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Providing oral contraceptives (OCs) to a young, healthy nonsmoker is an uncomplicated clinical decision, but what is your approach when dealing with patients with common conditions such as borderline high blood pressure?
Eileen Swanson, RN, women’s clinic coordinator for Kansas State University’s Lafene Health Center in Manhattan, poses such questions to Contraceptive Technology Update’s panel of experts.
Comments are from Andrew Kaunitz, MD, professor and assistant chair of obstetrics and gynecology at the Univer sity of Florida Health Sciences Center in Jackson ville; Michael Rosenberg, MD, MPH, clinical professor of obstetrics and gynecology and epidemiology at the University of North Carolina at Chapel Hill and president of Health Decisions, a private research firm; and Susan Wysocki, RNC, BSN, NP, president of the National Association of Nurse Practitioners in Women’s Health in Washington, DC.
Question: Which OCs are the best suited for a woman with a strong history of hypercholesterolemia? Should pills using norgestrel or levonorgestrel be avoided?
Kaunitz: Given the family history of lipid disorder, it would be appropriate to check a fasting lipid profile. If it returns normal, the choice of OC formulation is not necessarily of importance from a lipid perspective. However, if the patient is found to have elevated LDL and/or low HDL, an OC formulated with less androgenic progestins (norgestimate or desogestrel) would be appropriate. Specifically, norgestimate OCs and the 30 mcg estrogen/desogestrel formulation increase HDL and decrease LDL levels. If the sole abnormality is an increased triglyceride level, use of an OC with a more androgenic progestin (e.g., levonorgestrel) may lower the triglyceride level. However, if the baseline fasting triglyceride level is >300, avoid all estrogen-containing (combination) OCs and instead use progestin-only methods, which will not increase triglyceride levels, or an IUD.
Wysocki: While some studies have shown differences in laboratory parameters in HDL, LDL, and total cholesterol with various progestins, animal studies indicate that regardless of those laboratory parameters, low-dose combination OCs actually decrease the formation of athero scler otic plaque. In a study using macaque monkeys that were given high atherosclerotic diets, those on an OC formulation had fewer plaques than projected given the diet regimen.1 I am not aware of evidence that supports avoiding norgestrel or levonorgestrel.
Question: Should OC use be discontinued in patients with blood pressure (BP) elevations of 140/90? Is depot medroxyprogesterone acetate (Depo-Provera or DMPA) recommended for these patients? Also, please address your recommendations regarding a patient with a mild or moderately elevated BP who has a BMI of >30.0.
Kaunitz: All combination OCs raise ambulatory blood pressure to some degree. Therefore, clinicians should be very cautious recommending any combination OC to hypertensive women. I would only prescribe combination OCs to hypertensive women in the following circumstances:
• highly compliant woman with well- controlled hypertension;
• nonsmoking patient under age 35;
• communication with and support from clinician treating hypertension;
• close follow-up with frequent blood pressure monitoring is appropriate if OCs are prescribed in this setting.
Rosenberg: The literature linking OCs with increased blood pressure is both scanty and rather dated by today’s standards. In addition, elevated BP is easy to overdiagnose in obese subjects if the appropriate cuff is not used. In both cases, I believe that low-dose OCs — preferably 20 mcg, but also 30 mcg — should be instituted and then the BP carefully monitored. If the BP is elevated, then control with appropriate drugs or other measures is probably more significant than the contribution of OCs. In the end, each patient represents a mixture of risk that must be individually gauged and accordingly adjusted.
Wysocki: If this person’s blood pressure was normally 140/90, a trial of OCs could be initiated. Monitor — as you would even if not on OCs — the blood pressure to ensure that it doesn’t become elevated. DMPA is also an appropriate choice. The [Geneva, Switzerland-based] World Health Organi za tion Medical Eligibility Criteria specifies category 2 precaution for DMPA [can use method; advantages general outweigh theoretical or proven risks].2
Moreover, the issue with patients with mild hypertension and high BMI is to focus on helping them with lifestyle changes, such as diet and exercise. There is more chance of success with these strategies when a woman doesn’t experience an unintended pregnancy.
Question: Which OCs are best suited for a woman with a history of tension or migraine headaches?
Kaunitz: Traditionally, contraception experts have suggested that OCs can be prescribed to women with migraines provided:
• they were nonsmokers;
• migraines were without aura;
• no focal neurologic signs accompanied migraine;
• with close follow-up, migraine frequency and/or intensity did not increase after initiating combination OCs.
Recent U.S. and European epidemiologic studies, however, may suggest an even more conservative approach in this setting. In a U.S. study, use of combination OCs by women with a history of migraines was associated with an increased risk of stroke.3 A European study also found an increased risk of stroke in OC users with a history of migraine, whether or not the migraines were associated with aura.4
With or without OC use, strokes are fortunately very rare (but devastating) in reproductive age women. My perspective is that combination OCs do not represent an optimum contraceptive choice in any woman with a bona-fide history of migraine headaches. Progestin-only or intrauterine contraceptives are preferable in this setting. If a woman with migraines refuses to use these latter methods, combination OC use can be considered if the following criteria are met:
• nonsmoker, under age 35, with no history of diabetes or hypertension;
• close clinical monitoring, discontinuing OCs if frequency or intensity of migraines increases.
Rosenberg: There is little objective information, but anecdotal reports that Mircette [Organon, West Orange, NJ], which contains five days of 10 mcg of ethinyl estradiol during what would normally be a seven-day hormone-free interval, seems to work well.
Wysocki: There is no evidence to support claims that one OC is better than the next for tension headaches and menstrual (not neurological) migraines. However, since menstrual migraines are a result of decreased estrogen, those women may benefit from maintaining their estrogen level by decreasing or eliminating the hormone pill-free interval. One OC on the market [Mircette] offers 10 mcg of estrogen for five days during the week that is normally hormone-free.
The first consideration for choosing an OC for a woman with any special health circumstances, or any woman for that matter, is that the formulation is low-dose: less than 50 mcg. The second consideration is that the pill choice is covered under her insurance formulary.
1. Clarkson TB, Shively CA, Morgan TM, et al. Oral contraceptives and coronary artery atherosclerosis of cynomolgus monkeys. Obstet Gynecol 1990; 75:217-222.
2. Technical Guidance/Competence Working Group, and World Health Organization/Family Planning and Population Unit. Family planning methods: New guidance. Population Reports Series J; No. 44. Baltimore, MD: Johns Hopkins School of Public Health, Population Information Program; October 1996.
3. Schwartz SM, Petitti DB, Siscovick DS, et al. Stroke and use of low-dose oral contraceptives in young women: A pooled analysis of two U.S. studies. Stroke 1998; 29:2,277-2,284.
4. Chang CL, Donaghy M, Poulter N. Migraine and stroke in young women: Case-control study. The World Health Org anisation Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception. BMJ 1999; 318:13-18.