What is a recommended monophasic oral contraceptive (monophasic oral contraceptive) regimen for a patient?

Recommended Monophasic Oral Contraceptive Regimen

For patients requiring a monophasic oral contraceptive, a formulation containing 30-35 μg of ethinyl estradiol with a progestin such as levonorgestrel or norgestimate is recommended as the first-line option. 1

Rationale for Monophasic COC Selection

Monophasic oral contraceptives provide several advantages:

• Each tablet contains the same dose of estrogen and progestin throughout the active pill cycle
• Simpler regimen compared to multiphasic options
• Excellent contraceptive efficacy (typical use failure rate 5-9%) 2
• Predictable bleeding patterns for most users

Specific Recommended Formulations

• First-line option: 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate 1
• Alternative option: 30 μg ethinyl estradiol with desogestrel (demonstrated excellent efficacy and cycle control in clinical trials) 3
• Lower-dose option: 20 μg ethinyl estradiol with 100 μg levonorgestrel (Pearl index 0.88, good tolerability profile) 4

Administration Protocol

Standard 28-Day Regimen

• 21-24 active hormone pills followed by 4-7 placebo pills
• Can be initiated using either Sunday start or Day 1 start 5
• For Sunday start: First pill taken on first Sunday after menstruation begins
• For Day 1 start: First pill taken on first day of menstruation

Missed Pill Instructions

If one hormonal pill is late (<24 hours):

• Take the late pill as soon as possible
• Continue taking remaining pills at usual time
• No additional contraceptive protection needed 1

If one hormonal pill is missed (24 to <48 hours):

• Take the missed pill as soon as possible
• Continue taking remaining pills at usual time
• Use backup contraception for 7 consecutive days 1

If two or more consecutive hormonal pills are missed (≥48 hours):

• Take the most recent missed pill immediately (discard other missed pills)
• Continue taking remaining pills at usual time
• Use backup contraception for 7 consecutive days
• Consider emergency contraception if pills were missed during first week and unprotected intercourse occurred in previous 5 days 1

Benefits Beyond Contraception

Monophasic COCs provide several non-contraceptive benefits:

• Decreased menstrual cramping and blood loss
• Improvement in acne
• Protection against endometrial and ovarian cancers with >3 years of use
• Management of conditions exacerbated cyclically (e.g., migraine without aura, epilepsy, irritable bowel syndrome) 1

Safety Considerations

• Baseline risk of venous thromboembolism in young women: up to 1 per 10,000 woman-years
• COCs increase risk to 3-4 per 10,000 woman-years
• For comparison, pregnancy/postpartum period: 10-20 per 10,000 woman-years 1
• COCs are contraindicated in women with history of VTE, stroke, cardiovascular disease, age ≥35 years who smoke ≥15 cigarettes daily 6

Common Pitfalls and Caveats

1. Medication interactions: Certain medications (e.g., anticonvulsants, rifampin) may decrease COC effectiveness 6

2. Missed pills: Frequent missed pills significantly reduce effectiveness; consider alternative methods less dependent on user adherence (IUD, implant) for patients with adherence challenges 1

3. Breakthrough bleeding: Common during initial use and typically decreases with continued use; counsel patients that this does not indicate reduced effectiveness 6

4. Extended or continuous regimens: May be appropriate for patients with medical conditions like anemia, severe dysmenorrhea, or endometriosis, but may have more unscheduled bleeding, especially in early months 1, 6

5. STI protection: COCs do not protect against sexually transmitted infections; condoms should be recommended if STI protection is needed 6

Monophasic oral contraceptives remain one of the best-studied medications ever prescribed, are completely reversible, and have no negative effect on long-term fertility 1.