2 methods for prescribing third-generation OCs
The experts give you their recommendations
In light of the new data that indicate the risk for venous thromboembolism (VTE) for desogestrel OCs may be less than initially reported, how should clinicians approach prescribing them?
John Guillebaud, MA, FRCSE, FRCOG, MFFP, medical director of the Margaret Pyke Family Planning Centre in London and Andrew Kaunitz, MD, professor and assistant chair of OB/GYN at the University of Florida Health Sciences Center in Jacksonville offer the following insights:
Guillebaud’s recommendations.
• In the medico-legal environment prevailing in the United Kingdom, young women with no risk factors are generally started on the second-generation pills because these starter patients may include an unknown number of predisposed women for VTE.
Why start young women on second-generation pills? Think of starter patients as an unknown quantity, says Guillebaud. Within that group, there is likely to be a subgroup of women who are predisposed for VTE.
"Therefore, all starters should be put on second-generation pills to have the least risk of the thing that matters the most when they are young," he explains. "Almost the only thing that matters when they are young is venous thrombosis. Heart attacks don’t happen until they are quite a bit older."
• Patients with a venous thromboembolism risk factor, such as obesity or severe varicose veins, should definitely be taking a second- generation pill.
• For patients with an arterial risk factor (heavy smoker, diabetic, lipid disorder, or high blood pressure), Guillebaud suggests as they near age 30, clinicians should begin discussing a possible switch to third-generation pills.
Why? Guillebaud explains his reasoning:
The patient is nearing the age at which heart attacks are more of a concern.
The patient already has a risk factor for arterial disease.
Since the patient already has been on oral contraceptives for a number of years, she is in a category less likely to have a VTE.
"The very fact that she survived without [a VTE], despite being on the pill, makes it less likely now, or she may have had a full-term pregnancy," Guillebaud points out. "Any long-term user of any pill with ethinyl estradiol in it is somebody who has managed not to have a VTE, and therefore is unlikely to be a predisposed woman. The predisposed woman gets a thrombosis and leaves your population of continuing pill-takers."
So when your patient is nearing 30 and is a heavy smoker, you now have a "push and a pull" to move her to a third-generation pill, counsels Guillebaud.
"Your push is the fact that she is a survivor and hasn’t had venous thrombosis, and your pull is the fact that she has now reached the age group in which smokers do start getting heart attacks," he explains. "That’s a double reason why you might tend to shift at that age group."
The most important idea when counseling any woman about combined oral contraceptives is to "let the user be the chooser," Guillebaud advocates.
"The point to make is that all these differential risks between pills are so small that after counseling, if a woman chooses any brand for herself, she may do so," he says. "If a woman says she prefers Desogen because she finds it better for her skin or for her mood or for anything, we believe she should have the autonomy to use it at any time she likes, even if she is only 20, especially if she is a smoker, but even if she is a nonsmoker.
Kaunitz’s recommendations.
• For current users of desogestrel OCs who are doing well, continue them on their current OC.
• For those clinicians who prefer to begin "new start" patients on new progestin OCs and who believe that vascular disease risks may be higher with desogestrel pills, start your patients on norgestimate-containing OCs.
• Other clinicians can choose to use desogestrel-containing OCs in new start patients.
"Hopefully, further epidemiological research will clarify the association between use of various OCs and risk of VTE," says Kaunitz.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.