The Pill is available in monophasic, biphasic and triphasic preparations. Each of the tablets in the monophasic Pills (Brevinor, Microgynon) have the same dose of oestrogen and progestogen. They are sometimes used ‘back to back’ — that is, without a break for a menstrual bleed — for women with conditions such as severe migraines, menorrhagia or endo-metriosis. Biphasic (Biphasil) and triphasic (Triphasil, Triquilar and Logynon) Pills have varying amounts of oestrogen and progestogen throughout the cycle to follow the pattern of the secretion of endogenous hormones. In the biphasic regimens, the dose of oestrogen is constant, but the dose of progestogen is increased in the second half of the cycle. The oestrogen in the triphasic Pill is increased mid-cycle to prevent breakthrough bleeding and the progestogen is increased incrementally throughout the (Pill) cycle. Some Pills contain androgen-blocking agents (Diane, Brenda) and are used for acne and excessive male-pattern hair growth. A lot of factors need to be considered when prescribing oral contraceptives, and a doctor or gynaecologist skilled in this area should be consulted if difficulties are experienced.
When taken correctly, the Pill is an effective contraceptive, but other benefits are less obvious to all but the researcher and scientist because they are largely related to prevention of conditions and are almost entirely determined by epidemiological studies. They include a reduced rate of ovarian and endometrial cancer, benign breast disease, benign ovarian cysts, pelvic inflammatory disease, period pain, reduced menstrual blood loss and anaemia.
Today’s low-dose oral contraceptives are much safer than the earlier, higher-dose Pills. Usually these Pills contain 30-35 meg of ethynyloestradiol (older and high-dose Pills contain 50 meg). The side-effects of oral contraceptives are well known and can include venous thromboembolism (blood clots), stroke and heart attack. The risk is small except for Pill users who also smoke. Menstrual changes such as breakthrough bleeding or spotting can occur, and some women experience androgenic effects, including weight gain and acne, which are associated with the progestogen (synthetic progesterone) component of the Pill. One per cent of women develop post-Pill amenorrhoea during the first twelve months after cessation of the Pill. Amenorrhoea in women who have taken the Pill is thought to be no more common than amenorrhoea seen in the general population. Breast cancer risk with long-term use of the Pill has been shown to be negligible. Some women also report an increase in mood swings, depression and decreased libido while on the Pill.
These negative symptoms are more common when a woman first starts the Pill and may settle after two cycles, or they may necessitate a change to a different brand. For this reason doctors usually advise waiting for two months before trying a new Pill. Pills which contain high oestrogen levels are more likely to be associated with depression — this can be reduced by taking a lower dose of oestrogen (30-35 mg) and/or taking 50-100 mg vitamin B6 at the same time.
Apart from its use as a contraceptive, the Pill can be prescribed for menorrhagia. It usually reduces bleeding by thinning the endometrial lining. The Pill can also be used for dysmenorrhoea, especially when a contraceptive is needed as well, or when prostaglandin inhibitors have not helped. The Pill improves dysmenorrhoea about 90 per cent of the time by preventing ovulation and reducing the production of the series 2 prostaglandins which cause muscle spasm.
The Pill improves premenstrual syndrome symptoms in some women, has no effect in others and makes some women worse. It is difficult to predict which women will respond well, although women eighteen years and less experienced much more tearfulness on the Pill in one study. When effective, the Pill is believed to control the symptoms of premenstrual syndrome by superimposing a more balanced hormonal profile. Taking a monophasic Pill is the most suitable option for women who experience premenstrual syndrome (PMS). The biphasic and triphasic Pills, which simulate the hormonal changes of the menstrual cycle, can tend to be associated with an increased incidence of premenstrual syndrome in some women.
Pill regimes have been used to control the symptoms of premenstrual breast soreness and lumpiness. The rationale for these prescriptions is based on the observation that women on the Pill have a lower incidence of cyclic breast complaints including fibroadenoma and adenoma. Pills containing low doses of ethinyl oestrodiol and relatively potent proges-togens (such as norethindrone acetate) are recommended. The ethinyl oestradiol reduces ovarian oestrogen secretion while the effects of oes-trogens in breast tissue are modulated by the progestogen. Improvement is noted in up to 90 per cent of women, especially when oestrogen levels in the Pill are low. Some doctors recommend that women 40 and over, or women with abnormal HDL:LDL cholesterol ratios should take 400-1200 IU vitamin E while on this regime to prevent progestogen-induced reduction in HDL and increase in LDL.
Taking the Pill reduces the menstrual fluid volume and the risk of developing endometriosis. The latest contraceptive pills have much lower levels of oestrogen and seem to reduce the amount of both normal endometrium and the amount of endometriosis. This is particularly the case when the Pill is used continuously (without a break for ‘periods’) to create a pseudo-pregnancy state. The Pill compares favourably with other drug regimes for endometriosis that have more serious side-effects such as a decrease in bone density.
However, the Pill is not as effective for advanced endometriosis and is not suitable for women who want to become pregnant. In one study, most women had a return of symptoms within six months of stopping the Pill. The pregnancy rate of women who have endometriosis is also low following the use of the Pill, suggesting that the Pill does not influence the severity of the endometriosis.
All the oral contraceptives can potentially increase the size of fibroids because of the oestrogen component; however, it has been shown that fibroids do not necessarily increase in size when women take the Pill, that menstrual blood loss reduces significantly and that blood-iron levels increase. A woman with fibroids should discuss the risks and benefits of oral contraceptives in her particular case with her doctor.
Significant numbers of different drugs interact with the Pill. These include some anti-epileptic drugs, some antibiotics and possibly the anti-fungal medication, Griseofulvin, which can all decrease the contraceptive effect of the Pill. Some drugs are cleared more slowly from the body when women are on the Pill. Theophylline, the anti-asthma drug, is one of these.
Paracetamol-containing painkillers, such as Panadol, reduce the metabolism and exretion rate of the Pill, leading to higher oestrogen levels than required for contraception. Women on thyroxine may need to increase their dose if they are also prescribed the Pill. Some sedatives, tranquillisers and anti-depressant drugs may not work as well; others show increased availability, such as the tricyclic anti-depressants Tofranil and Melipramine. Women on the Pill should consult their doctor or pharmacist about the relevance of these and other possible drug interactions.
The Pill can cause increased pigmentation of the skin, which is known as chloasma or melasma. This usually occurs on the face and becomes much darker with exposure to the sun. It is thought to be caused by oestrogen and can occur in pregnancy, or sometimes when women are neither pregnant nor on the Pill. Stopping the Pill does not necessarily mean that it will go away completely, although it does tend to fade. Sunblock is necessary, and skin creams or peels that contain glycolic acid can lighten the pigmentation. Dermatologists sometimes recommend creams containing hydroquinone or the acne treatment, isotretinoin (Roaccutane), when the condition is severe.
Symptoms or conditions which indicate that the Pill should be stopped immediately include blood clots, high blood pressure or serious headaches. Women who smoke should not take the Pill because of an increased risk of developing these complaints. Doctors do not usually treat post-Pill amenorrhoea until a pregnancy is desired, when they will prescribe fertility drugs like Clomid. Until this time, the usual medical recommendation is for the woman to go back on the Pill to maintain her bone density.
Combined Pills containing oestrogen and progestogen influence a number of nutrients, some positively, others negatively. Requirements for vitamins B2, B3, B6, folic acid and zinc increase, but the need for iron is reduced because of the smaller blood loss during the period. Calcium is retained in the bones more effectively when women take the Pill, but this does not indicate a lower requirement because most women do not get enough calcium in their diet anyway.
Blood levels of vitamin A increase while taking the Pill and so vitamin A supplements (including cod liver oil), should not be taken with the Pill. The absorption of beta-carotene (the precursor to vitamin A) from food, however, may be lower and so it is wise to eat plenty of orange or yellow vegetables such as carrots, pumpkin and sweet potato.
The serum copper level increases on the Pill and may be partly responsible for the mood changes. High copper levels can lead to a zinc deficiency and zinc supplements may be necessary, especially for vegetarians and vegans. Information on zinc is included in ‘Adolescence’. The usual dose of zinc is 15-30 mg per day.
Side-effects, including mood changes and bloating, are often associated with the progestogen component of the Pill. Taking vitamin B6 50-100 mg or a B complex with 50 mg of B6 in the week before the period can reduce these symptoms. Herbal diuretics, especially dandelion leaf tea, can help with fluid retention symptoms. One or two teaspoons per cup twice daily (but not before bed!) is the usual dose. Many women also report that evening primrose oil (between 1000 and 3000 mg per day) is useful for many of the symptoms they experience while taking the Pill.
The risk of deep vein thrombosis (DVT) is higher when women on the Pill undergo extended periods of physical confinement such as air travel or prolonged bed rest. When a long trip is contemplated, extra precautions should be taken to reduce risk of thromboembolic events. These include taking ginger at doses of 500 mg three times daily and vitamin E 500 IU daily for several weeks before and a week after travel.
Women who smoke and take the Pill may reduce their risk of blood clot formation if they take 500 IU of vitamin E every day. It is not advisable for women who have a pre-existing heart condition or high blood pressure to self-prescribe vitamin E and they should consult a practitioner first.