Hormonal Contraceptive
methods
Prof Agzail Saad Elhddad, MBBS, MsC, MD
Faculty of Medicine; Omar Al-Mukhtar University.
2024-2025
Contraception
• Contraception is the intentional prevention of pregnancy
by artificial or natural means.
• There are different types of contraception; hormonal,
mechanical, short acting or long acting, reversible or
permanent; with varying rates of effectiveness depending
on correct usage.
• Health care providers play an important role in helping
couples to decide number, spacing and timing of births and
to have the information, education, and means to do so,
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The features of an ideal contraceptive
• It should be easily usable by both males and females.
• It should be easily removable and rapidly reversible.
• Independent of intercourse
• Widespread availability
• It should not have any side effects.
• It should be inexpensive and cost-effective.
• It should be effective for preventing STDs.
• Highly effective in contraception
• acceptable to all cultures and religions
• Can be administrated by non- health care personnel.
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Contraceptive methods: WHO;2021
Hormonal Emergency contraception (EC) or postcoital
❑ Progestogen-only contraceptives contraception
1. Progestogen-only pills (POPs) 1. Copper-bearing IUDs (Cu-IUD) for EC
2. Progestogen-only injectable 2. Emergency contraceptive pills (ECPs)
contraceptives (POIs) Intrauterine devices (IUDs)
3. Progestogen-only implants
1. Copper-bearing IUDs (Cu-IUD)
4. Levonorgestrel-releasing IUDs (LNG-
2. Levonorgestrel-releasing IUDs (LNG-IUD)
IUD)
Permanent methods
5. Progesterone-Releasing Vaginal Ring
1. Female sterilization (tubal ligation)
❑ Combined hormonal contraceptives 2. Male sterilization (vasectomy)
1. Combined oral contraceptives (COCs) Barrier methods
2. Combined contraceptive patch 1. Male and female condoms
3. Combined contraceptive vaginal ring 2. Other barrier methods
(CVR) Spermicides
4. Combined injectable contraceptives Fertility awareness methods
(CICs)
1. Standard Days Method (SDM)
2. Others
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Lactational amenorrhea method
Safe Period Contraception (Fertility Awareness Methods)
➢Avoiding intercourse during fertile period to prevent pregnancy.
➢ Involves monitoring menstrual cycle to predict ovulation.
➢How?
• Calendar Method: Based on length of previous menstrual cycles.
• Basal Body Temperature Method:
• Cervical Mucus Method
➢Advantage: hormone-free and cost-effective method
➢Disadvantage: this method may not be suitable for those with irregular
cycles or difficulty in maintaining daily records.
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Coitus interruptus (withdrawal method)
➢ Advantage: Cost-free, hormone-free that involves
withdrawing the penis from the vagina before
ejaculation.
➢ Disadvantage:
• High failure rate: requires precise timing and control,
• Pre-ejaculate fluid may contain sperm
• No protection against STD.
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Lactational Amenorrhea Method
➢Natural form of contraception
➢Breastfeeding suppresses hypothalamic release of
GnRH, in turn, inhibits pituitary LH&FSH secretion
and preventing ovulation
➢Criteria for Effectiveness:
• Exclusive Breastfeeding
• Amenorrhea since delivery .
• Infant's Age: less than six months old.
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Barrier contraception methods
-
➢Non-hormonal that physically
prevent sperm from entering the
uterus.
➢ They include male and female
condoms, diaphragms, cervical caps,
sponges, and spermicides.
➢Advantage:
▪ protection against STIs
▪ hormone-free contraception.
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Combined oral contraception
➢The first contraceptive pill was developed in 1960s,
➢It contains a combination of two hormones:
▪ Synthetic oestrogen and progestogen.
▪ The doses of both hormones have been reduced dramatically, which has
considerably improved its safety and compliance.
➢Easy to use and offers a very high degree of contraception independent of
intercourse.
➢It is mainly used by young, healthy women.
➢Types:
▪ Monophasic pills contain standard daily dosages of E2& P4.
▪ Biphasic or triphasic preparations: two or three incremental variations in
hormone dose.
▪ Current thinking is that biphasic and triphasic preparations are more
complicated to use and with few real advantages. 9
Mode of action
Both
• Centrally; the most important effect as both
hormones suppress the release of pituitary FSH and
LH, which prevents follicular development within
the ovary and therefore ovulation.
• Peripheral: altering cervical mucus to prevent
sperm ascending and making the endometrium
atrophic and hostile for embryo implantation.
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➢Most brands contain 21 pills;
▪ One pill taken daily, followed by 7 days pill-free interval.
▪ Every-day (ED) preparations: 21 contraceptive pills and
seven placebo pills.
▪ For maximum effectiveness, COC should be taken regularly
at roughly same time.
➢Ovulation after stopping COC:
• resume in 2-4 weeks.
• A bit longer: older women/ longer time.
• May take a few months.
• Some will have a post pill amenorrhea up to 6 months.
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Pills were divided into classes according to their
hormonal content
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➢Pills from all generations work same way, and very similar in
contraception effectiveness.
➢Why develop different generations of the pill?
▪ To improve patient safety
▪ To minimize pill side effects.
➢Over time, as new pill formulations were developed, newer
hormones were incorporated. Initially this was by changing
the progesterone constituent of the pill to a more modern
type, but more recently, combined pills have been
developed with newer estrogens too.
➢Newer generation oral contraceptives are an association of
low-dose ethinyl estradiol and potent testosterone-derived
progestins, developed in order to improve general and
vascular tolerance. They are highly efficient and well
tolerated by most users
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Contraindications
Absolute contra indications Relative contra indications
▪ Circulatory diseases: ▪ Generalized migraine
o ischaemic heart disease • Long-term immobilization
o cerebrovascular accident • Irregular vaginal bleeding (until a
o significant hypertension diagnosis has been made)
o arterial or venous thrombosis • Less severe risk factors for
o any acquired or inherited pro- cardiovascular disease, e.g . obesity,
thrombotic tendency heavy smoking, diabetes
o Any significant risk factors for
cardiovascular disease
▪ Acute or severe liver disease
▪ Oestrogen-dependent neoplasms,
particularly breast cancer
▪ Focal migraine
➢ Mainly related to side effects of sex steroid hormones on CVS& hepatic systems
➢ Women should ideally discontinue COC at least 2 months before any elective
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pelvic or leg surgery
Contraceptive transdermal patch
➢ Containing E2& P4 released over 24 hours.
➢ Applied weekly for 3 weeks, with a patch-free week.
➢ Same risks and benefits as COC
➢ Relatively more expensive, but may have better compliance.
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Hormonal vaginal contraceptive ring
➢ Releases E2& P4 .
➢ Placed by women and can be kept for 3 weeks,
➢ Take it out during period, then use in a new ring.
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Progestogen-only contraception
➢ Mode of action:
▪ All work by local effect on cervical mucus (hostile to ascending sperm) and on
endometrium (making it thin and atrophic), thereby preventing sperm transport
and implantation.
▪ Only the higher dose progestogen act centrally& inhibit ovulation in addition to the
peripheral effect.
➢ The current methods of progestogen-only contraception are:
▪ progestogen-only pill, or 'mini-pill'
▪ subdermal implant Implanon®
▪ injectables
▪ hormone-releasing intrauterine system
➢ The common side effects of progestogen-only methods include:
▪ erratic or absent menstrual bleeding
▪ functional ovarian cysts
▪ breast tenderness
▪ acne 18
Progestogen-only pills(POP)= Mini pill
• Ideal for women at times of lower fertility (breastfeeding
& older age)
• The POP is taken every day without a break.
• The failure rate of the POP is greater than that of COC& If
POP fails, there is slightly higher risk of ectopic pregnancy.
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Injectable progestogens
1- Depot medroxyprogesterone acetate 150 mg (Depo-Provera
or DMPA), highly effective method of contraception and given
by deep intramuscular injection lasts around 12-13 weeks
2- Norethisterone enanthate 200 mg (Noristerat), only lasts
for 8 weeks and is not widely used.
Advantage Disadvantage
▪ Most women develop very light ▪ weight gain of around 3 kg in the first year,
or absent menstruation ▪ delay in return of fertility - it may take
▪ Improve PMS around 6 months longer to conceive
▪ Can be used to treat menstrual compared to a woman who stops COC,
problems such as painful or heavy ▪ persistent menstrual irregularity,
periods ▪ very long-term use may slightly increase the
risk of osteoporosis because of low
oestrogen levels. 20
Subdermal implants
➢ Introduced into the UK in the late 1990s, six-rod implant
Norplant, which was withdrawn from the market.
➢Implanon consists of a single silastic rod that is inserted
subdermally under local anaesthetic into the upper arm. It
releases the progestogen etonogestrel 25-70 µg daily (the dose
released decreases with time),
➢Mechanisms that include suppression of ovulation, increased
viscosity of the cervical mucus, and alterations in the
endometrium.
➢It is highly effective with a rapid return of fertility when it is
removed
➢ It lasts for 3 years and thereafter can be easily removed or a
further implant inserted.
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Subdermal implants
Norplant implant Implanon implant
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Intrauterine devices (IUDs)
➢Placed inside uterus to prevent pregnancy
➢Highly effective, long-acting, and reversible
➢All IUDs induce an inflammatory response in the endometrium which
prevents implantation
➢Types: hormonal and copper.
❖Copper IUDs:
• Releases copper ions into uterus, toxic to sperm, preventing fertilization.
• Insertion discomfort
• May cause heavier periods and more cramping initially.
• Expulsion risk: especially in the first year after insertion.
• PID: slightly increased risk of PID shortly after insertion
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❖ Levonorgestrel-releasing intrauterine system (IUS)
➢ Prevents pregnancy primarily by a local hormonal effect on the
cervical mucus and endometrium and may inhibit ovulation.
Advantages of IUS Disadvantages of IUS
▪ Highly effective • Persistent spotting and irregular
bleeding in first few months of use
▪ Dramatic reduction in menstrual blood
loss • Progestogenic side effects, e.g. acne,
breast tenderness
▪ Protection against pelvic inflammatory
disease
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Levonorgestrel-releasing intrauterine system
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Emergency contraception (EC)
➢'morning-after pill' and 'postcoital contraception’
➢Used after intercourse has taken place and before implantation has
occurred.
➢EC should be considered if unprotected intercourse has occurred to
reduce the rate of unplanned pregnancies,
➢If there has been failure of a barrier method, e.g. a burst condom, or if
COC has been forgotten .
➢There are two types of EC in general use:
• Hormonal
• Copper IUD
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Hormonal emergency contraception
➢The original hormonal EC was a combination of oestrogen and
progestogen, but nausea and vomiting were common side effects
➢Levonorgestrel, in a single dose of 1.5 mg (Levonelle) has become
the main hormonal method of EC in UK
➢It has to be taken within 72 hours of an episode of unprotected
intercourse and is more effective the earlier it is taken.
➢There are no real contraindications
➢The precise mechanism of action is not known but probably
involves; disruption of ovulation or corpus luteal function,
depending on the time in the cycle when hormonal EC is taken.
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Non-contraceptive use of COC
➢Menstrual cycle disorder such as:
AUB , oligomenorrhea due to PCOS , dysmenorrhea ,
premenstrual tension syndrome.
➢Endometriosis (Continuous use of COCs not cyclic use)
➢Functional ovarian cysts
➢ Hyperandrogenism: can reduce dermatological manifestations
of hyperandrogenism such as acne, hirsutism.
➢COCs can be used as HRT in women with primary
hypogonadism or premature ovarian insufficiency
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Thanks for your attention
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