New Ways And Modern Possibilities
On personalizing the approach to a woman's reproductive health
Hormonal contraception is one of the most important components of preserving women's reproductive health. Combined hormonal agents provide not only reliable protection against unwanted pregnancy, but also have additional therapeutic non-contraceptive effects.
The main tool for choosing a method of contraception is counseling. The purpose of counseling is an informed choice of the method of contraception by the woman herself. The doctor gives information, and the woman chooses a method that meets her needs and expectations. A woman who is satisfied with the chosen method uses it correctly and for a long time.
A gynecologist can choose reliable contraception for many years and help solve not only medical problems, but also the personal needs of a woman, becoming a reliable partner in the life of his patients.
Until now, every 10th woman cannot get the necessary contraception (in Africa, 20% of such women, in Europe — no more than 5%). According to statistics, contraceptive deficiency leads to an abnormally high number of artificial abortions (abortions). And such a trend emerged in the 80s of the last century and without taking adequate measures is fraught with a sharp deterioration in reproductive health among the beautiful half of the human population.
About the use of hormonal contraception
It is important to remember several principles when prescribing hormonal contraception in a woman of reproductive age:
- It is necessary to choose a drug that will not contribute to weight gain;
- You should use a drug that will not contribute to an increase in blood pressure (one of the components of the metabolic syndrome);
- The selected drug should not contribute to an increase in atherogenic lipids in the blood;
- Finally, the appointment of COCs should not affect the increased risk of thromboembolic complications (overweight and metabolic syndrome are a serious risk factor for cardiovascular diseases).
With this approach , the specialist should discuss the following appointments with the patient:
- COCs with metabolically neutral or antiandrogenic progestogen;
- Hormonal patch or ring;
- Intrauterine system with levonorgestrel.
In the case of a visit to the gynecologist of a patient with metabolic syndrome solely for the purpose of selecting a contraceptive, the specialist is obliged to provide recommendations on lifestyle modification (including in the field of nutrition and expansion of physical activity). If necessary, a gynecologist prescribes a consultation with an endocrinologist-nutritionist.
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Lipid metabolism and "atherogenicity coefficient"
According to the WHO eligibility criteria for prescribing hormonal contraception, "established dyslipidemia without other known risk factors for cardiovascular diseases" is not an absolute contraindication to hormonal contraception. It is possible to prescribe both a hormonal pill and a hormonal ring and patch, as well as an intrauterine system with levonorgestrel.
If we are talking about COCs, then you should not prescribe a progestogen with androgenic activity, since it will contribute to an increase in atherogenic lipid fractions. In this situation, it is necessary to refrain from using ethinyl estradiol at a dosage of 35 mcg.
Studies at the Institute of Reproductive Medicine have shown that COCs with biologically identical estrogen (estradiol valerate) and progestogens with antiandrogenic activity have a metabolically neutral effect, including with respect to cholesterol fractions. An intrauterine device (IUD) with levonorgestrel, as well as a hormonal ring and a hormonal patch, as our studies have shown, also have a neutral effect on lipid metabolism. The choice of the drug should be built within the framework of individual counseling and according to the needs of each individual woman: a hormonal pill will be convenient and useful for someone, and an intrauterine system, or something else.
About recommendations for the patient
It is important to remember that such a patient requires a multidisciplinary approach. If we are talking about androgen-dependent dermopathies, we mean that we are also talking about acne, oily skin, seborrhea, excessive growth of body hair (face, chest, abdomen, etc.), as well as hair loss on the head (alopecia) in a woman. With such a diagnosis, the patient, along with the gynecologist, should be advised by a dermatologist, as well as other specialists - a gastroenterologist, a psychotherapist, a psychologist. Here it is important to exclude hormonal changes as the cause of the problems described above.
For example, with acne-type skin rashes, as well as in the presence of excessive hair growth on the body, women, as a rule, suspect changes in the "hormonal background". Our observations indicate that most women with acne have androgen levels within the reference values. In other words, most women with acne are not shown a routine endocrinological examination. The presence of acne is explained by an increase in the number of androgen receptors, an increase in their sensitivity, as well as an increase in the activity of 5-α-reductase. The level of androgens should be determined with acne resistance to external therapy in women over 20 years of age and in combination with other signs of hyperandrogenism, namely:
- Menstrual cycle disorders: amenorrhea, oligomenorrhea, polymenorrhea, irregular cycle, etc;
- Metabolic syndrome;
- Black acanthosis;
- Androgenic alopecia;
The modern type of nutrition of women has an additional adverse effect, contributes to an increase in the prevalence of acne.
Hair loss on the head can have both a dermatological cause and be a consequence of the presence of any endocrine problem. For example, with hair loss, thyroid dysfunction, hyperandrogenism syndrome (not only ovarian, but also adrenal genesis) should be excluded. We should not forget about the exclusion of deficiencies of the most important and vital trace elements and vitamins in women, for example: iron, vitamin D, calcium.
In the situation of androgen-dependent andropathies in a woman in need of contraception, preference is given to COCs with a progestogen with antiandrogenic activity: cyproterone acetate, dienogest and drospirenone. In Russia, some COCs with drospirenone are officially registered, where the instructions prescribe the indications "contraception and treatment of acne vulgaris of moderate severity". And it is very important to take this into account, since the doctor must work within the right field. It is preferable to choose methods of contraception that can have a complex effect on the mechanism of acne development.
Cyproterone acetate in the composition of COCs has the maximum antiandrogenic activity and at the same time its possibility is significantly limited, since this progestogen has the maximum risk of thromboembolic complications. Doctors and patients should always remember this.