Oral contraceptives

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The oral contraceptive pill (OCP) remains one of the most common forms of contraception in the USA, followed by condoms. The OCP is extremely effective when taken regularly.

Advantages to OCP use include apparent protection against benign breast disease, pelvic inflammatory disease (PID), and some forms of cancer. OCPs have the lowest rates of ectopic pregnancy compared with other methods of contraception. Combination OCPs provide significant reduction in endometrial cancer risk, which peaks at a reduced risk of nearly 30% at five years and persisting for up to ten years after discontinuing the pill.7 Additional observed advantages include decreased incidence of dysmenorrhea and decreased incidence of ascending bacterial pelvic infections.

The major concern regarding OCP use centers around malignancy risk and the development of thromboembolic disease - deep venous thrombosis, pulmonary embolism, cerebral thrombosis, and coronary artery thrombosis (Table 11.3). Despite the apparent protective effects of OCP use with respect to endometrial malignancy, there is increased relative risk of both breast and cervical cancer, which may remain for up to ten years after discontinuing the OCP. Cancer risk is not related to OCP preparation or duration of use.

Thromboembolic events are three to six times greater among OCP users compared with non-users. This risk is even greater among OCP users who smoke cigarettes, regardless of age or parity. OCP users also have significantly increased risk of postpartum development of DVT when compared with postpartum women who have not used OCPs. Use of OCPs in women over age 35 and who smoke is contraindicated because of increased thromboembolic risk.

Other potential adverse effects of OCP use include metabolic changes similar to pregnancy, including elevations in thyroid binding proteins and thyroxin, elevations in total cholesterol and triglycerides (in combination pills), decreased glucose tolerance, and the development of biliary diseases, including cholelithiasis, cholecystitis, and cholestatic jaundice.

There is a variety of OCPs, many of which now vary or reduce the amount of progesterone and estrogen throughout the cycle. Those with lower estrogen doses and/or lower progestin doses maybe tolerated better by older menstruating women.

Table 11.3 Contraindications to hormonal contraception

Absolute

History of thromboembolic disease - Pulmonary embolism, stroke, or CVA Structural heart disease Estrogen-dependent cancers - Breast, uterine Pregnancy

Major surgery and/or prolonged immobilization Unexplained or continuing liver or gallbladder disease Age over 35 years and smoker Uncontrolled hypertension

Relatively contraindicated

Undiagnosed vaginal bleeding Pregnancy, postpartum, lactation Interacting drugs Gallstones Severe headaches Uncontrolled diabetes Sickle cell disease Lipid disorder

Women may use hormonal therapy into their fifties and menopause, if they have no contraindications and are not smokers.8 However, menopause will then need to be diagnosed, because the woman will continue to cycle, even when menopausal, if she is still taking OCPs. After age 50, a follicle stimulating hormone (FSH) level should be obtained on the fifth to seventh afternoon of her week on placebos (withdrawal bleeding week). If her FSH level is 25 IU/dl or more, she is menopausal and should stop her OCP. She may still have a withdrawal bleed.8

One variation of OCP use includes non-stop progestin or the "mini-pill," which provides the daily medication without a special or preset schedule, and with a significant reduction in anovulatory bleeding and reduced side effects compared with OCPs containing estrogen. The precise mechanism of action of the mini-pill remains unknown. Failure rates of progestin-only pills are lower with older women (less than 0.3 per 100 women-years) than younger women.9

Progesterone-only OCPs may be a good choice for some women in this age group, especially those who smoke or who are on multiple medications or drugs that are metabolized by the liver, especially the P450 system, such as anti-seizure drugs, antidepressants, and phenothiazines. They cause more breakthrough bleeding and increased incidence of bloating and nausea than combination estrogen-progesterone pills, but taking them at the same time every day reduces the amount of breakthrough bleeding.

Table 11.4 Some proprietary methods of emergency contraception

Two tablets; repeat in 12 hours One tablet; repeat in 12 hours Four tablets; repeat in 12 hours

Levlen®, Triphasil, TriLevlen, Nordette Four tablets; repeat in 12 hours

Ovral® Ovrette

Two tablets; repeat in 12 hours Twelve tablets; repeat in 12 hours

Data from Andolsek, K. Contraception. In J. A. Rosenfeld (ed.). Handbook of Women's Health. Cambridge: Cambridge University Press; 2001. p. 159.

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