Pseudotumour cerebri in a young obese woman on oral contraceptives

Objectives Pseudotumour cerebri has been previously recognized as a neurological side effect of combined oral contraceptives but has not been diagnosed with a delay of 3 years after initiation of combined oral contraceptives.

Case report A 19-year-old obese woman developed visual impairment and headache, 4 months after starting combined oral contraceptives. Three years later symptoms deteriorated and she presented with prominent tendon-jerks and congested optical-discs. Normal CSF drained with high pressure from the spinal tap. Pseudotumour cerebri was diagnosed. Headache and visual impairment resolved within 3 weeks after discontinuation of combined oral contraceptives.

Conclusions Combined oral contraceptives-induced pseudotumour cerebri may remain undetected for years. Young, obese women with visual impairment and headache under combined oral contraceptives should undergo immediate neurological and ophthalmological investigation.     

Pseudotumor cerebri from sinus venous thrombosis, associated with polycystic ovary syndrome and hereditary hypercoagulability.

OBJECTIVE: The association of pseudotumor cerebri, visual impairment, hypothyroidism, polycystic ovary syndrome (PCOS), and a hypercoagulable state due to a factor V and a prothrombin mutation has not been reported previously. CASE REPORT: A 20-year-old obese woman developed menstrual cycle irregularities since age 14 years, initially bitemporal and latter diffuse headache since age 14 years, and bilateral visual impairment, described as sparkling black points. Ophthalmologically there was a recurrent papilledema. Clinical neurologic investigations revealed sore neck muscles and hirsutism. Magnetic resonance imaging of the brain, orbita and cervical spine, and investigations of cerebrospinal fluid were non-informative. Visually evoked potentials revealed demyelination of the optic nerves. Gynecologic investigations revealed PCOS and endocrinologic investigations hypothyroidism and hyperandrogenism. Tests for thrombophilia disclosed a heterozygote state for the G1.697A factor V Leiden and the G20.210A prothrombin mutation. A possible relationship between pseudotumor cerebri and the ophthalmologic, gynecologic, endocrinologic and coagulation abnormalities is discussed. CONCLUSIONS: For the first time we describe the association of pseudotumor cerebri, optic nerve demyelination, PCOS, other endocrinologic abnormalities, and thrombophilia due to a factor V and prothrombin mutation. A causal relationship between these abnormalities remains elusive.     

Pseudotumor cerebri from sinus venous thrombosis,associated with polycystic ovary syndrome and hereditary hypercoagulability

Objective. The association of pseudotumor cerebri, visual impairment, hypothyroidism, polycystic ovary syndrome (PCOS), and a hypercoagulable state due to a factor V and a prothrombin mutation has not been reported previously.

Case report. A 20-year-old obese woman developed menstrual cycle irregularities since age 14 years, initially bitemporal and latter diffuse headache since age 14 years, and bilateral visual impairment, described as sparkling black points. Ophthalmologically there was a recurrent papilledema. Clinical neurologic investigations revealed sore neck muscles and hirsutism. Magnetic resonance imaging of the brain, orbita and cervical spine, and investigations of cerebrospinal fluid were non-informative. Visually evoked potentials revealed demyelination of the optic nerves. Gynecologic investigations revealed PCOS and endocrinologic investigations hypothyroidism and hyperandrogenism. Tests for thrombophilia disclosed a heterozygote state for the G1.697A factor V Leiden and the G20.210A prothrombin mutation. A possible relationship between pseudotumor cerebri and the ophthalmologic, gynecologic, endocrinologic and coagulation abnormalities is discussed.

Conclusions. For the first time we describe the association of pseudotumor cerebri, optic nerve demyelination, PCOS, other endocrinologic abnormalities, and thrombophilia due to a factor V and prothrombin mutation. A causal relationship between these abnormalities remains elusive.     

Oral contraceptives and endometriosis.

Relief of pain of primary dysmenorrhea and endometriosis with oral contraceptives is contraindicated because their use can be harmful. Hexestrol, stilbestrol, or dinestrol plus a B-complex vitamin should instead be used. Endometriosis may be diagnosed by administering a small dose of stilbestrol (0.1 or, better, 0.05 mg), starting any day of the cycle, which should precede the use of the peritoneoscope. If oral contraceptives are prescribed after endometriosis has been diagnosed, their use may cause endometriosis to grow in many cases. This conclusion is based on observation of over 100 cases treated in this way, and applies to both adolescents and adults. Hexestrol, 3 mg tablets, and stilbestrol, 1.0, 5.0, and 25.0 mg tablets, are far superior to all of the oral contraceptives in the treatment of endocrine conditions.     

The effects of age, body mass index, smoking and general health on the risk of venous thromboembolism in users of combined oral contraceptives.

OBJECTIVES: To investigate the factors associated with idiopathic venous thromboembolism in combined oral contraceptive users and to estimate the crude and age-specific incidence rates ofidiopathic venous thromboembolism among this population. METHODS: The UK MediPlus Database and the General Practice Research Database were searched to identify women with evidence of venous thromboembolism while exposed to combined oral contraceptives. Cohort and nested case-control studies were carried out using the same methodology on both databases. We conducted a meta-analysis using the individual data for the cases and controls from the two case-control studies to identify factors associated with idiopathic venous thromboembolism in women using combined oral contraceptives. RESULTS: The incidence rate of idiopathic venous thromboembolism among oral contraceptive users was 39.4 per 100,000 exposed woman-years. The age-specific incidence rates were found to rise sharply after the age of 39 years. Factors identified as being significantly associated with idiopathic venous thromboembolism in women using combined oral contraceptives were: body mass index of 25 kg/m2 and over, the association rising dramatically in women with a body mass index of 35 kg/m2 or more; smoking; general ill health; and asthma. CONCLUSION: We believe that, before prescribing combined oral contraceptives, the venous as well as the arterial factors need to be considered and, in addition, age, obesity and smoking are all relevant when assessing an individual patient's risk.     

Contraceptive methods for women with neurologic disorders

Sex steroids in oral contraceptives exert several effects on the central nervous system and are therefore of concern when used by neurologically compromised women. In general, oral contraceptives do not aggravate epileptic seizures and are not contraindicated in cases of tension headache. Oral contraceptives can be used in cases of migraine without focal neurologic symptoms as long as headache symptoms do not worsen. Levels of sex steroids can be diminished through enzyme induction by antiepileptic drugs, giving rise to the possibility of contraceptive failure and exposure of the fetus to the teratogenic properties of antiseizure medications. Women with common migraine (without focal neurologic symptoms) who are taking oral contraceptives should be monitored for possible exacerbation of their symptoms. Women who do experience worsening of headache symptomatology when taking the pill should consider alternate means of contraception. (AM J OBSTET GVNECOL 1993;168:2027-32.)     

Use of multiphasic oral contraceptives and hospitalizations of women with functional ovarian cysts in the United States

A case-series report of seven women who developed functional ovarian cysts while taking multiphasic oral contraceptives has raised the possibility of an association between these two events. To address this question, we calculated the nationwide rates of hospitalization of women diagnosed with such cysts and examined the use of multiphasic oral contraceptives from 1979-1986. Whereas the use of multiphasic oral contraceptives grew from zero to three million users during the study interval, the hospitalization rate for functional ovarian cysts fluctuated between 472-522 per 100,000 women aged 15-44 years. Thus, there was no discernible association between taking these contraceptives and being hospitalized for functional ovarian cysts. Although this indirect assessment can neither confirm nor refute the postulated association, it suggests that if such an association does exist, its net public health impact has not been great.     

Cost-effectiveness analysis of endometrial cancer prevention strategies for obese women

OBJECTIVE: It is unknown whether obese women would benefit from oral contraceptives or screening as endometrial cancer prevention strategies. We estimated the net health benefits and cost-effectiveness of these strategies in a hypothetical cohort of obese women. METHODS: A Markov decision-analytic model evaluated 4 strategies: 1) no prevention (reference strategy); 2) oral contraceptive pills (OCPs) for 5 years; 3) annual screening with endometrial biopsy from age 30; 4) biennial screening from age 30. Net health benefit was life expectancy and primary outcome was the incremental cost-effectiveness ratio. Baseline and transition probabilities were obtained from published literature and the Surveillance Epidemiology and End Results database, and costs were from the U.S. Department of Health and Human Services and Agency for Healthcare Research and Quality. Sensitivity analyses were performed for uncertainty around various measures. RESULTS: Average life expectancy for all strategies ranged from 74.52 to 74.60 years. None of the strategies had an incremental cost-effectiveness ratio less than $50,000 per year of life saved relative to the next best strategy. Endometrial cancer risk in obese women had to be 13 times greater than the general population risk before OCPs were a cost-effective intervention. CONCLUSION: Oral contraceptives and current screening methods are not cost-effective endometrial cancer prevention strategies for obese women. Risk factors such as morbid obesity and longstanding anovulation may define a subgroup at highest risk of endometrial cancer for whom OCPs may be a cost-effective strategy. Interventions that reduce endometrial cancer risk further or those with additional health benefits are needed in this population. LEVEL OF EVIDENCE: III.     

Hormonelle Kontrazeption mit östradiolhaltigen Kombinationspräparaten

Development of contraceptives containing estradiol

Since the introduction of the pill, most research has dealt with dose reductions and alterations to the progestin component. One of the most recent developments in contraceptives has been the successful introduction of estradiol into combined oral contraceptives. The use of estradiol instead of ethinyl estradiol may result in better safety and tolerability. Previous attempts were unsuccessful because of irregular bleeding and unacceptable cycle control.

Currently available contraceptives

Two oral hormonal contraceptives with the “physiologic estrogen” are available now: estradiol valerate/dienogest (Qlaira®) in a four-phase regime and estradiol/nomegestrol acetate (Zoely®) in a monophasic regime. Both combinations are highly effective oral contraceptives with good cycle control and are safe and well tolerated. Qlaira® is the only oral hormonal contraceptive that is approved for the treatment of heavy menstrual bleeding with no recognizable cause in women who desire contraception.

Conclusion

Further studies need to be performed to determine whether clinically significant differences in safety exist in the replacement of ethinyl estradiol by natural estrogens.     

A new oral contraceptive regimen for endometriosis management: preliminary experience with 24/4-day drospirenone/ethinilestradiol 3 mg/20 mcg

We report our preliminary experience with the use of a low-dose oral contraceptive containing Drospirenone/Ethinylestradiol 3?mg/20 mcg, both in cyclic and continuous regimen for endometriosis management. A total of 93 women were retrospectively included: 52 were treated by medical therapy (exclusive combined oral contraceptives (COC)-users), while 41 were submitted to surgery followed by postoperative therapy (postoperative COC-users). A clinical examination was performed at baseline and at 6-months follow-up. Presence and intensity of endometriosis-related symptoms were assessed by a visual analogue scale. Presence and dimension of endometriotic lesions were evaluated by transvaginal ultrasonography. Adverse effects and tolerability were analysed. In exclusive COC-users, significant reductions in dysmenorrhoea and dyspareunia scores and in endometrioma mean diameter were observed at follow-up. In postoperative COC-users, anatomical and symptom recurrence rates at follow-up were 4.9% and 17%, respectively. The most frequent adverse effects were spotting and headache. No difference between cyclic and continuous regimen in terms of symptom relief, lesion progression and tolerability was observed. From our preliminary experience, Drospirenone/Ethinylestradiol 3?mg/20 mcg seems to be promising in endometriosis management.     

A new oral contraceptive regimen for endometriosis management: preliminary experience with 24/4-day drospirenone/ethinylestradiol 3 mg/20 mcg

We report our preliminary experience with the use of a low-dose oral contraceptive containing Drospirenone/Ethinylestradiol 3 mg/20 mcg, both in cyclic and continuous regimen for endometriosis management. A total of 93 women were retrospectively included: 52 were treated by medical therapy (exclusive combined oral contraceptives (COC)-users), while 41 were submitted to surgery followed by postoperative therapy (postoperative COC-users). A clinical examination was performed at baseline and at 6-months follow-up. Presence and intensity of endometriosis-related symptoms were assessed by a visual analogue scale. Presence and dimension of endometriotic lesions were evaluated by transvaginal ultrasonography. Adverse effects and tolerability were analysed. In exclusive COC-users, significant reductions in dysmenorrhoea and dyspareunia scores and in endometrioma mean diameter were observed at follow-up. In postoperative COC-users, anatomical and symptom recurrence rates at follow-up were 4.9% and 17%, respectively. The most frequent adverse effects were spotting and headache. No difference between cyclic and continuous regimen in terms of symptom relief, lesion progression and tolerability was observed. From our preliminary experience, Drospirenone/Ethinylestradiol 3 mg/20 mcg seems to be promising in endometriosis management.     

Postoperative administration of monophasic combined oral contraceptives after laparoscopic treatment of ovarian endometriomas: a prospective, randomized trial

OBJECTIVE: We sought to evaluate the efficacy of postoperative administration of monophasic, combined, low-dose oral contraceptives on endometrioma recurrence and on persistence-recurrence of associated pain symptoms after laparoscopic treatment of moderate-to-severe endometriosis. STUDY DESIGN: In a prospective, randomized trial 70 patients who were not attempting to conceive, aged 20 to 35 years, underwent laparoscopic excision of ovarian endometriomas, followed by either postoperative administration of low-dose cyclic oral contraceptives for 6 months or no treatment on the basis of a computer-generated sequence. At 3 and 6 months after surgery and then at 6-month intervals, both groups underwent ultrasonographic examination for possible evidence of endometrioma recurrence and for evaluation of the absence, persistence, or recurrence of pain symptoms. RESULTS: Two patients in the oral contraceptive group did not complete the study. After a mean follow-up of 22 months (range, 12-48 months), there were 2 (6.1%) endometrioma recurrences in the 33 patients who received postoperative oral contraceptives versus 1 (2.9%) recurrence in the 35 patients in the control group (not significant). The moderate-to-severe pain recurrence rate was 9.1% in the oral contraceptive group versus 17.1% in the control group (not significant). The mean time to recurrence of either symptoms or endometriomas was 18.2 months in the oral contraceptive group versus 12.7 months in the control group. The 12-month cumulative recurrence rate at life-table analysis was significantly lower for patients receiving oral contraceptives versus control subjects, whereas no significant difference was evident at 24 and 36 months. CONCLUSION: Postoperative administration of low-dose cyclic oral contraceptives does not significantly affect the long-term recurrence rate of endometriosis after surgical treatment. A delay in recurrence is evident at life-table analysis.     

The role of combined oral contraceptives in the management of acne and seborrhea.

Acne and seborrhea (or facial oiliness) are related androgenic skin disorders which affect a high proportion of women after menarche. They can have a negative effect on psychological well-being and social life. Androgens play an important role in the pathogenesis of acne through the stimulation of sebum secretion, increasing sebaceous gland size and possibly through follicular hyperkeratinization. Conversely, estrogens decrease sebum production by suppressing gonadotropin release and androgen production and increasing sex hormone binding globulin production. One of the treatment options for these conditions is hormonal therapy, especially for women who require contraception. The effect of combined oral contraceptives in androgenic skin disorders depends on their estrogen:progestogen balance and on the antiestrogenic activity of the progestogen component. Improved understanding of what women value about oral contraceptives suggests that the choice of product should be tailored as much as possible to the individual. Several combined oral contraceptives containing new-generation progestogens (e.g. desogestrel, gestodene) or progestational antiandrogens (e.g. cyproterone acetate, chlormadinone acetate) have demonstrated efficacy in the treatment of women with acne, although comparisons between trials are difficult because of differing endpoints. Seborrhea has been less well studied, but the few studies that are available show an improvement in women with this condition using combined oral contraceptives.     

Combined oral contraceptives and cervical cancer

PURPOSE OF REVIEW: The issue of whether there might be an increased risk of cervical cancer associated with the use of oral contraceptives has been debated for decades. Early studies found a modest association with long-term use. A literature review was performed over the past 3 years, to establish whether there is any new evidence linking cervical cancer with the use of oral contraceptives. RECENT FINDINGS: A new analysis from eight studies conducted by the International Agency for Research on Cancer and a systematic review of cervical cancer and the use of hormonal contraceptives are two recent major epidemiological links strongly suggesting the increased risk of cervical cancer (up to twofold), but only for women who were both long-term users (5 years or more) and who had persistent human papilloma virus infections of the cervix. SUMMARY: These findings seem biologically plausible, but weighing the various risks and benefits, the World Health Organization does not recommend any change in oral contraceptive use or practice.     

Family history of cancer, oral contraceptive use, and ovarian cancer risk.

OBJECTIVE: The purpose of this study was to determine whether women with a family history of ovarian cancer are at reduced risk of ovarian cancer from the use of oral contraceptives and to compare their risk with that of women with no family history of ovarian cancer. STUDY DESIGN: A population-based case-controlled study was conducted from May 1994 through July 1998 in which 767 women aged 20 to 69 years with a diagnosis of epithelial ovarian cancer were ascertained from 39 hospitals in 3 northeastern states. Personal interviews with the women and 1367 control subjects provided data that allowed us to estimate the relative risk of ovarian cancer in relation to a family history of cancer and total duration of oral contraception. RESULTS: Among the 33 case patients and 24 control subjects with a first-degree family history of ovarian cancer, risk of ovarian cancer declined with increasing duration of oral contraception (P =.01). Risk reduction from short-term use of oral contraceptives (< or = 48 months) did not differ significantly by family history (combined estimate of odds ratio, 0.72; 90% CI, 0.59%-0.87%). Risk reduction from long-term use of oral contraceptives (>48 months) was greater in women with a positive family history of ovarian cancer (odds ratio, 0.12) than in women with a negative family history of ovarian cancer (odds ratio, 0.51; test of interaction, P =.04; 692 case patients, 1279 control subjects). CONCLUSION: Four to 8 years of oral contraception may substantially reduce the risk of ovarian cancer by age 70 years in women with a family history of the disease, from approximately 4 women per 100 women who did not use oral contraceptives to only 2 women per 100 women who did use oral contraceptives.     

Successful pregnancy after limb-sparing hemipelvectomy for Ewing sarcoma: Case report and literature review

ObjectiveWe present a case of successful pregnancy in a patient who underwent limb-sparing hemipelvectomy combined with multi-agent chemotherapy and radiotherapy for Ewing sarcoma.Case reportA 17-year-old girl was diagnosed with Ewing sarcoma of the left pelvis at the age of 17 and received limb-sparing hemipelvectomy combined with multi-agent chemotherapy and radiotherapy. The patient received oral contraceptives as hormone replacement therapy after completion of treatment. A normal menstruation cycle restored after the withdrawal of oral contraceptives. The patient spontaneously conceived at the age of 25. The patient complained of difficulty walking due to pelvic distortion during pregnancy and delivered a healthy neonate at term by cesarean section.ConclusionSuccessful pregnancy and delivery can be achieved after limb-sparing hemipelvectomy combined with chemotherapy and radiotherapy for Ewing sarcoma. Our report provides important information on perinatal management, given the low incidence of pregnancy following treatment of Ewing sarcoma in the pelvis.     

Changes in coagulation and anticoagulation in women taking low-dose triphasic oral contraceptives: a controlled comparative 12-month clinical trial.

OBJECTIVE: The effects of two triphasic oral contraceptives on coagulation and anticoagulation factors were compared in a 12-month open-label study. STUDY DESIGN: Fifty-two women (mean age 26 years) were enrolled in and completed the study; 20 had been randomly assigned to receive levonorgestrel plus ethinyl estradiol, 24 had been randomly assigned to receive norethindrone plus ethinyl estradiol, and eight surgically sterile women acted as untreated controls. Coagulation and anticoagulation factors were measured at baseline and during the sixth and twelfth months. RESULTS: Both oral contraceptives produced significant decreases from baseline in prothrombin time and partial thromboplastin time; there were also significant changes in laboratory control times. Factor XII was significantly increased in both oral contraceptive groups after 6 and 12 months. Fibrinogen antigen was significantly increased for norethindrone plus ethinyl estradiol after 6 and 12 months and for levonorgestrel plus ethinyl estradiol after 12 months. Platelet counts were unchanged. There was a significant increase in antithrombin III activity with norethindrone plus ethinyl estradiol at 12 months. Antithrombin III antigen was unchanged with the oral contraceptives; however, significant increases existed for alpha 1-antitrypsin antigen and plasminogen antigen and activity after 6 and 12 months and for alpha 2-macroglobulin antigen after 12 months for both oral contraceptives. alpha 2-Antiplasmin antigen was significantly increased for norethindrone plus ethinyl estradiol at the 12-month evaluation. There were no significant differences between the oral contraceptives for any coagulation or anticoagulation factor, and mean values generally remained within reference ranges. CONCLUSIONS: Levonorgestrel plus ethinyl estradiol and norethindrone plus ethinyl estradiol had equivalent, minimal effects on hemostasis, and changes in coagulation factors appeared to be balanced by changes in anticoagulation factors.     

Case control study finds long-term pill use is associated with higher risk of benign liver tumors

A recent case-control study by a team of University of Southern California investigators follows published observations on a total of 107 liver tumors among young women. Most of them were, or had been, oral contraceptive users. The importance of duration of use in the etiology of these tumors was shown by data on 58 women reported at the 1976 annual meeting of the American College of Obstetricians and Gynecologists. Of the 58 women who developed these tumors, 85% had used the pill continuously for more than 4 years. An increasing number of such reports has induced the National Cancer Institute to undertake an investigation regarding these tumors. Almost all of the reported tumors have been benign and described as adenomas, hamartomas, or focal nodular hyperplasia. Some have been without symptoms. Others have been associated with severe abdominal pain or sudden bleeding. A case-control study of 34 young women diagnosed as having benign liver tumors in 1955-1976 was made with appropriate controls. Of the 34 tumor cases, 29 had used oral contraceptives but 26 of the controls had done so also. The tumor patients had taken the pills for significantly longer periods than the controls. The risk of developing liver tumors increased with duration of use and was 2.5 times greater than after 3-5 years than for 1 year or less of use. After 5 years of use, the risk increased sharply to 25 times greater after 9 or more years of pill use. A palpable mass was present in 34% of the cases and severe abdominal pain in 29% of 1 series. Pills containing mestranol seemed more likely to cause liver tumors than those containing ethinyl estradiol. Another report was of 44 case histories published within the past 5 years and 27 new cases reported to the Registry for Liver Tumors Associated with Oral Contraceptives. This Registry was established in 1975. Duration and type of pill use was recorded for 58 of them. Of these, 85% had taken the pill for over 4 years. Mestranol-containing pills had been mostly used. Norethindrone was often used. Of these tumors, 18 ruptured resulting in the death of 8 of the 71 women. In Louisville, 9 cases of benign liver tumors were diagnosed between 1968 and 1974 in women who had used oral contraceptives. No similar tumors had been observed in a comparable age group of women in the previous 13 years. In 1 case, a patient had the tumor removed and resumed the pills. After 6 years a 2nd similar tumor developed. It was not removed but regressed somewhat in 5 months when the oral contraceptive was omitted. In Britain and the U.S., 3 prospective studies of pill users are being conducted. The different types of liver tumors involved seem to have different etiologies. Focal nodular hyperplasia is sometimes found in men but liver-cell adenoma is almost exlusively found in women, many of whom have used oral contraceptives. The Central Registry may resolve some questions.     

Comparison of cycle control with a combined contraceptive vaginal ring and oral levonorgestrel/ethinyl estradiol

OBJECTIVE: The purpose of this study was to compare cycle control and tolerability of the NuvaRing (NV Organon, Oss, The Netherlands), a novel combined contraceptive vaginal ring, with a standard combined oral contraceptive pill. STUDY DESIGN: Healthy women aged 18 to 40 years who requested contraception received either NuvaRing or a combined oral contraceptive containing 30 microg ethinyl estradiol and 150 microg levonorgestrel for 6 cycles in 3 similarly designed studies. Each cycle comprised 3 weeks of ring or pill use, followed by 1 ring- or pill-free week. RESULTS: Two hundred forty-seven women began the studies, 121 women with NuvaRing and 126 women with the combined oral contraceptive. Withdrawal bleeding occurred in virtually all cycles in both groups. In the NuvaRing groups, the incidence of irregular bleeding was < or =5% in all cycles; this was lower than the combined oral contraceptive groups (5.4%-38.8%). Furthermore, the incidence of a normal intended bleeding pattern was significantly higher in the NuvaRing groups than in the combined oral contraceptive groups (P <.01). Both contraceptives were well tolerated. CONCLUSION: NuvaRing has excellent cycle control and is well tolerated.     

Relationship of migraine headache and stroke to oral contraceptive use

Are oral contraceptive users who also suffer from migraine headaches at higher risk of having a cerebrovascular accident? The data are inconclusive in establishing that women who used the relatively higher-dose pills prescribed in the 1960s have a higher risk of either thrombotic or hemorrhagic stroke. Furthermore, a review of the literature does not support the belief that those women who use oral contraceptives have a higher incidence of migraine headache. The available data do not indicate that migraine headache is necessarily a contraindication to prescribing oral contraceptives.