What are the recommended drugs and doses for prescribing Combined Oral Contraceptives (COCs)?

From the Guidelines

When prescribing combined oral contraceptives (COCs), I recommend starting with a monophasic pill containing 30-35 mcg ethinyl estradiol with either levonorgestrel or norethindrone as first-line options, as this regimen has been shown to be effective and well-tolerated in adolescents 1.

Key Considerations

• The estrogen component in COCs is typically ethinyl estradiol, with amounts varying from 10 to 50 μg, and "low-dose" pills (35 μg or less) are recommended as first-line options for adolescents 1.
• A progestin such as levonorgestrel or norgestimate is often used in combination with ethinyl estradiol, and many experts recommend starting adolescents on a monophasic pill with monthly bleeding 1.
• Specific examples of recommended COCs include Levora (30 mcg ethinyl estradiol/150 mcg levonorgestrel) or Ortho-Novum (35 mcg ethinyl estradiol/1 mg norethindrone) 1.

Contraindications and Precautions

• Before prescribing COCs, screen for contraindications including history of venous thromboembolism, stroke, coronary artery disease, breast cancer, migraine with aura, uncontrolled hypertension, diabetes with vascular complications, and smoking in women over 35 1.
• Counsel patients about potential side effects including nausea, breast tenderness, headaches, and breakthrough bleeding, which often improve after 2-3 months of use 1.

Administration and Follow-up

• COCs should be taken once daily at the same time, typically in a 21-day active pill regimen followed by 7 days of placebo pills, though extended or continuous regimens are also options 1.
• Advise using backup contraception for the first 7 days of the first pack, and counsel patients on what to do if pills are missed 1.
• A routine follow-up visit 1 to 3 months after initiating COCs is useful for addressing adverse effects or adherence issues 1.

From the FDA Drug Label

A positive association has been observed between the amount of estrogen and progestogen in oral contraceptives and the risk of vascular disease (31 to 33) A decline in serum high-density lipoproteins (HDL) has been reported with many progestational agents (14 to 16). A decline in serum high-density lipoproteins has been associated with an increased incidence of ischemic heart disease Because estrogens increase HDL cholesterol, the net effect of an oral contraceptive depends on a balance achieved between doses of estrogen and progestogen and the nature and absolute amount of progestogens used in the contraceptives. The amount of both hormones should be considered in the choice of an oral contraceptive Minimizing exposure to estrogen and progestogen is in keeping with good principles of therapeutics. For any particular estrogen/progestogen combination, the dosage regimen prescribed should be one which contains the least amount of estrogen and progestogen that is compatible with a low failure rate and the needs of the individual patient. New acceptors of oral contraceptive agents should be started on preparations containing 0. 035 mg or less of estrogen.

The recommended dose of estrogen in oral contraceptives should be 0.035 mg or less.

• The choice of oral contraceptive should consider the balance between doses of estrogen and progestogen.
• Minimizing exposure to both hormones is recommended.
• The dosage regimen should contain the least amount of estrogen and progestogen that is compatible with a low failure rate and the needs of the individual patient 2.

From the Research

Prescribing COCs Drugs and Doses

• The dosage and type of combined oral contraceptives (COCs) can affect the risk of venous thromboembolism (VTE) and other side effects 3, 4, 5, 6.
• A study found that an extended-cycle OC with the lowest doses of ethinyl estradiol (EE) and levonorgestrel (LNG) + continuous EE throughout the cycle had a similar efficacy and adverse effect profile compared to other extended-regimen OCs 3.
• Another study observed a slightly elevated VTE risk in association with continuous/extended COC use when compared with cyclic COC use, but the absolute risk difference was low 4.
• The risk of VTE varies according to the type of progestogen found in COCs, with androgenic progestogens being associated with a lower risk of VTE compared to non- or antiandrogenic progestogens 6.
• Progestin-only hormonal contraception is not associated with a significant increase in the risk of VTE, except for depot medroxyprogesterone acetate 5.
• A review of randomized controlled trials found that continuously administered COCs have equivalent efficacy and safety but improved bleeding profiles, amenorrhea rates, adherence, continuation, participant satisfaction, and menstrual symptoms compared with cyclic COCs 7.

Factors to Consider When Prescribing COCs

• The type and dose of estrogen and progestogen in the COC
• The patient's medical history, including any history of VTE or thrombophilia
• The patient's preferences and lifestyle, including any desire to avoid menstruation
• The potential risks and benefits of different COC regimens, including the risk of VTE and other side effects 3, 4, 5, 6.

COC Regimens and VTE Risk

• Continuous/extended COC use may be associated with a slightly elevated VTE risk compared to cyclic COC use 4.
• The risk of VTE varies according to the type of progestogen found in COCs, with androgenic progestogens being associated with a lower risk of VTE compared to non- or antiandrogenic progestogens 6.
• Progestin-only hormonal contraception is not associated with a significant increase in the risk of VTE, except for depot medroxyprogesterone acetate 5.