What is a good birth control alternative to Lo Loestrin Fe (ethinyl estradiol and norethindrone acetate) for a patient who is not tolerating it well?

Alternatives to Lo Loestrin Fe for Patients with Poor Tolerance

For patients who are not tolerating Lo Loestrin Fe well, a progestin-only contraceptive method such as a levonorgestrel IUD (Mirena) or progestin-only pill is the best alternative due to better side effect profiles and comparable efficacy.

Understanding Lo Loestrin Fe and Its Issues

Lo Loestrin Fe contains ethinyl estradiol (estrogen) and norethindrone acetate (progestin), which can cause side effects in some patients. Common issues include:

• Breakthrough bleeding
• Headaches
• Nausea
• Breast tenderness
• Mood changes

Best Alternatives Based on Evidence

First-Line Options:

1. Progestin-Only IUD (Levonorgestrel IUD/Mirena)

   • Highly effective (>99%)
   • No increased risk of thrombosis (relative risk 0.61) 1
   • May decrease menstrual bleeding and cramping 2, 1
   • Beneficial for patients with cardiovascular risk factors
   • Long-acting (3-7 years depending on type)

2. Progestin-Only Pills

   • No increased risk of thrombosis (relative risk 0.90) 1
   • Well tolerated in approximately two-thirds of patients 2
   • Particularly suitable for patients with contraindications to estrogen
   • Requires consistent daily use at the same time

Second-Line Options:

1. Copper IUD

   • Highly effective (>99%)
   • No hormones, so no hormonal side effects
   • Well tolerated by 83.3% of patients 2
   • May initially increase menstrual bleeding and cramping 1
   • Long-acting (up to 10 years)

2. Etonogestrel Implant (Implanon/Nexplanon)

   • Highly effective (>99%)
   • Has been well tolerated by some patients 2
   • Long-acting (3 years)
   • May cause irregular bleeding patterns

Algorithm for Selecting an Alternative

1. Assess thrombotic risk factors:

   • If patient has history of VTE or positive antiphospholipid antibodies:
     • Avoid all estrogen-containing methods 2, 1
     • Avoid DMPA due to potential thrombogenicity 2, 1
     • Prioritize levonorgestrel IUD, copper IUD, or progestin-only pills 2

2. Consider bleeding preferences:

   • If patient desires lighter periods:
     • Levonorgestrel IUD is optimal 2, 1
   • If regular periods are preferred:
     • Progestin-only pills may be better, though irregular bleeding can occur

3. Consider convenience factors:

   • If patient prefers long-acting method:
     • IUD or implant
   • If patient prefers user-controlled method:
     • Progestin-only pill

Important Considerations and Pitfalls

• Avoid combined hormonal contraceptives (pills, patches, rings) in patients with:

  • History of thromboembolism
  • Severe hypertension
  • Migraines with aura
  • Age ≥35 years and smoking ≥15 cigarettes daily 1

• Progestin-only pill limitations:

  • Must be taken at the same time daily
  • Up to 25% of users experience irregular bleeding 1
  • Lower efficacy than IUDs or implants

• Depot Medroxyprogesterone Acetate (DMPA) concerns:

  • Not recommended for patients with positive antiphospholipid antibodies 2
  • Limited data suggests potentially higher VTE risk than other progestin-only methods 1

• Transition period:

  • When switching from Lo Loestrin Fe to a progestin-only method, use backup contraception for 7 days
  • IUD can be inserted anytime during the menstrual cycle if pregnancy is ruled out

Follow-up Recommendations

• Schedule follow-up 3 months after switching methods to assess:
  • Tolerance of new method
  • Bleeding patterns
  • Any new side effects
  • Satisfaction with the method

By following this evidence-based approach, patients who are not tolerating Lo Loestrin Fe well can be transitioned to a more suitable contraceptive method that maintains efficacy while reducing side effects.