Hormonal Birth Control and the Ovarian Cycle Cara Beth Rogers Tanja Mehlo

Ovarian Cycle Hypothalamus Pituitary GnRH Ovary FSH LH estrogen FSH LH Ovulation estrogen, progesterone Uterus estrogen progesterone

– Suppress ovulation by inhibiting rise in FSH and LH, as in luteal phase Follicles do not develop; do not secrete estrogen, no LH surge, no ovulation – Thick cervical mucus as sperm barrier – Interfering with implantation of embryo by reducing initial buildup of endometrium Estrogen causes endometrial cell proliferation, progesterone inhibits proliferation and maintains the endometrium – Typically contain 3 weeks of active pills with one week of sugar pills Lack of progesterone to maintain endometrium causes “withdrawal bleeding” Combination Contraceptive: Estrogen and Progestin

Progestin-only Contraceptives Advantages: – Lactating mothers (high estrogen inhibit milk synthesis) – People who should not take estrogen Types: – Progestin-only pills (Mini pills): Dose may be too low to prevent ovulation Rely on cervical mucus to block sperm. Must be taken at same time every day to maintain progesterone level. – Long-acting progestin Shot = DepoProvera; Implant = Implanon, Intrauterine Device - Mirena) Progestin diffuses over time. Concern: High progestin level inhibits estrogen level significantly. Estrogen inhibit osteoclast activity  can cause low bone density

Emergency Contraception: High Dose Progestin (Plan B) Taken after unprotected intercourse Sperm viable in uterus for several days before ovulation happens Delays or inhibits ovulation if taken before LH surge

Risks: Blood Clots Blot clots leading to pulmonary embolism, heart attack, or stroke – Estrogen leads to increased plasma fibrinogen and coagulation factors – 1:3000 women per year taking oral contraceptives – People who are otherwise at higher risk for blood clots should not use hormonal birth control: Coagulation disorders History of stroke, heart attack Smokers over 35 or with high blood pressure Diabetes

Risks of endometrial and ovarian cancer appear to be reduced with the use of oral contraceptives, whereas the risks of breast and liver cancer appear to be increased. Modern low-estrogen contraceptives show no increase in breast cancer risk People with history of or otherwise at higher risk of breast cancer should not take exogenous estrogen. Burkman R, Schlesselman JJ, Zieman M. Safety concerns and health benefits associated with oral contraception. American Journal of Obstetrics and Gynecology 2004; 190(4 Suppl):S5–22 Risks: Cancer

Interesting Facts About Hormonal Contraceptives – 92-99% effective (depending on adherence) Most effective non-permanent method of contraception – Water retention vs. weight gain Estrogen leads to fluid retention Depo Provera shot, Nexplanon implant only methods linked to weight gain  due to increased appetite, not additional weight put on the body by the method – Slightly lower blood cholesterol – Antibiotics Only known antibiotic to interfere with effectiveness is rifampin – Lower testosterone Clearer skin Lower sex drive – Reduced endometrium buildup and shedding Less blood loss during menstruation  prevent anemia Reduced pain during menses due to less strong uterine contractions

References Burkman R, Schlesselman JJ, Zieman M. Safety concerns and health benefits associated with oral contraception. American Journal of Obstetrics and Gynecology 2004; 190(4 Suppl):S5–22 Hormonal contraception. Retrieved May 15, 2016, from Project, R. H. T. (2016). Reproductive health technologies project - fertility, pregnancy, and the cervix. Retrieved May 15, 2016, from Baggish, M. S., Valle, R. F., & Guedj, H. (2007). Hysteroscopy: Visual perspectives of Uterine anatomy, physiology, and pathology. United States: Lippincott Williams and Wilkins. Answers to frequently asked questions. (2015). Retrieved May 15, 2016, from Female cycle. Retrieved May 15, 2016, from