What combined oral contraceptives (COCs) with 30-35 micrograms of Ethinyl Estradiol (EE) or less, combined with levonorgestrel or norgestimate, are recommended for a healthy adolescent female with dysmenorrhea?

Combined Oral Contraceptives with 30-35 mcg Ethinyl Estradiol and Levonorgestrel or Norgestimate

For a healthy adolescent with dysmenorrhea, prescribe a monophasic combined oral contraceptive containing 30-35 mcg ethinyl estradiol with either levonorgestrel or norgestimate, as these formulations are specifically recommended by the American Academy of Pediatrics as first-line treatment. 1

Specific Formulation Options

Norgestimate-Based COCs

• Norgestimate 0.25 mg + Ethinyl Estradiol 0.035 mg (35 mcg) is an FDA-approved formulation available as monophasic tablets 2
• This formulation contains the exact dose range recommended by guidelines for adolescents with dysmenorrhea 1
• Norgestimate is a third-generation progestin that is FDA-approved for contraception in post-pubertal adolescents 2

Levonorgestrel-Based COCs

• Levonorgestrel 0.15 mg + Ethinyl Estradiol 0.030 mg (30 mcg) is a widely available second-generation formulation 3, 4
• Levonorgestrel formulations with 30-35 mcg ethinyl estradiol are specifically recommended as first-line options 1, 3
• Second-generation progestins like levonorgestrel demonstrate a safer coagulation profile compared to newer progestins 1

Why These Specific Formulations

Evidence for Dysmenorrhea Treatment

• Low-dose COCs containing 30-35 mcg ethinyl estradiol with levonorgestrel or norgestimate effectively reduce menstrual cramping and blood loss 1
• Combined oral contraceptives show significant benefit for pain relief compared to placebo (OR 2.01,95% CI 1.32-3.08) 5
• These formulations also protect against iron-deficiency anemia through reduced menstrual blood loss 1

Safety Profile Considerations

• COCs containing 35 mcg or less ethinyl estradiol have lower thrombotic risk than higher-dose formulations 1
• Second-generation progestins (levonorgestrel) have the safest thrombotic risk profile among all progestin generations 1
• The venous thromboembolism risk increases from 1 per 10,000 to 3-4 per 10,000 woman-years with COC use, which remains significantly lower than the 10-20 per 10,000 risk during pregnancy 1, 6

Prescribing Algorithm

Initial Selection

• Start with levonorgestrel 0.15 mg + ethinyl estradiol 0.030 mg as the first choice due to its second-generation progestin safety profile 1, 3
• If this formulation is not available or not covered by insurance, norgestimate 0.25 mg + ethinyl estradiol 0.035 mg is an appropriate alternative 1, 2
• Among low-dose pills, there are no clear data suggesting one formulation is superior to another for most users, so the lowest copay option on the patient's insurance formulary is often appropriate 1

Initiation Protocol

• Start the COC on the same day as the visit using "quick start" method in healthy, non-pregnant adolescents 1, 6
• Use backup contraception for the first 7 days for contraceptive efficacy 1, 6
• Prescribe up to 1 year of COCs at a time, as recommended by the CDC 6

Contraindications to Screen For

Do not prescribe COCs if the patient has: 1, 6

• Severe uncontrolled hypertension (≥160/100 mm Hg)
• Migraines with aura or focal neurologic symptoms
• Current or history of thromboembolism or thrombophilia
• Complicated valvular heart disease
• Ongoing hepatic dysfunction

Adherence Strategies

• Recommend cell phone alarms for daily pill reminders 1
• Involve family members or partners to support adherence 1
• Emphasize that strict adherence is necessary, as seven consecutive days of pill-taking is required to reliably prevent ovulation 1

Common Pitfalls to Avoid

• Do not prescribe formulations with more than 35 mcg ethinyl estradiol, as they have higher thrombotic risk without additional benefit 1
• Do not avoid COCs in adolescent smokers under age 35, as smoking is not a contraindication in this age group 6
• Do not prescribe third or fourth-generation progestins (desogestrel, drospirenone) as first-line, as they have higher thrombotic risk than levonorgestrel 1