History of Oral Contraceptives 2000 yrs ago - Arsenic, mercury, & strychnine 1920’s - Progesterone & estrogen isolated. 1935 - Progesterone synthesized. 1940’s - 50’s - Syntex: steroid synthesis 1950’s - Margaret Sanger - clinical trials 1960 - Enovid approved by FDA
Mechanisms of Oral Contraceptives Combination OCP: estrogen, progestin Inhibition of ovulation Thickened cervical mucous Endometrium less favorable for implantation Decreased tubal motility
Estrogen in OCP’s Ethinyl estradiol 20 30-35 - Most “low dose” OCP’s 50 Mestranol - converted to ethinyl estradiol 50
Progestins in OCP’s Varying progestational & androgenic potency 6 different progestins available in U.S. Newer progestins less androgenic?
Newer Progestins (‘92-’93) Norgestimate - OrthoCyclen, Tricyclen Desogestrel - OrthoCept, Desogen ‘95 UK warning VTE FDA, ACOG - no changes needed Gestodene - Not available in US
Newer Progestins: Advantages Decreased androgenicity Increased SHBG Decreased free testosterone Improved LDL:HDL ratio Best for hirsutism, acne
Triphasics vs. Monophasics Less total hormone per month No clear clinical advantage
Minor Side Effects of OCP’s Breakthrough bleeding Nausea Breast soreness Headache Weight gain - NOT!
Major Side Effects Cardiovascular Related to high estrogen content, early pills Venous thromboemboli, MI, CVA Hypertension 1-5%, reversible with DC Esp. >35 yrs & smoker Post-op thromboemboli: DC pills 4 wks pre-op
Major Side Effects Cancer Dec. risk of endometrial & ovarian ca. Breast & cervical ca. - no definitive inc. JAMA ‘01: +FH breast ca. & OCP’s Ô inc. risk of breast ca. BUT: Based on early hi dose pills Hepatocellular adenoma - benign, 3-4/100,000
Other Side Effects Lipid level changes - screen if hi risk Carbohydrate metabolism - follow diabetics Post-pill amenorrhea or infertility - disproven Congenital anomalies - disproven
Beneficial Effects of OCP’s Dec. acne Dec. dysmenorrhea Dec. ovarian cysts Dec. fibrocystic disease of the breast Dec. PID Dec. endometrial and ovarian ca.
Absolute Contraindications Thromboembolic disorders Coronary artery disease Estrogen-dependent neoplasia Breast Cancer Pregnancy Active liver disease Undiagnosed abnormal vaginal bleeding
Oral Contraceptives Summary Safe and effective for healthy adol. Use low estrogen pill (20-35 g) 28 day pack and Sunday start method Judicious advice about side effects Frequent follow-ups.
Progestin Only Methods The Minipill - daily pill Depo-Provera - injectable Norplant - subdermal implant
Progestin Only Pill Taken every day - no placebo pills Slightly less effective than combination pill; less forgiving of missed pill Indications - estrogen contraindication, lactation Disadvantages - unpredictable menses
Depo-Provera (Injectable Progestin) FDA approved 1992 Medroxyprogesterone acetate 150 mg. IM 1st injection within 1st 5 days of menses; neg Urine preg test Repeat q12 weeks ( up to 13.5 weeks) Cost: $50/dose
Depo-Provera Menstrual Changes Irregular menses Amenorrhea - 60% by 1 year Treatment of irregular bleeding: 1. Counseling 2. OCP 3. Ibuprofen 4. Estrogen
Depo-Provera Other Side Effects Weight gain - 2-5 lbs./yr. Delay to fertility - 9 mos. Depression Dec. libido Breast tenderness Decreased bone density - under study
NEW: Lunelle Combination injectable: Estrogen and progestin Given q28 days Advantage - regular menses Disadvantage - monthly visit
Subdermal Implants Norplant -FDA 1990, 6 levonorgestrel rods -Effective 5 years -Insertion and removal procedures -Bad publicity Implanon -Single rod, good for 3 years
Norplant Side Effects Irregular menses - greatest in 1st yr. Weight gain - less than Depo Headaches Acne Insertion site problems Depression Hair changes
Condoms Must always be recommended to prevent STD’s Latex or polyurethane only Reservoir-tipped, spermicide Effectiveness inc. with contraceptive foam Advantages: Safe, cheap, available Disadvantages: Coital dependent, male resistance
Condom Use 12-19 yr males 55% at first intercourse - Inc. from 20% in 1979 58% at last intercourse - Inc. from 21% in 1979 BUT - most teens use condoms sometimes
Spermicides Nonoxynol-9 Foam preferred When used with condoms, greatly inc. effectiveness.
Barrier Methods Diaphragm Sponge Cervical cap Lea’s shield
The Female Condom (1994) Polyurethane $3 each 5 - 25% failure Female controlled Cumbersome
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