Although COC use in the past was linked to development of hepatic ocal nodular hyperplasia and benign hepatic adenoma, large studies do not support this (Heinemann, 1998). Moreover, no evidence supports concern for greater risk of hepatocellular cancer (Maheshwari, 2007). For women with known tumors, COCs may be used in those with focal nodular hyperplasia, but avoided in those with benign hepatic adenoma and hepatocellular carcinoma (Kapp, 2009b). Rates of colorectal cancer appear to be reduced in ever users (Bosetti, 2009; Luan, 2015).
Cholestasis and cholestatic jaundice are uncommon, but they resolve when COCs are discontinued. In women who have active hepatitis, COCs should not be initiated, but these may be continued in women who experience a flare of their liver disease while already taking COCs. Use of progestin-only contraception in these women is not restricted. Moreover, there is no reason to withhold COCs from women who have recovered. Mild compensated cirrhosis does not limit the use of COCs or progestin-only methods. But in those with severe decompensated disease, all hormonal methods are avoided (Kapp, 2009a).
Chloasma, which is hyperpigmentation of the face and forehead, is more likely in women who demonstrated such a change during pregnancy (Chap. 4, p. 53). This is less common with lowdose estrogen formulations. Although previously used for treating unctional ovarian cysts, low-dose COC formulations have been shown to have no efects related to cyst resolution or prevention (European Society of Human Reproduction and Embryology, 2001; Grimes, 2014).
Many noncontraceptive beneits are associated with COC use (American College of Obstetricians and Gynecologists, 20 16c). And indeed, COCs may be used for these efects, even in those without contraceptive needs. Dysmenorrhea and heavy menstrual bleeding lessen with COC use. Another action is to improve androgenic conditions such as acne and hirsutism. For women with premenstrual dysphoric disorder (PMDD), several studies have shown symptom improvement in those who use the drospirenone-containing COC Yaz (Lopez, 2012b; Pearlstein, 2005; Yonkers, 2005).
he Ortho Evra patch contains ethinyl estradiol and the progestin norelgestromin. It has an inner layer containing an adhesive and hormone matrix, and a water-resistant outer layer. Thus, women can wear the patch in bathtubs, showers, swimming pools, saunas, and whirlpools without decreased eicacy. he patch may be applied to buttocks, upper outer arm, lower abdomen, or upper torso, but the breasts are avoided. Because the hormones are combined with the adhesive, improper skin adherence will lower hormone absorption and eicacy. herefore, if a patch is so poorly adhered that it requires reinforcement with tape, it should be replaced.
Initiation of the patch is the same as for COCs, and a new patch is applied weekly for 3 weeks, followed by a patch-free week to allow withdrawal bleeding. Although a patch is ideally worn no longer than 7 days, hormone levels remain in an efective range for up to 9 days. This afords a 2-day window for patch-change delays (Abrams, 2001).