Choosing the Best Birth Control Pill

Which is the best birth control pill? The pills available since 1960, the year of commercialization in the U.S. of Enovid the first oral contraceptive preparation (the result of studies conducted by Gregory Goodwin Pincus, Min Chueh Chang and John Rock) have undergone profound changes that concern both the estrogen and the progestin components and the mode of administration; not only oral, but also transdermal, intravaginal, subcutaneous, intramuscular.

Gregory Goodwin Pincus

Gregory Goodwin Pincus

Regarding the estrogen component, it has fallen progressively until reaching really low dosages but still effective as the current 0.020 mg of Ethinyl Estradiol and 1-1.5 mg of Estradiol Hemihydrate or Valerato (more similar to the natural hormone). Also, in terms of Progestins changes, they were not only quantitative but have been patented molecules with metabolic and hormonal very different skills. Some Progestins, in fact, have shown significantly greater anti-androgenic effects useful for example in situations of Hypertrichosis and Acne and other particularly neutral behaviors on lipid fractions and on coagulation.

Oral administration has been flanked by vaginal, subcutaneous, transdermal administration that in addition to improving the user compliance for an improved equality have also significantly improved tolerability, coagulation and cardiovascular-metabolic neutrality.

The introduction of placebo tablets in blisters (no drug) has enabled continuous administration schedules with zero errors related to the duration of the periods of suspension.

Back to the question “Which is the best birth control pill?” we can definitely say that there is a pill suited to the needs of the individual user: to his way of life, its aesthetic needs, its possible medical problems. Sometimes to make it even more clear this concept I take the example of how the choice of the contraceptive pill is similar to the packaging of a tailored suit.

Recently a AIFA (Italian Medicines Agency) report touched some security aspects that physicians should keep in mind when prescribing combined hormonal oral contraceptives (COCs).

Main findings:

  • Confirmed low risk of venous thromboembolism (VTE) for all contraceptives that have less than 50 micrograms of ethinyl estradiol;
  • The Progestin component is important regarding Venous Thromboembolism risk and currently available data indicate that combined hormonal contraceptives that contain the Progestin Levonorgestrel as Norethindrone or Norgestimate have the lowest risk of Venous Thromboembolism.

In addition, the report notes that:

  • When prescribing combined hormonal contraceptives (Estrogen plus Progesterone) it is better to carefully evaluate current risk factors for VTE and that related to different drugs;
  • There is no evidence of differences between the low dose hormonal contraceptives (estrogen) with regard to the Aerial Thromboembolism (TEA);
  • Risk factors for VTE and TEA should be re-evaluated periodically;
  • Women users of combined oral contraceptives should be awared at prescription in the identification of early symptoms of Venous and Arterial Thromboembolism ;
  • The risk of VTE is highest during the first year of use of any COC or when they start again the use of 4 or more weeks (small cyclical suspensions that some ginecologysts recommend would be dangerous) ;
  • It is known that the risk of TEA (myocardial infarction, cerebrovascular accident ) is increased with the use of combination hormonal contraceptives, but there are insufficient data to show whether this risk varies among different drugs.

Finally, specific conditions were identified in which COCs should not be used:

  • Past or current thromboembolic events, heart attack, stroke, angina pectoris, transient ischemic attack;
  • Aware of a blood clotting disorder;
  • History of migraine with aura;
  • Diabetes mellitus with vascular complications;
  • Severely elevated blood pressure (systolic> or equal to 160 or diastolic blood pressure> or = 100);
  • Very high blood fat;
  • Prediction of major surgery or a period of prolonged immobilization.

Caution must be given in case of:

  • age> 35 years;
  • Obesity (especially if BMI exceeds 30kg/m2);
  • Cigarette smoke (over 35 or you stop smoking or they can no longer use COCs);
  • Diseases that may increase the risk of thrombosis (eg, lupus, Crohn’s disease, etc. ..);
  • Taking medications that increase the risk of thrombosis (eg, corticosteroids, antidepressants atc ..);
  • diabetes;
  • High blood pressure;
  • Cardiovascular disease;
  • Recently birth;
  • Long range Air travel (more than 4 hours) or other type of travel longer than 4 hours per day;
  • Lipemia very high even among family members.

The combination of only two of the above conditions is an absolute ban on the use of the pill.

The Agency concludes by inviting doctors to a confrontation with the woman before prescribing the pill using a special checklist.

The same AIFA says that “the benefits associated with the use of COCs far outweigh the risk of serious side effects in the majority of women.”

The perfect pill does not exist but certainly it is possible to get to a safe prescription customized to the needs of women.

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Filiberto Di Prospero
Medical Doctor, Consultant in Gynecology and Obstetrics, Endocrinology and Metabolism. Director of Gynecologic Endocrinology Unit at Civitanova Marche General Hospital (Italy). Private clinics in Civitanova Marche, Rome and Milan.

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