acceptability Criteria for the Use of Contraceptive Methods”, WHO, 2004):
deep vein thrombosis, thromboembolism, including history;
long-term immobilization after surgery;
thrombogenetic mutations (Leiden factor, prothrombin mutations, etc.);
stroke, ischemic heart disease (including history);
diseases of the heart valves (complicated by pulmonary hypertension, atrial fibrillation, etc.);
multiple risk factors for developing cardiovascular diseases;
hypertension (system blood pressure > 160 mm Hg or dia. blood pressure > 100 mm Hg);
viral hepatitis;
malignant liver tumors;
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 suppression of ovulation and changes in the endometrium, during which egg implantation is impossible. The contraceptive effect is carried out
Rice. 2.16. Chemical structure of medroxyprogesterone acetate.
occurs at various levels of the hypothalamus-pituitary-ovary-uterus system (for more details on the contraceptive effect of progestogens, see the relevant sections of the Guide).
Advantages:
long-term prolonged contraception;
persistent protective effect against endometrial cancer;
absence of estrogen-dependent side effects;
no need for daily self-monitoring of use;
reduction in the volume of menstrual blood loss;
increased hemoglobin levels;
reducing the risk of inflammatory diseases;
reduction in the incidence of vulvovaginal candidiasis;
absence pronounced changes on the part of blood coagulation factors and lipid metabolism.
1. Menstrual irregularities.
They occur in most women while taking the drug and are more often characterized by acyclic light bleeding lasting 15 days or more, which are observed during the first months of using the drug. According to most researchers, with heavy bleeding, an effective treatment is a repeated injection of DMPA, made against the background. The third and subsequent injections should
be carried out within the usual time frame, i.e. with an interval of 90 days (Prilepskaya V.N., Tagieva T.T., 1996; Gertig D. et al., 2004).
With increasing duration of DMPA use, the frequency and duration of bleeding decreases, oligomenorrhea may occur, then amenorrhea, which is associated with changes in the endometrium, the cessation of cyclic processes in it as a result of ongoing contraception. In case of amenorrhea, it is recommended to exclude pregnancy using known methods. Treatment of amenorrhea is not required, since after discontinuation of contraception the cycle is restored on its own. independently (Bescrovniy S., Kira E., 2003; Gertig D., 2004).
2. Delayed restoration of fertility.
3 Bone resorption with long-term use.
4. The impossibility of quickly canceling this method of contraception.
Sometimes 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 progestin contraceptive, its use may be accompanied by the appearance of bloody discharge(of varying intensity), occurring, as a rule, during the first months of use and tending to decrease with further use drug. According to a study conducted at the State Research Center of Agipology and Pediatrics of the Russian Academy of Medical Sciences, during 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 bleeding did not exceed 8 days per month. Most patients have After the first 3 months of contraception, the frequency, duration and intensity of bleeding decreased with the subsequent development of amenorrhea. Thus, by the 6th month of contraception, amenorrhea was observed in 20% of women, after 12 months. - every third (Prilepskaya V.N., Tagieva T., 1996).
In case of light bleeding, no therapy is required, since they tend to decrease with further use of the drug.
Heavy bleeding while taking DMPA occurs extremely rarely, in less than 1 in 1000 women.
In the case of heavy and/or prolonged bleeding, it is first necessary to exclude previously unrecognized organic pathology of the reproductive system. Compulsory
is to determine the level of hemoglobin. If iron deficiency anemia is detected, appropriate medications should be recommended (Lamarque J.M., 2003).
For 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 ethinyl estradiol for 7-15 days over 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 using DMPA experience slight weight gain. Most studies report an increase in body weight of 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. Tagieva (1996), in 48% of women, the use of DMPA was accompanied by quickly passing adverse reactions in the form of weight gain, nausea, and minor edema.
The appearance 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 drug increases.
The results of the studies have shown that complications and adverse reactions are usually associated with uncontrolled and long-term 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, the pharmacological characteristics of the drug, indications and contraindications for their use.
Application diagram
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 hormonal contraceptives for early not yet diagnosed pregnancy, as well as to obtain 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 thoroughly shake the bottle before filling the syringe with the suspension. The solution is injected deeply intramuscularly into the gluteal or deltoid muscle. The initial level of DMPA in blood plasma is high and then gradually decreases. However, the high contraceptive effect of one injection persists for 3 months. and longer.
The administration procedure is simple, is not associated with sexual intercourse and, unlike most oral contraceptives, does not require daily self-monitoring.
Patients are monitored 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, including the UK, Germany, Belgium, France, and 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 over 1 year (Selim A.G., 2002).
Studies have shown that preventing pregnancy using intramuscular administration of DMPA at a dose of 150 mg every 3 months is not inferior in effectiveness to other methods of contraception and even surpasses many of them. Thus, the number of pregnancies within 1 year when using DMPA is 0.3-1%, oral contraceptives - 1-7%, barrier methods - up to 22% and 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 have a negative effect on the state of the gastrointestinal tract and liver function, thereby preventing the possibility of metabolic changes. It also does not cause changes in blood coagulation factors and lipid metabolism, which can occur when taking some oral contraceptives, which determines its advantages over them in relation to the risk of cardiovascular disorders.
Many researchers, analyzing data from epidemiological studies, have not found a connection between an increased risk of coronary artery disease and the use of DMPA. It has been established that DMPA does not increase the incidence 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, and does not affect the activity of transaminases, alkaline phosphatase and bilirubin levels 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 the blood plasma. There were also no significant changes in plasma concentrations of trace elements such as sodium, potassium, calcium, magnesium, zinc, phosphorus and copper (Sotanie-mi E.A., 2003; Parkin D.M., 2004).
Restoring fertility after DMPA withdrawal
After cessation of DMPA use, most women experience a delayed return to fertility. The average duration of the period from the last injection until 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 pregnancy and the total duration of DMPA use do not affect the rate of restoration of fertility.
There is evidence that 1 year after discontinuation 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 - to 95% (Ferguson D., 2003).
According to another large-scale study, during the first 12 months after stopping use
DMPA planned pregnancy occurred in 70% of women (Triae1., 2004).
In summary, 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 incidence 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, hemoglobin levels 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 endometrial hyperplastic processes, internal endometriosis, uterine fibroids small sizes, in connection with which the use of DMPA seems especially promising in women over 35 years of age (Kulakov V.I. et al., 1998; Kulakov V.I., Prilepskaya V.N., 2002).
Over the course of 3 years, at the State Institution Scientific Center for Agipology and Pregnancy of the Russian Academy of Medical Sciences, the effect of the drug on normal mammary gland tissue (35 women) and on hyperplastic processes in the mammary glands (35 patients) was studied. The condition of the mammary glands was assessed based on patient complaints, examination, and 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 after 1-2 years. As a result of the observation, it was revealed that under the influence of DMPA, 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, for a number of diseases, the use of DMPA can also have a therapeutic effect.
IMPLANTATION CONTRACEPTION
In the 80s of the 20th century, implantation contraception became very popular. This method continues to be improved to this day. The most famous of the implantation drugs is Norplant.
Development Norplanta 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.
Description of the method
The Norplant system consists of six cylindrical polymethylsiloxane (silastic) capsules containing a gestagen - levonorgestrel. Norplant capsules are installed subcutaneously on the inner surface of the left shoulder in the shape of a fan (Fig. 2.17) using a simple trocar.
Each capsule is 34 mm long, approximately 2.5 mm in diameter and contains 36 mg of levonorgestrel.
Rice. 2.17. Installation diagram of Norplant capsules.
The hormone diffuses through the silastic wall at a constant speed. It should be noted that in the first few months after the introduction of Norplant, the rate of diffusion of levonorgestrel into surrounding tissues and blood is 80 mcg/day, but then gradually decreases and by the end of the first year of use reaches 30-34 mcg/day.
Contraindications (according to the “Eligibility Criteria for 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 diseases;
Relative contraindications:
taking rifampicin or anticonvulsants;
angina pectoris;
stroke;
circulatory disorders;
benign or malignant liver tumors.
The contraceptive effect of Norplant is determined by several mechanisms. Suppression of ovulation is one of the main mechanisms of contraceptive action of levonorgestrel. It occurs as a result of an inhibitory effect on the hypothalamic-pituitary-ovarian system and, as a consequence, 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 effect 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 complicates and impairs sperm penetration. Under the influence of levonorgestrel, the maturation processes of cells of the stratified squamous epithelium of the vagina change - the number of intermediate cells increases. It is also assumed that levonorgestrel may influence the activity of enzymes involved in the process of sperm penetration 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 gamete transport and the function of the corpus luteum.
Application diagram
Implantation is carried out in the first 5-7 days from the beginning of menstruation or immediately after an 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 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 regular source of contraceptives, and to patients immediately after an abortion.
Non-contraceptive therapeutic effects
Research recent years have shown 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, repeated 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, suggests failure rates of 1.2, 1.6 and 0.4% of pregnancies per year, respectively, for the second, third, fourth and fifth years of Norplant use.
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 before implantation. Therefore, since 1995, WHO has recommended Norplant implantation during the first 7 days of the menstrual cycle or immediately after an abortion.
Norplant capsules must be removed at the end of the fifth year of use of the drug.
Thus, Norplant, subject to the recommendations on the timing of implantation and its removal or replacement, is among the effective forms of reversible contraception.
Restoring fertility after Norplant removal
Restoration of fertility, regardless of the reason for removal of the implanted drug, occurs quite quickly. Studies conducted by J.C. Konje et al. (1992) showed that after removal of Norplant, ovulation was restored gradually, but within 7 weeks. restoration of ovulation occurred in all women, and already in the first cycle after removal of Norplant, some women became pregnant.
Possible side effects and complications
One of the side effects of Norplant is menstrual irregularities. These disorders can manifest themselves in the form of prolonged menstrual-like bleeding, bloody discharge, irregular menstruation, and amenorrhea. However, it should be noted that menstrual irregularities are observed much more often in the first year of using Norplant, while the likelihood of amenorrhea increases as the duration of use of the drug increases.
Although there is no evidence of the adverse effects of irregular menstruation and amenorrhea on women's health, unpredictable episodes of bleeding or spotting can cause discomfort for women, 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 using Norplant, had various menstrual irregularities.
In addition, some women experience headaches, nausea, nervousness, mastalgia, acne, and weight gain. It is extremely rare that the introduction and removal of Norplant may be accompanied by an inflammatory process of the skin and subcutaneous tissue at the site of implantation. This is usually due to violations of asepsis rules.
Effect on metabolic processes
Based on studies by A. Benenson et al. (1995), J. Barbosa et al. (1995), Z.Haler et al. (1996) we can conclude that the use of Norplant is not associated with
improving the function of the liver, kidneys, adrenal glands, and thyroid gland. However, J. Veigas et al. (1988) found a decrease in high-density lipoprotein levels in women using Norplant.
Norplant has only a minor effect on carbohydrate metabolism. The identified 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 progestins, such as injectable contraceptives and subdermal implants, is an effective and acceptable means of contraception for breastfeeding mothers. Norplant does not have an adverse effect on lactation, composition breast milk and child development.
An analysis of observation of 100 women (50 in early reproductive age, 50 in late reproductive age) who were implanted with Norplant showed its high effectiveness (not a single case of pregnancy was recorded), good tolerability - 3% of implant removals 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 that a single-capsule implantation contraceptive was proposed in the early 90s of the last century. Implanon, containing etonogestrel - a highly selective gestagen of the latest generation, a biologically active metabolite of desogestrel.
Description of the method
Etonogestrel is a derivative of 19-nortestosterone and has 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 Implanon use. In addition to inhibiting ovulation, Implanon also causes a change in the viscosity of cervical mucus, which prevents sperm from penetrating.
Contraindications for the use of Implanon are the same as for Norplant.
Application diagram
Implanon is injected under the skin on days 1-5 of the menstrual cycle, immediately after an abortion, or on days 21-28 after childbirth.
Implanon is one silastic (evanate) capsule 40 mm long, 2 mm in diameter, without a cavity and consisting of a membrane system and the active substance etonogestrel, released at a constant rate along a 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 Implanon capsule contains 68 mg of etonogestrel.
After Implanon administration, 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 over a total of 73,429 cycles. The Pearl index for 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 removal of the implant. Although Implanon inhibits ovulation, complete suppression of ovarian function does not occur. The average concentration of estradiol remains at a level higher than that usually detected in the early follicular phase.
Effect on metabolic processes
The two-year study measured bone mineral density in 44 women using Implanon and compared it with 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, no clinically significant deviations in lipid metabolism were detected. However, acyclic bleeding and amenorrhea occur quite often with its use.
With increasing 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 on the use of Implanon are being conducted, but so far it has not been registered in Russia.
TRANSDERMAL RELEASING 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 relieving angina, antihypertensive), in oncology (pain relief for cancer), in gynecology (hormone replacement therapy), etc.
Progress in improving 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-term use, which, of course, has been the impetus for their use for contraception.
The transdermal method of “delivery” of the active substance eliminates the effect of primary passage through the liver, ensures a uniform concentration of the drug in the blood plasma throughout the day, and provides additional confidence in the contraceptive effect: there is no need for additional use of contraception in case of diarrhea, vomiting, and also in cases when the woman forgot to replace the patch with a new one (the contraceptive effect remains for 48 hours).
Transdermal contraceptive system present on the Russian market EURA is a thin patch, the contact area of which with the skin is 20 cm 2. Each patch contains 600 mcg ethinyl estradiol (EE) and 6 mg norelgestromin (NG). Within 24 hours, the system releases 150 mcg of NG and 20 mcg of EE into the blood, which provides a contraceptive effect. In terms of daily hormone release, EVRA corresponds to combined microdose oral contraceptives. Serum concentrations of norelgestromin and ethinyl estradiol, which are released from the transdermal patch, remain within 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, and is a biologically active metabolite of norgestimate. It has been proven that norelgestromin has 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 presented in Figure 2.18.
There are other methods of contraception. Probably, the contraceptive method that 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 long-acting contraception.
What is long-acting contraception?
Prolonged contraception means long-term contraception from the Latin word prolongus, which means “long-lasting, ongoing.” Unlike drugs that need to be taken regularly and constantly, long-acting drugs are administered into a woman’s body with an injection and protect against pregnancy for a long time: from 3 months to 5 years.
The most common type of long-acting contraception is the Depo-Provera injection. 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. The above-mentioned drugs prevent the maturation of the egg and thus fertilization cannot occur. Such drugs are best used by women over 35 years of age.
A long-acting contraceptive, Norplant, is also now common. 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 released from the capsules every day, and ovulation does not occur. "Norplant" is valid for 5 years. Doctors advise introducing the drug into a woman’s body within a week from the start of the menstrual cycle, after an abortion or after childbirth.
Pros and benefits of long-acting contraception
Long-acting medications can be taken for:
- Obesity
- Liver diseases; the 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, time is needed for fertilization to occur. On average, this will take about six months. Same with the menstrual cycle. He will recover in about 3 months.
