Oral contraceptives discontinuation

Rosenberg M, Waugh M. Oral contraceptive discontinuance a prospective evaluation of frequency and reasons. Am J Obstet Gynecol 1998 179 577-582. 

The incidence of serious known toxicities associated with the use of these drugs is low—far lower than the risks associated with pregnancy. There are a number of reversible changes in intermediary metabolism. Minor adverse effects are frequent, but most are mild and many are transient. Continuing problems may respond to simple changes in pill formulation. Although it is not often necessary to discontinue medication for these reasons, as many as one third of all patients started on oral contraception discontinue use for reasons other than a desire to become pregnant. 

The effects of warfarin may increase when administered with acetaminophen, NSAIDs, beta blockers, disulfiram, isoniazid, chloral hydrate, loop diuretics, aminoglycosides, cimetidine, tetracyclines, and cephalosporins. Oral contraceptives, ascorbic acid, barbiturates, diuretics, and vitamin K decrease the effects of warfarin. Because die effects of warfarin are influenced by many drugp, die patient must notify die nurse or die primary healdi care provider when taking a new drug or discontinuing... 

There is an increased risk of post-operative thromboembolic complications in women taking oral contraceptives Ifposs-bte, use of the drug is discontinued at least 4 weeks before a surgical procedure associated with thromboembolism or during prolonged immobilization. 

The risk of endometrial cancer among women who have used oral contraceptives for at least 1 year is approximately 40% less than the risk in women who have never used oral contraceptives.9 There is additional evidence to suggest that the benefit of reduced risk for endometrial cancer is detectable within 1 year of use10-12 and that the benefit may persist for years following discontinuation of oral contraceptives.9... 

Table 46-1 illustrates the pathophysiology of amenorrhea relative to the organ system(s) involved, as well as the specific condition that results in amenorrhea. Amenorrhea is also a normal side effect that may result from the use of low-dose oral contraceptives (OCs), extended-cycle OC pill use, or depot medroxyprogesterone acetate use.5 Many women may experience delayed return of menses after discontinuation of OCs. Postpill amenorrhea usually is a self-limited condition. Further evaluation for other unrecognized conditions, such as polycystic ovary syndrome (PCOS), should be considered if spontaneous resolution of the amenorrhea does not occur within 3 to 6 months following discontinuation of the OCs.6,7... 

A 0.5% incidence of migraines has been reported among users of oral contraceptives. Migraine headaches may be a warning signal for an oncoming stroke, and immediate discontinuation of oral contraceptive use is recommended. 

There is some delay in the return of fertility after discontinuation of oral contraceptive use. Gonadotropin profiles should be normal 3 months after combination oral contraceptive use is stopped. The incidence of prolonged amenorrhea extending beyond 6 months is 2 to 3%. This reaction is especially a problem with the use of progestin-only minipills. 

The use of oral contraceptives may interfere with lactation. In addition, the hormones may be present in the mother s milk, hence be taken in by the nursing ctfild. If breast feeding is planned, the use of oral contraceptives should be discontinued until after weaning. 

Levodopa or dopamine agonists produce diverse dyskinesias as a dose-related phenomenon in patients with Parkinson s disease dose reduction reverses them. Chorea may also develop in patients receiving phenytoin, carbamazepine, amphetamines, lithium, and oral contraceptives, and it resolves with discontinuance of the offending medication. Dystonia has resulted from administration of dopaminergic agents, lithium, serotonin reuptake inhibitors, carbamazepine, and metoclopramide and postural tremor from theophylline, caffeine, lithium, valproic acid, thyroid hormone, tricyclic antidepressants, and isoproterenol. 

A meta-analysis of epidemiological studies of ovarian cancer showed a summary estimated relative risk of 0.64 for ever-use of combined oral contraceptives, implying a 36% reduction in ovarian cancer risk (130). This protective effect increased with increasing duration of oral contraceptive use and continued for at least 10 years after discontinuation. Although most of the oral contraceptives reported in these studies were older, higher-dose formulations, the Cancer and Steroid Hormone (CASH) study included users of tablets containing ethinylestradiol 35 pg or less, and this subgroup of women had a reduced risk of ovarian cancer (115). 

Buhler H, Pirovino M, Akobiantz A, Altorfer J, Weitzel M, Maranta E, Schmid M. Regression of liver cell adenoma. A follow-up study of three consecutive patients after discontinuation of oral contraceptive use. Gastroenterology 1982 82(4) 775-82. 

Marks WH, Thompson N, Appleman H. Failure of hepatic adenomas (HCA) to regress after discontinuance of oral contraceptives. An association with focal nodular hyperplasia (FNH) and uterine leiomyoma. Ann Surg 1988 208(2) 190-5. 

Although it was originally believed that women who stopped taking oral contraceptives, particularly after a long period of use, were more likely to have amenorrhea, careful analysis has shown that that is not the case. The likelihood of conception is reduced during the first 1-2 months after discontinuation, but cumulative conception rates after several months are not affected. 

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