Hormonal contraceptives without estrogen. Combined estrogen-progestogen contraceptives

mD, professor Kuznetsova IV, Department of Obstetrics and Gynecology No. 1, Faculty of Medicine, MMA named after THEM. Sechenova

Obstetrics, gynecology and reproduction. 2008; N2: c.6-8

Summary:

The report from the perspective of today considers the requirements for contraceptives, the advantages and disadvantages of combined (estrogen-progestogen) oral contraceptives and justifies the use of pure progestogen contraceptives.

Keywords: contraception, progestins, COC, Charoset

Ideal contraception of the 21st century should provide high safety, efficacy, and also have additional positive effects. To date hormonal contraceptives  can be divided into two large groups: combined (estrogen-progestogen) and pure progestogen contraceptives. Moreover, in both groups there are both oral and parenteral forms.

Basis hormonal contraception  are progestins - these are all substances, natural and synthetic, with a characteristic antiproliferative and secretory-transforming effect on the endometrium. Progestins are synthetic progestogens, that is, part of a large group of progestogens (progestogens), which includes progesterone. They have the main antigonadotropic effect, thereby providing contraceptive effect. Doses of ethinyl estradiol (EE), which is part of modern COCs, are not enough to suppress ovulation, so EE is introduced into COCs solely for cycle control.

On the other hand, the estrogen component, affecting various organs and systems, can dose-dependently cause the appearance of a whole range of side effects that interfere with the use of drugs in certain groups of women.
The main concern is the relationship between COC administration and the development of venous thrombosis. For example, smoking women older than 35 years, the risk of developing myocardial infarction is slightly increased, and in women suffering from hypertension - the risk of developing a stroke. At the same time, the risk of developing myocardial infarction increases with an increase in the number of cigarettes smoked during one day. According to WHO (2004), the use of COCs in women with impaired hemostasis increases the risk of thrombosis. Studies have shown that overweight women (more than 30 kg / m2), using as contraceptive  COCs were at increased risk of thromboembolic complications compared to women not using COCs. However, the absolute risk of such a complication remains quite low. Therefore, COCs are not recommended or undesirable for women with high risk factors for the development of arterial and venous thrombosis. According to the Ministry of Health of the Russian Federation, the level of diseases of the cardiovascular system and metabolic disorders in our country is growing every year. Accordingly, the number of women who are undesirable in taking combined contraceptives is also growing.
Even in women who do not have contraindications for using OK, estrogens can cause side effectssuch as nausea, headacheengorgement of the mammary glands, which are the main causes of cessation of COC. The estrogens that make up COCs can affect the amount of breast milk  in lactating women and the duration of lactation.

Based on this, the appointment of COCs is impossible or less preferable compared with the appointment of pure progestin drugs in many common diseases and syndromes.

A representative of progestogen-containing contraceptives is Charozetta. Each Charozetta tablet contains 75 mcg of highly selective desogestrel progestogen. Charozetta is taken continuously.
One of the main advantages of Charozetta is the mechanism of action. In contrast to the mini-pill, the main mechanism of action of Charozetta is the suppression of ovulation, which is observed in 99% of the cycles. Due to this, when you miss a pill for less than 12 hours, contraceptive effectiveness does not decrease.

Numerous studies have shown that when using the drug, side effects are rare. Charozetta has no clinically significant effect on body weight, blood pressure, hemostasis, lipid and carbohydrate metabolism.

Clinical experience with the use of pure progestin contraceptives has shown that they have additional non-contraceptive effects, which is manifested by a decrease menstrual flow  and the frequency of anemia. Progestogen-containing contraceptives can be used to treat abundant blood dischargetreatment pain syndrome  with endometriosis, prevention of acute episodes inflammatory diseases  pelvic organs, prevention of endometriosis, hyperplastic processes and endometrial cancer. Due to the fact that ovulation is effectively suppressed against the background of a continuous regimen of using gestagen-containing contraceptives (except for mini-pill), it seems justified to use this effect in order to treat diseases that depend on changes in the level of female sex hormones.
Contraindications to gestagen contraception include confirmed or suspected pregnancy, bleeding from the genital tract of unknown etiology, breast cancer (including a history of), migraine with focal symptoms, violation cerebral circulation, severe illness  liver (active phase viral hepatitis, cirrhosis of the liver).

Thus, estrogen-free contraception is highly effective and acceptable, safe and has additional positive effects. Progestogen-containing drugs are relevant in the XXI century.

GYNECOLOGY - EURODOCTOR.ru -2005

The drugs in this group are called " oral contraceptives" (OK).Each OK tablet contains estrogen and progestogen. As an estrogenic component, mainly ethinyl estradiol is used, less often - mestranol. Ethinyl estradiol is slightly superior to mestranol in its activity. The progestogen component is represented by derivatives of 19-nortesto-sterone: norethinodrel (1st generation); norztisterone, ethinodiol diacetate, linestrenol, levonorgestrel, norgestrel (2nd generation); desogestrel, gestodene, norgestimate (3rd generation). Androgenic activity of third-generation progestogens in comparison with levonorgestrel is significantly reduced and, therefore, is characterized by a low frequency adverse reactions  androgenic type. In addition, third-generation progestogens do not disrupt lipid metabolism, do not affect body weight, and do not increase the risk of development cardiovascular disease. New Progestogen Compounds Provide Adequate Control menstrual cycle  and. therefore, the lowest frequency of menstrual dysfunction.

The mechanism of contraceptive action is OK.

The contraceptive effect of combined estrogen-progestogen drugs is based on the synergy of the central and peripheral mechanisms, i.e. on the suppression of ovulation as a result of the inhibitory effect on the hypothalamic-pituitary-ovarian system, a change in the nature of cervical mucus and changes in the endometrium that impede implantation. The degree of exposure to the hypothalamus-pituitary-ovary-uterus system is dose-dependent. composition, duration of use of the drug, as well as the initial functional level of this system.

Contraceptive effect okis 0-0.9 pregnancies per 100 women / years.

"Contraceptive failures" are due mainly to errors in taking the drugs (in particular, in missing pills, especially at the beginning or end of the menstrual cycle). So, according to most researchers, the correct use of OK provides a 100% contraceptive effect, including 7 day intervals between doses. Depending on the content of estrogenic and / or progestogen components, OCs are divided into mono- and multiphase.

Monophasic OK  - The dose of estrogen and progestogen in each tablet is stable. The package contains 21 tablets. Below are the most commonly used modern OK with monophasic action.

• Demulen (Demulen), SEARLE, USA 0.035 mg ethinyl rstradiol + 1.0 mg ethynodiol diacetate
• Diane-35 (Dianae-35), SCHERING, Germany 0.035 mg ethinyl estradiol + 2.0 mg cyproterone acetate
• Marvelon (Marvelon), ORGANON, the Netherlands 0.03 mg ethinyl estradiol +0.15 mg desogestrel
• Mersilon, ORGANON, The Netherlands 0.02 mg ethinyl estradiol +0.15 mg desogestrel
• Minisispyun (Minisislon), JEN AR HARM, Germany 0.03 mg ethinyl estradiol +0.125 mg levonorgestrel
• Norethin (Norethin), SEARLE, USA 0.035 mg ethinyl estradiol + 1.0 mg norethindrone
• Ovismen, CILAG A.G., USA 0.035 mg ethinyl estradiol +0.5 mg norztisterone
• Rigevidori, GEDEON RICHTER, Hungary 0.03 mg ethinyl estradiol + 0.125 mg levonorgestrel
• Silest (Cilest), CILAG A.G., USA 0.035 mg ethinyl estradiol + 0.25 mg norgestimate
• Femoden (Femoden). SCHERING. Germany 0.03 mg ethinyl estradiol + 0. 075 mg gestodene

The above-mentioned drug Diane-35 contains cyproterone acetate - a unique progestogen with pronounced antiandrogenic properties. This drug, in addition to contraception, is used with therapeutic purpose  in women with increased level male sex hormones and those suffering from external manifestations of this condition: acne (acne), oily skin, hair loss, menstrual irregularities.

Zhanin, one of the most modern OKs, contains a "hybrid" gestagen - dienogest, which is of natural origin (in a package of 21 tablets, in one tablet - 30 μg of ethinyl estradiol and 2 mg of dienogest). Indications for use are the same as for Diana-35. Janine has a slightly milder effect than Diane-35 and, in this regard, is better suited for long reception  (more than 1 year).

Yarina is another modern monophasic contraceptive with antiandrogenic properties.

Drospirenone contained in Yarin also has antimineralocorticoid activity, which helps to prevent weight gain and other symptoms associated with fluid retention. It prevents sodium retention caused by estrogens, provides very good tolerance and has a positive effect on premenstrual syndrome. One tablet contains 3 mg of drospirenone and 0.03 mg of ethinyl estradiol.

Monophasic OK regimen. In the first cycle, most modern drugs are started from day 1 of menstruation and take 1 tablet a day at the same time for 21 days. After this, a 7-day break is made, during which (usually 2-3 days after taking the last pill), a menstrual-like reaction occurs. After a 7 day break, they start taking the next package, i.e. the application scheme is as follows: 21 days of taking OK - 7 days break - etc. So, from 1 day of the cycle, the drug should be taken only at the very beginning of use this method. The main conditions for reliable contraception are strict adherence to the 7-day interval and regular use. If the drug begins to be taken from the 5th day of the menstrual cycle, then contraception in the first cycle cannot be considered reliable, and in this case it is necessary to use an additional method of pregnancy protection (for example, mechanical) for 14 days.

Multiphase OKthe variable ratio of estrogen and progestogen is distinguished, and the dose of estrogen is almost stable in all 21 tablets, while progestogen is administered in an increasing dosage, i.e. in phases, increasing by the end of administration by 2-3 times (two- or three-phase preparations). In two-phase preparations, the first phase is 11, the second - 10 days. In three-phase - the duration of all three phases is different and is determined by the manufacturer.

Modern multiphase OK:

• Anteovin, GEDEON RICHTER. The Republic of Hungary 0.05 mg ethylethyl estradiol + 0.05 mg levonorgestrel (1 tab.) 0.05 mg ethinyl estradiol + 0.125 mg levonorgestrel (10 tab.)
• Tri-Regol, GEDEON RICHTER, Hungary 0.03 mg ethinyl estradiol + 0.05 mg levonorgestrel (6 tablets) 0.04 mg ethinyl estradiol + 0.075 mg levonorgestrel (5 tablets) 0.03 mg ethinyl estradiol + 0.125 mg levonorgestrel (10 tablets)
• Triziston (Trisiston), JENAPHARM, Germany 0.03 mg ethinyl estradiol + 0.05 mg levonorgestrel (6 tab.) 0.04 mg ethinyl estradiol + 0.075 mg levonorgestrel (6 tab.) 0.03 mg ethinyl estradiol +0.125 mg levonorgestrel (9 tab.)
• Triquilar 28 (Tricvilar 28), SCHERING, Germany 0.03 mg ethinyl estradiol + 0.05 mg levonorgestrel (6 tablets) 0.04 mg ethinyl estradiol + 0.075 mg levonorgestrel (5 tablets) 0.03 mg ethinyl estradiol + 0.125 mg levonorgestrel (10 tablets)
• Trinovum (Trinovum), CILAG A.G .. USA 0.035 mg ethinyl estradiol + 0.5 mg norethisterone (7 tablets) 0.035 mg ethinyl estradiol + 0.75 mg norethisterone (7 tablets) 0.035 mg ethinyl estradiol + 1.0 mg norethisterone (7 tablets)
• Trinordiol 21 (Trmordiol21), WYETH GROUP. Germany 0.03 mg ethinyl estradiol + 0.05 mg levonorgestrel (6 tablets) 0.04 mg ethinyl estradiol + 0.075 mg levonorgestrel (5 tablets) 0.03 mg ethinyl estradiol + 0.125 mg levonorgestrel (10 tablets)
• Synphase, SYNTEX, Switzerland 0.035 mg ethinyl estradiol + 0.5 mg norethisterone (7 tablets) 0.035 mg ethinyl estradiol + 1.0 mg norethisterone (9 tablets) 0.035 mg ethinyl estradiol + 0.5 mg norethisterone (5 tablets)

Multiphase OK Mode. Anteovin is prescribed in a 21-day contraceptive regimen from 5 (in the first cycle) to the 25th day of the menstrual cycle, followed by a 7-day interval. The first intake of three-phase drugs begins with 1 day of menstruation (which provides reliable contraception  already in the first cycle) and continue for 21 days. Thus, the first menstrual-like reaction with the administration of three-phase OK occurs earlier - on the 23-24 day of the cycle, which should be warned to the patient. The further scheme is traditional — 7 days off — 21 days, etc. (The duration of the cycle ranges from 27 to 29 days). A number of companies produce packages of 28 tablets, in which the last 7 are either placebo or contain iron preparations. This form of release eliminates the need to calculate the 7 day interval to continue receiving the next package.

The female hormone estrogen is one of the most important hormones in the body of a girl. It is thanks to its activity that the development of secondary sexual characteristics occurs, the uterus matures and the mammary glands develop when the girl enters the stage of puberty.

The hormone determines such parameters as the deposition of fat according to the female type, the formation of the vaginal microflora and the installation of an acidic environment in it. Estrogen also plays an important role during menstruation, ensuring the proliferation of the endometrium.

Estrogen oversees not only the proper development of the reproductive system. He also regulates cardiovascular systeminfluencing fluctuations blood pressure, normalizes cholesterol, preventing it from affecting the vessels with atherosclerotic plaques. Estrogen promotes calcium absorption, improves brain activity, and in the liver is responsible for the synthesis of coagulation factors of the blood.

Estrogen hormone level

An analysis to determine the level of estrogen in the blood is carried out on an empty stomach. 24 hours before taking the blood, it is necessary to exclude stress, smoking, alcohol, sexual intercourse, as all this can erode the results of the analysis. Typically, hormone levels are determined on days 21-22 of the cycle.

Women of childbearing age normally have a hormone level of 13-191 pg / ml

During ovulation, the norm increases to 90-300 pg / ml

In menopause, the estrogen norm is 11-95 pg / ml

In girls under 11 years old, the norm is<15 пг/мл

Hormone levels in men - 0-35 pg / ml

Estrogen and conception

After the sperm fertilizes the egg in the female body, the female hormone estrogen begins to be synthesized much more actively. Estrogen helps prepare the inner surface of the uterus for implantation of a fertilized egg. Subsequently, the hormone begins to be produced in the formed placenta.

The normal development of the fetus, the proper functioning of the placenta, the preparation of the female body for the upcoming birth process and breastfeeding are all under the control of the female hormone estrogen.

The woman’s appearance also undergoes changes during and after pregnancy precisely because of estrogen: the breast “pours”, increasing in size, the woman blossoms before her eyes. Estrogen also regulates changes in mood and well-being.

Estrogen contraceptives

First of all, it is worth mentioning that the composition of all contraceptives, in addition to estrogen, also includes progesterone, which provides the woman with the opportunity not to become pregnant. Estrogen also performs a function aimed at maintaining the right. This ensures the same effectiveness of all birth control pills, and their division into two large groups is based only on how much estrogen in them is contained.

Allocate:

Microdosage

These contraceptives are recommended for women who have sex, but have never yet given birth. Microdosed preparations are favorably characterized in that they are easily tolerated and cause minimal side effects. Recommended for those who first decide on the use of oral contraceptives. Microdosed contraceptives are also prescribed to women after 35 years for a period of time before.

Preparations:

Zoely (a new drug; contains naturally occurring hormones)

Klayra (a new drug, maximally adapted to hormonal levels)

Jes (there is a cosmetic anti-androgenic effect)

Dimia (similar to Jess)

• Novinet et al.

Low dose drugs

They have similar indications, that is, they are suitable for nulliparous young women with regular sex life. They are prescribed if, when taking microdosed tablets, spotting appears. Also suitable for women giving birth and women in late reproductive age.

Preparations:

Yarina (last generation, there is a cosmetic anti-androgenic effect)

Midian (analogue of Yarina)

Three Mercy (latest generation)

• Belara et al.

Drugs containing estrogen

High-dose drugs contain a large amount of the female hormone estrogen. They are used to correct and treat various diseases of a hormonal nature, as well as contraceptives while the main hormonal pathology is being treated.

Highly dosed drugs are taken exclusively for medical purposes!

Preparations:

Tri-regol

Used to prevent pregnancy and to treat menstruation cycle disorders.

Triquilar

Used to prevent pregnancy and to treat functional menstrual irregularities.

Triziston

Hormonal contraceptive.

Non-ovlon

They are used to prevent pregnancy, delay or accelerate the menstrual cycle, and are used for uterine hypoplasia, dysmenorrhea, and functional infertility.

Ovidon

Used for the treatment of dysmenorrhea, pain in the middle of the menstrual cycle, functional, pregnancy prevention.

Drugs of this group are usually called   "oral contraceptives" (OK). Each tablet contains estrogen and progestogen.

The mechanism of contraceptive action is OK.  COCs suppress ovulation (they prevent the egg from maturing and exiting, giving the reproductive system a kind of rest and leaving it possible for a healthy pregnancy in the future), in addition, they thicken cervical mucus, making the cervix impassable for spermatozoa. They also alter the mucous membrane of the uterus, which prevents the implantation of a fertilized egg, it is rather a precaution so that a woman is completely confident in the effectiveness of the drug. The degree of exposure depends on the dose, composition, duration of use of the drug, as well as the initial functional level of this system.

Contraceptive effect ok  is 0-0.9 pregnancies per 100 women / years. "Contraceptive failures" are due mainly to errors in taking the drugs (in particular, in missing pills, especially at the beginning or end of the menstrual cycle). So, according to most researchers, the correct use of OK provides a 100% contraceptive effect, including 7 day intervals between doses.

Side effects (harmful or undesirable reactions at normal doses) often occur in the first months of taking COCs (in 10–40% of women), and subsequently their frequency decreases to 5–10%. According to epidemiological studies, the risk of a woman's health disturbance while taking low-dose COCs is 10 times lower than that during pregnancy, childbirth and abortion.

After stopping the use of COCs, restoration of the function of the hypothalamus-pituitary-ovary system occurs rather quickly. Over 85-90% of women after canceling COCs are able to become pregnant within 1 year, which corresponds to the biological level of fertility. Taking COC before the start of the conception cycle does not adversely affect the fetus, course and outcome of pregnancy. Accidental use of COCs in the early stages of pregnancy is not dangerous and is not a reason for abortion, but with the first suspicion of pregnancy, a woman should immediately stop taking COCs.

Depending on the type and dose, COCs differ in both the structure of adverse reactions and the biological effect on the body, therefore it is selected for women strictly individually, taking into account the peculiarities of somatic and gynecological status, data of individual and family history.

In modern COCs, the content of the estrogen component is reduced to 20-35 μg, and the progestogen component to 50-150 μg.

• High dosage(the tablet contains more than 35 μg of estrogen (ethinyl estradiol)): Chloe (Chloe), Diane-35, Demoulin, Triquilar, Triziston, Tri-regol, Milvane, Ovidon, Non-Ovlon. Usually used to treat a number of gynecological diseases.
• Low dose(ethinyl estradiol content 30-35 mcg): Jeanine, Lindinet-30, Silest, Minisiston, Marvelon, Microginon, Femoden, Regulon, Rigevidon, Jeanine, Belara
• Microdosed(content of ethinyl estradiol 15-20 mcg): Jes, Minisiston 20 fem, Yarina, Lindinet-20, Novinet, Tri-Mercy, Logest, Mercilon, Klayra. Due to the reduced dose, the hormonal load on the body is reduced and the number of adverse reactions due to the estrogen component is reduced. Separately, mention may be made of Claira, a new microdosage drug released by Bayer. Its distinguishing feature is that the estrogen (estradiol valerate) that it contains is natural, that is, identical to that produced by the woman's ovaries. Natural estrogen is familiar to the body, easier to digest, better tolerated, fewer side effects.

When choosing drugs, preference should be given to low-dose contraceptives containing third-generation progestogens.

The new generation of drugs not only protects a woman from an unplanned pregnancy, but also favorably affects the body and mood of a woman as a whole: they have few adverse reactions, do not disrupt lipid metabolism, do not affect body weight, prevent fluid retention in the body, and do not increase the risk of development cardiovascular diseases, provide adequate control of the menstrual cycle and, therefore, the lowest frequency of menstrual dysfunction, eliminate premenstrual symptoms and pain on the days of the month chi, have a positive effect on skin condition, hair growth, mood and overall health of women. This is due to careful selection of a dose of hormones, as well as a different composition of drugs that have not only a direct contraceptive effect.

Depending on the combination scheme  estrogen and progestogen secrete monophasic and multiphase  COC.

• In monophasic COCs, the dose of estrogen and progesterone per cycle is unchanged,
• In multiphase COCs, the ratio of estrogen and progestogen in tablets of one cycle is variable (2 types of tablets are two-phase, 3 types of tablets are three-phase).

Monophasic OK   - The dose of estrogen and progestogen in each tablet is stable. The package contains 21 tablets.

The most commonly used modern monophasic OK: Demoulin, Diane-35, Marvelon, Mercille, Minisispune, Noretin, Ovisman, Rigevidon, Silest, Femoden.

• Diana 35  contains cyproterone acetate - a unique progestogen with pronounced antiandrogenic properties. In addition to contraception, this drug is used for therapeutic purposes in women with elevated levels of male sex hormones and suffering from external manifestations of this condition: acne (acne), oily skin, hair loss, menstrual irregularities.
• Jeanine  - one of the most modern OK contains a "hybrid" gestagen - dienogest, which is of natural origin (in a package of 21 tablets, in one tablet - 30 μg of ethinyl estradiol and 2 mg of dienogest). Indications for use are the same as for Diana 35. Jeanine  has a slightly milder effect than Diana 35  and, in this regard, is better suited for long-term use (more than 1 year).
• Yarina  - Another modern monophasic contraceptive with antiandrogenic properties. Drospirenone contained in Yarinepossesses antimineralocorticoid activity, which helps to prevent weight gain and other symptoms associated with fluid retention. It prevents sodium retention caused by estrogens, provides very good tolerance and has a positive effect on premenstrual syndrome. One tablet contains 3 mg of drospirenone and 0.03 mg of ethinyl estradiol.

Monophasic OK regimen.  In the first cycle, most modern drugs are started from day 1 of menstruation and take 1 tablet a day at the same time for 21 days. After this, a 7-day break is made, during which (usually 2-3 days after taking the last pill), a menstrual-like reaction occurs. After a 7 day break, they start taking the next package, i.e. the application scheme is as follows: 21 days of taking OK - 7 days break - etc. So, from 1 day of the cycle, the drug should be taken only at the very beginning of using this method. The main conditions for reliable contraception are strict adherence to the 7-day interval and regular use. If the drug begins to be taken from the 5th day of the menstrual cycle, then contraception in the first cycle cannot be considered reliable, and in this case it is necessary to use an additional method of pregnancy protection (for example, mechanical) for 14 days.

Multiphase OK the variable ratio of estrogen and progestogen is distinguished, and the dose of estrogen is almost stable in all 21 tablets, while progestogen is administered in an increasing dosage, i.e. in phases, increasing by the end of administration by 2-3 times (two- or three-phase preparations). In two-phase preparations, the first phase is 11, the second - 10 days. In three-phase - the duration of all three phases is different and is determined by the manufacturer.

Modern multiphase OK:  Anteovin, Tri-Regol, Triziston, Trikvilar 28, Trinum, Trinordiol 21, Sinfase.

Multiphase OK reception mode. Anteovin is prescribed in a 21-day contraceptive regimen from 5 (in the first cycle) to the 25th day of the menstrual cycle, followed by a 7-day interval. The first intake of three-phase drugs begins from 1 day of menstruation (which ensures reliable contraception already in the first cycle) and continues for 21 days. Thus, the first menstrual-like reaction with the administration of three-phase OK occurs earlier - on the 23-24 day of the cycle, which should be warned to the patient. The further scheme is traditional — 7 days off — 21 days, etc. (The duration of the cycle ranges from 27 to 29 days). A number of companies produce packages of 28 tablets, in which the last 7 are either placebo or contain iron preparations. This form of release eliminates the need to calculate the 7 day interval to continue receiving the next package.

COC selection rules

COCs are selected for women strictly individually, taking into account the features  somatic and gynecological status, individual and family history, sexual activity, initial hormonal background, the possibility of adverse reactions. In this case, the doctor conducts a survey, examination and assessment of a woman's health. The drug is selected taking into account its properties and, if necessary, therapeutic effects. The decision to change or cancel the COC is made after the follow-up of a woman during the entire period of use of the COC.

The first choice drug should be monophasic COC with an estrogen content of not more than 35 μg / day and low androgen progestogen.

Three-phase COCs can be considered as reserve drugs when signs of estrogen deficiency appear against the background of monophasic contraception (poor control of the cycle, dryness of the vaginal mucosa, decreased libido). In addition, three-phase preparations are indicated for primary use in women with signs of estrogen deficiency.

When choosing a drug should take into account the particular state of health of the patient.

Clinical situation	Recommendations
Acne and / or hirsutism, hyperandrogenism	Preparations with antiandrogenic progestogens
Menstrual irregularities (dysmenorrhea, dysfunctional uterine bleeding, oligomenorrhea)	COC with a pronounced progestogen effect (marvelon, microginon, femoden, zhanin). With a combination of dysfunctional uterine bleeding with recurrent endometrial hyperplastic processes, the duration of treatment should be at least 6 months
Endometriosis	Monophasic COCs with dienogest, levonorgestrel, desogestrel or gestodene, as well as progestational COCs, are indicated for use in a long-term mode. The use of COCs can help restore generative function
Complicated diabetes mellitus	Drugs with a minimum estrogen content of 20 mcg / day
Primary or reassignment of COCs to a smoking patient	When smoking under the age of 35 years - COC with a minimum content of estrogen. For patients over 35 years old, COCs are contraindicated
Previous COC techniques were accompanied by weight gain, fluid retention, mastodynia	Yarina
In previous doses of COCs, poor control of the menstrual cycle was observed (in cases where other reasons, except for COC, are excluded)	Monophasic or three-phase COC (Three-Mersey)

The first months after starting COC  serve as a period of adaptation of the body to hormonal changes. At this time, the appearance of intermenstrual spotting hemorrhages or less often - “breakthrough” bleeding (in 30-80% of women), as well as other side effects associated with hormonal imbalance (in 10-40% of women).

If these undesirable effects do not disappear within 3-4 months, this may be the basis for a change in the contraceptive (after excluding other causes - organic diseases of the reproductive system, missing tablets, drug interactions).