What is a suitable Oral Contraceptive Pill (OCP)?

Recommended Oral Contraceptive Pill Selection

For most patients without contraindications, start with a monophasic combined oral contraceptive containing 30-35 μg ethinyl estradiol combined with levonorgestrel or norgestimate. 1, 2, 3

First-Line Formulation

Prescribe a monophasic pill with ethinyl estradiol 30-35 μg plus a second-generation progestin (levonorgestrel or norgestimate). 1, 3

• Second-generation progestins like levonorgestrel have the safest thrombotic risk profile compared to newer generation progestins 1
• These formulations are effective, well-established, and typically have the lowest copay on insurance formularies 1
• Among low-dose pills, no clear data suggests one formulation is superior to another for most users 1, 2

Specific Clinical Scenarios

For Patients with Hypertension Concerns or Risk Factors

Consider drospirenone-containing OCPs (30 μg ethinyl estradiol/drospirenone) if blood pressure elevation is a concern. 4, 1, 5

• Drospirenone has anti-mineralocorticoid effects that may help mitigate blood pressure increases associated with estrogen 4, 1
• However, progestin-only pills (POPs) remain the safest option for patients with existing hypertension or multiple cardiovascular risk factors 4
• POPs are not associated with blood pressure elevations, suggesting estrogen is primarily responsible for BP changes 4

For Patients with Acne

Use norgestimate/ethinyl estradiol, norethindrone acetate/ethinyl estradiol, or drospirenone/ethinyl estradiol formulations. 1

• These are the FDA-approved COC formulations for treating acne in women who desire contraception 1
• Drospirenone-containing pills with 30 μg ethinyl estradiol are as effective as cyproterone acetate combinations for acne 6

For Patients with Dysmenorrhea, Endometriosis, or Heavy Menstrual Bleeding

Prescribe continuous or extended-cycle regimens using monophasic formulations. 1, 2

• Extended regimens are particularly appropriate for anemia, severe dysmenorrhea, endometriosis, and abnormal uterine bleeding 1, 2
• The most common adverse effect is unscheduled bleeding, which improves with continued use 1, 7

For Patients Requiring Lower Estrogen Doses

Consider 20 μg ethinyl estradiol formulations for patients with chronic headaches, mastodynia, or concerns about estrogen-related side effects. 7, 6

• Lower estrogen doses reduce water retention, edema, and breast tenderness 6
• However, strict adherence is critical with 20 μg formulations, as seven consecutive days of pill-taking is necessary to reliably prevent ovulation 1
• Studies show more follicular activity when 20 μg pills are missed compared to 30 μg formulations 1

Absolute Contraindications to Combined OCPs

Do not prescribe combined OCPs for patients with: 1

• Severe and uncontrolled hypertension 1
• Ongoing hepatic dysfunction 1
• Complicated valvular heart disease 1
• Migraines with aura or focal neurologic symptoms 1
• Thromboembolism or thrombophilia 1
• Complications of diabetes 1

Initiation Protocol

Start OCPs on the same day as the visit ("quick start") in healthy, non-pregnant individuals. 1, 2

• Use backup contraception for at least the first 7 days 1, 2
• If starting more than 5 days after menstrual bleeding began, backup contraception is necessary for 7 days 1

Prescribing Duration and Monitoring

Prescribe up to 1 year of OCPs at a time. 1

• Blood pressure should be assessed before initiating any OCP and monitored regularly during use 2, 5
• Blood pressure measurements can be obtained in nonclinical settings to facilitate ongoing monitoring 1

Safety Context

The baseline risk of venous thromboembolism increases from 1 per 10,000 woman-years to 3-4 per 10,000 woman-years during COC use 1, 2. This risk remains significantly lower than the 10-20 per 10,000 woman-years risk during pregnancy 1. OCCs containing 35 μg or more of ethinyl estradiol show statistically higher odds ratios for VTE than lower doses 1.