Contraception in patients with uterine fibroids

What are COCs and how do they work?

Combined oral contraceptives are means of preventing unwanted pregnancy that contain estrogen and progestogen.

Mechanism of action of drugs:

• Proliferation of the inner lining of the uterus is maintained, which prevents implantation of the fertilized egg.
• Ovulation is suppressed, due to which the mature egg cannot leave the follicle to meet the sperm.
• Hormones thicken the cervical mucus, and male gametes are not able to penetrate the uterine cavity to meet the egg.

Pharmacodynamics and pharmacokinetics

According to the abstract, the mechanism of action of the drug is based on the ability of its active substances to suppress the synthesis of gonadotropins by the pituitary gland (in particular, luteinizing and follicle-stimulating hormones ).

This makes ovulation , increases the density of cervical mucus and, as a result, prevents the penetration of sperm into the internal space of the uterine body .

Ethinyl estradiol is a synthetic analogue of estradiol , which begins to be produced in a woman’s body, starting with the first menstruation.

Desogestrel has a pronounced progestogenic and antiestrogenic effect , similar to that of endogenous progesterone . The substance is characterized by weak anabolic and androgenic activity .

During the period of taking Regulon tablets, a woman (in the case of initial menorrhagia ) significantly reduces blood loss during menstruation and improves the condition of the skin (especially in the presence of acne vulgaris ).

Both desogestrel and ethinyl estradiol are quickly and almost completely absorbed from the digestive tract. Desogestrel immediately metabolized to form a biologically active metabolite - 3-keto-desogestrel .

Plasma concentration reaches its maximum:

• after 1.5 hours - for desogestrel (plasma concentration indicator - 2 ng in 1 ml);
• after 1-2 hours - for ethinyl estradiol (plasma concentration indicator - 80 pg in 1 ml).

Bioavailability indicator:

• for desogestrel - from 62 to 81%;
• for ethinyl estradiol - about 60% (this is due to presystemic conjugation and the effect of the first passage of the substance through the hepatic barrier).

Half-life:

• for 3-keto-desogestrel - 30 hours ( metabolic products are excreted in the urine and intestinal contents in a ratio of 4:6);
• for ethinyl estradiol - 24% (approximately 40% of the substance and its metabolites are excreted in the urine, the remaining approximately 60% in the intestinal contents).

Is it possible to prescribe COCs for uterine fibroids?

Combined oral contraceptives are prescribed to patients with fibroids as an effective means of protection against unwanted pregnancy. A benign tumor of the uterus, reaching certain values, interferes with normal pregnancy and causes miscarriage or premature birth. In this regard, gynecologists recommend getting rid of fibroids before conceiving a child, and often we are talking about surgical intervention. Until the tumor is removed, your doctor may recommend taking oral contraceptives.

It is important to know: before surgery to remove fibroids, it is recommended to stop taking oral contraceptives, since the risk of thrombosis increases after surgery.

Experts say that in addition to the contraceptive effect, COCs can, when taken regularly, reduce the growth rate of fibromatous nodes, and also, to a certain extent, prevent the formation of new ones. Oral contraceptives are one of the methods of conservative treatment of uterine fibroids and are actively used in modern gynecology.

Gynecologists also prescribe COCs for the treatment of the following concomitant pathologies:

1. Anemia. When using combined oral medications, the volume of discharge during menstruation decreases.
2. Concomitant gynecological diseases. Quite often, along with uterine fibroids, endometrial hyperplasia, polyps, etc. appear. Hormonal drugs can treat these ailments.
3. Mastopathy. Since its development is also associated with disturbances in the content of sex hormones, taking COCs is beneficial for women.
4. Menstrual pain. The drugs can reduce discomfort in the lower abdomen and the severity of PMS.

Causes

Predisposing factors for the occurrence of fibroids include hormonal imbalance, in particular excess estrogen in the body.

Also, provoking factors of the disease include mechanical trauma to the uterus and genetic predisposition:

Why are you interested in this disease?

The doctor made this diagnosis, I’m clarifying the details. I’m making a guess, looking for confirmation/refutation. I’m a doctor, clarifying the symptoms. My own version.

Expected effects: what will happen if you take birth control pills with fibroids?

Doctors believe that at an early stage of development, the fibromatous lesion is highly sensitive to the effects of sex hormones - estrogen, progesterone and prolactin. There is a change in the number of receptors for these substances, which in the future stimulates the growth of target tissues. Over time, connective tissue grows in the tumor, and the node becomes denser. In the future, the tumor is not able to regress even with normalization of hormonal levels.

Uterine fibroids are sensitive to endogenous hormones only when they are small. When the tumor reaches a size of 2.5-3 cm, it acquires the ability to grow autonomously.

Birth control pills prescribed by a doctor for fibroids change a woman’s hormonal levels and lead to the development of the following conditions:

1. Inhibition of ovulation and suppression of proliferation in tissues. The monotonous level of hormones prevents the growth of the myomatous node and inhibits its development.
2. Regular use of combined oral contraceptives prevents the formation of new nodes and to some extent slows down the growth of old ones. The fact is that instead of progesterone, progestogen, which has a similar structure but differs in its action, binds to the receptors.

The effect of taking COCs occurs after 2-3 months and persists throughout the duration of taking the drug. Against the background of the use of birth control pills, the following is noted:

• Reduction in the size of small myomatous nodes.
• Inhibition of tissue proliferation: the tumor stops growing, new nodes do not appear.
• The volume of menstrual flow decreases.
• The pain syndrome goes away.
• The risk of developing uterine bleeding is reduced.
• The general condition of the woman improves.
• The likelihood of relapse of the disease after surgical treatment is reduced.

Birth control pills are used to reduce the size of the tumor if it is less than 2.5 cm.

Interaction

The effectiveness of oral contraceptives is reduced in combination with drugs that induce liver enzymes: rifampicin , hydantoin, carbamazepine , barbiturates , oxcarbazepine , felbamate , primidone , topiramate , St. John's wort , griseovulfine .

In addition, when used in combination with Regulon, these drugs increase the likelihood of breakthrough bleeding.

The level of induction reaches its maximum no earlier than 2-3 weeks later, but can persist up to 4 weeks after discontinuation of the drug.

Menstrual irregularities and decreased contraceptive effect may occur when used simultaneously with:

• antibiotics (especially with Tetracycline and Ampicillin);
• barbiturates;
• some antispasmodics ;
• laxatives;
• antidepressants.

In cases where taking the above medications is necessary, it is recommended to protect yourself using barrier contraceptives (during the entire treatment period, as well as for an additional 7-28 days, depending on which medicine was prescribed).

If it is necessary to use anticoagulants while taking Regulon, additional monitoring of prothrombin time . In some situations, adjustment of the anticoagulant .

Due to the increased likelihood of complications, Regulon should not be combined with hepatotoxic drugs .

While taking oral contraceptives, you may:

• decreased tolerance to carbohydrates;
• increased need for oral antidiabetic drugs and insulin .

Benefits: why COCs are prescribed for fibroids

Combined oral contraceptives have proven to be reliable and effective against tumors. They have advantages for which experts prescribe them to patients with uterine fibroids:

1. The drugs not only have a contraceptive effect, but also reduce the progression of the disease.
2. They allow you to avoid abortion, which also benefits the woman. There is evidence that termination of pregnancy provokes the growth of fibroids.
3. Capable of stopping the growth of a node whose size does not exceed 2.5 cm.
4. They affect the reduction of fibroids measuring less than 1.5 cm.
5. Eliminate or alleviate the manifestations of fibroids.
6. Characterized by reliability and high efficiency.
7. Easy to use: just take one tablet a day.
8. Affordable: The cost of oral contraceptives is lower than other hormonal drugs for the treatment of uterine fibroids.

Application diagram

Oral contraceptives begin to be taken daily from the first day of the menstrual cycle, 1 tablet per day at the same time of day. There are several dosage regimens:

1. Classic 21+7: you need to take pills for 21 days, and then take a break for 7 days or use dummy pills during this time.
2. Prolonged regimen 63 +7: the contraceptive is taken continuously for three months, and then a 7-day break is taken, followed by repeating the regimen.

Note: the first day of the menstrual cycle is the first day of bleeding during menstruation.

Experts say that the classic regime “tugs” the reproductive system and does not allow the body to get used to the new hormonal model of functioning. In contrast, the prolonged circuit turns the system off and on less often, only once every 3 months. However, the 63+7 option has one significant drawback. Long-term use of COCs increases the risk of mid-cycle spotting and breakthrough bleeding, so this option is not suitable for every woman.

The course of treatment with COCs is at least 3 months. At the end of this period, a control ultrasound is performed and the size of the myomatous node is assessed. Your doctor may recommend using birth control pills for therapeutic purposes and for a longer period of time.

If a woman is undergoing surgery, it is necessary to stop taking the drug 4 weeks before surgery. If the operation is an emergency, you must inform your doctor about taking combined oral contraceptives. The fact is that COCs promote blood thickening and the formation of blood clots. Knowing that a woman is using such contraceptives, the doctor will prescribe medications to thin the blood. You can resume taking combined oral contraceptives 14 days after surgery.

Reviews from medical practitioners indicate that combined oral contraceptives do their job well and really help stabilize the growth of the node. Studies have shown that taking COCs for 5 years reduces the risk of developing pathology by 17%. Among women who took birth control pills for 5-10 years, this figure was 31%.

There are several options for prescribing COCs for fibroids:

1. As the main method of conservative therapy. Indicated for newly diagnosed small fibroids (up to 2-2.5 cm).
2. As a preparation for surgical treatment, a course of 3-6 months. It is used in situations where stronger drugs (gonadotropin-releasing hormone agonists) cannot be used.
3. After removal of fibroids to prevent relapse of the disease.

Review of popular remedies for the treatment of uterine fibroids

Medicines in the COC group are represented by many drugs. Most often, doctors use the following tablets to treat uterine fibroids:

1. Novinet, Mercilon or Marvelon: these are medications containing Ethinyl Estradiol + Desogestrel.
2. Rigevidon, Ovidon: consist of the hormones Ethinyl estradiol + Norgestrel.
3. Logest, Lindinet: active ingredients are Ethinyl estradiol + Gestodene.

Gynecologists advise taking COCs for fibroids that contain a strong progesterone component - levonorgestrel, gestodene or desogestrel. The use of oral contraceptives based on dienogest is considered promising. Which medications the doctor prescribes is decided individually. It is strictly forbidden to use combined oral contraceptives on your own, since such actions can cause harm by provoking tumor growth.

Note: women over 35 years of age are prescribed microdose COCs containing a minimal dosage of estrogen.