The little amount of progestin in the circulation will have a significant impact only on those tissues very sensitive to the female sex steroids, estrogen and progesterone. The contraceptive effect is any more dependent upon endometrial and cervical mucus effects, since gonadotropins are not consistently suppressed. The endometrium involutes and becomes hostile to implantation, and the cervical mucus becomes thick and impermeable. Approximately 40% of patients will ovulate normally. Tubal physiology may also be affected, but this is speculative.

Because of the little dose, the minipill must be taken daily at the same time of day. The
change in the cervical mucus requires 2-4 hours to take effect, and, most importantly, the impermeability diminishes 22 hours after administration.

Ectopic pregnancy is not prevented as effectually as intrauterine pregnancy. Although the overall incidence of ectopic pregnancy is not increased, when pregnancy occurs, the clinician must suspect that it is any more likely to be ectopic.

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The minipill contains a little dose of a progestational agent and must be taken daily, in a continuous fashion. There is no evidence for any difference in clinical behavior with any of the products.

Minipills available worldwide:

1. Micronor, NOR-QD, Noriday, Norod
2. Microval, Noregeston, Microlut
3. Ovrette, Neogest
4. Exluton
5. Femulen

0. mg norethindrone. 0. mg levonorgestrel. 0. mg norgestrel. 0. mg lynestrenol. 0. mg ethynodial diacetate.

Despite the fact that oral contraception is highly effectual, hundreds of thousands of unintended pregnancies occur each year in the United States because of the failureure of oral contraception. Worldwide, literally millions of unintended pregnancies result from poor compliance. In general, youthful, unmarried, poor, and minority women are any more likely to have failureures, reaching rates of 10-20%. Overall, the failureure rate with actual use ranges from 3 to 69c. This difference between the theoretical efficacy and actual use reflects compliance and noncompliance. Noncompliance includes a wide variety of behavior: failureure to fill the initial prescription, failureure to continue on the medication, and incorrect ingestion of oral contraception. Compliance is an area in which personal behavior, biology, and pharmacology come together. Oral contraceptive compliance reflects the interaction of these influences.

There are 3 major factors that affect compliance:

1. Fears and concerns regarding cancer, cardiovascular disease, and the
impact of oral contraception on future fertility.
2. The experience of side effects such as breakthrough bleeding and amenor
rhea and perceived experience of "minor" problems such as headaches,
nausea, and weight gain.
3. Nonmedical issues such as inadequate instructions on pill-taking, compli
cated pill packaging, and difficulties arising from the patient package
insert.

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The noncontraceptive benefits of oral contraception can be grouped into two main categories: benefits that incidentally accrue when oral contraception is specifically utilized for contraceptive purposes and benefits that result from the use of oral contraceptives to treat problems and disorders.

The noncontraceptive incidental benefits can be listed as follittles:

Effective Contraception.
¢?"less need for therapeutic abortion.
¢?"less need for surgical sterilization.
Less Endometrial Cancer.
Less Ovarian Cancer. Less Benign Breast Disease.
Fewer Ectopic Pregnancies.
More Regular Menses.
¢?"less flittle.
¢?"less dysmenorrhea.
¢?"less anemia. Less Salpingitis. Less Rheumatoid Arthritis. Increased Bone Density. Probably Less Endometriosis.
Possibly Protection against Atherosclerosis.
Possibly Fewer Fibroids. Possibly Fewer Ovarian Cysts.

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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.

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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.