What oral contraceptive pill is recommended for a woman who cannot tolerate Yaz (ethinyl estradiol/drospirenone) and Sronyx (combined oral contraceptive)?

Recommended Oral Contraceptive After Yaz and Sronyx Intolerance

Switch to a monophasic combined oral contraceptive containing 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate, as these second-generation progestin formulations offer the safest thrombotic profile and are recommended as first-line options by the American Academy of Pediatrics. 1

Why This Specific Recommendation

Understanding What Wasn't Tolerated

Since Yaz contains drospirenone (a fourth-generation progestin) with 20 μg ethinyl estradiol in a 24/4 regimen, and Sronyx is a levonorgestrel-containing pill, the intolerance pattern suggests:

• If bleeding irregularities were the issue with Yaz: The 20 μg ethinyl estradiol dose shows more follicular activity when pills are missed and requires stricter adherence, with seven consecutive days of pill-taking necessary to reliably prevent ovulation 2
• Moving to 30-35 μg ethinyl estradiol provides better cycle control and more forgiving adherence requirements (backup needed only if started >5 days after menses vs. >1 day for drospirenone formulations) 2

The Optimal Alternative: Norgestimate or Levonorgestrel with 30-35 μg EE

Norgestimate-based options (e.g., Ortho-Cyclen, Sprintec, MonoNessa):

• Second-generation progestin with established safety profile 1
• Demonstrates safer coagulation profile compared to newer progestins 1
• FDA-approved for acne treatment, providing non-contraceptive benefits 1
• Among low-dose pills, no clear data suggests one formulation is superior to another for most users 1

Levonorgestrel-based options (e.g., Levora, Nordette, Portia):

• Second-generation progestin with the safest thrombotic risk profile 1
• Lower VTE risk compared to third and fourth-generation progestins 1
• Well-established efficacy and safety data 1

Dosing and Initiation Protocol

• Start with 30-35 μg ethinyl estradiol rather than lower doses, as COCs containing 35 μg or more show statistically higher VTE odds ratios, but 30-35 μg balances efficacy with safety 1
• Use "quick start" method: Can initiate same day as visit in healthy, non-pregnant individuals 1
• Backup contraception: Use barrier methods for 7 days if starting >5 days after menses began 2
• Prescribe up to 1 year supply at a time per CDC recommendations 1

Critical Safety Monitoring

• Blood pressure measurement required before initiation 2
• Regular BP monitoring is the primary safety requirement for long-term use 1
• Counsel on expected bleeding patterns: Irregular bleeding during first 3-6 months is common, benign, and typically improves with continued therapy 1

Common Pitfalls to Avoid

• Don't immediately switch to ultra-low-dose formulations (10-20 μg EE): These require stricter adherence and show more follicular activity when missed 2, which may perpetuate intolerance issues
• Avoid third and fourth-generation progestins initially: Desogestrel, drospirenone, and dienogest carry higher thrombotic risk compared to levonorgestrel 1
• Don't interpret early breakthrough bleeding as treatment failure: Unscheduled spotting in the first 3-6 months should not prompt immediate switching 1
• Consider a short course of NSAIDs (5-7 days) if persistent unscheduled bleeding occurs rather than immediately discontinuing 1

Alternative Considerations

If hypertension or blood pressure concerns exist:

• Drospirenone-containing formulations (15-30 μg EE + 3 mg drospirenone) lower systolic BP by 1-4 mm Hg after 6 months due to anti-mineralocorticoid activity 1
• However, given prior Yaz intolerance, this may not be appropriate unless BP elevation was specifically the issue

If the patient ultimately cannot tolerate any combined hormonal contraceptive:

• Consider progestin-only pills (norethindrone or norgestrel POP) 2
• Consider long-acting reversible contraception (LNG-IUD or implant) 2

Contraindications to Verify Before Prescribing

Ensure the patient does NOT have 2, 1:

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