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.

Misoprostol

Cytotec (misoprostol) by Pfizer

The New York Times
Op-Ed Columnist
July 31, 2010
By NICHOLAS D. KRISTOF

Another Pill That Could Cause a Revolution

“Could the decades-long global impasse over abortion worldwide be overcome — by little white pills costing less than $1 each?

That seems possible, for these pills are beginning to revolutionize abortion around the world, especially in poor countries. One result may be tens of thousands of women’s lives saved each year.

Five-sixths of abortions take place in developing countries, where poor sterilization and training often make the procedure dangerous. Up to 70,000 women die a year from complications of abortions, according to the World Health Organization.

But researchers are finding an alternative that is safe, cheap and very difficult for governments to restrict — misoprostol, a medication originally intended to prevent stomach ulcers.

“I feel like people must have felt when they discovered the nuclear bomb,” says Dr. Beverly Winikoff, president of Gynuity Health Projects, a nonprofit research institution on reproductive health. “This technology is world-shaking.”

This pharmaceutical approach is called “medical abortion.” In the United States and Europe it typically consists of two sets of “M” pills. The first is mifepristone, formerly known as RU-486, and then a day or two later the misoprostol.

Using the drugs in combination produces a miscarriage more than 95 percent of the time in early pregnancy. But mifepristone is difficult to obtain in much of the world, because it is used only to induce abortions. In contrast, misoprostol is very widely available and can’t easily be banned because it is also used for ulcers and can save lives of women with postpartum hemorrhages. Whatever one thinks of misoprostol for abortions, it also is a potential lifesaver for women who hemorrhage after childbirth.

Researchers are finding that if women take misoprostol alone, effectiveness drops to 80 to 85 percent. That may sound low, but it’s typically far better and safer than alternatives that women turn to, Dr. Winikoff noted.

“Medical abortion represents a revolution in women’s reproductive health,” said Dana Hovig, the chief executive of Marie Stopes International, an aid group that provides women’s reproductive health services in 43 countries around the world. “It saves women’s lives and has enormous potential to increase access to safe abortion at minimal cost.”

Medical abortion causes a miscarriage that is indistinguishable from a natural one. That’s important for women in countries where they risk arrest if they seek help in a hospital after a botched abortion. The risks to a woman seem no greater than with a natural miscarriage, and there’s no known harm to a woman who turns out not to have been pregnant after all. One serious downside is that misoprostol is suspected of causing birth defects, perhaps 1 percent of the time, but only if it fails and the pregnancy continues to term.

In the United States, only about one abortion in eight is done with pills. Partly that’s because by law, mifepristone must be taken in a clinic. But worldwide, the number of medical abortions is surging, accounting for nearly 70 percent of all abortions in Scotland, according to Marie Stopes International.

It’s not clear how late in pregnancy medical abortion is feasible. “It sounds like a simple question, but it’s not,” Dr. Winikoff said. In some form and strength, medical abortion seems to work “from Day 1 to the end of pregnancy,” she said — but the effectiveness and safety of later-stage abortions still need to be worked out.

In the United States, the pills can be taken up to nine weeks’ gestation. In Britain, inpatient use of the pills is permitted up to 24 weeks.

What do these pills mean for the political battles over abortion? To firm opponents of abortion, the means of ending a pregnancy doesn’t matter. But my hunch is that, for those in the middle, taking pills at home may seem a more natural process than a surgical abortion, and the result may be a tad more acceptance.

In any case, it would be tough to carry out a ban on medical abortion. Indian companies are producing mifepristone and misoprostol in a big way, and blister packs with the combination of drugs can be purchased for less than $5 — and then shipped anywhere.

In addition, misoprostol on its own can be found all over the world, from Internet sites to over-the-counter pharmacies in Delhi. In India, misoprostol costs just pennies per pill.

Misoprostol is likely to become even more widely available, because last year the World Health Organization expanded its uses as an “essential medicine” to include treatment of miscarriages and incomplete abortions.

Brazil and some other countries have tried to tighten access to misoprostol because of its use for abortion. But curbing access to misoprostol would mean that more women would die of hemorrhages.

As word spreads among women worldwide about what a few pills can do, it’s hard to see how politicians can stop this gynecological revolution.”

Personal comment: Using Misoprostol by itself may be an option in countries where abortion is banned, but our clinic recommends against trying to induce a medical abortion using Misoprostol alone. For medical terminations the clinic uses Mifeprex and has had a very high success rate with it. Misoprostol alone used for a termination (rather than Mifeprex which uses both Mifepristone and Misoprostol) results in lower effectiveness of the procedure and more severe side effects such as pain and heavy bleeding. But if Mifeprex is not available then using Misoprostol alone will usually work.

The website Women on Waves: http://www.womenonwaves.org/set-274-en.html posted the following World Health Organization instructions for performing a medical abortion using Misoprostol alone.

“Misoprostol alone can be used to cause an abortion. However, incorrect use of Misoprostol can be harmful for the health of a woman!!

To cause an abortion, a woman must put 4 pills of 200 micrograms (in total 800 mcg) Misoprostol under the tongue. Do not swallow the pills (at least until 30 minutes after putting the tablets under the tongue!!)

After 3 hours she should put another 4 pills of Misoprostol under the tongue.

After 3 hours she should put another 4 pills of Misoprostol under the tongue again for a third time. Do not swallow.

The success rate is 80%- 90%.

After the first dose of Misoprostol a woman should expect bleeding and cramps. Bleeding mostly starts within four hours after using the pills, but sometimes later. Bleeding is often the first sign that the abortion starts. If the abortion continues, bleeding and cramps become more severe. Bleeding is often more and heavier than a normal menstruation, and there can be clots. The longer the pregnancy, the more heavy the cramps and the bleeding will be. If the abortion is complete, the bleeding and the cramps diminish. The moment of abortion can be noticed with a peak of heavier blood loss and more pain and cramps. Depending on the length of the pregnancy, a small pregnancy sac with some tissue around can or cannot be seen. For instance, if the woman is only five to six weeks pregnant, there will be no visible sac. At nine weeks, a woman could probably find a sac in between the blood.

If no bleeding occurs after the third dose, the abortion did not take place and the woman has to try it again after a couple of days or travel abroad to a country where it is legal or try again to find a doctor.

If a woman would want to relieve the pain, she can use painkillers such as Paracetamol.

(Von Hertzen H, ea WHO Research Group; Efficacy of two intervals and two routes of administration of misoprostol for termination of early pregnancy: a randomized controlled equivalence trial, Lancet. 2007 Jun 9;369(9577):1938-46. )”