Monday, November 14, 2011

Lara Croft and extended cycle BCPs

Advert for Lybrel the continuous regimen oral contraceptive

Why Do Oral Contraceptives that Cause Monthly Bleeding Still Predominate?

Healthcare providers' attitudes about menstruation and medically induced amenorrhea are key factors.

Extended or continued use of oral contraceptive pills (OCs) remains low despite obvious advantages of menstrual cycle regulation and symptom management. To determine the factors that influence physicians' OC prescribing habits, researchers analyzed survey responses from 211 obstetrician-gynecologists (OB/GYNs) and family medicine physicians (FPs) in Oregon. Physicians were asked whether they prescribed extended-use (hormone-containing pills for >28 days with scheduled withdrawal bleeding) and continuous use (hormone-containing pills indefinitely without a scheduled withdrawal bleed) OCs, and, if yes, how often. A 5-point Likert scale was used to assess attitudes toward menstrual suppression.

In all, 90 respondents (44%) identified their principal specialty as OB/GYN, and 115 (56%) as FP. Most respondents who reported ever prescribing OCs also said that they prescribed extended- or continuous-use OCs sometimes (50%) or often (23%). OB/GYNs were more likely than FPs to suggest these options (92% vs. 60%), as were urban (79%) versus rural (58%) physicians.

OB/GYNs and urban physicians showed greater acceptance of medically induced amenorrhea as well as more-favorable attitudes about health and economic benefits of suppressing ovulation and safety of extended-use OCs. Most respondents (68%) did not realize that menstrual-related symptoms are most common during the placebo week, and 17% of respondents (most of whom were FPs) were unaware that endometrial thickening does not occur with extended-use OCs. After adjusting for physicians' age, practice location, knowledge, specialty, and sex, the only factor that was significantly associated with prescribing extended- or continuous-use OCs was attitude toward medically induced amenorrhea.

Comment: The gaps in knowledge among the respondents are surprising and underscore the need for ongoing education about menstrual suppression. The authors acknowledge that their small sample size (particularly of rural providers) curtails the generalizability of these results. Moreover, nurse practitioners, physician assistants, and certified nurse midwives were not included. Despite these study limitations, the benefits of extended- and continuous-use oral contraceptives remain clear — and the attitudes of healthcare providers are critical in promoting acceptance of these dosing regimens as mainstream options. — Anne A. Moore, WHNP/ANP-BC, FAANP”

Extended cycle pills in real life: The first combined (estrogen/progestin) oral contraceptive pill designed to be taken continuously with no hormone free days is Lybrel. Lybrel has .90 mcg of the progestin levonorgestrel and 20 mcg of the estrogen ethinyl estradiol and is taken continuously 365 days/yr, in 28 day packs (13 per year). For women who can adjust to the continuous dose of hormones – it can take three or four months for a significant percentage of users to stop experiencing irregular bleeding – being period free can be liberating if the woman has been experiencing heavy or painful periods or significant PMS. Another positive for Lybrel is that it uses a very low dose of an older progestin, levonorgestrel, which has a lower incidence of causing blood clots. Most other extended cycle pills have 84 active and 7 placebo pills limiting a woman taking them to four pill-periods a year. Some of those are Seasonale, Jolessa, Quasense, Seasonique and LoSeasonique and they all use the progestin levonorgestrel.

The down side of extended cycle pill is that in addition to taking a long time to adjust to being continuously on hormones levonorgestrel does not have the long half-life of the progestin drospirenone used in Yaz and Yasmin and as a result the hormone levels can more easily drop below the effectiveness level if a woman is late with or vomits her pill. Too, there is no monthly assurance that the user is not pregnant by the arrival of ‘Aunt Flo’. Unless a user is cautious enough to test every few weeks she has no way of knowing if she is pregnant until she begins to develop symptoms such as noticeable breast changes, lethargy and repeated nausea.

A consequence of the Hex or Sex party: Returning readers will remember from my post entitled ‘The Doorman’ on October 31, 2011 and the following post on Nov 2 about the wood chipper that a UNLV friend’s sorority was running a bordello charity over Halloween at one of Adolph’s vacant estates in the hills. The 13 girls who were hostesses in latex body condoms are fine and suffered no ill effects other than sore muscles from their unusual level of exertion. Even the girl who had her cervix battered so brutally is recovering well and probably will only have to wear a supportive pessary for a few months.

However, one of the other sorority sisters, a 26 y/o grad student, who was working as support staff and was costumed as Lara Croft in a silver latex dive-skin had apparently gotten off her pill regimen enough that she was fertile and had breakthrough ovulation during the four days the bordello was operating. We knew she was sampling unprotected male customers, but she was on Lybrel and since there was a waiting list and she was discreetly servicing men who were waiting at the bar for seconds or thirds no one called her on siphoning off potential profits that we didn’t have time to handle. The fourteen of us, Cyndi and I pitched in when it became apparent that the sorority girls were under staffed as far as available commercial pussy was concerned, were getting the guys off as fast as we could while ensuring we were giving them their moneys worth.

Lara Croft and the fertilized egg: So Lara Croft called me on Saturday. I could tell she was nervous and she told me about the struggle she had been having getting regulated on Lybrel with irregular bleeding that would come and go and she couldn’t get a good pill taking regimen so she could develop a habit of taking her pill at the same time each day. I’m wondering why she was calling me about that when she finally got to the point. She began getting nausea attacks three days ago, tested and found she was positive for hCG and she wanted my help getting an abortion. I said she could go to UNLV Student Health and she freaked out. She is terrified of her father finding out she is not only sexually active, but that she wasn’t careful enough and has no idea who the father is. Her father is a prosperous evangelical fundamentalist in a state in the Deep South and she is scared to death of him. She has a bit of money of her own that she gets from her mother so she can pay clinic rates for the termination.

It was pretty early to be having pregnancy symptoms after only fifteen days (she began sampling the clients the day the place opened for business on the 28th) but certainly possible so I had her meet me at the clinic and one of the NPs did a serum pregnancy test and she was indeed very newly preggers. Go figure! So she signed the patient agreement and was given the first three pills (Mifepristone) and Saturday counted as day one in the Mifeprex regimen to terminate her pregnancy. She was so relieved to be getting the problem quickly taken care of. I told Adolph about her pregnancy and he wondered if it was his since he had taken her each of the four days she was helping at the estate. She was to return to the clinic on day three, today, so I met her at the clinic and the NP said she should take two misoprostol tablets which she did. The misoprostol can cause cramping, bleeding and nausea so I took her back to the sorority house where there will be other students to take care of her if she starts to bleed heavily. Mifeprex is about 95% effective in terminating pregnancies so she should be fine. In two weeks she will need to go back to the clinic to make certain that everything is normal and her reproductive tract has recovered.


  1. When I saw the title, I was wondering if you were just talking about the video game character (btw, the correct spelling is Lara) or someone who went by that name. When you said the sorority girl was in cosplay as Lara Croft, I knew you were talking about the character. It seems "Lara" needed to make sure she had back-up protections if she didn't want to become pregnant until she got into the routine with her BCP.

  2. Thanks Eric! I corrected the post. I knew better, sigh... Brain freeze! I think 'Lara' will have Nexplanon implanted when she gets over the result of the misoprostol she took today.

  3. Why not GyneFix? Did you just want hormones or not want an IUD?

  4. It's Lara's choice and she thinks IUDs are too invasive, and she has had painful periods which etonogestrel would help with. She has a few days before making a final decision and could change her mind and go with a Mirena IUD which would last longer, 5 rather than 3 years for Nexplanon, so we'll see.


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Powys , Wales, United Kingdom
I'm a classically trained dancer and SAB grad. A Dance Captain and go-to girl overseeing high-roller entertainment for a major casino/resort