What is the recommended initial regimen for combined oral contraceptives (COCs)?

From the Guidelines

The recommended initial regimen for combined oral contraceptives (COCs) is a low-dose pill containing 30 to 35 μg of ethinyl estradiol and a progestin such as levonorgestrel or norgestimate. This regimen is recommended because it balances efficacy with a favorable side effect profile, as noted in the study published in Pediatrics 1. The estrogen component, typically ethinyl estradiol, prevents breakthrough bleeding and ovulation, while the progestin component provides additional ovulation suppression and thickens cervical mucus to prevent sperm penetration.

Key Considerations for COC Use

• COCs can be started on the same day as the visit (“quick start”) in healthy, nonpregnant adolescents, with the recommendation that a backup method be used for at least the first 7 days for contraceptive efficacy 1.
• Patients should be counseled on the potential for common transient adverse effects, including irregular bleeding, headache, and nausea, and informed about the increased risk of blood clots associated with COC use 1.
• Drug interactions should be avoided, particularly with medications that decrease COC effectiveness, such as anticonvulsants and antiretroviral drugs 1.

Management of Adverse Effects and Missed Pills

• Recommendations for managing adverse effects have been published elsewhere and can be found online 1.
• If a pill is missed, it should be taken as soon as remembered, and if more than one pill in a row is missed, only the most recently missed pill should be taken as soon as possible, with the remaining pills taken at the usual time 1.
• Emergency contraception (EC) is indicated if two or more pills are missed in the first week of the cycle or if one or more pills were missed earlier in the same cycle as a missed pill or late in the previous cycle 1.

Benefits of COC Use

• COC use does not increase the risk of infertility or breast cancer, and use for more than four years provides significant protection against endometrial and ovarian cancers 1.
• Extended or continuous cycles may be useful for treating medical conditions such as anemia, acne, severe dysmenorrhea, endometriosis, and dysfunctional or heavy menstrual bleeding, as well as for adolescents who prefer amenorrhea 1.

From the FDA Drug Label

To achieve maximum contraceptive effectiveness, Kariva® must be taken exactly as directed and at intervals not exceeding 24 hours. Kariva® may be initiated using either a Sunday start or a Day 1 start.

SUNDAY START When initiating a Sunday start regimen, another method of contraception should be used until after the first 7 consecutive days of administration

DAY 1 START Counting the first day of menstruation as “Day 1”, tablets are taken without interruption as follows: One white tablet daily for 21 days, one light-green (inert) tablet daily for 2 days followed by 1 light-blue (ethinyl estradiol) tablet daily for 5 days.

The recommended initial regimen for combined oral contraceptives (COCs) is to take the tablets exactly as directed, with options for either a Sunday start or a Day 1 start. For a Sunday start, an additional method of contraception should be used for the first 7 days. For a Day 1 start, tablets are taken without interruption, starting on the first day of menstruation. 2

From the Research

Combined Oral Contraceptives (COCs) Regimen

The recommended initial regimen for combined oral contraceptives (COCs) is typically a low-dose monophasic combination containing 100 microg levonorgestrel and 20 microg ethinyl estradiol 3. This regimen has been shown to be effective in preventing pregnancy, with a Pearl index of 0.88 and a cumulative pregnancy rate of 1.9% at the end of a 3-year open-label trial 3, 4.

Efficacy and Safety

The efficacy and safety of low-dose COCs have been evaluated in several studies. A study published in the American Journal of Obstetrics and Gynecology found that a low-dose monophasic combination oral contraceptive containing 100 microg levonorgestrel and 20 microg ethinyl estradiol was effective in preventing pregnancy and had a good tolerability profile 3. Another study published in Contraception found that low-dose oral contraceptives containing 20 microg of ethinyl estradiol coupled with levonorgestrel resulted in fewer side effects and cycle control comparable with higher-dose pills 5.

Key Points

• Low-dose monophasic combination containing 100 microg levonorgestrel and 20 microg ethinyl estradiol is a recommended initial regimen for COCs 3
• This regimen has been shown to be effective in preventing pregnancy, with a Pearl index of 0.88 and a cumulative pregnancy rate of 1.9% at the end of a 3-year open-label trial 3, 4
• Low-dose COCs have a good tolerability profile, with common adverse events including headache and metrorrhagia 3, 4
• Cycle control with low-dose COCs is generally good, with the incidence of intermenstrual bleeding decreasing over time 4