Posts tagged ‘bleeding’

Progesterone In Your Pill: If the shoe fits, wear it!

So, what makes one combination oral contraceptive pill (OCP) different from another?  What’s the difference between brand-name and generic versions, if any? 

The answer generally boils down to one word: progesterone.  How do we know this?  Because the chemical composition of the estrogen component of almost every OCP marketed in the U.S. is exactly the same.  It’s ethinyl estradiol.  The only thing that changes from pill-to-pill is the dose (thus the idea of “low dose” pills, “triphasic” pills etc), as described in my previous post

So, although all “low dose” OCP’s may contain 20 micrograms of estrogen, there are dozens of different kinds because each manufacturer uses one of eight different kinds of progesterone in each type of pill. 

Progesterone

The type of progesterone is indicated by the second word in the pill’s generic name.  For example, Loestrin is ethinyl estradiol and NORETHINDRONE.  Other pills have other progesterone components (i.e. Ortho-Tri-Cyclen and Ortho-Tri-Cyclen-Lo contain NORGESTIMATE, Yasmin andYaz contain DROSPERINONE).  You get the idea.

So, why do we need so much variety?  Can’t everyone just use the same pill in different doses?  Like Advil or Tylenol, just use a higher dose if you need more of it?

Well, it’ s not that simple.  The dose isn’t the important thing (it’s usually low, about 1-2 mg).  It’s the differences in the chemical characteristics of the progesterone that make each pill unique and separate it from its similar contraceptive cousins.   

Some progesterones have a higher level of progestational activity.”  This means the degree to which it binds with progesterone receptors in the body.  In addition to preventing pregnancy, stronger progestational agents can lessen menstrual bleeding, reduce acne, lessen excessive hair growth, etc. 

Some progesterones have an effect on blood levels of potassium or cholesterol.   Some can increase a person’s risk of blood clots.   These risks and benefits are an important topic to discuss with your gynecologist (or other prescriber). 

As if things weren’t confusing enough, generic OCP’s have active ingredients (estrogen and progesterones) which are chemically identical to the brand-name version.  They are, however, made by different manufacturers. They may contain different additives or be formulated in a slightly different way.

That’s why some people find that, while the brand name version worked well for them, different symptoms occur when they switch to the generic version(or vice-versa).   This means you may need to pay more (or less) for the version you prefer.  The cost difference can be significant ($50 or more!), so consider the choice carefully. 

It’s often difficult to predict which oral contraceptive (and which progesterone) will work best with a particular person’s chemistry.  While your gynecologist (or other provider) can often guide you toward picking an oral contraceptive which is the most likely to satisfy your partiuclar needs, sometimes, it’s necessary to try out a few different types before you hit on a pill that you like.  

But when you do…  Wow.  It’s like Cinderella fitting perfectly into that glass slipper and living happily ever after.   And not getting pregnant on that pumpkin-carriage ride home.

Happily Ever After

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June 21, 2010 at 11:16 pm 4 comments

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

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

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


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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