What is the most common oral contraceptive prescribed?

Combined Oral Contraceptives (COCs) Are the Most Common Oral Contraceptives Prescribed

Combined oral contraceptives (COCs) are the most popular method of hormonal contraception for adolescents and the most commonly used reversible method of contraception in the United States, comprising 21.9% of all contraception in current use. 1, 2

Composition and Formulations

• COCs contain both a progestin and an estrogen component 1
• In almost every pill, the estrogen component is ethinyl estradiol (EE), with daily doses typically ranging from 10-50 μg 1
• Many providers begin with a COC containing 30-35 μg of ethinyl estradiol and a progestin such as levonorgestrel or norgestimate 1
• Progestins in COCs are categorized by generations:
  • First-generation: norethindrone, ethynodiol diacetate 1
  • Second-generation: levonorgestrel, norgestrel 1
  • Third-generation: norgestimate, desogestrel (less androgenic) 1
  • Fourth-generation: drospirenone, dienogest (anti-androgenic properties) 1

Commonly Prescribed Formulations

• Low-dose pills (containing ethinyl estradiol 35 μg or less) are considered first-line 1, 3
• Pills containing levonorgestrel or norethindrone in combination with ethinyl estradiol 35 μg or less are commonly prescribed 3
• Four COCs are FDA-approved for treatment of acne in women who desire oral contraception:
  • Norgestimate/EE
  • Norethindrone acetate/EE/ferrous fumarate
  • Drospirenone/EE
  • Drospirenone/EE/levomefolate 1

Effectiveness and Usage

• Pregnancy rates of women using oral contraceptives are 4% to 7% per year with typical use 2
• COCs can be started on the same day as the visit ("quick start") in healthy, nonpregnant individuals 1
• A backup method (condoms or abstinence) should be used for at least the first 7 days for contraceptive efficacy 1
• The CDC recommends prescribing up to 1 year of COCs at a time 1
• A routine follow-up visit 1 to 3 months after initiating COCs is useful for addressing adverse effects or adherence issues 1

Safety Considerations

• The most serious adverse event associated with COC use is the increased risk of blood clots, which increases from 1 per 10,000 to 3-4 per 10,000 woman-years during COC use 1
• Lower doses of ethinyl estradiol are recommended to minimize potential increased stroke risk 1
• COCs should not be prescribed for patients with:
  • Severe and uncontrolled hypertension (systolic pressure ≥160 mm Hg or diastolic pressure ≥100 mm Hg)
  • Ongoing hepatic dysfunction
  • Complicated valvular heart disease
  • Migraines with aura or focal neurologic symptoms
  • Thromboembolism or thrombophilia
  • Complications of diabetes (nephropathy, retinopathy, neuropathy, or other vascular disease)
  • Complicated solid organ transplantation 1

Non-Contraceptive Benefits

• COCs offer numerous health benefits beyond contraception:
  • Protection against ovarian and endometrial cancers 4
  • Treatment of acne through anti-androgenic properties 1
  • Reduction in benign breast disease 4
  • Improvement in menstruation-related symptoms 5
  • Reduced risk of pelvic inflammatory disease requiring hospitalization 4
  • Prevention of ectopic pregnancy 4
  • Reduction in iron-deficiency anemia 4

Clinical Pearls

• Blood pressure should be assessed before initiation of oral contraceptives 5
• For patients with specific stroke risk factors (age >35 years, tobacco use, hypertension, or migraine with aura), progestin-only contraception or nonhormonal contraception may be more appropriate 1
• While smoking should be discouraged, it is not a contraindication to COC use in individuals younger than 35 years old 1
• The absolute risk of venous thromboembolism associated with COC use is small compared to the risk during pregnancy 1
• Extended cycle regimens with fewer or no inactive pills may be preferred by some patients 3