Combination oral contraceptives

1. Estrogen-progestin oral contraceptives act by inhibiting ovulation through suppression of gonadotropin secretion. Triphasic oral contraceptives decrease the incidence of progestin-related side effects and breakthrough bleeding.

2. Second-generation oral contraceptives contain norgestimate or levonorgestrel as the progestin. Third-generation agents contain desogestrel or gestodene as the progestin. Estrostep is a lower-dose estrogen preparation with varying amounts of estrogen.

Contraindications to Use of Hormonal Contraceptive Methods



Oral combination contraceptive

Active liver disease, hepatic adenoma, thrombophlebitis, history of or active thromboembolic disorder, cardiovascular or cerebrovascular disease, known or suspected breast cancer, undiagnosed abnormal vaginal bleeding, jaundice with past pregnancy or hormone use, pregnancy, breast-feeding, smoking in women over age 35

Progestin-only pill

Undiagnosed abnormal vaginal bleeding, known or suspected breast cancer, cholestatic jaundice of pregnancy or jaundice with previous pill use, hepatic adenoma, known or suspected pregnancy

Depot-medroxyprogesterone acetate (Depo-Provera) injection

Acute liver disease or tumor, thrombophlebitis, known or suspected breast cancer, undiagnosed abnormal vaginal bleeding

Levonorgestrel implant (Norplant)

Acute liver disease or tumor, active thrombophlebitis, known or suspected breast cancer, history of idio-pathic intracranial hypertension, undiagnosed abnormal vaginal bleeding, pregnancy, hypersensitivity to any component of the implant system

Side Effects of Hormones Used in Contraceptive Agents

Type of effect



Nausea, breast tenderness, fluid retention


Acne, increased appetite, weight gain, depression, fatigue


Weight gain. hirsutism, acne, oily skin, breakthrough bleeding

3. Androgenic effects attributable to progestin include hair growth, male-pattern baldness, nausea and acne. If such side effects develop, a switch to a second- or third-generation agent with lower androgenic potential may resolve these problems. Women who experience nausea may benefit from taking the medication at night.

4. Hypertension, usually less than 5 mm Hg, may occur in some patients. If significant hypertension develops, a lower dose of progestin may be tried.

5. Weight gain may be countered by switching to a different formulation.

C. Administration issues

1. If started during the first five days of the menstrual cycle, oral contraceptives are effective throughout the first cycle of use. The medication should be taken at the same time each day.

2. Amenorrhea may occur with long-term use. Administration of an agent with higher estrogen or lower progestin activity may resolve this problem. A missed menstrual period indicates a need for a pregnancy test.

3. Breakthrough bleeding often occurs during the first three months of use. If breakthrough bleeding is a problem, a higher-dose progestin or estrogen agent may be tried. Agents that contain norgestrel are associated with low rates of breakthrough bleeding.

4. If a woman misses an oral contraceptive dose, she should take the dose as soon as she remembers it or take two doses the next day and then continue administration of the remainder of the monthly pack as usual. If two doses are missed during the first two weeks of the cycle, two doses per day should be taken for two days, and an additional form of contraception should be used for one week. The remainder of the pack should be administered as usual. If two or more doses are missed during the third week, the pack should be discarded, a new pack should be started, and an additional contraceptive method should be used for one week.

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