Oral contraceptives can be composed of a combination of the hormones estrogen and a progestogen or progestogen alone.
The oral contraceptives act as ovarian hormones. If they are ingested, they inhibit the release of gonadotropin-releasing hormone (GnRH) by the hypothalamus and consequently the release of pituitary hormones ovulationsstimulierenden. Oral contraceptives also affect the lining of the uterus and cause the cervical mucus is thick and impervious to sperm. If they are applied consistently and correctly, provide oral contraceptives is an effective form of contraception. Oral contraceptives can consist of a combination of the hormones estrogen and a progestogen or progestogen alone. Most of the combination products (estrogen plus progestin) is taken daily active pill over 21-24 days. Then an inactive pill (placebo) will be taken to allow for withdrawal bleeding for 4-7 days every day. In some preparations, the placebo iron and folate contains (folic acid), others the placebo is not really inactive, but contains 10 micrograms of ethinyl estradiol. Most of combination products containing 10-35 micrograms of ethinyl estradiol. This dose is considered low. Low-dose contraceptives are generally preferred over high-dose contraceptives (50 micrograms of estrogen) because low-dose oral contraceptives appear to be equally effective and have fewer side effects; However, they have in the first months of the application for increased incidence of irregular vaginal bleeding. A new product contains estradiol valerate instead of ethinylestradiol. The estrogen and progestin doses are in some combination products over the same months (Einphasenpille); in others they change during the month (multiphase pill). The effectiveness of all combination products is about the same; the pregnancy rate after 1 year is 0.3% for ideal and about 9% at typical (i. e. occasionally incorrect) application. To be effective, progestin preparations must be taken daily at the same time of day. They contain no inactive pills. The contraceptive effect of the gestagen preparations mainly due to a thickening of the cervical mucosa and prevention of sperm migration through the cervical canal and uterine cavity for fertilization of the oocyte. In some cycles, these oral contraceptives also inhibit ovulation, and this effect is not the primary mechanism of action. Common side effects include irregular bleeding. Progestin preparations are commonly prescribed in women with the desire for oral contraception, but in which estrogen is contraindicated. The pregnancy rates in ideal and typical use of progestin preparations are similar to those of combination products. An oral contraception can always be up to menopause started. However, some women have combination products with special care taking (more information at US Medical Eligibility Criteria for Contraceptive Use, which are available under US Medical Eligibility Criteria for Contraceptive Use, 2010). In the following cases, combination products are contraindicated in patients with <21 days after birth, or <42 days after birth at an increased risk of venous thromboembolism smoking> 15 cigarettes / day in women> 35 years Current or undergone breast cancer Severe decompensated cirrhosis, hepatocellular adenoma or hepatocellular carcinoma venous thromboembolism (deep vein thrombosis or pulmonary embolism), thrombogenic mutation or SLE with unknown or positive antiphospholipid antibody status migraine with aura or migraine of any kind in women> 35 years, hypertension Ischemic heart disease peripartum cardiomyopathy diabetes for> 20 years or with vascular disease (eg. as neuropathy, nephropathy, retinopathy) Malabsorptive bariatric surgery in the history He rzklappenerkrankungen with complications state after organ transplantation complications Current or therapied gallbladder disease or cholestasis related to contraception history of hypertriglyceridemia Acute hepatitis side effects Although some side effects can occur with oral contraceptives, the risk of this is low. Oral contraceptives can cause breakthrough bleeding (which usually disappear after increasing the estrogen dose) or amenorrhea; Amenorrhoea can decay by reducing the progestin dose. In some women, ovulation is inhibited even after discontinuation of oral contraceptives for a few months. Oral contraceptives do not have adverse effects on pregnancies that occur during application. Estrogens increase aldosterone production and cause a Na retention, whereby a dose-dependent, reversible increase in blood pressure and weight (up to about 2 kg) can occur. Weight gain may be accompanied by bloating, edema and breast tenderness. Most of the gestagens contained in oral contraceptives are derivatives of 19-Nortestosterons with androgenic properties. Norgestimate, and desogestrel are less androgenic etonogestrel as levonorgestrel, norethindrone, norethindrone acetate and ethynodiol diacetate. The main androgenic effects are acne, nervousness and an anabolic effect, which leads to weight gain. If a woman is> 4.5 kg / year increases, they should be given a less androgen-acting oral Kontrazeptivaum. Newer anti-androgenic progestins 4th generation contain dienogest and drospirenone (a descendant of the diuretic spironolactone). The incidence of deep vein thrombosis and thromboembolism (z. B. pulmonary embolism) increases with increasing dose of estrogen. Preparations containing 10-35 ug of estrogen increases the risk to about 2 to 4 times the standard. However, the increased risk is much lower than the incidence during pregnancy. A variety of progestins in combination preparations can also influence this risk. Levonorgestrel-containing oral contraceptives appear to reduce this risk and include oral contraceptives, drospirenone or desogestrel, there seem to increase. The risk is probably increased by the formation of clotting factors in the liver and platelet adhesion. On suspicion of deep vein thrombosis or pulmonary embolism in a woman with oral contraceptives stop taking the oral contraceptives should be immediately terminated and suspended until diagnostic tests to confirm the diagnosis or exclude. Even oral contraceptives prior to major surgery, in which an immobilization is required for a long time, as early as possible should be discontinued. Women with idiopathic venous thromboembolism family history should not take estrogen-containing preparations. The risk of breast cancer is increased by either modern oral contraceptives even by the previous administration in women aged 35-65 years. The risk is in high-risk groups (eg. As in women with certain benign breast disease or breast cancer in the family history) does not increase. The Zervixkarzinomrisiko in women taking oral contraceptives have taken over> 5 years, increased slightly; the risk is reduced to the 10-year value by using the contraceptive. Whether this risk of endocrine disruption or the behavior (d. H. No use of barrier methods of contraception) depends, is not clear. Although oral contraceptives was attributed to an increased risk of stroke, low-dose combination drugs do not appear to increase the risk of stroke in healthy, normotensive Non smoking inside. Nevertheless, should oral contraceptives in the occurrence of focal neurological symptoms, aphasia and other symptoms that can precede a stroke, be discontinued. Effects of drugs on the CNS may be nausea, vomiting, headaches, depression and sleep disorders. Although progestogens may cause reversible dose-related insulin resistance, the use of oral contraceptives with low dose progestin only rarely leads to hyperglycemia. Serum concentrations of high-density lipoprotein (HDL) cholesterol may decrease with a high progestin dose during the use of oral contraceptives, but they usually increase with patients taking preparations with low progestin and estrogen doses. The estrogen in the preparations increased triglyceride levels and can aggravate a pre-existing hypertriglyceridemia. Most of the changes in serum levels of other metabolites have no clinical significance. The capacity of thyroxine-binding globulin may increase with oral contraception; however, the concentrations of free thyroxine and thyroid-stimulating hormone and thyroid function are not affected. The concentrations of pyridoxine, folic acid, vitamins of the B complex, ascorbic acid, calcium, manganese and zinc decrease with oral contraception; vitamin A levels increase. None of these effects is clinically significant, and the administration of vitamins in addition to an oral contraceptive is not recommended. Recent studies show that low-dose oral contraceptives do not increase the risk of gallstones. However, should women who developed cholestasis under oral contraception, not once taking oral contraceptives. Women who had one of pregnancy (idiopathic recurrent Schwangerschaftsikterus) may develop jaundice with oral contraceptives; the preparations should be taken with caution. In rare cases, benign liver adenomas, which can rupture spontaneously develop. The incidence increases with duration of use and dose of oral contraceptives; Such adenomas usually regress when the drugs are sold. In some women, melasma occur; they darken by sunlight and slowly disappear after stopping the drugs. Because the treatment is difficult (melasma (chloasma)) be discontinued oral contraceptives at the first signs of melasma. Do not increase the incidence of melanoma. Benefits Oral contraceptives have some significant health benefits. High and low-dose combination drugs reduce the risk of endometrial or ovarian by about 50% for a period of at least 20 years after their discontinuation. to develop the risk of benign ovarian tumors, vaginal bleeding abnormalities, dysmenorrhea, osteoporosis, premenstrual dysphoric disorders, iron deficiency anemia, benign breast disease and functional ovarian cysts decreases. The risk of ectopic pregnancy and salpingitis, which may limit the fertility decreases with oral contraception. Drug interactions Although oral contraceptives the metabolism of certain drugs (eg. As pethidine) can slow down these effects are of no clinical significance. Some drugs (eg. B. cytochrome P-450 enzymes) can induce liver enzymes, which accelerate the conversion of oral contraceptives to metabolites with less biological activity. Women who are taking these medicines, should not use oral contraceptives at the same time when other contraceptive methods are not available or are not accepted. These drugs include certain anticonvulsants (most commonly phenytoin, carbamazepine, barbiturates, primidone, topiramate and oxcarbazepine), protease inhibitors with ritonavir gain, rifampin and rifabutin. Lamotrigine should not be administered with oral contraceptives as they may reduce lamotrigine levels and affect the setting of the seizure disorder. Start Before you start taking an oral contraceptive, a thorough medical, social and family history should be created to identify possible contraindications. Blood pressure is measured, and performed a urine pregnancy test. As long as the blood pressure is not normal and the urine pregnancy test is not negative, no oral contraceptive should be prescribed. A physical examination is, even if it is often performed to start taking a preparation is not required. However, a physical exam within the first year is recommended after the start. A follow-up visit at 3 months may be useful to discuss potential adverse effects and to determine the blood pressure again. An oral contraceptive can be prescribed for a period of 13 months. Already on the Verodnung day can be started with the intake of the preparation (often referred to as quick-start method). The weekday and the time in the menstrual cycle are not important for taking the start. However, when taking the start is> 5 days after the first day of menses, taking a precaution, an additional contraception (eg. as a condom) should be made in the first 7 days. Progestin-only OCs must be taken every day, at the same time every day. Lying between the two income of a progestin preparation> 27 hours should be applied for 7 days in addition to the daily intake for safety’s sake an additional method of contraception. The timing of administration of combination products is not as crucial. However, if the revenue was missed at a contraception with a combined Nina Transportation preparation should be taken at two pills the next day. If the dose is missed on 2 days, the daily intake should be resumed and prevents for 7 days on top with another method. After a spontaneous or induced abortion during the first trimester of pregnancy, a combination preparation may be added immediately. In women who are released between the 12th to 28th week of pregnancy (SSW), can be started after 1 week with the gift of a combination product. In women who are released after the 28th week of pregnancy,> 21 days to wait with the gift of a combination product because they may increase the risk of thromboembolism, which is increased after childbirth anyway. Women who exclusively breastfeed (breastfeeding on demand including nocturnal breastfeeding and without additional administration of other food) or an increased risk of venous thromboembolism have (z. B. due to a Caesarean section performed) should postpone taking a combination product for 42 days. 98% of women who exclusively breastfeed and where the menses fails, do not become pregnant, even if not prevented within the first 6 months after birth. However, it is usually still recommended that beginning a contraception within 3 months after delivery. Taking a progestin preparation can begin immediately after childbirth. In women with a history of liver disease, the liver values ??should be determined to confirm the normal liver function before oral contraceptives are prescribed. A determination of glucose in plasma and a full serum lipid profile annually in women at increased risk of diabetes (eg. As in those with a positive family history of gestational diabetes, infants at high birth weight or physical signs of insulin resistance, such as acanthosis nigricans) is required. The use of low-dose oral contraceptives in pathologies of blood glucose or lipid provisions is not contraindicated unless the triglycerides reach> 250 mg / ml. Most women with diabetes should not take combination products; The exceptions are women with vascular complications (eg. As neuropathy, retinopathy, nephropathy) and those who have been> 20 years have diabetes. Summary All combination products (estrogen plus progestin) are equally effective; Preparations with low estrogen dose are preferred because they have fewer side effects. In progestin preparations may cause irregular bleeding; they must be taken at the same time every day. Oral contraceptives may – if there are no contraindications – be taken continuously until menopause. The risk of thrombotic diseases is increased by combination preparations, it being lower than the risk during pregnancy. Oral contraceptives do not increase breast cancer risk. Before prescribing oral contraceptives a thorough medical history is required; a physical examination does not take place, but they should ideally be made within one year of taking the start.