ORIGINAL RESEARCH ARTICLE Oral Contraceptive Practice Guidelines Ronald T. Burkman and Lee P. Shulman Introduction O ral contraceptives (OC) are currently being used by 65 million women worldwide, ap- proximately 6% of all women of reproductive age. 1 One-fourth of all women of reproductive age in the United States use OCs, which are now more widely used in the United States than any other method, including sterilization. 2 Their widespread use throughout the world for several decades suggests that both medical professionals and the lay public believe that the benefits of OCs outweigh potential side effects. 1 Greater awareness of the metabolic effects of OCs and the role of smoking and hypertension in the development of cardiovascular disease has led to more selective prescribing and a substantial reformu- lation of the steroidal components. 3 A variety of formulations are available, but all combination OCs contain two components: an estrogen, which main- tains the endometrium and prevents breakthrough bleeding, and a progestin with sufficient activity to suppress pituitary gonadotropin secretion. Each of the steroids also has additional functions. The progestin component causes changes in the cervical mucus and the endometrium that enhance the antifertility ef- fects of OCs should ovulation occur 4 and the estrogen acts synergistically with the progestin to inhibit the pituitary. 4 Since OCs were first introduced, both hormonal components have been substantially re- duced in amount and reformulated. Prior to 1992, OCs in the United States contained one of two estrogens, either ethinyl estradiol (EE) or mestranol. Since then, all low-dose OCs (ie, prepara- tions containing 50 g) have contained EE exclu- sively. Low-dose formulations are now the standard, accounting for almost all OC prescriptions. Prior to 1992, OCs in the United States contained one of four progestins: norethindrone; norgestrel and its active isomer, levonorgestrel; norethindrone ace- tate; or ethynodiol diacetate. All of these medium- and high-androgenic progestins were less selective than later formulations, and they were associated with a variety of adverse androgenic effects. They had a negative effect on carbohydrate and lipid metabo- lism 3,5 and often produced acne, 6 hirsutism, 7 and weight gain. 8,9 In 1992, low-androgenic progestins, norgestimate and desogestrel, were introduced in the United States. Because the affinity of these progestins for progester- one receptors is higher than for androgen receptors, their activity is more selective. Consequently, andro- genic side effects associated with OCs containing these progestins are less common compared with the side effects of OCs containing high doses of the more androgenic progestins. 10 –14 All currently available OCs are highly effective for preventing pregnancy, but variations in their hor- monal components are clinically important. Varia- tions in progestin formulations, for example, modu- late the overall metabolic and clinical effect of a given combination OC. 3 Variations in estrogen dose among formulations containing 50 g EE may also affect cycle control. However, all low-estrogen dose formu- lations are safe for use by nonsmoking women with- out major cardiovascular risk factors such as uncon- trolled hypertension. To assist clinicians in selecting the most appropri- ate OC for their patients, a panel of experts in gyne- cology and contraception has developed a set of prac- tice guidelines for OC selection. These physicians, who are members of the editorial board of Dialogues in Contraception, reviewed the guidelines with a panel of 70 visiting faculty members. 15,16 Together, they reviewed the clinical effects of the variations in OC formulations on safety, cycle control, side effects, and noncontraceptive benefits—the factors which, collectively, provide the basis for selecting one OC over another for a particular patient. (It must be recognized that these guidelines were developed within the context of countries with advanced med- ical systems and low maternal mortalities. In less developed countries, with high rates of maternal morality and limited health care resources, the use of any form of oral contraceptive with limited screening and follow-up may be quite appropriate.) Department of Obstetrics and Gynecology, Baystate Medical Center, Spring- field, Massachusetts; and Department of Obstetrics and Gynecology, University of Tennessee at Memphis, Memphis, Tennessee Name and address for correspondence: Ronald T. Burkman, Chairman, Department of Obstetrics and Gynecology, Baystate Medical Center, 765 Chestnut St., Springfield, MA 01109 © 1998 Elsevier Science Inc. All rights reserved. ISSN 0010-7824/98/$19.00 655 Avenue of the Americas, New York, NY 10010 PII S0010-7824(98)00081-X