"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 around puberty, menstruation, pregnancy, menopause, and aging, but some people experience continual, irregular hormonal imbalances leading to a variety of health issues. The symptoms of hormonal imbalance in women are heavy or irregular periods, hair loss, night sweats, headaches, and psychosocial disturbances to the individual & family.

General population 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 oestrogen, testosterone, and progesterone are instrumental for sexuality and fertility. They are responsible for puberty, menstruation, pregnancy, menopause, sex drive, ovum production and more.

Balancing or preserving our hormone levels within normal ranges helps us 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 of us, as we 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 are more common during puberty, menstruation, pregnancy, menopause, and aging, but 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].

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), which are interrelated and get affected as we age in turn affect our health and happiness [1].

General population think 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 to avoid health problems. A simple blood biomarker can determine hormone levels and help us to decide if therapy is needed.

Balancing hormones to retain youthful feelings!

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 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.

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, the reduction of the risks of chronic menopausal conditions like osteoporosis and bone fractures, heart disease, endometrial cancer, colon cancer, type 2 diabetes, are other long-term indications. 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 symptoms alleviation. The hormones can be delivered as pills, dermal patches or gels, creams, or suppositories [1].

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.

Case Reports:

1. Peri-menarche problems:

Case of Precocious Puberty:

A worried well to do family parents of Laxmi a rural girl of about 8 years approached a mentee (a young lady doctor) of mine in early years of his practice in early 2010, complaining of a sudden spurt in changes in body shape and size in last 6 months and bleeding per vagina since previous day.  She had grown tall by about 15 cms 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 130 cms 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, who were worried as most girls in that village attain menarche by age 12 or 13. She was referred to Gynaecologist who had put her on a monthly oestradiol injection. Her height stagnated at 140 cms only in the next 5 years as I followed her, and the injections were stopped.

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 130 cms, weight of 30kg. The mother confirmed presence of secondary characteristics of axillary and pubic hair, breast enlargement stage 2, and primary amenorrhea, apart from undernourishment, that was tried to rectify in the last 2 years with not much success. Suspecting a case of Constitutional delay of growth and puberty, got done a biomarker test of oestrogen levels that confirmed the diagnosis. She was 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 and yet to be married.

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 with asthma at age 2 months. Previous health issues: Recurrent right ear infections for which she was operated tympanomastoidectomy. No other significant history. Family history- mother had delayed menarche at age 15 years, two older sisters, age 18 and 20 years, both 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. 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) at 1 month after the Free T4 level had increased into the normal range. Continued hydrocortisone, levothyroxine, and growth hormone with excellent compliance for 3months. Latest bone age at chronological age 17 years and 5 months is 12 years. Patient was on oestrogen (oestradiol transdermal patch 0.375 mg/day) for psychosocial reasons.

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.

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, on day 3 of the sex she took Levonorgestrel as a tablet by mouth. She prevented the 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 using free distribution of OCPs. After using the OCPs she stopped taking and conceived after a gap of 5 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. Her Food- and Nutrition- History: Pallavi non-vegetarian who consumes fish with loves but being in university’s girls’ hostel has no access except week ends. Hostel. She typically has cereal based breakfast, and same but packed lunch. She enjoys a full dinner of vegetarian curry, rice, vegetables, and lentils. She reported having gained 5 kg since she joined MPH course year ago. Nutrients-wise most calories consumed at night diet 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 in their late forties -48) and late fifty years (58 years) sough my help in January 2022 with post-menopausal symptoms. The elder sister had Vaginal dryness, hot flashes, Sleep problems and mood changes mainly depression for over 7 years and not responding to household remedies like diet control, morning walking, diet management. 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 and the younger one was advised to strictly follow i) weight reduction, ii) walking, muscles strengthening and Yoga including meditation for 45-60 minutes day iii) regular sleeping practices between 1000 PM to 0600 AM every day iv) avoid 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 42 years, had intractable menorrhagia since early 2022. A mother of 2 grown-up children (youngest-15 years), reported heavy blood flow in each period since February 2022. First considered as transitional phase to Menopause, she took all conservative approaches and finally sought a gynaecologist’s consultation. Following a CT scan and hormones assay, she was diagnosed as having Fibroids and endometritis. She was put on oral contraceptives for 3-4 cycles, then advised a total hysterectomy. Being typical conservative Indian women, she waited for the completion of annual exams of the both the children and underwent the surgery in April 2023. Having recovered from the surgical onslaught, she is put on progestin for last 3 months 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 menopausal symptoms after trying conservative treatment for about a year by a private Gynaecologist. 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. The Bilateral hearing loss was progressive. After all conservative treatment failed, she was asked to discontinue the HRT that only arrested the progress, but her hearing did not improve after 12 months.

6. post-Contraceptive use- 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 nearly a year now! I have advised them weight for another 6 months, before we resort to other methods for conception.

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,

The needs of hormonal balancing in Indian women based on the stages described above are:

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

1.Peri-Menarche:

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. Central precocious puberty (CPP) is due to early maturation of the hypothalamo 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.  Rarely, a tumour in the adrenal glands or in the pituitary gland that releases oestrogen or testosterone, Ovarian cysts and Ovarian tumours, McCune-Albright syndrome, a rare genetic disorder causes hormonal problems, may cause precocious puberty. Girls are much more likely to develop precocious puberty than boys. Being obese, exposure to external sex hormones like creams or ointments, using an oestrogen cream or ointment, or other substances that contain these hormones (like adult’s medication or dietary supplements), in rare cases, hypothyroidism, radiation therapy of the central nervous system tumours, leukaemia etc. increase the risk of precocious puberty.

The outcome is such children grow quickly at first and be tall, compared with their peers, but often stop growing earlier than usual, resulting in them to be shorter than average as adults. These girls become self-conscious affecting self-esteem and increase the risk of depression.

The treatment, with Gn-RH analogue therapy, usually includes a monthly injection, which delays further development. The child continues to receive this medication until he or she reaches the normal age of puberty [3].

Table-2: Female breast developmental stages

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. 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. Delayed puberty is roughly estimated to occur in about 3% of children, with 90% of these cases being caused by a constitutional delay which is 10 times more common in boys than girls. The key causes of delayed puberty include Chromosomal problems, Genetic disorder, Chronic illness including Tuberculosis, severe acute malnutrition (SAM), tumours of the pituitary gland or hypothalamus, hypopituitarism, hypothyroidism, 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. Girls with delayed puberty are prescribed the hormone Oestrogen typically taken by mouth once a day, which stimulates growth of breasts and uterus [4]. A one-year study on forty-eight adolescents with delayed puberty revealed aetiology of constitutional delay, hypogonadism (hypo or hyper-gonadotropic), chronic systemic disease, hypothyroidism, and sex reversal in 14, 13, 12, 5, 3 and 1 case, respectively.

Another study of 392 girls with delayed puberty, constitutional delay was the most common cause, found in 32% of girl. The probability of entering puberty within the next year for 12- to 15.5-year-old girls with delayed puberty ranged between 38%. No differences in the rates of pubertal entry were seen between girls and boys [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.

1.Reproductive Phase:

Ovulation and Oral Contraceptive use: Ovulation normally takes place in response to a surge of LH that triggers an egg to be released from the ovary. With hormonal birth control, there is no LH surge, so the egg's release is not activated, and ovulation does not take place. People who take oral contraceptives, or birth control pills, generally don't ovulate. During a typical 28-day menstrual cycle, ovulation occurs about two weeks before next period, though this can vary. The need to bust out a different bra size before your period comes, or changes to cervical mucus, or abdominal pain and changes to basal body temperature are the signs of ovulation after stopping the pill. As ovulation nears, discharge will become wet, stretchy, and slippery. The most common analogy used for super fertile cervical mucus is looking and feeling like raw egg whites. After ovulation, your cervical mucus goes back to being thick and dry. Hormonal contraceptives are designed to temporarily delay fertility and prevent pregnancy. But when you stop taking them, your normal fertility levels will eventually return. After the egg is released, it generally remains in the fallopian tube for 12 to 24 hours. Ovulation happens just once in a monthly menstrual cycle. While ovulation itself only lasts for 12 to 24 hours, a lady is most likely to get pregnant in the 5 days before and on the day of ovulation, a window of around six days as sperms can survive for about 5 days. Timing sex during fertile window (the five days before ovulation and on the day of ovulation) increases the chances of becoming pregnant quickly. Tracking the menstrual cycle with apps that note changes in cervical mucus and basal temperatures can help you determine your fertile window. During the reproductive phase women may need hormone supplementation 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% of injection users and 55% of OCP users 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 (a contraceptive failure or if birth control method not used). They come as tablets to be taken orally. In Public sector Ezy-Pill (Levonorgestrel) as a single tablet product, is available for free, to be taken as soon as possible 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%, if taken as per instructions. It is very safe and effective when used as directed. Side effects include changes in periods, nausea, abdominal pain, tiredness, headache, dizziness, and breast tenderness. If vomited within 2 hours of taking the medication, must consult a professional to repeat the dose [6].

A rural Delhi based cross section study in 2019, identified that only one third (34%) were aware and most respondents lacked adequate knowledge about ECPs, less than 10% had ever used ECPs. Factors that were associated with the use of ECPs were age, literacy, socioeconomic status, and knowledge about the method. Creating a sustainable awareness on ECPs and their use may serve them with power to control their parity.

It is not useful if pregnancy has already 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

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