A 28-year-old mother of two who often suffers from headaches has traveled two hours to reach the family planning clinic. She wants a contraceptive method that will help her delay the birth of another child and is considering combined oral contraceptives (COCs). She has steady work that involves a regular schedule and feels that she could consistently take pills each morning before work. She has heard from her friends that COCs will not cause any irregular bleeding that might interfere with her work. Would COC use be advisable in her case?
Unless she has risk factors for stroke, a woman experiencing headaches that are not migraines can safely initiate COC use. However, distinguishing severe headaches from migraines and evaluating any new headaches with aura (visual, auditory, olfactory, or other symptoms before pain onset) or marked changes in headaches is important. Thus, before COCs are prescribed, likely causes of the woman's headache should be explored and a diagnosis made. In the meantime, nonhormonal contraceptives such as condoms should be offered to her.
Women with a history of both migraine and COC use are two to four times more likely to have a stroke than women with a history of migraine alone, according to case-control studies that have examined COC use, history of migraine, and risk of stroke1 The World Health Organization's medical eligibility criteria state that women with migraines can safely use COCs as long as they do not have focal neurologic symptoms and are younger than 35 years.2 But COC initiation by women who are 35 years or older and have migraines (even those without focal neurologic symptoms) is not recommended. No woman experiencing migraines with focal neurologic symptoms (such as an aura) should use COCs.
DMPA Use by Adolescents
A 17-year-old, sexually active student wants a contraceptive that is discreet and convenient. After counseling, she chooses the progestin-only injectable depot-medroxyprogesterone acetate (DMPA). The method appeals to her because it is highly effective and requires only four clinic visits each year. But will DMPA be appropriate for this young client?
Women younger than 18 years can safely use DMPA, as the advantages of using the method generally outweigh the risks, according to the World Health Organization's medical eligibility criteria. However, bone demineralization occurs in DMPA users, especially those younger than 21 years.3 Extent of bone loss in the spine and proximal femur depends upon the duration of use, with bone loss occurring as early as the first three months of use and becoming magnified by 15 years of use and longer.4 Biochemical studies of bone resorption and formation have confirmed an association between DMPA use and bone loss.5 A marked increase in bone density, especially at the spine, occurs following discontinuation,6 but complete recovery may not occur in all bones. The adolescent years are the time of maximum bone deposition, and impairment of mineral deposition during this interval may have long-lasting effects. The concern is that women who have used DMPA as adolescents may enter menopause with a bone deficit and thus be more likely to suffer fractures than those who have not used the contraceptive method.
However, DMPA has several advantages for teenagers. Its use is discreet. Also, it offers long-term pregnancy protection, convenience, high effectiveness, and low cost.7 The disadvantages of unplanned adolescent pregnancy probably outweigh the potential risk of bone loss. This client should be told, however, that DMPA will not protect her from sexually transmitted infections (STIs). If she is at risk for STIs/HIV, she should consistently use — in addition to DMPA — a condom for STI protection.
Management for Missed COCs
An unmarried, 24-year-old woman comes to the family planning clinic for advice. She had been using combined oral contraceptives (COCs) regularly. But three days ago, she traveled out of town to see her sister and forgot to take her COCs with her. During that interval, she had unprotected sex and is now worried about becoming pregnant. Discuss your management options in this case.
The chance that pregnancy will occur depends not only on how many pills were missed (in this case, three) but also on when those pills were missed. If this woman missed taking three of the first seven active (hormonal) pills in a pack (days 1-7), she will be at risk of pregnancy and should be offered emergency contraception as an option that can prevent most pregnancies when administered correctly. She should abstain from sex or use additional contraceptive protection for the next seven days.
What to Do If You Miss One or More Pills
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Recommendations for the resumption of regular pill taking are the same whether the woman missed taking three of the first seven active pills in a pack (days 1-7), three of the middle seven active pills in a pack (days 8-14), or three of the last seven active pills in a pack (days 15-21). She should take the first missed pill as soon as possible (discarding the other two missed pills). She should then take the next pill at the usual time (even if this means taking two pills on the same day or at the same time) and continue taking the remaining pills daily. (If she missed taking three of the last seven active pills in a pack, she should discard the inactive pills and immediately begin using the next pack of pills.)8
Hormonals and Hypertension
A 34-year-old woman who delivered her second baby nine weeks ago comes to the family planning clinic wishing to delay the birth of a third child. She experienced severe preeclampsia during her pregnancy, and her blood pressure now is 165/115 mm Hg. This elevated pressure was confirmed by measurements repeated several weeks apart. She used an intrauterine device (IUD) in the past but discontinued it because it increased her menstrual bleeding. She thinks diaphragms and spermicides are messy, and her husband dislikes condoms. Can she use hormonal contraceptives?
Evidence is growing that, among women with a history of hypertension, combined oral contraceptive (COC) users have a higher risk of adverse cardiovascular events, such as stroke and heart attack, than non-users.9 As blood pressure increases, this risk increases. Because this client's blood pressure is quite elevated (exceeding 160/100 mm Hg), she should not use COCs or combined injectable contraceptives, according to the World Health Organization's medical eligibility criteria. The use of the progestin-only injectable depot-medroxyprogesterone acetate (DMPA) is not usually recommended, but progestin-only pills and subdermal implants can generally be used. For women with multiple risk factors for arterial cardiovascular disease — such as hypertension (blood pressure that exceeds 140/90 mm Hg), smoking, older age, history of cardiovascular disease, and diabetes — the same recommendations described above generally apply.10
Blood pressure measurements should be taken, if possible, before initiating the use of combined hormonal methods. The benefit of doing so has been demonstrated in various studies, including a World Health Organization collaborative, multicenter study involving users of low-dose COCs in developed and developing countries. In these studies, risks of ischemic stroke and heart attack were higher among women who did not have their blood pressure checked before starting COCs (a measure that would have screened out women with hypertension), compared with women who had their blood pressure checked.11 However, if blood pressure cannot be measured, women should not be denied use of hormonal methods. This is because the absolute risk of any adverse cardiovascular events in women of reproductive age is low; even among hypertensive women ages 20 to 24 years who use COCs, such adverse events are estimated to be only 312 per million woman-years.12 That risk is less than the risk associated with pregnancy and childbirth resulting from non-use of contraception, particularly in many resource-constrained settings.
Of note, however, this woman's blood pressure is dangerously high, meriting prompt evaluation and treatment.
COCs and Acne
An 18-year-old client seeks contraception at a family planning clinic. After family planning counseling, she opts for combined oral contraceptives (COCs), primarily for their convenience. The client, you notice, has marked facial acne. She explains that she began experiencing the acne about three months before and was just considering seeing a doctor for advice about treating it. Would COCs be advisable for contraception and also be helpful in controlling her acne?
Low-dose COCs not only serve for contraception but also reduce acne, a common dermatological problem for adolescents that can leave both psychological and physical scars. Acne can be treated by reducing the effect of androgen in the body,13 either directly (with anti-androgen) or indirectly (with estrogen). Estrogen reduces the availability of active free androgen by increasing sex hormone-binding globulin in the blood, and several randomized controlled trials have found COCs to improve acne when compared with placebos.14 Similarly, combinations of low-dose estrogens and such progestins as cyproterone or drospirenone are effective in treating acne and providing contraception at the same time.15
The questions above were answered by Dr. David Grimes, vice president of biomedical affairs at FHI, and Dr. Ayodele Arowojolu, an FHI clinical research fellow in contraceptive technology who is on leave from his position as senior lecturer/consultant in obstetrics and gynecology at the College of Medicine, University of Ibadan, Nigeria. The FHI fellowship program, based in Research Triangle Park, North Carolina, USA, aims to increase the number of qualified clinical researchers in contraceptive technology worldwide, and to establish a collegial relationship between FHI and the fellows' sponsor institutions.
References
Curtis KM, Chrisman CE, Peterson HB. Contraception for women in selected circumstances. Obstet Gynecol 2002;99(6):1100-12; Lidegaard O. Oral contraceptives, pregnancy and the risk of cerebral thromboembolism: the influence of diabetes, hypertension, migraine and previous thrombotic disease. Br J Obstet Gynaecol 1995;102(2):153-59; Chang CL, Donaghy M, Poulter N, et al. Migraine and stroke in young women: case-control study. BMJ 1999;318(7175):13-18; Tzourio C, Tehindrazanarivelo A, Iglésias S, et al. Case-control study of migraine and risk of ischemic stroke in young women. BMJ 1995;310(6983):830-33; Schwartz SM, Petitti DB, Siscovick DS, et al. Stroke and use of low-dose oral contraceptives in young women: a pooled analysis of two U.S. studies. Stroke 1998;29(11):2277-84.
World Health Organization. Improving Access to Quality Care in Family Planning. Medical Eligibility Criteria for Contraceptive Use. Geneva, Switzerland: World Health Organization, 2000.
Scholes D, LaCroix AZ, Ott SM, et al. Bone mineral density in women using depot medroxyprogesterone acetate for contraception. Obstet Gynecol 1999;93(2):233-38; Cundy T, Cornish J, Roberts H, et al. Spinal bone density in women using depot medroxyprogesterone contraception. Obstet Gynecol 1998;92(4 Pt 1):569-73; Cromer BA, Blair JM, Mahan JD, et al. A prospective comparison of bone density in adolescent girls receiving depot medroxyprogesterone acetate (Depo-Provera), levonorgestrel (Norplant), or oral contraceptives. J Pediatr 1996;129(5):671-76.
Scholes; Cundy.
Ott SM, Scholes D, LaCroix AZ, et al. Effects of contraceptive use on bone biochemical markers in young women. J Clin Endocrinol Metab 2001;86(1):179-85.
Scholes D, LaCroix AZ, Ichikawa LE, et al. Injectable hormone contraception and bone density: results from a prospective study. Epidemiology 2002;13(5):581-87.
Davis AJ. Use of depot medroxyprogesterone acetate contraception in adolescents. J Reprod Med 1996;41(5 Suppl):407-13.
World Health Organization. Selected Practice Recommendations for Contraceptive Use. Geneva, Switzerland: World Health Organization, 2002.
World Health Organization. Cardiovascular Disease and Steroid Hormone Contraception: Report of a WHO Scientific Group. WHO Technical Report Series 877. Geneva, Switzerland: World Health Organization, 1998.
World Health Organization. Improving Access to Quality Care in Family Planning.
Heinemann LA, Lewis MA, Spitzer WO, et al. Thromboembolic stroke in young women. Contraception 1998;57(1):29-37; Dunn N, Thorogood M, Faragher B, et al. Oral contraceptives and myocardial infarction: results of the MICA case-control study. BMJ 1999;318(7198):1579-84; WHO Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception. Ischaemic stroke and combined oral contraceptives: results of an international, multicentre, case-control study. Lancet 1996;348(9026):498-505.
Farley TM, Collins J, Schlesselman JJ. Hormonal contraception and risk of cardiovascular disease. Contraception 1998;57(3):211-30.
Slayden SM, Moran CM, Sams WM Jr, et al. Hyperandrogenemia in patients presenting with acne. Fertil Steril 2001;75(5):889-92.
Lucky AW, Henderson TA, Olson WH, et al. Effectiveness of norgestimate and ethinyl estradiol in treating moderate acne vulgaris. J Am Acad Dermatol 1997;37(5):746-54; Redmond GP. Effectiveness of oral contraceptives in the treatment of acne. Contraception 1998;58(3 Suppl):29S-33S; Thiboutot D, Archer DF, Lemay A, et al. A randomized, controlled trial of a low-dose contraceptive containing 20 µg of ethinyl estradiol and 100 µg of levonorgestrel for acne treatment. Fertil Steril 2001;76(3):461-68; Redmond GP, Olson WH, Lippman JS, et al. Norgestimate and ethinyl estradiol in the treatment of acne vulgaris: a randomized, placebo-controlled trial. Obstet Gynecol 1997;89(4):615-22.
van Vloten WA, van Haselen CW, van Zuuren EJ, et al. The effect of two combined oral contraceptives containing either drospirenone or cyproterone acetate on acne and seborrhea. Cutis 2002;69(4 Suppl):2-15.
