ORAL CONTRACEPTIVES
The era of modern contraception dates from 1960 when oral contraception was first approved by the US Food and Drug Administration, and intrauterine devices were re-introduced. A few catastrophes attributable to oral contraceptive pills (OCP) usage, particularly from the older higher-dose pills, caused considerable public alarm in the 1970's. Now the birth control pill has become safer and better tolerated, with reduced dosage of both the estrogen and the progestin components. The 1990's are seeing multiple reports on the health benefits of the Pill. According to the 1988 Ortho Survey, approximately 14 million women in the United States use the pill; about 60 million women worldwide use OCPs. ("OCP" usually refers to combined oral contraceptive pills containing both estrogen and progestin).
Few women are not candidates to take OCPs. Table 1 lists absolute and relative contraindications. Most of the contraindications are related to the estrogen component. Risks of hormonal contraception must always be weighed against risks of pregnancy and acceptability of other options. A woman is 15 to 20 times more likely to die from continuing a pregnancy than from using oral contraceptive pills.
OCP Contraindications
Absolute Contraindications:
Thromboembolic disorder (or history thereof)
Cerebrovascular accident (or history thereof)
Coronary artery disease (or history thereof)
Impaired liver function (current)
Hepatic adenoma (or history thereof)
Breast cancer, endometrial cancer, other estrogen-dependant malignancies (or history hereof)
Pregnancy
Undiagnosed vaginal bleeding
Tobacco user over age 35
Relative Contraindications:
Migraine headaches, esp. worsening with pill use
Hypertension
Uterine leiomyomata
Diabetes mellitus or previous gestational diabetes
Elective surgery (needs 1 to 3 month discontinuation)
Seizure disorder, anticonvulsant use
Obstructive jaundice in pregnancy
Sickle cell disease (SS or sickle C disease (SC)
Gall bladder disease.
Studies to look at the complications of oral contraceptive pills are confounded by the higher-dose pills used in the 1960's and 1970's. Estrogen and progestin doses have been steadily lowered, with attendant lowered morbidity. The currently prescribed low-dose pills (<50 micrograms of ethinyl estradiol cause cardiovascular complications; myocardial infarction, cerebrovascular accident, thromboembolism) almost exclusively in women over age 35 who smoke, or in some women with underlying medical problems, particularly with conditions predisposing to thrombosis. Healthy OCP users who undergo surgery are at increased risk of venous thrombosis and pulmonary embolism. Pills should be discontinued prior to surgery and reinstated six to eight weeks postoperatively. This, too, should be balanced against the risk of pregnancy.
Side Effects
Breakthrough bleeding is the most common side effect for which women discontinue OCP usage. This may be due to estrogen or progestin deficiency or to missing pills. Estrogen excess side effects may include nausea, water retention, vascular headaches, and chloasma. Progestin excess may lead to increased appetite and weight gain, acne, depression, and pill amenorrhea. With current low-dose formulations, most women experience mild or no side effects.
Benefits
Benefits of taking contraceptive pills have been under-publicized. Long-term use is not only safe, but it is protective against many serious disorders and nuisance complaints. There is no need for a pill-free interval for reproductive or general health.
Noncontraceptive Benefits of OCPs
Effective contraception
--less need for therapeutic abortion
--less need for surgical sterilization
Less endometrial cancer (50% reduction)
Less ovarian cancer (40% reduction)
Less benign breast disease
Fewer ovarian cysts (50% to 80% reduction)
Fewer uterine fibroids (31% reduction)
Fewer ectopic pregnancies
Fewer menstrual problems
--more regular
--less flow
--less dysmenorrhea
--less anemia
Less salpingitis (pelvic inflammatory disease)
Less rheumatoid arthritis (60% reduction)
Increased bone density
Probably less endometriosis
Possibly protection against atherosclerosis
Besides providing protection from the above medical disorders, OCPs are used to manage many gynecologic disorders.
Noncontraceptive Uses of OCPs
Definitely beneficial:
--Dysfunctional uterine bleeding
--Dysmenorrhea
--Mittelschmerz
--Endometriosis prophylaxis
--Acne and hirsutism
--Hormone replacement
--Prevention of menstrual porphyria
Beneficial in many cases:
--Functional ovarian cysts
--Premenstrual syndrome
--Control of bleeding (dyscrasias, anovulation)
Surgical sterilization of women and oral contraceptive use by women are the most common methods of contraception in the U.S., and are some of the most effective methods.
Contraindications to combined estrogen/progestin OCP use are thromboembolic disorders, cerebrovascular accidents, coronary artery disease, liver abnormalities, estrogen dependent cancers, pregnancy, undiagnosed vaginal bleeding and tobacco use over age 35.
Non contraceptive benefits of combined oral contraceptives include decreased endometrial cancer, uterine cancer, benign breast disease, ovarian cysts, uterine fibroids, ectopic pregnancy, menstrual irregularities, salpingitis, rheumatoid arthritis, endometriosis, atherosclerosis, and increased bone density.
Intrauterine devices are safe and effective contraceptive methods especially for monogamous females near the end of their reproductive careers.
Barrier methods and rhythm methods are highly dependent on the individuals involved.
Pregnancies in women who have undergone a surgical sterilization should be considered ectopics until proven otherwise. Likewise, a positive pregnancy in a woman with an IUD may be an ectopic pregnancy.
The era of modern contraception dates from 1960 when oral contraception was first approved by the US Food and Drug Administration, and intrauterine devices were re-introduced. A few catastrophes attributable to oral contraceptive pills (OCP) usage, particularly from the older higher-dose pills, caused considerable public alarm in the 1970's. Now the birth control pill has become safer and better tolerated, with reduced dosage of both the estrogen and the progestin components. The 1990's are seeing multiple reports on the health benefits of the Pill. According to the 1988 Ortho Survey, approximately 14 million women in the United States use the pill; about 60 million women worldwide use OCPs. ("OCP" usually refers to combined oral contraceptive pills containing both estrogen and progestin).
Few women are not candidates to take OCPs. Table 1 lists absolute and relative contraindications. Most of the contraindications are related to the estrogen component. Risks of hormonal contraception must always be weighed against risks of pregnancy and acceptability of other options. A woman is 15 to 20 times more likely to die from continuing a pregnancy than from using oral contraceptive pills.
OCP Contraindications
Absolute Contraindications:
Thromboembolic disorder (or history thereof)
Cerebrovascular accident (or history thereof)
Coronary artery disease (or history thereof)
Impaired liver function (current)
Hepatic adenoma (or history thereof)
Breast cancer, endometrial cancer, other estrogen-dependant malignancies (or history hereof)
Pregnancy
Undiagnosed vaginal bleeding
Tobacco user over age 35
Relative Contraindications:
Migraine headaches, esp. worsening with pill use
Hypertension
Uterine leiomyomata
Diabetes mellitus or previous gestational diabetes
Elective surgery (needs 1 to 3 month discontinuation)
Seizure disorder, anticonvulsant use
Obstructive jaundice in pregnancy
Sickle cell disease (SS or sickle C disease (SC)
Gall bladder disease.
Studies to look at the complications of oral contraceptive pills are confounded by the higher-dose pills used in the 1960's and 1970's. Estrogen and progestin doses have been steadily lowered, with attendant lowered morbidity. The currently prescribed low-dose pills (<50 micrograms of ethinyl estradiol cause cardiovascular complications; myocardial infarction, cerebrovascular accident, thromboembolism) almost exclusively in women over age 35 who smoke, or in some women with underlying medical problems, particularly with conditions predisposing to thrombosis. Healthy OCP users who undergo surgery are at increased risk of venous thrombosis and pulmonary embolism. Pills should be discontinued prior to surgery and reinstated six to eight weeks postoperatively. This, too, should be balanced against the risk of pregnancy.
Side Effects
Breakthrough bleeding is the most common side effect for which women discontinue OCP usage. This may be due to estrogen or progestin deficiency or to missing pills. Estrogen excess side effects may include nausea, water retention, vascular headaches, and chloasma. Progestin excess may lead to increased appetite and weight gain, acne, depression, and pill amenorrhea. With current low-dose formulations, most women experience mild or no side effects.
Benefits
Benefits of taking contraceptive pills have been under-publicized. Long-term use is not only safe, but it is protective against many serious disorders and nuisance complaints. There is no need for a pill-free interval for reproductive or general health.
Noncontraceptive Benefits of OCPs
Effective contraception
--less need for therapeutic abortion
--less need for surgical sterilization
Less endometrial cancer (50% reduction)
Less ovarian cancer (40% reduction)
Less benign breast disease
Fewer ovarian cysts (50% to 80% reduction)
Fewer uterine fibroids (31% reduction)
Fewer ectopic pregnancies
Fewer menstrual problems
--more regular
--less flow
--less dysmenorrhea
--less anemia
Less salpingitis (pelvic inflammatory disease)
Less rheumatoid arthritis (60% reduction)
Increased bone density
Probably less endometriosis
Possibly protection against atherosclerosis
Besides providing protection from the above medical disorders, OCPs are used to manage many gynecologic disorders.
Noncontraceptive Uses of OCPs
Definitely beneficial:
--Dysfunctional uterine bleeding
--Dysmenorrhea
--Mittelschmerz
--Endometriosis prophylaxis
--Acne and hirsutism
--Hormone replacement
--Prevention of menstrual porphyria
Beneficial in many cases:
--Functional ovarian cysts
--Premenstrual syndrome
--Control of bleeding (dyscrasias, anovulation)
Surgical sterilization of women and oral contraceptive use by women are the most common methods of contraception in the U.S., and are some of the most effective methods.
Contraindications to combined estrogen/progestin OCP use are thromboembolic disorders, cerebrovascular accidents, coronary artery disease, liver abnormalities, estrogen dependent cancers, pregnancy, undiagnosed vaginal bleeding and tobacco use over age 35.
Non contraceptive benefits of combined oral contraceptives include decreased endometrial cancer, uterine cancer, benign breast disease, ovarian cysts, uterine fibroids, ectopic pregnancy, menstrual irregularities, salpingitis, rheumatoid arthritis, endometriosis, atherosclerosis, and increased bone density.
Intrauterine devices are safe and effective contraceptive methods especially for monogamous females near the end of their reproductive careers.
Barrier methods and rhythm methods are highly dependent on the individuals involved.
Pregnancies in women who have undergone a surgical sterilization should be considered ectopics until proven otherwise. Likewise, a positive pregnancy in a woman with an IUD may be an ectopic pregnancy.
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