Estrogen, Progestins, and Birth Control

Estrogen and Progestins

Hormones with multiple actions: promote female maturation, help regulate ongoing activity of female reproductive organs, estrogens affect bone mineralization and lipid metabolism

Estrogen Therapy

Suppression of menopausal symptoms and prevention of bone loss. Increased risk: endometrial cancer, DVT, and stroke

Selective Estrogen Receptor Modulators (SERMS)

Activate receptors in some tissues and block receptors selectively in others. Developed to provide benefits of estrogen while avoiding the drawbacks. Types: Tamoxifen, Toremifene, Raloxifene

Tamoxifen (Nolvadex)

Breast cancer tx, promotes against osteoporosis, produces hot flashes, risk for endometrial cancer and thromboembolism

Raloxifene (Evista)

Breast cancer tx, protects against osteoporosis, promotes thromboembolism, induces hot flashes, does NOT promote endometrial cancer

Progestins

Produced by ovaries and placenta. Postmenopausal hormone therapy, amenorrhea, infertility prematurity prevention, endometrial carcinoma, and hyperplasia. May also cause: depression, breast tenderness, bloating, weight gain

Birth Control Methods

Pharmacological: oral contraceptives, etonogestrel implants, injectable medroxyprogesterone acetate, intrauterine devices, vaginal rings.

Non-pharmacological: surgical sterilization (tubal ligation, vasectomy); mechanical devices (condom, diaphragm, cervical cap); avoiding intercourse during period of fertility (calendar, temperature, or cervical mucus method)

Select a method based on: effectiveness, safety, personal preference

Oral Contraceptives

Inhibition of ovulation; Combination of oral contraceptives (OCs) - estrogen and progestin; Progestin only OCs (“mini -pills”)

Combination OCs: Ethinyl Estradiol/ Norethindrone

Adverse Effects: thromboembolic disorders, HTN, cancer, stroke in pts w/ aura, nausea, breakthrough bleeding.

Contraindicated: heavy smokers, women w/ hx of thromboembolism, women w/ other risk factors for thrombosis

S/Sx Thrombosis: leg tenderness or pain, sudden chest pain, shortness of breath, severe heachache, sudden visual disturbance

Noncontraceptive Benefits: decrease risk of - ovarian cx/ endometrial cx, ovarian cysts, pelvic inflammatory disease, benign breast disease, anemia. Favorable effect on menstrual cycles, diminished cramps, lighter/shorter/ more predictable flow.

Missed Pills - Combination OCs

> 1 first week: take 1 pill ASAP and continue w/ the pack, use an additional form of contraception for 7 days

1 - 2 second or third week: take 1 pill ASAP and continue w/ active pills in the pack, skip placebo and go straight to a new pack

>3 second or third week: follow instructions given for missing 1 or 2 pills, use additional contraception for 7 days

Progestin - Only OCs

Do not cause thromboembolic disorders, headache, nausea, or most other adverse effects associated w/ combination OCs. Slightly safer than combination OCs, decrease efficacy and increase irregular bleeding.

Transdermal Contraceptive Patch

1 a week for 3 weeks, followed by 1 week off. Breast discomfort, headache, local irritation, nausea, menstrual cramps

Vaginal Contraceptive (NuvaRing)

1/mo, left in place for 3 weeks and then removed, a new ring is inserted 1 week later.

May cause: vaginitis, headaches, upper respiratory infection, leukorrhea, sinusitis, weight gain, nausea

If expelled before 3 weeks have passed, it can be washed off in warm water and reinserted, if < 3 hours elapse between expulsion and reinsertion use backup protection. If ring cannot be reused, insert a new on.

Subdermal Etonogestrel Implants

Daily release of etonogestrel, gradually declines over 3 years, replaced after 3 years. May cause: irregular bleeding, weight gain

Depot Medroxyprogesterone Acetate (MPA)

IM or SubQ injection. protects against pregnancy for 3 months or longer. May cause: menstrual irregularities, bone loss, weight gain

Intrauterine Devices (IUD

Among the most reliable forms of reversible birth control, placed within 7 days of onset of menses. Replacement can be inserted during any phase of the cycle - good for 5 to 10 years.