Combined oral contraceptives adverse effects

A woman experienced increased combined oral contraceptive adverse effects whiie taking nefazodone. 

While there are many non-contraceptive benefits associated with the use of combined oral contraceptives, their use is not without risk or potential for adverse effects. 

As with all medications, there are potential adverse effects with combined oral contraceptives (COCs). Many side effects can be minimized or avoided by adjusting the estrogen and/or progestin content of the oral contraceptive. It is also important to have proper patient selection for oral contraceptives because some women are at increased risk for potentially serious side effects. 

Lipid changes seen with the most widely used combined oral contraceptives comprise an increase in low density lipoprotein and reductions in high density lipoprotein and cholesterol. The third-generation products have these effects to a much smaller extent, leading to claims that they would be less likely to have long-term adverse cardiovascular effects related to atherosclerosis. However, such a claim reflects an all too readily adopted belief that the lipid changes produced by the more traditional combined oral contraceptives are in this respect capable of causing this type of (primarily arterial) cardiovascular disease. This is of itself far from certain. 

Data on the risk of infection with HIV (human immunodeficiency virus) with combined oral contraceptives are sparse some studies suggest an adverse effect and others show no association (270,285). 

However, on theoretical and practical grounds, such combinations have been developed and used for relatively short periods of treatment during the climacteric itself to regularize bleeding and to relieve menopausal symptoms. The pattern of short-term adverse effects of these products is very similar to that of the combined oral contraceptives. 

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 ... 

World Health Organization Category 3 Exercise caution if combined oral contraceptives are used or considered in the following situations and carefully monitor for adverse effects. 

A case report describes raised clozapine levels with associated adverse effects when a patient also took a combined oral contraceptive. 

The manufacturer also points out that combined oral contraceptives (and presumably the combined hormonal contraceptive patch) must not be taken with co-cyprindiol. To do this would be analogous to doubling the ethinylestradiol dose with consequent increased risk of adverse effects. In addition, some of the progestagens in combined oral contraceptives have weak androgenic effects, which could oppose the benefits of cyproterone. 

In a pharmacokinetic study, sodium valproate 200 mg twice daily had no effect on the AUC of a single dose of a combined oral contraceptive (ethi-nylestradiol/levonorgestrel 50/250 micrograms) given to women with epilepsy 8 to 16 weeks after they started sodium valproate. However, a 50% increase in the peak plasma levels of ethinylestradiol was noted. Conversely, one pregnancy was identified in a woman who took sodium valproate and an oral contraceptive (unspecified) in the adverse reactions... 

The adverse effects of isotretinoin and combined oral contraceptives on plasma lipids may be additive. A case-control study found that women who had hypertriglyceridaemia and/or hypercholesterolaemia while taking isotretinoin were 2 to 12 times as likely to be also taking an oral contraceptive. ... 

The pharmacokinetics of a single 20-mg dose of pravastatin were found to be unaffected in 15 young women taking combined oral contraceptives (ethinylestradiol with norethisterone, norgestrel or levonorgestrel), when compared with similar women not taking contraceptives. No adverse effects attributable to concurrent use were seen. ... 

The cardiovascular effects reported do not appear to be attributable to any effect of smoking on the metabolism of contraceptives steroids (see below). Rather, the adverse effects of combined oral contraceptives on cardiovascular risk factors, such as plasma lipids and coagulation parameters, appear to be accentuated by smoking. 

Although data are limited, the minor to modest possible ineieases in frov-atriptan, naratriptan, sumatriptan and zoimitriptan pharmacokinetics described are not likely to produce clinically relevant adverse effects. Almotriptan, rizatriptan and sumatriptan do not appear to have any clinically important effect on levels of contraceptive steroids. The significance of the single case report of ischaemic colitis associated with concurrent use of naratriptan and a combined oral contraceptive is unclear. Note that ischaemic colitis has, rarely, been reported with naratriptan itself The manufacturers have found no cases of ischaemic colitis in approximately 450 women on oral contraceptives and taking naratriptan for prophylaxis for 5 to 6 days. However, caution may be needed with concurrent use in those patients with risk factors for ischaemic colitis, such as those with a history of abdominal surgery, low blood pressure, diabetes, cardiovascular disease or stroke. 

A comparative study in men, women, and women taking combined oral contraceptives found that the clearance of clofibrate was increased by 48% in those taking combined oral contraceptives, apparently due to an increase in clofibrate glucuronidation. Another study found that combined oral contraceptives increased the excretion of clofibric acid glucuro-nide (the pharmacologically active form of clofibrate) by 25%. None of these studies addressed the question of whether concurrent use significantly reduces clofibrate efficacy, but it would seem prudent to monitor for increases in blood lipid levels. It should be noted that combined oral contraceptives themselves can have various adverse effects on lipid levels, and these may impair the effects of treatment. 

Fluvoxamine causes a very marked 33-fold increase in tizanidine levels with a consequent increase in hypotensive and sedative effects. The combination is potentially hazardous and should be avoided. Ciprofloxacin markedly increases tizanidine levels and adverse effects, and particular caution is required if this combination is considered essential Combined oral contraceptives increase tizanidine levels fourfold and might increase adverse effects. other inhibitors of CYP1A2 are predicted to interact similarly. 

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