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Chapter 66: Contraception and Pharmacotherapy of Obstetrical and Gynecological Disorders

INTRODUCTION

Drugs to control fertility and treat disorders of the female reproductive organs collectively are among the most frequently prescribed agents in clinical practice. This chapter discusses a number of common clinical issues and their drug therapies that are central to women's health. The focus is on reproductive disorders and aspects of therapy rather than comprehensive coverage of the drugs themselves, which are described in more detail elsewhere (e.g., see Chapter 33 for prostaglandins; Chapter 38 for the gonadotropins, gonadotropin-releasing hormone [GnRH] agonists and antagonists, and oxytocin; Chapter 40 for estrogens and progestins; Section VII for antibiotics).

CONTRACEPTION

Contraception can be administered as planned prophylaxis or postcoitally for emergency contraception (i.e., high-dose estrogen-containing oral contraceptive pills, high-dose progestin pills, a progesterone antagonist, intrauterine devices). A progesterone antagonist also can be used to terminate an established pregnancy.

PLANNED CONTRACEPTION

COMBINATION ORAL CONTRACEPTIVES. Pills containing an estrogen and progestin are the most widely used (Table 66–1); they act primarily by suppressing the luteinizing hormone (LH) surge and thereby preventing ovulation. A wide variety of preparations are available for oral, transdermal, and vaginal administration (see Table 66–2 in the 12th edition of the parent text for a list of branded formulations, many of which are available as generics). Almost all contain ethinyl estradiol as the estrogen and a 17α-alkyl-19-nortestosterone derivative as the progestin, and are administered for the first 21-24 days of a 28-day cycle.

Table 66–1One-Year Failure Rate with Various Forms of Contraception
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Table 66–1 One-Year Failure Rate with Various Forms of Contraception
BIRTH CONTROL METHOD FAILURE RATE (Perfect Use) FAILURE RATE (Typical Use)
Combination oral contraceptive pills 0.3% 8%
Progestin-only minipill 0.5% 8%
DEPO-PROVERA 0.3% 3%
Copper intrauterine device 0.6% 0.8%
Progestin intrauterine device 0.2% 0.2%
IMPLANON 0.05% 0.05%
ORTHO EVRA 0.3% 8%
NUVARING 0.3% 8%
Condoms/diaphragms 2% 15%
Spermicides 18% 29%
Tubal ligation 0.5% 0.5%
Vasectomy 0.1% 0.15%
None 85% 85%
Table 66–2Sexually Transmitted Gynecological Infections and Recommended Therapies
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Table 66–2 Sexually Transmitted Gynecological Infections and Recommended Therapies
Genital ulcers
Chancroid

Azithromycin, 1 g oral single dose or

Ceftriaxone, 250 mg IM single dose or

Ciprofloxacin, 500 mg oral 2×/day × 3 days or

Erythromycin base, 500 mg oral 3×/day × 7 days
Genital herpes
 First infection

Acyclovir, 400 mg oral 3×/day × 7-10 days or

Acyclovir, 200 mg oral 5×/day for 7-10 days or

Famciclovir, 250 mg oral 3×/day for 7-10 days or

Valacyclovir, 1 g oral 2×/day × 7-10 days
 Suppression

Acyclovir, 400 mg oral 2×/day or

Famciclovir, 250 mg oral 2×/day or

Valacyclovir, 500 mg oral once daily
 Recurrent Same drugs at lower dose for longer duration
Granuloma inguinale Doxycycline, 100 mg oral 2×/day × >21 days
Lymphogranuloma venereum Doxycycline, ...

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