What is the first-line oral birth control pill (OBCP) for stopping menstrual periods?

First-Line Oral Birth Control Pill for Stopping Menstrual Periods

Start with a monophasic combined oral contraceptive containing 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate, used in an extended or continuous regimen (skipping the hormone-free interval) to achieve amenorrhea. 1

Recommended First-Line Approach

Initial Formulation Selection

• Monophasic pills are the first-line choice for women beginning hormonal contraception, as there is no evidence that biphasic or triphasic formulations offer any clinical advantage in efficacy, bleeding patterns, or side effects. 1
• Prescribe monophasic pills containing 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate due to extensive safety and efficacy data available for these formulations. 1, 2
• These formulations are effective, have relatively low risk of venous thromboembolism, and are widely available. 2

Extended/Continuous Dosing Strategy

• Use extended or continuous monophasic regimens (taking active hormone pills without the hormone-free interval) to achieve menstrual suppression. 3, 1
• Combined hormonal contraceptives are sometimes used for an extended period with infrequent or no hormone-free days specifically for this purpose. 3
• Extended or continuous monophasic regimens are particularly recommended for patients with severe dysmenorrhea, endometriosis, heavy menstrual bleeding, anemia, or bleeding disorders. 1

Important Counseling Points

Expected Bleeding Patterns

• Patients should be informed that extended or continuous regimens may cause unscheduled breakthrough bleeding initially but this typically improves over time while optimizing contraceptive effectiveness. 1
• Breakthrough bleeding is most common during the first few cycles and decreases with continued use. 4
• Amenorrhea does not require any medical treatment and patients should be reassured that this is an expected and safe outcome. 3

Management of Breakthrough Bleeding

• If breakthrough bleeding occurs during extended use, NSAIDs for short-term treatment (5-7 days) or brief hormonal treatment with low-dose COCs or estrogen (10-20 days) can be considered. 3
• If heavy or prolonged bleeding persists and the woman finds it unacceptable, counsel on alternative contraceptive methods. 3

Alternative Considerations

Lower Dose Options

• If the patient experiences unacceptable side effects on the initial 30-35 μg formulation, switching to a different monophasic formulation is recommended rather than moving to biphasic or triphasic options. 1
• Formulations with 20 μg ethinyl estradiol may be considered, though they may have slightly higher rates of breakthrough bleeding. 5, 4

Common Pitfalls to Avoid

• Do not automatically switch to biphasic or triphasic pills if the patient experiences side effects; try a different monophasic formulation first. 1
• Do not prescribe more than 30-35 μg ethinyl estradiol for women with normal menstrual cycles, as higher doses increase thromboembolic risk without additional benefit. 6
• Ensure at least 7 consecutive hormone pills are taken to prevent ovulation, which is critical for both contraceptive efficacy and menstrual suppression. 1