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Table 17 3 Commonly used low-dose oral contraceptives
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Name COMBINATION Alesse2,3 Loestrin 1/202 Mircette2 Yaz Loestrin 15/302 Lo-Ovral2 Levlen2 Ortho-Cept Desogen Yasmin Brevicon2 Modicon Demulen 1/352 Ortho-Novum 1/352 Ortho-Cyclen Ovcon 35
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Progestin 01 mg levonorgestrel 1 mg norethindrone acetate 015 mg desogestrel 3 mg drospirenone 15 mg norethindrone acetate 03 mg norgestrel 015 mg levonorgestrel 015 mg desogestrel 3 mg drospirenone 05 mg norethindrone 1 mg ethynodiol diacetate 1 mg norethindrone 025 mg norgestimate 04 mg norethindrone
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Estrogen (Ethinyl Estradiol) 20 mcg 20 mcg 20 mcg 20 mcg 30 mcg 30 mcg 30 mcg 30 mcg 30 mcg 35 mcg 35 mcg 35 mcg 35 mcg 35 mcg
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COMBINATION: OTHER Seasonale 015 mg levonorgestrel Seasonique TRIPHASIC Estrostep 015 mg levonorgestrel (days 1 84)/ 0 mg levonorgestrel (days 85 91)
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30 mcg 30 mcg (84 days)/10 mcg (7 days)
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10 mg norethindrone acetate (days 1 5) 10 mg norethindrone acetate (days 6 12) 10 mg norethindrone acetate (days 13 21) 01 mg desogestrel (days 1 7) 0125 mg desogestrel (days 8 14) 015 mg desogestrel (days 15 21) 018 norgestimate (days 1 7) 021 norgestimate (days 8 14) 025 norgestimate (days 15 21) 005 mg levonorgestrel (days 1 6) 0075 mg levonorgestrel (days 7 11) 0125 mg levonorgestrel (days 12 21) 05 mg norethindrone (days 1 7) 075 mg norethindrone (days 8 14) 1 mg norethindrone (days 15 21) 018 mg norgestimate (days 1 7) 0215 mg norgestimate (days 8 14) 025 mg norgestimate (days 15 21) 05 mg norethindrone (days 1 7) 1 mg norethindrone (days 8 16) 05 mg norethindrone (days 17 21)
20 mcg 30 mcg 35 mcg 25 mcg
$4607
Cyclessa2
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Ortho-Tri-Cyclen Lo
25 mcg
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Triphasil2,3
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Ortho-Novum 7/7/72, 3
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Ortho-Tri-Cyclen2,3
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Tri-Norinyl2,3
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PROGESTIN-ONLY MINIPILL Ortho Micronor2,3 035 mg norethindrone to be taken continuously Ovrette
(None) (None)
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0075 mg norgestrel to be taken continuously
Average wholesale price (AWP, for AB-rated generic when available) for quantity listed Source: Red Book Update, Vol 26, No 3, March 2007 AWP may not accurately represent the actual pharmacy cost because wide contractual variations exist among institutions 2 Generic equivalent available 3 Multiple other brands available
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flow of milk It is often tried by women who want minimal doses of hormones and by patients who are over age 35 They lack the cardiovascular side effects of combination pills The minipill can be safely used by women with sickle cell disease (S/S or S/C) 3 Complications and contraindications Minipill users often have bleeding irregularities (eg, prolonged flow, spotting, or amenorrhea); such patients may need regular pregnancy tests Ectopic pregnancies are more frequent, and complaints of abdominal pain should be investigated with this in mind The absolute contraindications and many of the relative contraindications listed in Table 17 4 apply to the minipill Minor side effects of combination oral contraceptives such as weight gain and mild headache may also occur with the minipill
ACOG Committee on Practice Bulletins Gynecology ACOG practice bulletin No 73: Use of hormonal contraception in women with coexisting medical conditions Obstet Gynecol 2006 Jun;107(6):1453 72 [PMID: 16738183] Hatcher RA et al Contraceptive Technology, 18th edition Ardent Media, New York, 2004 Reproductive Health and Research; World Health Organization: Medical Eligibility Criteria for Contraceptive Use WHO/RHR 2004, Geneva http://wwwwhoint/reproductive-health/ publications/mec/indexhtm Reproductive Health and Research; World Health Organization: Selected Practice Recommendations for Contraceptive Use WHO/RHR 2004, Geneva http://wwwwhoint/reproductivehealth/publications/spr/indexhtm
Table 17 4 Contraindications to use of oral contraceptives
Absolute contraindications Pregnancy Thrombophlebitis or thromboembolic disorders (past or present) Stroke or coronary artery disease (past or present) Cancer of the breast (known or suspected) Undiagnosed abnormal vaginal bleeding Estrogen-dependent cancer (known or suspected) Benign or malignant tumor of the liver (past or present) Uncontrolled hypertension Diabetes mellitus with vascular disease Age over 35 and smoking > 15 cigarettes daily Known thrombophilia Migraine with aura Active hepatitis Surgery or orthopedic injury requiring prolonged immobilization Relative contraindications Migraine without aura Hypertension Cardiac or renal disease Diabetes mellitus Gallbladder disease Cholestasis during pregnancy Sickle cell disease (S/S or S/C type) Lactation
h Other disorders Depression may occur or be worsened with oral contraceptive use Fluid retention may occur Patients who had cholestatic jaundice during pregnancy may develop it while taking birth control pills 6 Minor side effects Nausea and dizziness may occur in the first few months of pill use A weight gain of 2 5 lb commonly occurs Spotting or breakthrough bleeding between menstrual periods may occur, especially if a pill is skipped or taken late; this may be helped by switching to a pill of slightly greater potency (see section C, above) Missed menstrual periods may occur, especially with lowdose pills A pregnancy test should be performed if pills have been skipped or if two or more menstrual periods are missed Depression, fatigue, and decreased libido can occur Chloasma may occur, as in pregnancy, and is increased by exposure to sunlight
2 Contraceptive Injections & Implants (Long-Acting Progestins)
The injectable progestin medroxyprogesterone acetate (DMPA) is approved for contraceptive use in the United States There is extensive worldwide experience with this method over the past 3 decades The medication is given as a deep intramuscular injection of 150 mg every 3 months and has a contraceptive efficacy of 997% A subcutaneous preparation, containing 104 mg of DMPA is available in the United States Common side effects include irregular bleeding, amenorrhea, weight gain, and headache It is associated with bone mineral loss that is usually reversible after discontinuation of the method Users commonly have irregular bleeding initially and subsequently develop amenorrhea Ovulation may be delayed after the last injection Contraindications are similar to those for the minipill A monthly injectable containing both depot medroxyprogesterone acetate and an estrogen, estradiol cypionate (Lunelle), has been available in the United States, although it is not being marketed currently It is highly effective, with a first-year pregnancy rate of 02% and a side effect profile similar to that of oral contraceptives A single-rod, subdermal progestin implant, Implanon, has been approved for use in the United States Implanon is a 40-mm by 2-mm rod containing 68 mg of the progestin etonogestrel that is inserted in the inner aspect of the nondominant arm Insertion and removal are much simpler and faster than with Norplant Hormone levels drop rapidly after removal, and there is no delay in the return of
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