What is the best oral birth control option for managing heavy menses in patients with contraindications to estrogen, including prescribing information for combination oral contraceptives (COCs) and progestin-only pills (POPs)?

Oral Contraceptives for Heavy Menses: Contraindications and Best Options

First-Line Recommendation

For patients without contraindications to estrogen, start a low-dose monophasic combined oral contraceptive (COC) containing 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate; for patients with estrogen contraindications, use a progestin-only pill (POP), though efficacy for heavy menses is less established. 1

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Absolute Contraindications to Combined Oral Contraceptives

COCs should not be prescribed if the patient has any of the following: 1

• Severe uncontrolled hypertension (systolic ≥160 mmHg or diastolic ≥100 mmHg)
• Migraines with aura or focal neurologic symptoms
• Active or history of venous thromboembolism (VTE) or thrombophilia
• Complicated valvular heart disease
• Ongoing hepatic dysfunction
• Diabetes with complications (nephropathy, retinopathy, neuropathy, or vascular disease)
• Complicated solid organ transplantation
• Current or history of breast cancer
• Age >35 years AND current smoking (≥15 cigarettes/day) 1

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Best Oral Contraceptive Options for Heavy Menses

For Patients Eligible for Estrogen (No Contraindications):

Preferred Initial Choice: 1

• Monophasic COC with 30-35 μg ethinyl estradiol combined with:
  • Levonorgestrel OR
  • Norgestimate
• These formulations reduce menstrual blood loss by 50-60% and improve treatment success from 3% (placebo) to 12-77% 2

Extended or Continuous Cycle Regimens are particularly beneficial for heavy menses: 1

• 24/4 regimen (24 active pills, 4 placebo days)
• 84/7 regimen (84 active pills, 7 placebo days)
• Continuous dosing (no placebo interval)
• These regimens are especially appropriate for patients with anemia, severe dysmenorrhea, endometriosis, or bleeding disorders 1
• Extended cycles optimize ovarian suppression and minimize hormone-free intervals that can trigger breakthrough bleeding 1

Mechanism of Benefit: 1, 2

• COCs reduce menstrual blood loss by decidualizing and thinning the endometrium
• Suppress ovulation via inhibition of LH and FSH mid-cycle surge
• Induce regular, predictable shedding of thinner endometrial lining

For Patients with Estrogen Contraindications:

Progestin-Only Pills (POPs): 1, 3

• Work primarily by thickening cervical mucus, not by inhibiting ovulation
• Desogestrel-containing POP shows contraceptive effectiveness similar to COCs 3
• Important caveat: Evidence for POPs specifically treating heavy menses is limited; they are primarily used when estrogen is contraindicated 1
• Adherence is critical: Must be taken at the same time daily (within 3-hour window) due to shorter half-life 1
• Most common side effect is irregular bleeding patterns 3

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Prescribing Information

Combined Oral Contraceptives:

Initiation: 1

• Can start any time if reasonably certain patient is not pregnant
• If started within first 5 days of menstrual bleeding: no backup contraception needed
• If started >5 days after bleeding started: use backup contraception (condoms or abstinence) for 7 days

Dosing: 1

• Standard: 21-24 active hormone pills followed by 4-7 placebo pills
• Extended cycle: 84 active pills followed by 7 placebo pills
• Continuous: Active pills daily without placebo interval

Missed Pill Management: 1

• One pill missed (<48 hours late): Take missed pill immediately, continue as usual
• Two or more pills missed (≥48 hours): Take most recent missed pill, discard others, use backup contraception for 7 days
• If pills missed in last week of active pills: Skip placebo week and start new pack immediately

Follow-up: 1

• Routine visit at 1-3 months after initiation to address side effects and adherence
• Can prescribe up to 1 year supply at initial visit 1

Progestin-Only Pills:

Initiation: 1

• Same timing guidelines as COCs
• Backup contraception for first 7 days if not started within first 5 days of menses

Dosing: 1, 3

• Must be taken at the same time every day (no placebo pills)
• Strict adherence required due to mechanism of action

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Important Safety Considerations

Venous Thromboembolism Risk: 1

• Baseline VTE risk in adolescents/young women: 1 per 10,000 woman-years
• COC use increases risk 3-4 fold to 3-4 per 10,000 woman-years
• For comparison: Pregnancy-associated VTE risk is 10-20 per 10,000 woman-years (1-2% fatal) 1
• Drospirenone-containing COCs may have slightly higher VTE risk (10 per 10,000 woman-years) 1

Blood Pressure Monitoring: 4

• Assess blood pressure before initiating COCs
• COCs should not be used in patients with severe uncontrolled hypertension 1

Common Side Effects: 1, 2

• Irregular bleeding (especially in first 3 months)
• Nausea
• Breast tenderness
• Headache
• These typically improve after 3 months of use

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Alternative Consideration

If oral contraceptives fail or are unacceptable: 2

• The levonorgestrel-releasing intrauterine system (LNG-IUS) is more effective than COCs for reducing menstrual blood loss (OR 0.21,95% CI 0.09-0.48) 2
• However, this requires a procedural visit and is not an oral option

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Clinical Pearls

• Smoking is NOT a contraindication to COCs in women <35 years old 1
• No pelvic exam required before prescribing COCs 1
• Extended/continuous regimens reduce breakthrough bleeding over time and are ideal for heavy menses management 1, 5
• Counsel patients about expected bleeding patterns before initiation to improve adherence 1
• COCs provide long-term cancer protection: >3 years use significantly reduces endometrial and ovarian cancer risk 1