Management of excessive menstrual bleeding has changed over the past two decades with the promotion of effective medical treatments and in particular the use of the levonorgestrel-releasing intrauterine device. The aims of therapy are to reduce blood loss, reduce the risk of anaemia and improve quality of life. Non-hormonal treatment options for excessive menstrual bleeding are non-steroidal anti-inflammatory drugs, antifibrinolytics, and etamsylate. Intrauterine administration of levonorgestrel, oral and intramuscular progestogens, oestrogen/progestogen combinations, and antiprogestogens are used as hormonal treatments for excessive menstrual bleeding. Plasminogen activator inhibitors have been promoted as a treatment for excessive menstrual bleeding because of increased endometrial fibrinolytic activity in women. The use of progestogens is based on the erroneous concept that women with excessive menstrual bleeding principally have anovulatory cycles and require progestogen supplementation. From clinical experience, combined oral contraceptives (COCs) are generally considered to be effective in the management of dysfunctional menstrual bleeding.

Over the past 50 years, there have been hundreds of clinical studies investigating whether hormonal contraception changes the risk of cancer among users. Most of the epidemiological evidence comes from observational case control and cohort studies examining cancer risk among users of combined oral contraceptives (COCs). Although women may be at increased risk of several cancers (breast, cervix, liver and thyroid) whilst using this contraceptive method, the effects appear to be transient, disappearing within a few years of stopping. Conversely, COCs protect against several other cancers (ovary, endometrium and colorectum), with the benefits persisting for many years after stopping. This sustained protection may produce major public health benefits over time, through reduced overall cancer incidence and mortality. Limited data suggests that users of progestogen-only contraceptives (especially injectables and implants) experience a similar pattern of cancer risks and benefits as COC users.

In the area of contraception, especially combined oral contraceptives (COCs), ethinyl oestradiol (EE) has been the clear market leader for many decades. This chapter sets out the rather peculiar background to the inclusion of oestrogens in contraception as well as reviews some simple pharmacology. The classic mechanism of action for all steroid hormones is to bind to specific intracellular receptors and induce change in their shape, encouraging dimerization (two pairs of hormone/receptor complexes forming a single unit) and leading to recruitment of co-regulators. The complexes formed through this route are able to influence gene transcription and hence the production of proteins with biological activities. Until the last few years a prescriber discussing contraceptive options with a woman could bring in issues such as the route of administration of contraceptive steroids, their doses and dosing schedules and the type of progestogen.