Given the teratogenicity of certain psychiatric drugs like mood stabilizers and antipsychotics, it is logical and responsible to offer contraception to patients for whom these drugs are prescribed. However, actually doing so can be complicated.

Ideally, a patient has a psychiatrist managing her mental health care and a primary care physician or gynecologist overseeing her reproductive health needs, including contraceptive management, cervical cancer screening, and routine testing for sexually transmitted diseases.

In reality, however, patients may not visit their PCPs or gynecologists regularly, or may not even have a primary care doctor. Psychiatrists may be placed in the situation where they either prescribe their patients birth control or the patients go without.

While there are a variety of contraceptive options for patients to choose among, this article will address combined oral contraceptives (COCs). All sexually active patients should be strongly encouraged to use condoms for STD protection, regardless of what other methods of pregnancy prevention they use.

Assessing the appropriateness of combined oral contraceptives (COCs)
Deciding whether a patient is a candidate for COC therapy depends on the patient’s medical history—in particular if she has a contraindication to estrogen. The World Health Organization has developed medical eligibility criteria for initiating contraception, which can be downloaded at http://bit.ly/bP9K8N.

Contraindications to estrogen therapy include personal history of a venous thromboembolism (VTE) or pulmonary embolus, a known thrombogenic mutation, personal history of breast cancer, smoking in women aged 35 years or older, uncontrolled hypertension, and migraine headaches with aura or other neurologic symptoms (World Health Organization. Medical Eligibility Criteria for Contraceptive Use. 4th ed. Geneva, Switzerland: World Health Organization; 2009). Please note that this is not a comprehensive list and you should be familiar with full WHO guidelines before prescribing hormonal contraceptives.

In addition, it is important to consider your patients’ limitations and opinions in regard to taking birth control pills. For example, certain patients may have difficulty remembering to take a pill every day. You should educate these patients about long-term contraceptive options such as Depo Provera, Implanon, and intrauterine devices.

Some patients have inaccurate ideas about contraception, eg, they may think that COCs cause weight gain or affect future fertility. Multiple studies have documented that there is no association between a low-dose estrogen COC and weight gain (Pitts SAB and Emans SJ, Curr Opinions in Pediatr 2008;20(4):383–389).

You should see a patient three months after starting an OCP to check blood pressure, discuss side effects, and check in on compliance. If the patient is doing well, you can see her on a yearly basis (Zieman M et al, A Pocket Guide to Managing Contraception. Tiger, Ga: Bridging the Gap Foundation; 2007).

Differences among COC brands/types
COCs differ in the following ways:

1. The amount of estrogen;


2. the amount and type of progestins;


3. monophasic vs multiphasic formulations; and


4. ratio of active pills to inactive pills.

When starting a patient on a COC, begin with a 35 mcg or lower estrogen concentration, because starting higher than this can lead to an increased risk of VTE. Choosing the type of progestin in a COC depends on the clinical history of the patient.

Second generation progestins—norgestrel and levonorgestrel—provide excellent potency and stabilization of the endometrium. Common preparations include Aviane, Lo-Ovral, and Seasonale. However these provide no anti-androgenic effects, so are not the best choices for patients with acne, polycystic ovarian syndrome, and/or hirsutism.

For these patients, it is best to choose a COC with a third or fourth generation progestin. Third generation progestins—norgestimate and desogestrel—are found in Ortho-Cyclen, Ortho Tri-Cyclen, Kariva and Mircette, among other pills.

The fourth generation progestin, drosperidone, is found in Yaz and Yasmin. Because drosperidone is an analog of spironolactone, it should be avoided in patients who are taking ACE inhibitors or have underlying medical conditions, such as renal disease, that can contribute to elevated potassium levels (Hatcher RA et al eds. Contraceptive Technology. 19th ed. New York, NY: Ardent Media, Inc; 2007).

COCs come in monophasic and multiphasic formulations. Monophasic formulations contain active pills that all contain the same concentration of hormones, while multiphasic formulations contain active pills with varying levels of hormones. This difference in formulation explains the difference between Ortho Cyclen and Ortho Tri-Cyclen, for example.

Monophasic formulations are recommended if patients wish to modify cycle length by occasionally eliminating the week of placebo pills to skip or delay a menstrual period (Zieman op.cit).

Traditionally, a pill pack would contain 21 days of active hormone-containing pills and seven days of inactive, or placebo, pills. This allowed women to have a period during the last week of the pill pack. Newer trends in COCs have been to increase the ratio of active pills to inactive pills so that women will experience fewer menstrual periods per year. For example, Seasonale is designed to have women menstruate only four times per year.

While safe and desirable for many patients, extended cycling can cause increased breakthrough spotting between periods. Also, some patients find it disconcerting to not have a menses every month because it may increase anxiety about possible pregnancy.

Risks and side effects of COCs
Among the greatest concerns related to COC therapy is increased incidence of venous thromboembolism (VTE). Depending on the age and medical profile of the patient, other serious risks include myocardial infarction, stroke, hypertension, andbenign liver tumors (Hatcher op.cit).

VTE risk is associated primarily with the dose of estrogen contained in COCs, which is why it is so important to assess risk factors for estrogen use when starting COCs. In the general population, a woman’s risk of developing a VTE is four to eight in 100,000 women per year. This risk increases to 10 to 30 in 100,000 women per year when a patient is on a low-dose COC. However, when explaining this increased risk to patients, it is important to remind them that the risk of VTE when on a COC is still significantly lower than the risk during pregnancy, which is 60 in 100,000 women per year (Zieman op.cit).

It is crucial to counsel patients about this increased VTE risk and symptoms to watch for. You can use the ACHES mnemonic to help patients remember symptoms related to VTE complications:
Abdominal pain
Chest pain
Headaches
Eye symptoms (such as vision changes)
Swelling or pain in the legs

Other common side effects of COCs include nausea, breast tenderness, and irregular menstrual bleeding. Taking the pill at night may help with nausea, and breast tenderness and irregular spotting often resolve after the first few cycles of COCs. If these symptoms persist, you should consider switching pill formulas.

Multiple studies have shown there is no statistically significant increased risk of depression in women on COCs. However, some patients do report increases in moodiness, depression, and other emotional states while on COCs. Such complaints deserve careful evaluation and may warrant a decrease in hormone doses or discontinuing COCs (Hatcher op.cit).

COC effectiveness
With perfect use, COCs have a 0.3% failure rate in the first year of use. However, with typical use, they have a failure rate of 8% in the first year of use (Hatcher op.cit).

Health benefits of COCs
There are many non-contraceptive benefits to COCs. Long-term users have decreased risks of ovarian and endometrial cancer. Depending on the type of progestin in a COC, certain formulations can improve acne and hirsutism. Also, many women enjoy that COC use leads to more regular menstrual cycles with less dysmenorrheal and decreased blood loss (Hatcher op.cit).

Migraine headaches and COC therapy
Migraines headaches with aura or focal neurologic symptoms are absolute contraindications to using an estrogen-containing contraceptive, regardless of a patient’s age, because of the increased risk of stroke (Blake DR and Huppert J, Contemp Pediatr 2007;24:38–59).

If a patient younger than age 35 has a history of migraine without aura or neurologic symptoms, benefits of COC therapy are thought to outweigh the risks. However, in patients age 35 or older who have a history of any migraines, COCs are not recommended (WHO op.cit).

Once a patient is placed on COC therapy, it is important to assess on follow-up visits if there are new or worsened headaches. If so, the following actions are recommended (Hatcher op.cit):

1. If patient develops new/worsening headaches that have accompanying focal neurologic symptoms, such as loss of vision, dizziness, slurred speech, flashing lights, weakness, abnormal cranial nerve exam, then discontinue COC. Refer for medical evaluation if appropriate. Consider changing to a progestin-only or non-hormonal method of birth control.


2. If patient develops headache symptoms that occur only during or worsen with menses, then consider a trial of extended cycling, such as using Seasonale.


3. If patient develops severe headache symptoms or is at high risk for stroke, then discontinue COCs. Refer for medical evaluation if appropriate. Consider changing to a progestin-only or non-hormonal method of birth control.


4. If patient develops mild headache symptoms without neurologic findings, then consider decreasing estrogen content of COCs and monitor closely.

Medications that interfere with the efficacy of COCs
Rifampin, rifabutin, St. John’s Wart, ritonavir-boosted protease inhibitors, and certain anticonvulsants can lead to decreased efficacy of COCs. Anticonvulsants that interact negatively with COCs are phenytoin (Dilantin), barbiturates, carbamazepine (Tegretol), primadone (Mysoline), topiramate (Topamax), and oxcarbazepine (Trileptal).

Also, it is notable that pharmacokinetic studies show that levels of lamotrigine decrease significantly with concurrent COC use (WHO op cit). COCs may increase the effect of diazepam (Valium), chlordiazepoxide (Librium), and tricyclic antidepressants (Hatcher op.cit).

Prescribing patients emergency contraception
Emergency contraception (EC) can be prescribed in several ways. In the past, it was administered via high dose combined hormonal methods. This was problematic for some patients due to the nausea and vomiting that accompanied the increased estrogen dose.

Today, the preferred method of EC is Plan B. Plan B contains only levonorgestrel, so it is a safe method even if a patient has a contraindication to estrogen. Plan B contains two pills, and package instructions state to take the two pills 12 hours apart from each other. However, many practitioners advise their patients to take them both at once.

Plan B can be used up to five days after unprotected intercourse. However, the efficacy of Plan B decreases significantly as time from the encounter increases. If taken within 24 hours of unprotected intercourse,

Plan B is 77% effective in preventing pregnancy. If taken between 49 and 72 hours, the efficacy decreases to 31%. If menstruation does not occur within 21 days of taking Plan B, patients should see their doctor for a pregnancy test.

Plan B is available over the counter for patients 18 years and older. For patients younger than 18, a prescription is required (Zieman op.cit).

Alternatives to COCs to prevent conception
Patients who wish to use a combined hormonal contraceptive but have difficulty remembering to take a daily method may be interested in using the contraceptive patch (changed weekly) or vaginal ring (monthly). Depo Provera is a monthly injection that can be used in women with a contraindication to estrogen, and IUDs are now considered viable options for adolescents and can be used for five to 10 years. Another new option is a subcutaneous progesterone implant (Implanon) that is effective for up to three years.