Discuss the non-contraceptive uses of oral combined contraceptive pill.

• COCP consist of both estrogen and progesterone in variable doses.
• The main action of COCP is the inhibition of ovulation by inhibiting release of LH and FSH by anterior pituitary.
• Also it causes decidualization of endometrium, which would inhibit blastocyst implantation.
• Non contraceptive uses of COCP
  • Treatment for menstrual irregularities
    • Dysmenorrhea
    • Menorrhagia
      • Acute heavy menstrual bleeding
    • Perimenopausal bleeding
  • Treatment for hyperandrogenism
    • Acne treatment
    • Hirsuitism
  • Treatment of PMS
  • Protection for cancers
    • Endometrial cancer
    • Ovarian cancer
    • Colon cancer

• Menstrual irregularities
  • Dysmenorrhea
    • Dysmenorrhea can be categorized as primary and secondary.
    • Primary dysmenorrhea is cyclical painful menstruation in the absence of pathology while secondary dysmenorrhea has undelying pathology such as endometriosis, adenomyosis, submucous fibroids.
    • Pain is caused by stimulation of type C afferent nerve fibres form uterine contractions and vasoconstriction due to PGF 2 alpha, PGE2 and vasopressins released from disintegrating endometrial cells (angina).
    • COCP inhibits ovulation therefore it reduces estrogen dependent proliferation of endometrium. Due to lack of progesterone secreted from the gland it lowers blood flow to the endometrium. This may reduce painful menstruation.
    • Cochrane reveals there is significant reduction of pain scores with even low dose (<35 micrograms) COCP when used for dysmenorrhea.
    • Also tricyclical use of COCP is effective as GnRH analogues in reducing secondary dysmenorrhea due to endometriosis.
  • Heavy menstrual bleeding
    • Can be due to ovulatory or non ovulatory pathology
    • There are many causes for HMB- PALM COIEN
    • Anovulatory cycles would cause unopposed estrogen activity result in thickening of endometrium.
    • Thickened endometrium would break down at some point and cause heavy periods.
    • COCP would cause decidualization of endometrium leads to less blood flow to endometrium which in tern reduces blood flow.
    • COCP would reduce HMB by 43% as RCT suggests.
    • COCP seemed to be beneficial in reducing menstrual blood flow in coagulopathies, perimenopausal women and acute menstrual bleeding (large dose short period).
  • Hyperandrogenism
    • Increased sebum production at sebaceous gland is one factor causing acne.
    • Androgens/testosterones causes increased sebum production at sebaceous glands in the skin.
    • Hirsutism is male pattern growth of thick, pigmented androgen dependent terminal hair in female.
    • Hyperandrogenism is commonly caused by PCOD.
    • COCP acts to reduce androgen production from theca cells by inhibiting LH action on theca cells. Also COCP increases sex hormone binding globulins production from liver resulting in low free testosterone levels.
    • COCP also inhibit the action of 5 alpha reductase which converts testosterone to more potent DHT at the terminal hair follicles. Therefore it inhibits anagen and catogen phases of hair growth (not existing hair)
    • All these action prevents acne formation and hirsutism effectively. Eg:- cyproterone acetate- Dianette, drosperinone – Yasmin
  • PMS
    • Premenstrual syndrome is defined as presence of physical and/or psychological premenstrual symptoms which affects activities of daily living.
    • COCP- drosperinone is found to reduce physical symptoms of PMS when used in continuously (without PFI). This might be beneficial for physical symptoms predominating PMS.
  • Protection for cancers
    • COCP reduces endometrial cancer by 50% and effect last for 15-20 years after stopping pill.
    • Reduction of cancer risk increases with duration of pill.
    • Ovarian cancer is reduced in COCP users.
    • RR reduced by 20% fro 5 years of use.
    • Effect last up to 30 years stopping therapy.
    • Chemoprophylaxis effect beneficial in BRCA1 & 2 also.

17 Non-contraceptive benefits of COC

Potential benefits of combined hormonal contraception (in order of strength of evidence)-TOG 2012

1.  50% reduction in risk of ovarian and endometrial cancer.

COCs reduce three major histologic types of endometrial cancer:

1. adenocarcinoma,
2. adenosquamous carcinoma and
3. adenoacanthoma
4.  Improvement in acne.
5.  Reduction in heavy menstrual bleeding.
6.  Regulation of menstrual cycles.
7.  Alleviation of dysmenorrhea.
8.  Treatment of hirsutism and polycystic ovary syndrome.
9.  Treatment of premenstrual syndrome.
10.  Reduction in risk of colorectal cancer.

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