Oral contraceptive health benefits: perception versus reality

Many women remain unaware of classic oral contraceptive (OC) noncontraceptive health benefits even as new health advantages emerge from experience and research. An extensive body of evidence has established that OC protect women against dysmenorrhea and menorrhagia, menstrual cycle irregularities, iron deficiency anemia, ectopic pregnancy, pelvic inflammatory disease, ovarian cysts, benign breast disease, endometrial cancer, and ovarian cancer. In addition, the FDA has stated for the first time that an OC-triphasic norgestimate/35 micrograms ethinyl estradiol--is an effective treatment for moderate acne vulgaris. OC use also appears to prevent osteopenia in hypoestrogenic women. In addition to these noncontraceptive health benefits, OC have proven valuable in the management of a variety of gynecologic disorders, including dysfunctional uterine bleeding, persistent anovulation, premature ovarian failure, functional ovarian cysts, pelvic pain (including secondary dysmenorrhea), mittelschmerz, endometriosis, and the control of bleeding in women with blood dyscrasias. Educating healthcare providers and women about these important noncontraceptive health benefits will result in increased compliance, greater continuation, and fewer unintended pregnancies.

The cardiovascular safety of triphasic contraceptive steroids

It was hypothesized that estrogen-induced cardioprotection is mediated by up-regulation and down-regulation of expression of nitric oxide (NO) and P-selectin, respectively. Published data on circulating levels of the vasodilator NO, atherogenic glycoprotein P-selectin, and lipoprotein-a [Lp(a)] in users of triphasic contraceptive steroids are lacking. A total of 30 healthy women (nonusers, controls) and 82 women using oral triphasic contraceptive steroids (ethinyl estradiol and levonorgestrel: Triovlar, Schering AG) for 18 to 24 cycles participated in this study. Fasting blood samples were obtained from users and nonusers for the determination of P-selectin and Lp(a) by enzyme immunoassay and NO by a colorimetric method. The serum Lp(a) levels in OC users were significantly higher than those of nonusers. On the other hand, the serum NO levels in OC users were significantly elevated when compared to nonusers. Plasma P-selectin was significantly lowered in OC users p < 0.005. These results demonstrate the beneficial effects of ethinyl estradiol in the triphasic contraceptive regimen. Ethinyl estradiol may afford a degree of anti-atherogenic-cardioprotective effect by up-regulation of the expression of the vasodilator NO and down-regulation of the expression of the atherogenic P-selectin. This may outweigh the cardiovascular risk of the increased atherogenic Lp(a). This study may explain the very low rate of mortality from venous thromboembolism in OC users, which compares favorably with the risks that many people accept in daily life.

Modeled estimates of myocardial infarction and venous thromboembolic disease in users of second and third generation oral contraceptives

Consistent reports from several recent studies suggest that users of third generation oral contraceptives (OCs) containing gestodene and desogestrel may be at increased risk of venous thromboembolic disease (VTE). Paradoxically, other reports indicate that these users may be at decreased risk of acute myocardial infarction (MI) compared with users of second generation OCs. To determine whether the potentially increased risk of VTE would outweigh the potentially reduced risk of MI in users of third generation OCs, we conducted an analysis to quantify the trade-offs providers and users may be faced to make between these formulations. The baseline rates of VTE and MI among non-users were calculated using US data on incidence and mortality of these conditions and estimates of the proportion of women exposed to these formulations in the US. These were multiplied by relative risks published in recent studies on third generation progestins to produce age- and formulation-specific risks. Results indicate that there would be small differences in disease burden between users of second and third generation OCs under the model assumptions at younger ages. However, among women 35-44 years of age, modeling results indicate that the potentially decreased incidence of MI among users of third generation OCs more than offsets the potentially increased risk of VTE at this age.

Ovarian and endometrial cancers

Trends in the incidence and mortality of endometrial and ovarian cancer are described for England and Wales from 1950 to 1991 and for other selected countries from 1955 to 1985. The mortality from endometrial cancer has been falling in England and Wales since 1950 in all age groups. This has not been reflected by a decline in incidence. Most of the other countries show a similar decline in mortality in all ages but stable incidence rates. Mortality from ovarian cancer has been declining in women aged under 55 in England and Wales since the early 1970s but has been rising in women over 55. The international pattern is varied, but several countries show a decline in mortality in younger women that began in the early 1970s. The incidence in younger women has not fallen to the same degree. It is difficult to explain the trends in endometrial cancer mortality in terms of the known risk factors for the disease. The trends in ovarian cancer mortality are consistent with an effect of the combined oral contraceptive pill.

Bone loss, contraception and lactation

Loss of bone mass with age, is a universal phenomenon and is more pronounced in women than in men. The condition where the bone loss has proceeded to the extent that fractures occur is termed osteoporosis. As the number of elderly persons in the population increases, its magnitude is likely to increase, both in the developing and the developed countries. Bone mass increases rapidly in childhood and the adolescent years, reaching a peak in the third decade of life, and begins to decline soon thereafter. Several factors are thought to influence bone loss: these include race, diet, smoking, and physical exercise. Although the rate of bone loss accelerates in the immediate postmenopausal period, the process actually begins in the premenopausal years. By the time osteoporosis is clinically apparent and manifested by fracture, it probably cannot be reversed. The peak adult bone mass achieved, and the subsequent rate of bone loss are the major factors that determine a woman's susceptibility to postmenopausal osteoporosis. A primary cause of bone loss after menopause is the associated decline in ovarian function. Scanty information is available on the factors that affect bone mineral density or initiate bone loss before menopause, although both estrogens and progestins have been shown to prevent bone loss in postmenopausal women. Available data on the relationship between steroid hormone contraceptive use and bone mass/density is limited to combined oral contraceptives and one report related to the use of depot medroxyprogesterone acetate.(ABSTRACT TRUNCATED AT 250 WORDS)

Benefits and risks of oral contraceptive use

As a general rule, the lowest-dose oral contraceptive should be prescribed that minimizes side effects while maintaining contraceptive protection. A woman who experiences mild side effects should be encouraged to tolerate symptoms for three menstrual cycles before a decision is made to change the prescription. Compliance may also be improved by informing women of the noncontraceptive health benefits of oral contraceptives: less menstrual blood loss and a lower incidence of menorrhagia, irregular bleeding, benign breast disease, endometrial cancer, dysmenorrhea, ovarian cysts or tumors, and salpingitis. Adequate patient education and supportive counseling are key factors in patient satisfaction and hence compliance.

Oral contraceptives and gynecologic cancer: an update for the 1990s

The most recent statistical evidence confirms a protective effect of oral contraceptive use against ovarian and endometrial cancers. Studies of the association between oral contraceptive use and cervical cancer continue to be hampered by confounding factors; however, results suggest that the overall risk of invasive cervical neoplasia is not increased. Although the association between oral contraceptive use and breast cancer remains controversial, existing data strongly suggest that overall risk of breast cancer is not increased by the use of oral contraceptives. In most candidates for oral contraceptive use, the benefits greatly outweigh the risks.

Oral contraceptive type and functional ovarian cysts

OBJECTIVE

We tested the hypothesis that multiphasic, low-dose monophasic, and high-dose monophasic oral contraceptives share a common protective effect against functional ovarian cysts.

STUDY DESIGN

We conducted a cohort study using the automatic files of Maine Medicaid to assemble a population of 7462 women between the ages of 15 and 44 who were prescribed an oral contraceptive between Jan. 1, 1987, and Dec. 31, 1988. We included as cases 32 women with a principal diagnosis of a functional ovarian cyst confirmed by medical records as being greater than 20 mm in diameter.

RESULTS

At comparison with the absence of an oral contraceptive prescription, we observed decreasing rates of functional ovarian cysts among women prescribed multiphasic pills (rate ratio 0.91, 95% confidence interval 0.3000 to 2.31), low-dose monophasic pills with less than or equal to 35 micrograms estrogen (rate ratio 0.52, 95% confidence interval 0.17 to 1.33), and high-dose monophasic pills with greater than 35 micrograms estrogen (rate ratio 0.24, 95% confidence interval 0.01 to 1.34).

CONCLUSIONS

The protective effect of oral contraceptives against functional ovarian cysts reported previously for high-dose monophasic pills may be attenuated with newer pills of lower hormonal potency.

Selectivity and minimal androgenicity of norgestimate in monophasic and triphasic oral contraceptives

The contraceptive progestin norgestimate (NGM) has a high affinity for uterine progestin receptors and a lack of affinity for androgen receptors similar to that of natural progesterone. NGM's selectivity results in excellent efficacy, cycle control, and minimal androgenicity when it is combined with ethinyl estradiol (EE). Clinical studies of a monophasic regimen of NGM/EE indicate a positive impact on lipid metabolism, revealing an increase in serum levels of high-density lipoprotein cholesterol with a concomitant and significant decrease in the low-density lipoprotein/high-density lipoprotein cholesterol ratio. Little impact on carbohydrate metabolism was noted. Serum levels of sex hormone binding globulin, an indicator of androgen-estrogen balance, also increased significantly with NGM/EE in accordance with its low androgenic activity. A significant between-regimen difference in SHBG was seen in a comparison study of NGM/EE and LNG/EE triphasic formulations (a mean rise of 68.6% with NGM/EE vs a decrease of 6.1% with LNG/EE). NGM's lack of estrogenicity was evidenced by unchanged prolactin levels and absence of effect on the coagulation system. In a large study of the monophasic formulation in 59,701 women, some improvement in acne was reported as well as minimal weight gain. An overview of clinical data is provided from United States and European trials as well as some preclinical data relevant to NGM's selectivity.

[Clinical experiences with femovan (Gynera)]

The low dose oral contraceptive Femovan/Gynera which contains 0.03 mg Ethinylestradiol and 0.075 mg Gestoden was examined in several clinical trials. Those trials proved its contraceptive effectiveness, its controlling influence on the menstrual cycle and a low incidence of unwanted side-effects. The data reported are based on the experience of more than 100,000 women representing nearly 600,000 treatment cycles. The results of all the different investigations compiled here underline a high contraceptive effectiveness and excellent control of the cycle when using the respective preparation. The rate of unwanted side-effects was low.

Reassessment of the metabolic effects of oral contraceptives

During the 30 years of experience with oral contraceptives, dramatic changes have occurred in their formulations and in prescribing practices. This article analyzes the latest information on the metabolic effects of oral contraceptives and makes recommendations for practice.

Oral contraceptives: a reassessment

Cardiovascular risks attributable to oral contraceptive use may now be subdivided into those that appear to be secondary to the estrogen component, i.e., venous thrombosis, pulmonary embolism, and those linked to the progestin component, i.e., small vessel disease including myocardial infarction and cerebrovascular accident. It appears that venous risk is attributable to subtle changes in clotting factors, while arterial risk may be secondary to changes in glucose and lipid metabolism. In order to determine which women are at greatest risk from oral contraceptive use, Spellacy et al. has developed a risk scoring form that aids in the screening process. After excluding women with an absolute contraindication to pill use, women at greatest risk for cardiovascular disease related to oral contraceptive use are those with a family history of hyperlipidemia, gestational or overt diabetics, hypertensives, and smokers over the age of 35. The gradual reduction by manufacturers of the steroid content of oral contraceptives appears to have lessened the incidence of adverse effects. Our current knowledge of risk factors permits the clinician to reduce exposure to oral contraceptive-related mortality by as much as 86 per cent. As we continue to search for ways to reduce risk among oral contraceptive users, it is important to note that more than 25 per cent of women are still taking formulations containing 50 micrograms of estrogen. It becomes the responsibility of the practicing physician to "step-down" these patients to lower-dose preparations such as the multiphasics. Such preparations also represent optimal therapy for first-time pill users.

The influence of a combined oral contraceptive on uterine activity and reactivity to agonists in primary dysmenorrhea

The mechanisms underlying the therapeutic effect of an oral contraceptive (150 micrograms levonorgestrel and 30 micrograms ethinyl estradiol daily for 21 days) in primary dysmenorrhea were studied by recordings of uterine activity and reactivity to lysine (L) vasopressin (VP) and prostaglandin (PG) F2 alpha on the first day of menstruation in 14 women before and after one period of oral contraceptive treatment. During the first session, when all women had moderate to severe dysmenorrhea, intra-uterine pressure recording showed an intensive uterine activity, and bolus injections of LVP (6 pmol/kg body weight; 6 subjects) or PGF2 alpha (6 or 12 nmol/kg body weight; 4 subjects in each group) increased contractile activity and discomfort. After oral contraceptive treatment, spontaneous uterine activity, measured as total pressure area, decreased significantly (p = 0.02 and p = 0.03 in the VP and PG groups, respectively). The mean uterine responses to LVP and PGF2 alpha were on average smaller after oral contraceptive treatment and the women experienced minimal discomfort after this injection. It is suggested that inhibition of uterine activity could be an important mechanism for the therapeutic effect of gestagen-dominated oral contraceptives in primary dysmenorrhea and that reduced uterine reactivity to agonists might contribute to this effect.

The effects of desogestrel and ethinylestradiol combination in normal and hyperandrogenic young girls: speculations on contraception in adolescence

Hormone profile and ovarian morphology were studied in two groups of adolescents (group 1:19 girls with slight signs of hyperandrogenism; group 2: 14 normal adolescents) in basal conditions and during a contraceptive combination of 30 micrograms ethinyl estradiol (EE) and 150 micrograms desogestrel (D). Treatment was associated with a low incidence of side effects in both groups. In group 1, acne generally improved within 12 months while hirsutism was only reduced in some subjects (58%) after 12 months of therapy (basal hair score 8.50 +/- 1.60 vs 5.81 +/- 1.53 p less than 0.001). Significant falls in plasma levels of LH, total and free testosterone and an increase in sex-hormone-binding globulin levels were observed during treatment especially in group 1. High percentage of multifollicular ovaries (75%) characterized hyperandrogenic subjects. Ovarian volume and number of follicles, higher in group 1 than 2 in basal conditions, showed a significant reduction in both groups and normal ovarian morphology was restored in hyperandrogenic subjects. Considering the high incidence of hyperandrogenemia in adolescence and its implications, our data suggest that the EE.D combination suits adolescent biological condition and is one of the suitable contraceptive methods in adolescents which also has therapeutic effects.

Oral contraceptives. Who, which, when, and why?

The risks of oral contraceptives are very small, and they cluster in a subset of users, although warning signs of cardiovascular complications must be heeded. The best choice of an oral contraceptive is one with an estrogen content of 30 to 35 micrograms. A greater (50 micrograms) content may be necessary if breakthrough bleeding or amenorrhea persists beyond a few treatment cycles. The starting date for the pill can be up to the sixth day of the cycle. Noncontraceptive benefits of the pill may include a protective effect against endometrial and ovarian malignancy, benign breast disease, and infection of the upper genital tract. Both the contraceptive and noncontraceptive benefits of low-dose combination oral contraceptives are desirable. They far outweigh the risks in women who require a high-efficacy, reversible contraceptive and who have no significant contraindication to use of the pill.

Current perspectives on combination oral contraceptives

The physiology, mechanism of action, therapeutic use and effectiveness, potential risks, and noncontraceptive benefits of combination oral contraceptives (COCs) are reviewed with a discussion of patient considerations and management guidelines for common side effects. Modifications of the earlier COCs have both a lower estrogen and progestogen content. The contraceptive effects of estrogenic agents are related to modifications in ovulation, ovum transport, and implantation. The progestational agents act mainly by inhibiting ovulation and creating a hostile uterine environment. Biphasic and triphasic COCs are designed to deliver the hormones, throughout the menstrual cycle, in varying amounts that are similar to the natural physiologic quantities. The COC is the most effective method of birth control available with the exception of sterilization. If the low-dose COCs are taken at approximately the same time each day, they are as effective as 50-micrograms of estrogen in preventing pregnancy with a theoretical failure rate of less than 0.5 per 100 women-years. Three long-term cohort studies of the risks associated with COC use are described. Although the primary focus of early research was on the adverse effects of COCs related to estrogen content, recent studies indicate that there are some noncontraceptive benefits associated with the use of the low-dose COCs. In addition, the effects of progestogen content have been more closely examined in association with cardiovascular disease and metabolic effects. Guidelines for managing breakthrough bleeding and spotting, absence of withdrawal bleeding, nausea and vomiting, weight change, depression, and headaches are presented. Recommendations to give to women who are starting to take COCs for the first time are outlined. Low-dose COCs given at the appropriate dose can provide relatively safe and very effective contraception for many women.