ACs and birth control

[Kyzr]

So, I know Tinneas posted a topic like this recently... so, I'm sorry for a repeat. But I'm fucking pissed and can't contain myself.

When my pdoc prescribed Lamictal, she told me nothing of the side effects with birth control... at first, my understanding was that Lamictal would make the birth control less effective. I know now that that ISN'T the case (that it's the other way around), but at the time it was a big deal. And I called the office, was only allowed to talk to the secretary and she told me to just use a second form of birth control. More on that later.

Pdoc and I have had the discussion of how birth control can affect the Lamictal MANY times over...because it seems that the Lamictal's effectiveness changes according to which week of pills I'm on. She's WELL AWARE that I'm on birth control. And if she's forgotten, it's IN THE CHART. Or at least it should be.

Today, I went to my pdoc, and she's added Trileptal. She said nothing about the interaction with the birth control. I didn't find out about it until the pharmacist said..."Hey, you might wanna look at this. Do you want me to call your doctor and get back to you, because this could be a problem." So, Trileptal can reduce the effectivness of the birth control, of course.

Problem one: Is my pdoc not paying attention to this? Why doesn't she say anything to me about it? Why does it seem she has overlooked this again? Why do I have to wait until I'm at the pharmacist to find this stuff out? And what the hell is wrong with me to not have asked when I was in the office?

So, you'd think I would just use condoms, right? Yeah, no. This leads to...

Problem two: Every single condom I've ever tried has caused me problems - bladder infections, other girly area infections, etc. I've tried spermicide, non-spermicide, lubed, non-lubed, latex, non-latex, multiple brands... on and on. Infection, infection, infection.

This is part of why I use birth control. And if something is going to make it NOT work, then why bother taking it? (And now I can't stop because of its relationship with Lamictal. Pdoc has said that it would be very bad to stop the birth control right now.)

So... I'm really frustrated. She really does seem like an otherwise good pdoc. I like her. My tdoc likes her. But, really? Why does the pharmacist catch this and she doesn't? And why, when I talked about the, albeit rare, dental side effects of some ACs, she said she'd never heard of it? (Maybe it doesn't exist really exist, but I have read about it in places.)

I'm sorry this is so long... it's just... even though I won't hear back until tomorrow and I haven't taken anything yet, I feel certain that they'll just tell me to use condoms again. And I'm really distraught over it.

[lottacrazy]

Hey there. Sounds awful, I must say. My professor just mentioned this so it kind of clicked, a lot of doctors are not aware or have to much info in their brains to remember all side effects, they depend on the Pharmacists to deal with that mostly, which is where there can be a problem, you had a great pharmacist luckily who noticed this and warned you .

I have an issue with condoms as well, I have a latex allergy well plastic allergy really and I get rashes and infections too. I have no advice their, maybe the IUD or the Ring or the patch? Lambskin condoms maybe?

I would talk to the doctor about this, if she acts ignorant to the issue then I would look for another doc.

[DarkendHour]

Maybe your pdoc knew about the side effect... but maybe the risk wasn't all that great?

I know with side effects in general if there is even a chance of them they must be listed. With your particular meds I haven't the slightest clue what the risk % is.

I think your pdoc should have said something though being that they should know that would be a major concern of yours from past experience.

I mean if I had an ongoing topic of concern with my pdoc and she started me on a new med I would think she would let me know if it involved the ongoing concern and I wouldn't think to ask about it.

Hope this get straighted our for ya soon.

Oh and about other forms of birthcontroll... the ring and the patch may have the same components in them as the birth control that are interacting with the ACs, check into that before/if you think about switching to one of them.

lottacrazy the IUD is a great idea, I never would have thought to suggest that.

It really does suck for those of us who can't use condoms with out bad things happening.

[Silver]

I agree, Kyzr. I think it's not good.

I think it's worth bringing up with your psychiatrist, if you feel you can do that in an OK way and maintain a therapeutic relationship. This isn't "challenging" your doc's treatment decisions. This is an example of advocating for yourself as a patient (and reminding your psychiatrist that her/his scope of practice doesn't stop at your chin, thanks.)

I am thinking that, were you pregnant, s/he might be suddenly very unwilling to prescribe some of these meds, and there'd be a lot of risk/benefit discussions.

Working with you in trying to prevent pregnancy is also worth the cognitive effort on your doc's part.

At a minimum, saying, "I think I need you to go see your [whoever manages your contraception] to discuss options, like maybe a higher dose pill," would be a good start, you know?

It's not as if this is news to anyone. There are approximately five gazillion articles about this in the neurology / epilepsy literature.

Perhaps you could print this out and take it in, and explain that you know you're taking these drugs for conditions other than epilepsy, but, uh, you can still get all pregnant and stuff.

And, yes, it's a genuine real Interaction with Trileptal.

[LunaRufina]

Another option, though I don't know if it's a route you want to take, is to try depo provera, a shot every 12 weeks. There is a possible mood side effect, however so it may not be an option for you. But if you have few to no other options it may be one you want to look into. The only possible adjustment would be to get the shot in closer intervals than usual if it's suspected it's necessary. I don't have break through bleeding, though, so I've been told that it isn't necessary.

[Kyzr]

Thanks for all the info. And for the validation on my thoughts and feelings on some of this.

When I started taking the Lamictal, there was a big runaround between me, my pdoc's office, and the drug rep. It was emphatically expressed by the drug rep that Lamictal does not change the effectiveness of hormonal contraceptives. Instead, it's the other way around. So, we're still okay there. But, because it's the other way around, my pdoc has said specifically that I cannot discontinue the current bc that I'm on. I'm not supposed to switch to a different pill either. So, for now, I suppose that's off the table. I dunno.

I wanted to get an IUD a few years back and was blown off by my gyn because..... I dunno. Because I'm of child bearing age and said that I might want children in the not-so-near future? Also, potentially because I used to get very bad menstrual cramps when not on the pill? I'm not sure. So, I will look into that again. Thanks for reminding me.

The other thing is that I haven't been with this pdoc for a year quite yet, I don't think. I started seeing her when I got better insurance and Lexapro turned me in to a chubby slug. (see: I gained weight and slept a l l t h e t i m e.) Yadda, yadda... and she didn't start treating me as BP until about 6 months ago when I started the Lamictal. And that's the only thing I've tried aside from a couple SSRIs and Wellbutrin. So, it seems that there MUST be other things to try? It almost seems like she has a formula to prescribing. Try drug A, then B, then C, then C+D, etc. (I have no basis in reality for this... it just... feels like it.)

Though, to her credit, I'm pretty nuts about not getting on a drug that could cause me to gain weight. So, I think I've probably taken a lot of them off the table with that.

The knowledge or lack thereof side effects bothers me quite a bit when it's in regard to something as major as contraception. I guess I could excuse the more obscure ones... but the hormonal contraceptive thing just seems like it would be a big deal to large portion of her clients. She does have tons of clients (as it's a non-profit), so I'm sure it's difficult to keep everyone's stories straight, but wouldn't that be a good reason to keep meticulous documentation in the chart(s)?

So, if I were to go to her office right now, I'd think, "This is so unprofessional. How do you not know this shit? I'm so distraught....nevermind the stress of being in a mixed state (or something) about 75% of the time lately. I need help. This is not helping. This is hurting. We've been over this. Write it in the chart. Would you like me to write it in there? Why is this so fucking hard?! Fuck, fuck, fuck. "

But, what I would actually say is, "I'm sorry... I really don't want to be a problem, but I don't think I can do this. I'm sorry."

Should I try to hold my ground on finding something that isn't going to have interactions? I just always feel like I'm at the mercy of the "let's try this" statements.

Good Lord...could someone please loan me a spine?

(I know...issues. I'm workin on it with my tdoc.)

Will update after I hear from the pharmacist tomorrow.

[Silver]

because it's the other way around, my pdoc has said specifically that I cannot discontinue the current bc that I'm on. I'm not supposed to switch to a different pill either.

There are other OCPs.

Or (and I apologize to those of you who've heard me say this before) - you guys can draw a serum lamotrigine level. After you change contraception, re-check the level as needed, then dose to the level. That's what my neurologist (and psychiatrist) do... Lamotrigine isn't 'dosed to the level,' but it can be monitored by level for this sort of thing. Very useful in pregnancy, for example.

You can in fact switch within different OCPs in terms of androgenicity, etc., and other aspects of the types of progesterone used in that specific pill. It's the level of ethinyl estradiol, not the progestin, that affects lamotrigine level, by the way (I have a post on this somewhere with reference to the specific article that I'm too lazy to hunt for right now.)

Here's the thing: most COCs (combined oral contraceptives) use ethinyl estradiol (some use mestranol), at fairly standard doses. But there is a RAINBOW of progestins and progestin doses. Handy, in this case.

Here's a summary - not the be-all/end-all, but it gives you an idea of the range of doses, if you go down a few pages. Damn it, I have a really good summary somewhere of this and I can't find it...

Now - this doesn't mean you're out of the woods. Trileptal still kicks OCPs around. Sorry.

I have been in the position of taking an enzyme inducing AED for mood that would induce clearance of estradiol AND a little progestin (norethindrone, actually), and I took a COC with a higher dose of ne. However, I had to sign about 4 informed consents to do that. And I finally ended up... after five months of nail biting... getting an IUD, because I couldn't take counting the weeks any more. So... I'm sympathetic.

If you do OK with progesterones, Depo-Provera is worth a look-see. As Luna says, there's the option of spacing it up tighter.

Uh. Your psychiatrist DOES know that Trileptal decreases Lamictal level, right? Since she's so concerned about that?

If weight gain is a big issue, yes, it's knocked out a lot of meds, maybe. Might be worth backing off on this and working with your doc, and saying "I'm willing to consider these options if you're willing to listen to me when I say I'm over my threshold."

Depakote doesn't interact with hormonal contraception, but it is generally not on the A-list for women of child-bearing potential due to the risk of PCOS. Weight gain risk is there. As with any other drug, you monitor for it. The endocrine stuff is a real concern, though, for a lot of women.

Lithium doesn't interact with hormonal contraception.

You're on the boards, you've read lots on these meds, I'm guessing.

I think I might wait on this discussion a little bit til you can formulate it and have the discussion that you want to have. If you can wait on this discussion a little bit and not get pregnant, that is. You have a spine (obviously.) But it would be ideal if you can speak for yourself in your true organized voice.

This might be one of those "write a letter" things.

You can practice with us.

The being part of a non-profit has nothing to do with it. That might explain a certain amount of overloadedness, but not being underinformed. (I have opinions, can you tell?)

OK, I'm drooling on my keyboard, have to go to bed.

[Kyzr]

So now I've talked to the pdoc's secretary and they're going to call in Celexa for me instead. So I said, "I assume there are no interactions with the birth control on that one?" And she responded by saying that she wouldn't think so, but that pdoc really leaves that up to the pharmacist to figure out. Um... really? This seems at least mildly irresponsible to me. I get that the pharmacist's job is to be REALLY on top of the drug interactions, but this does not seem as though it ought to be completely out of the realm of the prescriber's jurisdiction.

Also... I was on Lexapro before. It made me fat and tired. Okay, maybe I'm overstating the fat part...though I did gain enough weight that it became a very serious problem for me congnitively. Really. And I'm not overstaing the tired thing at all. I would sleep 10 or more hours at night and nap all day long. For months.

Doesn't this seem weird? Does anyone understand the logic in putting me on Celexa even though I had such problems with Lexapro? Also, any idea what the logic is in going from an AC to an SSRI in this case? (I'm not criticizing this part...I just really don't understand it.)

I should say, for the sake of full disclosure of my potential idiocy, it's only going to be 5mg of Celexa. So, maybe at that level there will be just about zero side effects for me. I don't know.

I know I'm making it difficult to deal with me, and I really do feel bad about it, but is she paying any attention? I just feel upset and scared.

Uh. Your psychiatrist DOES know that Trileptal decreases Lamictal level, right? Since she's so concerned about that?

I really have no idea if she does or not. As a patient, maybe very ignorantly, I can only assume that she does...since it seems that her primary job is to prescribe these drugs. But, clearly, she doesn't know some things that it seems that she would know. And frankly, if it's not her part of her job to worry about how the drugs she's prescribing interact with one another, what is her job? I see her for meds. That's it. I feel like I should be able to trust her knowledge and experience.

If weight gain is a big issue, yes, it's knocked out a lot of meds, maybe. Might be worth backing off on this and working with your doc, and saying "I'm willing to consider these options if you're willing to listen to me when I say I'm over my threshold."

It really is an enormous concern for me. I already have all kinds of issues with my self-image and when I start to gain weight, any weight, my anxiety level increases notably. The SSRI cons have, in the past, typically outweighed the pros. (No pun intended.) I do talk to tdoc about my body image issues.... and when I'm happy about my weight, the negative self-image diminishes significantly and I don't even think about it except to maintain current weight/clothing size, etc. At any rate...irrational fear or not, weight gain scares me.

You're on the boards, you've read lots on these meds, I'm guessing.

I've read some, but not nearly as much about meds that I'm not on or haven't been on. That's my bad, and it does make it more difficult to be informed when the pdoc says, "lets try this." But, I can't read everything and really don't know what kinds of meds I should anticipate. I'm still trying to educate myself.

The being part of a non-profit has nothing to do with it. That might explain a certain amount of overloadedness, but not being underinformed. (I have opinions, can you tell?)

Yeah, I guess my only point about the non-profit was that she may be a little overloaded with patients. I have no idea if she is or not. I'm trying to give her the benefit of the doubt, regardless of my frustration (both rational and irrational). Having said that... I agree, underinformed is not good.

I am going to try the Celexa, because I feel like I have no other option. Maybe I'll manage to settle down about it after a little time.

Thank you so much for your help so far. You're all are amazing.

[peanutbutter]

OKay, so I didn't read everything, but I just want to mention if you find that every week something funky is going on because of the lamictal/birth control reaction, I'm assuming you're on a kind of pill that the hormones change every week, so why not try one where the hormones are the same all month? Your week off might be interesting, but for three weeks (or more if you decide to skip your periods yay!) you've got consistent levels.

As for the other stuff, there are lots of birth control options.

[Kyzr]

Yeah, I suggested the same, PB. Pdoc says no. She doesn't want me to change my bc. Confuses me a little. So, I have no idea what to do on that note. I will say that it's gotten somewhat better with the last Lamictal dosage increase (100 to 150mg...'bout a month ago).

To update a little...

Now that I've calmed down from my initial irrational freakout, I'm taking the tiny 5mg dose of Celexa.... I can't imagine it's anything but coincidence, but within the first 4 hours of taking it, I felt SO tired. And the next day I felt SO tired, especially during my workout. But, I seem to not notice it quite as much at the moment. I'm still afraid even the small dose will initiate a weight gain or make me sleep or be tired constantly. But, I'm going to try to be calm and realistic and just see what happens.

And regardless of all that, the lack of knowledge on my pdoc's part still makes me a little uneasy. Will have to see how things go.

[I Am Bien]

Yeah, I suggested the same, PB. Pdoc says no. She doesn't want me to change my bc. Confuses me a little. So, I have no idea what to do on that note. I will say that it's gotten somewhat better with the last Lamictal dosage increase (100 to 150mg...'bout a month ago).

To update a little...

Now that I've calmed down from my initial irrational freakout, I'm taking the tiny 5mg dose of Celexa.... I can't imagine it's anything but coincidence, but within the first 4 hours of taking it, I felt SO tired. And the next day I felt SO tired, especially during my workout. But, I seem to not notice it quite as much at the moment. I'm still afraid even the small dose will initiate a weight gain or make me sleep or be tired constantly. But, I'm going to try to be calm and realistic and just see what happens.

And regardless of all that, the lack of knowledge on my pdoc's part still makes me a little uneasy. Will have to see how things go.

I specifically took myself off of Trileptal when I learned about it decreasing effectiveness of birth control. I do not want to take the risk. The truth is that the doctor does not know MY chemistry specifically. He has general knowledge. For all I know my birth control can be useless if I take Trileptal. It depends on your liver, how and how quickly your absorb it, your blood levels,etc.

I do not want to play russian roulette lol