Hormones in Oral Contraceptive Pills

Oral contraceptive pills have synthetic hormones similar to estrogen and progesterone. There are two types of pills – the combination oral contraceptive that contains both estrogen and progesterone, and the pill that contains progesterone only. These two hormones  – estrogen and progsterone – have very important effects in the female body. It essentially prepares the body for pregnancy and should pregnancy occur, these hormone levels increase substantially to sustain pregnancy. When the oral contraceptive pill is used it basically mimics a state of pregnancy that activates the same mechanisms as in pregnancy to prevent fertilization of another egg cell.

Actions of Oral Contraceptives

Elevated levels of the female hormones suppress the secretion of two important regulators of the reproductive functions – follicle-stimulating hormone (FSH) and luteinizing hormone (LH). Without these hormones the follicles in the ovary cannot mature and rupture to release an egg cell (ovum). However, progesterone only pills also referred to as the Minipill are not as reliable in preventing ovulation. It depends on other mechanisms to prevent pregnancy should ovulation occur. This includes changing the quantity and viscosity of the cervical mucus which hampers the entry of sperm into the uterus as well as thinning of the uterine lining so that a fertilized egg cannot implant on the uterine wall.

Period while on the Pill

There are two types of pills in a 28 day pack – the active pill (21) and the placebo pill (7). Menstrual bleeding occurs when taking the placebo pills as the hormone levels gradually decrease. With a 21 day pack, menstrual bleeding will occur in the 7 days where no pill is being used. This is sometimes referred to as a false or fake period. Normally, a menstrual period occurs when the thickened inner lining of the uterus is shed since pregnancy does not occur. This thickening does not occur when using the pill. Instead the bleeding that occurs during this time is a withdrawal bleed from temporarily stopping the pill. Newer birth control pills known as extended-cycle pills may suppress this bleeding for 3 months or even one year.

Pregnancy after the Pill

Ovulation can occur as early as two weeks after stopping the pill. This means that a woman could fall pregnant at this point. However, it is advisable to wait for the first menstrual period to occur before planning conception. Some women experience what is known as period pill amenorrhea where the menstrual periods do not return despite having discontinued the birth control pill. It is not a cause for concern if the menstrual period does not return within the first 3 months of stopping the pill. After this time, however, a woman will need to see a doctor and undergo further testing to establish why the normal menstrual period has not returned. Appropriate measure may then be taken to restore the periods.

Menstruation is the cyclic monthly bleeding that occurs in a woman throughout her childbearing age. The menstrual cycle is controlled by a number of hormones, of which fluctuating estrogen and progesterone levels at different phases of the cycle are responsible for the bleeding produced during menstruation. In the first half of the menstrual cycle, there is a rise in the female hormone estrogen. Ovulation (release of the ova or egg from the ovary) usually occurs on day 14 of a regular 28 day cycle. The ovaries secrete both estrogen and progesterone which help to prepare the uterus for pregnancy, should fertilization take place. If the egg is not fertilized by a sperm and pregnancy does not occur, the hormone levels fall. This results in the uterine lining being shed, which comes out with blood through the vagina as menstruation.

Reasons for Postponing Menstruation

• Traveling.
• Going on a holiday.
• Wedding.
• Honeymoon.
• Taking part in a sporting event.
• During examinations.
• Taking part in a religious ceremony.
• Any other major life event.

How to Delay a Period

For Women on Birth Control Pills

The combined oral contraceptive pill or the birth control pill contains both estrogen and progesterone. Normally, these pills are taken every day for 21 days, with a break of 7 days during which the hormone levels fall and breakthrough bleeding occurs similar to menstruation. The next set of pills is started again after the 7 day break.

If 2 packets of pills are taken back to back, that is without the break of 7 days, there will not be a fall in the hormone levels and breakthrough bleeding will not occur hence there will be no menstruation. Once the pills are stopped, bleeding will occur in 2 to 3 days time.

Some packets contain 28 pills of which the last 7 contain an inactive ingredient or a folate supplement. With these pills, the last 7 pills are eliminated and back to back pills are taken after 21 days.

For Women Not on Birth Control Pills

Norethisterone is a synthetic hormone similar to the sex hormone progesterone. As explained earlier, decreasing levels of the hormone in the later part of the cycle leads to menstrual flow. Norethisterone is most often used for delaying the onset of periods by maintaining the high progesterone level and thus preventing bleeding.

Norethisterone is usually started at least 3 days before the expected menstrual date. Norethisterone 5 mg tablets are taken 3 times a day. This may be continued for 1 or 2 weeks or till menstruation is to be delayed. Periods normally start 2 to 3 days after stopping the drug.

These pills are usually safe but norethisterone taken in this manner is not a contraceptive. Occasional side effects may include nausea, weight gain, breast discomfort, dizziness, headache, spotting, and risk of thromboembolism.

Emergency contraception is a means of preventing pregnancy in a woman after unprotected sexual intercourse. It should only be used after isolated episodes of unprotected intercourse and not on a regular basis. Emergency contraception can reduce the risk of an unwanted pregnancy and the need for subsequent abortion. The most common form is a pill, also referred to as the morning after pill, but an intra-uterine device (IUD) may also be used for this purpose.

When Should Emergency Contraception be used?

Emergency contraception may become necessary when :

• A woman is raped.
• A woman has sex without using any form of contraception.
• A condom breaks (split sheath) or slips off.
• A diaphragm or cervical cap slips out of place.
• A woman forgets to take birth control pills for more than 3 consecutive days.
• Progestogen-only pill (minipill) taken more than 3 hours late.
• Progestogen-only contraceptive injection overdue by more than 2 weeks.
• Combined estrogen-plus-progestogen monthly injection overdue by more than 7 days.
• Failure of other methods of contraception such as coitus interruptus.
• Miscalculation of safe period for intercourse.
• IUD expulsion.

Types of Emergency Contraception

Emergency Contraceptive Pills (ECPs)

Use of emergency contraceptive pills is a safe and effective way of preventing unintended pregnancy after unprotected sexual intercourse. Although called the “morning-after pill”, it is usually effective when taken within 72 hours (3 days) of unprotected sex, and has a good chance of preventing pregnancy even when taken within 120 hours (5 days), depending upon the choice of pills. The chances of avoiding pregnancy are better the sooner the pills are taken. Once implantation occurs, it will not be effective.

Some facts about ECPs :

• ECPs are not the same as abortion pills, which are used to terminate a known pregnancy, and do not cause anabortion. If pregnancy continues despite taking the pills, studies indicate that it is unlikely to harm the mother or baby.
• ECPs do not protect against sexually transmitted infections.
• ECPs act in several ways, such as inhibiting ovulation, preventing sperm from reaching the egg, or inhibiting implantation of the embryo in the uterus.
• Side effects may include nausea, vomiting, headache, dizziness, irregular periods, and breast tenderness.

The different types of ECPs are :

• Progestin-only pills (levonorgestrel). This may be taken as a single dose pill or two pills taken 12 hours apart. Its effectiveness decreases with time.
• Combination pills. A higher than normal dose of birth control pills containing a combination of estrogen and progesterone may be taken in 2 doses. It may not be as effective as progestin-only pills.
• Ulipristal. This is taken as a single tablet. It acts by delaying or preventing ovulation. Its effectiveness seems to be superior to that of progestin-only pill.

Copper-T Intrauterine Device (IUD)

A copper-T IUD, when inserted within 120 hours (5 days) of unprotected intercourse, may be more effective than emergency contraceptive pills in preventing pregnancy. Failure rates are extremely low with this type of emergency contraception. Even if exposure was more than 5 days ago, it can still be inserted up to 5 days after expected ovulation.

When there is risk of infection, such as after sexual assault and rape, the IUD may be inserted under antibiotic cover.

• IUDs prevent pregnancy by inhibiting implantation of the embryo in the uterus.
• Side effects may include intermenstrual bleeding or heavy periods.

Any lower abdominal pain or abnormal vaginal bleeding occurring within 2 to 6 weeks of emergency contraception should be brought to the doctor’s notice because of the risk of ectopic pregnancy.

While the pill (oral contraceptive) and injection are the favored methods, there are odd cases where teen girls are using hormonal skin patches and vaginal rings that release hormones. The “morning after pill” is an emergency hormonal contraceptive, which is effective when used within a certain period of time after having unprotected sex.

Whatever the method of use, this means of contraception makes use of hormones such as estrogen and progesterone, together in certain preparations, or progesterone alone in others. These are hormones, that are normally present in a woman’s body, vary in concentration at different stages of a woman’s life such as at the time of puberty, pregnancy and menopause.

In trying to prevent unwanted pregnancies by using hormones you are increasing the levels of these hormones in the body. In an adolescent, where the body is already trying to cope with a surge of hormones, the addition of extra hormones may lead to effects that may have long term complications.

Complications and Effects of Teen Hormone Contraception

As a teenager, before you think of starting on hormone contraceptives, you should be aware of the risks so that you can make a well informed decision about it. It might help to talk to your doctor or the school nurse before even contemplating hormone contraceptives. They may be convenient and effective in preventing pregnancy but can give a false sense of security in that you may opt not to use condoms during intercourse. This results in an increased risk of contracting STD’s (sexually transmitted diseases) like HIV, syphilis and gonorrhea.

Research has shown that use of hormonal contraceptives in young girls definitely increases the chance of breast cancer. The younger the age of starting on hormonal contraceptives, the greater risk of developing breast cancer at a later stage. Another effect of earlier and hence prolonged use of hormonal contraceptives is that there is a risk of infertility developing later on in adulthood. As a result of suppressing ovulation artificially for a long time, ovarian function may not be able to restore completely when contraceptives are withdrawn.

Hormonal contraceptives may cause weight gain. As a teenager or young woman, this can have a significant impact on your self image, confidence and social interaction. While some type of oral contraceptives may be used for the treatment of acne in teen girls, it is also possible that using a hormone contraceptive can trigger or aggravate acne. Similar to weight gain, acne has a profound psychosocial impact particularly in teens.

Increased risk of developing cervical cancer after prolonged use is a well-documented fact and needs to be considered before starting on hormonal contraceptives from a young age. Smoking and the increased risk of developing heart attacks or stroke with the use of oral contraceptives in young women is another consideration that should not be overlooked. Teens with a history of liver disease or migraines may aggravate their conditions further with the use of hormone contraceptives.

Chances of blood clots, especially deep vein thrombosis (DVT) are also increased. Mood changes, irritability, depression, nausea, headache, painful breasts and spotting are some of the side effects which may occur. Depletion of certain vitamins from the body, such as vitamin B6, and folic acid is also a possibility and while these micronutrients are necessary for all age groups, they are of particular importance to the developing body of a teenager.

There is also the danger of weakening bones due to calcium loss if hormone contraceptives are used for a long time. This is more so if injectable forms of hormonal contraceptives are used and is of special significance in teenagers whose bones are still growing. Bones may become brittle and fracture easily. With some types of contraceptives (those containing progesterone only, as in the mini pill or implants) your periods can become irregular, scanty or stop altogether.

A teenager may not be able to fully understand the impact of sexual intercourse and the responsibility that comes with it. Some teens may see this as a ‘license’ to become more liberal with their bodies, practicing unprotected sex with more than one partner. This increases the chance of contracting STD’s and with the ever increasing rate of HIV infection, this could be disastrous for a young person.  Abstinence is always a better option until a person is mature and within a secure relationship to partake in sex and the early use of hormone contraceptives may blur these lines at at times for teens.

The considerations above are not only relevant for the teenager in question but also for the parent(s) who assist teens with acquiring hormone contraceptives. While avoiding a teen pregnancy may be the main focus, the impact of using a hormone contraceptive from an early age can have other consequences, some of which can be more detrimental to one’s life and career, than teen pregnancy.

How does the oral contraceptive pill work?

The oral contraceptive delivers high doses of estrogen and progesterone to the body, thereby mimicking pregnancy. The body is ‘fooled’ to believe that ovulation should not occur due to the state of perceived pregnancy and through this mechanism, the pill prevents pregnancy. Unlike other forms of the contraception, the oral contraceptive pill requires discipline and fastidiousness on the part of the user and missing the pill, even for one day, can hamper its function.

Oral Contraceptives and Antibiotics

While the oral contraceptive is a very effective form of contraception if taken according to directions, certain drugs and medical conditions can affect its action. The most common drug known for interacting with an oral contraceptive and causing failure of the pill, is an antibiotic. Antibiotic therapy may disturb the natural intestinal flora (bacteria in the bowels) and this hampers the absorption of the pill. A reduced absorption alters the hormone levels needed to ‘trick’ the body into believing that a state of pregnancy already exists. This leads to failure of the oral contraceptive and possibly resulting in unplanned pregnancy.

Antibiotics are one of the most commonly prescribed drugs, second to analgesics (pain killers), and in most cases, it does not interefere with the absorption of the pill. However, it is important to be cautious when using an antibiotic and other forms of contraception, like the condom should be considered if possible failure of the oral contraceptive is suspected. Your doctor should be informed of your oral contraceptive use when you visit him or her for any condition that may require the use of antibiotics.

Drug Interaction and Herbal Remedies with the Oral Contraceptive Pill

Other drugs and chemical compounds that are known to affect the efficacy of the oral contraceptive are antiepileptic drugs. If you suffer with epilepsy, antiepileptic drugs are necessary for the management of your condition and in these cases you should not rely entirely on the pill as a form of contraception. Speak to your doctor about other methods of contraception that could be considered in your case. Herbal remedies like St. John’s Wort (Hypericum perforatum) has also been reported to compromise the oral contraceptive pill and while this remedy can be purchased over the counter, it is important to first consult with your doctor or pharmacist. New research has revealed that other herbal remedies may also lead to the failure of oral contraceptives.

Diarrhea, Vomiting (Gastric Flu) and the Oral Contraceptive Pill

Lastly, diarrhea and vomiting, common symptoms during the gastric flu or in cases of traveler’s diarrhea, may also affect the absorption of the oral contraceptive. If you have suffered with a bout of diarrhea and vomiting, your oral contraceptive may not offer the same level of protection. As a precaution, do not partake in unprotected sex within the first seven days after your bout of diarrhea and vomiting ceases.

References

1. Contraception. Netdoctor.co.uk
2. Oral Contraceptives. Mayo Clinic