What are some recommended low dose oral contraceptives, such as Alesse (levonorgestrel and ethinyl estradiol) or Mircette (desogestrel and ethinyl estradiol), for patients seeking a low dose option?

Low Dose Oral Contraceptive Options

For patients seeking low dose oral contraceptives, levonorgestrel-releasing intrauterine devices (LNG-IUDs) and low-dose combined oral contraceptives containing ≤20 mcg of ethinyl estradiol are the most recommended options, with LNG-IUDs having superior efficacy (>99%) compared to oral formulations (91-95% with typical use). 1

Low Dose Oral Contraceptive Options

Recommended Low Dose Combined Oral Contraceptives:

1. Levonorgestrel-based options:

   • Alesse (100 mcg levonorgestrel/20 mcg ethinyl estradiol)
     • Demonstrated efficacy with Pearl index of 0.88 2
     • Good safety profile with headache and metrorrhagia being the most common adverse events (2% each) 3

2. Desogestrel-based options:

   • Mircette (150 mcg desogestrel/20 mcg ethinyl estradiol)
     • Comparable efficacy to other low-dose formulations
     • May provide better cycle control than Alesse in the first two cycles for new users 4

Efficacy Comparison

• LNG-IUDs and implants: >99% effective (typical failure rate 0.1-0.2%) 1
• Combined oral contraceptives: 91-95% effective with typical use 1
• Alesse specifically: Pearl index of 0.88 (pregnancies per 100 woman-years) 2

Benefits of Low Dose Formulations

• Reduced risk of estrogen-related side effects compared to higher-dose formulations 5
• Fewer side effects such as bloating, breast tenderness, and nausea (approximately 50% less common with 20 mcg vs. 35 mcg ethinyl estradiol) 4
• Acceptable cycle control, particularly after the first few cycles of use 3

Important Considerations and Contraindications

• Estrogen-containing contraceptives are contraindicated for women at high risk of thromboembolic events, including those with:

  • Cyanosis
  • Fontan physiology
  • Mechanical heart valves
  • Prior thrombotic events
  • Pulmonary arterial hypertension 6

• Cardiovascular risk assessment is essential:

  • Smoking significantly increases risk, especially in women over 35 7, 8
  • Hypertension, diabetes, hyperlipidemia, and obesity compound risks 7, 8
  • New users should start with preparations containing ≤0.035 mg of estrogen 7, 8

Alternative Low Dose Options

For women with contraindications to estrogen-containing contraceptives:

1. Progestin-only pills: 91-95% effective with typical use 1
2. Depot medroxyprogesterone acetate (DMPA): 94-97% effective (typical failure rate 0.3-6%) 1
3. Contraceptive implant: >99% effective (typical failure rate 0.05%) 1

Clinical Pearls

• Brand-name low-dose oral contraceptives may have better bioavailability than generic equivalents, potentially resulting in fewer breakthrough bleeding episodes and better adherence 9
• Breakthrough bleeding is highest during the first few cycles and typically decreases with continued use 3
• For women over 40, the benefits of low-dose oral contraceptives in healthy non-smoking women may outweigh the possible risks 7, 8

When selecting a low-dose oral contraceptive, consider the patient's cardiovascular risk factors, previous experience with contraceptives, and preference for non-contraceptive benefits such as cycle control and reduction of menstrual symptoms.