Introduction
According to Scott and Terri (2009), hormonal contraceptive method of birth control refers to birth control methods that act on the endocrine system. Hormonal contraceptive methods use various types of female hormones to prevent ovulation (the release of an egg) so it cannot be fertilized by sperm from a man. Other changes in the uterus make it unlikely that a pregnancy will develop. Hormonal contraceptive methods come in form of pills, an implant in the arm, or a device inserted in the uterus (Trussell, 2007).
Haignere, Gold and McDanel (2013) stated that as more and more adolescents are becoming more sexually active, so also the use of different contraceptive methods which includes the use of hormonal methods. So many sexually active adolescents explore different hormonal contraceptive methods to prevent the occurrence of pregnancy.
Speroff, and Darney (2011) stated that the use of hormonal contraceptives among adolescents is associated with several implications. Among other implications they adolescents are exposed to sexually transmitted disease since hormonal contraceptive has no protection against sexually transmitted diseases. Kirby (2011) highlighted implications of hormonal contraception among adolescents to include Irregular menstrual pattern (missed menses, scanty bleeding, spotting, breakthrough bleeding), headaches (new onset or worsening headaches), depression, breast tenderness, nausea and vomiting, skin changes and hair loss.
As a result of these implications, Bruckner and Bearman (2015) underscored the importance of adequate awareness of adolescents in reproductive health to help promote healthy decision-making around sexuality and include abstinence as a way to avoid the negative consequences associated with risky sexual behaviours by postponing sexual activity until they are ready, because any sexual activity for which the adolescent is ill-prepared may have emotional, physical, and financial consequences. However, Eaton, Kann and Jinchen (2010) noted that most of the adolescents are sexually active or will choose to become so. Most adolescents, even those participating in formal programmes that advocate abstinence and signing abstinence pledges do not result in abstinence behaviours which necessitated encouraging the use contraception to reduce the risk of unintended pregnancies and to prevent sexually transmitted infections (STIs).
Conceptual framework
Hormonal contraception refers to birth control methods that act on the endocrine system. Almost all methods are composed of steroid hormones, which prevent pregnancy by preventing the ovary from releasing an egg, thickening the cervical mucus making it difficult for the sperm to reach the egg, and changing the lining of the uterus making implantation difficult. Hormonal contraceptives include the combined oral contraceptive pill and the progestogen-only pill (also known as the ‘mini-pill’). Other hormonal methods include contraceptive patches, injections, implants, the vaginal ring and the intrauterine system (IUS) (Scott and Terri, 2009).
According to Trussell (2007), hormonal contraceptive methods use various types of female hormones to prevent ovulation (the release of an egg) so it cannot be fertilized by sperm. Other changes in the uterus make it unlikely that a pregnancy will develop. Hormonal methods come in a variety of forms such as a pill, a patch worn on the skin, a shot, a ring inserted in the vagina, an implant in the arm, or a device inserted in the uterus.
Beach (2014) stated that the effects of hormonal agents present in hormonal contractive on the reproductive system is complex. It is believed that combined hormonal contraceptives work primarily by preventing ovulation and thickening cervical mucus. Progestogen-only contraceptives can also prevent ovulation, but rely more significantly on the thickening of cervical mucus. While combined hormonal contraceptives were developed to prevent ovulation by primary mechanism of action.
Historical background on hormonal contraceptives
In 1921, Ludwig Haberlandt demonstrated a temporary hormonal contraception in a female rabbit by transplanting ovaries from a second, pregnant, animal. By the 1930s, scientists had isolated and determined the structure of the steroid hormones and found that high doses of androgens, oestrogens or progesterone inhibited ovulation. A number of economic, technological, and social obstacles had to be overcome before the development of the first hormonal contraceptive, the combined oral contraceptive pill (COCP). In 1957 Enovid, the first COCP, was approved in the United States for the treatment of menstrual disorders. In 1960, the U.S. Food and Drug Administration approved an application that allowed Enovid to be marketed as a contraceptive (Levin and Hammes, 2011).
The first progestogen-only contraceptive referred to as Depo-Provera was introduced in 1969. Over the next decade and a half, other types of progestogen-only contraceptive were developed which are a low-dose progestogen only pill (1973); Progestasert, the first hormonal intrauterine device (1976); and Norplant, the first contraceptive implant (1983) (McFadden, 2014).
Combined contraceptives was also been made available in a variety of forms. In the 1960s a few combined injectable contraceptives were introduced, notably Injectable Number 1 in China and Deladroxate in Latin America. A third combined injection, Cyclo-Provera, was reformulated in the 1980s by lowering the dose and renamed Cyclofem (also called Lunelle). Cyclofem and Mesigyna, another formulation developed in the 1980s, were approved by the World Health Organization in 1993. NuvaRing, a contraceptive vaginal ring and Ortho Evra, the first contraceptive patch was first marketed in 2002 (Oragnon, 2012).
Attitude of adolescents towards hormonal contraceptives
The attitude of adolescents on hormonal contraceptives is a combination of several interwoven factors. Ezebialu and Eke (2013) in a study carried out in South Eastern Nigeria revealed that most (40%) of the adolescents survey agreed that adolescents who use hormonal contraceptives are described as girls. Other perception statements generated varied responses. For example, 31.5% of them had the perception that hormonal contraceptives were only for adult married persons, whereas 43% thought that the process of acquiring hormonal contraceptives was often embarrassing.
Findings from Ekanem and Umoh (2015) indicate that some adolescents especially girls feel that the use of hormonal contraceptives exposes adolescents to cancer and infertility. Ojofeitimi (2013) stated that the attitude of adolescents towards the use of hormonal contraceptives is extremely poor as a result of the alienation that many adolescents face when they visit maternal or child health clinics or pharmaceutical shops which are primary sources of contraceptive methods to get information or access hormonal contraceptives. In addition, Okonofua (2010) stated that because of overt social disapproval of premarital sexual activity and the general lack of privacy at these places, many adolescents’ feel that procuring seeking hormonal contraceptives services will make them subjects of ridicule and gossip. Some adolescents are likely to face other forms of negative attitudes from health personnel, an embarrassment most adolescents’ may want to avoid.
Prevalence of hormonal contraceptive use in Nigeria
In a study carried out by Igbodekwe, Oladimeji, Oladimeji, Adeoye, Akpa and Lawson (2014) on hormonal contraceptive use and its correlates among Nigerian women of childbearing age (15-49 years) to examine the prevalence of hormonal contraceptive use by Nigerian women, and the factors that might influence their use across the six geopolitical zones of the country. It also identified socioeconomic factors, as well as maternal factors that influenced hormonal contraceptive use among Nigerian women. The overall rate for hormonalcontraceptive use was 13.2%. In addition the study revealed that women residing in urban areas were significantly more likely to currently use hormonal contraceptive method compared to the women who live in rural areas.
Olalekan and Olufunmilayo (2012) stated that there was a direct relationship between hormonal contraceptive use and levels of education of the women as we observed that women who had higher, secondary and primary education were all more likely to currently use hormonal contraceptive than their counterparts who had no form of education. In addition, hormonal contraceptive use has been shown to affect the timing for fertility among career women. For instance, late marriage due to time spent studying has been documented to facilitate more use of hormonal contraception among educated women than illiterates (Adebowale, Fagbamigbe and Bamgboye, 2011).
Aniekan, Etiobong, Ntiense and Aniefiok (2011) stated that currently married women and formerly married women were significantly less likely to currently use hormonal contraceptive method than women who were never married. Married women have high frequency of sexual exposure and are at higher risk are more at risk of pregnancy than unmarried women. Therefore have a greater need for hormonal contraceptive especially for spacing and limiting births.
Further study revealed that the hormonal contraceptives used in the Southwest and South-south regions of Nigeria is significantly more as compared to the respondents from the north central zone of the country, while those from the Northeast, Northwest and Southeast were less likely to use contraceptive. This is related to the postulation that family planning is more acceptable in the southern states of Nigeria than in the Northern states (Oladipo, 2015).
Methods of hormonal contraceptives
Hormonal contraceptives methods use hormones to regulate or stop ovulation and prevent pregnancy. Ovulation is the biological process in which the ovary releases an egg, making it available for fertilization. Hormones can be introduced into the body through various methods, including pills, injections, skin patches, transdermal gels, vaginal rings, intrauterine systems, and implantable rods. Depending on the types of hormones that are used, hormonal contraceptives can prevent ovulation by thicken cervical mucus, which helps block sperm from reaching the egg or thin the lining of the uterus.
Methods of hormonal contraceptives as identified by Ezebialu and Eke (2013) are:
- Combined oral contraceptives (“the pill”): Combined oral contraceptive pills (COCs) contain different combinations of the synthetic estrogens and progestins and are given to interfere with ovulation. A woman takes one pill daily, preferably at the same time each day. Many types of oral contraceptives are available, and a health care provider helps to determine which type best meets a woman’s needs. Use of COC pills is not recommended for women who smoke tobacco and are more than 35 years old or for any woman who has high blood pressure, a history of blood clots, or a history of breast, liver, or endometrial cancer (Ezebialu and Eke, 2013).
- Progestin-only pills (POPs): A woman takes one pill daily, preferably at the same time each day. Progestin-only pills may interfere with ovulation or with sperm function. POPs thicken cervical mucus, making it difficult for sperm to swim into the uterus or to enter the fallopian tube. POPs alter the normal cyclical changes in the uterine lining and may result in unscheduled or breakthrough bleeding. These hormones do not appear to be associated with an increased risk of blood clots (Ezebialu and Eke, 2013).
- Contraceptive patch: This is a thin, plastic patch that sticks to the skin and releases hormones through the skin into the bloodstream. The patch is placed on the lower abdomen, buttocks, outer arm, or upper body. A new patch is applied once a week for 3 weeks, and no patch is used on the fourth week to enable menstruation (Ezebialu and Eke, 2013).
- Injectable birth control: This method involves injection of a progestin, given in the arm or buttocks once every 3 months (Ezebialu and Eke, 2013).
- Vaginal rings: The ring is thin, flexible, and approximately 2 inches in diameter. It delivers a combination of a synthetic estrogen and a progestin. The ring is inserted into the vagina, where it continually releases hormones for 3 weeks. The woman removes it for the fourth week and reinserts a new ring 7 days later (Ezebialu and Eke, 2013).
- Implantable rods: Each rod is matchstick-sized, flexible, and plastic. A physician surgically inserts the rod under the skin of the woman’s upper arm. The rods release a progestin and can remain implanted for up to 5 years (Ezebialu and Eke, 2013).
- Emergency Contraceptive Pills(ECPs):ECPs are hormonal pills, taken either as a single dose or two doses 12 hours apart, that are intended for use in the event of unprotected intercourse. If taken prior to ovulation, the pills can delay or inhibit ovulation for at least 5 days to allow the sperm to become inactive. They also cause thickening of cervical mucus and may interfere with sperm function (Ezebialu and Eke, 2013).
Adverse effects of hormonal contraceptive
Glasier (2010) identified some of the implications of hormonal contraceptives to include: intermenstrual spotting, nausea, breast tenderness, headaches, weight gain, missed periods, decreased libido and vaginal discharge
- Intermenstrual spotting: Intermenstrual spotting also known as breakthrough bleeding occurs in approximately 50% of people using the hormonal contraceptives experience vaginal bleeding between expected periods most commonly within the first three (3) months. Generally, this resolves in over 90% of cases by the third pill pack. During spotting, the pill is still effective as long as it has been taken correctly and no doses were missed. Intermenstrual spotting may occur due to the uterus adjusting to having a thinner endometrial lining, or maybe due to the body adjusting to having different levels of hormones.
- Nausea: Some people experience mild nausea on the first use of hormonal contraceptives but symptoms usually subside after a short period of time.
- Breast tenderness: Hormonal contraceptives may cause breast enlargement or tenderness. This side effect tends to improve a few weeks after the first time of use.
- Headaches: The sex hormones have an effect on the development of headaches and migraine. Hormonal contraceptives with different types and doses of hormone may result in different headache symptoms. Some studies have previously suggested that headaches are least likely to occur with pills that contain low doses of hormones. Headache symptoms are likely to improve over time.
- Weight gain: Clinical studies have found no consistent association between the use of hormonal contraceptives and weight fluctuations. However, many people involves in hormonal contraceptives report experiencing some fluid retention, especially in the breast and hip areas. Fat cells can also be affected by the estrogen in hormonal contraceptives, although the hormone causes the cells to become larger rather than more numerous.
- Missed periods: There are times when, despite proper hormonal contraceptive use, a period may be skipped or missed. Several factors can influence this, such as stress, illness, travel, and hormonal or thyroid abnormalities.
- Decreased libido: The hormone(s) in hormonal contraceptive pill can affect sex drive (libido) in some people. However, many other factors can contribute to a decrease in libido.
- Vaginal discharge: Some people experience changes in vaginal discharge when making use of hormonal contraceptives. This can range from an increase to a decrease in vaginal lubrication, an alteration in the nature of the discharge, and changes which can affect sexual intercourse.
Management of adverse effects of hormonal contraceptives
According to Monjok, Andrea, Ekabua and Essien (2010), adverse effects of hormonal contraceptives usually diminish with continued use of the same method. Often, physicians only need to reassure patients that these symptoms will likely resolve within three to five months.
In the case of weight gain, medroxyprogesterone acetate is the only hormonal contraceptive that is consistently associated with weight gain; other hormonal methods are unlikely to increase weight independent of lifestyle choices. So cases of weight gain can be managed by lifestyle changes (Olalekan and Olufunmilayo, 2012).
Switching combined oral contraceptives is not effective in treating headaches, nor is the use of multivitamins or diuretics. There are no significant differences among various combined oral contraceptives in terms of breast tenderness, and nausea. Breakthrough bleeding is common in the first months of combined oral contraceptive use. If significant abnormal bleeding persists beyond three months, other methods can be considered, and the patient may need to be evaluated for other causes (Glaiser, 2010).
Studies of adverse sexual effects in women using hormonal contraceptives are inconsistent, and the pharmacologic basis for these symptoms is unclear. If acne develops or worsens with progestin-only contraceptives, the patient should be switched to a combination method if she is medically eligible. There is insufficient evidence of any effect of hormonal contraceptives on breast milk quantity and quality. Patient education should be encouraged to decrease the chance of unanticipated adverse effects. Women can also be assessed for medical eligibility before and during the use of hormonal contraceptives (Scott and Terri, 2009).
Adverse effects of hormonal contraceptives usually diminish to the point of acceptance with continued use of the same method. Reassurance that symptoms will likely resolve within three to five months is often the only treatment required. Educating patients about common adverse effects of hormonal contraceptives helps to establish realistic expectations (Monjok, 2010).
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