Oral contraceptive uses -Tips of selecting most appropriate OCP.

Tips in choosing   the best OC formulation .  How to select the most appropriate an OCP  formulation ??

What to take into account?? A) It is   generally recommended to use   the lowest effective  dose.
B)  Age of the woman(the contraceptive sekers) :-As women age   there are different   issues  that affect  hwer metabolic profile which includes lipid, LFT status.

 . Because  of the higher   potency of EE    , OCs   containing   35 ug EE are  similar  to the 50 ug  OCs   containing menstranol .

New  start  Healthy   patients

Adolescents : 20    ug EE OCs  , the  lowest dose 20 ug    EE (except Minesse which contain 15 mcg) in adolescents may  be  associated    with BTB ( a lack of bleeding    control )-  a leading   cause of  discontinuation   . In this  population  starting with a 25(not available in our country)    or 30 ug  EE OC may be associated   with better   bleeding control   and ultimately  better compliance. However the biphasic or monophonic   20 ug OCs  with shortened  pill free   intervals are associated  with improved  bleeding    control  and may    be a good   option  to consider. Indicatiosn of OCP in adolescents?? It is prescribed for  many    non  contraceptive    benefits :

I Dysmenorrhea   2) bleeding    control  . All OC  brands   show benefit   25 and 30 ug  OCs  may have better  bleeding  control than  traditional 20 ug OCs with a 7 day pill free  interval. Reviews have   shown   that OCs   with levonorgestrel (androgenic progesterone) have good  bleeding control.

3) Acne   : Choice is nonandrogenic prog liked desogestrel:-androgenic problems. All OCs   brands   show benefit  but  If  symptoms are  severe  or continue to be a problem  while on an OC   switch   OC with   formulation  containing  a low   androgenic  progestin desogestrel , ortho Tri  Cyclen ( abroad) is approved   by the Food  and Drug   administration to treat acne   vulgaris.

4) If engaged regularly in illegal/illicit sex(married /unmarried) i/e  users    with at risk of STD or HIV   exposure   need additional protection and   should  use  condoms and OCs .

Take home meassage:-Don’t prescribe low dose formulation which may cause BTB (an unacceptable side effects for teen agers).:_Early   reproductive  first choice : :-Don’t prescribe 20 ,25  ug EE OCPs  in   young women as these brands  may  have increased bleeding problems on 20 ug  OCs  with a  traditional    7 day pill free  interval   a 25 ug  EE OC may result in better bleeding  control Use of  a levonorgestrel containing pill is  associated   with  good  bleeding   control.

Dysmenorrhea    bleeding  control   all OC  brands show  benefit 25 and 30 ug  OCs   better  than   some of the 20 ug  OCs   Reviews  have shown  levonorgestrel  containing   OCs    to have good   bleeding  control

PMS   PMDD or fluid   retention  all OCs  may show  benefit. The  progestin DRSP is a derivative of   spironolactone  and has some diuretic effect . Selection   of an OC with   DRSP  is a good choice for  users  with significant   complaints   of PMS  PMDD  or fluid  retention.

Acne    androgenic problems all OCs  show benefit Consider low androgenic    progestin OCs    if severe or if nonresponsive  to other  OCs   Ortho  Tri cyclen is FDA   approved  to treat   acne vulgaris.

Late    reproductive   first choice : 20-25 ug EE OCs 

Menorrhagia : all  OCs  show    benefit ?If   menorrhagia is a problem while on an OC switch  to OC with  levonorgestrel  or one with    lower EE  dose. Switching to pill with  higher   progestin   to estrogen    ratio results   in less endometrial  stimulation    and may result   in less menstrual   bleeding

Bleeding  problems all Cos   show benefit . If  midcycle  bleeding and spotting   is a problem  while on OC  consider switching to an CO with stronger     progestin such as one  with levonorgestrel or consider   switching  to a higher EE dose  OC Estrogen increases   endometrial    growth and may  improve    bleeding control In   some instances  switching to   a   lower EE done   OC may be   effective   because   it lowers   endometrial  stimulation  which results    in less endometrial     tissue and less bleeding.

Fibroids or endometriosis   all OCs may  show benefit  consider a stronger   progestin OC  such  as one with levonorgestrel  or OC   with as low   a  dose of  EE as  possible.

Significant   menstrual related    problems  consider  a low dose   21 day extended  cycle or continuous OC.

Obesity   for heavier women   consideration of 30  to 35 ug pill extended  use OC or   vaginal  ring   . Using   more than  35 ug OCs may  increase   the risk of venous   thrombo embolisms and  a risk  benefit   ratio should  be considered . As a user get older risk of thrombosis  may increase   and fecundity decreases     therefore   using a low  EE dose OC may be considered . Women   over 35   with long standing obesity   are good candidates for progestin only methods    barriers  IUDs or tubal   sterilization.

Perimenopausal or women over  35 years old  who  are healthy  non hypertensive  nonsmokers  first choice is 20 ug Cos Women  in this age group   with longstanding obesity hypertension   cigarette  smoking  known   or suspected   vascular   disease or diabetes  may consider   progestin only methods  barriers    IUDs or tubal  sterilization.

Perimenopausal symptoms   during  pill free interval  consider   switching  to CO with   shortended  pill   free interval   with EE 20 ug  /150 ug  DSG  for 21 days   , 5days   of 10 ug EE and only  2 days   hormone free   interval or  the new 20 ug OC  containing  3 mg DRSP   with a 4 day hormone free interval

The   amount and potency   of either  the particular  estrogen  or progestin  component   in an OC an d the balance    between the particular     estrogen  and progestin is associated with hormonal side effects as listed . Management   of these problems    generally involves  changing    to an OCP  with a different estrogen   to progestin  balance.

Consider   switching to another OC if   current OC is associated with :

Breakthrough    bleeding   heavy  menses irregular     bothersome  or heavy  bleeding   that continues after 2 months of use    consider OC  with levonorgestrel or   lower EE or  progestin ration pill.

Amenorrhea for two cycles after negative pregnancy   test switch  to OC with   higher EE to  progestin ratio

Acne is exacerbated on OC  switch    to OC with  Norgestimate DSG or DRSP    ortho Tri Cyclenis  FDA    approved to treat  acne vulgaris.

Minor   estrogen     related   side effects  that continue  after 2 months switch  to OC   with lower  EE dose   consider  20 ug EE OC .

Nausea or vomiting Switch   to OC  with lower EE   

Headaches : Stop OCS   immediately  if there are concomitant  localizing  signs auras  blurred  vision weakness or numbness or if the users  is experiencing   a worsening of migratines  

Check  blood pressure

If blood   pressure   normal   headaches  are simple and there are none of the  symptoms above   consider  switching to 20 ug EE OC or progestin only method.

Decreased libido there is a dose dependent  suppression of endogenous  testosterone production by OCs . Additionally estrogen   dominant   pills increase   sex hormone  binding  globulin that binds up endogenous androgens   switching to OC with     20 ug EE or to a progestin  only  OC may result in  more normal   free testosterone levels  and less negative impact  on libido.

Melasma : switch  to  progestin  only OCP  or consider one with  20 ug EE

Mood    swings   to 20 to 25 ug OC  consider  OC with a different  progestin  from current OC consider   DRSP  Norgestimate   or DSG  consider   extended cycle or   continuous  OC.

Weight   gain : Currently   available low dose OCs  are generally   not associated  with   a weight    gain consider   switching to 20- 25f ug EE OC if fluid retention  is problem use an OC containing  DRSP  .

Although  OCs   are safe in healthy normotensive women there  are important   contraindications to their sue and it is important to identify certain risk factors Additionally OCs  are associated with many  non contraceptive      benefits   and the  identification of conditions that may  be improved  with OC  use is also   important.

Pertinent gynecological  issues

Menstrual cycle   irregularities heavy  bleeding anemia

Leiomyomata  uterus previous  surgery 

Polycystic ovary syndrome   recurrent  ovarian cysts

 Dysmenorrhea  pelvic  pain

  Sexual   history exposure   to HIV

Current  and future   childbearing  plans

Androgen   excess  acne hirsutism alopecia

Premenstrual syndrome

Demographics

Age  gravity   parity marital status  occupation

Medications

Good   data  stating that certain  drugs  accelerate  the biotransformation of steroids  in OCs    and concomitant use may make OCs  less effective

Rifampin   sulfonamides   cyclophosphamide barbiturates   certain antiepileptics , butazolindin

St John ‘s Wort

Data    less convincing  for certain   antibiotics   fulconazole 

Low dose    long  term antibiotic     use for acne   appears to be compatible with   oc use

Product   labeling suggests that women taing  potassium sparing diuretics angiotensin converting enzyme   inhibitors  angiotensin II receptor    antagonists chronic    daily use   of nonsteoidal anti  inflammatory   drugs    should   consult  their health  care provider  to check  if a drospirenone   containing   OC is   right for them. Under   these conditions  serum potassium levels   should be checked   during the first  months . Clinical  studies  have reported   minimal incidence   of problems  in women    on these  medications who also take  a  DRSP  containing OC  

Potassium sparing drugs : Women who are ACE  inhibitors  potassium sparing  diuretics heparin angiotensin II receptor  inhibitors aldosterone antagonists or  daily  NSAIDs    should be monitored   for potassium before   and during   use of DRSP   containing  OCs. Multiple  studies  demonstrate safety   of DRSP  containing  pills in for patients  on these medications.

Valvular heart disease this   thrombogenic   complications

Pulmonary hypertension subacute   bacterial endocarditis or atrial fibrillation  

Known   or suspected vascular disease 

Cerebro vascular  or coronary artery  disease  history  of   stroke

Myocardial    infarction known   atheroscelerosis

Diabetes with vascular disease   including retinopathy  or nephropathy

Diabetes  for more  than 20 years

Hypertension

WHO  medical  criteria   classify controlled    adequately  evaluated hypertension  as category     3 the risks generally outweigh  the benefit

Multiple risk factors for   atheroscelerosis  

Personal   history  of thrombosis    or high risk for thrombosis

Thromboembolism   thrombophlebitis deep  vein thrombosis

Polycythemia vera

K own or suspected   inherited  clotting disorder   

Cigarette  smoking in women older than 35

Cancer    of the breast

Any current  estrogen   dependent   neoplasia

Known  or suspected pregnancy

Migraine headaches   with localizing  neurological signs  including scotomata at  any age .

Migraine  without  aura over   age 35

Worsening migraines  during use of  OC .

Acute  or  chronic  lives disease

Active   viral hepatitis  abnormal liver  functions severe  cirrhosis

Benign  hepatic  adenomas / liver   carcinoma

Prolonged immunobilization major surgery

Hypersensitivity to any component of the pill

  History  of  Oc   induced cholestatic   jaundice   or current  symptomatic  gall bladder  disease   treated  medically

Mild   compensated cirrhosia

Postpartum less than  21 days or less  than  6 months  if primarily breastfeeding

Cigarette smoking of less than  15  cigarettes  per day in women 35 years or older or older .

History    of hypertension   in which blood pressured cannot be   monitored    or moderately   elevated systolic blood  pressure   140-159   mmHg   or diastolic    blood pressure  90-99 mmHg

Hypertrigltyceridemia  known   hyperlipidemias 

Migraine without  aura  over 35 years of age

Previous    breast cancer but no evidence  of current  disease for 5 years.,

Certain antibiotics   or anticonvulsants

 Unexplained    vaginal bleeding before   evaluation 

Undiagnosed breast  mass

Varicose veins

Migraine    headaches  without localizing neurological    signs  or aura  more than   35  years .

Non  migrainous  headaches mild or severe  during use.

Cigarette   smoking by women   younger  than age 35 

Age  over 40

Prolactin secretion  pituitary  microadenoma

Valvular heart  disease  uncomplicated

Unexplained amenorrhea after evaluation

Diabetes  with no vascular    disease  in women

Under   35 years of  age and less  than 20 years duration of diabetes

Surgery   without   prolonged  immobilization

Known   hyperlipidemias   with  no other   risk factors  for cardiovascular   disease.

On  antiretinoviral   therapy 

On  Griseofulviin

Obesity   body mass index 30 kg / m or more

Non   migrainous mild  or  sever headache

Cervical   cancer awaiting   treatment

Cervical   intraepithelial neoplasia

Sickle   cell disease  or trait.

Symptomatic   gall bladder   disease treated with cholecytectomy or asymptomatic

Gall bladder disease or history  of pregnancy     induced cholestatic jaundice  

History   of pregnancy   induced hypertension 

Family  history  in first  degree relative of deep  vein  thrombosis / pulmonary embolism.

Superficial  thrombophlebitis.