Best Starting Combined Oral Contraceptive Pill in Australia
For most healthy women in Australia, a combined oral contraceptive pill (COCP) containing 30-35 μg of ethinyl estradiol with levonorgestrel or norgestimate is recommended as the first-line option due to its established safety profile, effectiveness, and availability on the Pharmaceutical Benefits Scheme. 1, 2, 3
First-Line Recommendations
- Monophasic pills containing 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate are considered first-line options in Australia due to their established safety profile and effectiveness 2, 3
- Second-generation progestins like levonorgestrel demonstrate a safer coagulation profile with lower risk of venous thromboembolism compared to newer progestins 2, 4
- Low-dose pills (containing ≤35 μg ethinyl estradiol) provide excellent contraceptive efficacy while minimizing estrogen-related side effects 1, 2
- Pills containing levonorgestrel or norethisterone in combination with ethinyl estradiol 35 μg or less are listed on the Australian Pharmaceutical Benefits Scheme, making them more affordable 3
Safety Considerations
- The most serious adverse event associated with COCP use is venous thromboembolism (VTE), which increases from 1 per 10,000 to 3-4 per 10,000 woman-years during COCP use 1, 2
- Second-generation progestins (like levonorgestrel) have a lower thrombotic risk profile compared to third and fourth-generation progestins 2, 4
- Drospirenone-containing COCPs may be associated with a higher risk of VTE compared to those containing levonorgestrel, according to FDA data 4
- Smoking is not a contraindication to COCP use in women younger than 35 years, but should still be discouraged 1, 5
Specific Formulations to Consider
- For most healthy women, a monophasic pill containing 30-35 μg ethinyl estradiol with levonorgestrel (e.g., Levlen, Microgynon, Nordette) is appropriate 2, 3
- Low-dose ethinylestradiol/levonorgestrel (20 μg/100 μg) formulations (e.g., Femme-Tab ED 20/100) may be suitable for women concerned about estrogen-related side effects while maintaining good contraceptive efficacy 6
- For women with specific concerns about fluid retention or weight gain, pills containing drospirenone (which has anti-mineralocorticoid properties) may be considered as a second-line option, despite the potentially higher VTE risk 2, 7
Clinical Pearls
- COCPs can be started on the same day as the consultation ("quick start") in healthy, non-pregnant women, with a backup method used for at least the first 7 days 1, 2
- A routine follow-up visit 1-3 months after initiating COCPs is useful for addressing adverse effects or adherence issues 1
- Extended or continuous cycle regimens (skipping the inactive pills) can be useful for women with heavy menstrual bleeding, dysmenorrhea, or conditions exacerbated cyclically 2, 8
- Common transient adverse effects of COCPs include irregular bleeding, headache, and nausea, which often resolve within the first few months of use 1, 2
Special Considerations
- For women with heavy menstrual bleeding, a monophasic COCP containing 30-35 μg of ethinyl estradiol with levonorgestrel or norgestimate is appropriate, with the option of extended cycle use 2, 9
- For women with hypertension concerns, careful monitoring is required, and lower estrogen doses may be preferable 1, 5
- For women with acne, COCPs with anti-androgenic progestins may be considered as a second-line option if the first-line options are not tolerated 2, 7
Contraindications
- COCPs should not be prescribed for patients with severe uncontrolled hypertension, ongoing hepatic dysfunction, complicated valvular heart disease, migraines with aura, thromboembolism or thrombophilia, or complications of diabetes 1, 2
- Women with multiple risk factors for cardiovascular disease should be carefully evaluated before starting COCPs 1, 5
Remember that while COCPs are an effective contraceptive method with additional non-contraceptive benefits, other contraceptive options should always be discussed to ensure the woman makes an informed choice 3.