Considerations for the use of progestin-only contraceptives.

PURPOSE: To highlight the characteristics of progestin-only contraceptives (POCs) currently available in the United States, and to explore the potential of these agents as first-line contraceptive options for women seeking health promotion by prevention of an unwanted pregnancy. The progestin-only pills (Micronor and Ovrette), depot medroxyprogesterone acetate (DMPA) injections (Depo-Provera and depo-subQ provera 104), levonorgestrel intrauterine system (IUS) (Mirena), and etonogestrel implant (Implanon) will be reviewed. The use of levonorgestrel (Plan B) as an emergency contraceptive will also be considered briefly. DATA SOURCES: Worldwide medical literature and the prescribing information for the specified products. CONCLUSIONS: A number of POCs are currently available for routine birth control in the United States, ranging from the daily progestin-only pill to nondaily contraceptive options such as injectable DMPA, the levonorgestrel-releasing IUS, and the etonogestrel-releasing contraceptive implant. Each of these methods has specific advantages, but also specific drawbacks that can result in discontinuation of treatment if users are not given adequate information about what to expect in terms of side effects. It is critical that clinicians provide adequate and accurate information along with detailed counseling to women who are considering using POCs, as well as providing periodic reinforcement of the information at regular clinic visits for those already using POCs. IMPLICATIONS FOR PRACTICE: Given that a large number of pregnancies are unplanned and create a significant impact on social, economic, and health outcomes, it is important for the clinician to have a vast knowledge of contraceptive options. POCs offer significant choices in contraception. By proactively addressing common concerns (such as potential effects on weight, mood, menstrual bleeding patterns, and bone mineral density), clinicians may improve the likelihood of adherence and continuation with POCs for routine birth control.

European Society of Contraception oral contraceptives survey update: birth control methods in "Europe of the 12".

The European Society of Contraception developed a survey to examine birth control methods in the 12 countries++ of the European Community. Responses to those questions relating to prescribing++ practices of oral contraceptives (OCs) are presented herein. The survey was sent to 400 physicians. One hundred two responded, most from France, Belgium, and the United Kingdom. The responses revealed that the most popular OCs are modern combined formulations containing low doses of ethinyl estradiol and progestogens such as norgestimate, desogestrel, gestodene, and levonorgestrel. More than half of physicians prescribe a particular formulation because of its tolerability and 20% because of its hormonal content. More than 90% prescribe OCs to healthy, nonsmoking women over 40. However, three fourths will not prescribe OCs to smokers over 35. Half of physicians recommend mammography for their older OC patients. Half also recommend cholesterol screening, but 8% only for women over 30. Most physicians are no longer reluctant to prescribe OCs to their diabetic patients: 61% prescribe OCs for women with non-insulin-dependent diabetes, 56% for those with insulin-dependent diabetes, and 85% for those with a history of gestational diabetes. Despite recent studies showing no relation between past OC use and cardiovascular disease, 42% of physicians said that their greatest OC-related health concern is cardiovascular disease. One third cited noncompliance as their greatest concern. These results reveal inhomogeneous prescribing practices for OCs among European physicians. ¿Over-screening¿--not prescribing the pill because of perceived (but not necessarily real) health risks--may be depriving many women of the contraceptive and noncontraceptive benefits of OCs. Complete and accurate information--as promoted by the European Society of Contraception--is one way to combat such overscreening.

PIP: Findings are presented from the 1993 European Society of Contraception Oral Contraceptive Survey conducted in 12 member countries among 102 physicians. Findings are considered suggestive because of the low response rate of 25% to the mailed questionnaire to 400 physicians. The aim is to determine the prescribing practices of oral contraceptives. Over 50% of physicians prescribed the following modern, low-dose combined formulations: Marvelon, Mercilon, Minulet, Gynera, Cilest, and Femodene. 66% of physicians prescribed monophasic pills containing 20-30 mcg of ethinyl estradiol and low doses of desogestrel, gestodene, levonorgestrel, or norgestimate. 58% preferred oral pills because of their tolerability. Other desirable features were the cost, hormonal content, and other factors. 94% prescribed oral pills for women aged over 40 years who were healthy and did not smoke. 75% would not prescribe oral pills to women who were over the age of 35 years and who smoked. Over 50% of physicians recommended mammograms for women aged over 35 years who used oral pills. 45% routinely performed lipoprotein screening of oral pill users. 8% did so only for patients aged over 30 years. 42 physicians out of the 102 responding had a protocol based on the total cholesterol level. 61% prescribed oral pills for women with non-insulin-dependent diabetes. The majority prescribed oral pills for women with insulin-dependent diabetes. 38% of physicians who prescribed oral pills for women with diabetes prescribed very-low-dose monophasic oral contraceptives. 85% prescribed oral pills for women with gestational diabetes. 42% were concerned about patient risk of cardiovascular disease. The study revealed a range of practices among physicians.

[The latest progestagens]. / Les derniers progestatifs.

The new progestative molecules have allowed to reduce the doses of steroids in the combined pills. They have a reduced androgenic activity allowing the positive effects of ethinyl estradiol to act on lipid metabolisms, which may lead to a reduction of atherogenesis. However these new pills should not be administered if the classical contraindications exist. On the contrary the strong gonadotropic effect of the latest nor-pregnane derivates can be used (the chlormadinone as well) on patients with thromboembolic history on the condition that the still partially experimental aspect of this mode of contraception is taken into consideration.

[Side effects of third generation progestins]. / Inconvénients des progestatifs de 3e génération.

A large number of publications on oral contraceptives (OC) can be found in the medical literature. These reports deal not only with mode of action or efficacy of OCs but also with side effects. Adverse drug reactions (ADR) are not accepted nor acceptable from a population of young women free of disease who expect from their mode of contraception to be fully efficient and devoid from side effects. In most instances, side effects observed with OCs as well as their efficacy are related to the total dose of steroïds contained in the combination, to the balance between the estrogen and the progestin content and to the specific characteristics of the molecules. Cardiovascular morbidity and mortality reported in OC users have been related firstly to the ethinylestradiol (EE) and as a first step, the estrogen dose has been reduced in the OCs synthesized in the 70s. Later on, cardiovascular risk has been correlated to lipid profile changes and progestins with androgenic properties have been made responsible for cardiovascular events reported in OC users. In order to minimize the incidence of ADRs and to induce beneficial changes in lipid patterns, new progestational molecules devoid of androgenic properties have been recently synthesized. Three compounds called "third generation" progestins, derived from levonorgestrel are presently available in Europe. These three gonane progestins demonstrate affinity for the androgenic receptor, but when administered together with EE do not oppose the estrogenic effect observed on protein markers such as the Sex Hormone Binding Globulin (SHBG) or the High Density Lipoprotein (HDL).(ABSTRACT TRUNCATED AT 250 WORDS)