What are the guidelines for prescribing Oral Contraceptive Pills (OCPs)?

Guidelines for Prescribing Oral Contraceptive Pills (OCPs)

Combined hormonal contraceptives (CHCs) are recommended as first-line treatment for contraception in eligible women, with careful consideration of cardiovascular risk factors and contraindications before prescribing. 1

Patient Selection and Contraindications

Absolute Contraindications

• Women over 35 years who smoke 2
• History of or high risk for arterial or venous thrombotic diseases 2
• Uncontrolled hypertension or hypertension with vascular disease 2, 3
• Breast cancer 2
• Liver tumors or liver disease 2
• Renal impairment 2
• Adrenal insufficiency 2
• Undiagnosed abnormal uterine bleeding 2
• Co-administration with Hepatitis C drug combinations containing ombitasvir, paritaprevir/ritonavir, with or without dasabuvir 2

Relative Contraindications

• Controlled hypertension (requires careful monitoring) 3
• Multiple cardiovascular risk factors 3
• Diabetes with vascular complications 2
• Uncontrolled dyslipidemia 2

OCP Formulation Selection

Estrogen Component

• Most current CHCs contain ≤50 μg of ethinyl estradiol 3
• Lower doses (15-35 μg) are preferred to minimize thrombotic risk 3, 4
• Newer formulations containing estradiol valerate or estetrol may have fewer adverse effects but require more post-marketing data 3

Progestin Component

• First-generation progestins (e.g., norethindrone): Higher androgenic effects, may worsen acne 4
• Second-generation progestins (e.g., levonorgestrel): Lower thrombotic risk profile 4
• Third-generation progestins: Reduced off-target effects on androgen receptors 3
• Fourth-generation progestins (e.g., drospirenone): Anti-androgenic and anti-mineralocorticoid properties, beneficial for acne and PMDD 3, 5

Special Considerations

• For women with acne or hirsutism: Consider OCPs with anti-androgenic progestins 4, 5
• For women with PMDD: Consider drospirenone-containing OCPs 2, 5
• For women with fluid retention symptoms: Consider drospirenone-containing OCPs due to antimineralocorticoid effects 6

Dosing Regimens

Traditional Regimen (21/7)

• 21 days of active hormonal pills followed by 7 days of placebo/hormone-free interval 7

Extended Cycle Regimens

• 24/4 regimen: 24 days of active hormones followed by 4 days of placebo 8
• 84/7 regimen: 84 days of active hormones followed by 7 days of placebo 8
• Continuous regimen: Active hormones taken continuously without placebo 8

Starting OCPs

Sunday Start

1. Begin first pill on the first Sunday after menstruation begins
2. If menstruation begins on Sunday, start that day
3. Use backup contraception for the first 7 days 7

Day 1 Start

1. Begin first pill on the first day of menstruation
2. No backup contraception needed if started on day 1 of cycle 7

Managing Missed Pills

If One Pill is Late (<24 hours)

• Take the missed pill as soon as remembered
• Continue taking remaining pills at usual time
• No additional contraceptive protection needed 3

If One Pill is Missed (24 to <48 hours)

• Take the most recent missed pill immediately
• Continue taking remaining pills at usual time
• Use backup contraception for 7 days 3

If Two or More Pills are Missed (≥48 hours)

• Take the most recent missed pill immediately
• Continue taking remaining pills at usual time
• Use backup contraception for 7 days
• If pills were missed in the last week of active pills, skip the hormone-free interval and start a new pack immediately 3
• Consider emergency contraception if pills were missed in the first week and unprotected intercourse occurred in the previous 5 days 3

Monitoring and Follow-up

Initial Monitoring

• Blood pressure measurement before initiation 3
• Consider serum potassium monitoring in first treatment cycle for women on drospirenone-containing OCPs who are also on medications that may increase potassium levels 2

Ongoing Monitoring

• Regular blood pressure checks, especially in women with controlled hypertension 3
• Monitor for signs of thromboembolism (leg pain, chest pain, severe headache, visual changes) 2
• Assess for changes in headache patterns 2
• Evaluate irregular bleeding or amenorrhea 2

Common Side Effects and Management

• Breakthrough bleeding: Common in first 3-6 months, typically improves with continued use 1
• Nausea/vomiting: Taking pill with food may help 9
• Breast tenderness: Usually improves after 2-3 months 9
• Mood changes: Monitor and consider changing formulation if persistent 9
• Weight changes: Generally minimal with modern low-dose formulations 6

Special Situations

Postpartum Initiation

• Can be initiated 4 weeks postpartum in non-breastfeeding women
• Consider increased thrombotic risk in postpartum period 7

Switching Between Contraceptives

• When switching from another OCP, start the new OCP the day after taking the last active pill of the previous OCP 7

Remember that OCPs do not protect against sexually transmitted infections, and condoms should be recommended if STI protection is needed 1.