What is the best combined oral contraception (COC) for managing premenstrual syndrome (PMS) symptoms?

Best Combined Oral Contraceptive for PMS

For managing premenstrual syndrome (PMS) symptoms, a combined oral contraceptive (COC) containing drospirenone with ethinyl estradiol is the most effective option. 1

Understanding COC Options for PMS

Drospirenone-containing COCs

• COCs containing drospirenone (DRSP) and ethinyl estradiol (EE) have shown effectiveness in improving overall premenstrual symptoms with small to moderate effects compared to placebo 1
• Drospirenone is a spironolactone-like progestin with unique antimineralocorticoid and antiandrogenic properties that may specifically benefit PMS symptoms 2
• These formulations have demonstrated improvement in functional impairment related to PMS, including productivity, social activities, and relationships 1

Dosage Considerations

• A formulation containing drospirenone 3 mg with ethinyl estradiol 20 μg has been specifically approved for treating premenstrual dysphoric disorder (PMDD), which is a severe form of PMS 3
• For adolescents and women with less severe symptoms, many experts recommend starting with a monophasic pill containing 30-35 μg of ethinyl estradiol with a progestin such as levonorgestrel or norgestimate 4

Benefits of Extended or Continuous Cycle Regimens

• Extended or continuous cycle regimens (with shorter or no hormone-free intervals) may be particularly beneficial for PMS symptoms 4
• These regimens provide:
  • Decreased menstrual cramping and blood loss 4
  • Improved management of conditions exacerbated cyclically, such as migraines (without aura), epilepsy, irritable bowel syndrome, and certain psychiatric symptoms 4
  • Optimized ovarian suppression, potentially increasing contraceptive effectiveness 4
• The most common adverse effect of extended-cycle regimens is unscheduled bleeding 4

Mechanism of Action and Efficacy

• Estrogen is clearly effective in relieving symptoms of PMS, while progesterone alone may be ineffective or even worsen symptoms 5
• Combined oral contraceptives are effective primarily due to their estrogen component 5
• Maximizing the relative estrogenic potency of the oral contraceptive appears logical for PMS symptom management 5
• Studies show that drospirenone with ethinyl estradiol may improve specific PMS symptoms including appetite changes, acne, and food cravings 2, 6

Practical Considerations

Starting COCs

• COCs can be initiated at any time if it is reasonably certain that the woman is not pregnant 4
• If started >5 days after menstrual bleeding began, additional contraceptive protection is needed for 7 days 4
• Blood pressure measurement is recommended before initiation 4

Managing Missed Pills

• If one pill is late (<24 hours): Take the late pill as soon as possible and continue the remaining pills at the usual time 4
• If one pill is missed (24-48 hours): Take the missed pill immediately and continue the pack, no additional protection needed 4
• If two or more consecutive pills are missed (≥48 hours): Take the most recent missed pill, continue the pack, and use backup contraception for 7 days 4

Potential Side Effects and Monitoring

• Common side effects of drospirenone-containing COCs compared to placebo include:
  • Nausea 1
  • Intermenstrual bleeding 1
  • Breast pain 1
• Regular blood pressure monitoring is important for all COC users 4
• The baseline risk of venous thromboembolism in young women is approximately 1 per 10,000 woman-years, which increases to about 3-4 per 10,000 woman-years with COC use 4

Clinical Pearls and Pitfalls

• Depressive symptoms may not respond adequately to hormonal treatment alone; selective serotonin reuptake inhibitors might be particularly effective for these symptoms 5
• For women who frequently miss pills, consider alternative methods less dependent on user compliance (e.g., IUD, implant, or injectable) 4
• If PMS symptoms persist despite COC use and are unacceptable, counsel on alternative contraceptive methods 4
• Seven days of continuous combined hormonal contraceptive use is necessary to reliably prevent ovulation 4