Managing Contraceptive Pill/Drug Patients, 14th edition
By Richard P Dickey, MD, PhD in Pharmacology
As therapists offering premarital counseling and sexual therapy, it is important to be aware of the hormonal impact of various oral contraceptives (OCs) and other contraceptive drugs. Because of the differences in the makeup of the components, each hormonal contraceptive has a different pattern of biological activity. “The results of the estrogenic, progestational, and androgenic activities may be seen in the side effects that occur when an excess or deficiency of one of the steroid components occurs (see Table 11) . . .” pg. 24. Table 11 is on pages 147-148. We give women who are planning to start or wanting to change a hormonal contraceptive, the hormonal symptom survey, which we formulated from Section 20, pages 172-177 and have available for your use. The woman marks her symptoms with an X. We use Table 11 to determine whether she needs less or more estrogenic activity; less or more progestational activity. If sexual drive and/or responsiveness have decreased since on a hormonal contraceptive, we look for an OC with higher androgenic activity. Table 11 only deals with symptoms of androgen excess, not deficiency. Yet, we most commonly deal with androgen deficiency for women on hormonal contraceptives, which is discussed on pages 173-174 “Libido Changes”. We use Table 6 to choose the OC with the best fit (based on the next paragraph): “The clinical actions of OCs are based primarily on the activities of the progestin and estrogen components and not on amount of the drug. An OC’s endometrial, estrogenic, progestational, and androgenic activities are dependent on the biological activities and the dose of individual estrogen and progestin components and by potentiating and antagonistic effects of one steroid component upon the other [see references indicated]. The endometrial, estrogenic, progestational, and androgenic activity profiles of ‘Index’ OCs are shown in Table 6.” . . . Endometrial activity is expressed in Table 6 as a percentage of patients who experience spotting, BTB [breakthrough bleeding], or early withdrawal bleeding (onset of menses before last active pill has been taken) during the third cycle of OC use.” pg. 26. Spotting, BTB, or early withdrawal bleeding is common during the first two months of OC use.
1. Most commonly, we give the Hormonal Symptom Survey to the woman.
She marks the symptoms that she is or has experienced and indicates when in her cycle she has these symptoms.
If the woman is on a hormonal birth control, we first go to Table 12
on pages 149 &150 to look to see if she marked any symptoms of serious or potentially serious nature. If she did, we would immediately refer her to her physician for evaluation, stressing the urgency of either getting off of the hormonal contraceptive or getting medical help.
If the woman is not on hormonal birth control or is on one but does not
have any serious symptoms, we first we go to Table 11 on pages 147&148 to see if we can easily determine whether her symptoms indicate she would do well with a hormonal contraceptive with less or more of any of the components. For example, if she has symptoms of estrogen excess, we will look for an OC with less estrogenic activity.
If we need more detail related to her symptoms, we go to Section 20 on
pages 172-177 and write next to her symptoms the page numbers referred to for each symptom she has marked. For example, if she marked abdominal bloating, we note on page 172 that we are referred to page 245, so we write 245 next to that symptom on her survey. We do that for each of her symptoms.
Then we read about each symptom and keep notes. For abdominal
bloating, it is suggested that the woman be switched to an OC with lower estrogenic activities if other fluid retention symptoms are indicated on her survey. If symptoms of progestin and/or androgen excess are also present (look back at Table 11), we would look for an OC with lower progestational activities.
We go to Table 6 to find OC’s with the components needed for this
woman, given her symptoms. If she has spotting or breakthrough bleeding, we look for an OC with greater endometrial activity as indicated in the first column (see pg 180 for more explanation). If her symptoms indicate that she needs lower activity of one of the hormonal components, we look for a low number under that column. For decreased sex drive and/or response, we look for a pill with low progestational activity and high androgenic activity.
2. Situation - Premarital couple: The woman has just started on Alesse and has
gained 3 lbs. Since she is in her first month, we would encourage her to wait a full cycle or more, but we also look at the symptom of weight gain (pg 147 of Table 11).
We read, on pg 147, that if the weight gain is cyclic – in her premenstrual phase - she may be on a pill with too much estrogen and not enough progestin. So we find Alesse on pg. 135 of Table 6 to look at the balance of components. Alesse has 17 mcg of estrogenic activity, which is low in comparison to most other OC listed. Alesse has 0.5 mg of progestational activity, which is also low compared to others. For more detail, we go to the hormonal symptom list in section 20 and find weight gain on page 177. That refers us to page 294. We read pages 293 & 294 to find a differentiation between types of weight gain. So we go back to the client and find that she was likely underweight to start with so may need the extra 3 lbs (top of pg 294), but also encourage her to determine if it is cyclic or due to an increased appetite. If in fact, she still wants to change pills due to weight gain, we would look for a corrective balance of components dependent on her response to the above determination. If her wt gain is cyclic, accompanied by bloating or edema and occurs mainly in the breasts, hips and thighs at the end of her cycle, we will look for an OC with lower estrogenic activities as recommended on the bottom of pg. 294. If she reports increased appetite and symptoms of hypoglycemia, we will look for an OC with lower progestational/androgenic activities. So we go back to Table 6, pages 134-136. If she reports her wt gain is cyclic, we find the OCs with lower estrogenic activity are Loestrin 1.5/30 (has 14 mcg) and Loestrin 1/20 (has 13 mcg). If she reports her wt gain is due to increased appetite, we find the OCs with lower progestational and androgenic activities, which are Ortho Tri-Cyclen LO and Desogen/Ortho-Cept, which I would hesitant to recommend to a premarital women because they are so connected with decreasing sex drive and response. My final decision is to encourage her stay on Alesse, which she has decided to do. Her weight has stabilized between what she weighed before starting on Alesse and the minimal increase she had noted.
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