Post focus: Hormonal contraception — mechanism, combined and progestin-only pills, injectables, implants, patch/ring, emergency hormonal contraception, initiation, missed doses, contraindications, interactions, adverse effects, counselling and follow-up.
Learning objectives
- Explain how oestrogen and progestin prevent ovulation, fertilisation and sperm transport.
- Compare pills, injectables, implants, patch/ring and emergency pills by duration, effectiveness, reversibility and bleeding effects.
- Screen for contraindications using WHO MEC and identify urgent adverse events.
- Provide exact use, missed-dose and resupply advice, including postpartum, breastfeeding, adolescent and HIV/ART considerations.
1. What hormonal contraception does
Hormonal methods deliver synthetic oestrogen, progestin or both. Progestin thickens cervical mucus, suppresses follicle development/ovulation, slows tubal transport and makes the endometrium less receptive. Oestrogen suppresses follicle-stimulating hormone and stabilises the endometrium; combined methods inhibit the luteinising-hormone surge. They do not terminate an established pregnancy and do not cause infertility.
2. Method comparison
| Method | Typical schedule/duration | Main strengths | Limitations |
|---|---|---|---|
| Combined oral contraceptive (COC) | One active pill daily; 21/7, 24/4 or continuous packs. | Highly effective with adherence; predictable bleeding; may improve dysmenorrhoea/acne. | Oestrogen contraindications; adherence and drug interactions. |
| Progestin-only pill (POP) | One pill every day, at the same time; product-specific late window. | Suitable for many breastfeeding/oestrogen-ineligible clients; rapid return to fertility. | Irregular bleeding; strict timing for some formulations. |
| DMPA-IM | Medroxyprogesterone acetate 150 mg IM every 13 weeks (3 months). | Private, effective, no daily action. | Irregular/absent bleeding, weight/appetite change, delayed return to fertility; bone-health review. |
| DMPA-SC | Medroxyprogesterone acetate 104 mg SC every 13 weeks where available. | Self-injection potential; discreet. | Training, bleeding changes and same progestin cautions. |
| NET-EN | Norethisterone enanthate 200 mg IM every 8 weeks where supplied. | Effective short-term injectable. | Repeat visits; bleeding changes. |
| Implants | Etonogestrel 68 mg rod (about 3 years); levonorgestrel two-rod systems (about 4–5 years, product-specific). | Very effective, long acting, rapidly reversible, no daily adherence. | Unpredictable bleeding; insertion/removal requires trained provider. |
| Patch/ring | Patch weekly (with hormone-free interval); ring monthly (3 weeks in, 1 week out). | Less frequent than pills; user-controlled. | Oestrogen contraindications, availability, adherence and privacy. |
3. Combined oral contraceptives
3.1 Use and initiation
Most COCs contain ethinylestradiol (commonly 20–35 micrograms) plus a progestin such as levonorgestrel, norethisterone or desogestrel. Take one active tablet at the same time each day. Start on day 1–5 of menses for immediate protection; if starting later when pregnancy is reasonably excluded, use condoms for seven days (follow product/national instructions). Continuous or extended cycling is acceptable when prescribed.
3.2 Benefits
- Excellent efficacy with correct use; lighter, more predictable bleeding and less dysmenorrhoea.
- Reduced risk of endometrial and ovarian cancer, ovarian cysts, iron-deficiency anaemia and some benign breast disease.
- May improve acne and symptoms of endometriosis/PCOS; benefits vary by formulation.
3.3 Contraindications/high-risk conditions
Do not use (MEC 4) with current breast cancer, migraine with aura, severe/uncontrolled hypertension, current or previous high-risk VTE/thrombophilia, ischaemic heart disease/stroke, complicated diabetes with vascular disease, severe liver disease or certain postpartum periods. Smoking at older age, multiple cardiovascular risks and breastfeeding early postpartum require careful MEC classification.
3.4 Adverse effects and danger signs
- Common: nausea, breast tenderness, headache, mood change and unscheduled bleeding, usually improve after 2–3 cycles.
- Urgent review: severe chest pain/breathlessness, unilateral leg swelling/pain, sudden neurologic deficit, severe abdominal pain or jaundice (ACHES warning).
4. Progestin-only pills
POPs avoid oestrogen and are useful during breastfeeding or when oestrogen is contraindicated. Take one tablet daily without a pill-free interval. Traditional desogestrel/non-desogestrel products have different “late” windows—follow the exact pack instructions.
- If late/missed, take the missed pill as soon as remembered and use condoms for the product-specified interval (often 2 days for traditional POPs; 7 days for desogestrel in many protocols).
- Irregular bleeding, amenorrhoea, acne, breast tenderness and mood changes can occur; assess pregnancy or pathology if bleeding is heavy/persistent.
- Most breastfeeding clients can start POPs immediately postpartum according to WHO MEC and Uganda guidance.
5. Progestin-only injectables
5.1 DMPA-IM 150 mg
Give 150 mg deep IM every 13 weeks (approximately every three months), using aseptic technique and recording the next due date. DMPA suppresses ovulation and thickens cervical mucus. It can be started when pregnancy is reasonably excluded; use backup contraception for the product-specific initiation interval if not started in the first days of menses.
5.2 DMPA-SC 104 mg
Inject 104 mg subcutaneously every 13 weeks where available. Provide self-injection training only within an approved programme; teach sharps disposal and what to do if late.
5.3 NET-EN 200 mg
Give 200 mg IM every eight weeks where this formulation is part of the national method mix. Do not interchange schedules without checking the product.
5.4 Benefits, cautions and side effects
- Benefits: private, effective, no daily adherence, suitable for many who cannot use oestrogen; may reduce sickle-cell pain and heavy bleeding in some people.
- Common: irregular bleeding/spotting, amenorrhoea, headache, weight/appetite change, mood symptoms and injection-site discomfort.
- Fertility may take several months longer to return after the last DMPA dose; explain this before initiation.
- Review bone-health risk (adolescence, prolonged use, low BMI, steroids, fracture risk), nutrition, calcium/vitamin D and weight-bearing activity; do not deny effective contraception solely on this basis.
- Do not give repeat injections without considering pregnancy, severe liver disease, current breast cancer and unexplained bleeding.
6. Hormonal implants
6.1 Types and mechanisms
Implants are flexible rods inserted under the skin of the upper arm by a trained provider. Etonogestrel 68 mg is usually licensed for about three years; levonorgestrel two-rod systems (e.g., Jadelle-type) provide about four to five years, depending on product and national guidance. They continuously release progestin, suppress ovulation and thicken cervical mucus.
6.2 Insertion and removal
- Exclude pregnancy and active local infection; obtain informed consent and explain palpability, bleeding changes and reversibility.
- Use aseptic technique, local anaesthetic and correct subdermal placement; document lot, rods, site and expected removal date.
- Teach wound care, infection signs, inability to feel the rod, migration concerns, severe pain or neurovascular symptoms.
- Remove at any time on request, for complications, expiration or pregnancy intention; fertility generally returns rapidly.
6.3 Interactions
Rifampicin/rifabutin, some anticonvulsants (e.g., carbamazepine, phenytoin, phenobarbital, topiramate at some doses) and certain antiretrovirals can reduce progestin levels. Use a reliable alternative/condoms according to current interaction guidance; do not remove a valuable implant without counselling.
7. Patch and vaginal ring (where available)
Combined patch releases oestrogen/progestin through skin and is generally changed weekly for three weeks with a hormone-free interval. A combined vaginal ring is usually left in for three weeks and replaced monthly. They share COC oestrogen contraindications and ACHES warning signs. Explain correct placement, accidental expulsion, adhesive/skin reactions, privacy and backup after delayed changes.
8. Hormonal emergency contraception
- Levonorgestrel 1.5 mg orally once as soon as possible after unprotected intercourse; effectiveness declines with time. If vomiting occurs soon after dosing, follow product advice regarding repeat dose.
- Ulipristal acetate 30 mg orally once where available; delay starting progestin contraception for the product-specific interval (often five days) and use condoms until effective.
- Emergency pills do not protect against future intercourse, established pregnancy or STIs. Offer ongoing contraception, HIV PEP assessment and STI testing after assault/condom failure.
9. Drug interactions and medical conditions
| Issue | Clinical action |
|---|---|
| Enzyme-inducing medicines | Rifampicin/rifabutin and certain anticonvulsants/antiretrovirals may reduce oral/implant efficacy. Use MEC/interaction guidance, condoms or non-interacting method. |
| Migraine with aura | Avoid combined oestrogen methods; progestin-only or non-hormonal methods are usually options. |
| Hypertension/VTE/stroke | Measure BP and assess history; avoid combined methods in severe/high-risk disease. |
| Breast cancer | Current breast cancer generally contraindicates hormonal methods; use copper IUD/barrier and specialist guidance. |
| Liver disease | Severe/decompensated disease may limit hormones; assess and refer. |
| Postpartum/breastfeeding | Method timing varies; progestin-only methods are often available earlier, while oestrogen is restricted early postpartum. |
| HIV/ART | Most methods are usable; check specific ART interactions and offer condoms for STI prevention. |
10. Missed pills and late injections
- COC: Follow the pack/WHO missed-pill algorithm. One late/missed active pill is usually taken immediately with continuation; multiple missed pills require condoms for seven days and emergency contraception consideration if missed in the first week with recent unprotected sex.
- POP: Rules vary by product (late window and backup interval). Give the exact written instruction for the brand rather than a generic rule.
- Injection: Give late injection after reasonably excluding pregnancy; use condoms/backup until protection is re-established according to product guidance and consider emergency contraception after unprotected sex.
- Implant: If beyond approved duration, use condoms and replace/remove promptly; assess pregnancy before reinsertion.
11. Counselling and follow-up
- Explain that irregular bleeding is common and not necessarily harmful; assess anaemia, pregnancy, infection or malignancy if heavy/prolonged.
- Offer a no-penalty method switch or discontinuation at any time.
- Provide condoms and STI/HIV testing; hormonal methods do not reduce STI risk.
- Review blood pressure for combined users, injection dates, implant site, interactions, pregnancy intention and adverse effects.
- Urgently return for severe chest/leg/neurologic/abdominal pain, jaundice, very heavy bleeding, suspected pregnancy/ectopic symptoms, implant infection or inability to feel a previously palpable implant.
12. Worked cases
Case 1: migraine with aura
Do not prescribe an oestrogen-containing method. Confirm aura history and stroke/VTE risks, offer a progestin-only pill, injectable, implant, IUD or barrier method per MEC, and provide condoms.
Case 2: breastfeeding at six weeks postpartum
Assess feeding, postpartum complications and pregnancy exclusion. Discuss POP/implant/injectable or IUD timing under Uganda guidance; explain that fertility can return before the first menses.
Case 3: rifampicin for tuberculosis
Review interactions before choosing pills or implant. Use a non-interacting method or reliable condoms/alternative according to national guidance; document the plan and reassess after TB therapy.
13. Quick self-test
- What are the three main contraceptive actions of progestin?
- State the common DMPA-IM dose and interval.
- What does ACHES warn about?
- Name three enzyme inducers that can reduce hormonal efficacy.
- Do hormonal methods prevent HIV or other STIs?
Answers
- Suppress ovulation, thicken cervical mucus and alter the endometrium/tubal transport.
- Medroxyprogesterone acetate 150 mg IM every 13 weeks (product and national protocol apply).
- Severe Abdominal pain, Chest pain/breathlessness, Headache/neurologic symptoms, Eye/vision problems, Severe leg pain/swelling.
- Rifampicin/rifabutin and anticonvulsants such as carbamazepine, phenytoin or phenobarbital.
- No. Condoms and HIV prevention services are still needed.
Further study and source material
- Slideshare: Hormonal method of contraception.
- WHO contraception overview.
- WHO MEC, sixth edition.
- WHO Family Planning Global Handbook.
- Uganda reproductive-health policy and service standards.
Take-home: Match the hormonal method to the client’s reproductive goal, medical eligibility, medicines, bleeding preferences and ability to adhere. Explain exact schedules and danger signs, offer condoms, and make switching or stopping easy.
