Abstract

PIP: Recent data on oral contraceptives (OCs) employing new low-dose formulations appear to indicate that most of the previously reported metabolic effects are minimized, particularly when a product is neigher ovverly estrogenic nor progestational. Evidence suggests that elevated levels of cholesterol and triglycerides in the plasma are correlated with the risk of cardiovascular disease. Epidemiologic students have indicated a correlation between elevation of low denisty lipoprotein (LDL) cholesterol and coronary heart disease, and a correlation between decreases in high density lipoprotein (HDL) cholesterol and arterial disease. Epidemiologic evidence seems to suggest that combination OCs are associated with increased cardiovascular risk, especially risks of venous thrombosis, myocardial infarction, and stroke. There is some debate as to whether OCs themselves are an independent risk factor or whether they increase the effects of other risk factors. Women using combination OCs have been reported to have higher total serum triglyceride and cholesterol concentrations, related primarily to the estrogen dose. While most of the earlier literature associated estrogens with a higher risk of cardiovascular disease, recent studies have increasingly implicated the progestin component. Increasing potencies of progestin have been found to proportionally lower the HDL-cholesterol level. There is a positive association between the estrogen dose and HDL-cholesterol level. Among combination pill users, HDL levels gevverally depend on the relative amounts and potencies of both components. It is generally agreed that there are some high-risk women who should be carefully monitored while using the pill or who should not use it at all. Steroid type and dosage both play a role in affecting carbohydrate metabolism. Ethinyl estradiol (EE), the estrogen component in most OCs, does not seem to have the same biphasic effect on carbohydrate metaolism as most other estrogens. Most of the recent literature suggests that 19-norprogestins alter carbohydrate metabolism in a dose-related manner. The major problems in carbohydrate metabolism have been caused by high dose OCs and the progestin norgestrel. The recent literature confirms the advantages of the new low-dose compounds, with 1 study finding no adverse effects on carbohydrate metabolism and no significant change in plasma insulin levels with a dose of 35 mcg EE and .4-.5 mg norethindrone. The use of OCs in prediabetic and insulin-dependent diabetic women must be weighed against the dangers of pregnancy and the characteristics of the individual patients.