Long-term contraception. Use of long-acting contraceptive regimens for therapeutic purposes Subcutaneous long-acting contraceptive

This group of contraceptives gets its name from Latin word prolongus, which means “long-lasting, ongoing.” Unlike hormonal birth control pills, which must be taken daily, long-acting drugs are introduced into a woman’s body at a time and protect against pregnancy for a long period: from three months to five years.

The most common type of long-acting contraception is the injection of the hormonal drug Depo-Provera. This procedure is popularly known as the "three-month syringe" because one injection prevents pregnancy for three months. The hormonal agent Netoen (“Net-en”) is used in the same capacity. It is an oily solution that is injected intramuscularly (into the buttock) once every 2 months. These drugs inhibit the maturation of the egg, thereby preventing pregnancy. These drugs are suitable for women over 35 years of age.

IN Lately The Finnish contraceptive Norplant is becoming widespread. It consists of six 3.4 cm long capsules that contain special hormones. The effect of the drug is designed for 5 years; it is injected under the skin of the forearm. The contraceptive effect is that the required dose of hormones is released daily from the capsules, and ovulation does not occur. It is recommended to administer Norplant from the first to the seventh day menstrual cycle, after a medical abortion or 6-8 weeks after childbirth.

What are the benefits of long-acting contraception?

Long-term methods are highly effective. Their reliability is 98-99%. In the case of Norplant, pregnancy was observed in only four women out of 10 thousand using this drug. These contraceptives protect against pregnancy for a long time, without requiring any additional hassle or effort. Injections and implants (implantation of a capsule) do not affect sex life. Long-acting preparations do not contain estrogen hormones and therefore can be recommended for those women who cannot take birth control pills with estrogenic components.

Unlike pills, long-acting contraceptives can be used for:

• Chronic diseases of various systems.
• Liver diseases.
• Hypertension.
• Diabetes
• Obesity
• Varicose veins.
• Thrombophlebitis (inflammation of blood vessels).
• Over the age of 35
• During breastfeeding (but not earlier than 6-8 weeks after birth).

The use of these drugs reduces the number of inflammatory diseases of the genitourinary organs and contributes to the attenuation of chronic sexual diseases. The drugs have a therapeutic effect in certain liver diseases (incipient cirrhosis, chronic hepatitis). The ability to conceive is restored 6 months after cessation of the drug, the menstrual cycle returns to normal after 3 months.

Modern effective methods of contraception began to be used only in the 20th century, and special progress in birth planning began with the beginning of the use of combined estrogen-progestogen oral contraceptives (COCs) 30 years ago.

According to WHO, currently oral contraception is the most popular method of family planning throughout the world (Prilepskaya V.N., 2005). Big variety modern methods Birth control makes it possible to reduce maternal mortality and preserve reproductive health, primarily by abandoning induced abortion as the main and even the only method of family planning in the past. However, this does not mean that contraception has reached perfection and does not need to be developed.

In the second half of the last century there was a significant revision of the role of women in modern society and family. The associated changes in a woman’s lifestyle require a new approach to some physiological characteristics of the body, previously considered normal and natural. Until the end of the twentieth century, it was generally accepted that perylar bleeding cleanses the body of “poisons” accumulated in it and “serves as a means of removing pathogenic and, in some cases, malignant juices, the preservation of which would seem extremely harmful” (Vercellini P. et al., 1999). Anthropologist B. Strassman, who visited Africa in 1986 to study the reproductive biological characteristics of tribes living in conditions close to the primitive communal system, published data that women living in these tribes have about 100 menstrual bleedings in their entire lives. , while for residents of modern industrial society this figure is close to 400. Based on these observations, the author concludes that such an increased “menstrual load” and associated problems are not evolutionarily necessary (Strassman B.I., 1996).

Currently, to a certain extent, it is possible to consider a modern woman from the position of “yesterday” and the same woman from the position of “today”. From the point of view of an obstetrician-gynecologist, the “woman of yesterday” is, first of all, 160 ovulations during her life, early marriage and at the same time the virtual absence of abortions, a higher frequency of pregnancies and childbirth and, as a consequence, long-term, up to 3 years, lactational amenorrhea. At the same time, the “woman of yesterday” was given almost no role either in society, or in politics, or in business.

Considering “a woman today,” we can focus on several aspects of her life, and first of all, on her reproductive history. U modern women there is a long menstrual and ovulatory period - up to 450 ovulations during life, and even a new term has been introduced - “chronic ovulation”. It is assumed that this increase in the frequency of menstruation, accompanied by significant changes in hormone levels, partially explains the increase in the incidence of a number of diseases, such as endometriosis, anemia, uterine fibroids, ovarian and endometrial cancer (Wiegratz I., Kuhl H., 2004).

It is well known that menstrual irregularities are one of the leading causes of gynecological morbidity in the world (Andrist L.C. et al., 2004). At the same time, the main treatment today is symptomatic and has almost no effect on the menstrual cycle and its hormonal components.

For the purpose of regulating and treating menstrual irregularities, reducing the number side effects observed with the traditional mode of reception of oral contraceptives, long-term regimens for combined oral contraceptives have been proposed.

Side effects are the most common reason for stopping oral contraceptives and are most common in the first months of use. The most common side effects include: nausea and vomiting, breast engorgement, swelling, headache, breakthrough bleeding, spotting bloody issues and mood swings. IN last years It has been established that in most cases these adverse reactions occur during a seven-day interval without taking pills, regardless of the composition of oral contraceptives (Sulak P. et al., 2002).

The classic 21/7 combined oral contraceptive regimen was developed to simulate the normal menstrual cycle. Women taking COCs experience withdrawal bleeding for one week every 28 days. Even based on the position that monthly menstruation is beneficial to health, in patients taking contraceptives in the standard “21/7” mode, from a medical point of view, menstruation is absent, but symptoms of discomfort remain, the possibility of developing iron deficiency anemia and other conditions that appear every month.

One of the common beliefs, both among women and among health workers, is the need to

Diminishment of monthly bleeding for the prevention of malignant diseases of the endometrium. However, it does not have sufficient grounds due to the fact that during menstrual bleeding only the upper, functional layer of the endometrium is removed, while tumors in most cases develop from the deeper, basal layer.

Since the 1950s, it has been known that the combination of relatively large doses of oral estrogens and progestins initiates amenorrhea and endometrial changes that mimic early stages pregnancy. In 1958, Kistner concluded that suppression of menstrual bleeding and induction of pseudopregnancy in the endometrium could be therapeutically beneficial for women with endometriosis. However, the author used dosages that are perceived today as very high: up to 0.6 mg/day. ethinyl estradiol and 40 mg/day. norethinodrel.

The first studies of long-term dosing regimens were studies using the depot form of medroxyprogesterone acetate. In the early 1960s, Csapro found that pregnant women who received high doses of medroxyprogesterone acetate before childbirth experienced no ovulation or menstrual bleeding for several months after birth (Diamond M.R. et al., 1985). Based on these data, E.M. Coutinho et al. developed a contraceptive regimen that included Depo-Provera injections once every 3 months. (WHO, 1979; WHO, 1983). The experience of using such a scheme allowed E.M.Coutinho to write a philosophical essay that the ancient idea of ​​the necessity and usefulness of monthly menstruation is not suitable for the modern era (Coutinho E.M., Segal S J., 1999).

The study of the acceptability of menstrual suppression began in 1975 by a group of psychiatrists at Stanford University, who showed that artificial suppression of menstruation should be included in the list of contraceptive options chosen by women (Hencel M.R., Poulan M.L., 2004). This work stimulated the development of long-acting contraceptive methods and showed that the concepts of “regular” and “normal” menstruation are ambiguous.

The next very important work appeared in 1977. A team of specialists at the University of Edinburgh studied a new regimen of oral contraceptive therapy, consisting of daily doses of 0.25 mg linestrol and 0.05 mg ethinyl estradiol. The tablets were taken for 84 days, and after that, withdrawal bleeding was observed for 1 6 days free from taking the drug (Loudon N.B., 1997). This scheme was called the “Edinburgh three-cycle” - after the name of the university in

Which it was first tested (Goldzieher J., 2003). The majority of women participating in the study noted the beneficial effect on the body of reducing the amount of menstrual bleeding. Interestingly, the medical staff participating in this study had less positive views of the trial compared to the women taking the drug.

Currently, a regimen with a large number of active tablets is being actively studied around the world and is already being used in clinical practice, used to delay the menstrual-like reaction and eliminate symptoms of withdrawal of oral contraceptives. For this purpose, several schemes for prolonged use of oral contraceptives have been developed:

1. Short dosing regimens allow you to increase the interval between menstruation and delay the onset of menstruation by 1-4 weeks.

2. Long-term dosing regimens are designed to delay the onset of menstruation from 7 weeks. up to several months, which reduces the frequency of menstrual bleeding throughout the year.

Thus, contraceptives are used not only to prevent unwanted pregnancy or treat diseases associated with the menstrual cycle, but also as a means of choosing a lifestyle for women themselves.

Medical indications for the use of long-term dosing regimens include: various premenstrual and menstruation-related pathological disorders, endometriosis, the need to reduce bleeding in anemia, etc. The need for reliable contraception, long-term sports training, peculiarities professional activity(actresses, ballerinas) form a group of indications for long-term contraception based on image

Life. Very often one patient experiences a combination various reasons to apply such a scheme.

For use in long-term dosing regimens, the FDA (US Food and Drug Administration) in the fall of 2003 registered and recommended for use a new combined oral contraceptive drug "Seasonale", designed for use for 91 days, of which for 84 days, tablets containing active substances (30 mcg ethinyl estradiol and 150 mcg levonor gestrel) are taken continuously, and in the next 7 days - placebo tablets. When using this scheme, the number of menstrual-like bleedings is 4 (and not 13 standard) during the year.

However, the appearance of the new drug was received ambiguously by the medical community and women (National women's health, 2004). In order to study the attitude of women to taking low-dose oral contraceptive drugs in a prolonged mode for 9 weeks. followed by a week's rest, compared with the traditional 21/7-day regimen, a randomized trial was conducted in three different Swedish clinics using a combined oral contraceptive containing 30 mcg ethinyl estradiol and 150 mcg desogestrel. As a result of the study, the following data were obtained: levels blood pressure and hemoglobin in both groups remained the same. There were no significant differences in changes in body weight in both groups. In the group of women with a prolonged regimen of COCs, there was a higher incidence of breakthrough bleeding and spotting compared to the standard regimen group, but over time their number decreased significantly: from 24% in the first cycle of use to 4% by the end of the study . The most common complaint when taking combined oral contraceptives in the standard regimen group was headache, especially during the break between taking “active pills”; a larger number of women in the comparison group dropped out of the study due to headaches. The incidence of headache was the same as in other studies (Ramos R. et al., 1989). Therefore, for women who suffer from headaches during a week-long break from taking combined oral contraceptives, a long-acting regimen may be a viable alternative.

A long-acting regimen may also improve the combination oral contraceptive regimen.

BOB, since reducing the number of breaks reduces the risk of missing pills, which ultimately increases the contraceptive effectiveness of the method.

In women with underlying medical conditions, such as diabetes, a long-acting regimen helps reduce fluctuations in blood glucose levels (Klein B.E.K. et al., 1990).

Using medicines, interacting with combined oral contraceptives (for example, phenytoin), a prolonged regimen may provide more stable drug levels in the blood (Fotherby K., 1990).

It has also been proven that the prolonged regimen reduces unwanted fluctuations in serum lipid levels (Percival-Smith R.K.L. et al., 1989). In women prone to anemia, long-acting contraception may also have a positive effect.

As a result of the research, the authors obtained data that the majority of women consider the long-term contraceptive regimen interesting and important. The overwhelming number of patients who had previously used combined oral contraceptives according to the usual regimen preferred a long-acting contraceptive regimen.

In a study conducted by N.B. Loundon et al. (1997), about 80% of women endorsed the ability to reduce the number of menstrual-like reactions and relieve premenstrual and menstrual symptoms. W. Rutter et al. (1988), who studied “women's attitudes toward menstrual-like reactions and their knowledge and opinions about combined oral contraceptives,” concluded that if myths about negative influence combined oral contraceptives, many women would prefer their prolonged use.

In 1999, a study was conducted in Holland in which women were asked about their views on the frequency of menstruation and changes they would like to make to their pattern (shorter, less heavy, less painful or no periods at all). The researchers found that sparser and shorter periods were preferred primarily by girls aged 15 to 19 years, and 71.5% of the 1,300 survey participants would like to make at least one change in the nature of menstruation. Women who prefer monthly menstruation made up less than a third of those surveyed, 9% would like not to menstruate at all (Sulak P. et al., 2002).

In 2002, the US Association of Reproductive Physicians (ARHP) and National Association A survey of midwives and gynecological nurses was conducted among participants in annual meetings, which showed that 77% had already recommended a prolonged regimen of combined oral contraceptives to patients in the following cases: endometriosis (83%), patient request (79%), lifestyle (78%), menorrhagia (73%) and dysmenorrhea (73%) (Association of Reproductive Health Professionals, 2003).

In addition, the Association of American Fertility Practitioners (ARHP) surveyed women about their menstruation. 44% of respondents said they prefer not having periods. At the age of 40-49 years, the percentage of such women increased to 59. 15% of respondents were already using combined oral contraceptives to delay or suppress menstruation (Association of Reproductive Health Professionals, 2004).

There is evidence that for the majority of women who choose to have regular withdrawal bleeding while taking combined oral contraceptives, the main reason for this decision was fear of pregnancy, infertility and side effects, as well as the belief that menstruation is a natural process (Tonkelarr I. , Oddens V., 1999). In addition, regular menstrual-like reactions while taking oral contraceptives allow a woman to make sure that she has not become pregnant. Despite the fact that this bleeding is induced, some women consider it a natural process indicating the preservation of fertility and health.

However, it has been shown that the risk of pregnancy is greatest when you skip a dose of the drug, before starting to take it, or after a seven-day interval of hormone withdrawal (Guillebaud J., 1987). If the interval for discontinuation of oral contraceptives is more than 7 days, the risk of pregnancy also increases, and if the interval for withdrawal of hormones decreases, it decreases. The suppressive effect of the hormones included in oral contraceptives depends on the duration of their action and reaches a maximum at the end of the treatment cycle. During the seven-day interval, the negative feedback system ceases to function and the level of natural gonadotropins rises, causing the growth of follicles in the ovaries, which is indicated by an increase in estradiol levels. It has been shown that when using low-dose regimens of oral contraceptives, shortening the hormone withdrawal interval to 5 days increases the degree of

Pressure of gonadotropins and reduces the likelihood of ovarian activation (WHO, 1983; Eraser I.S. et al., 1983; Kuhl H. et al., 1988). The fewer days of hormone withdrawal, the more pronounced this effect is. It was observed even with the use of ultra-low doses of oral contraceptives (ethinyl estradiol 15 mcg and gestodene 60 mcg) after reducing the duration of the hormone withdrawal interval to 4 days (Sullivan H. et al., 1999). Thus, it seems highly likely that by completely eliminating the hormonal withdrawal interval between taking 2 packs of oral contraceptives, contraceptive effectiveness will increase.

It is well known that simultaneous use of COCs and certain drugs may reduce the contraceptive effectiveness of oral contraceptives. Impairment of the activity of contraceptive steroids can occur through two mechanisms. Some drugs, such as barbiturates or rifampicin, can induce cytochrome P450 (CYR)-dependent enzymes involved in the metabolism of ethinyl estradiol and progestogens. In this case, the rate of steroid inactivation may increase, and their level in the blood serum may decrease. A number of antibiotics can affect the intestinal-hepatic metabolism of ethinyl estradiol, destroying the intestinal flora that hydrolyzes ethinyl estradiol conjugates, which promotes the reabsorption of free ethinyl estradiol (BackDJ.etal., 1981; D"Arcy RE, 1986; Back D.J., Orme M.L.E., 1990; Diamond M.P. et al., 1985). Since reducing the withdrawal interval to 4 days causes a significant suppression of follicular maturation when taking even ultra-low doses of oral contraceptives containing only 15 mcg ethinyl estradiol (Sullivan H. et al., 1999), patients receiving drug therapy should affect the effectiveness of steroids, complete avoidance of hormonal contraceptive withdrawal intervals may be recommended. Ethinyl estradiol levels during treatment with ultra-low-dose oral contraceptives are half those observed with oral contraceptives containing 30 mcg ethinyl estradiol. As with enzyme induction (e.g., rifampicin, fentine), the average degree of reduction in the level of ethinyl estradiol and progestogens in the serum does not exceed 50% (Park V.K. et al., 1996), and an extended cycle regimen of oral contraceptives containing 30 mcg ethinyl estradiol provides sufficient contraceptive effect, probably greater than that of a conventional high-dose oral contraceptive regimen. Therefore, this group of patients should be recommended

Recommend a continuous regimen of oral contraceptives, without a hormone withdrawal interval, rather than increasing the daily dose as part of regular oral contraceptive cycles (Birkhauser M. et al., 2000).

Once introduced into the body, Implanon begins to release an effective contraceptive substance in small doses, which prevents the growth of eggs and their release from the ovaries. It also modifies the cervical mucus, making it thicker, which significantly complicates the movement of sperm.

Iplanon is also a very convenient contraceptive. With its help, women can be spared the need to regularly take birth control pills. This reliable contraceptive works without failure. Implanon remains in the body for the specified period and reliably protects against unplanned pregnancy.

Implanon - a convenient means of contraception

The Implanon subcutaneous implant reliably prevents egg fertilization in 99% of women who use it. In terms of its characteristics, it is not inferior to the oral contraceptives familiar to everyone. Implanon is administered under local anesthesia under the skin of the arm. Manipulations are carried out exclusively by a doctor who is fluent in this technique.

The duration of the procedure for introducing a contraceptive is less than one minute. After its completion, a special bandage is applied to the arm, which is removed after a few hours. The subcutaneous contraceptive is also removed exclusively by a doctor through a small incision, no larger than 2 mm, using local anesthesia.

Price

Implanon costs from 8,600 to 10,500 rubles. The price for it varies depending on the size of the pharmacy markup and the region of sale.

Side effects

The installation of this contraceptive may affect the nature of menstrual flow. They become scarcer, less painful, and in some patients they disappear completely. Even breastfeeding women can use it, and it can be administered as early as four to five weeks after birth. Side effects are described in the instructions for the drug and can occur if the hormone or its dosage is incorrectly selected. Only a doctor should select Implanon or another hormonal drug.

If a woman decides to switch to another method of contraception or simply remove Implanon for some other reason, this can be done at any convenient time, even without waiting for its expiration date.

Injectable contraception (IC) is used by more than 18 million women worldwide. The composition of the IR includes long-acting progestogens, devoid of estrogenic and androgenic activity:

depot medroxyprogesterone acetate (Tsepo-Provera),

norsthisterone enanthate ("NET-EN"). Mechanism of contraceptive action of IR:

suppression of ovulation (inhibitory effect on the hypothalamic-pituitary system),

changes in the physicochemical properties of the mucus of the cervical canal (its viscosity and fibrousness increase), preventing the penetration of sperm,

disruption of the level of enzymes “responsible” for the fertilization process,

transformations in the endometrium that prevent implantation.

Contraceptive effectiveness of IC- 0.5-1.5 pregnancies per 100 women/years. IR usage mode: "Depo-provera-.150"- the first dose of the drug (150 mg/1 ampoule) is administered in the first 5 days of the menstrual cycle: subsequent injections are made every 12 weeks (3 months + 5 days); "NET-EN" - injections of the drug are performed once every 8 weeks (200 mg/1 ampoule). Before administering IR, shake the bottle. The drug is injected deep into the gluteal muscle. The injection area is not massaged. Fertility restoration occurs within 4-24 months after the last injection. Indications:

 inability to regularly take other hormonal medications on a daily basis if you want to increase the interval between births.

 late reproductive age (over 35 years),

 contraindications to the prescription of estrogens (a number of extragenital diseases or a history of estrogen-dependent complications),

 lactation period (6 weeks after birth),

 use as “post-abortion” contraception.

Contraindications:

pregnancy

pathological uterine bleeding of unknown origin,

planning pregnancy in the near future (especially in patients aged 30 to 40 years),

malignant diseases of the reproductive system (with the exception of endometrial cancer) and mammary glands,

NET-EN is not acceptable during lactation. Side effects:

menstrual irregularities (especially in the first months of contraception),

galactorrhea,

dizziness, headache,

fatigue,

irritability,

depression,

weight gain.

decreased libido.

Limitations of the method:

menstrual irregularities, especially in the first months of contraception (dysmenorrhea, acyclic uterine bleeding, oligomenorrhea, amenorrhea),

the need for regular injections. Advantages of the method:

high contraceptive effect,

simplicity and confidentiality of use,

low incidence of metabolic disorders (due to the absence of an estrogenic component),

therapeutic effect for endometriosis. premenstrual and menopausal syndromes, dysfunctional uterine bleeding, algomenorrhea. hyperpolymenorrhea. hyperplastic processes in the endometrium. recurrent inflammatory diseases internal genital organs.

 injections of the drug should be carried out every 3 months (+5 days) medical institution.

 if you have any complaints (profuse uterine bleeding, headaches, depression, weight gain, frequent urination deserve special attention), consult a doctor,

 stop administering the drug several months before the planned pregnancy (it must be taken into account that fertility after stopping injections of the drug is restored after 4-24 months),

 in case of prolonged amenorrhea, consult a doctor to exclude pregnancy.

The role of women in modern society and family. Survey results. A new regimen for hormonal contraception.

V.N. Prilepskaya, State Institution Scientific Center of Obstetrics, Gynecology and Perinatology (Dir. - Academician of the Russian Academy of Medical Sciences V.I. Kulakov) Russian Academy of Medical Sciences, Moscow.

In the second half of the last century, there was a significant revision of the role of women in modern society and the family. The associated significant changes in a woman’s lifestyle require a corresponding transformation of the medical care system, not only in the field of obstetrics and gynecology, but also in healthcare in general. One of the reasons for this is the fact that some physiological characteristics of the body, previously considered normal and natural, need to change their medical interpretation and approach to them (WHO, 2000).

At the beginning of the 21st century, a group of renowned scientists and doctors published the concept that monthly ovulation and menstruation are unnecessary and, in certain cases, due to significant fluctuations in hormone levels, pose a risk to a woman's health. This is primarily due to the occurrence in women of reproductive age of anemia, arthritis, bronchial asthma, dysmenorrhea, endometriosis, uterine fibroids, premenstrual syndrome (PMS) and other diseases that may be caused or associated with the menstrual cycle.

It is well known that menstruation-related disorders and menstrual irregularities are one of the leading causes of gynecological morbidity in the world.

Analysis of general population data indicates significant changes in the function of the female reproductive system over the past 30–35 years (WHO, 2001). For example, in the 70–80s of the last century, the average age at menarche was 15.5 years, sex life girls started no earlier than 18 years old, and, as a rule, this coincided with marriage, and accordingly, the first pregnancy occurred at the age of 19–20 years. In the modern population, the age of menarche is 12–13 years, and early onset of sexual activity is noted – at the age of 14–15 years. Despite this, modern young women are in no hurry to get married and have children; currently the frequency of civil marriages is quite high, while most couples are in no hurry to have children, and in most cases the first pregnancy, usually planned, occurs at age 25–30 years and even later. Unfortunately, the percentage of lactating women has decreased significantly: if previously up to 85% of women breastfed, currently this figure is no more than 20%. In addition, the average age at menopause has increased from 40–45 years several decades ago to 50–55 years now. All this indicates that in the modern population of women, the reproductive period of their lives has significantly extended.

Currently, to a certain extent, it is possible to consider a modern woman from the position of “yesterday” and the same woman from the position of “today”. From the point of view of an obstetrician-gynecologist, “the woman of yesterday” is, first of all, 160 ovulations during her life, early marriage and, at the same time, practicallyabsence of abortions, high frequency of pregnancies and childbirths and, as a consequence, long-term, up to 3years, lactational amenorrhea. At the same time, the “woman of yesterday” was not assigned a role at all, neither in society, nor in politics, nor in business.

When considering a “woman today,” we can focus on several aspects of her life and, first of all, on her reproductive history. Modern women have a long menstrual and ovulatory period - up to 450 ovulations during their lives, and even a new term “chronic ovulation” has been introduced. Unfortunately, in the modern population the frequency of medical abortions is high, women give birth less and at the same time the period breastfeeding short-lived.

The social status of women has also changed: it has increased average duration a woman’s life (for example, in economically developed countries this figure is 86 years), our contemporary woman is active in the family, business, politics, always wants to look good, is actively involved in sports, and tries to be financially independent.

Along with this, changes in the endocrine profile occur: monthly ovulations lead to large fluctuations in hormone levels and desynchronization of the hypothalamic-pituitary system. The consequence of this is a significantly increased frequency of various gynecological diseases, including menstrual irregularities, the development of PMS, the formation of functional ovarian cysts, as well as hyperplastic processes of the endometrium and mammary glands, uterine fibroids, endometriosis, polycystic ovaries, etc.

Thus, “woman yesterday” and “woman today” are different women, which differ from each other in a number of parameters: social status, reproductive history, morbidity, etc.

Taking this into account, the approach to a woman as a patient must change; in particular, in modern literature the issue is currently being actively discussed: “Can monthly menstruation be optional?” . However, a number of researchers are of the opinion that “there is no equal sign between a “regular” and a “normal” menstrual cycle” , and according to K. Blanchard et al., “menstrual cycles should be a woman’s choice, not a disaster” .

Despite the fact that this issue is actively discussed in the medical community, it is first of all important to know the opinion of the women themselves. It was for this purpose that in 1999, for the first time in Holland, a survey was conducted in which 1,300 women took part. The results of the study showed that 1/3 of the women surveyed preferred monthly menstruation, 9% would not like to menstruate at all.

In 2002, the Association for Reproduction conducted a similar study. Of the 491 women surveyed, 44% preferred not to have periods, and 155 women were already using combined oral contraceptives to suppress or delay their next period.

In 2004, a study was conducted in Germany among 1,195 women of reproductive ageand the following was established: monthly menstrual bleeding is preferred by 26–35%Of women, 16–27% of respondents would like to have menstruation every 3.6 or 12 months, and 37–46% of women would not like to have menstrual bleeding at all. The main reasons for this were the desire of women to improve their quality of life, reduce the degree of blood loss and pain during menstruation. According to respondents, reducing the number of menstruation allows you to improve personal hygiene and even solve some sexual problems associated with a regular menstrual cycle.

Similar surveys were conducted not only among women, but also among medical workers, and as their results show, the attitude towards this issue in the professional environment is also ambiguous. For example, according to the results of a survey conducted by C. Linda et al. in 2005 among doctors and nurses, the following data were obtained. According to 11% of respondents, it is important to menstruate monthly, 22% believe that monthly menstruation is harmful to health, 44% of health workers responded that suppressing menstruation is necessary only in certain cases, and 23% abstained from answering.

One of the first publications dedicated to practical application long-acting contraception, were the results of a 7-year clinical study conducted by Sulak et al. in 2000 (26). The results of this study showed that almost all side effects observed with combined oral contraceptives (COCs) were more pronounced during the 7-day break, and the authors called them “withdrawal symptoms.” In order to prevent side effects, women were asked to increase their COC intake to 12 weeks and shorten the interval to 4–5 days. Increasing the duration of use and shortening the interval reduced the frequency and severity of “withdrawal symptoms” by 4 times.

It has now been proven that during a 7-day interval when taking COCs from the 3rd–4th day of the cycle, there is an increase in the level of FSH, which leads to the growth of follicles and increases the endogenous production of estradiol. By the 6-7th day, follicles with a diameter of 8 mm or more may be detected, possessing aromatase activity, producing estradiol, and capable of developing into a dominant follicle.

Long-acting contraception has been proposed to regulate the menstrual cycle, treat a number of diseases and reduce the number of side effects observed with the traditional regimen of taking COCs. The use of COCs in a continuous mode (long-term contraception) determines better suppression of FSH and better suppression of follicular activity of the ovaries; against this background, stabilization of the function of the endocrine system is observed and thereby turns out to be positive influence for various hyperestrogenic conditions.

The idea of ​​long-term contraception was proposed back in 1968 by the creator of the first contraceptive pill, Gregory Pincus.

Long-term contraception is effective method fertility control, allowing you to regulate the menstrual cycle, prevent unplanned pregnancy and protect againsta number of gynecological and extragenital diseases.

Prolonged contraception provides for an increase in cycle duration from 7 weeks to several months. For example, it may include taking 30 mcg ethinyl estradiol and 150 mcg desogestrel (Marvelon) or any other COC in a continuous regimen. There are several long-acting contraceptive regimens. The short-term dosing scheme allows you to delay menstruation for 1–7 days and is practiced before an upcoming surgical intervention, vacation, honeymoon, business trip, etc. The long-term dosage regimen allows you to delay menstruation from 7 days to 3 months, as a rule, it is used for medical reasons for menstrual irregularities, endometriosis, uterine fibroids, anemia, diabetes mellitus etc.

Due to the urgency of the problem, at the end of 2003, the FDA (Food and Drug Administration) approved the use of a new extended-release COC, Seasonale®, specifically designed to reduce the total number of menstrual periods from 13 to 4 per day. year. Each tablet of the drug contains 30 mcg of ethinyl estradiol and 150 mcg of levonorgestrel; the regimen includes 84 days of administration + 7 days of placebo.

Long-acting contraception can be used not only to delay menstruation, but also with therapeutic purpose. For example, there is evidence in the literature of continuous use of oral

a contraceptive containing 30 mcg ethinyl estradiol and 150 mcg desogestrel (Marvelon®), after surgical treatment endometriosis. According to the results of the study, the use of this drug continuously for 3–6 months significantly reduced the symptoms of dysmenorrhea, dyspareunia, and improved the quality of life of patients and their sexual satisfaction.

The prescription of prolonged contraception is also justified in the treatment of uterine leiomyoma, since in this case the synthesis of estrogen by the ovaries is suppressed, the level of total and free androgens, which under the influence of aromatase synthesized by the tissues of leiomyoma, can be converted into estrogens, decreases. At the same time, there is no estrogen deficiency in the woman’s body due to its replenishment with ethinyl estradiol, which is part of the COC.

Currently, experience is accumulating in the use of long-acting contraception for polycystic ovary syndrome. Studies have shown that continuous use of COCs for 3 cycles causes a more significant and persistent decrease in LH and testosterone.

In addition to the treatment of various gynecological diseases, the use of the method of prolonged contraception is justified in the treatment of dysfunctional uterine bleeding, hyperpolymenorrhea syndrome in perimenopause, as well as for the purpose of relieving vasomotor and neuro- mental disorders climacteric syndrome. In addition, prolonged contraception enhances the cancer-protective effect of hormonal contraception and helps prevent bone loss in women of this age group.

The main problem with the prolonged regimen is the high frequency of bleeding.va" and "spotting" bloody discharge compared to the traditional regimen of taking COCs. ByAccording to the results of clinical studies, intermenstrual bleeding is usually observed during the first 2 months of use and is the reason for refusal of further continuous use of drugs in 10–12% of women. Currently available data indicate that the incidence of adverse reactions with extended cycle regimens is similar to those for conventional dosing regimens.

The global clinical experience accumulated to date shows that today a woman, depending on her personal needs or for medical reasons, has the right to choose to use one or another regimen for taking COCs. An alternative standard mode taking oral contraceptives is long-term contraception using COCs of varying composition and dosage. At the same time, it must be remembered that long-acting contraception is not suitable for all women, and before its prescription and during its use, careful monitoring, dynamic monitoring and consideration of contraindications to the use of COCs in general are required.

Of course, further analysis of multicenter studies on this issue is required and detailed study the influence of a prolonged regimen on a woman’s body.

A new regimen of hormonal contraception, in which hormonal drugs are taken continuously for several cycles, a seven-day break is taken, and the regimen is repeated. The most common regimen is to take hormonal contraceptives continuously for 63 days, then take a 7-day break. Along with the 63+7 mode, a 126+7 scheme is proposed, which in its portability does not differ from the 63+7 mode.

According to studies, against the background of prolonged use, women practically cease to encounter such common PMS problems as headache, dysmenorrhea, tension in the mammary glandsswelling. When there is no break in taking hormonal contraceptives P stable suppression of gonadotropic hormones occurs, but does not occur in the ovariesmaturation of follicles and a monotonous state is established in the body model hormonal levels. This is what explains the reduction or complete disappearance of menstrual symptoms and better tolerability of contraception in general.