Before prescribing a \"morning after\" contraceptive, the practitioner should determine at what point in the cycle the unprotected intercourse took place. The anxiety of the woman should be taken into account in deciding whether to prescribe such a method. In the absence of contraindications, estrogens at high doses should be given if the coitus occurred with 72 hours of the consultation. Distilbene can be given at 50 mg/day for 5 days, or ethinyl estradiol at 5 mg/day for 5 days, or Premarin i.v. at 50 mg/day for 2 days or 25 mg/day for 3 days. The Pearl index for these formulations ranges from 0-2.4. The exceptional nature of the prescription should be explained to the woman in all cases. The practitioner should also be aware of the possibility of prescribing d-Norgestrel at a dose of .6 mg-1 mg taken within 3 hours of intercourse, which is better tolerated than the estrogens and provides a Pearl index of 0-6. Patients given estrogens should be advised that side effects are possible. An antiemetic can be prescribed to lessen the most common side effects of nausea and vomiting. Patients should be advised to take the estrogens during meals. Vaginal adenocarcinoma and epididymal cysts will not occur in children born to mothers who took Distilbene in an effort to avoid pregnancy. The genital teratogenic risk appears to be null before the 6th week of pregnancy. The IUD can be an excellent morning after method if it is inserted within 5 days and all contraindications are respected. The patient should be advised that some changes in the timing and amount of menstrual bleeding may occur. Possible signs of ectopic pregnancy should not be ignored with any postcoital method. The mechanisms of action of the methods are enzymatic modifications of the mucus which opposite nidation in the case of the IUD, and antinidatory modifications of the mucus, anti-corpus luteum activity, or changes in the speed of tubal migration of the egg in the case of the hormonal methods.

BACKGROUND: Depot medroxyprogesterone acetate is a popular contraceptive among young, physically active women. However, its administration has been linked to a relative decrease in estrogen levels. Since bone resorption is accelerated during hypoestrogenic states, there has been growing concern about the potential development of osteoporosis and fractures with the use of this contraceptive method.
METHODS: A physically active, 33-year-old woman demonstrated a 12.4% drop in femoral neck bone mineral density (BMD), 6.4% drop in lumbar BMD and 0.8% drop in total BMD with the subsequent development of a tibial stress fracture while on depot medroxyprogesterone acetate. Bone mineralization rapidly improved, and the stress fracture resolved with discontinuation of the medication.
CONCLUSIONS: The long-term effects of depot medroxyprogesterone acetate on bone mineralization in physically active women should be evaluated more thoroughly.
This case report illustrates the potential development of osteoporosis and fractures with the use of depot medroxyprogesterone acetate (DMPA), a popular contraceptive among young women. The case of a physically active 33-year-old woman who received 150 mg DMPA intramuscularly every 10 weeks, for a total of 3 injections, is presented. She demonstrated a 12.4% drop in femoral neck bone mineral density (BMD), a 6.4% drop in lumbar BMD, and a 0.8% drop in total BMD with the subsequent development of a tibial stress fracture while on DMPA. Bone mineralization rapidly improved, and stress fracture resolved with discontinuation of the medication. Women using DMPA are in a state of relative estrogen deficiency, which may not be adequate to maintain BMD in some patients. The long-term effects of DMPA on bone mineralization in physically active women should be evaluated more thoroughly.

OBJECTIVE: To assess the risk of cerebral thromboembolism in women using low dose oral contraceptives.
METHODS: A retrospective case-control study.
METHODS: All Danish medical, neurological, neurosurgical, and gynaecological departments.
METHODS: All 794 women in Denmark aged 15-44 who had suffered a cerebral thromboembolic attack during 1985-9 and 1588 age matched randomly selected controls.
RESULTS: Of 692/1584 case/control questionnaires sent out, 590/1396 (85.3%/88.1%) were returned. Among the cases, 15 refused to participate, 69 had a revised or unreliable diagnosis, 40 had had thromboembolic disease previously, 13 were pregnant, and 152 had a disease predisposing to a cerebral thromboembolic attack. Of the 323 cases without a known predisposition, 320 reported use or non-use of oral contraception. Among the 1396 controls, eight refused to participate, were mentally retarded, or lived abroad; 18 returned an uncompleted questionnaire; 17 had had thromboembolic disease previously; 31 were pregnant; and 130 had a disease predisposing to a cerebral thromboembolic attack. Thus 1198 non-predisposed controls were available, among whom 1197 reported use or non-use of oral contraception. Among the 320 cases, 116 (36.3%) were oral contraceptive users at the time of the cerebral thromboembolic attack. By comparison there were 191 users (16.0%) among the 1197 controls, giving a crude odds ratio of 3.0. After multivariate analysis, including confounder control for age, smoking, years of schooling, and trend in use of different types of oral contraceptives during 1985-90, pills containing 50 micrograms oestrogen were associated with an odds ratio for cerebral thromboembolic attack of 2.9 (95% confidence interval 1.6 to 5.4), those containing 30-40 micrograms oestrogen an odds ratio of 1.8 (1.1 to 2.9), those containing progestogen only an odds ratio of 0.9 (0.4 to 2.4). The odds ratio did not change with increasing age or with duration of oral contraceptive use. A 50% increased risk of a cerebral thromboembolic attacks among cigarette smokers (after confounder control) was independent of oral contraception status and age.
CONCLUSIONS: Low dose oral contraceptives are associated with an increased risk of cerebral thromboembolic attack. Combined or sequential pills containing 30-40 micrograms oestrogen are associated with a one third reduced risk compared with preparations containing 50 micrograms oestrogen. Progestogen only pills did not increase the risk of a cerebral thromboembolic attack.
The objective a retrospective case-control study was to assess the risk of cerebral thromboembolic attack during 1985-89 and 1588 age matched randomly selected controls were investigated. 590 case (85.3%) and 1396 control (88.1%) questionnaires were returned. Exclusions occurred for refusal to participate, unreliable diagnosis, previous thromboembolic disease, pregnancy, and a disease predisposing to a cerebral thromboembolic attack. Of the 323 cases without a known predisposition, 320 reported use or nonuse of OCs. From among the 1396 controls, 1198 nonpredisposed controls were available, among whom 1197 reported use of nonuse of OCs. Among the 320 cases, 116 (36.3%) were OC users at the time of the cerebral thromboembolic attack. By comparison, there were 191 users (16.0%) among the 1197 controls, giving a crude odds ratio of 3.0. Multivariate analysis controlled confounding factors for age, smoking, years of schooling, and use of different types of OCs during 1985-90. OCs containing 50 mcg estrogen were associated with an odds ratio for cerebral thromboembolic attack of 2.9, those containing 30-40 mcg estrogen with an odds ratio of 1.8, those containing progestogen only with an odds ratio of 0.9. A 50% increased risk of a cerebral thromboembolic attack among cigarette smokers was independent of OC status and age. Low dose OCs were associated with an increased risk of cerebral thromboembolic attack. Combined or sequential pills, containing 30-40 mcg estrogen, are associated with a one third reduced risk compared with preparations containing 50 mcg estrogen. Progestogen-only pills did not increase the risk of a cerebral thromboembolic attack.

A case is described wherein a 29 year old woman was admitted to the hospital because of the possibility of a hepatic tumor; symptoms included abdominal pain, diffuse hepatic enlargement and absence of uptake in an area of the right hepatic lobe. After a normal pregnancy and delivery 11 years earlier the patient used oral contraceptives (OCs) composed of norethindrone with mestranol until 8 years before entry; 5 years before admission she resumed use of an OC containing norethindrone and ethinyl estradiol. She smoked 1.5 packages of cigarettes and drank 1 glass of wine daily, and there was no history of nausea, vomiting, melena, jaundice, dark urine, light stools, hepatitis, or blood transfusions. Benign lesions which are known to be caused by OCs fall into 2 groups: designated focal nodular hyperplasia and liver-cell adenoma. The evidence linking the latter with OCs is more convincing since in case-controlled studies the risk of development of adenomas has been shown to increase with the estrogen strength of the OCs and duration of use; in women who have been taking OCs over 7 years the relative risk is 500 times that for matched control nonusers. The vascular complications of OC therapy include Budd-Chiari syndrome, peliosis hepatis, and periportal sinusoidal dilatation. The patient in this case was diagnosed to have periportal and midzonal hepatic sinusoidal dilatation association with OC medication. She underwent an operation on her liver which proved to be successful combined with cessation of OC use. The mechanism by which OCs cause these lesions is not known. In 5 of 13 cases similar to the one described here clinical and biochemical abnormalities resolved and 1 patient had a follow-up liver biopsy that revealed normal findings 10 months after cessation of OC therapy; there is no evidence to suggest that sinusoidal dilatation is irreversible.

Gossypol has been used as oral contraceptive for man in People\'s Republic of China. There are also some reports of studies in which gossypol acetic acid is used in animal experiments. In this study we used tablet preparation of gossypol, which is actually used as oral contraceptive for male in People\'s Republic of China, on a volunteer. The administration of 20 mg/day gossypol tablets for 19 days resulted in a tendency of decreasing sperm density and total sperm count, but had no effect on serum LH, FSH, PRL or testosterone. Furthermore, the volunteer had no complaints of side effects and his general laboratory findings were normal. Ten days after the termination of gossypol administration, sperm density returned to its preadministrative level. Our study suggests gossypol may be effective as a male oral contraceptive with no acute side effect.
A case report is presented of the use of a tablet preparation of gossypol on a volunteer male in China. The man, who was 35-years old, 75kg of body weight and 175 cm in height, had no special past history of illness and was living with his wife and 3 children. 19 preparations of gossypol each containing 20 mg of gossypol were administered over a 19-day period. Semen volume, percent spermatozoa motile, morphological anomaly, sperm density, pH of sperm, and white blood cell count (WBC) were examined. The sperm density level gradually decreased. 10 days after the termination of gossypol the sperm density was recovered to its preadministrative level. Gossypol had no effect on serum luteinizing hormone (LH), follicle stimulating hormone (FSH), PRL, or testosterone. Gossypol medication induced no ill effect according to the laboratory findings. The volunteer did not complain of side effects. The study suggests that gossypol might be effective in decreasing sperm density and total sperm count without influences on LH, FSH, PRL, and testosterone, or acute side effects.

A case report of a 26-year old woman on chronic hemodialysis for pyelonephritis who took 10 mg of norethisterone acetate daily for suppression of menstruation. 1 week before admission colic-like pains appeared in right upper abdominal quadrant which were relieved by spasmolytics. Laboratory parameters (except those related to renal insufficiency), physical examination, x-rays of chest, stomach and biliary tract showed no abnormalities. Sonography revealed various round space-occupying lesions in the lower liver lobe. Before further studies could be initiated and following a hemodialysis session patient died of an intrahepatic hemorrhage confirmed by ultra-sonic and CAT-scan. Autopsy showed a large hematoma with more than 700 ml coagulated blood which caused rupture of the right liver lobe. Round adenomas were found in both lobes. The relationship between oral contraceptives and primary liver adenomas in young women without previous liver disease has been reported in the literature since 1973. 200 cases were found in the literature since 1977. Although mostly estrogens are blamed for liver adenomas, in this case it was a pure progestogen preparation. In another study of women with primary liver adenomas only 1 in 100 women used a pure progestin contraceptive. A relationship between androgens or anabolic steroids has been found in a number of case reports in the literature. It can be assumed that both combination preparations with estrogen components, and pure progestin preparations play a similar role in the pathogenesis of benign liver tumors.

The risks and benefits of Depo-Provera, the controversial contraceptive, are examined. In April 1983 Upjohn Limited, the American manufacturers of Depo-Provera, presented evidence about its product before a government appointed panel at a hearing held in public. This was the 1st time this had happened in Britain. The panel also read submissions from the Coordinating Group on Depo-Provera, a group of women who argue that a longterm license should not be granted. A 150 mg dose of Depo-Provera, a synthetic progestogen (medroxyprogesterone), injected into the muscle is slowly released into the body over a 3-month period and inhibits ovulation by suppressing the pituitary hormones which cause release of a mature egg. It was initially licensed in the UK in 1973 for treatment of endometriosis. In 1978 it was approved for short term contraception in limited circumstances. At present it is only recommended for women who have been immunized against German measles to provide contraceptive cover during the active period of the virus and for those whose partners have had a vasectomy but whose sperm count is not yet negative. In 1981 it was licensed for use as a treatment for endometrial, renal, and breast cancer. The UK Committee on Safety of Medicines (CSM) now recommends that Depo-Provera should be used in the longterm but only as a last resort when all other contraceptive methods are unsatisfactory. It also wanted 4 warnings to be entered on the data sheet to which doctors refer: that Depo-Provera could be secreted in breast milk; that doctors should ensure their patients are not already pregnant; that tumors have developed in monkeys given 50 times the human dose; and that a few cases of breast cancer have been reported but no causal relationship with Depo-Provera has been established. The licensing authority considered that the potential risk associated with Depo-Provera use appeared to outweigh the benefits, and it rejected the CSM\'s advice. Kenneth Clarke was particularly concerned that the drug might be given to women without their informed consent, a concern raised by the women\'s group. Upjohn maintains that Depo-Provera is a safe, efficient contraceptive which has had no known death attributed to it and that its failure rate is lower than with other methods. It is recognized, in Upjohn data, that Depo-Provera frequently disrupts the menstrual cycle and that there may be irregular bleeding or spotting. After 1 year of taking the drug many women suffer amenorrhea, and a woman may not regain her fertility for up to 18 months after stopping the injections. Upjohn argues that excessive bleeding is rare, but the women\'s group submits numerous experiences from women who have suffered heavy bleeding long after the effects of the drug would be expected to have worn off.

A 35-year-old previously healthy woman started using oral contraceptives in May 1965. In June ergotamine was prescribed for right temporal headaches. On November 4 she took 5 ergotamine tablets between 4-7 AM. By 9 AM she was confused and did not answer when spoken to. She was admitted to the hospital at 11 AM with an apoplexy picture. On November 6 carotid angiography on the right side showed a total occulsion of the internal carotid artery. An attempt at thrombectomy proved fruitless. In spite of intensive therapy, the patient died in cardiac arrest on the 3rd post operative day. Autopsy showed thrombotic masses in the right carotid artery and left ventricle. A contributory cause may have been the use of oral contraceptives in conjuction with ergotamine medication.

This case report concerns a 29-year-old caucasian woman who developed cholestatic jaundice while taking Ortho-Novum 2 mg. Biliary stasis was diagnosed from laboratory tests and gradually subsided when the medication was withdrawn. The condition was found to be reproducible when Ortho-Novum 2 mg. was given again. The patient was later given C-Quens with no return of symptoms which indicated norethindrone was the cholestatic agent.

This is a case report of a hyperplastic lesion of the endocervix which histologically and clinically mimicked cancer in a patient using a contraceptive pill. The 24-year-old woman had been taking Enovid-E for 1 year. She was diagnosed as having advanced cervical cancer; a large granular erosion of the cervix and several vaginal cysts were in the region of a former episiotomy. Cone biopsy of the cervix and excision o f the lesions were interpreted as carcinoma in both. However a vaginal smear was reported negative. On reexamination the lesions were atypical, softer and with less surrounding induration than expected for cancer. Review of the histologic sections showed that, although a malignant architectural pattern was present, the individual cells lacked the essential malignant characterisitics. Oral contraceptives had not been taken for 1 month and no more were given. Follow-up examinations a t 2-week intervals showed gradual recession of the lesions. Vaginal smears continued negative. A hysterectomy was done; removed tissues showed no evidence of malignancy. There was residual cystic hyperplasia of atypical glands. The patient\'s subsequent course has been uneventful. The lesions are regarded as having been florid hyperplasia of endocervical glands and of similar epithelium in the lower vagina. S everal experienced gynecologists and pathologists had originally accepte d the lesions as malignant. This is a rare complications of a hormonal contraceptive.