OC PRACTICE GUIDELINES - MINIMIZING SIDE-EFFECTS

The side effects of oral contraceptives (OCs) can be minimized by appr opriate OC selection. Side effects or perceived side effects that mani fest themselves physically - e.g., weight gain, breakthrough bleeding (BTB), nausea, headache, breast tenderness, mood swings, acne, and hir sutism - are the most common causes of premature discontinuation of or al contraception. The relative androgenicity of the progestin componen t of combination OCs has become an important differential in selecting OC formulations. Several studies have indicated that preparations wit h less androgenic potential can minimize some of the ''physical'' side effects and adverse metabolic effects traditionally associated with o ral contraception. Acne and hirsutism, common pre-existing conditions that are clearly related to the androgenicity of the progestin compone nt, can be eliminated or improved by use of OCs with low androgenic ac tivity. Many women perceive that OCs cause weight gain; although weigh t gain is to some extent androgen related, most studies comparing low- androgenic OCs with medium- or high-androgenic preparations have found little or no change in weight regardless of formulation. BTB, which u sually subsides within a few months, is related to the dose, potency, and ratio of the estrogen and progestin in the OC formulation. Low-est rogen-dose OCs (<35 mu g ethinyl estradiol [EE]) containing less andro genic progestins are associated with bleeding patterns as acceptable a s older low-estrogen-dose formulations. The same analysis found that s moking cigarettes promotes BTB in women who use OCs. There is no convi ncing evidence that the use of one progestin or another is less likely to cause or exacerbate headache; however, changing preparations somet imes reduces the incidence. Women with persistent headaches during the pill-free interval may benefit from a longer cycle of OC treatment. N ausea and breast tenderness are primarily estrogen-related effects; if a woman experiences persistent nausea, switching to an OC formulation containing 20 mu g EE may be appropriate as long as the patient is ca utioned that BTB is more likely. Mood changes are a common, highly sub jective complaint whose relationship to OC use is hard to assess. Conc erns about the potentially deleterious effects of combination OCs on l ipid/lipoprotein and carbohydrate metabolism have been substantially d iminished by new epidemiologic findings relative to cardiovascular dis ease as well as by the development of low- androgenic progestins. Form ulations containing these progestins lower LDL cholesterol and increas e HDL cholesterol; they do not affect carbohydrate metabolism as much as older, more androgenic formulations.