In theory, contraception is 100% effective, brings no risks and side effects, but extended health benefits. How do the preparations available on the Swiss market perform in this respect?
The term “contraception” describes the separation of sexuality and reproduction. People who want to make this separation use contraceptive methods. Over the last decades, the number of available methods and preparations has increased significantly. Whereas 100 years ago one had to choose essentially between coitus interruptus, the rake method and the condom – methods based on the sperm and egg not coming together – the discovery of hormonal control of reproductive processes has opened up the possibility of inhibiting ovulation by means of the administration of steroid hormones.
Starting with the first “pill” called Enovid, a tree of hormonal contraception has grown, with large and small branches. The major branches are combined hormonal contraceptives with different dosages, compositions and forms of application (oral, transdermal, vaginal). The other thick branch is the methods based on the exclusive use of progestogens, with different types of synthetic progestogens and different forms of application (implants, intrauterine devices).
But the “old” contraceptive principle of preventing fertilization (sperm cannot reach the egg) has also been further developed: Either by mechanical blocking (intrauterine contraceptive methods such as copper IUDs, female condoms, diaphragms, etc.) or by determining fertile days (Billings method of mucus monitoring, LH determinations, computer-based calculation apps).
Who has the agony, has the choice
So especially the women today have many options to prevent pregnancy. Physicians should help them find the method that suits their needs and best fits their particular medical and psychosocial profile (indications and contraindications).
Combined hormonal contraceptives
What these methods have in common is that they consist of two components: an estrogen and a progestin. The effectiveness is high, provided that the tablets are taken correctly. The most important health risk is venous thrombosis. It is very rare overall. The incidence of thromboembolic disease in the population is 3-4 per 10,000. For users of combination drugs, the risk increases to 6-10 per 10,000. This means that 9990 women are not expected to have such complications. At the same time, it should be remembered that the risk of thrombosis during and after pregnancy is 20-25 per 10,000 women. The venous risk can be reduced or even avoided by
- Reduction of estrogen dose (“low dose” and “ultra low dose”): Woman chooses a pill with a low dose of ethinyl estradiol
- Abandonment of estrogen: Woman uses a progestin-only preparation
- Choosing the right progestogen: Studies show that progestogens with a so-called anti-androgenic effect, which have beneficial effects on skin and hair, have a slightly higher risk of thrombosis compared to the so-called older “androgenic” progestogens, which are said to have an inhibitory effect on the estrogen in the pill.
- Avoidance of use: In women with additional risks for cardiovascular disease.
These are probably the most important measures. Women who have already experienced thrombosis or with a family history of thrombosis, heavy smokers, and women who are significantly overweight should use other contraceptive methods.
Other health risks include breast cancer and cervical cancer. In breast cancer, study results are controversial. There may be a slightly increased risk, but this disappears after discontinuation. So far, there is no evidence that taking a pill earlier increases the risk of developing breast cancer after menopause. In cervical cancer, a slight increase in risk is described, depending on the duration of use. However, the most important and necessary risk factor for this disease is HPV infection. This means that the pill itself does not increase the risk, but this can only happen through an interaction with the virus. Another important practical aspect of risk management is that early detection options exist with regard to cervical carcinoma.
In general, the tolerability of combination preparations is good. As with all medications (and the pill is, of course, a medication), different users experience different side effects. The side effects can often be attributed to one of the two components in the combination drug:
- Too much estrogen can contribute to breast discomfort and headachesLess estrogen causes bleeding between periods
- Too much progestogen effect may lead to mood deterioration in predisposed women
- Too little progestin effect is possibly related to symptoms such as restlessness and nervousness.
An accurate knowledge of the dosage and composition makes it possible to achieve better tolerability by making adjustments or choosing a different pill.
At the same time, the preparations offer health benefits that have nothing to do with actual contraception (prevention of diseases and therapy of complaints). It is often forgotten that combined hormonal contraceptives contribute to a significant and long-lasting risk reduction for ovarian cancer and endometrial cancer, and that these contraceptives are effective in treating disorders of the menstrual cycle and menstruation itself (irregular and heavy bleeding, painful menstruation, etc.). Combined hormonal contraceptives reduce the incidence of ovarian cysts and fibrocystic disease of the breast. They can relieve endometriosis-related pain and reduce hyperandrogenetic symptoms such as acne and hirsutism.
Further developments
The observation that, in practice, daily use of the contraceptive is difficult and that noncompliance results in unintended pregnancies has led to the development of the contraceptive patch (weekly use) and the vaginal contraceptive ring (monthly use). Both methods essentially act like oral contraceptives in terms of risks, negative and positive side effects. Over the years, it has also been shown that the so-called long cycle brings advantages for users. In this case, there is no monthly hormone withdrawal (the seven pill-free days), but the pill is taken daily for three months or longer, which reduces the occurrence of typical hormone withdrawal symptoms and is particularly suitable for women with menstrual cramps.
Two preparations in which the ethinyl estradiol has been replaced by natural estrogen (estradiol valerate plus dienogest; estradiol plus nomegestrol acetate) represent an innovation. This may reduce the unwanted, rather potent estrogenic effects of ethinyl estradiol on protein synthesis in the liver, and at least theoretically it is hoped that this will also reduce the risk of thrombosis. Recent studies point in this direction.
Progestin methods
The oldest forms of “progestin-only” are oral preparations, which initially did not have an ovulation-inhibiting effect and therefore had a higher failure rate in practice. These “mini-pills” have been replaced by desogestrel 75 ug. This pill must be taken continuously and inhibits ovulation.
An older preparation from this group is the so-called three-month injection (Depo-DMPA), which is applied every twelve weeks and has a high efficiency with prescribed regularity.
The highest practical effectiveness has the so-called long-term contraceptive methods. In addition to copper IUDs, there are two progestin-based methods, namely a subcutaneous implant containing ketogestrel (effective for three years) and several intrauterine devices that deliver the progestin levonorgestrel (effective for three to five years). These methods are independent of the compliance of the user and therefore very effective. Furthermore, the contraceptive effect is given for long periods after insertion or insertion (“fix and forget” methods).
All hormonal methods based on the use of progestogens without estrogens have in common that so far there is no evidence of increased cardiovascular risk. Overall, this group of hormonal contraceptive methods is thus suitable for all those women who have contraindications to estrogen-containing contraceptives.
The most common side effects of “progestin-only” contraceptive methods are bleeding disorders, less commonly mood swings and mood deterioration, acne, and weight gain (possibly depot injection).
The main therapeutic application is the use of the levonorgestrel-containing IUD to treat heavy bleeding. This method has its own indication for this.
More recent developments include the introduction of levonorgestrel-containing intrauterine systems with other masses and dosages and, more recently, progestin-containing vaginal rings.
Non-hormonal methods
Copper IUDs: Copper IUDs are highly effective; they are independent of the user and ensure a long-lasting effect of at least five to twelve years. The health risks are low and independent of age. Failure shows an increased rate of extrauterine pregnancy; rare complications include perforation and expulsion. The most common side effects are pain during menstruation and increased menstrual bleeding, which can also lead to iron deficiency and anemia. This is of importance in perimenopausal women with pre-existing heavy or painful bleeding, which occurs more frequently during this phase of life. The risk of adnexitis depends on an existing sexually transmitted infection (e.g., chlamydia) and is not actually caused by the IUD. Several studies have shown that copper IUDs have a protective effect related to cervical cancer.
Many doctors still believe that a young nulliparous woman should not be given an IUD. Various studies have shown that the rate of side effects is not increased, and international guidelines have removed the contraindications of “age” and “nulliparity.” It is important to exclude an existing vaginal infection (especially chlamydia).
Barrier methods: Barrier methods include male condoms, female condoms, diaphragm, and cervical caps. Effectiveness is significantly lower, highest in perimenopausal women. The spermicidal nonoxynol is associated with an increased risk of HIV virus transmission because of irritation of the vaginal mucosa.
Take-Home Messages
- Numerous methods of pregnancy prevention are available today.
- None of the methods meet the theoretical ideal: 100% effective, no health risks, no side effects, additional health benefits.
- The art of contraceptive counseling is to help the patient find the right method for her on an individualized basis. This can be defined as follows: It meets the needs and values of the woman in terms of application and characteristics; there are no medical or psychosocial contraindications; the method is effective and has a high probability of good tolerability and favorable additional effects with regard to the characteristics of the user.
Literature list at the author
HAUSARZT PRAXIS 2018; 13(7): 13-15
