Which OC would you choose? Test your skills with these 3 cases

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Applied Evidence

Which OC would you choose? Test your skills with these 3 cases

J Fam Pract. 2011 February;60(2):76-83

By

Leanne Leblanc, MD

Herbert L. Muncie Jr, MD

In selecting the optimal oral contraceptive for your patient, your experience and the patient’s preference should be your guide.

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References

1. American College of Obstetricians and Gynecologists. (ACOG) Committee on Practice B. ACOG practice bulletin no. 73: Use of hormonal contraception in women with coexisting medical conditions. Obstet Gynecol. 2006;107:1453-1472.

2. Bezemer ID, van der Meer FJM, Eikenboom JCJ, et al. The value of family history as a risk indicator for venous thrombosis. Arch Intern Med. 2009;169:610-615.

3. Bracken MB. Oral contraception and congenital malformations in offspring: a review and meta-analysis of the prospective studies. Obstet Gynecol. 1990;76:552-557.

4. Petri M, Kim MY, Kalunian KC, et al. Combined oral contraceptives in women with sy stemic lupus erythematosus. N Engl J Med. 2005;353:2550-2558.

5. Trussell J, Vaughan B. Contraceptive failure, method-related discontinuation and resumption of use: results from the 1995 national survey of family growth. Fam Plann Perspect. 1999;31:64-72.

6. Petitti DB. Combination estrogen-progestin oral contraceptives. N Engl J Med. 2003;349:1443-1450.

7. US Food and Drug Administration. FDA approves newcombina-tion product oral contraceptive. May 6, 2010. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm211176.htm. Accessed January 19, 2011.

8. Vlieg AH, Helmerhorst FM, Vandenbroucke JP, et al. The venous thrombotic risk of oral contraceptives, effects of oestrogen dose and progestogen type: results of the MEGA case-control study. BMJ. 2009;339:2921-2928.

9. Lidegaard O, Lokkegaard E, Svendsen AL, et al. Hormonal contraception and risk of venous thromboembolism: national follow-up study. BMJ. 2009;339:2890-2897.

10. Davis PS, Boatwright EA, Tozer BS, et al. Hormonal contraception update. Mayo ClinProc. 2006;81:949-955.

11. Gallo MF, Nanda K, Grimes DA, et al. 20 mcg versus >20 mcg estrogen combined oral contraceptives for contraception. Cochrane Database Syst Rev. 2005(2);CD003989.-

12. van Vliet HA, Grimes DA, Lopez LM, et al. Triphasic versus monophasic oral contraceptives for contraception. Cochrane Database Syst Rev. 2006(3);003553.-

13. Van Vliet HA, Grimes DA, Helmerhorst FM, Schulz KF. Biphasic versus triphasic oral contraceptives for contraception. Cochrane Database Syst Rev. 2006(3);003283.-

14. US Food and Drug Administration. Office of Women’s Health Update, September-October 2003. Available at: http://www.fda.gov/ForConsumers/ByAudience/ForWomen/ucm118642.htm. Accessed January 19, 2011.

15. US Food and Drug Administration. FDA listing of approved generics as of December 13, 2010. Available at: AG_LISTING_pdf. Accessed January 19, 2011.

16. Drugs.com. FDA approves Seasonique. May 27, 2006. Available at: http://www.drugs.com/newdrugs/fda-approves-duramed-s-seasonique-extended-cycle-oral-contraceptive-1161.html. Accessed January 19, 2011.

17. Edelman AB, Gallo MF, Jensen JT, et al. Continuous or extended cycle vs. cyclic use of combined oral contraceptives for contraception. Cochrane Database Syst Rev. 2005();004695.-

18. US Food and Drug Administration. FDA approves contraceptive for continuous use. May 22, 2007. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2007/ucm108918.htm. Accessed January 19, 2011.

19. Legro RS, Pauli JG, Kunselman AR, et al. Effects of continuous versus cyclical oral contraception: a randomized controlled trial. J Clin Endocrinol Metabol. 2008;93:420-429.

20. Choice of contraceptives. Treatment Guidelines from the Medical Letter. 2007;5:101-108.

21. Foster DG, Parvataneni R, de Bocanegra HT, et al. Number of oral contraceptive pill packages dispensed, method continuation, and costs. Obstet Gynecol. 2006;108:1107-1114.

22. Willis SA, Kuehl TJ, Spiekerman AM, Sulak PJ. Greater inhibition of the pituitary—ovarian axis in oral contraceptive regimens with a shortened hormone-free interval. Contraception. 2006;74:100-103.

23. Westhoff C, Heartwell S, Edwards S, et al. Initiation of oral contraceptives using a quick start compared with a conventional start: A randomized controlled trial. Obstet Gynecol. 2007;109:1270-1276.

24. Edwards SM, Zieman M, Jones K, et al. Initiation of oral contraceptives - start now! J Adolesc Health. 2008;43:432-436.

25. Lesnewski R, Prince L. Initiating hormonal contraception. Am Fam Physician. 2006;74:105-112.

26. Truitt ST, Fraser AB, Grimes DA, et al. Combined hormonal versus nonhormonal versus progestin-only contraception in lactation. Cochrane Database Syst Rev. 2003(2);CD003988.-

27. Queenan JT. Contraception and breast feeding. Clin Obstet Gynecol. 2004;47:734-739.

28. Potter L, Oakley D, de Leon-Wong E, et al. Measuring compliance among oral contraceptive users. Fam Plann Perspect. 1996;28:154-158.

29. PlannedParenthood. Whattodoifyouforgettotakethepill. Available at: http://www.plannedparenthood.org/health-topics/birth-control/if-forget-take-pill-19269.htm. htm. Accessed September 4, 2009.

30. von Hertzen H, Piaggio G, Ding J, et al. Low dose mifepris-tone and two regimens of levonorgestrel for emergency contraception: A WHO multicentre randomised trial. Lancet. 2002;360:1803-1810.

31. Physicians’ Desk Reference. Montvale, NJ: PDR Network; 2010.

32. Hannaford PC, Selvaraj S, Elliott AM, et al. Cancer risk among users of oral contraceptives: cohort data from the royal college of general practitioner’s oral contraception study. BMJ. 2007;335:651.-

33. Lurie G, Thompson P, McDuffie KE, et al. Association of estrogen and progestin potency of oral contraceptives with ovarian carcinoma risk. Obstet Gynecol. 2007;109:597-607.

34. Kiley J, Hammond C. Combined oral contraceptives: A comprehensive review. Clin Obstet Gynecol. 2007;50:868-877.

PRACTICE RECOMMENDATIONS

• Before you decide on a particular formulation, ask the patient whether she wishes to menstruate monthly, quarterly, or not at all. C

• Avoid prescribing oral contraceptive pills (OCPs) with a low dose of estrogen for women who are not meticulously compliant, as low-dose pills are associated with a greater failure rate compared with OCPs with higher doses of the hormone. A

• Advise patients to begin taking their OCPs on the same day as their office visit. B

• Remind patients taking progestin-only pills that they must be taken at about the same time every day; even a 3-hour day-to-day variation increases the risk of contraceptive failure. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

Like most family physicians, you’ve probably prescribed oral contraceptive pills (OCPs) for countless patients. But are you up to date on the intricacies of dosage and hormone formulations, biphasic and triphasic pills, and non-traditional dosing schedules that allow patients to extend the frequency of—or even avoid—scheduled withdrawal bleeds?

Use the 3 patient scenarios that follow to test your knowledge of today’s OCPs and the text and tables that follow to fill in any details you may be missing. We’ll discuss the best approach for each patient at the end of this article.

CASE 1 Mandy, age 33, comes in asking for OCPs. She is newly married and would like to start a family in 2 or 3 years. The patient—a smoker—previously used a transdermal contraceptive patch.

CASE 2 Julie, age 18, recently became sexually active and would like to start taking OCPs. She will be spending much of the coming year abroad, Julie explains, and would really like to take “the pill that keeps you from getting your period. “ Other than acne, which she is treating with a topical benzyl peroxide/ antibiotic combination, Julie has no health problems—and no medical coverage.

CASE 3 Sandra, age 41, has taken OCPs in the past, but was taken off them after she was hit by a car and sustained a pelvic fracture 2 years ago. A mother of 4, Sandra delivered twins 6 weeks ago. She would like to take OCPs again, but wonders whether the hormones would interfere with nursing.

Is your patient a candidate for an OCP?

Before you prescribe OCPs for these women, or for any patient, there are a number of things to consider. First and foremost, does the patient have any contraindications to hormonal contraceptives related to the risk of adverse vascular events?

Absolute contraindications. Oral contraceptives are contraindicated (TABLE 1) in women older than 35 years who smoke and in women who have uncontrolled hypertension, a past history of venous or arterial vascular complications or a family history of thrombosis, diabetes with end-organ damage, migraine headaches with focal neurologic symptoms, or a history of breast cancer or liver disease.^1,2 (A venous thromboembolism [VTE] that occurred in a clinical setting with a clear initiating risk factor—a fractured femur secondary to trauma complicated by a VTE, for example—is not an absolute contraindication to OCP therapy, particularly if it occurred years ago. Such patients may use OCPs if other contraceptive methods are not acceptable.¹)

Relative contraindications. Pregnancy is a relative contraindication, as no prescriber would intentionally give a contraceptive medication to a woman known to be pregnant. It is important to note, though, that no harm has been associated with inadvertent use of OCPs during pregnancy.³

Obesity is also a relative contraindication. There is evidence that obese women (body mass index >30 kg/m²) have a higher failure rate with OCPs compared with women who are not overweight. The American College of Obstetricians and Gynecologists (ACOG) recommends nonhormonal contraception for obese patients due to the reduced efficacy of hormonal contraception and increased risk of VTE based on case-control studies.¹ An obese patient should not, however, be precluded from using OCPs if her only other option is to use a less effective contraceptive.

FAST TRACK

Women with a BMI >30 have a higher failure rate with OCPs compared with women who are not overweight.

Lupus was previously considered a relative contraindication, but recent studies did not find any exacerbation of stable lupus with OCPs.⁴

Compliance. In determining whether a patient is a candidate for oral contraceptives, you should also discuss the need for daily compliance, the moderate effectiveness of OCPs (which have a 7% failure rate with typical use⁵), and the importance of refilling the prescription in a timely manner. If the patient indicates that she has trouble following a daily routine, you may want to discuss other contraceptive options.