Few people realize that in fact the selection of the drug takes place in the doctor’s head, and he takes into account many factors obtained during the conversation and examination. Usually, the doctor’s decision-making process takes place in three stages, which are not always obvious to the patient.
Step 1: Is this particular patient even allowed to take OCs?
In 1994, the World Health Organization developed a classification system for contraceptive methods. Any condition/disease affecting the ability to use a method was assigned to one of 4 classes.
Step 2: Are there any additional tests that may be needed?
All standard tests that a woman may be sent for when prescribing hormonal pills are categorized into 3 groups:
- Class A – necessary tests to guarantee the safety of the method
- Class B – recommended, but optional tests
- Class C – tests that are not a criterion for the use of the method.
In short, the only thing the doctor is obliged to do before prescribing OCs is to measure blood pressure. If the patient admits that she once had a significant increase in blood pressure or takes medication to reduce it, COCs are not suitable, it is safer to choose another method of contraception. If the blood pressure is below 140/90 mmHg, the woman can use OCs.
If the patient comes to me for the first time, after a detailed discussion, I will definitely proceed to the examination. I will probably perform a cervical screening or take smears. I may find some disease or condition that needs to be clarified. But most importantly, I’ll watch and listen. Slightly yellowish sclerae– what’s going on with the liver function? Hair growth in androgen-dependent areas– where’s our Ferriman-Golway scale? There may well be a situation in which I have questions and seek answers by referring the patient to an ultrasound, a lab, or an allied colleague. For example, if a woman tells me that her father had three heart attacks by the age of 47 and passed away, I will strongly recommend testing for genetic polymorphisms in thrombophilia genes (mutations in the genes encoding F II (prothrombin factor), F V (Leiden factor) and protein C and S deficiency. Even heterozygous carriage of these mutations would be a categorical contraindication for OC – grade 4 eligibility due to the high risk of thrombotic events. Fortunately, such defects are rare, about 4% of the population, so absolutely everyone should not prescribe such a study.
But the usual coagulogram before starting to take OCs is completely unable to in any way identify a predisposition to thrombosis, because the system of blood coagulation-anti-coagulation is very mobile, changes in it occur quickly, and nothing can be predicted.
Thus, clarifying tests and counseling before prescribing OCs can be quite varied. The main purpose of the tests is to confirm that OCs will not cause harm to a particular patient.
Ironically, the most committed to hormonal contraception are those women to whom it is categorically contraindicated. The main task of the doctor – quickly and as accurately as possible to determine who can not take OCs, who can with reservations, and who without restrictions.
If contraindications are identified, it is necessary to inform the woman that from now on and forever she can not take OCs. It is useful to explain in detail why, so that she will not be tempted to choose the drug herself with the help of the Internet or the pharmacist at the pharmacy.
Step 3: Does the patient have the discipline to take OCs?
Before making a final choice, the doctor should get an answer to another important question: whether the woman is ready to take one pill every day, without forgetting or skipping.OCs are very effective when taken regularly, consistently and correctly. If “you drank or didn’t drink, or 11 hours late, or 6 hours late, or forgot to take 3 pills at all”, nothing good will happen.If the patient is not confident in her discipline, it is worth discussing the use of a transdermal patch or contraceptive vaginal ring.Implants and hormone-releasing IUDs belong to purely progestin contraception, but can also be recommended if it is impossible to comply with the regimen.Do I need to take a blood test for “all hormones”?Many women are under the illusion that for individual selection of OCs must necessarily study the “hormonal status” or “take blood for all hormones”. And then everything is simple: where there is not enough – topping up, where the excess – to take away. This, of course, is not the case. There is no hormonal “status” or “background” in nature. Status is something unchangeable, and the hormonal balance in the female body is flexible and mobile.That’s why we get different results on different days of the cycle.There are no strictly “nailed down” days when it is supposed to pass this or that hormone.Studies on hormones in serum are appropriate if the patient has obvious problems – irregular menstruation, atypical hair loss, acne, heavy menstruation.
The purpose of such tests will in no case be “individualized” selection of OCs.The aim is not to miss a disease for which such situations are a symptom.When a woman starts taking OCs, she has calm and regular menstrual-like reactions, while in the meantime a disguised disease may be progressing.