Combination pill

The progestagens in combined pills include des-ogestrel, gestodene, norgestimate, ethynodiol, lev-onorgestrel and norethisterone. The first two agents have more favorable effects on plasma lipids and cardiovascular risk but are associated with higher risks of venous thromboembolism (see below). 

Patients taking the combined pill should be warned about loss of contraceptive effect due to... 

Of the various pharmacologic approaches to contraception, the combination pills are by far the most convenient and the most effective. In addition, several noncontraceptive benefits are recognized for combination oral contraceptives ... 

This is a combined pill but biphasic or triphasic in nature e.g. the estrogen level is kept constant but the progestin amount is low in early phase and increasing in subsequent phases of menstrual cycle. 

Small doses of progestins administered orally or by implantation under the skin can be used for contraception. They are particularly suited for use in patients for whom estrogen administration is undesirable. They are about as effective as intrauterine devices or combination pills containing 20-30 meg of ethinyl estradiol. There is a high incidence of abnormal bleeding. 

Bonnar J, Daly L, Carroll E. Blood coagulation with a combination pill containing gestodene and ethinyl estradiol. Int J Fertil 1987 32(Suppl) 21-8. 

Kamau RK, Maina FW, Kigondu C, Mati JK. The effect of low-oestrogen combined pill, progestogen-only pill and medroxyprogesterone acetate on oral glucose tolerance test. East Afr Med J 1990 67(8) 550-5. 

Connor, J., Rafter, N., and Rodgers, A. (2004), Do fixed-dose combination pills or unit-of-use packaging improve adherence A systematic review. Hr. World Health Org., 82, 935-939. 

Q10 In younger women, prescription of a combined oral contraceptive would both prevent pregnancy and reduce the symptoms of which Shabana complains. But at Shabana s age the combined pill is not recommended. What factors are considered when deciding to prescribe oral contraceptives in older women and what adverse effects have been linked to the use of these drugs ... 

Q7 The combined pills are a safe and effective method of contraception for most women. They decrease the incidence of amenorrhoea, irregular periods and intermenstrual bleeding, iron-deficiency anaemia, premenstrual tension and... 

The use of the progestogen-only pill is less reliable than the combined pill, and irregular bleeding might occur. 

The Royal College of General Practitioners (UK) recruited 23 000 women takers of fhe pill and 23 000 controls in 1968 and issued a report in 1973. It found an approximate doubled incidence of venous thrombosis in combined-pill takers (the dose of oestrogen has been reduced since this study). 

The combination is conveniently started on the first day of the cycle (first day of menstruation) and continued for 21 days (this is immediately effective, inhibiting the first ovulation). It is followed by a period of 7 days when no pill is taken, and during which bleeding usually occurs. Thereafter, regardless of bleeding, a new 21-day course is begun, and so on, i.e. active tablets are taken daily for 3 weeks out of 4. For easy compliance, some combined pills are packaged so that the woman takes one tablet every day without interruption (21 active then 7 dummy). 

Serious adverse effects of the combined pill are rare and several times a rare event is still a rare event. ... 

Missed pill. The following refers to the combined pill (see later for the progesterone-only pill). 

Intramuscular progestogen. A 3-month depot injection is equal in efficacy to the combined pill and is tin alternative. It works by inhibiting ovulation, and also renders cervical mucus impenetrable to sperm. 

Progestogen-only contraception is particularly appropriate to women having an absolute contraindication for oestrogen, e.g. history of thromboembolism, smokers over 35 years (who refuse to give it up), and for diabetics. Hypertension is not an absolute contraindication to the more effective combined pill since only a proportion of women have oestrogen dependent hypertension (and often such women are normotensive until exposed to increased levels of oestrogen). It is used by lactating women as it interferes with the milk less than the combined pill. 

A missed oral dose allows even less latitude than the combined pill. If a dose is more than 3 hours late it should be taken at once and a barrier method used for 7 days. Act similarly where there has been vomiting, severe diarrhoea, or if an enzyme-inducing drug has been taken. 

---