If it has been in place for more than 4 weeks, she
should remove it, confirm that she is not pregnant, reinsert a new one, and use backup
The contraceptive vaginal ring should be inserted anytime during the first 5 days of
the menstrual cycle or inserted using the quick start method.
should be used for the first week. When changing from the COC, S.F. should insert
the ring within 7 days of the last active pill and no backup contraception is needed.
The ring is believed to have the same contraindications and precautions as COCs.
The most common side effects with the ring are vaginal infections, irritation, and
discharge; headache; weight gain; and nausea. Unlike the patch, the ring has not been
shown to increase VTE risk or has reduced efficacy in obese women.
1,950 women using the contraceptive ring for 13 months found a high degree of
patient satisfaction and adherence to the contraceptive method.
the least amount of EE exposure when compared with other CHCs.
despite the lower levels of EE provided, one study has shown an increased risk of
VTE with the use of the contraceptive vaginal ring when compared with
levonorgestrel-containing contraceptives.
68 Though this study indicated a possible
increase in VTE with the vaginal ring, the FDA has not required any labeling changes
or communicated any safety issues with the vaginal ring. Given the good adherence
rates and lower EE levels, the vaginal ring may be appropriate for S.F. if she is
comfortable with the dosage form.
is using the contraceptive vaginal ring.
Current vitals at clinic: weight, 132 lb; height, 5
Respiratory rate, 16 breaths/minute
Laboratory test results: rapid streptococcal antigen test, positive
What other drug interactions are of concern with CHCs?
A variety of drugs may alter the levels of CHCs and in turn affect their efficacy
7,69–72 Currently, most data available regarding drug interactions are
with COCs. However, as a precaution the potential drug–drug interactions observed
with COCs are also applied to the other CHC dosage formulations (e.g., vaginal ring
The antibacterials rifampin and griseofulvin are known to cause contraceptive
failure, as these products increase the metabolism of estrogen. For other
antibacterials, the possible interaction is more complicated.
EE is conjugated in the liver, excreted in the bile, hydrolyzed by intestinal
bacteria, and reabsorbed as active drug.
72 Antibacterials, by reducing the population
of intestinal bacteria, interrupt the enterohepatic circulation of the estrogen, resulting
in a decreased concentration of circulating estrogen. Theoretically, any antimicrobial
with significant effects on intestinal bacterial flora could affect COC efficacy.
Numerous reports of changes in bleeding patterns and contraceptive failure have
72 Cases of pregnancy in COC users taking antibiotics have been
72–74 About 30 case reports of contraceptive failure with concomitant COC
and antibiotic use have been published.
72 The antibacterials in the case reports
include rifampin, ampicillin, penicillin G, tetracycline, and minocycline. In addition,
surveys conducted on patients in clinics have revealed about 20 other cases of COC
72 A major limitation of survey data is that it relies on patient reporting, which
is often unreliable. Some believe that the probability of a clinically significant drug
interaction between COCs and antibacterials is low and the CDC US Medical
Eligibility Criteria does not recommend a need for alternative birth control methods
while taking broad-spectrum antibiotics that do not affect hepatic enzymes.
Common Combined Oral Contraceptive (COC) Drug
Acetaminophen Amprenavir Amoxicillin Acetaminophen
Ascorbic acid Aprepitant Ampicillin Amprenavir
Atazanavir Barbiturates Ciprofloxacin Antidepressants, tricyclic
Atorvastatin Bexarotene Clarithromycin Benzodiazepines
Ginseng Bosentan Colesevelam β-blockers
Indinavir Carbamazepine Doxycycline Caffeine
b Darunavir Erythromycin Clofibric acid
Rosuvastatin Efavirez Fluconazole Corticosteroids
Tranexamic acid Felbamate Itraconazole Cyclosporine
Voriconazole Griseofulvin Ketoconazole Lamotrigine
Isotretinoin Metronidazole Levothyroxine
Lopinavir Minocycline Morphine
Modafinil Penicillins Paclitaxel
Mycophenolate mofetil Phenylbutazone Salicylic acid
Nelfinavir Ofloxacin Selegiline
Nevirapine Tetracyclines Tacrine
Oxcarbazepine Topiramate Tacrolimus
Phenytoin/Fosphenytoin Tizanidine
aDrug list is not all inclusive. Some drug interactions may exist that are not cited in this table.
Indicates drug may have variable effect on CHC either increasing or decreasing effect.
cMay decrease anticoagulant effect of warfarin, not warfarin drug levels.
CHC, combined hormonal contraceptive.
Source: Borgelt L et al., eds. Women’s Health Across the Lifespan: A Pharmacotherapeutic Approach .
Washington DC: American Society of Health Systems Pharmacists; 2010.
Numerous factors may affect the likelihood of an interaction: the hormonal content
of the COC relative to the patient’s requirements, the dosage and duration of use of
the interacting drug, variation in the patient’s response to bacterial flora alteration,
and the fertility of the couple.
72 The number and complexity of these variables make
prediction of outcome in a specific patient exceedingly difficult. Even if a drug
produces a several-fold increase in unintended pregnancies in women taking COCs,
the likelihood of pregnancy in a given patient still will be low. For patients who
require long-term, low-dose tetracycline use for acne therapy (e.g., tetracycline 250
mg by mouth daily), it is unlikely to interfere with COC efficacy.
topical antibacterials often can control acne and are viable alternatives to oral
A practical approach to managing patients taking COCs and antibacterials is to
educate patients about the available data. To be conservative, S.F. should be advised
to use backup contraception while taking the amoxicillin/clavulanate and to continue
the backup method until her next menses occurs though this is controversial and the
CDC Medical Eligibility Criteria does not call for it.
7 For other antibiotics that affect
hepatic enzymes such as rifampin, isoniazid, and griseofulvin, backup contraception
should be used while taking the medication and for 4 weeks after discontinuation of
Ethinyl estradiol is a substrate of cytochrome P-450 3A4 (CYP3A4), so drugs that
induce CYP3A4 activity may decrease COC efficacy. In earlier years, COC efficacy
was not decreased significantly by other drugs because of their high hormone content.
Because the estrogen and progestin concentrations of COCs have gradually been
decreasing, reports of menstrual irregularities (e.g., spotting) and unintended
pregnancies attributable to drug interactions have been increasing.
Anticonvulsants such as carbamazepine, oxcarbazepine, phenytoin, phenobarbital,
primidone, and topiramate are CYP3A4 inducers and are known to cause increased
metabolism of COCs (see Chapter 60, Seizure Disorders).
shown that another inducer of COC metabolism is St. John’s-wort.
can influence COC efficacy, COCs also can affect the activity of other drugs. For
example, COCs have been reported to decrease serum levels of lamotrigine and can
affect seizure control; as well increased levels of lamotrigine have been reported
79 Other drugs may increase the hormone levels of COCs
(Table 47-5), increasing the risk of COC side effects (Table 47-4).
Unlike many drug classes that are carefully dosed to maintain a therapeutic range
of monitored blood levels, contraceptive estrogen and progestin blood levels are
obtained only in clinical drug studies. Therefore, patients are managed by monitoring
side effects and by changes in menstrual patterns. Some prescribers suggest using a
50-mcg EE COC in patients taking interacting drugs, although others might
recommend using an alternative method of contraception if drug interactions are an
Noncontraceptive Benefits of Combined Hormonal
QUESTION 1: D.S., a 20-year-old woman, presents to her primary-care physician for a yearly pelvic
cravings, cramps, and bloating near the time of her period.
Vitals: weight, 118 lb; height, 5
Respiratory rate, 13 breaths/minute
Past medical history: acne (since age 16)
Social history: denies tobacco and alcohol use, not sexually active
Allergies: no known drug allergies
Current medications: benzoyl peroxide 5% cream, apply topically twice daily
Benzoyl peroxide 2.5% wash, wash affected area twice daily
Retin-A micro 0.1%, apply topically twice a week as tolerated
Multivitamin with iron by mouth daily
Past medications: doxycycline 100 mg by mouth twice daily for acne, stopped because of vaginal yeast
Physical examination: unremarkable with the exception of moderate facial acne
Laboratory test results: white blood cells, 6.0 × 10
Mean corpuscular hemoglobin concentration, 31 g/dL
Red blood cell diameter width, 15%
which COC would you recommend for D.S.?
Depending on the patient, a CHC may cause acne to appear, disappear, or
4 D.S. is interested in COCs. Four COC products
(norethindrone acetate/EE [Tri-Legest 21 and Tri-Legest Fe 28], norgestimate/EE
[Ortho Tri-Cyclen], and drospirenone/EE [YAZ, Beyaz]) are US Food and Drug
Administration (FDA)-approved for the treatment of moderate acne vulgaris in
women at least 15 years old (at least 14 years old for Beyaz and YAZ), who have no
known contraindications to CHCs, reached menarche, desire contraception, and have
component. Higher doses of estrogen may decrease acne by suppressing the activity
of sebaceous glands, decreasing the production of androgens, and increasing the
synthesis of sex hormone-binding globulin (SHBG). The SHBG binds androgens and
thereby diminishes their effects.
80 Progestins with higher androgenic activity may be
more likely to increase acne because they stimulate sebaceous glands to produce
more sebum. Both desogestrel- and norgestimate-containing oral contraceptives are
less androgenic, whereas drospirenone has antiandrogenic properties, thereby
decreasing acne associated with androgenic activity.
reached menarche, and has not responded to different acne treatments, and she
therefore is a candidate for COC therapy. Her acne appears to be hormonally
mediated, particularly because it appears around the time of her menses. It is likely
that D.S.’s acne should improve with COC use, particularly if she uses a formulation
with higher estrogenic activity and low androgenic activity (e.g., Beyaz, Safyral
YAZ, Yasmin, Ortho Tri-Cyclen, Ortho Tri-Cyclen Lo, Mircette, Tri-Legest 21; see
help reduce her menstrual bleeding or menstrual cramps?
COCs help regulate menstrual cycles and reduce monthly blood loss.
reflect the progressive thinning of the endometrium of COC users and the lack of
irregular bleeding. Bleeding may be decreased the most by COCs that have a high
ratio of progestin to estrogen because endometrial thinning is maximized.
COCs have iron pills instead of placebos, often denoted with “Fe” in the name (e.g.,
Tri-Legest Fe 28, Femcon Fe, Loestrin Fe, Lo Loestrin Fe). Others have folic acid
(e.g., Beyaz, Safyral) but D.S. would likely benefit more from the formulations with
iron. Another option would be to have D.S. take COCs continuously so she has fewer
Dysmenorrhea, or painful menstruation, may be of unknown origin or may be
attributable to endometriosis or uterine fibroids. Data suggest menstrual pain might
decrease by 60% after the initiation of a COC.
3 A COC with decreased estrogenic
and increased progestational activity may be the best at relieving dysmenorrhea (see
Chapter 50, Disorders Related to the Menstrual Cycle).
PREMENSTRUAL SYNDROME AND PREMENSTRUAL DYSPHORIC
CASE 47-2, QUESTION 3: D.S. also complains of PMS symptoms such as bloating and mood changes.
What treatment approaches are appropriate? What other noncontraceptive benefits do CHCs have?
Premenstrual syndrome (PMS) is a cyclic occurrence of one or more symptoms
before the onset of menses. Most women complain of at least one PMS symptom,
which includes irritability, bloating, and depressed mood.
disorder (PMDD) is a more severe form of PMS and has diagnostic criteria by the
American Psychiatric Association. Premenstrual tension has been reported to be
reduced in COC users, and other premenstrual symptoms seem to improve as well.
Nevertheless, the effect of COCs on PMS symptoms is inconsistent and
unpredictable, probably because PMS symptoms are neither consistent nor
There may be augmentation of depression and mood swings by the progestational
component, although the probability of this effect is low with a low-dose product
(see Chapter 50, Disorders Related to the Menstrual Cycle, for further discussion of
PMS). Some patients may also notice depressed mood during the hormone-free
period, in which case a continuous-use COC may be helpful.
Two products, drospirenone/EE (YAZ, Beyaz), have the FDA-approved
indication for treatment of symptoms of PMDD. Drospirenone/EE has been studied
most extensively in patients with PMDD.
42 D.S. may try any CHC to help with her
PMS symptoms; however, because YAZ and Beyaz have more data to show that they
are effective for PMDD and acne, one of them may be the preferred initial product
for her. In addition, both products are 24-day formulations, which may help minimize
her menstrual bleeding and help her iron-deficiency anemia.
Clinical data suggest that COCs protect against endometrial cancer. This effect
continues for 20 years after the last pill.
83 The protection is directly related to
duration of use and may persist for many years after discontinuation of the COC.
meta-analysis of 11 studies showed a 56%, 67%, and 72% reduction in endometrial
cancer risk after 4, 8, and 12 years of COC use, respectively.
OVARIAN CANCER AND FUNCTIONAL OVARIAN CYSTS
The risk of developing functional ovarian cysts is decreased, preexisting cysts are
more rapidly resolved, and surgery rates for ovarian masses are reduced in women
85,86 This is likely attributable to reducing ovulation, suppressing
androgen production, or increasing progesterone levels.
Each year of COC use decreases the relative risk of developing ovarian cancer by
86 The risk reduction continues to be seen in women using COCs for more
than 15 years and persists after discontinuation.
83 D.S. should be reassured that COC
use may decrease her risk of ovarian cancer given that she has a positive family
Combined Hormonal Contraceptive Risks and Adverse
Some patients may not be candidates for CHCs because of the risks and adverse
effects associated with their use. Other patients may experience minor side effects
with CHCs that may be managed by changing to a CHC with different types or doses
of estrogen or progestin. All patients should be counseled on the most serious side
effects, which include pulmonary embolism or VTE, hepatotoxicity, or visual
disturbances (could be a sign of retinal and corneal changes in the eye) and stroke. A
helpful acronym to remember when counseling is “ACHES” (Table 47-2),
can be used to increase a patient’s awareness of serious potential adverse effects that
warrant immediate medical attention.
Other less severe adverse effects are listed in Table 47-4.
resolve within 3 months of use. If a patient experiences adverse effects other than
those described in “ACHES,” (Table 47-2) she should be encouraged to continue the
CHC for at least 3 months before switching to a different contraceptive.
BREAKTHROUGH BLEEDING, SPOTTING, AND AMENORRHEA
Intermenstrual bleeding is a bleeding that occurs at times other than the regular
menses timing. Intermenstrual bleeding that requires a pad or tampon is designated
breakthrough bleeding, whereas a lesser amount of intermenstrual bleeding is called
spotting. Intermenstrual bleeding is experienced by many women in the first months
Intermenstrual bleeding may also occur if a patient is
not adherent to her COCs or taking medications that decrease COC effectiveness
Most clinicians will recommend that patients continue the same COC for at least 3
months if breakthrough bleeding or spotting is the only complaint, because this
complication usually resolves within 3 months.
3 Early-cycle intermenstrual bleeding,
which usually starts before the 14th day of the menstrual cycle (or never ceases
completely after menses), is usually caused by insufficient estrogen. Late-cycle
intermenstrual bleeding, occurring after day 14, is usually attributable to insufficient
progestational support of the endometrium. Another cause of intermenstrual bleeding
is drug interactions (see Case 47-1, Question 8, for more information about drug
The balance between estrogen and progestin components in COCs determines its
endometrial activity and, therefore, the likelihood of intermenstrual bleeding
problems. It may be helpful to envision the estrogen component as the basic building
blocks or “bricks” of the endometrium and the progestational component providing
the mortar that holds the bricks together. The estrogenic activity of the progestin
component increases the number of bricks, whereas its antiestrogenic activity
decreases their numbers. If there are not enough bricks or mortar or if they are
present in the wrong proportions, the wall will crumble and bleeding will occur
If D.S.’s intermenstrual bleeding continues late in her cycle after 3 months, another
COC with the same estrogen activity, more progestin activity, and low androgen
activity should be prescribed. Desogestrel 0.15 mg/EE 30 mcg (e.g., Apri,
Reclipsen) would be a good choice because progestational activity would be
increased and estrogenic activity would be maintained with minimal androgenic
liability (Table 47-3). If D.S. had experienced intermenstrual bleeding early in the
cycle after several months of use, she should be changed to a formulation with a
higher ratio of estrogen to progestin such as norethindrone 0.4 mg/EE 35 mcg
(e.g.,Ovcon-35, Femcon Fe, Balziva, Zenchent). For D.S., products with low
androgenic activity should be selected because of her acne.
Intermenstrual bleeding may also be the sign of other health conditions such as
cervical or uterine cancer. If a patient presents with intermenstrual bleeding and has
not had a recent pelvic examination, a healthcare provider may perform an
examination to rule out other possible causes of intermenstrual bleeding. D.S.
recently had a normal pelvic examination 2 months ago. Given the timing of when she
began her COCs, it is likely her intermenstrual bleeding is caused by her COCs.
Some patients experience amenorrhea (no menstrual bleeding) with CHCs. If this
occurs, pregnancy should first be ruled out. If the patient is not pregnant and
amenorrhea is acceptable to the patient, then the CHC need not be changed. But this
does make it difficult for the patient to recognize whether she may become pregnant
D.S. calls with complaints of nausea. What counseling should the clinician provide to D.S.?
Nausea from COCs can generally be attributed to the estrogen component. To help
alleviate nausea, D.S. can take her pill at bedtime rather than in the morning. Another
alternative may be to take it with food or to try another COC with a lower estrogen
strength or property. Ovcon-35 has a higher amount of EE as compared with YAZ
(35 mcg of EE vs. 20 mcg of EE), which may be causing nausea to D.S. D.S. should
be advised that nausea generally resolves within 3 months of use.
Headache is a common complaint in women taking CHCs or COCs, as is the case
with D.S. Women may notice headaches while taking active pills, which may be
related to sensitivity of estrogen. Others may experience headaches during the
placebo week as a result of the withdrawal of estrogen.
find that their headaches either improve or worsen when CHCs are initiated.
Mild headaches may improve with time or if the woman is changed to a pill with
less estrogen or progestin. Headaches that occur during the placebo week can be
managed by trying desogestrel 0.15 mg/EE 10 to 20 mcg (e.g., Mircette, Kariva),
which minimizes the estrogen withdrawal by having only 2 days of placebos, or by
taking CHCs continuously (i.e., skipping placebo pills or the hormone-free week).
Patients with severe headaches should discontinue CHCs and should be evaluated by
their healthcare provider (see Contraindications above). D.S. is experiencing
headaches during the placebo week, indicating withdrawal of estrogen as the cause.
Skipping the placebo pills and using an extended-cycle regimen may help decrease
Weight gain associated with CHC use is another common concern for women. A
Cochrane review of three trials concluded that available evidence was insufficient to
determine an association between COCs and weight gain and also stated no large
If weight gain is a concern, a low-dose estrogen and low-dose
progestin products should be considered. Cyclic weight gain is generally caused by
the mineralocorticoid effects of EE-stimulating aldosterone receptors to retain
sodium, causing water retention and bloating. Too much progestin may cause an
increased appetite and noncyclic weight gain. Drospirenone with
antimineralocorticoid properties opposes EE effects, resulting in less water retention
and weight gain, and increases in appetite may not be as apparent. D.S. recently
increased her estrogen dose, which may be causing the “on and off” bloated feeling
and weight gain. She also stopped taking a drospirenone-containing product, which
may be why she did not experience the effects of bloating and weight gain with the
previous product. The clinician should explain that weight gain is a potential side
effect associated with COC use and is likely related to the estrogen component. It is
reasonable to consider an alternative COC because she is having estrogen
withdrawal headaches and weight gain. Desogestrel 0.15 mg/EE 10 to 20 mcg (e.g.,
Mircette) has lower estrogen activity than norethindrone 0.4 mg/EE 35 mcg (e.g.,
Ovcon-35; Table 47-3), which may help to decrease the cyclic weight gain and
headaches while still helping to control her acne. In addition, desogestrel 0.15
mg/EE 10 to 20 mcg retains high progestational activity to address D.S.’s previous
breakthrough bleeding and has low androgenic activity that will likely help her acne.
BREAST CANCER, CERVICAL DYSPLASIA, AND CERVICAL CANCER
CASE 47-2, QUESTION 8: The medical history and physical examination of D.S. are negative for breast
There are conflicting data regarding the association of COC use and breast cancer.
The reported overall lifetime risk of breast cancer in American women is 12% to
88 Older studies have indicated a possible link between COC use and breast
89–92 More recent studies suggest that COC use does not increase breast cancer
risk even with long-term use (e.g., 10 years).
In addition, other studies concluded
breast cancer rates in high-risk women with BRCA 1 and 2 mutations or strong
family history of breast cancer did not increase with COC use.
Congress of Obstetricians and Gynecologists (ACOG) does not consider a family
history of breast cancer (including BRCA 1 and 2) or benign breast disease a
COCs would not be expected to increase the risk of breast cancer in D.S. She
should be instructed to perform monthly breast self-examinations and to return
annually for a physical examination by her primary-care physician.
With regard to D.S.’s concern of cervical cancer, it is important to educate D.S.
about the incidence of cervical cancer and its relation to COC use. The American
Cancer Society estimates that more than 12,000 cases of invasive cervical cancer
will be diagnosed in 2017 and more than 4,000 women will die of it.
genetics, is the usual cause of cervical cancer.
Women at highest risk for cancer are those who are positive for certain subtypes of
human papillomavirus (HPV), who have certain sexual behaviors, who are
immunosuppressed, or who smoke.
3 Sexual behaviors associated with cervical
cancer include beginning sexual activity at a young age, having multiple male sexual
partners, and having a male sexual partner who has had
multiple partners. Women at low risk for cancer are those who have two or fewer
partners, whose partners use condoms, and who do not smoke.
Pooled data on cervical cancer risk from eight case–control studies found that oral
contraceptive users positive for HPV were more likely to develop cervical cancer.
Women who had ever used oral contraceptives and those who had used oral
contraceptives for more than 5 years were 1.5 and 3.4 times, respectively, more
likely to develop cervical cancer. This is consistent with older studies that suggest
that oral contraceptive users have an increased risk of developing or dying of
cervical cancer. In contrast, a large cohort study conducted in England found no
significant increase in deaths attributable to cervical cancer in women who had ever
Epidemiologic comparisons of the prevalence of cervical cancer in oral
contraceptive users versus nonusers often are difficult to interpret because yearly
medical examinations and regular Pap smears of COC users result in early detection
and treatment of precancerous lesions. Three vaccines for HPV are available for
women aged 9 to 26 years. Because D.S. is 20 years old, she may be a candidate for
the HPV vaccine (see Chapter 64, Vaccinations). D.S. may use COCs, should be
encouraged to have regular Pap smears, and should be counseled on the behaviors
that put her at risk for cervical cancer and the risks and benefits of the HPV vaccine.
USE DURING PREGNANCY AND BREAST-FEEDING
confirm the results and discuss the effects of her current medications on her unborn baby.
Vitals: weight, 143 lb; height, 5
Respiratory rate, 16 breaths/minute
Past medical history: history of abnormal menses, initiated on COC therapy to help regulate
Medications: desogestrel 0.15 mg/EE 30 mcg (Reclipsen)
Laboratory test results: blood test, qualitative human chorionic gonadotropin >25 mlU/mL
The fact that CHCs were classified as pregnancy category X (contraindicated, fetal
risks clearly outweigh maternal benefit) is very misleading.
designed studies found an association between COC use and cardiac or limb
anomalies, newer data suggest that CHC use does not substantially increase the risk
of anomalies over that expected in other uneventful pregnancies.
Although a CHC should not be started in a woman who might possibly be pregnant,
P.K. should be instructed to stop using her COC and be reassured that the risks to her
fetus from the use of a low-dose CHC during the first trimester are likely minimal,
while also informing her no drug is without risk and she should follow up with her
use while breast-feeding. What contraceptives are best for her while she is breast-feeding?
P.K. may use CHCs 6 weeks after she has her baby even if she is breast-feeding,
although it is preferable for her to use a progestin-only method.
recommends waiting at least 6 weeks before starting any estrogen-containing
contraceptive regardless of breast-feeding status. By this time, the increased risk of
postpartum and 6 weeks postpartum if solely breast-feeding and in some cases 3
weeks postpartum if partially breast-feeding.
26 However, COCs have been reported
to decrease milk quantity and quality.
26 Therefore, many providers suggest avoiding
postpartum to ensure the newborn is able to metabolize and clear the medication
because progestins enter breast milk.
Progestin-Only Pill (Minipill)
CASE 47-3, QUESTION 3: What advantages and disadvantages of the minipill should you discuss with
The minipill is devoid of some of the nuisance side effects (Table 47-4) caused by
estrogen (e.g., headaches, chloasma).
3 More importantly, estrogen-mediated
hypertension and clotting factor changes will be avoided. Confusion with pill taking
is minimized because there is no placebo week and all 28 pills in each pack are the
same. Therefore, the missed-dose directions are the same whenever any pill is
missed. Minipills also have noncontraceptive benefits, including decreased
dysmenorrhea and bleeding and possible protection against pelvic inflammatory
disease (PID) and endometrial cancer.
3 Women may also choose them because they
are not estrogen containing and fertility returns rapidly after discontinuation.
Theoretically, progestin use in the early postpartum period may decrease milk
production because milk production is triggered by the decline in progesterone that
occurs after delivery. However, no data have consistently shown this to be a problem
26 Once breast-feeding has been established, progestins have
not been shown to interfere with the quantity or quality of milk produced by a nursing
mother. Thus, a contraceptive method that is nonhormonal or only contains progestin
is preferred for a patient who plans to breast-feed her infant.
The minipill, with a failure rate of 0.3% to 8%, is similarly effective as COCs in
preventing pregnancies (Table 47-1).
3 Minipills, however, must be taken even more
and some shift back and forth between ovulatory and anovulatory (no ovulation
occurring) menstrual cycles. Women who consistently have menses on the minipill
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