Ovarian function during low-dose oral contraceptive use

Pharmacodynamics of combined estrogen-progestin oral contraceptives 3. Inhibition of ovulation

INTRODUCTION

Following a historical overview, the ovulation-inhibiting effect of various orally administered estrogen-progestin combinations (combined oral contraceptives [COCs]) are examined for their components alone or in the various combined formulations. Special emphasis is given to products containing natural estrogens. Areas covered: Inhibition of ovulation with progestins alone; estrogens alone; various progestins in combination with ethinyl estradiol; various progestins in combination with natural estrogens (estradiol, estradiol valerate, and estetrol). Expert commentary: The original idea to achieve ovulation blockage through the administration of steroid hormones involved the use a progestogen (both progesterone and its synthetic homologous). The ability of a progestin to inhibit ovulation depends on the type of compound and on its dosage and a difference of more than 20-fold in activity exists between compounds utilized today in COCs. Initially, the estrogenic component was present only because it contaminated the first progestin utilized. It was soon found that an estrogen is necessary for proper cycle control. It was also found that the estrogen acts synergistically in inhibiting ovulation. For almost half a century, most COCs contained ethinyl estradiol. Today, also natural estrogens are being employed. Inhibition of ovulation was complete with all early high dose preparations. Decreasing dosage allowed some ovarian activity to occur, occasionally leading to a mature follicle. Even in this situation, defective corpus luteum formation assured contraceptive protection.

Oral contraceptive use and mortality after 36 years of follow-up in the Nurses' Health Study: prospective cohort study

OBJECTIVE

To determine whether use of oral contraceptives is associated with all cause and cause specific mortality.

DESIGN

Prospective cohort study.

SETTING

Nurses' Health Study, data collected between 1976 and 2012.

POPULATION

121,701 participants were prospectively followed for 36 years; lifetime oral contraceptive use was recorded biennially from 1976 to 1982.

MAIN OUTCOME MEASURES

Overall and cause specific mortality, assessed throughout follow-up until 2012. Cox proportional hazards models were used to calculate the relative risks of all cause and cause specific mortality associated with use of oral contraceptives.

RESULTS

In our population of 121,577 women with information on oral contraceptive use, 63,626 were never users (52%) and 57,951 were ever users (48%). After 3.6 million person years, we recorded 31,286 deaths. No association was observed between ever use of oral contraceptives and all cause mortality. However, violent or accidental deaths were more common among ever users (hazard ratio 1.20, 95% confidence interval 1.04 to 1.37). Longer duration of use was more strongly associated with certain causes of death, including premature mortality due to breast cancer (test for trend P<0.0001) and decreased mortality rates of ovarian cancer (P=0.002). Longer time since last use was also associated with certain outcomes, including a positive association with violent or accidental deaths (P=0.005).

CONCLUSIONS

All cause mortality did not differ significantly between women who had ever used oral contraceptives and never users. Oral contraceptive use was associated with certain causes of death, including increased rates of violent or accidental death and deaths due to breast cancer, whereas deaths due to ovarian cancer were less common among women who used oral contraceptives. These results pertain to earlier oral contraceptive formulations with higher hormone doses rather than the now more commonly used third and fourth generation formulations with lower estrogen doses.

Oral contraceptives for functional ovarian cysts

BACKGROUND

Functional ovarian cysts are a common gynecological problem among women of reproductive age worldwide. When large, persistent, or painful, these cysts may require operations, sometimes resulting in removal of the ovary. Since early oral contraceptives were associated with a reduced incidence of functional ovarian cysts, many clinicians inferred that birth control pills could be used to treat cysts as well. This became a common clinical practice in the early 1970s.

OBJECTIVES

This review examined all randomized controlled trials that studied oral contraceptives as therapy for functional ovarian cysts.

SEARCH METHODS

In March 2014, we searched the databases of CENTRAL, PubMed, EMBASE, and POPLINE, as well as clinical trials databases (ClinicalTrials.gov and ICTRP). We also examined the reference lists of articles. For the initial review, we wrote to authors of identified trials to seek articles we had missed.

SELECTION CRITERIA

We included randomized controlled trials in any language that included oral contraceptives used for treatment and not prevention of functional ovarian cysts. Criteria for diagnosis of cysts were those used by authors of trials.

DATA COLLECTION AND ANALYSIS

Two authors independently abstracted data from the articles. One entered the data into RevMan and a second verified accuracy of data entry. For dichotomous outcomes, we computed the Mantel-Haenszel odds ratio with 95% confidence interval (CI). For continuous outcomes, we calculated the mean difference with 95% CI.

MAIN RESULTS

We identified eight randomized controlled trials from four countries; the studies included a total of 686 women. Treatment with combined oral contraceptives did not hasten resolution of functional ovarian cysts in any trial. This held true for cysts that occurred spontaneously as well as those that developed after ovulation induction. Most cysts resolved without treatment within a few cycles; persistent cysts tended to be pathological (e.g., endometrioma or para-ovarian cyst) and not physiological.

AUTHORS' CONCLUSIONS

Although widely used for treating functional ovarian cysts, combined oral contraceptives appear to be of no benefit. Watchful waiting for two or three cycles is appropriate. Should cysts persist, surgical management is often indicated.

Comparison of cervical mucus of 24/4 vs. 21/7 combined oral contraceptives

BACKGROUND

Few studies have examined the action of combined oral contraceptives (COCs) on cervical mucus. We hypothesized that midcycle cervical mucus of women taking COCs is of poor quality when compared to their own midcycle mucus prior to initiating COCs. We sought to compare the effect upon quality and sperm penetration of the cervical mucus on the last hormone-free day with a 24/4 regimen to a 21/7 regimen.

METHODS

This is an open-label, investigator-blinded, randomized, controlled, crossover equivalency study. All subjects received, in random order, 2 months of a 21/7 regimen and 2 months of a 24/4 regimen, each containing 20 mcg ethinyl estradiol and 1 mg norethindrone acetate. Analysis of cervical mucus quality (CMQ) and sperm penetration took place midcycle and on the last day of the hormone-free interval during the second month of each COC treatment.

RESULTS

From April 2010 to November 2011, 18 subjects completed all study visits. Mean midcycle CMQ was poor (mean CMQ=1) and did not differ between 24/4 and 21/7 regimens (p=.92). On the last day of the pill-free interval, the quality and sperm penetration were poor with both regimens.

CONCLUSION

This study indicates that thickening of cervical mucus is a major mechanism of contraceptive action of COCs and that both 21/7 and 24/4 regimens result in poor quality and impenetrable mucus on the last day of the pill-free interval.

The state of hormonal contraception today: established and emerging noncontraceptive health benefits

In the 50 years since the advent of combined oral contraceptives the amount of estrogen in oral contraceptives dropped from over 100 mcg to less than 30 mcg. Many noncontraceptive health benefits have emerged that decrease mortality and improve quality of life. Some of the immediate benefits include improvement of menorrhagia and dysmenorrhea, reduction in premenstrual dysphoric disorder symptoms, and decreased acne. As an effective birth control method oral contraceptives also decrease pregnancy-related deaths by preventing pregnancy. After the reproductive years, previous use of oral contraceptives continues to be beneficial, reducing the risk of death from ovarian and endometrial cancer. All these benefits have held up over time whereas cardiovascular risks have lessened because of the decrease in oral contraceptive pill dosage. Decreased ovarian cyst formation is an example of benefit with higher-dose oral contraceptive formulations that no longer holds true with low-dose pills.

Oral contraceptives for functional ovarian cysts

BACKGROUND

Functional ovarian cysts are a common gynecological problem among women of reproductive age worldwide. When large, persistent, or painful, these cysts may require operations, sometimes resulting in removal of the ovary. Since early oral contraceptives were associated with a reduced incidence of functional ovarian cysts, many clinicians inferred that birth control pills could be used to treat cysts as well. This became a common clinical practice in the early 1970s.

OBJECTIVES

This review examined all randomized controlled trials that studied oral contraceptives as therapy for functional ovarian cysts.

SEARCH STRATEGY

We searched the databases of CENTRAL, MEDLINE, POPLINE, and EMBASE, as well as clinical trials databases (ClinicalTrials.gov and ICTRP). We also examined the reference lists of articles and wrote to authors of identified trials to seek articles we had missed.

SELECTION CRITERIA

We included randomized controlled trials in any language that included oral contraceptives used for treatment and not prevention of functional ovarian cysts. Criteria for diagnosis of cysts were those used by authors of trials.

DATA COLLECTION AND ANALYSIS

Two authors independently abstracted data from the articles. One entered the data into RevMan and a second verified accuracy of data entry. For dichotomous outcomes, we computed the Mantel-Haenszel odds ratio with 95% confidence interval (CI). For continuous outcomes, we calculated the mean difference with 95% CI.

MAIN RESULTS

We identified eight randomized controlled trials from four countries; the studies included a total of 686 women. Treatment with combined oral contraceptives did not hasten resolution of functional ovarian cysts in any trial. This held true for cysts that occurred spontaneously as well as those that developed after ovulation induction. Most cysts resolved without treatment within a few cycles; persistent cysts tended to be pathological (e.g., endometrioma or para-ovarian cyst) and not physiological.

AUTHORS' CONCLUSIONS

Although widely used for treating functional ovarian cysts, combined oral contraceptives appear to be of no benefit. Watchful waiting for two or three cycles is appropriate. Should cysts persist, surgical management is often indicated.

Studying the use of oral contraception: a review of measurement approaches

BACKGROUND

Although oral contraception (OC) misuse is presumed to play an important role in unwanted pregnancy, research findings have often been equivocal, perhaps reflecting unaddressed inconsistencies in methodological approaches.

METHODS

Using established databases, we performed a systematic review of measurement methods for OC use using primary research reports published from January 1965 to December 2009.

RESULTS

Terminology used to describe OC use, which included "continuation," "compliance," and "adherence," differed across studies and was rarely defined. The majority of studies (n = 27 of 38, 71%) relied solely on self-report measures of OC use. Only two reports described survey or interview questions, and reliability and validity data were seldom described. More rigorous measurement methods, such as pill counts (electronic or manual), serum and urinary biomarkers, and pharmacy records, were infrequently employed. Nineteen studies simultaneously used more than one method, but only three studies compared direct and indirect methods.

CONCLUSIONS

The lack of a consistent, well-defined measurement of OC use limits our understanding of contraceptive misuse and related negative outcomes. Future research should clarify terminology, develop standardized measures, incorporate multimethod approaches with innovative methods, and publish details of measurement methods.

Oral contraceptives for functional ovarian cysts

BACKGROUND

Functional ovarian cysts are a common gynecological problem among women of reproductive age worldwide. When large, persistent, or painful, these cysts may require operations, sometimes resulting in removal of the ovary. Since early oral contraceptives were associated with a reduced incidence of functional ovarian cysts, many clinicians inferred that birth control pills could be used to treat cysts as well. This became a common clinical practice in the early 1970s.

OBJECTIVES

This review examined all randomized controlled trials that studied oral contraceptives as therapy for functional ovarian cysts.

SEARCH STRATEGY

We searched the databases of CENTRAL, MEDLINE, POPLINE, and EMBASE, as well as clinical trials databases (ClinicalTrials.gov and ICTRP). We also examined the reference lists of articles and wrote to authors of identified trials to seek articles we had missed.

SELECTION CRITERIA

We included randomized controlled trials in any language that included oral contraceptives used for treatment and not prevention of functional ovarian cysts. Criteria for diagnosis of cysts were those used by authors of trials.

DATA COLLECTION AND ANALYSIS

Two authors independently abstracted data from the articles. One entered the data into RevMan and a second verified accuracy of data entry. For dichotomous outcomes, we used Peto odds ratios with 95% confidence intervals (CI). For continuous outcomes, we calculated mean differences with 95% CI.

MAIN RESULTS

We identified seven randomized controlled trials from four countries; the studies included a total of 500 women. Treatment with combined oral contraceptives did not hasten resolution of functional ovarian cysts in any trial. This held true for cysts that occurred spontaneously as well as those that developed after ovulation induction. Most cysts resolved without treatment within a few cycles; persistent cysts tended to be pathological (e.g., endometrioma or para-ovarian cyst) and not physiological.

AUTHORS' CONCLUSIONS

Although widely used for treating functional ovarian cysts, combined oral contraceptives appear to be of no benefit. Watchful waiting for two or three cycles is appropriate. Should cysts persist, surgical management is often indicated.

Missed hormonal contraceptives: new recommendations

OBJECTIVE

To provide evidence-based guidance for women and their health care providers on the management of missed or delayed hormonal contraceptive doses in order to prevent unintended pregnancy.

EVIDENCE

Medline, PubMed, and the Cochrane Database were searched for articles published in English, from 1974 to 2007, about hormonal contraceptive methods that are available in Canada and that may be missed or delayed. Relevant publications and position papers from appropriate reproductive health and family planning organizations were also reviewed. The quality of evidence is rated using the criteria developed by the Canadian Task Force on Preventive Health Care.

BENEFITS, HARMS, AND COSTS

This committee opinion will help health care providers offer clear information to women who have not been adherent in using hormonal contraception with the purpose of preventing unintended pregnancy.

SPONSORS

The Society of Obstetricians and Gynaecologists of Canada. SUMMARY STATEMENTS: 1. Instructions for what women should do when they miss hormonal contraception have been complex and women do not understand them correctly. (I) 2. The highest risk of ovulation occurs when the hormone-free interval is prolonged for more than seven days, either by delaying the start of combined hormonal contraceptives or by missing active hormone doses during the first or third weeks of combined oral contraceptives. (II) Ovulation rarely occurs after seven consecutive days of combined oral contraceptive use. (II) RECOMMENDATIONS: 1. Health care providers should give clear, simple instructions, both written and oral, on missed hormonal contraceptive pills as part of contraceptive counselling. (III-A) 2. Health care providers should provide women with telephone/electronic resources for reference in the event of missed or delayed hormonal contraceptives. (III-A) 3. In order to avoid an increased risk of unintended pregnancy, the hormone-free interval should not exceed seven days in combined hormonal contraceptive users. (II-A) 4. Back-up contraception should be used after one missed dose in the first week of hormones until seven consecutive days of correct hormone use are established. In the case of missed combined hormonal contraceptives in the second or third week of hormones, the hormone-free interval should be eliminated for that cycle. (III-A) 5. Emergency contraception and back-up contraception may be required in some instances of missed hormonal contraceptives, in particular when the hormone-free interval has been extended for more than seven days. (III-A) 6. Back-up contraception should be used when three or more consecutive doses/days of combined hormonal contraceptives are missed in the second and third week until seven consecutive days of correct hormone use are established. For practical reasons, the scheduled hormone-free interval should be eliminated in these cases. (II-A) 7. Emergency contraception is rarely indicated for missed combined hormonal contraceptives in the second or third week of the cycle unless there are repeated omissions or failure to institute back-up contraception after the missed doses. In cases of repeated omissions of combined hormonal contraceptives, emergency contraception may be required, and back-up contraception should be used. Health care professionals should counsel women in these situations on alternative methods of contraception that do not demand such stringent compliance. (III-A).

20 microg versus >20 microg estrogen combined oral contraceptives for contraception

BACKGROUND

Concern about estrogen-related adverse effects has led to progressive reductions in the estrogen dose in combination oral contraceptives (COCs). However, reducing the amount of estrogen to improve safety could result in decreased contraceptive effectiveness and unacceptable changes in bleeding patterns.

OBJECTIVES

To test the hypothesis that COCs containing </=20 microg ethinyl estradiol (EE) perform similarly as those containing >20 microg in terms of contraceptive effectiveness, bleeding patterns, discontinuation, and side effects.

SEARCH STRATEGY

We searched computerized databases (CENTRAL, MEDLINE, EMBASE, and POPLINE) up to January 2008, and searched the references of eligible trials. We wrote to oral contraceptive manufacturers to identify eligible trials.

SELECTION CRITERIA

English-language reports of randomized controlled trials were eligible that compare a COC containing </=20 microg EE with a COC containing >20 microg EE. We excluded studies where the interventions were designed to be administered for less than three consecutive cycles or to be used primarily as treatment for non-contraceptive conditions. Trials had to report on contraceptive effectiveness, bleeding patterns, trial discontinuation due to bleeding-related reasons or other side effects, or side effects to be included in the review.

DATA COLLECTION AND ANALYSIS

The primary reviewer evaluated all titles and abstracts located in the literature searches to determine whether they met the inclusion criteria. Two reviewers independently extracted data from the studies identified for inclusion. We wrote to the authors when clarifications or additional data were needed. Data were entered and analyzed with RevMan 4.2.

MAIN RESULTS

No differences were found in contraceptive effectiveness for the 13 COC pairs for which this outcome was reported. Compared to the higher-estrogen pills, several COCs containing 20 microg EE resulted in higher rates of early trial discontinuation (overall and due to adverse events such as irregular bleeding) as well as increased risk of bleeding disturbances (both amenorrhea or infrequent bleeding and irregular, prolonged, frequent bleeding, or breakthrough bleeding or spotting).

AUTHORS' CONCLUSIONS

While COCs containing 20 microg EE may be theoretically safer, this review did not focus on the rare events required to assess this hypothesis. Data from existing randomized controlled trials are inadequate to detect possible differences in contraceptive effectiveness. Low-dose estrogen COCs resulted in higher rates of bleeding pattern disruptions. However, most trials compared COCs containing different progestin types, and changes in bleeding patterns could be related to progestin type as well as estrogen dose. Higher follow-up rates are essential for meaningful interpretation of results.

Menstrual-cycle-related symptoms: a review of the rationale for continuous use of oral contraceptives

As many as 80% of reproductive-aged women experience physical changes associated with menstruation, and 20% to 40% experience menstrual-cycle-related symptoms. Decades of research in women with menstrual disorders, such as dysmenorrhea and menorrhagia, have shown that continuous use of oral contraceptives (OCs), without the hormone-free interval, is a safe and effective method to relieve these symptoms and ultimately induce amenorrhea in many women. If given the opportunity, a majority of women would opt for extended-cycle or continuous regimens, and numerous clinical trials have shown that continuous OC regimens induce amenorrhea in 80% to 100% of women by 10 to 12 months of use. For women who do not wish to become pregnant, a continuous OC regimen should be an available option.

Oral contraceptives for functional ovarian cysts

BACKGROUND

Functional ovarian cysts are a common gynecological problem among women of reproductive age worldwide. When large, persistent, or painful, these cysts may require operations, sometimes resulting in removal of the ovary. Since early oral contraceptives were associated with a reduced incidence of functional ovarian cysts, many clinicians inferred that birth control pills could be used to treat cysts as well. This became a common clinical practice in the early 1970s.

OBJECTIVES

This review examined all randomized controlled trials that studied oral contraceptives as therapy for functional ovarian cysts.

SEARCH STRATEGY

We searched the computer databases of CENTRAL, PubMed, POPLINE, and EMBASE for randomized controlled trials. We also examined the reference lists of articles and wrote to authors of all studies identified to seek articles we had missed.

SELECTION CRITERIA

We included randomized controlled trials in any language that included oral contraceptives used for treatment and not prevention of functional ovarian cysts. Criteria for diagnosis of cysts were those used by authors of studies.

DATA COLLECTION AND ANALYSIS

Two authors independently abstracted data from the articles and entered them into RevMan 4.2. We used Peto odds ratios with 95% confidence intervals for dichotomous outcomes.

MAIN RESULTS

We identified four randomized controlled trials from three countries; the studies included a total of 227 women. Treatment with combined oral contraceptives did not hasten resolution of functional ovarian cysts in any trial. This held true for cysts that occurred spontaneously as well as those that developed after ovulation induction. Most cysts resolved without treatment within a few cycles; persistent cysts tended to be pathological (e.g., endometrioma or para-ovarian cyst) and not physiological.

AUTHORS' CONCLUSIONS

Although widely used for treating functional ovarian cysts, combined oral contraceptives appear to be of no benefit. Watchful waiting over several cycles is appropriate. Should cysts persist, surgical management is often indicated.

Effects of oral contraceptives administered at defined stages of ovarian follicular development

OBJECTIVE

To elucidate the effects of initiating oral contraceptives (OC) at defined stages of ovarian follicle development.

DESIGN

Prospective longitudinal study.

SETTING

Healthy volunteers in an academic research environment.

PATIENT(S)

Forty-five healthy women between the ages of 18 and 35 years, randomized to initiate OC when a follicle diameter of 10, 14, or 18 mm was first detected.

INTERVENTION(S)

The OC administration at defined stages of dominant follicle development.

MAIN OUTCOME MEASURE(S)

Fates of all dominant follicles and serum concentrations of E(2)-17beta, LH, and P before and after initiating OC.

RESULT(S)

No ovulations (0/16) were observed when OC use was initiated at a follicle diameter of 10 mm, 4/14 (29%) follicles ovulated when OC were initiated at 14 mm, and 14/15 (93%) ovulated when OC were initiated at 18 mm. When ovulation did not occur, follicles regressed or became anovulatory cysts. Peak LH and E(2) levels were lowest in the 10-mm group, moderate in the 14-mm group, and greatest in the 18-mm group. Peak endocrine levels in all treatment groups were lower than the historic reference group.

CONCLUSION(S)

Follicular development, ovulation, and endocrine concentrations were not suppressed effectively when OC were initiated at late stages of dominant follicle development.

20 mcg versus >20 mcg estrogen combined oral contraceptives for contraception

BACKGROUND

Concern about estrogen-related adverse effects has led to progressive reductions in the estrogen dose in combination oral contraceptives (COCs). However, reducing the amount of estrogen to improve safety also could result in decreased contraceptive effectiveness and unacceptable changes in bleeding patterns.

OBJECTIVES

To test the hypothesis that COCs containing </=20 mcg ethinyl estradiol (EE) perform similarly as those containing >20 mcg in terms of contraceptive effectiveness, bleeding patterns, discontinuation, and side effects.

SEARCH STRATEGY

We searched computerized databases (CENTRAL, MEDLINE, EMBASE, and POPLINE) from their inception to November 2003, searched the references of eligible trials, and wrote to oral contraceptive manufacturers to identify eligible trials.

SELECTION CRITERIA

English-language reports of randomized controlled trials that compare a COC containing </=20 mcg EE with a COC containing >20 mcg EE were eligible. We excluded studies where the interventions were designed to be administered for less than three consecutive cycles or to be used primarily as treatment for non-contraceptive conditions. Trials had to report on contraceptive effectiveness, bleeding patterns, trial discontinuation due to bleeding-related reasons or other side effects, or side effects to be included in the review.

DATA COLLECTION AND ANALYSIS

The primary reviewer evaluated all titles and abstracts located in the literature searches to determine whether they met the inclusion criteria. Two reviewers independently extracted data from the studies identified for inclusion. We wrote to the authors when clarifications or additional data were needed. Data were entered and analyzed with RevMan 4.2.

MAIN RESULTS

No differences were found in contraceptive effectiveness for the 11 COC pairs for which this outcome was reported. Several COCs containing 20 mcg EE resulted in higher rates of early trial discontinuation (overall and due to adverse events such as irregular bleeding) as well as increased risk of bleeding disturbances (both amenorrhea/infrequent bleeding and irregular, prolonged, frequent bleeding, or breakthrough bleeding or spotting) than their higher-estrogen comparison pills.

AUTHORS' CONCLUSIONS

While COCs containing 20 mcg EE may be theoretically safer, this review did not focus on the rare events required to assess this hypothesis. Data from randomized controlled trials are inadequate to detect possible differences in contraceptive effectiveness. Low-dose estrogen COCs resulted in higher rates of bleeding pattern disruptions. However, most trials compared COCs containing different progestin types, and changes in bleeding patterns could be related to progestin type as well as estrogen dose.

Hormonal Contraception and Physiology: A Research-based Theory of Discontinuation Due to Side Effects

Side effects influence the acceptability and continuation of hormonal contraceptives. Counseling the client about the management of side effects is a principal approach advocated for increasing continuation. Evidence of a biological basis for variation in women's tolerance of hormonal contraceptives argues, however, that greater attention should be given to altering the product rather than principally attempting to alter a woman's ability to deal with the product. Discontinuation rates for hormonal contraceptives, largely attributable to side effects and health concerns, are high in nearly all less-developed countries for which Demographic and Health Survey data are available. Oral contraceptives appear to be particularly problematic for Latin American women, most notably in Bolivia. Clinical trials suggest substantial variation in the physiological response to exogenous hormones, and new evidence confirms the hypothesis that the normal hormonal profiles of Bolivian women are significantly lower than those of women in the United States. These findings suggest a need for more population-specific physiological research linked to analyses of the possible association between endogenous hormone differences and contraceptive continuation. Appropriately adjusting the level of the steroid delivered may benefit women's health and improve the acceptability and continuation of hormonal contraceptives.

Ovarian follicular development is initiated during the hormone-free interval of oral contraceptive use

We evaluated ovarian follicular development in women during compliant use of oral contraceptives (OC). Thirty-six healthy women received: [35 microg ethinyl estradiol (21)/180 microg norgestimate (7), 215 microg norgestimate (7), 250 microg norgestimate (7)]; [30 microg ethinyl estradiol (21)/150 microg desogestrel (21)]; or [20 microg ethinyl estradiol (21)/100 microg levonorgestrel (21)] for 3 consecutive 28-day cycles. Transvaginal ultrasonography was performed every third day to monitor follicular development. If a follicle reached > or = 14 mm, ultrasonography was performed daily and blood drawn every other day to determine estradiol-17beta concentrations. Seventeen of 36 women (47%) grew follicles > or = 10 mm. Nine of the 17 women (53%) grew follicles > or = 14 mm, in association with increased serum concentrations of estradiol-17beta. Thirty-seven of 43 follicles > or = 10 mm (86%) emerged during the hormone-free interval (HFI). No ovulations were observed. Our results supported the hypothesis that follicular development to an ostensibly ovulatory diameter occurs during compliant OC use, in association with loss of endocrine suppression during the HFI.

Ovarian follicular development during the use of oral contraception: a review

Over the past 40 years, alterations to the composition of oral contraceptives (OCs) have been made in attempts to reduce adverse effects and to improve patient compliance while maintaining contraceptive efficacy. However, there is growing evidence to indicate that reducing the estrogen dose to minimize adverse effects may have compromised the degree of hypothalamo-pituitary-ovarian suppression, particularly during the hormone-free interval (HFI) or following missed doses. Follicle development during OC use appears to occur in association with a loss of endocrine suppression during the HFI. This information provides a rationale for reducing or eliminating the HFI in OC regimens. There is also evidence for an increased risk of follicle development and ovulation in women who use delayed OC initiation schemes, such as the "Sunday Start" method. It is not currently known why some follicles ovulate during OC use while others regress or form anovulatory follicle cysts. Continued research about follicle development during OC use would provide insight into understanding the precise mechanisms of action underlying combined OCs, as well as those of continuous OC formulations and emergency contraceptive regimens.

Bleeding patterns and patient acceptability of standard or continuous dosing regimens of a low-dose oral contraceptive: a randomized trial

The purpose of this study is to compare bleeding patterns and acceptability of a contraceptive regimen of combined 20 microg ethinyl estradiol/100 microg levonorgestrel taken with and without a hormone-free interval. Thirty-two women desiring oral contraception were randomized to six 28-day cycles (standard group) or 168 days without a pill-free interval (continuous group). Participants kept a daily bleeding calendar documenting bleeding events (none, spotting or required sanitary protection) and side effects (headache, nausea, breast tenderness, depression, premenstrual syndrome and bloating). Primary outcome was number of bleeding days. Secondary outcomes included bleeding days requiring sanitary protection, amenorrhea, patient acceptability of bleeding patterns, method satisfaction and affective side effects. There were no differences in the baseline characteristics of the two groups. Although total bleeding days were fewer in the continuous group (mean = 25.9 vs. 34.9 days), this result did not reach statistical significance. However, women in the continuous group reported significantly fewer bleeding days that required protection (18.4 vs. 33.8 days, p < 0.01), and were more likely to have amenorrhea. Although both groups reported a high level of satisfaction with bleeding patterns and side effect profiles, women in the continuous group reported significantly fewer days of bloating (0.7 vs. 11.1 days, p = 0.04), and menstrual pain (1.9 vs. 13.3 days, p < 0.01). Continuous use of 20 microg ethinyl estradiol/100 microg levonorgestrel is associated with less bleeding requiring protection, and more amenorrhea than standard administration. Taken with or without a hormone-free interval, this oral contraceptive formulation is highly acceptable with regard to bleeding patterns and side effect profile. The continuous group had fewer light and moderate bleeding days, less bloating and menstrual pain. For patients who are seeking these results, this method may be more desirable.

St. John's wort and oral contraceptives: reasons for concern?

St. John's wort (Hypericum perforatum) is one of the best-selling herbal remedies in the United States. It has been implicated as an inducer of the P450 enzyme system, and as such, may cause increased metabolism of certain drugs, including oral contraceptives. Women using oral contraceptives have been warned against using St. John's wort. To date, there are some case reports but little clinical data demonstrating risk of contraceptive failure if they do. This article reviews available data and discusses theoretical reasons for concern about possible drug-herb interactions.

Functional ovarian cysts in premenopausal and gynecologically healthy women

The present study describes 29 women coincidentally found to have ovarian cysts while participating in a cross-sectional study. The prevalence of functional ovarian cysts is determined. In this study, 428 women, aged 14-45 years, were examined by transvaginal ultrasonography. The women were gynecologically healthy and were using either no contraception, intrauterine contraceptive devices, none of which were hormone releasing, or oral contraception (OC). Cysts were defined as cystic spaces larger than 30 mm. All women were asymptomatic and regularly menstruating.The prevalence of ovarian cysts was lower for women using OC than for women using no contraception or using intrauterine contraceptive devices. The relative risk (measured as the prevalence proportion ratio) of having an ovarian cyst when using OC was 0.22 (CI: 0.13-0.39), compared to women not using OC. No difference was found in the prevalence of ovarian cysts between women using intrauterine contraceptive devices and women using no contraception. The prevalence of ovarian cyst increased throughout the menstrual cycle in women not using OC. This relation was not found in the group of users of OC. The majority of the cysts resolved within the first few days of menstruation. Sixty-five percent of the cysts persisting after menstruation had resolved at the first control examination 3 months later, independently of use of OC. Low-dose monophasic contraceptive pills seem to have a protective effect against development of functional ovarian cysts, independent of the type of gestagen and the dose of ethinylestradiol used. Ovarian cysts resolved independently of treatment with OC. The use of intrauterine contraceptive device had no influence on the occurrence of functional ovarian cysts.

Current perspectives on oral contraceptive use

Oral contraceptives are one of the most highly effective forms of contraception and provide many short- and long-term noncontraceptive health benefits. They control menstrual cycle irregularities, such as breakthrough bleeding and amenorrhea, and are effective in treating dysfunctional uterine bleeding. In addition, for decades after oral contraceptive use is discontinued they are associated with substantial decreases in the risk of ovarian cancer (up to 80%) and of endometrial cancer (40%-50%), and nearly eliminate benign functional ovarian cysts. Long-term oral contraceptive use confers protection against benign breast disease and colorectal cancer, may help prevent rheumatoid arthritis, decreases ectopic pregnancy and hospitalizations for pelvic inflammatory disease, and helps preserve bone mineral density to reduce risk of fractures. Large bodies of evidence from extensive research have clarified the perceived association of oral contraceptive use with cardiovascular disease and with breast cancer. Findings indicate that there is no increased risk of myocardial infarction or stroke associated with oral contraceptive use in healthy, nonsmoking, normotensive women. Although there is a 3- to 4-fold increased risk of venous thromboembolism with current oral contraceptive use, the absolute risk is very small and is half that associated with pregnancy. Women of all reproductive ages, including perimenopausal women, can realize many health benefits through oral contraceptive use, including improved health status later in life.

Prescribing and managing oral contraceptive pills and emergency contraception for adolescents

Combination OCPs are safe and effective ways to prevent unintended adolescent pregnancy if they are used properly. Numerous noncontraceptive benefits of OCPs can bolster continued combination OCP use. Progestin-only OCPs are an option, particularly for young women with medical contraindications to taking estrogens; however, because of their lower efficacy, progestin-only pills are not the first choice for oral contraception for adolescents. Health care providers can give young women a second chance to prevent unintended pregnancy by improving their access to emergency contraception through educating and counseling about emergency contraception at all office visits, by prescribing emergency contraceptive pills in advance, or by prescribing emergency contraceptive pills over the telephone.

Evaluation of adnexal masses in adolescents

The detection of adnexal masses in adolescents is worrisome to patients, their families, and physicians. Reassurance can be given that the vast majority of these lesions are benign. Furthermore, a significant fraction of benign masses are functional ovarian cysts, most of which resolve spontaneously and never need surgery. Imaging is critical in determining the management of these patients. Sonography is the preferred first-line diagnostic tool. When surgery is necessary, physicians must recognize the importance of conserving the ovaries and uterus to avoid the loss of reproductive and endocrine function.

Low dose oral contraceptives and quality of life

This study investigated the effects of a low dose oral contraceptive (OC) (Mercilon) on women's satisfaction and quality of life based on a detailed questionnaire. A total of 614 first-time users of oral contraceptives were enrolled by 102 gynecologists for a treatment period of > or = 4 months. The Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) was filled in both before and during pill intake. The total quality of life score was significantly increased under OC intake. In contrast to older preparations, modern low dose OCs appear to act favorably on a number of psychological parameters, thus increasing satisfaction with various aspects of daily life and, consequently, improving quality of life.

Ovarian cysts in the pediatric population

With the widespread availability and use of pelvic sonography, the rate at which ovarian cysts are detected in the pediatric population has increased, and such cysts are an important problem encountered in pediatric surgical practice. Rational management should take into account key factors such as symptoms, patient age, menarchal status, cysts size, and character, as well as associated medical conditions. The purpose of this review is to discuss the incidence and pathophysiology of ovarian cysts in children. A management strategy is presented based on the above-mentioned key factors.

The effects of monophasic and triphasic oral contraceptives on ovarian function and endometrial thickness

OBJECTIVE

To analyze and compare the effects of seven low-dose oral contraceptives (OCs) on ovarian function and endometrial thickness.

METHODS

Cross-sectional study of users of one of five monophasic OCs, one of two triphasic OCs and a control group of non-users. Ovarian function, endometrial thickness and serum hormone levels were monitored during days 10-12 and 16-18 of the cycle.

RESULTS

Serum estradiol was suppressed in OC users to a greater degree during days 16-18 than during days 10-12, whereas serum progesterone during 16-18 was in the anovulatory range with each preparation. Ovarian activity as measured by follicular size was lowest with desogestrel-containing OCs, whereas greater activity was seen with triphasic levonorgestrel/ethinylestradiol and triphasic norgestimate/ethinylestradiol. Endometrial thickness in OC users was significantly smaller than in controls.

CONCLUSIONS

All preparations demonstrated profound suppression of ovarian activity and effectively prevented ovulation. Ovarian suppression with desogestrel/ethinylestradiol 150/20 did not differ from that of other OCs despite its lower ethinylestradiol content. The use of both triphasic OCs, having a relatively low progestogenic activity, was associated with a higher ovarian activity than that of the monophasic OCs.