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Oral contraceptives - modern approach
The advantages of three-phase contraception and monophasic preparations containing third-generation progestogens:
a. low hormone levels provide a decrease in the inhibitory effect on the hypothalamic-pituitary system, while maintaining high contraceptive effectiveness.
b. in multiphase preparations, fluctuating estrogen and progestogen ratios mimic cyclical changes in hormone levels during the physiological cycle,
c. cyclic changes in the endometrium during multiphase contraception (short proliferative phase, formation of a secretory transformation identical to the average stage of secretion of the physiological cycle; more complete proliferation and development of the spiral arteries) cause a low frequency of menstrual dysfunction,
d. good tolerance, low incidence of adverse reactions,
e. early recovery of fertility (after 6-12 months of intake, ovulation is restored within 1-3 cycles),
f. adequate therapeutic effect in functional disorders of the menstrual cycle,
g. minimal effect on the blood coagulation system, lipid and carbohydrate metabolism.
• the need for reliable contraception,
• therapeutic effects in menstrual dysfunction and / or some pathological conditions (dysmenorrhea, functional ovarian cysts, pre-menstrual syndrome, menopausal syndrome, post-hemorrhagic anemia, inflammation of the uterus and its appendages at the resolution stage, endocrine sterility, rehabilitation after ectopic pregnancy, acne , oily seborrhea, hirsutism; it should be emphasized that in the last three conditions, preference is given to preparations containing third-generation progestogens - Marvelon, Mersilon, Silest),
• the need for reversible birth control and / or an appropriate interval between births,
• sexual activity of young non-giving women (adolescents are recommended to take multiphase or monophasic drugs containing third-generation progestogens),
• a state after an abortion or childbirth (of course, after stopping breastfeeding),
• family history of ovarian cancer.
• the ability to comply with the mode of drug administration
• Lack of active smoking (more than 10–12 cigarettes / day) over the age of 35 years.
Contraindications are divided into absolute and relative. Absolute contraindications to the use of oral contraceptives: pregnancy, thromboembolic diseases, vascular lesions of the brain system, malignant tumors of the reproductive system and mammary glands, severe abnormal liver function, cirrhosis. These diseases are currently or noted earlier. Relative contraindications to the use of oral contraceptives: severe toxemia in the second half of pregnancy, history of idiopathic jaundice, pregnant women, itching during pregnancy, severe depression, psychosis, bronchial asthma, epilepsy, severe hypertension (160/100 mm Hg.), Sickle -cellular anemia, severe diabetes, rheumatic heart disease, otosclerosis, hyperlipidemia. severe kidney disease, varicose veins and thrombophlebitis, calculous cholecystitis, cystic skid (until the disappearance of chorionic gonadotropin in the blood), bleeding from the genital tract of unknown etiology, hyperprolactinemia, 3-4 degree obesity, active smoking (over 10-12 cigarettes / day) especially over the age of 35. Adverse reactions and complications due to oral contraceptives are associated with impaired estrogen-progestin balance and can occur both with an excess of hormones and with their deficiency. These complications (side effects) are usually divided into estrogen and progestin-dependent. Estrogen dependent side effects: nausea, sensitivity and / or breast augmentation, fluid retention and. associated with this cyclic weight gain, increased vaginal mucous secretions, ectopia of the cervical epithelium of the cervix, headache, dizziness, irritability, leg cramps, bloating, chloasma, hypertension, thrombophlebitis. Progestin-dependent (androgen-dependent) side effects: increased appetite and body weight, depression, fatigue, decreased libido, acne, increased greasiness of the skin, neurodermatitis, itching, rash, headache (between taking the drug), an increase and tenderness of the mammary glands, poor menstruation, hot flashes, vaginal dryness, vaginal candidiasis, cholestatic jaundice. With a lack of estrogen, irritability may occur, spotting intermenstrual bleeding at the beginning and / or middle of the cycle, a poor menstrual-like reaction or lack of it, a decrease in the mammary glands, headache, and depression.
With a lack of progestogens: intermenstrual bleeding at the end of the cycle, copious menstrual-like reaction, or its delay. Acceptability OK is determined by the development, duration and severity of adverse reactions that are of a purely individual nature. Depending on the time of occurrence of adverse reactions are divided into early and late. Early (nausea, dizziness, tenderness and enlargement of the mammary glands, intermenstrual bleeding, pain in the abdomen) are usually formed in the first 3 months of the drug and, in most cases, disappear over time. Late (fatigue, irritability, depression, acne, weight gain, decreased libido, impaired vision, delayed menstrual-like reaction) - develop at a later time (more than 3-6 months).
• the need for daily intake of the drug,
• does not protect against sexually transmitted infections,
• the possibility of development (less than 1%) of cardiovascular complications (hypertension, myocardial infarction, thromboembolic and cerebrovascular conditions) associated with the presence of an estrogen component (especially in actively smoking women over 35 years of age, as well as in the presence of risk factors for the occurrence of these diseases) , adenomas and hepatocellular carcinomas of the liver; At the same time, it is necessary to emphasize that, firstly, a decrease in the dose of estrogen in modern preparations significantly reduces the risk of their development (from 2.9% at 50 µg to 1.8% at 30-40 µg), and, secondly, the mortality among women under 40 years of artificial abortion (1.9% - up to 24 years; 9.2% - 35-39 years), significantly higher than with hormonal contraception.
• the possibility of adverse reactions (see above), as well as metabolic disorders caused by both the influence of estrogens and progestogens (similar changes are observed during pregnancy or taking corticosteroids and are transient; moreover, reducing the dose of estrogen (up to 30 mg) and progestogen (up to 150 mcg), the use of third-generation progestogens minimizes the risk of developing metabolic disorders. Advantages of the method:
• high contraceptive effect.
• good tolerability.
• availability and ease of use,
• adequate control of the menstrual cycle.
• reversibility (full restoration of fertility within 1-12 months),
• safety for most somatically healthy women (especially non-smoking women under 35),
• removes the "fear" of an unwanted pregnancy,
• the possibility of a “postponement” (using monophasic preparations) of the next menstrual-like reaction during exams, competitions, rest (by skipping the 7-day interval and continuing to take the drug from the next package; the reception must be stopped 3 days before the start of the desired menstrual-like reaction; it is not recommended to resort to "delay" more than 3 cycles in a row),
• the possibility of using monophasic OK as an "emergency" contraception (see below).
The benefits of oral contraception should also include medical (non-contraceptive) effects of combined estrogen-progestin drugs, namely:
• regulation of the menstrual cycle (arresting algomenorrhea, hyperpolymenorrhea, ovulatory pain, certain symptoms of premenstrual syndrome),
• prevention of benign and malignant ovarian tumors, endometrial cancer, cystic mastopathy, and benign breast tumors (using OK for four years or more reduces the risk of developing these diseases by 50%),
• prevention of postmenopausal osteoporosis,
• prevention of uterine fibroids, endometriosis, functional ovarian cysts,
• OK prevent the development of ectopic pregnancy: inflammatory processes of the genital organs due to changes in the physicochemical properties of cervical mucus (the latter provides a tight barrier not only for spermatozoa, but also for pathogenic flora, including gonococci)
• prevention of rheumatoid arthritis, gastric ulcer,
• therapy of acne, seborrhea, hirsutism,
• the presence of a "rebound effect" used to treat some forms of infertility.
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