| YES |
| Debra A. Taubel, MD |
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As a practicing gynecologist with a primarily reproductive-age
patient population, I often prescribe “traditional” 21/7 oral contraceptives
(OCs). Am I in the minority? I don’t think so. Many patients
coming in to my office for the first time are already on 21/7 OCs.
The spectrum of combination (estrogen/progestin) OCs—which includes
the 21/7, 24/4, and extended-cycle pills—allows the practitioner to
prescribe medication based on the patient’s history, needs,
and desires. The physician must also consider previous success or
failure
with an OC formulation, in addition to other medications and conditions
(eg, endometriosis, menorrhagia, seizure disorder). On this basis
the appropriate OC can be selected and the patient monitored for
satisfaction
and adherence.
In many practices, extended-cycle OCs are discussed together with
other forms of contraception,1 and
many patients will initiate the topic. Breakthrough bleeding, common
in the first 3 months of use,2 may
not be an acceptable side effect for many patients. Other patients
do not
like the prospect of eliminating monthly periods, despite the evidence
that monthly menstruation is not necessary. Many patients are happy
with their current 21/7 OC, and do not wish to change—especially
when they are using a less expensive generic formulation.
Both of the available extended-cycle OCs have a 0.03-mg dose of
ethinyl estradiol, which may not provide sufficient estrogen to inhibit
breakthrough bleeding or ovulation if a patient is also using antiseizure
medication. In this case a traditional 21/7 pill would be the only
OC option.
Finally, many physicians use the 21/7 OCs to extend cycles by instructing
patients to skip the placebo pills and start a new pack without any
medication-free days. This allows patients the flexibility to delay
or skip a period to suit their needs and activities. Also, there
are many instances when gynecologists do not want patients to have
a period; for example, patients with symptomatic anemia due to menorrhagia
are often given OCs without the placebo pills, starting with two
pills per day to stop bleeding quickly. The availability of a higher
dose of estrogen per pill affords an efficient method for managing
these patients, especially in an emergency department where the 21/7
OCs are likely to be on formulary.
Extended-cycle OCs are an excellent addition to the OB/GYN’s
armamentarium but should not be viewed as a replacement for all other
OCs. They are a new way to deliver excellent contraception, but they
may not be the right choice for every patient for a variety of reasons.
Each patient should make the appropriate contraceptive choice for
herself based on thorough evaluation and discussion.
Debra A. Taubel, MD, is associate professor, Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York Presbyterian Hospital, New York.
References
- Sulak P, Buckley T, Kuehl
TJ. Attitudes and prescribing preferences of health care professionals
in the United States regarding use of extended-cycle oral contraceptives.
Contraception. 2006;73(1):41-45.
- Coffee A, Sulak P, Kuehl
TJ. Long-term assessment of symptomatology and satisfaction
of an extended oral contraceptive regimen. Contraception. 2007;75(6):444-449.
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| NO
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| Patricia J. Sulak, MD |
| |
| Slowly but surely OB/GYNs are seeing the death of 21/7 oral contraceptives
(OCs). Until recently, modifications of OC regimens have primarily
involved lowering hormone content and utilizing new progestin components.
The 21/7 OC regimen was created arbitrarily to mimic the average spontaneous
menstrual cycle of 28 days by inducing artificial withdrawal bleeding.
Today, however, this traditional regimen is undergoing necessary, overdue
changes in design.
Numerous studies have documented that lowering the hormone dosage in
OCs without altering the 7-day, hormone-free interval (HFI) compromises
ovarian suppression effects1 and can induce hormone withdrawal symptoms.2 Additionally, although today’s low-dose OCs effectively prevent
pregnancy if taken properly, nonadherence can compromise pituitary-ovarian
inhibition, leading to follicular growth, endogenous hormone production,
and potential ovulation.
The question is not whether the 21/7-day OC regimen should be altered,
but rather how should it be altered. There are currently several new
approaches to the OC regimen. Shortening the HFI of low-dose 21/7 OCs
can provide greater pituitary-ovarian inhibition, reducing the risk
of hormone withdrawal symptoms and pregnancy. Two OC products utilize
24 days of active hormones and a 4-day HFI. Extending the number of
active-pill days to 6, 9, 12, or more weeks is another alternative.
An 84/7 regimen is also available, but a 7-day HFI with an extended
regimen can lead to the same problems seen with the 21/7 OCs. A new
84-day OC adds low-dose estrogen to the 7 days that were previously
hormone-free, completely eliminating the HFI and the potential for
hormonal symptoms and ovulation. Such continuous OC regimens have been
used extensively for decades to treat endometriosis and other disorders.
The data are clear. The current 21/7 OCs using less than a .05-mg dose
of ethinyl estradiol need to be overhauled. They have documented design
flaws, including lack of ovarian suppression, possible ovarian cyst
formation and ovula
tion, and hormone withdrawal symptoms. These problems can result in
discontinuation and unintended pregnancy. Shortening the HFI, adding
estrogen to eliminate the HFI, and extending the active components
are all effective approaches providing greater ovarian suppression
and should eventually lead to the death of the 21/7 regimens. Physicians
need to set women up for success rather than failure, and the sooner
the better.
Patricia J. Sulak, MD, is professor, Department of Obstetrics and Gynecology, Texas A&M Health Science Center, College Station; director, Division of Ambulatory Care; and director, Sex Education Program, Scott & White Clinic Memorial
Hospital; Temple, TX.
References
- Willis SA, Kuehl TJ, Spiekerman AM, Sulak PJ. Greater inhibition of the pituitary-ovarian axis in oral contraceptive regimens with a shortened hormone-free interval. Contraception. 2006;74(2):100-103.
- Sulak PJ, Scow RD, Preece C, Riggs MW, Kuehl TJ. Hormone withdrawal symptoms in oral contraceptive users. Obstet
Gynecol. 2000;95(2):261-266.
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