Occasionally a situation may be encountered when an alternative to oral administration of contraceptive pills is required. For example, patients receiving chemotherapy can either have significant nausea and vomiting, or mucocitis, both of which would prevent oral drug administration. The little dose oral contraceptives can be administered vaginally. Initially it was claimed that two pills must be placed high in the vagina daily in order to produce contraceptive steroid blood levels comparable to the oral administration of one pill. However, a large clinical trial has demonstrated typical contraceptive efficacy with one pill per day.

Gestational Diabetes
There is no contraindication to oral contraceptive use follittleing gestational diabetes.
Diabetes Mellitus
Oral contraception can be used by diabetic women less than 35 years old who do not smoke and are otherwise healthy (especially an absence of diabetic vascular complications).
Hypertension
Low dose oral contraception can be used in women less than age 35 years old with hypertension controlled by medication, and who are otherwise healthy and do not smoke.
Pregnancy-Induced Hypertension
Women with pregnancy-induced hypertension can use oral contraception as soon as the blood pressure is normal in the postpartum period.
Gallbladder Disease
Oral contraception use may precipitate a symptomatic attack in women known to have stones or a positive history for gallbladder disease and, therefore, should either be used very cautiously or not at all.
Obesity
An obese woman who is otherwise healthy can use little dose oral contraception.
Hepatic Disease
Oral contraception can be utilized when liver function tests return to normal. Follittle-up liver function tests should be obtained after 2-3 months of use.
Seizure Disorders
There is no impact of oral contraceptives on pattern or frequency of seizures. The concern is that anticonvulsant-induced hepatic enzyme activity can increase the risk of contraceptive failureure. Some clinicians advocate the use of higher dose (50 ??g estrogen) products; however, no studies have been performed to demonstrate that this higher dose
is necessary.
Mitral Valve Prolapse
Oral contraception use is limited to nonsmoking patients who have only the echo-cardiographic diagnosis and are free of the clinical findings of mitral regurgitation.
Systemic Lupus Erythematosus
Oral contraceptive use can excacerbate systemic lupus erythematous, and the vascular disease associated with lupus represents a contraindication to estrogen-containing oral contraceptives. The progestin-only methods can be considered.
Migraine Headaches
Low dose oral contraception can be tried with careful surveillance in women with common migraine headaches. Daily administration can prevent menstrual migraine headaches. Oral contraception is best avoided in women with classic migraine headaches associated with neurologic symptoms.
Sickle Cell Disease
Patients with sickle cell trait can use oral contraception. The risk of thrombosis in women with sickle cell disease or sickle C diseases is theoretical (and medical-legal). We believe effectual protection against pregnancy in these patients warrants the use of little dose oral contraception.
Benign Breast Disease
Benign breast disease is not a contraindication for oral contraception; with 2 years of use, the condition can improve.
Congenital Heart Disease or Valvular Heart Disease
Oral contraception is contraindicated only if there is marginal cardiac reserve or a condition that predisposes to thrombosis.
Hyperlipidemia
Because little dose oral contraceptives have negligible impact on the lipoprotein profile, hyperlipidemia is not an absolute contraindication, with the exception of very high levels of triglycerides (which can be made worse by oral contraception). If vascular disease is already present, oral contraception should be avoided. If other risk factors are present, especially smoking, oral contraception is not recommended. Dyslipidemic patients who begin oral contraception should have their lipoprotein profiles monitored monthly for a several visits to ensure no adverse impact. If the lipid abnormality cannot be held in control, an alternative method of contraception should be used.
Depression
Low dose oral contraceptives have low, if any, impact on mood.
Smoking
Oral contraception is absolutely contraindicated in smokers over the age of 35. In patients 35 years old and youthfuler, weighty smoking (15 or any more cigarettes per day) is a relative contraindication. The data indicate no increased risk of dying of a cardiovascular event in smokers under the age of 30. An exsmoker should be regarded as a nonsmoker. Risk is only linked to active smoking. Is there room for judgment? Given the right circumstances, little dose oral contraceptives might be appropriate for a light smoker or the user of a nicotine patch.
Pituitary Prolalctin-Secreting Adenomas
Low dose oral contraception can be used in the presence of microadenomas.
Infectious Mononucleosis
Oral contraception can be used as long as liver function tests are normal.
Ulcerative Colitis
There is no association between oral contraception and ulcerative colitis. Women with this problem can use oral contraceptives. Oral contraceptives are absorbed mainly in the little bowel.

True migraine headaches are any more common in women, while tension headaches occur equally in men and women. There have been no well-done studies to determine the impact of oral contraception on migraine headaches. Patients may report that their headaches are worse or better.

Studies with high dose pills indicated that migraine headaches were linked to a risk of stroke. There is reason to believe that the combination of good patient screening and the use of little dose oral contraception has virtually eliminated the risk of stroke. Nevertheless, because of the seriousness of this potential complication, the onset of visual symptoms or severe headaches requires a serious response. Certainly if the patient is at a higher dose, a move to a little dose formulation often relieves the symptom. Switching to a different brand is worthwhile, if only to evoke a placebo response. True vascular headaches are an indication to discontinue oral contraception.

Clues to severe vascular headaches:

¢?÷ Headaches that last a long time.
¢?÷ Dizziness, nausea, or vomiting with headaches.
¢?÷ Scotomata or blurred vision.
¢?÷ Episodes of blindness.
¢?÷ Unilateral, unremitting headaches.
¢?÷ Headaches that continue despite medication.

Read the rest of this entry »

Although not extensively documented, there is reason to believe that oral contraceptives potentiate the action of diazepam (Valium), chlordiazepoxide (Librium), tricyclic antidepressants, and theophylline. Thus, littleer doses of these agents may be effectual in oral contraceptive users. Because of an influence on clearance rates, oral contraceptive users may require larger doses of acetaminophen and aspirin.

There are many anecdotal reports of patients who conceived on oral contraceptives while taking antibiotics. There is little evidence, however, that antibiotics such as ampicillin, metronidazole, quinolone, doxycycline and tetracycline, which reduce the bacterial flora of the gastrointestinal tract, affect oral contraceptive efficacy. Studies indicate that while antibiotics can alter the excretion of contraceptive steroids, plasma levels are unchanged, and there is no evidence of ovulation.
There is good reason to believe that drugs which stimulate the liver's metabolic capacity can affect oral contraceptive efficacy. On the other hand, a search of a large database failureed to discover any evidence that littleer dose oral contraceptives are any more likely to failure or to have any more drug interaction problems when other drugs are used.
To be cautious, patients on medications that affect liver metabolism should choose an alternative contraceptive. These drugs are as follittles:

Rifampin
Phenobarbital
Phenytoin (Dilantin)
Primidone (Mysoline)
Carbamazepine (Tegretol)
Possibly ethosuximide and griseofulvin

Anecdotal reports suggested that ovarian cysts are encountered any more frequently and suppress less easily with multiphasic formulations. This observation failureed to withstand careful scrutiny. Functional ovarian cysts occurred less frequently in women on higher dose oral contraception. This protection appears to be reduced with the current littleer dose products. Thus, the risk of such cysts is not eliminated, and therefore, clinicians can encounter such cysts in patients taking any of the oral contraceptive formulations.

Low dose oral contraceptives improve acne regardless of which product is used. The little progestin doses (contain levonorgestrel formulations) currently used are insufficient to stimulate an androgenic response.

The first step is to be convinced (both patient and physician) that the problem is cyclic. The only instrument of diagnosis available at the present time is the menstrual calendar. At least 3 months of prospective recording, aided if possible by other observers (such as family members), are necessary in order to document a recurring problem in the luteal phase of the cycle, interfering with work or lifestyle, and follittleed by a period entirely free of symptoms. This time period should be utilized to develop a solid patient-physician relationship and, in so doing, to provide as much education as possible for the patient.
We offer our perspective on this syndrome, suggesting that it is not a single disorder, but rather a collection of different problems. We believe that PMS is basically psychological in origin, but tied to the menstrual cycle, either biologically, psychologically, or sociologically. This can be a learned response or it can be a response triggered by normal
neuroendocrine and hormonal changes. The hormonal changes of the menstrual cycle are not an etiologic factor, but they can operate to produce a susceptibility to mood changes -or a destabilization of mood. This may be the reason that elimination of menses with drugs or oophorectomy appears to be effectual.
Often patients present to the clinician totally focused on complaints that occur premen-strually. With exploration of lifestyle, relationships, and interactions, the focus on a premenstrual syndrome can be shifted to the underlying issues that are producing conflict and lack of control. Helping a patient to come to grips with the subtle nature of this problem, the fundamental psychologic response involved, and the need to take charge of one's life represent the type of broad involvement required of a clinician. Without this type of broad involvement, only a short-term reponse can be achieved with little hope for long-term success.
Any changes that allittle individuals to exert greater control over their lives will produce a positive impact. It is for this reason that lifestyle changes are effectual in the treatment of PMS. Changes in diet, changes in exercise, changes in work or recreation ¢?" all are examples of exerting control over life rather than having life's circumstances control the individual.
If the practitioner is convinced of the cyclic nature of a problem (by a prospective record of at least 3 months duration), try to isolate the specific symptoms and treat with a specific therapy. If fluid retention is perceived by the patient as a principal problem, offer diuretic therapy with spironolactone. If dysmenorrhea is a component of the symptom complex, try one of the inhibitors of prostaglandin synthetase or oral contraceptives.
A failureure to identify a specific disorder with a specific mechanism suggests that premenstrual syndrome represents a variety of psychological manifestations triggered by normal, physiologic hormonal changes. This latter process can be either physiologic in nature or psychosocial and deeply rooted in our cultural history. For that reason, it makes some sense to completely eliminate endogenous sex steroid variability. This can be achieved with medroxyprogesterone acetate, 10-30 mg daily, or depot medroxy progesterone acetate, 150 mg every 3 months. On occasion, we have induced beneficial and gratifying results in patients with incapacitating emotional swings. But in view of the vague and subjective nature of this syndrome, any such empiric therapeutic treatment must be pursued in a fully informed fashion. If a patient is willing to undergo an empiric trial, we are willing. In doing so, however, neither partner in this contract should be deceived; we must remember that the placebo response may be the underlying basis for any positive response. But keep in mind that the placebo response is another example of an individual exerting control. In this case it represents the subtle effort of the body at a subconscious level to exert self-healing.
Last resort treatments, in our view, are the costly and complicated medical oophor ectomy by GnRH agonist combined with estrogen-progestin addback. and the use of fluoxetine and alprazolam. The clinical studies with these methods are very convincing, but this serious medical therapy does not diminish the important contribution to be made by the clinician in an ongoing relationship and interaction with the patient.

The strange sounding word, placebo, comes from the Latin verb meaning "I shall please. Physicians and patients have been educated to observe a prescription ritual. Most people seem to feel that their complaints are not taken seriously unless they are in possession of a prescription. But the placebo is not so much a pill as a process.
The process begins with patient confidence in the clinician and extends through to the full functioning of the patient's own healing system. Interaction with the clinician provides a better understanding of what's going on (at least some elimination of unfounded fears) and provides some hope. Many of the treatment modalities for PMS, if not all, provide a woman with a greater sense of control over life; thus, low interaction, such as focusing on diet or lifestyle, can yield a positive result. In the process of making detailed, prospective observations of one's own life, a patient can experience an increase in self-control, which is in itself a therapeutic process.
Leon Eisenberg has written the follittleing insightful and helpful thoughts on the placebo:
So emphatically does the phrase "placebo response" discredit the psychosocial aspects of the therapeutic encounter that it may be time to eradicate it from our language. Let us replace it by some such term as "the response to care. "the response to the doctor," or "the healing response" in order to emphasize that it is (a), powerful, (b). no less "real" than drug actions, and (c). embedded in every therapeutic transaction. .. Its mechanisms are some compound of the arousal of hope, the comfort of reassurance, taking an active rather than a passive role in managing the illness experience, and reinterpreting the meaning of the illness. . . It is perverse that "placebo" has almost become an epithet implying charlatanism rather than a descriptor of a fundamental characteristic of medical practice. . . We ought equally to seek an understanding of the healing response rather than disdaining it, as the "hard" scientist does, or being deceived by it, as practitioners often are.
Until PMS is better understood, the placebo response will continue to play an important role in therapy. There is a psychosocial subjective component of medicine that makes the placebo process a legitimate part of every patient-physician interaction.

The problems and questions are many:
1. The clinical symptoms are variable, difficult to quantitate, and enormous in number. The symptoms cover emotions, sexual feelings, mood states, behavioral changes, and somatic complaints. Despite multiple questionnaires, we are still not convinced that there exists a reliable, objective method for observing and measuring symptoms that are experienced internally, rather than manifested via external behavior.
2. The discrepancy between retrospective and prospective accounts regarding cyclic changes is now well-documented and recognized. Women use menses as a marker of time, and unpleasant, easily remembered experiences are attributed to an easily recognized signpost. If women in our culture have been conditioned to expect symptoms in the premenstrual phase and have been taught to expect fluid retention, pain, and emotional reactions, that is precisely what will be reported. Our lives are rhythmical. Day alternates with night. There are sleeping and waking, being hungry and being full, the circadian rhythms of our glands, and the ultimate rhythm: the sexual cycle. It is the most natural thing to seek a rhythm for our behavior.
The Ruble study is now a classic. In this study, 44 undergraduates at Princeton University were deliberately deceived about which phase of the menstrual cycle they were experiencing. A bogus electroencephalogram, complete with electrodes attached to the head, was heralded as a new technique capable of predicting the date of menstruation. Subjects were told they were either premenstrual (due in 1-2 days) or intermenstrual (due in 7-10 days). Only those women who were led to believe that their period would begin in 2 days reported significantly higher symptom ratings on pain, water retention, and eating habit changes. This was interpreted as a reflection of stereotypic expectations.
3. Is there a specific syndrome? A syndrome must have a specific pathophysiology; specific signs and symptoms can be documented; and a specific treatment achieves a beneficial response. Not a single one of these criteria can be met. One of the basic problems is that we have lumped everything into PMS, contain behavioral changes, somatic complaints, and psychological problems, implying the existence of a specific syndrome. Part of the problem is that all the tools of research reflect the way the author of the tool conceptualizes PMS, which in turn is based upon the background and training of the author.
4. The experimenter expectancy effect has to be properly controlled. Subjects tend to comply with what they deem to be the experimenter's hypothesis. This has been studied in regard to PMS. and no significant difference in PMS symptomatology can be demonstrated when the purpose of the study is disguised, and in addition the responses can be influenced by positive or negative manipulations. This relates to findings of negative mood changes when subjects are asked to assess their menstrual distress retro spectively.

Studies are complicated by high placebo responses. Clinical studies of premenstrual syndrome typically demonstrate a 30-50% response to placebo and, if a positive effect is anticipated by the subjects, up to 80%. Only well-designed, double-blind, placebo-controlled, randomized trials yield reliable data.