1. Oral contraceptive pill – what for who? Mark Wilshere 2011

2. Content Introduction – the importance of the matter Types of oral contraception Oral contraception comparison Oestrogen/Progestogen/Androgen activity Tackling the side effect Summary

3. Introduction Pill is commonly used, especially in younger women Benefits include reliable contraception, easy to use, less bleeding, controls cycle, less painful periods Perceived negative effects include, nausea, headache, mood change, weight gain, irregular bleeding

4. Introduction Side-effects are an issue as compliance can subsequently be affected. Up to 20% of younger women may not take because the do not like it. 50% pregnancies in UK unintended 91% abortions funded by NHS 42% abortion rate in teenagers in 2001

5. Choice Very important Numerous to chose from Ethinylestradiol (standard) Progestin (variable) – oestrogen potency small if any

6. Combined 21 day standard strength COCP - 30-35mcg 21 & 7 day ED (Every Day) standard strength COCP – 30-35mcg for 21 days and 7 days of inactive pills 21 day low strength COCP – 20mcg

7. Ethinylestradiol 20mcg 21d monophasic Progestogen content BrandPrice (3 cycle pack) Desogestrel 150mcg Gedarel 20/150 Mercilon £5.98 £7.97 Gestodene 75mcg Femodette Millinette 20/75 Sunya 20/75 £8.85 £6.37 £6.62 Norethisterone acetate 1000mcg Loestrin 20£2.75

8. Ethinylestradiol 30mcg 21d monophasic Progestogen contentBrandPrice (3 cycle pack) Desogestrel 150mcgGadarel 30/150 Marvelon £4.93 £6.45 Drospirenone 3000mcgYasmin£14.70 Gestodene 75mcgFemodene Katya 30/75 Millinette 30/75 £6.73 £5.03 £4.85 Levonorgestrel 150mcgLevest Microgynon 30 Ovranette Rigevidon £2.55 £2.82 £2.20 £1.89 Norethisterone acetate 1500mcg Loestrin 30£3.95

9. Ethinylestradiol 35mcg 21d monophasic Progestogen contentBrandPrice (3 cycle pack) Norgestimate 250mcg Cilest£2.87 Norethisterone 500mcg Brevinor Ovysmen £1.99 £1.49 Norethisterone 1000mcg Norinyl-1£2.19

10. Ethinylestradiol 50mcg 21d monophasic Norethisterone 1000mcg Norinyl-1 £2.19

11. Ethinylestradiol 30mcg 28d monophasic Progestogen content BrandPrice (3 cycle pack) Gestodene 75mcg Femodene ED (21 active, 7 inactive) £6.73 Levonorgestrel 150mcg Microgynon ED (21 active, 7 inactive) £2.54

12. Ethinylestradiol Variable 21d phasic BrandEthinylestradiol dose/Progestogen (mcg) TabletsPrice Triadene (gestodene) 30 / 50 40 / 70 30 / 100 6 5 10 £8.99 Logynon OR TriRegol (levonorgestrel) 30 / 50 40 / 75 30 / 125 6 5 10 £3.96 £2.87 BiNovum (norethisterone) 35 / 500 35 / 1000 7 14 £1.96 Synphase (norethisterone) 35 / 500 35 / 1000 35 / 500 795795 £3.60 TriNovum (norethisterone) 35 / 500 35 / 750 35 / 1000 777777 £2.72

13. Ethinylestradiol Variable 28d ED phasic BrandEthinylestradiol dose/Progestog en (mcg) TabletsPrice Logynon ED (levonorgestrel) 30 / 50 40 / 75 30 / 125 6 active 5 active 10 active 7 inactive £3.82 Qlaira (estradiol / dianogest) 3mg / 0 2mg / 2mg 2mg / 3mg 1mg / 0 2 active 5 active 17 active 2 active 2 inactive £25.18

14. Progestogen only BrandProgestogenPrice per 3 pack CerazetteDesogestrel 75mcg£8.68 FemulenEtynodiol diacetate 500mcg £3.31 MicronorNorethisterone 350mcg £1.66 NoridayNorethisterone 350mcg £2.10 NorgestonLevonorgestrel 30mcg£2.76* (35 pack = £0.92 x3)

15. Oestrogen activity Higher number of micrograms of ethinyl estradiol lead to more potent estrogenic effects. A higher amount of estrogenic activity helps to decrease androgen- related side effects. However, progestins tend to counter some of the estrogenic effects of ethinyl estradiol.

16. Progestational Activity Each progestin has a different potency Hence the differences in doses Is possible to compare potency of progestins and their androgenic activity High androgenic activity associated with acne, hair growth etc

17. ProgestinProgestational ActivityAndrogenic Activity Norethindrone 1mg (control) 1.0 Norethrindrone acetate 1mg 1.21.6 Norgestimate 1mg1.31.9 Norelgestromin 1mg1.31.9 Ethynodiol diacetate 1mg 1.40.6 Drospirenone 1mg1.50.0 Dinorgestrel 1mg2.64.2 Levonorgestrel 1mg5.38.3 Desogestrel 1mg93.4

18. What pill? Need to consider; –Oestrogen dose –Progestin potency –Androgen potency

19. Side effect / problemSolutionSuggestions Acne↑o ↓aLoestrin 30, Brevinor, Ovysmenn, gadarel, marvelon, cilest, Yasmin (price) Break through bleed↑o ↑p ↓aGadarel 30/150, Marvelon, Gestodene/levoner containing Yasmin (price) Weight gain↓o ↓pLower O dose Breast soreness↓o ↓pLower O dose Severe cramps↑pHigher P potency Headaches↓o ↓pLower O dose, mercilon Depression, moody, irritable↓p?norethisterone based a/oligo-menorrhoea↑o ↓p Endometriosis↓o ↑p ↑aLevon, deso based

20. Progestogenic side effects Acne, hirtuism, vaginal dryness, wt gain, loss of libido, breast tenderness Try a pill with; –Less of same progestogen –Oestrogen dominant pill –Try different progestogen

21. Oestrogenic side effects Nausea, headache, dizziness, breast enlargement, cyclical wt gain, loss of libido Try a pill with; –Lower oestrogen content –Try progestogen dominant pill –Try progestogen only pill

22. Summary Numerous types of oral contraception available Vary in oestrogen content and progesterone / androgen activity Tailor to individual needs Trial and error may be needed and explained May be variance between individuals It takes about 2 cycles to see if suitable Studies lacking in comparison