would like to say that, based on my 28 years of gynecologic practice,
the best of all available contraceptive methods continues to be the "old
Pill", that is, the oral hormonal contraceptives. And, to my point
of view, this observation about the oral contraceptives is valid considering
their highly positive benefit/risk relation and, obviously, the high efficacy
of the method. These products have been used for about 40 years and constitute
some of the most studied and researched medicines to date. The fact is
that, for most women, the contraceptive security, tranquility and comfort
provided by the oral hormonal contraceptives by far outweigh the rare
and occasional risks and problems that eventually may occur. We must also
consider that, during the last decades, the hormonal doses contained in
these medicines have been considerably reduced, and new synthetic hormones,
better tolerated and with fewer side effects, have also been developed
and utilized in the more recent products. In this way, the "Pill"
is constantly evolving and being improved.
Let us see, for instance, the
reduction in the estrogen dose of the oral contraceptives that took place
in the last three decades. Up to 1974, the usual dose of ethinyl estradiol
contained in each tablet was 0.05mg ( considered excessive according to
the desired safety standards, mostly regarding the occurrence of some important,
though fortunately rare, side effects ). However, in that same year it was
already possible to successfully reduce the daily ingestion of ethinyl estradiol
to 0.03mg, preserving the same efficacy with excellent tolerability and
considerably fewer side effects. Recently a new generation of oral contraceptives
was developed, in which the daily ingestion of ethinyl estradiol was once
again successfully reduced to 0.02mg ( the low-dose "Pills" ).
Reductions in the progestogen doses of these medicines have also been done.
Therefore, as I have already said, we can easily verify that the "Pill"
actually has evolved and has been considerably improved throughout the years.
And, very recently,
another product was released reducing once again the aforementioned daily
ethinyl estradiol dose to 0.015mg, together with a reduction in the respective
dose of the progestin associated to it. In order to counterbalance this
considerable reduction without lessening the contraceptive efficacy, this
very new "Pill" is to be taken in series of 24 days ( instead
of the usual 21 days ) and the interval between the series was reduced
to 4 days ( instead of the usual 7 days ). Nevertheless, I want to make
it clear that this product is too new, the dosage is too low and, personally,
I still do not have all the necessary information regarding its real contraceptive
security. Though it seems to be effective if taken in this new regimen
of administration, I believe this new oral contraceptive still demands
more clinical studies.
All oral hormonal
contraceptives consist of combinations of the already mentioned synthetic
estrogen ethinyl estradiol with one of the several existing progestogens
or progestins ( synthetic "progesterones" ). Of all progestogens
or progestins that have been utilized in these products, the more important
ones are the levonorgestrel, norethysterone, cyproterone, desogestrel
and gestodene. The newest generations of "Pills" contain preferably
the progestogens desogestrel and gestodene, since some of their general
metabolic effects seem to be smaller and more favourable than those of
the other progestins. This implies an improved general metabolic profile.
The oral contraceptives
that combine the estrogen ethinyl estradiol with the progestogen cyproterone
are specifically indicated for women with hypertrichosis or slight hirsutism
( excessive growth of hair on several parts of the body ) and acne, due
to the well-known anti-androgenic effect of cyproterone. This happens
because cyproterone has the property of inhibiting the androgenic action
on almost all androgen-receptors of the body, among them obviously the
hair follicles. As a consequence, the hypertrichosis/hirsutism and acne
can be reduced under the effect of "Pills" containing cyproterone.
Nevertheless, this treatment must only be prescribed after the completion
of a careful investigation of these androgenic or hyperandrogenic manifestations
intended to correctly diagnose the real origin of this increased growth
of hair on several parts of the female body.
oral contraceptives used along the last decades are considered "combined"
and "monophasic." "Combined Pills" are those in which
all tablets in a series contain both estrogen and progestogen. "Combined
monophasic Pills" are those in which the respective doses of estrogen
and progestogen contained in all tablets along the series are the same.
Whenever the respective dose of estrogen or progestogen varies along a
series, implying the existence of two or three different kinds of tablets
in it, these "Pills" are said to be "biphasic" or
"triphasic" ones, and there are a few products of this kind
in the market. Nevertheless, as I have already said, almost all modern
oral contraceptives are "combined and monophasic", that is,
the daily hormonal ingestion is the same along the usual 21 days that
constitute each series of the "Pill."
remark that this hormonal composition varies according to each specific
kind of oral contraceptive available in the market - that is to say, with
each product. Therefore, there are and there have been lots of different
contraceptive pills, making use of different estrogenic-progestogenic
associations in many different respective doses. This great existing number
of different hormonal contraceptives, making use of different hormones
in varying doses, allows us to get close to "choosing the ideal 'Pill'
for each woman", individualizing the prescription as close as possible.
The "combined" oral
hormonal contraceptives work by means of three basic mechanisms:
1) they interrupt
most of the ovarian function due to an interference in the intricate feedback
mechanisms of the hypothalamus-pituitary-ovaries axis. The usual pattern
of secretion of FSH ( follicle stimulating hormone ) and LH ( luteinizing
hormone ) by the pituitary is considerably altered. As a result, the development
of the ovarian follicles is interrupted at their first stages of growth,
and no one of them reaches the stage of a mature follicle. The pituitary
ovulatory peak of LH is also abolished. This interference in the hypothalamus-pituitary-ovaries
axis constitutes the main mechanism of action of the hormonal contraceptives,
resulting on the suppression of ovulation;
2) they produce
specific alterations in the endometrium ( the mucosa that covers the interior
of the uterine cavity ) which, in the case of an eventual failure in the
inhibition of ovulation, creates considerable difficulty for the implantation
of the fertilized egg;
3) they produce a thickening of
the uterine cervix mucous secretion, thus making it difficult for the ascension
of the spermatozoa inside the uterus.
In this way, the "combined"
oral contraceptives present a main contraceptive mechanism ( the interruption
of the ovarian function and the consequent inhibition of ovulation ) and
two other complementary mechanisms ( which, isolated, are not reliable but,
associated with ovulatory suppression, increase the final contraceptive
As it is well
known, the usual oral contraceptives are taken in series of 21 days, with
an interval of 7 days of rest between the series. In the artificial cycles
induced by the "Pill", this interval is intended for imitating
the usual hormonal fall that takes place at the end of each natural cycle
( which the female organism is physiologically used to ) and for allowing
menstruation to come ( though the menses that come after each series of
the "Pill" are artificial, since they are caused just by this
periodic interruption in the use of the hormonal contraceptive ). Considering
that the hormonal contraceptives inhibit the ovarian function, it is advisable
that, at least once a year, women using the "Pill" stay one
or two cycles without taking it, in order to avoid a prolonged inhibition
of the aforementioned hypothalamus-pituitary-ovaries axis.
As to the present
proposal of abolishing menstruation through the continuous use of hormones,
my opinion is clearly expressed in my article "Uninterrupted
use of hormonal contraceptives for menstrual suppression: why I do not
recommend it", published at the Museum
of Menstruation and Women's Health (
something else must be added about the oral hormonal contraceptives. In
the beginning of this article, I expressed my opinion that they are the
best and the safest of all contraceptive methods, because the benefits
provided by their use by far outweigh some risks and problems that rarely
may occur. But besides the great benefit of their high contraceptive efficacy
allied to the simplicity of their use, other positive aspects related
to the use of the "combined" hormonal contraceptives have been
demonstrated over the last years. They consist basically on a reduction
in the incidence of ovarian and endometrial cancer.
The minor incidence
of ovarian cancer in women who have used the "Pill" for a long
time may be related precisely to the inhibition of ovulation. Though the
subject is still controversial, it is possible that very frequent ovulations
may be one of the many factors that predispose women to some kinds of
ovarian malignant neoplasias. As to the reduction in the occurrence of
endometrial cancer, the reason is that, during the use of the "combined
type" of hormonal contraceptives, women take an association of estrogen
and progestogen for three weeks each cycle. As a result, the progestogenic
component of these "Pills" taken for 21 days along each cycle
prevents the development of endometrial hyperplasias, a very common group
of pathologies of which some types can be precursors of endometrial cancer.
is a gynecologist dedicated to Clinical, Preventive and Psychosomatic
Gynecology. Graduated in 1974 by Faculdade de Medicina da Universidade
Federal do Rio de Janeiro, he is the author of several articles published
in medical journals, and of the books "Novas
Perspectivas em Ginecologia" ("New Perspectives in Gynecology")
and "Os Órgãos Sexuais Femininos:
Forma, Função, Símbolo e Arquétipo" ("The
Female Sexual Organs: Shape, Function, Symbol and Archetype"),
published by Imago Editora, Rio de Janeiro, 1990, 1993.
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