Hormones in human body have mythical qualities to some people. Most of us, as we age would say- If I just had my hormones back the way they were, it would all work out better’! Hormonal imbalances are more common in women around puberty, menstruation, pregnancy, menopause, and even years after Menopause (Post-menopause) aging.  Some women experience continual, irregular hormonal imbalances leading to a variety of health issues, including mental health disturbances like depression or Anxiety. The symptoms of hormonal imbalance in women are heavy or irregular periods, hair loss, night sweats, headaches, and psychosocial disturbances to the individual & family.

Most individuals think that Oestrogen and Testosterone are exclusively female and male hormones respectively. The reality is both are present and required in both sexes. The main reproductive hormones testosterone, oestrogen, and progesterone are instrumental for sexuality and fertility. They are responsible for puberty, menstruation, pregnancy, menopause, sex drive, ovum production and more.

Preserving individual’s hormone levels within normal ranges helps every single woman to retain youthful feelings. While managing hormonal imbalance with natural remedies, like- regular physical exercises, maintaining age-appropriate weight, reducing getting stressed or anxious, avoiding sugars, and having adequate sleep is better, it may not be possible for all and always. For individuals who can’t balance hormones naturally consulting a doctor for a hormone therapy (HT) would be the best option. The hormones usually used are oestrogen and progesterone, to replace those that the body has stopped making or doesn't make enough or to negate the effect if what is produced is higher than required.

It is current day need and urgency for the primary care /Family physicians to ensure that patients with hormonal imbalance are heard, their symptoms recognized and ascribed to the appropriate problems and referred and followed-up or managed. 

This article is meant to provide the evidence of when and when not to prescribe Oestrogen.

Materials and Methods: The author has used cases from his personal practice over 5 decades and close specialist friends who guided hormone therapy. A thorough literature research both national a d global practices are to put together to the evidence of when and when not to prescribe hormones for women.

Hormones in human body have mythical qualities to some people. Most women, as they age would say- 'If I just had my hormones back the way they were, it would all work out better’. When a human body produces too much or too little of the hormones required a hormonal imbalance is expected. Hormonal imbalances in women are more common during puberty, menstruation, pregnancy, menopause, and aging after 50 years. However, some people experience continual, irregular hormonal imbalances leading to a variety of health issues. Medical conditions that affect or involve the endocrine system or glands can lead to a hormone imbalance. The symptoms of hormonal imbalance in women are heavy or irregular periods, hair loss, night sweats, headaches, and psychosocial disturbances to the individual & family [1].

General understanding among common people is that Oestrogen and Testosterone are exclusively female and male hormones respectively. The reality is both are present and required in both sexes.  The healthy level of these in the bloodstream varies widely, influenced by thyroid function, protein status, and other factors. It’s important for women and men alike to balance hormone levels, after testing hormonal blood biomarker and decide if therapy is needed.

The main reproductive hormones oestrogen, testosterone, and progesterone are instrumental in sexuality and fertility. They are responsible for puberty, menstruation, pregnancy, menopause, sex drive, ovum production and more. The hormones are produced in the ovaries (F) and testes (in males). The pituitary gland produces, stores, and stimulates other reproductive hormones -namely, Human Chorionic Gonadotropin (HcG), Prolactin, Luteinizing Hormone (LH) and Follicle-Stimulating Hormone (FSH). Other hormones which influence hormonal balance like growth hormone, adrenalin, ovarian, testicular, thyroid, osteoporosis, Insulin, and antidiuretic arginine vasopressin (AVP), are interrelated and get affected as women age in turn affect their health adversely and disrupting their happiness [1].

There are different Types of Hormonal Imbalance. For example, poor sleep and fatigue indicate that there is something wrong with the adrenals, the glands that are responsible for the production of stress hormones. Fatigue, combined with symptoms like brittle nails, thinning hair, weight gain, and constipation, suggest thyroid-related problems. Menstrual problems and menopausal issues point out to imbalances with oestrogen, progesterone, and testosterone- the sex hormones.  Fatigue and weight gain are typically a combination of these three hormonal imbalances. However, only weight gain indicates that there are too many starches and sweets in the diet. 

Balancing hormones to retain youthful feelings! Natural way:

Balancing or preserving our hormone levels within normal ranges helps us retain youthful feelings. Regular physical exercises, maintaining age-appropriate weight, reducing getting stressed or anxious, avoiding sugars, and having adequate sleep are key natural ways of keeping the hormones balanced [2]. While managing hormonal imbalance with natural remedies, is better, it may not be possible for all and always. For individuals who can’t balance hormones naturally consulting a specialist doctor for a hormone therapy (HT) would be the best option. The hormones usually used for women are oestrogen and progesterone, to replace those that their body doesn't make enough or to negate the effect if their body is producing more than required. 

While acute symptoms like Hot flashes, Vaginal dryness, disrupted sleep, depression, and cognitive impairment, compromising the quality of life, are the key indications for HT. More importantly the reduction of the risks of chronic menopausal conditions like endometriosis, endometrial hyperplasia, endometrial cancer, colon cancer, type 2 diabetes, osteoporosis and bone fractures, heart disease, are other long-term indications for HT. In clinical practice HT is recommended for i) precocious puberty, ii) delayed puberty, iii) Birth spacing iv) Emergency contraception, v) polycystic ovarian syndrome (PCOS) and vi) post-menopausal spotting, menorrhagia, dysmenorrhea like symptoms alleviation. The hormones are delivered as pills, dermal patches or gels, creams, or suppositories [1]. 

It is current day need and urgency that the primary care /Family physicians to ensure that their patients with hormonal imbalance are heard, their symptoms recognized and ascribed to the appropriate problems and referred and followed up or managed.  This article is meant to provide the evidence of when and when not to prescribe Oestrogen and Progesterone.

Peri-menarche problems:

A.    Case of Precocious Puberty:

A worried well to do family parents of Laxmi a rural girl of about 8 years approached one of my mentored young lady doctors, in early years of her practice in 2010, complaining of a sudden spurt in changes in their daughter’s body shape and size in last 6 months and bleeding per vagina since previous day.  She had grown tall by about 6 inches in the last six months. There was no history of injuries. She consulted me over phone and on my suggestion examined the girl and reported that she was a well-built girl of about 60 inches and weighting 35 kg. She had pubic and underarm hair growth, breast growth at stage 3. The parents were informed that it was a regular menstrual period and needed hormone treatment. The parents got were worried as most girls in their attain menarche by age 12 or 13. Consulting a Gynaecologist she was put on a monthly Triptorelin (GnRH analogue) injection. Her height stagnated at 65 inches in the next 5 years, when the injections were stopped, and she leads a normal life thereafter and has 2 kids now. 

B.  Cases of Delayed Puberty:

i) In 2018 a distant relative of mine contacted me worriedly complaining about their daughter of 16 years, who had not attained menarche and local doctor was unable to help. On a video assessment of the girl, I found her with small structure of 60 inches height, weight of 30kg. The mother confirmed presence of secondary characteristics of axillary and pubic hair, breast enlargement stage 2, and primary amenorrhea and undernourishment. Her nutritional was tried to rectify with protein supplementation in the last 2 years with not much success. Suspecting a case of Constitutional delay of growth and puberty, I got done oestrogen levels test that confirmed the diagnosis. She was put on Oestrogen therapy for about 6 months when she attained her menarche at the age of 16 years 7 months. After a full year of treatment, the hormones were stopped. The girl continues to be thin built but with normal periods. 

ii) The parents of a girl of about 15 years born in a remote village of Kalburgi district, Karnataka consulted me for delayed puberty. She was born full term, unknown birth weight, reported as “average” and was diagnosed as asthmatic since the age 2 years. 

Previous health issues: 

But for Recurrent right ear infections for which she underwent a tympano-mastoidectomy, there was no other significant history. Family history- mother had delayed menarche at age 15 years, two older siblings, age 18 and 20 years, had menarche at age 12 years. On physical examination her height 132.5 cm, Weight 29.5 kg, BMI 16.9 m2, Puberty Tanner stage: Axillary hair 1, Breast 1, Pubic hair 1 and BP: 84/58 mmHg. Bone age: Chronologic age of 15 years 2 months with bone age of 10 years, Pelvic ultrasound: Small uterus with no visible endometrium, right ovary small (0.33 mL), left ovary not visualized. MRI: Absent pituitary infundibulum and hypoplastic anterior pituitary gland in the pituitary fossa. She was treated with hydrocortisone 10mg three times daily for 1 week, then started on levothyroxine 50 μg/day. Started on recombinant human growth hormone 0.18 mg/kg per week (0.026 mg/kg per day), after a month Free T4 level increased to the normal range. Hydrocortisone, levothyroxine, and growth hormone were continued with excellent compliance for 3months. Bone age at 17.5 years is 12 years. Shet was on oestradiol transdermal patch 0.375 mg/day for psychosocial disturbance. 

iii) Two delayed puberty cases with the chief complaint of primary amenorrhea reported in a Govt. Medical College in early 2022. Both cases showed hypoplasia of uterus and ovaries on pelvic imaging and hormonal assay showed low FSH. The first case was gonadal dysgenesis with 46, XX karyotype and low level of oestrogen and the second case was a turner syndrome with 45, X karyotype and normal level of oestrogen. Both patients are put on oestrogen, but development so far compared to them to their peers is limited and they may remain infertile, impacting on their mental health.

2.Pregnancy Prevention: 

a) Emergency Contraception: Ms. Parvathy aged 22 years eloped with her boyfriend and had unprotected sex before marriage that was scheduled next week. But the marriage got postponed due to a death in the family. Fortunately, based on a medical advice she took Levonorgestrel tablet by mouth on day 3 of the sex, that prevented pregnancy, saving her image and prestige of the family.

b) Successful Birth Spacing: Ms. Girija aged 30 years with one child of 12 months, started taking her Mala-D contraceptive pills, like thousands of women in reproductive age group in India are using freely distributed OCPs. She stopped taking OCPs after 2 years to conceive after 6 months.

3. polycystic ovarian syndrome (PCOS) cases on HRT: 

a) Ms. Jyotsana a 25-year girl now, one of MPH scholars, presented the current and third episode of PCO for discussions in one of our clinico-social case study. She consulted a gynaecologist at a private hospital in GADAG, Karnataka, 582101, with the complaints of white discharge, backache, hirsutism and hair fall, acne, feeling stressed apart from irregular periods and adding fat around her waist since 13 January 2021. On clinical examination Gynaecologist found breasts normal but with darkening of areola and nipple, a few hairs, and some milky fluid oozing on squeezing the nipple. Her BP was 130\90 mm hg, pulse rate – 102/minute, RR – 20/ minute, weight 63 kg, height – 155.4 cm. The laboratory reports showed increased testosterone, low FSH, elevated LH, elevated oestrogens, increased prolactin, and ultrasound showed bilateral enlarged ovaries with multiple cysts with more than 15 follicles. She was diagnosed with a case of PCOS and put on oral contraceptive pill for 3 months and then on Myo-Inositol (Myo Inositol, D-Chiro Inositol with Folic Acid) one tablet twice a day for 3 months, once a day for the next 2 months. All signs disappeared in 6 months’ time except for periodical episodes of headache. She had similar PCOS episodes and hormonal therapy since she was 19 years old on 2 occasions and recurred after 6-8 months of stopping HRT. 

b) Pallavi, a 25-year-old Indian female, another MPH student consulted me with diagnoses of PCOS. A non-vegetarian who loves to consume fish was unable to do so being in university’s girls’ hostel that does not serve non-vegetarian food except week ends. She typically ate cereal based breakfast, and packed lunch. She enjoys a full dinner of vegetarian curry, rice, vegetables, and lentils. Despite an average food intake, she reported having gained 5 kg since she joined MPH course a year ago. Nutrients-wise most calories consumed at night diet was high in carbohydrates. Activities: Very minimal physical activity, Anthropometrics: Height: 5 feet, 3 inches, Weight: 65 Kgs, BMI: 28.7 kg/m2, Waist circumference: 38.4 inches. Biochemical Data: HbA1C: 5.5%, (normal <5>

4. MHT in menopausal, Pre and Post menopausal women: 

a) Ms. Prabha 72 years old underwent Hysterectomy and left sided Oophorectomy in 2006 at the age of 54 years. She had postmenopausal symptoms since early 2007 and has been advised by a well-known Gynaecologist in Delhi and using Evalon (Estriol intravaginal) Cream BP with an applicator for nearly 16 years now to help alleviate symptoms of vaginal dryness. This is prescription is renewed after a thorough check up (PAP smear, Mammography. CT Scan etc) of annually for the first 10 years and now alternate years. She is comfortable using it. 

b) Two sisters aged 48 and 58 years sough my help in January 2022 with post-menopausal symptoms. The elder sister had Vaginal dryness, hot flashes, dyspareunia and Sleep problems and mood changes including anger and depression for over 7 years. She had tried household remedies like diet control, morning walking, and some homeopathy drugs with not much of success. The younger sister had the complaints of Irregular periods, night sweats, acne over face, sleep problems, mood changes, weight gain and anxiety of falling in elder sisters’ situation since a year. 

I put the elder sister on HRT a low-dose vaginal oestrogen cream Osphena® (a selective oestrogen receptor modulator (SERM) tablet daily orally.  The younger one was advised to strictly follow i) weight reduction, ii) walking, muscles strengthening exercises, Yoga & meditation for 45-60 minutes day iii) adhering to regular sleeping between 1000 PM to 0600 AM every day iv) avoiding sugary drinks and junk food. They were monitored quarterly and at the end of December 2022 evaluation both had benefited. While the elder sister reported significant benefits in her sexual life and reduction in menopausal symptoms the younger sister reported significant benefits of better sexual life, weight reduction, acne, physical activity & 6-7 hrs. of uninterrupted sleep daily. 

c) Total Hysterectomy case on HRT: Ms. Priyanka a middle-aged lady of around 50 years, menopause around 45th years had spotting 2 years ago, that stopped after 5 times with no intervention.  A mother of 2 grown-up children (youngest-15 years), reported heavy blood as if in menstrual flow with pain in abdomen for 5 days in each month since February 2022. Following a CT scan and hormones assay, she was diagnosed as having endometritis or endometrial hyperplasia. She was put on oral contraceptives for 3-4 cycles, that did not help much. Though advised for a hysterectomy, being typical conservative Indian woman, she waited for the completion of annual exams of the both the children and underwent the surgery in April 2023. she was put on progestin for last 6 months and is recovering well, though anaemia needs to be recouped.

Case of Negative Reactions to HRT:

5. A Case of Hearing Loss due to PMHRT: Mrs. Yellavva a lady of 58 years attained menopause 5 years ago and was put on oestrogen therapy for her endometritis after trying conservative treatment for about a year by a private Gynaecologist. In the first six months of therapy, she was happiest, as most of her symptoms disappeared. However, after a year her husband observed deafness, and took her to an ENT specialist. She was diagnosed to be having “progressive Bilateral deafness “After conservative management, she was advised to discontinue the HRT. After that deafness progress was interrupted, but her hearing did not improve after 12 months.

6. Secondary Infertility: A young couple managed about 36 years and his wife aged about 32 years, followed multiple spacing methods after the first child. Between 2018-2021.The lady used combined oral pills (Active pills contain two combinations of oestrogen and progestin) In 2022, the lady switched to Depo-Provera {Depot-medroxy progesterone acetate (DMPA which suppresses ovulation} injections every three months a total of 4 injections. She stopped the injections in July 2022 and tried to conceive second baby but so far have not been successful. The couple is frustrated due to delay in resumption of ovulation for over 2 years now! I have advised them weight for another 6 months, before we resort to other investigations for secondary infertility.

A girl child’s life changes at menarche (around 13 years in India), due to hormonal influence. Her reproductive years are divided into early, peak, and late and are characterized by regular menstrual cycles despite being variable during the early phase. 

Note: V= Variable, R= Regular, N= Normal, D=Different, VCL= Variable cycle length, FSH= Follicle Stimulating Hormone

*= Stages most likely by vasomotor symptoms, 

Table-1: The image depicting the stages and nomenclature of normal reproductive aging in women.

Feeling, and looking ill isn’t a normal side-effect of aging, but it basically points to the fact that our hormones might be out of balance, seeking a total reboot. All women must look for a way to fight back and balance the hormones. Fixing the Underlying Cause of Hormonal Imbalance involves: 

1. Cut back, way back on the sweets and starches: Too many sweets and starches set the hormones on a ride. Try to limit or even better, eliminate them completely for a few weeks and see body reacts. 

2. Try reducing your grains, legumes, and high sugar fruits for two weeks: Many people are carbohydrate-intolerant, unaware of it and result in metabolic problems or insulin resistance.

3. Eat more healthy fats- and let off fat-phobia: Adding more healthy fats to daily diet helps stimulate the production of hormones that boost energy, suppress cravings, and increase feeling of satiety.

4. Be good to your microbiome: Filling the gut with fermented foods and fiber helps support good bacteria and keeps bad ones under control.  Apart from keeping both elimination and digestion functioning properly, it boosts hormone function as well.

5. Avoid reactive, inflammatory foods:  Avoid Gluten, sugar, and processed foods which are considered as inflammatory foods, and take toll of the gut, immune and the endocrine system.

6. Aim to sleep more and better: Lack of sleep and poor sleep affect the entire organism and inhibit body`s ability to release the hormones needed to restore and refresh the cells. Consequently, one ends up with more rapidly aging brain and body.  So, aim at getting more and better sleep!

7. Cool it on the stimulants: High caffeine intake -coffee soda, tea, or energy drinks, interfere with the hormones responsible for restorative sleep.

8. Cut the chemicals: Lowering your exposure to chemicals commonly found in food, water, air, cosmetic, and household cleaners, helps balancing hormones & keeping them functioning optimally. 

9. Minimize the medications: Long-term exposure to medications, cause hormone imbalance and stress out the microbiome. Make sure you avoid hormone-disrupting OTC medications as much as possible! In case you must take them, ask for the smallest dose possible.

10. Train yourself to unwind: Training oneself to unwind and relax through watching a movie, laughing, dancing, or simply having fun with friends. A regular meditation session to daily life routine will naturally balance your hormones, while staying more relaxed and fit.

If the natural way described above do not succeed, the needs of hormonal balancing in Indian women based on the stages described above are discussed herewith:

1.Peri-Menarche Phase:

Early Puberty & HT: Precocious puberty is when a child’s body begins changing into that of an adult too soon showing symptoms of Breast growth, Pubic or underarm hair, rapid growth, first period in girls, Acne before Rapid growth of bones and muscles, changes in body shape and size, and development of the body’s ability to reproduce age 8 in girls. The commonly used key indicator is development of breasts and hair growth in arums and pubic area.

Table-2: Female breast developmental stages

Central precocious puberty (CPP) is due to early maturation of the hypothalamus-pituitary gonadal (HPG) axis but the cause of CPP is often can’t be found. A course of puberty, at an age <8>3.5 cm and uterine volume of >1.8 ml are two most specific indicators for true CPP. The frequency of CPP is quoted to be around 1 in 5000-1 in 10,000 and is more common in girls (F:M 3/1 to 23/1.  Girls are much more likely to develop precocious puberty than boys. Being obese, use of external sex hormones like creams or ointments, add extra risk. The outcome in such children is they grow quickly at first and be tall, compared with their peers, but stop growing earlier than usual, and become shorter than average as adults in the community. These girls become self-conscious affecting self-esteem and increase the risk of depression. 

The treatment includes Gn-RH analogue therapy, usually a monthly injection, which delays further development. The child must continue to receive monthly injections she reaches the normal age of puberty in the community [3]. 

Delayed Puberty & HT: Puberty is called as delayed in girls with no breast’s development (sateg-1) by age 13 or menarche does not begin by age 16. Delayed puberty is roughly estimated to occur in about 3% of children, caused by a constitutional delay and girls are at around 10% risk of total problem but is more common in boys. The most common cause of delayed puberty is a functional delay in production of gonadotropin-releasing hormone (GnRH) from the hypothalamic neuronal networks that initiate the episodic or pulsatile release of the GnRH and activate the hypothalamic-pituitary-gonadal axis. The key causes of delayed puberty include Chromosomal problems, Genetic disorder, Chronic illness including Tuberculosis, severe acute malnutrition (SAM), tumours of pituitary gland, hypothalamus, and abnormal development of the reproductive system. 

Delayed puberty affects adult psychosocial functioning and educational achievement and carry a higher risk for metabolic and cardiovascular disorders. A study of 392 girls with delayed puberty, pointed to constitutional delay as the most common cause, found in 32% of girl [4].

Giving Oestrogen at very low doses, either orally or as a patch and monitoring the growth changes and increasing the dose every 6 to 12 months is the management strategy recommended. Oestrogen given orally a day, which stimulates growth of breasts and uterus [4]. 

Management of young people delayed puberty and precocious puberty (PP) often requires specialist multidisciplinary input to address the endocrine and nonendocrine features of these complex conditions, as well as the psychological challenges posed by their diagnosis due to lack of standardized definition, gonadotrophins assay, gonadotrophin stimulation, timings for blood sampling, and parameters for assessing outcomes. 

2. Reproductive Phase:

Ovulation and Oral Contraceptive (OCP) use: Ovulation normally takes place in response to a surge of LH that triggers an egg to be released from the ovary. When a hormonal birth control pill is used, there is no LH surge, so the egg's release is not activated, and ovulation does not take place. During a typical 28-day menstrual cycle, ovulation occurs about two weeks before next period, though this can vary. Hormonal contraceptives are designed to temporarily delay fertility and prevent pregnancy. When a lady stops taking OCPs, her normal fertility levels will return. 

Ovulation happens just once in a monthly menstrual cycle. After the egg is released, it generally remains in the fallopian tube for 12 to 24 hours. However, any woman can get pregnant in the 5 days before and on the day of ovulation, (a total window of around 6 days) as sperms can survive in her uterus for about 5 days. Timing sex during this fertile window (the five days before ovulation and on the day of ovulation) increases the chances of becoming pregnant quickly. 

During the reproductive phase women may need hormone therapy for emergency contraception, planned birth spacing or pathological conditions called polycystic ovarian syndrome (PCOS) and after total hysterectomy for various uterine and ovarian pathologies.

Pregnancy Prevention: Overall, less than 6% of women in the age group of 15-49 used hormone-based contraceptives in 2019-21 in India. Among ever users 66% were injection users.  Among OCP users 55% discontinued within 12 months mainly due to adverse reactions [5].

i) Emergency Contraceptive Pills (ECPs): {e.g., I-pill-, Levonorgestrel, 1.5 mg {Tab. AfterPlan™ (Sun Pharma), ECONTM morning after (Aurohealth LLC), 72-Hours - VHB (Cronus), I-Pill – (Cipla)} ECPs also known Morning after pill is used by women to reduce chance of pregnancy after an unprotected sex as was in our case of Parvathy.  In Public sector Ezy-Pill (Levonorgestrel) as a single tablet product, is available for free, to be taken as soon as possible but within 72 hours after unprotected sexual intercourse. It works mainly by stopping the release of an egg from the ovary, by preventing fertilization of an egg or by preventing fertilized ovum implantation in the uterus. The success rate in preventing pregnancy is around 85-90%.  Though it is very safe and effective some of the side effects include nausea, abdominal pain, tiredness, headache, dizziness, and breast tenderness. If vomited within 2 hours of taking the medication, repeat the dose in consultation with a professional [6]. It is not useful if pregnancy has already been confirmed or for regular birth control.

ii) Oral contraceptive pills (OCPs): Oral contraceptive pills (OCPs) are small tablets taken orally by women to prevent pregnancy. They contain synthetic hormones which mimic the hormones in human bodies. Synthetic hormones alter the menstrual cycle in women and create an imbalance in the uterus, making it unfavourable to fertilize or hold a baby. OCPs consist of the hormone’s progestin and oestrogen, or only progestin, and must be taken orally once per day to prevent pregnancy. Oestrogen is responsible for ovulation, while Progestin is responsible for thickening the cervical mucus and thinning the endometrium key processes for pregnancies. Oral contraceptive pills create a hormonal imbalance, make the environment of the uterus unsuitable for pregnancy. These pills also alter the thickness of the cervical mucus, making it difficult for sperm to enter the cervix. Oral contraceptives have a 99% success rate when taken properly. Due to hormonal imbalance, a healthcare professional must check women on prolonged oral contraception at least once a year. Currently, there are three type tablets on the market: the combination pill, the progestin-only pill, & the continuous use pill [6]. 

A) Progesterone only Pills (POPs): POPs also called “Minipills”, contain very low doses of a synthetic hormone- progestin which is like the natural hormone progesterone in a woman’s body. The available generic products are Levonorgestrel (LNG) and Desogestrel. Tab. Desogestrel 0.075 mg (generic name, e.g.-Cerazette Tablet 28'S, Micronor)- work by preventing the sperms from entering the uterus changing the lining of uterus and by increasing the thickness of cervical mucus thus preventing the fertilization process and reducing the chance of pregnancy [6]. 

B) Combined Oral Contraceptives pills (COCs): Combined Pills contain low doses of two synthetic hormones progestin and an oestrogen which are like the natural hormones in woman’s body. They are of 2 types- i) 21-day packs: e.g., Bandhan, Yasmin, Ovral- L- to be taken 1 pill per day for 21 days, followed by 7 days of non-use for menstruation ii) 28-day packs: e.g., Yaz, Saheli- contain 21 or 24 hormonal pills (The remaining pills either contain Iron supplement or oestrogen). Indian National Family Welfare program distributes “Mala-Free and Saheli as 28 days pack OCPs free of cost. It is safe to start within first 5 days of last period, though it can be started anytime in a period, if the woman is certain that she is not pregnant. It is not recommended in the first 6 months after delivery as it affects breastfeeding.  Aranelle- a low dose oestrogen with Progestin, suitable for women struggling with excess weight and suffering from PCOS [6].

C) Extended Pills: Camrese is an extended-cycle oral contraceptive pill. These pills are available in a 3-month course. One tablet is to be taken every day for 3 months. Skip 7 days (bleeding occurs). Repeat for another 3 months. Women who take this pill will only have 4 periods in a year. It is recommended for women with a heavy period flow. Bleeding that occurs is a light flow. The tablet is extremely safe with minimal side effects [6]. 

iii. Depot medroxyprogesterone acetate Injection (DMPA, also known as Depo-Provera): DMPA is an injectable progestin-only contraceptive that provides highly effective, three-month-long reversible contraception [7]. It is given as an intramuscular injection into the buttock or the upper arm and is effective over the next 12 weeks as the DMPA is slowly released into the bloodstream. It acts by i) stopping the ovulation, ii) thickening the mucus at the cervix which forms a mucous plug, which stops sperm getting through to the uterus to fertilise an egg iii) Thinning the lining of the uterus, which makes it difficult for a fertilized egg, to implant in the uterus and develop. Though 99.8