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Oral ContraceptiveAka: Birth Control Pill

See Also
Epidemiology
1. United States: 18 million users
2. Average length of use: 4.8 months
3. Efficacy
  1. Typical use: 3-5% failure rate
  2. Perfect use: 0.1% failure rate
Benefits
1. Long Term benefits
  1. Ovarian Cancer risk decreased (30-50% reduction)
  2. Endometrial Cancer risk decreased (30-50% reduction)
  3. Fibrocystic breast disease decreased Incidence
  4. Acute Pelvic Inflammatory Disease risk decreased
2. Menses Effects
  1. Increased Menstrual Cycle regularity
  2. Decreased blood loss
  3. Decreased Incidence of Dysmenorrhea
  4. Endometriosis risk reduced
3. Ovulation Inhibition effects
  1. Decreased functional Ovarian Cysts
  2. Decreased Ectopic Pregnancy Incidence
Risks associated with Oral contraceptive use
1. Venous Thrombosis or Pulmonary Embolism
  1. Overall Relative Risk = 4
  2. Thromboembolism risk (per 10,000 person years)
    1. All women of child-bearing age: 1
    2. Levonorgestrel OCPs: 3-4
    3. Desogestrel and Gestodene OCPs confer a higher risk
      1. General: 6-8
      2. New users in first year: 10
    4. Drospirenone (Yasmin) may also have higher risk
      1. Sheldon (2002) BMJ 324:869
  3. References
2. Hemorrhagic Cerebrovascular Accident
  1. Tobacco abuse with Oral contraceptive: 3.6 Odds Ratio
3. Myocardial Infarction
  1. Progestin related effect and HDL effect
  2. Relative Risk
    1. Oral Contraceptive alone: 3
    2. Combined with Tobacco abuse: 10
  3. References
    1. Lewis (1996) BMJ 312:88
4. Breast Cancer
  1. Initial studies showed relative risk of 1.24
    1. No risk 10 years after stopping Oral contraceptive
    2. Lancet (1996) 347:1713
  2. Recent retrospective study shows no increased risk
    1. Marchbanks (2002) N Engl J Med 346:2025
Indications
1. Contraception
2. Menstrual irregularities
3. Endometriosis risk
4. Acne Vulgaris
Contraindications
1. Absolute (based on ACOG and WHO guidelines)
  1. Venous Thrombosis history or risk
  2. Vascular disease
    1. Coronary Artery Disease
    2. Cerebrovascular Accident
  3. Liver disease (e.g. Viral Hepatitis, Cirrhosis)
  4. Undiagnosed Vaginal Bleeding
  5. Pregnancy
  6. Breast Cancer
  7. Tobacco Use (>15 Cigarettes per day and over age 35)
    1. ACOG: Any Tobacco over age 35 is contraindication
2. Relative
  1. Hypertension
    1. Hypetension with vascular disease
    2. Systolic Blood Pressure >160 mmHg
    3. Diastolic Blood Pressure >99 mmHg
  2. Hyperlipidemia
    1. LDL Cholesterol >160 mg/dl
  3. Diabetes Mellitus with secondary complication
    1. Neuropathy
    2. Retinopathy
    3. Nephropathy
    4. Vascular Disease
    5. Diabetes Mellitus duration >20 years
  4. Postpartum <3 weeks
    1. Hypercoagulable state (risk of thromboembolism)
    2. Consider IUD or Progestin-only pill instead
  5. Lactation (first 6 weeks to 6 months)
    1. Adverse effect on quality and quantity of milk
    2. Adverse effect of newborn brain, liver development
  6. Migraine Headaches
    1. Focal neurologic symptoms
    2. Age over 35 years
  7. Long leg cast or other prolonged immobility
  8. Non-Compliance
    1. Consider weekly Contraceptive Patch
    2. Consider Depo Provera or Norplant
3. No significant increased risk with oral contraceptive
  1. Superficial Varicosities
  2. Bleeding Disorder
    1. OCP may be preventive in von Willebrand's
  3. Anticoagulation
  4. Sickle Cell Disease
  5. Obesity
  6. Hypertension (Controlled)
  7. Seizure disorder
  8. Organic heart disease or anticoagulant use
  9. Resolved Liver Disease
  10. Cervical Dysplasia or neoplasia
  11. Mitral Valve Prolapse (asymptomatic)
  12. Age over 35 years does not contraindicate OCP
    1. Choose agents with low Estrogen
    2. Monitor Blood Pressure and lipids
    3. Do not use if Cigarette use >10-15 per day
    4. Seibert (2003) Ann Intern Med 138:54
4. References
  1. Petitti (2003) N Engl J Med 349:1443
Adverse Effects
1. Estrogen
  1. Headache
  2. Nausea
  3. Hypertension
  4. Leg Pain
  5. Varicosity
2. Progestin
  1. Lipid abnormalities (lowers HDL-2)
3. Adverse effects not associated with oral contraceptives
  1. Weight gain is not significant
    1. Hordinsky (2000) Eighth World Congress Int Gyn Endo
Combined Contraceptive Formulations
1. Monophasic
2. Triphasic Progesterone
3. Triphasic Estrogens (20-35 ug)
Cycle Types
1. Standard: 21 days hormonal, 7 days hormone free
2. Extended: 24 day regimen, 4 days hormone free
3. Seasonal: 84 day regimen, 5-7 days hormone free
  1. See Seasonal Oral Contraceptive Cycle
Efficacy
1. High failure rate with P450 inducer medications
  1. Antiepileptic medications with 6% risk of pregnancy
  2. See Oral Contraceptive Drug Interactions
2. Higher oral contraceptive failure rate in obese women
  1. Weight over 70 kg: Relative risk of pregnancy 1.6
  2. Even higher risk with low Estrogen doses
  3. Holt (2002) Obstet Gynecol 99:820
Protocol: Starting the pill
1. Typical start (start at first sunday after Menses)
  1. Begin pill on first Sunday after onset of Menses
  2. If Menses start on Sunday, then start pill Day 1
    1. Use barrier Contraception for Days 1-7
  3. If pill started after Day 5:
    1. OCP may not suppress Ovulation for first cycle
    2. Use barrier Contraception for first month
2. Quick start (start at time other than post-Menses)
  1. Last menstrual period within last 5 days
    1. Start oral contraceptive now
    2. Use backup Contraception for 1 week
  2. Last menstrual period >5 days
    1. Obtain pregnacy test and if negative proceed
    2. No unprotected intercourse since LMP
      1. Start oral contraceptive
      2. Follow protocol as for LMP within 5 days
    3. Last unprotected intercourse was >5 days ago
      1. Counsel that urine Pregnancy Test not conclusive
      2. Can start oral contraceptive without fetal harm
    4. Unprotected intercourse within last 5 days
      1. Offer Emergency Contraception
      2. Follow protocol for last intercourse >5 days ago
  3. References
    1. Lesnewski (2006) Am Fam Physician 74:105
Protocol: Other
1. After first cycle:
  1. Start new pack 7 days after last active pill
2. If pill missed:
  1. One Pill Missed
    1. Take forgotten pill when remembered
    2. Take next pill as scheduled
  2. Two Pills Missed
    1. Take 2 per day for 2 days
    2. Use backup method of Contraception for cycle
  3. Three Pills Missed
    1. Discontinue pill and allow withdrawal bleed
    2. Resume pill after 1 week using new pack
3. If Vomited within 2 hours of taking pill
  1. Repeat pill and use backup method
Drug Interactions
1. See Oral Contraceptive Drug Interactions
References
1. Burkman (2001) Clin Obstet Gynecol 44(1):62
2. Cerel-Suhl (1999) Am Fam Physician 60(7):2073
3. Speroff (1993) Obstet Gynecol 81:1034
4. Dickey (1998) Managing Contraceptive Pill Patients

Contraceptives, Oral (C0009905)
Definition (MSH)	Compounds, usually hormonal, taken orally in order to block ovulation and prevent the occurrence of pregnancy. The hormones are generally estrogen or progesterone or both.
Concepts	Pharmacologic Substance (T121)
English	Birth control pill, birth control pills, oral contraceptive, Oral contraceptive agent, Oral contraceptive drug, Oral contraceptive pill, Oral contraceptive preparation, Oral contraceptives
Spanish	ACO, agente anticonceptivo oral, anticonceptivo oral, droga anticonceptiva oral, pÃldora anticonceptiva, pÃldora anticonceptiva oral, pÃldora para el control de la natalidad, pildora anticonceptiva, pildora anticonceptiva oral, pildora para el control de la natalidad
Credits	Derived from the NIH UMLS (Unified Medical Language System)

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Contraception Management

Endocrinology

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Oral ContraceptiveAka: Birth Control Pill

Contraceptives, Oral (C0009905)

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