What are the recommendations for managing side effects associated with hormonal contraceptives, such as combined oral contraceptives (COCs) containing ethinyl estradiol (EE) and levonorgestrel (LNG)?

Managing Side Effects of Hormonal Contraceptives

For patients experiencing side effects from hormonal contraceptives like combined oral contraceptives (COCs) containing ethinyl estradiol and levonorgestrel, most adverse effects will resolve within 3-5 months of continued use, and reassurance is often the only intervention needed.

Common Side Effects and Management Strategies

Irregular Bleeding

• Most common in the first few months of COC use 1
• Management:
  1. Reassure patient that bleeding typically improves within 3-5 months of continued use 2
  2. For persistent bleeding beyond 3 months:
     • NSAIDs (ibuprofen or mefenamic acid 500mg three times daily for 5 days) can reduce bleeding 1
     • For COCs: Consider increasing estrogen content from 20mcg to 35mcg 3
     • For continuous combined contraception users: Add a hormone-free interval of 4-5 days 3

Nausea

• Often transient and resolves with continued use
• Management:
  1. Take pill with food or at bedtime
  2. No significant differences among various COC formulations for nausea management 2
  3. If severe, consider switching to a lower estrogen dose formulation (20μg EE) 1, 4

Headaches

• Management:
  1. Rule out migraine with aura (contraindication to COCs) 1
  2. For common headaches: Standard analgesics as needed
  3. Switching between different COCs is not effective for headache treatment 2
  4. If headaches occur during hormone-free interval, consider extended or continuous regimen 1

Breast Tenderness

• Management:
  1. Reassure that symptoms typically resolve within 3 months
  2. No significant differences among various COC formulations 2
  3. Consider lower estrogen dose if persistent

Mood Changes

• Management:
  1. Reassure that there is limited evidence linking hormonal contraceptives to mood disorders 2
  2. Monitor for 3 months before considering method change
  3. If symptoms persist, consider non-hormonal contraceptive methods

Weight Changes

• COCs are not consistently associated with weight gain 2
• Only DMPA (injectable) has been consistently linked to weight gain
• Management: Reassurance and lifestyle counseling

Special Considerations

Drug Interactions

• Medications that may decrease COC effectiveness 1, 5:
  • Rifampin/rifabutin (strongest evidence)
  • Some anticonvulsants (carbamazepine, phenytoin)
  • Some HIV medications (ritonavir-boosted protease inhibitors)
• Most broad-spectrum antibiotics do NOT affect COC effectiveness 1

Serious Adverse Effects Requiring Immediate Attention

• Severe abdominal pain
• Chest pain or shortness of breath
• Severe headache or visual changes
• Severe leg pain or swelling
• These may indicate thromboembolism, which is rare but serious 6, 5

Algorithm for Managing Persistent Side Effects

1. First 3 months: Reassurance and supportive care for most side effects
2. If side effects persist beyond 3 months:
   • For bleeding issues: Try NSAIDs or adjust hormone content
   • For nausea/headaches: Consider lower estrogen formulation
   • For acne with progestin-only methods: Consider switching to combined method if medically eligible 2
3. If side effects remain intolerable after interventions:
   • Consider switching to a different contraceptive method
   • For those who cannot use estrogen: Consider progestin-only options (POP, implant, LNG-IUD) 6

Important Caveats

• Always rule out pregnancy with new-onset irregular bleeding
• Assess for serious complications like thromboembolism with concerning symptoms
• COCs are contraindicated in women with severe hypertension, complicated heart disease, migraines with aura, thromboembolism history, or liver dysfunction 1
• The risk of venous thromboembolism increases from 1 per 10,000 to 3-4 per 10,000 woman-years with COC use 1

Patient education about expected side effects before starting hormonal contraceptives can significantly improve continuation rates and satisfaction with the method.