What are some oral contraceptive pill (OCP) brands to prescribe?

Oral Contraceptive Pill Brands to Prescribe

For most patients requiring oral contraception, a combined hormonal contraceptive (CHC) containing ethinyl estradiol 20-30 mcg with a third or fourth generation progestin is recommended as first-line therapy, with specific brand selection based on patient characteristics and potential non-contraceptive benefits. 1, 2

Types of Oral Contraceptive Pills

Combined Hormonal Contraceptives (CHCs)

CHCs contain both estrogen and progestin components and are available in various formulations:

1. Monophasic pills (same hormone dose throughout cycle)

   • Drospirenone-containing pills (4th generation progestin):

     • Yasmin® (drospirenone 3mg/ethinyl estradiol 30mcg) 3, 4
     • Yaz® (drospirenone 3mg/ethinyl estradiol 20mcg) - 24/4 day regimen 3, 5
     • Yasminelle® (drospirenone 3mg/ethinyl estradiol 20mcg) 6

   • Norgestimate-containing pills (3rd generation progestin):

     • Ortho-Cyclen® (norgestimate 0.25mg/ethinyl estradiol 35mcg) 7

2. Multiphasic pills (varying hormone doses throughout cycle)

   • Ortho Tri-Cyclen® (norgestimate 0.18-0.25mg/ethinyl estradiol 35mcg)

Progestin-Only Pills (POPs)

• Norethindrone 0.35mg (Micronor®, Nor-QD®) 8
• Drospirenone 4mg (Slynd®)

Selection Algorithm Based on Patient Characteristics

1. For patients with no specific concerns:

• Start with a low-dose CHC (20-30mcg ethinyl estradiol) with a third or fourth generation progestin
• Examples: Yasminelle® (drospirenone/EE 20mcg) or Ortho-Cyclen® (norgestimate/EE 35mcg)

2. For patients with specific concerns:

Acne or hirsutism:

• Choose CHCs with anti-androgenic progestins:
  • Yaz® or Yasmin® (drospirenone-containing) 3, 9
  • Ortho Tri-Cyclen® (norgestimate-containing)

Premenstrual symptoms/PMDD:

• Yaz® (drospirenone 3mg/ethinyl estradiol 20mcg) - FDA approved for PMDD 3, 5

Water retention/bloating concerns:

• Drospirenone-containing pills (Yaz®, Yasmin®) due to antimineralocorticoid properties 10, 9

History of headaches (without aura):

• Lower estrogen dose (20mcg) options like Yaz® or Yasminelle® 9

Heavy menstrual bleeding:

• Higher estrogen dose (30-35mcg) options like Yasmin® or Ortho-Cyclen® 9

Medical contraindications to estrogen:

• Progestin-only pills like norethindrone 0.35mg 8
• Consider non-oral options like IUDs or implants for higher efficacy 2

Important Considerations

Efficacy

• CHCs have a typical failure rate of approximately 5-8% with typical use 1, 8
• POPs have a typical failure rate of approximately 5% with typical use 8
• Perfect use failure rates are much lower (0.1-0.5%) 8

Safety Considerations

• Blood pressure measurement is required before initiating CHCs 1
• Avoid CHCs in women with:
  • History of VTE, stroke, or coronary artery disease
  • Migraine with aura
  • Uncontrolled hypertension
  • Age ≥35 years who smoke
  • Multiple cardiovascular risk factors 1

Medication Interactions

• Efficacy may be reduced with:
  • Certain anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine)
  • Rifampin or rifabutin
  • St. John's wort 1

Starting Regimens

• CHCs can be started anytime in the menstrual cycle if reasonably certain patient is not pregnant
• If started >5 days after menses began, abstain from sex or use barrier methods for 7 days 1
• For norethindrone or norgestrel POPs, use backup for 2 days if started >5 days after menses began
• For drospirenone POPs, use backup for 7 days if started >1 day after menses began 1

Common Pitfalls to Avoid

1. Not accounting for drug interactions - Always check for medications that may reduce contraceptive efficacy
2. Overlooking medical contraindications - Screen for VTE risk factors, migraines with aura, and cardiovascular disease
3. Not providing clear instructions on missed pills and backup methods
4. Failing to consider non-contraceptive benefits when selecting a specific formulation
5. Not discussing potential side effects like breakthrough bleeding, especially in the first 3-6 months of use

While long-acting reversible contraceptives (LARCs) like IUDs and implants are more effective than OCPs 2, oral contraceptives remain a popular choice for many patients and can be tailored to provide additional non-contraceptive benefits.