Why are there so many different types of oral contraceptives? – The Estrogen Equation

Well, if you’ve read my previous post (which I’m sure you did!) you already know that the two main components of combined OCP’s are estrogen and progesterone.  What makes each type of pill distinct is the way in which these two components are dosed and formulated.  In this post, let’s discuss only the estrogen component.  We can talk about the progesterone later.

Combination OCP’s can be described as low-dose, medium-dose or (rarely) high-dose.  This refers to the dose of estrogen in the tablet.  A low-dose pill usually contains 20 micrograms of estrogen.  Medium dose pills contain between 30 and 35 micrograms.  Higher doses can go up to 50 micrograms.   

Why does it matter?  Well, a low-dose pill is great for somebody who needs the pill for pregnancy prevention, but doesn’t require the higher doses needed to suppress other conditions (like endometriosis or excessive menstrual bleeding).  A low dose of estrogen also minimizes the risk of complications from oral contraceptives (such as an increased risk of blood clots and other potentially life-threatening medical conditions). 

So, why wouldn’t everyone choose to take a low-dose pill?  Some women taking low-dose pills may not have bleeding during the week of placebos (inactive pills) because the low dose of estrogen keeps the lining of the uterus (womb) very thin.  Therefore, little tissue is shed (as menstrual flow) when the body withdraws from the estrogen.  Amenorrhea (absence of a period) can be normal and healthy in this situation and is not a cause for concern in the absence of other symptoms. 

In some women, bleeding between periods (metrorrhagia) may occur when the dose of estrogen is too low to stabilize the lining of the uterus between cycles.  If this occurs, it doesn’t mean the pill isn’t protecting you against pregnancy.  It just means you may need to switch to a different pill in order to reduce inconvenient or unpredictable bleeding

Spotting or mid-cycle bleeding can also be more likely to occur on a low-dose pill if doses are missed or are taken late.  Therefore a low-dose pill may be a poor option for women who can’t manage to take their pill on time every day.  Obviously, back-up contraception (a condom, perhaps?) should be used when necessary.

Oral contraceptives with 30 to 35 micrograms of estrogen may be a better choice for women who need to suppress their menstrual cycles because of endometriosis, pelvic pain, excessive menstrual bleeding (menorrhagia), or who have had irregular bleeding on lower dose oral contraceptives. 

If they dose of estrogen is the same in every pill, the type of pill can be called “monophasic.”  Some oral contraceptives have a dose of estrogen which varies from the first to the third week (triphasic).  These pills are meant to mimic the natural variation in hormones that occurs during a normal menstrual cycle.  Whether a monophasic or a triphasic pill is right for you will depend on a number of factors which you may wish to discuss with your gynecologist.

June 9, 2010 at 10:12 pm 1 comment

Oral Contraceptives: The little pill that could (and did!)

Continuing our journey through the world of contraception, I think The Pill deserves special mention.  It has been used in the US since 1960 as a way of preventing pregnancy.  It continues to be one of the most popular methods of birth control.

Running the risk of waxing overly poetic, I’ll tell you that The Pill has a long and storied history which has helped shape the roles of women in society.  It has freed a generation of women from fear of unwanted pregnancy and has helped countless others battle the miseries associated with their monthly gift.  But what is this miracle tablet?  What’s in it?  And  how is it used?  

‘The Pill’ is a common term for what the medical community calls a ‘combined oral contraceptive’ or ‘oral contraceptive pill’ (OCP).  This consists of a combination of estrogen and progesterone which is taken in order to prevent pregnancy. 

It does this in several ways.  The most important of these is that OCP’s prevent ovulation, the release of an egg from a woman’s ovary.  No egg, no baby.  Easy. 

It also causes a thickening of cervical mucus.  While this may sound kinda icky, it actually serves the important purpose of reducing the likelihood sperm will be able to pass through the cervix and up through the uterus and tubes on its way to fertilize an awaiting egg (which isn’t going to be there anyway… see above).  No egg-sperm rendezvous, no baby.

It also causes a thinning of the lining of the uterus, reducing the likelihood that, even if a runaway egg and super-ambitious sperm were to elope successfuly, a resulting embryo would not be able to implant.  No implantation, no pregnancy.  (This, by the way, is NOT an abortion.  An embryo needs to implant in order to establish a pregnancy.  Otherwise, you get a normal period.) 

In order for an OCP to effectively prevent pregnancy, it needs to be taken every day for 21-24 days a month.  In a best-case scenario, it should be taken at the same time every day.  This is what’s called “perfect use.”  Humans are not perfect.  Given an opportunity to screw up, we will most likely take it at some point in our lives.  This is called “typical” use.  Therefore, when we talk about the likelihood somebody will get pregant while taking OCP’s we talk about “perfect” and “typical” use patterns. 

The pregnancy rate among “typical” users of OCP’s varies depending on the population being studied and ranges from 2-8% per year. On the other hand, the rate of pregnancy among “perfect” users of OCP’s is about 0.3% per year.  I don’t know about you, but I think that’s pretty good motivation to stive for “perfection.” 

Some combined oral contraceptives aren’t pills at all, but are administered as a vaginal ring (Nuvaring) or a patch (Ortho-Evra).  These can be good options for some patients who can’t reliably take a pill every day.  (However, the Ortho-Evra patch has been scrutinized for the possibility that it delivers more estrogen than most other combined contraceptives, including the ring, and that it may lead to an increased risk of blood clots in some patients.  See below.)

A caveat:  You want to talk to your gynecologist before starting an OCP.  The pill doesn’t protect you against sexually transmitted diseases (STD’s).  If you are at risk for STD’s, you should be using a condom and getting tested at regular intervals.

The Pill also has some risks.  That’s because combined oral contraceptives (those containing estrogen) can increase a woman’s risk of blood clots, heart attack and stroke.  This risk is minimal if you are young (under 35– ouch!), otherwise healthy, and do not smoke.  You should ask your gynecologist (or other healthcare provider) about your risk factors to help determine whether The Pill is a safe option for you.

If you have certain medical problems (like heart disease, a prior blood clot, or a history of certain types of cancer), are a smoker over 35, or are taking certain other types of mediation, you should not take estrogen-containing combined oral contraceptives. Ever. There are other, potentially safer options out there for women who can’t take OCP’s.  More on that in a future post.

I’m also planning a post to explain WHY OH WHY there need to be SO MANY different pills out there!  Really, I promise there’s a good reason.  See you soon!

June 4, 2010 at 3:55 pm 7 comments

Condoms: A little something for everybody

Condoms are one of the cheapest and most widely available methods of pregnancy prevention. They are a type of barrier protection. This means that they work by forming a physical barrier between sperm and egg. Most condoms are made of either latex or lamb skin and may be lubricated (or not) with spermicide (a chemical intended to kill sperm).

A condom is placed over the penis prior to intercourse. If the condom is put sometime in the middle of intercourse (ie prior to ejaculation), unintended pregnancy is still possible. This is because the penis does emit some pre-ejaculatory fluid which can (and often does) contain sperm.

Female condoms are also availabe. These are placed in the vagina and are held in place by a flexible plastic ring. They are a little more expensive than male condoms and a little trickier to put in place, but they work essentially the same way.

So if you choose to use condoms, the rules are

1. put one on before intercourse

2. leave it on until after intercourse is complete

3. use a new condom with each act of intercourse

4. never “double-wrap” with more than one condom at a time (this causes friction and can lead to breakage)

Condoms come in a variety of shapes and sizes. Some have features like flavor (a plus if you are using one to protect your partner during fellatio [oral sex]), texture (ie “ribbed for her pleasure”), color (to match your partner’s dress and/or eyes?), or glow in the dark (for… I don’t know what– A sudden loss of electrical power?!).  In short, there’s something for everybody.

Condoms are cheap and, when used correctly, over 90% effective in preventing pregnancy.  They are also one of the only methods of birth control that can also help prevent the transmission of a number of sexually transmitted diseases, including gonorrhea, chlamydia, HIV/AIDS, hepatitis, syphillis, HPV (human papilloma virus), herpes and other unpleasant nasties.

So what do you do if the condom breaks, falls off, or never made it out of your partner’s wallet? Plan B is a medication intended to prevent unintended pregnancy if used within 72 hours of unprotected intercourse. It’s more effective the sooner it is taken (ie 24 hourse is better than 48 hours is better than 72 hours). It contains progesterone, a hormone that is one of the 2 main components of conventional birth control pills.

Plan B is not the abortion pill and won’t bring an end to an already-established pregnancy. It is available over the counter at a number of major pharmacy chains nationwide. If you have questions about how to use it properly or how to make sure it was effective, or you need testing for sexually transmitted diseases, you should call your doctor.

May 25, 2010 at 2:31 pm 4 comments

Abstinence: The world’s oldest form of contraception

There’s a lot more buzz about abstinence than there was when I was a teenager. My high school generated a lot of buzz back in the 1995 when it was the first on Long Island to distribute condoms.  (Then again, a lot of the fashion in those days had an unintended contraceptive effect.)  But I think the pendulum has begun to swing the other way in a lot of communities.  So I think it may be time to take another look at abstinence.

Abstinence is the oldest and cheapest form of contraception.  Not having sex with a male partner is a sure way for a woman to avoid pregnancy. 100%.  Pretty simple math.

Historically, abstinence has the method of choice for a lot of people because of expectations set by religious faith and family roles.  You remember: First comes love, then comes marriage, then comes baby in a baby carriage.  Premarital sex and unintended pregnancy don’t rhyme well.  (Neither does Baby Bjorn, so I guess baby carriages are also a more moral option for infant transport).

The downside of abstinence is that it can be an unrealistic expectation, especially for younger people.  Teens in particular may struggle with their natural inclination and interest toward sex.  This is compounded by things like peer pressure and widening social acceptance of premarital sex and sex outside of monogamous relationships.  We won’t even go into what constitutes maintaining one’s “virginity.”  But oral sex doesn’t get you pregnant.

If you choose to abstain from sex, it’s not a bad idea to have a back-up plan (ie condoms, the pill, etc…).  This doesn’t mean you’re not committed to abstinence, it means you’re realistic.  You wouldn’t drive a car without a spare tire, would you?  Does that mean you’re planning on getting a flat?  No.  It means you’re responsible.  What?  You don’t know how to change a flat?  Well, that’s what boyfriends are for.

May 19, 2010 at 1:40 pm 3 comments

Demystifying Hysterectomy Part III: Risks and Benefits

Having a hysterectomy means that you will no longer have the ability to bear children.  It also means you should no longer experience menstrual bleeding (although you may experience other cyclic changes depending upon whether you still have ovaries).  Hysterectomy alone (ie without removal of or damage to the ovaries) does not result in menopause.  However, hormonal changes after hysterectomy are possible. 

Many women are concerned that removal of the uterus will adversely affect their sexual functioning and satisfaction.  There are no studies demonstrating that hysterectomy (with or without removal of the cervix) has a negative effect on patients’ sex lives.  Neither the uterus nor cervix itself contributes to vaginal lubrication or orgasmic response. Most patients’ male partners can not detect the presence or absence of a uterus or cervix and among those who can, few feel that it impacts their experience during intercourse.  Therefore, the best predictor of sexual satisfaction and functioning after hysterectomy is your sexual satisfaction and functioning prior to surgery.

You should discuss these concerns with your gynecologist before considering any kind of surgery to remove all or part of your uterus.

Complications from hysterectomy are uncommon but can be serious.  Although it is impossible to predict or list every possible problem, these infrequent complications may include infection, bleeding, thromboembolic events (blood clots), injury to adjacent organs, bladder or bowel dysfunction, nerve injury, postoperative pain, and anesthesia complications.  You should talk to your doctor about the possible complications of any treatment you consider undergoing.

Hysterectomy is permanent.  Even when performed via minimally invasive techniques, it is still a major surgery. 

Other options for managing certain gynecologic conditions may be appropriate.  These options may include expectant management (watchful waiting), therapy with hormonal or other types of medication, the use of interventional radiology (uterine artery embolization), targeted ultrasound ablation, or other fertility-sparing surgical procedures (myomectomy, ablation of endometrium or endometriosis).

The choice of whether hysterectomy is the right option for you depends on a number of factors.  Talk to your doctor about your condition and all of your options when considering hysterectomy as part of a treatment plan.

May 17, 2010 at 6:32 pm 3 comments

Demystifying Hysterectomy Part II: “How and why is hysterectomy performed?”

A hysterectomy can be performed in several ways. Minimally invasive surgical techniques include the removal of the uterus (and/or ovaries) through laparoscopy, a surgical technique which involves the insertion of long thin instruments through very small holes in the patient’s abdomen.  Hysterectomy can also be done via the vagina in a procedure called vaginal hysterectomy.  Despite the proven benefits of minimally invasive surgical techniques, the most common method of removing the uterus is still through an open abdominal incision called a laparotomy.  

Hysterectomy is used to treat a number of gynecologic conditions including uterine fibroids, adenomyosis, endometriosis, intractable pelvic pain, pelvic organ prolapse, and certain types of cancer.  It may also be required in certain types of emergencies (such as hemorrhage during childbirth) or electively (in persons undergoing gender reassignment).

May 14, 2010 at 3:42 pm 3 comments

Demystifying Hysterectomy Part I: What is a hysterectomy?

Hysterectomy is the most commonly performed gynecological surgical procedure. Over 600,000 hysterectomies are performed in the United States every year, most often for benign (non-cancerous) conditions. 

But what is hysterectomy?  Literally, the term means “removal of the uterus.”  But there are many types of hysterectomy and several ways in which it can be performed.

First, the types:

A total hysterectomy (often called a complete hysterectomy) means surgical removal of the uterine body or corpus, the dome of the uterus or fundus, and the neck of the uterus or cervix.

The term partial hysterectomy is often used to describe what doctors call a supracervical hysterectomy.  This surgery involves removal of the uterine body and fundus.  It leaves all or a portion of the cervix intact. 

Patients with certain types of cervical cancer may require a procedure called radical hysterectomy, which involves the removal of all parts of the uterus as well as other tissues adjacent to it the pelvis, including the upper vagina. 

The removal of the ovaries and fallopian tubes, called salpingoophorectomy, is not included in any of the terms describing hysterectomy, even if both procedures are done at the same time.

May 11, 2010 at 6:55 pm Leave a comment

Minimally Invasive Gynecologic Surgery: Pursuing a gentler path

Minimally invasive surgery includes a diverse and varied set of techniques which differ from traditional “open” surgery.  When open surgery occurs in the abdomen, it is performed through an incision called a  laparotomy.  Put simply, the goal of minimally invasive gynecologic surgery is to avoid unnecessary laparotomy.

Avoiding large incisions allows a surgeon to offer patients a faster recovery, decreased pain from surgical incisions, a more rapid return of bowel function, and decreased risk of certain types of complications.  Patients usually go home the same day or stay in the hospital only one night.

There are several common techniques used in minimally invasive surgery.  These include the use of laparoscopy (aka bandaid surgery, keyhole surgery, or pinhole surgery) and mini-laparotomy.

Laparoscopy is a type of sugery in which a camera is attached to a thin instrument (the laparoscope) which can be inserted into the abdomen through a very small incision.  This allows the surgeon to see the entire abdominal cavity without creating a large incision.  Additional small incisions may be made so that thin surgical instruments can be inserted into the abdominal cavity. 

Many types of surgery can be performed in this manner, including certain types of hysterectomy (removal of the uterus), removal of fibroids and ovarian cysts, treatment of endometriosis, and treatment of other kinds of gynecologic disorders.

Mini-Laparotomy is sometimes combined with laparoscopy to allow a much smaller abdominal incision in certain types of surgery which would otherwise have to be done by laparotomy.

When you need surgery, it is important to have a discussion with your doctor about how your recovery can be optimized.  Minimally-invasive surgery could be the best option for you.

May 9, 2010 at 8:02 pm 5 comments

Understanding Ovarian Cysts

Ovarian cysts are very common and can affect women of all ages.  Most women will have an ovarian cyst at some time in their reproductive lives.  Although they are less common after a woman stops menstruating, they are present in up to 14.8% of postmenopausal women.

But what is an ovarian cyst?  An ovarian cyst is any collection of fluid, surrounded by a very thin wall, within an ovary (one of a pair of organs in the pelvis responsible for producing female hormones and eggs).  Eggs normally mature within the ovaries in small, fluid filled spaces called follicles.  Any ovarian follicle larger than two centimeters can be called an ovarian cyst.  They vary greatly in size (as big as a cantaloupe or larger!) and in etiology.  Most ovarian cysts are benign (non-cancerous) in nature.  Several common types are

  1. functional (or simple) ovarian cysts, which are related to the menstrual cycle and often resolve on their own
  2. endometrioid cysts, which are due to endometriosis, are often called “chocolate” cysts or endometriomas
  3. dermoid cysts (or teratomas) which can have solid components like hair or teeth

 

Many ovarian cysts are asymptomatic and are discovered only incidentally at the time of an exam or ultrasound.  However, some ovarian cysts cause problems.  Rupture of an ovarian cyst can cause bleeding or pain.  An enlarged ovarian cyst can cause an ovary to twist on the stalk containing its blood supply, a condition called torsion.  Ovarian cysts may also interfere with fertility treatments and goals. 

Surgery may be required to remove large cysts or to make sure a cancer is not present.

If you think you have symptoms consistent with an ovarian cyst, it is important to be evaluated by a physician.  Ultrasound or other imaging as well as simple blood tests may be done to help determine whether treatment is necessary. 

 

May 8, 2010 at 2:57 pm 38 comments

Tackling your first gynecologic visit – No fear!

 

At your first gynecologic visit, your doctor should introduce him or herself and discuss the reason for your visit.  You should be open and honest about your reasons for needing gynecologic care.  

THE HISTORY: Your doctor will take a complete gynecologic and menstrual history.  Never be embarrassed to bring up concerns regarding bleeding or pain, sexual activities and concerns, current or past sexual or physical abuse, or questions about changes in your body

 **Believe me, you are NOT the first or only person who has these concerns.  Your doctor should be familiar with them and make sure you are comfortable discussing them.  If not, you should consider finding a doctor who DOES make you comfortable.** 

Your doctor will also discuss your medical and surgical history, any medications you may be taking, any allergies you may have to medicines or foods, and will ask whether you drink alcohol, smoke cigarettes, or use drugs.  Your doctor will be able to provide the best of care if he or she receives complete and honest information from you. 

THE PHYSICAL EXAM: The majority of your physical examination will be very familiar to you from visits with other types of doctors.  The examination of your head, neck, heart, lungs, abdomen (belly), and extremities will not differ much from that performed by your primary care physician. 

The parts of your exam which may be new and unfamilar include the breast and pelvic exam

The breast exam includes a visual inspection of your breasts.  Then your doctor will examine your breasts by palpation (touch).  He or she is looking for abnormal lumps or masses.  Many breast lumps are benign (non-cancerous).  Some are malignant (cancer).  Your doctor may order tests such as a mammogram or breast ultrasound if he or she detects abnormalities of the breast during your exam.   

Your doctor should also ask you whether you are performing breast self-examination.  He or she can teach you how to do a good breast exam on yourself at home.   If you have questions about how and when to do this type of exam at home, you should ask them during the breast exam.  

The pelvic exam consists of two parts.  The first part is usually the speculum examination.  This part of the exam is often accompanied by a great deal of anxiety and trepidation.  This is understandable, as the speculum examination can be uncomfortable.  It should not, however, be painful.  It helps if you try to maintain a relaxed, calm attitude as this REALLY can make the exam more physically comfortable. 

A speculum is a metal or plastic instrument that is inserted into the vagina.  It is usually warmed (if metal) and lubricated (with gel) to make the exam more comfortable.  The speculum is not used to ‘clamp’ anything.  This is a common misconception. The speculum is actually designed to gently open the vaginal canal to allow visualization and sampling of the cervix (which is the lowest part of the uterus, protruding into the vagina). Once this is done, the speculum is gently removed. 

The speculum exam

  

The second part of the pelvic examination is called the bi-manual examination.  The examiner will insert one or two fingers into the vagina, placing the other hand on your abdomen (belly).  This is done so that the examiner can feel the size and shape of your uterus and ovaries.  Ovarian cysts, fibroids, and some types of endometriosis can be detected this way.

A rectal examination may also be necessary to evaluate certain types of conditions and is a necessary part of the examination of any woman over 50 years of age.  The examiner inserts a lubricated finger into the anus (the lowest part of the rectum).  This may occur in conjunction with a vaginal exam (a recto-vaginal examination) or may include sampling of fecal material for blood (a stool sample). 

THE WRAP-UP: After that, you’re all done!  Your doctor may include certain types of testing such as a PAP smear or a cervical culture for STD’s as part of the gynecologic evaluation.  Always ask your provider what tests you require and how you will be informed of the results.

May 7, 2010 at 6:52 pm 2 comments

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Linda M. Nicoll, MD

Welcome to my blog! Here you will find information about minimally invasive gynecologic surgery as well as some more general information about common gynecologic disorders such as endometriosis, ovarian cysts, fibroids, infertility, and pelvic pain.

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