Oral contraceptive pill – what for who?

Mark Wilshere

2011

Content

• Introduction – the importance of the matter

• Types of oral contraception

• Oral contraception comparison

• Oestrogen/Progestogen/Androgen activity

• Tackling the side effect

• Summary

Introduction

• Pill is commonly used, especially in younger women

• Benefits include reliable contraception, easy to use, less bleeding, controls cycle, less painful periods

• Perceived negative effects include, nausea, headache, mood change, weight gain, irregular bleeding

Introduction

• Side-effects are an issue as compliance can subsequently be affected. Up to 20% of younger women may not take because the do not like it.

• 50% pregnancies in UK unintended

• 91% abortions funded by NHS

• 42% abortion rate in teenagers in 2001

Choice

• Very important

• Numerous to chose from

• Ethinylestradiol (standard)

• Progestin (variable) – oestrogen potency small if any

Combined

• 21 day standard strength COCP -

30-35mcg

• 21 & 7 day ED (Every Day) standard strength COCP – 30-35mcg for 21 days and 7 days of inactive pills

• 21 day low strength COCP – 20mcg

Ethinylestradiol 20mcg 21d monophasic

Progestogen content

Brand Price (3 cycle pack)

Desogestrel 150mcg

Gedarel 20/150

Mercilon

£5.98

£7.97

Gestodene 75mcg

Femodette

Millinette 20/75

Sunya 20/75

£8.85

£6.37

£6.62

Norethisterone acetate 1000mcg

Loestrin 20 £2.75

Ethinylestradiol 30mcg 21d monophasic

Progestogen content Brand Price (3 cycle pack)

Desogestrel 150mcg Gadarel 30/150

Marvelon

£4.93

£6.45

Drospirenone 3000mcg Yasmin £14.70

Gestodene 75mcg Femodene

Katya 30/75

Millinette 30/75

£6.73

£5.03

£4.85

Levonorgestrel 150mcg Levest

Microgynon 30

Ovranette

Rigevidon

£2.55

£2.82

£2.20

£1.89

Norethisterone acetate 1500mcg

Loestrin 30 £3.95

Ethinylestradiol 35mcg 21d monophasic

Progestogen content Brand Price (3 cycle pack)

Norgestimate 250mcg

Cilest £2.87

Norethisterone 500mcg

Brevinor

Ovysmen

£1.99

£1.49

Norethisterone 1000mcg

Norinyl-1 £2.19

Ethinylestradiol 50mcg 21d monophasic

• Norethisterone 1000mcg

• Norinyl-1

• £2.19

Ethinylestradiol 30mcg 28d monophasic

Progestogen content

Brand Price (3 cycle pack)

Gestodene 75mcg

Femodene ED(21 active, 7 inactive)

£6.73

Levonorgestrel 150mcg

Microgynon ED(21 active, 7 inactive)

£2.54

Ethinylestradiol Variable 21d phasic

Brand Ethinylestradiol dose/Progestogen (mcg)

Tablets Price

Triadene

(gestodene)

30 / 50

40 / 70

30 / 100

6

5

10

£8.99

Logynon

OR

TriRegol

(levonorgestrel)

30 / 50

40 / 75

30 / 125

6

5

10

£3.96

£2.87

BiNovum

(norethisterone)

35 / 500

35 / 1000

7

14

£1.96

Synphase

(norethisterone)

35 / 500

35 / 1000

35 / 500

7

9

5

£3.60

TriNovum

(norethisterone)

35 / 500

35 / 750

35 / 1000

7

7

7

£2.72

Ethinylestradiol Variable 28d ED phasic

Brand Ethinylestradiol dose/Progestogen (mcg)

Tablets Price

Logynon ED

(levonorgestrel)

30 / 50

40 / 75

30 / 125

6 active

5 active

10 active

7 inactive

£3.82

Qlaira

(estradiol / dianogest)

3mg / 0

2mg / 2mg

2mg / 3mg

1mg / 0

2 active

5 active

17 active

2 active

2 inactive

£25.18

Progestogen only

Brand Progestogen Price per 3 pack

Cerazette Desogestrel 75mcg £8.68

Femulen Etynodiol diacetate 500mcg

£3.31

Micronor Norethisterone 350mcg

£1.66

Noriday Norethisterone 350mcg

£2.10

Norgeston Levonorgestrel 30mcg £2.76*(35 pack = £0.92 x3)

Oestrogen activity

• Higher number of micrograms of ethinyl estradiol lead to more potent estrogenic effects. A higher amount of estrogenic activity helps to decrease androgen-related side effects. However, progestins tend to counter some of the estrogenic effects of ethinyl estradiol.

Progestational Activity

• Each progestin has a different potency

• Hence the differences in doses

• Is possible to compare potency of progestins and their androgenic activity

• High androgenic activity associated with acne, hair growth etc

Progestin Progestational Activity Androgenic Activity

Norethindrone 1mg (control)

1.0 1.0

Norethrindrone acetate 1mg

1.2 1.6

Norgestimate 1mg 1.3 1.9

Norelgestromin 1mg 1.3 1.9

Ethynodiol diacetate 1mg

1.4 0.6

Drospirenone 1mg 1.5 0.0

Dinorgestrel 1mg 2.6 4.2

Levonorgestrel 1mg 5.3 8.3

Desogestrel 1mg 9 3.4

What pill?

• Need to consider;

– Oestrogen dose– Progestin potency– Androgen potency

Side effect / problem Solution Suggestions

Acne ↑o ↓a Loestrin 30, Brevinor, Ovysmenn, gadarel, marvelon, cilest, Yasmin (price)

Break through bleed ↑o ↑p ↓a Gadarel 30/150, Marvelon,

Gestodene/levoner containing

Yasmin (price)

Weight gain ↓o ↓p Lower O dose

Breast soreness ↓o ↓p Lower O dose

Severe cramps ↑p Higher P potency

Headaches ↓o ↓p Lower O dose, mercilon

Depression, moody, irritable ↓p ?norethisterone based

a/oligo-menorrhoea ↑o ↓p

Endometriosis ↓o ↑p ↑a Levon, deso based

Progestogenic side effects

• Acne, hirtuism, vaginal dryness, wt gain, loss of libido, breast tenderness

• Try a pill with;– Less of same progestogen– Oestrogen dominant pill– Try different progestogen

Oestrogenic side effects

• Nausea, headache, dizziness, breast enlargement, cyclical wt gain, loss of libido

• Try a pill with;– Lower oestrogen content– Try progestogen dominant pill– Try progestogen only pill

Summary

• Numerous types of oral contraception available• Vary in oestrogen content and progesterone /

androgen activity• Tailor to individual needs• Trial and error may be needed and explained• May be variance between individuals• It takes about 2 cycles to see if suitable• Studies lacking in comparison