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

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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.

There is no evidence of any advantage of triphasic pills over monophasic pills in terms of effectiveness, bleeding patterns, or discontinuation rates,¹² but there is some evidence that biphasic pills result in more adverse effects.¹³

Frequency of withdrawal bleeds
Traditional OCPs have 21 active pills and 7 days of placebos. Women taking them have a menstrual cycle every 4 weeks during the placebo days. Patients can choose to have less frequent periods or avoid a menstrual cycle altogether either by taking one of the name-brand OCPs designed for extended or continuous dosing (TABLE 2) or by skipping the placebo pills in a traditional OCP regimen and starting the next pill pack immediately after taking the final active pill of the previous pack.

In 2003, a continuous OCP with 30 mcg EE and 0. 015 mg levonorgestrel (Seasonale) was approved. Its pill pack contains 84 mono-phasic active pills, plus 7 days of placebos.¹⁴Patients taking Seasonale—which is now available in generic form¹⁵—have a menstrual bleed every 3 months. A second 84/7-day OCP with a slightly different formulation (Seasonique) was approved in 2006.¹⁶ Patients who follow an 84/7-day regimen have been found to have outcomes that are very similar to those of women using OCPs in the traditional 21/7-day pattern in many respects, including the bleeding pattern, discontinuation rates, and satisfaction reported.¹⁷

FAST TRACK

At press time, a study in the January 2011 issue of Obstetrics & Gynecology reported that a 24/4-day regimen had greater contraceptive efficacy compared with a 21/7-day regimen.

In 2007, an OCP featuring 365 active pills and no placebo pills was approved (Lybrel).¹⁸ The dosage of EE (20 mcg) and levonorgestrel (0. 09 mg) remains constant each day of the year, with the intention that women on this regimen go an entire year without menstruating. No increase in adverse effects has been noted with the use of this OCP. Patients report improved symptomatology, but not a significant reduction in bleeding days compared with cyclic oral contraceptives.¹⁹ In fact, a potential downside is the possibility that women on extended or continuous dosing regimens may have more frequent unscheduled bleeding days.

FAST TRACK

Extended and continuous dosing regimens have benefits for women with endometriosis, dysmenorrhea, and chronic pelvic pain.

Extended and continuous dosing regimens have benefits for patients with gynecologic conditions responsive to the suppression of menstruation, including endometriosis, dysmenorrhea, and chronic pelvic pain (TABLE 3). In fact, OCPs are often prescribed for these conditions, as well as for acne vul-garis, menorrhagia, premenstrual syndrome, and polycystic ovarian syndrome, as patients taking them have been found to have less difficulty with hormonal withdrawal side effects and no increased risk of adverse events.¹⁹

The only problem with extended or continuous dosing is cost (TABLE 4).²⁰ Brand-name OCPs designed as extended-cycle contraceptives are more expensive than generic pills. Similarly, creating a continuous-dosing cycle with a monthly OCP requires more than 13 pill packs a year, and some insurers will not cover the cost of the additional pills.

Currently, no particular OCP or dosing regimen has any evidence-based advantages or indications regarding contraceptive efficacy or bleeding patterns. Until there is ample evidence to show that a particular frequency of withdrawal bleeds has advantages compared with other regimens, the frequency chosen can be at the patient’s and physician’s discretion.

TABLE 2
Traditional vs nontraditional dosing*³¹

Oral contraceptive	Combination pills (No.)	Placebos (No.)	Other pills (No.)
Traditional OCP	21	7	0
Femcon Fe^†	21	7	0
Mircette	21	2	5 (10 mcg EE)
Natazia	22	2	2 (3 mg EV); 2 (1 mg EV)
Lo Loestrin FE	24	0	2 (10 mcg EE); 2 (75 mg ferrous fumarate)
Yaz	24	4	0
Seasonique	84	0	7 (10 mcg EE)
Lybrel	365	0	0
*A partial list.
^†The tablets are chewable mint-flavored.
EE, ethinyl estradiol; EV, estradiol valerate; OCP, oral contraceptive pill.

TABLE 3
Noncontraceptive benefits—and risks—of OCPs

Benefits	Risks
Reduce dysmenorrhea Improve endometriosis Improve acne Reduce symptoms of PMS Suppress ovarian and breast cyst formation²⁰ Eliminate mittelschmerz Reduce risk of endometrial, ovarian, and colorectal cancers^32,33 Increase hemoglobin concentration by reducing menstrual flow²⁰ Lower incidence of ectopic pregnancy Lower incidence of benign breast disease Reduce risk of PID³⁴	CVD (especially in smokers >35 years of age) MI CVA cervical cancer VTE
CVA, cerebrovascular accident; CVD, cardiovascular disease; MI, myocardial infarction; OCPs, oral contraceptive pills; PID, pelvic inflammatory disease; PMS, premenstrual syndrome; VTE, venous thromboembolism.

TABLE 4
Cost of hormonal contraceptives

Hormonal contraceptive	Monthly cost	Yearly cost (52 weeks)
Combination pill (brand name)	$23-$60	$299-$780
Combination pill (generic)	$8	$96
Extended-cycle pill	$44-$58	$578-$753
Progestin-only pill	$19-$61	$377-$793
Transdermal patch	$90	$1080
Transvaginal suppository	$77	$924
Source: Epocrates.com. Accessed January 14, 2011.

Patient preferences, prescribing concerns

FAST TRACK

For a patient with a history of OCP use, a pill that was previously used is a reasonable starting point

In addition to considering OCP characteristics, patient-specific factors and preferences should be taken into account. Before you decide on a particular formulation, ask the patient whether she wishes to menstruate monthly, quarterly, or not at all (and explain that, even with continuous dosing, there will be some breakthrough bleeding). Patients should also be queried about any prior use of—and side effects or difficulty with—oral contraceptives.