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Benefits of Oral Contraceptives The substantial and widespread benefits of oral contraceptives are often taken for granted or forgotten amid the controversies and concerns about the pill that range from legitimate scientific questions to unfounded neighborhood rumors. The chief benefit of OCs, of course, is their effectiveness in preventing pregnancy. OCs protect millions of women from the burden of unwanted pregnancies and childbearing and prevent thousands of women’s deaths in childbearing. Other important benefits of OCs are reductions in the risks of iron-deficiency anemia and of endometrial and ovarian cancer.

The fertility-related benefits of oral contraceptives include not only:

* Effectively preventing unwanted pregnancy, but also

* Better maternal and child survival,

* Prevention of ectopic pregnancy, and

* Reduced risk of pelvic inflammatory disease.

Preventing pregnancy. The most important benefit of the pill is its convenient, highly effective, and reversible protection against unwanted pregnancy. All widely available types of pills–combined estrogen-progestin, progestin-only, and multiphasics–are highly effective. Among women using combined estrogen-progestin OCs correctly, in the first year of use pregnancy occurs in fewer than one in every 100.

Most authorities consider combined pills containing less than 50 [mu]g of estrogen to be as effective as those containing 50 [mu]g or more. The few comparative studies have reported no significant difference (48, 259, 313).

Few studies have been conducted in which women were randomly assigned to use one type of pill or the other. A multicenter World Health Organization (WHO) study compared six combined OCs containing 20 to 50 [mu]g estrogen. No significant differences in effectiveness appeared. Even the highest pregnancy rate observed was less than 1.5 pregnancies per 100 woman-years of use (545).

Progestin-only pills may be slightly less effective than any combined pills. In clinical trials failure rates range from about 1 to 3 per 100 woman-years of use. While minipills fail to prevent ovulation in about 40 percent of users, other effects contribute to contraceptive protection. In particular, progestins change cervical mucus so that sperm find it more difficult to penetrate (153, 194, 398, 511).

Because all pills are so effective, identifying any small differences in effectiveness among specific formulations would require very large studies. In clinical trials other factors may be more important than formulation. Such factors include differences among pill groups in age and other characteristics of women recruited, the number lost to follow-up, and compliance with the pill-taking regimen (487).

Because women sometimes forget to take their pills, switch to another method, or discontinue contraceptive use altogether, actual effectiveness in day-to-day use is often less than reported in clinical trials. Surveys of married women in the US have found that 2 to 3 percent of women have unplanned pregnancies in the first year of pill use (170, 171, 432, 499). Actual failure rates are probably somewhat higher, however, since abortions are seriously underreported in most surveys (143, 205).

In some developing countries OC failure rates have been much higher. For example, according to World Fertility Survey data from five Latin American countries in the 1970s, the pregnancy rate among OC users was 8 per 100 per year. By comparison, the pregnancy rate among IUD users was 5 ler 100 (165). In the Philippines a 1980 national survey reported 19 pregnancies per 100 woman-years of pill use compared with 4 per 100 among IUD users (273). Other population-based surveys report pregnancy rates among OC users of 15 per 100 woman-years in Bangladesh (85) and 13 per 100 woman-years in Sri Lanka (480). Irregular pill-taking may explain these relatively high pregnancy rates.

Multiphasic pills have only recently been widely used, but some evidence suggests that one triphasic formulation may be slightly less effective than combined pills. During their first year on the market in Britain, several pregnancies were reported among users of a triphasic pill consisting of .05/.075/.125 mg levonorgestrel and 30/40/30 [mu]g ethinyl estradiol (133, 173). Subsequently, a study in the Netherlands found that, from 1982 to 1984–when this triphasic formulation was the only one marketed–women using triphasics were about twice as likely to request abortions as were users of combined pills (259). Finally, a 6-month clinical trial conducted in 11 centers in Denmark, Norway, and Sweden reported three pregnancies in 1,063 cycles among women using the formulation, two of the pregnancies attributed to pill failure (101).

Maternal and child health. By preventing unwanted pregnancies and enabling women to time births, OCs–like other reliable methods of contraception–contribute to both maternal and child health. Worldwide, an estimated half a million women die in pregnancy and childbirth every year. About 99 percent of these deaths occur in developing countries, where, excepting China, on average 550 women die per 100,000 live births, or one for every 180 live births (422). Among children, as many as 20 percent of infants die in parts of Africa and Asia. Worldwide each year an estimated 14 million children die before age five (174).

* Objective.-Peritoneal washings are routinely performed during gynecologic surgery. The presence or absence of malignant cells in washings helps determine the stage of the malignancy. However, the efficacy of this procedure has not been studied recently.

Design.-All intraoperative washings for gynecologic disease at our hospital from 1992 through 1994 (901 cases) were reviewed. Of these, 380 were gynecologic malignancies that were reviewed for changes in staging based on the presence of malignant cells.

Results.-Histologically, 380 cases were gynecologic

malignancies, 521 benign, 79 nongynecologic, and 25 had no accompanying surgical pathology. Of the malignancies, 125 had a diagnosis of cancer on washings. In 12 cases (3.1 %), a change in stage resulted.

Conclusions.-In a small but significant number of cases, malignant cells in the washings changed postoperative staging, impacting therapeutic measures and prognosis for these patients greatly. Peritoneal washings remain a simple yet effective tool in the evaluation and management of gynecologic malignancies.

(Arch Pathol Lab Med. 1997;121:604-606)

Cytologic sampling of peritoneal fluid from the pouch of Douglas at the time of surgery, as a concept, was introduced in 1958. Peritoneal washings are now commonly performed during any exploratory laparotomy for gynecologic disease because peritoneal involvement can be undetectable by visual inspection alone. The application of peritoneal lavage in laparotomies serves three purposes: detection of occult tumor, determination of recurrent or persistent tumor, and staging. The presence of peritoneal tumor indicates a worse prognosis, and thus the results of peritoneal washing cytology are incorporated in staging and treatment decisions. In this era of managed care and cost containment, the significance of this procedure is being tested anew.

Cytologic preparations of all intraoperative washings from 1992 through 1994 at The Johns Hopkins Hospital, Baltimore, Md, were studied retrospectively. A total of 901 peritoneal washings from women undergoing laparotomy for gynecologic disease were reviewed, and 380 of these cases were reviewed for changes in staging.

All cytologic specimens were obtained intraoperatively; some had washings separately collected from multiple intra-abdominal sites, and these fluids were interpreted as all positive or all negative in all patients. All cytologic preparations (cytospin, Millipore filter preparations; Millipore Corp, Bedford, Mass) were subsequently stained with modified Papanicolaou and/or DiffQuik stains. All cell blocks were stained with hematoxylin-eosin.

In cases with documented malignancy, the results of peritoneal cytology and corresponding malignant histology, as well as pertinent clinical data, were reviewed for each patient to determine whether the cytopathologic diagnosis changed the FIGO (International Federation of Gynecology and Obstetrics,1988) stage of disease.

RESULTS

Histologically, 380 of the 901 cases were gynecologic malignancies, and 521 were benign. Of the 521 washings from patients with histologically benign genital disease, no false positives were found. This excellent concordance may be a result of good cytohistologic correlation, which enhanced the accuracy of interpretation. Of the gynecologic malignancies reviewed, a diagnosis of cancer was made in 125 cases, and in 12 cases (3.1%), a change in stage resulted (Table). Four of the 12 cases were endometrioid carcinomas of the uterus (one clear cell carcinoma [Fig 1], three endometrial cancers), two were clear cell carcinomas of the ovary, two were serous carcinomas, and one was a serous tumor of low malignant potential. The remaining cases involved three rare tumors, namely, a small cell carcinoma of the uterus (Fig 2), a mixed mullerian tumor, and a fallopian tube carcinoma. All but one of these 12 cases (the fallopian tube carcinoma) were primary neoplasms and not recurrences. Over the short follow-up period (at time of submission, 1992-1996), none of these cases had, nor subsequently developed, a second primary tumor, confirming that the malignant cells seen were not from an occult tumor. Four of the patients are dead of disease, six are disease-free, and one has evidence of disease. One patient was lost to follow-up. It is interesting to note that two of the patients with apparently limited disease (cases 2 and 4 in the Table) are dead of disease. The other two deceased patients (cases 10 and 11 in the Table) had minimal disease, but aggressive tumors with poor prognoses. On review of all the gynecologic malignancies, 25 were recurrences or second-look operations.

COMMENT

Pelvic malignancies with accompanying exudates have been evaluated since as early as 1867. Peritoneal washing cytology as a diagnostic tool was proposed in 1958. The prognostic value for pelvic tumors was shown by Morton et al in 19611 and 10 years later by Creasman and Rutledge in 1971.23

Today, peritoneal washings have become an accepted adjunct to the pathologic evaluation of gynecologic malignancies.3 This was considered necessary because the rationale for peritoneal washing cytology since its inception has included the concept that some cases will be cytologically diagnostic before a clinically suspicious focus is found.2,5 The information obtained by this procedure is used to plan adjuvant therapy and management for patients with cytopathologic evidence of malignancy established by positive peritoneal washings.

Ever since oral contraceptives came on the market 35 years ago, questions have lingered over their safety: Do they increase the risk of stroke and breast cancer? Do they decrease libido? Two new studies and a survey have provided some answers–most of it encouraging.

Stroke is rare among reproductive-age women, and today’s oral contraceptives which contain a low dose of estrogen do not appear to increase the risk. The finding comes from a study by Diana B. Petitti, M.D., and colleagues at the Kaiser Permanente Medical Care Program (The New England Journal of Medicine, 4 July 1996). The researchers compared the 295 women who suffered strokes with the 1.1 million young women enrolled in their health maintenance program.

When the birth control pill first went on the market, it was associated with the risk of stroke because it contained very high doses of estrogen. Women today can choose among more than 50 brands of the birth control pill, which contain about one-fifth the estrogen of the earlier versions.

A slightly increased risk of breast cancer was found among women currently using combined oral contraceptives and those who had used them in the past ten years (The Lancet, 22 June 1996). This is the conclusion of a British team of researchers who analyzed 54 studies conducted in 25 countries. The combined number of participants included over 53,000 women with breast cancer and over 100,000 without the disease.

The researchers found no evidence of an increased risk of breast cancer diagnosed ten or more years after stopping the use oral contraceptives. Age appears to be a factor. The older a woman is at last use of oral contraceptives, the higher her odds of developing breast cancer. However, the cancers diagnosed among pill users tended to be less advanced than the cancers diagnosed among women who never used birth control pills.

When the birth control pill first came on the market, some researchers thought it might decrease sexual desire, but a new survey found that libido and sexual satisfaction are enhanced by one type of oral contraceptive known as the triphasic pills. Questionnaires were filled out by 364 women, aged 18 to 26 years, all sexually active and users of oral contraceptives.

Drs. Norma L. McCoy and Joseph R. Matyas reported that they had not expected to find sexual desire and satisfaction increased by any version of oral contraceptives. They theorized that the reason the triphasic pills had this effect was its varying levels of one hormone, progestin. Monophasic pills, on the other hand, provide the same level of estrogen and progestin per dose for 21 days of each menstrual cycle.

The two brands used by most women in this survey, which was conducted between 1989 and 1990, were Ortho-novum 7/7/7 triphasic pills or Ortho-novum 1/35 monophasic pills.

Earlier research has shown that oral contraceptives lower the rates of ovarian and uterine cancers and slightly increase the incidence of cervical cancer.

Hysterectomy, the most common major nonobstetric operation, is performed in more than 570,000 women in the United States each year. Although the number of hysterectomies has decreased In recent years, many authorities believe that hysterectomy is often unnecessary and unjustified. There is no universally accepted set of criteria regarding the appropriate indications for hysterectomy. The main indications for hysterectomy include the following conditions: uterine leiomyomas, dysfunctional uterine bleeding, endometriosis/adenomyosis, chronic pelvic pain and genital prolapse. Current literature, however, routinely recommends conservative management of most nonmalignant gynecologic conditions, with hysterectomy reserved for refractory cases. Several nonmedical factors, such as patient race, age, geographic location, medical history and background, as well as health care provider characteristics, such as time since completion of training, gender, and affiliation with teaching hospitals, are also associated with hysterectomy rates.

Annual hospital costs associated with hysterectomy, the second most common major surgery performed in the United States, surpass $5 billion.[1] After peaking in 1975 at 725,000 per year, the number of hysterectomies performed each year has declined and is currently estimated to be 576,000 per year.[2]

The majority of hysterectomies are elective, and more than 90 percent of all procedures are performed in women with nonmalignant conditions.[3] Currently, appropriate indications for hysterectomy remain controversial among health care professionals. Besides the medical indications for hysterectomy, both patient and health care provider characteristics may influence hysterectomy rates.

This article reviews the current recommendations concerning common nonmalignant indications for hysterectomy, suggests alternative treatments and discusses nonmedical predictors of hysterectomy.

Medical Indications for Hysterectomy

UTERINE LEIOMYOMAS

Uterine leiomyomas are the most common indication for hysterectomy and are the reason given for 25 to 30 percent of hysterectomies.[3,4] Leiomyomas, or benign tumors composed of smooth muscle cells and fibrous connective tissue, arise most often in women 30 to 49 years of age and are typically slow-growing, multiple and variable in size. Although the precise etiology of leiomyomas is unknown, sex steroid hormones, specific enzymes and epidermal growth factor are believed to play a role in their development.[5]

Women with leiomyomas are usually asymptomatic. They may, however, have abnormal uterine bleeding, pelvic pain and pressure, lower urinary tract symptoms, infertility, spontaneous abortion and preterm labor.

Medical management of symptomatic uterine leiomyomas may involve hormonal therapy or nonsteroidal anti-inflammatory drugs (NSAIDs) to relieve menorrhagia, dysmenorrhea or pelvic discomfort. Gonadotropin-releasing hormone (GnRH) agonists may induce a state of hypoestrogenemia, causing a reduction in tumor size.[6] However, use of GnRH agonist therapy is limited by the rapid regrowth of tumors following cessation of therapy, decreases in bone density and vasomotor symptoms.[7,8]

Myomectomy is a conservative surgical management option for uterine leiomyoma, is often performed laparoscopically on an outpatient basis, and appears to have good long-term effectiveness.[7] The advantages of hysteroscopic resection of leiomyomas include preservation of fertility, reduced postoperative discomfort and a relatively short recovery period.[9] Unfortunately, leiomyomas recur in an estimated 15 to 30 percent of patients following myomectomy, and operative risks increase with multiple myomectomies.[10]

Hysterectomy is the appropriate and definitive treatment for a woman who has finished childbearing and who has large, symptomatic uterine leiomyomas.[7] Table 1 summarizes the recommendations of the American College of Obstetricians and Gynecologists (ACOG) regarding hysterectomy for leiomyoma.[11] Experts, however, disagree on whether hysterectomy is justified for a woman with asymptomatic or minimally symptomatic fibroids.[12] Traditionally, indications for hysterectomy in a woman with asymptomatic leiomyomas include the following: (1) nonpalpable adnexa that interferes with the diagnosis of ovarian cancer; (2) prophylaxis against future symptoms; (3) avoidance of increased surgical morbidity from continued uterine enlargement, and (4) avoidance of the rare disorder leiomyosarcoma.[12,13] Available evidence challenges these traditional arguments, and current guidelines do not recommend hysterectomy for an enlarged uterus caused by asymptomatic leiomyomas.[12,13]

TABLE 1

Criteria for Hysterectomy for Leiomyomas

Confirmation of leiomyomas (presence of 1 or 2 or 3)
1. Asymptomatic leiomyomas of such size that they are palpable
abdominally and are a concern to the patient
2. Excessive uterine bleeding evidenced by either of the following:
a. Profuse bleeding with flooding or clots or repetitive periods
lasting more than eight days
b. Anemia due to acute or chronic blood loss
3. Pelvic discomfort caused by myomas (presence of a or b or c)
a. Acute and severe
b. Chronic lower abdominal or low back pressure
c. bladder pressure with urinary frequency not due to urinary
tract infection

Actions prior to procedure
1. Confirm the absence of cervical malignancy
2. Eliminate anovulation and other causes of abnormal bleeding
3. When abnormal bleeding is present, confirm the absence of
endometrial malignancy
4. Assess surgical risk from anemia and need for treatment
5. Consider patient’s medical and psychologic risks concerning
hysterectomy

Contraindications
1. Desire to maintain fertility, in which case myomectomy should
be considered
2. Asymptomatic leiomyomas of size less than 12 weeks of gestation
determined by physical examination or ultrasound examination

From Quality assessment and improvement in obstetrics and
gynecology. Washington, D.C.: American College of Obstetricians
and Gynecologists, 1994. Used with permission.

Oral contraceptives, or birth control pills, have been used by more than 60 million women worldwide, and are considered by many to be the most socially significant medical advance of the twentieth century. The birth control pill is a tablet taken daily by a woman to prevent pregnancy. The birth control pill does this by inhibiting the development of the egg in the woman's ovary during her monthly menstrual cycle. During a woman's menstrual cycle, a low estrogen level normally triggers the pituitary gland to send out a hormone that initiates development of an egg. The birth control pill releases enough synthetic estrogen to keep that hormone from being released during the monthly cycle. The birth control pill also contains a second synthetic hormone, progestin, which increases the thickness of cervical mucus and impedes development of the uterine lining to further prevent pregnancy. Studies have shown that the birth control pill is 99% effective in preventing pregnancy. The results of studies on the safety of the birth control vary. Some studies show that its use increases the risk of certain types of cancer, while others show that risk to be minimal. There are also claims that the birth control pill increases risk of stroke and heart attacks.

The Planned Parenthood Federation of America commissioned Dr. Gregory Pincus and Dr. John Rock to develop a simple and reliable form of contraception in 1950. Over the next several years, the doctors worked on formulating a birth control pill at the Worcester Foundation for Experimental Biology in Massachusetts. They tested their invention on 6,000 women in Puerto Rico and Haiti. The invention was then marketed in the United States in 1960 as Enovid-10.

Many attribute the changing social land-scape in the United States during the 1960s to the widespread acceptance and use of the birth control pill. As sexual relations outside of marriage and for reasons other than childbearing became more socially acceptable and women seeking careers sought family planning methods, the environment was ripe for introduction of this discreet, easy-to-use form of contraception.

Despite its popularity, soon after the birth control pill was introduced, the public began to raise concerns about side effects and safety. As early as 1961, reports had begun to circulate that the birth control pill increased a woman's risk of suffering a stroke or a heart attack by causing blood clotting. In 1965, the federal Food and Drug Administration (FDA) provided a scientist at Johns Hopkins School of Hygiene and Public Health to study the side effects of the birth control pill. The agency also established an Advisory Committee on Obstetrics and Gynecology to study the relationship between oral contraceptives and blood clotting, as well as whether the birth control pill increased risk of breast, cervical, or endometrial cancer. The committee, the first-ever advisory committee established by the FDA, reported in 1966 that it had found no evidence to render the birth control pill unsafe for human use.

Unsatisfied, the FDA called for a larger study of the effects of the birth control pill on blood clotting. The agency also determined, Using a process known as the wet granulation method, the active ingredients are mixed together with a dilutant and a disintegrant in a large mixer. Once mixed, the powder mass is forced through a mesh screen. however, that the birth control pill had not been in use long enough for a study of its relationship to cancer to be observed. At the same time, the World Health Organization (WHO) also determined that the effects of the birth control pill on blood clotting warranted study. By 1968, a British study revealed an increase in blood clots among women taking oral contraceptives. The FDA required that packages of birth control pills contain warning labels. In 1969, the agency concluded that the amount of estrogen affected the level of blood clotting and that birth control pills containing lower dosages of estrogen were as effective as their high-estrogen counterparts. The agency began advising doctors to prescribe the lowest estrogen dosage possible to their patients.

An oral contraceptive containing only progestin was introduced in the early 1970s. Dubbed the mini-pill, this form of oral contraceptive prevented pregnancy solely by causing changes in the uterus and cervix. An egg was produced, but the changes caused by the mini-pill made it difficult for the egg to unite with sperm from the male. While the mini-pill eliminates the risks posed by estrogen, it has been found to be less effective in preventing pregnancy than pills containing estrogen. Throughout the 1970s, pills containing consistently lower doses of estrogen were introduced on the market.

In 1982 a biphasic birth control pill was introduced, followed by a triphasic pill in 1984. These low-dose pills contained varying ratios of progestin to estrogen. In 1988 all three drug companies still manufacturing high-dose birth control pills withdrew their high-dose products from the market, at the FDA's request. By 1990, the amount of estrogen in birth control pills had been reduced by at least two-thirds. Studies show that the risk of blood clotting in women taking the birth control pill has decreased accordingly. Further studies have shown that high-dose birth control pills actually reduced a woman's risk of ovarian and endometrial cancers, benign cysts of the ovaries and breasts, and pelvic inflammatory disease. The risk of breast or cervical cancer is still disputed.

In 1987, over 13 million women of reproductive age (15 to 44 years) reported using oral contraceptives. Despite widespread use, women are still concerned about adverse effects. A 1985 Gallup poll reported that three out of four women believe that the use of birth control pills causes serious health problems, including cancer, stroke and myocardial infarction.

Mishell points out that the current scientific literature does not support the belief that the use of oral contraceptives poses a significant health risk for most healthy women of reproductive age. For example, studies have shown that the use of oral contraceptives actually decreases the risk of ovarian and uterine cancer. There is no conclusive evidence that oral contraceptives increase cancer risk, with the exception of cervical cancer, which can be more easily diagnosed and treated than other types of cancer.

Previous studies suggesting an increased risk of cardiovascular disease in oral contraceptive users were conducted among women who received formulations that contained 50 lAg or greater of estrogen. This increased risk, however, was found only among older women with preexisting risk factors, such as smoking, hypercholesterolemia, diabetes and hypertension. Recent studies of healthy women taking primarily low-dose oral contraceptives (35 [mu]g or less of estrogen) indicate that there is no increased risk of myocardial infarction or stroke. In fact, studies suggest that estrogen may have a protective effect against atherosclerosis by increasing high-density lipoprotein levels and decreasing low-density lipoprotein levels. Estrogen use also causes a modest increase in triglyceride levels.

Consumers are generally unaware of other benefits of oral contraceptives. These include reduced risk of iron deficiency anemia, corpus luteal and follicular cysts, salpingitis, dysmenorrhea and premenstrual syndrome. Premenopausal use of oral contraceptives may also provide protection against the development of postmenopausal osteoporosis.

Now more than 40 years since it was first approved by the U.S. Food and Drug Administration (FDA) in 1960, “the pill” continues to be the most popular and one of the most effective forms of reversible birth control ever invented. According to the Johns Hopkins School of Public Health Population Information Program, more than 100 million women worldwide and 18 million U.S. women rely on birth control pills (BCPs) today. In the U.S. alone, about 40 different products are available.

Unlike the original oral contraceptives that women took decades ago, there are new low-dose forms of BCPs that have few health risks and many health benefits. Despite the fact that they are safe for most women, birth control pills do carry some health risks. For example, if you are over 35 and smoke or have certain medical conditions (a history of blood clots or breast or endometrial cancer), you may be advised against taking them. Likewise, birth control pills are not designed to reduce your risk of transmitting or acquiring sexually transmitted diseases (STDs), including HIV (human immunodeficiency virus), the virus that causes AIDS.

Unlike other forms of birth control sold over-the-counter, a health care professional’s prescription is needed to purchase BCPs; many health insurers are starting to cover their cost.

It is important to consult with a health care professional about the pros and cons of any form of birth control you are considering. Factors to be considered are outlined below in this article. (For more information on contraceptive devices and methods other than oral contraceptives, see the health topic at the Web site titled “Contraception.”)

How Birth Control Pills Work

The pill is a synthetic form of the body’s own hormones that works by suppressing ovulation-the monthly release of an egg from one of the ovaries. At the beginning of each menstrual cycle, levels of the hormone estrogen begin building. This thickens the endometrium (the lining of the uterus) in preparation for a fertilized egg. Estrogen levels peak and then, at approximately 14 days into the cycle, an egg is released from one of the ovaries. After ovulation, levels of progesterone rise for the next seven days. This further prepares the endometrium for a fertilized egg to attach itself to the endometrium, which is called conception or implantation. If conception does not occur, levels of both estrogen and progesterone drop to their lowest point. This drop signals the thickened uterine lining to slough off, resulting in the monthly period. When a woman is taking the pill, hormone levels are more constant. If there is never a peak of estrogen, there is no signal for the ovary to release an egg. No egg, no fertilization, no pregnancy.

Types of Birth Control Pills

The three most common types of birth control pills are:

Progestin-only pills (POP):

One type of pill contains no estrogen at all. Called the progestin-only pill, or “mini-pill”, it’s ideal for breast-feeding women because estrogen reduces milk production. It’s also ideal for women who cannot take estrogen. However, POPs are not as effective at preventing pregnancy as pills containing both estrogen and progestin. POPs primarily work by thickening the cervical mucous, thereby preventing sperm from entering the uterus. In order to do this, POPs must be taken at a certain time every 24 hours.

Combination pills:

When you hear the term “birth control pill”, it most often refers to those containing two hormones. Each pill in the pack is a combination of estrogen and progestin.

* “Monophasic” pills: Each of the 21 active pills in one of these packs contains the same amount of estrogen and progestin. The other seven pills are placebos (they contain no hormones); they are meant to be taken the week a woman has her period. In September 2003, the FDA approved Seasonale, a 91-day oral contraceptive regimen. Tablets containing progestin and estrogen are taken for 12 weeks (84 days), followed by one week of placebo tablets. Therefore, the number of expected menstrual periods are reduced from once a month to about once every three months.

* “Multiphasic” pills: Multiphasic pills are those that have different hormone doses throughout the pill-taking schedule. This formulation was developed in an effort to reduce hormone levels to their lowest effective dose in hopes of reducing side effects such as breakthrough bleeding, spotting and amenorrhea (lack of a menstrual cycle), although there is no data showing that these pills are superior to monophasic pills.

The following ‘Questions To Ask’ may help facilitate discussion with your surgeon or health care professional.

* What kinds of problems are treated with a hysterectomy?

* What are all the methods available to treat this problem?

* Why are you recommending one medical or surgical approach over others to treat my condition?

* What is the worst that can happen if I decide not to follow this recommendation?

* If I need a hysterectomy, which type and surgical approach are most appropriate for me?

* Can you recommend a specialist who can give me a second opinion?

* What changes should I anticipate following surgery?

* What reading material can you recommend to help me learn more about hysterectomy, as well as other treatment options?

* How many times have you performed my procedure? What is your complication rate compared to the national complication rate?

* What’s the success for this procedure, and how is success measured?

* Can I talk to other patients who had this same procedure? (Although patient information is confidential, your health care professional may know women who have indicated an interest in helping others.)

* If my ovaries are removed, would I be a candidate for postmenopausal hormone therapy? What are the risks and benefits of hormone therapy in my case?

The unexpected news that you have a fertility problem can create a great deal of stress and frustration. Being infertile can make you feel out of control and that the next step in your life is blocked. Faced with the loss of a natural part of life, some people feel grief, loss and guilt.

Emotional Aspects of Treatment

Many infertile couples aren’t prepared for the emotional roller coaster of grief and loss of infertility treatments. The layers of stress are multiple:

* Financial-How will we pay for treatment easily costing thousands of dollars?

* Professional-Will I miss job promotions or will my work suffer because of treatment needs?

* Emotional-How will we cope as a couple if treatment fails?

Facing friends, family members or co-workers who have children is another stressor in an infertile couple’s life.

There are a number of issues that are critical for a couple facing treatment:

Be prepared to experience a lot of unfamiliar and uncomfortable feelings and to learn how to manage them. Understand that there are psychological reactions to infertility that are very real and related to the stress of diagnosis, treatment and lack of pregnancy. Being infertile is overwhelming. So is treatment.

Understand that men and women cope with stress and infertility differently. While a woman is physically and emotionally dealing with the effects of treatment, her outlets may involve many people. She may want to talk a lot about her experiences-with her husband-or with anyone who will listen. Her partner may be perceived as being emotionally and physically distant because he is trying to remain calm, despite his deep concern for and commitment to his partner.

Know that marriages will either be strengthened or pulled apart by infertility treatment. What happens depends on the couple’s relationship prior to treatment: Can you discuss intimate feelings? Do you have a good marriage? A good sex life? Are you a cohesive unit as a couple?

Realize that infertility and its wide range of treatment options can be overwhelming. There are many complicated issues, such as preserving embryos by freezing them for future use, adoption, donor eggs, fetal reduction, in which a woman carrying multiple embryos is induced to miscarry one or more, surrogacy and a host of other related topics. Couples who educate themselves as much as possible about treatment have a better chance of not being overwhelmed by its intensity.

Understand from the outset that treatment may not be successful. It’s typical for couples at the beginning of treatment to do whatever it takes to achieve a pregnancy. Eventually, most realize that emotionally and financially there is a limit. However, before most couples decide to pursue a different course, like adoption or remaining comfortably childless, for example, they must resolve their infertility. They have to get to the point that they can grieve and put closure on the fact that one or both biological bodies are not going to give them a child. This stage of infertility has its own stages of grief and loss. Couples must be ready to say, “I’m ready to stop this.”

Treatments for Infertility

Fertility drugs are typically the first step. Up to 90 percent of infertile women are treated with these drugs. Fertility drugs are designed to correct specific hormonal imbalances. The most common fertility drugs-clomiphene citrate (Clomid) and gonadotropins-are used to stimulate the production of mature eggs. Fertility drug treatment can include the following:

* Clomiphene citrate, also known as Clomid or Serophener. This drug is inexpensive and easy to use. For women with ovulation problems, 60 percent of those taking Clomid will ovulate following treatment and, of these, approximately 40 percent will become pregnant within six months. Clomid is a fertility medication, taken in pill form, which induces ovulation. Clomid may cause swelling of the ovaries, multiple pregnancies, hot flashes, mood swings, depression and irritability. Common side effects include weight-gain and water-retention.

While Clomid treatment is generally effective in women who experience abnormal ovulation cycles, it is far less effective in leading to a pregnancy in women who do ovulate. This treatment strategy is termed controlled ovarian hyperstimulation (COH) not ovulation induction. With COH, the goal is to allow the ovary to mature and release several eggs, not just a single egg. Further, when used for COH, Clomid treatment must be coupled with artificial insemination (AI) to yield its impact. Without AI, Clomid treatment has no added value. This strategy also overcomes any negative effects of Clomid on the cervical mucus. In some cases, Clomid can thin the uterine lining. While the impact of this thinning is not completely understood, most data do not indicate that supplementing with additional hormone like estrogen and progesterone provide any benefit.

* injectable medications. These drugs include:

* Lupron (leuprolide acetate) a synthetic version of the naturally occurring gonadotropin releasing hormone (GnRH), which causes the production and release of the pituitary hormone, follicle-stimulating hormone (FSH). FSH is a hormone that the pituitary gland uses to guide ovarian egg development and, as such, it is critical to egg maturation. –Synarel (nafarelin acetate) is a non-injectable form of GnRH, that is administered via a nasal spray.

The symptoms of ovarian cancer come into notice mostly when it grows for some time and the cancer mass becomes large enough. Some women, however, may feel some symptoms, like pelvic pain, even in the early stages. As the symptoms are vague and are often similar to those of common benign conditions, the victims often tend to ignore them.

Detection of ovarian cancer is difficult in its early stages because the two small, almond shaped organs are deep within the abdominal cavity, one on each side of the uterus.

Among the common initial symptoms are bloating, pressure, pain or discomfort caused by fluid buildup or masses within the abdominal cavity. Fluid may also accumulate around the lungs, causing breathing problems, in case the cancer spreads to the diaphragm.

Because of the pressure on the stomach, one can also lose appetite or experience a feeling of fullness even after an extremely light meal. When the tumor begins exerting pressure on the bowel or bladder, the victim may experience nausea, vomiting, gas, diarrhea, constipation, or frequent urination. Some other symptoms, though not so frequent, are fever, vaginal bleeding and lower backache. One may also experience unexplained weight gain or loss, abnormal fatigue or changes in bowel habits.

If the symptoms persist in spite of normal procedures of diet change, exercise, or the use of laxatives, the patient should not delay in consulting a doctor. As the signs and symptoms of ovarian cancer are vague or silent, only a small percentage of cases are detected in the early stages. Symptoms begin to manifest themselves in the advanced stages, when tumor growth exerts pressure on the bladder and rectum, and fluid begins to form.