Combination Estrogen and Progesterone

Abstract: Hormonal methods are generally the halachic first choice for prescribed contraception. However, breakthrough bleeding associated with these methods is quite significant for this patient population, as it may render the wife niddah and prohibit any physical contact.

Discussion: Hormonal contraception is generally regarded as the first choice in the halachic system because intercourse is not affected in any way. As there is no barrier to the progression of the sperm to the uterus, there is no concern of violating the prohibition against illegitimate expulsion of semen. According to Jewish Law, the situation becomes analogous to intercourse during pregnancy, when Jewish law permits and even encourages conjugal activity despite the fact that conception cannot occur. The various forms of delivery of combination hormonal contraceptives are halachically equivalent.

Women who experience any bleeding from the uterus that is not caused by injury enter the halachic status of niddah. During niddah, couples must refrain from all forms of physical contact (not only intercourse). Breakthrough and withdrawal bleeding from hormones will render a woman niddah if she experiences a significant flow of blood. Bloodstains larger than a minimal size will also render her niddah when found on her inner thighs or white undergarments. Even light spotting can interfere with the internal examinations (bedikot) required before mikveh immersion. Therefore, any bleeding side effects of hormones [1] [2] [3] are of particular concern in this patient population.

Implications for Patient Care: Couples will often be concerned about the possibility of breakthrough bleeding when starting combined estrogen and progesterone, even if the effects are medically negligible. When beginning such contraception, it is important for the physician to emphasize that the body needs a cycle or two to adjust to the new hormonal environment, and that bleeding is likely to decrease after a few months of use [4].

Women taking hormonal contraception may ask about the possibility of prolonging the time on the active preparation in order to decrease the frequency with which they become niddah. Although halacha prescribes specific behavior for couples during niddah, there is no halachic obligation for a woman to become niddah. Therefore, this request should be considered seriously. Extending the cycle up to 35 or even 42 days is unlikely to cause medical problems [5] . However, the longer a woman continues taking active pills, the greater the chances of breakthrough bleeding. This is a concern with the new 84 day preparations as well [5].

Women may also ask about the possibility of occasionally prolonging use of the active pills to avoid being niddah during travel or while on vacation.

Observant patients immerse in the mikveh monthly. This procedure requires that all physical barriers be removed from the body. Therefore, when prescribing either the patch or ring forms of contraception, the doctor should discuss how long the patch or ring can be removed without decrease in contraceptive effect.  The manufacturers indicate that the ring may be removed for up to 3 hours without impacting on its contraceptive effect . It should be placed in a dry and cool location during that time. The manufacturer indicates that the patch can be removed for up to 24 hours. The same patch can be reapplied if it is still sticky. If it is no longer sticky, a new patch needs to be used [6].

When doing the internal examinations known as bedikot, the woman can either remove the ring for a few minutes or simply push it aside with the cloth enclosed finger that she uses to perform the bedikot.

Medical References

[1] Hill GA; Wheeler JM. Incidence of breakthrough bleeding during oral contraceptive therapy. J Reprod Med 1991 Apr;36(4 Suppl):334-9. PMID: 2046082

[2] Rosenberg MJ, Waugh MS, Higgins JE. The effect of desogestrel, gestodene, and other factors on spotting and bleeding. Contraception 1996 Feb 53(2):85-90.

[3] Approach to Oral Contraceptive Nuisance Side Effects.  The Contraception Report 2004 Feb;14(4):13-15.

[4] Danforth's Obstetrics and Gynecology. 9th Ed. Gibbs, Karlan & Haney; 2003:546.

[5] The Suppression of Menstruation with Extended OC Regimens. The Contraception Report 2002 Oct;13(3):8-11.

[6] Available at http://www.nuvaring.com/Authfiles/Images/309_103003.pdf



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