The most important use of combined estrogens and progestins is for oral contraception. A large number of preparations are available for this specific purpose, some of which are listed in Table 40–3. They are specially packaged for ease of administra-tion. In general, they are very effective; when these agents are taken according to directions, the risk of conception is extremely small. The pregnancy rate with combination agents is estimated to be about 0.5–1 per 100 woman years at risk. Contraceptive failure has been observed in some patients when one or more doses are missed, if phenytoin is also being used (which may increase catabolism of the compounds), or if antibiotics are taken that alter enterohepatic cycling of metabolites.
Progestins and estrogens are also useful in the treatment of endometriosis. When severe dysmenorrhea is the major symptom, the suppression of ovulation with estrogen alone may be followed by painless periods. However, in most patients this approach to therapy is inadequate. The long-term administration of large doses of progestins or combinations of progestins and estrogens prevents the periodic breakdown of the endometrial tissue and in some cases will lead to endometrial fibrosis and prevent the reactivation of implants for prolonged periods.
As is true with most hormonal preparations, many of the unde-sired effects are physiologic or pharmacologic actions that are objec-tionable only because they are not pertinent to the situation for which they are being used. Therefore, the product containing the smallest effective amounts of hormones should be selected for use.