What is the recommended contraception for a 36-year-old female with no known medical contraindications, specifically considering levonorgestrel-containing Combined Oral Contraceptives (COCs)?

Levonorgestrel-Containing Combined Oral Contraceptives for a 36-Year-Old Woman

For a healthy 36-year-old woman with no medical contraindications, a monophasic combined oral contraceptive containing 30-35 μg ethinyl estradiol with levonorgestrel is an excellent first-line contraceptive choice. 1

Recommended Formulation

• Start with a low-dose monophasic COC containing 30-35 μg ethinyl estradiol combined with levonorgestrel, as this represents the most commonly recommended formulation by adolescent medicine experts and has extensive safety data 1, 2

• Levonorgestrel is a second-generation progestin with well-established safety profiles and lower androgenic effects compared to older formulations 2, 3

• Any low-dose pill (≤35 μg ethinyl estradiol) is Category 1 (no restrictions) for women at this age according to CDC guidelines 2

Initiation Protocol

• Perform only a blood pressure measurement before initiation—no gynecologic examination is required 1, 2

• Use "quick start" same-day initiation without waiting for menses 1, 2

• If started >5 days after menses began, use backup contraception (condoms or abstinence) for 7 days 1, 2

• Prescribe up to 1 year of COCs at initial visit 1

• Schedule a follow-up visit 1-3 months after initiation to address adverse effects or adherence issues 1

Critical Safety Considerations at Age 36

Smoking status is the most important factor to assess at this age. 1

• If she smokes, COCs become increasingly risky as she approaches age 35 and are contraindicated at age >35 1, 4

• The FDA black box warning specifically states that COCs are contraindicated in women over 35 years of age who smoke due to increased cardiovascular risk 4

• If she is a non-smoker, COCs remain safe and appropriate 1

Absolute Contraindications to Screen For

Do not prescribe levonorgestrel-containing COCs if she has: 1

• Severe uncontrolled hypertension (systolic ≥160 mm Hg or diastolic ≥100 mm Hg)
• Ongoing hepatic dysfunction
• Complicated valvular heart disease
• Migraines with aura or focal neurologic symptoms
• History of thromboembolism or thrombophilia
• Complications of diabetes (nephropathy, retinopathy, neuropathy, or vascular disease)
• Complicated solid organ transplantation

Venous Thromboembolism Risk Counseling

• Baseline VTE risk increases from 1-5 per 10,000 woman-years to 3-4 per 10,000 woman-years with COC use 1, 2

• This is substantially lower than pregnancy-related VTE risk of 10-20 per 10,000 woman-years, of which 1-2% are fatal 1, 2

• COC use has not been shown to increase breast cancer risk 1

Non-Contraceptive Benefits

Counsel her about significant health benefits beyond contraception: 1, 2

• Decreased menstrual cramping and blood loss
• Improvement in acne
• Significant protection against endometrial and ovarian cancers with use >3 years 1, 2
• Extended or continuous cycles can be offered for severe dysmenorrhea, anemia, or menstrual-related symptoms 1, 2

Adherence Counseling

Provide clear instructions for missed pills to maximize effectiveness: 1

• If one pill is late (<24 hours): Take it as soon as remembered and continue as usual
• If one pill is missed (24-48 hours): Take the most recent missed pill immediately, continue remaining pills at usual time, use backup contraception for 7 days 1
• If two or more pills are missed (>48 hours): Take the most recent missed pill, discard others, use backup contraception for 7 days 1
• If pills were missed in the last week of hormonal pills (days 15-21), skip the hormone-free interval and start a new pack immediately 1
• Emergency contraception should be considered if pills were missed during the first week and unprotected intercourse occurred in the previous 5 days 1

Drug Interactions to Screen For

The following medications reduce COC effectiveness: 1, 2

• Rifampin or rifabutin
• Certain anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine)
• St. John's wort

Reassure her that broad-spectrum antibiotics, antifungals, and antiparasitics do NOT reduce COC effectiveness 1, 2

Common Adverse Effects Management

Counsel about transient adverse effects that typically improve over time: 1

• Irregular bleeding, headache, and nausea are common initially
• Breakthrough bleeding does not indicate medical problems and typically resolves 2
• Weight gain is not consistently associated with COC use in most formulations 2

Efficacy

• Typical-use failure rate is 9% in adults 1, 2
• Perfect-use failure rate approaches 0.3% 2
• COCs are completely reversible with no negative effect on long-term fertility 1, 2