From the Guidelines
The safest oral contraceptive is generally considered to be the progestin-only pill (POP), also known as the "mini-pill," due to its lack of estrogen, which eliminates the risk of estrogen-related side effects and complications. This is particularly important for women who are at high risk of thrombosis, such as those with cyanosis, Fontan physiology, mechanical valves, prior thrombotic events, and PAH, as noted in the 2019 guideline for the management of adults with congenital heart disease 1. The progestin-only pill works primarily by thickening cervical mucus to prevent sperm from reaching an egg and thinning the uterine lining. Some key points to consider when using POPs include:
- Taking the pill at the same time every day, with a window of only 3 hours before efficacy may decrease
- If a pill is missed by more than 3 hours, taking it as soon as possible and using backup contraception for the next 48 hours
- Potential side effects, which are generally mild and may include irregular bleeding, headaches, breast tenderness, and nausea
- The importance of using condoms in addition to POPs if protection against sexually transmitted infections is needed. It's also worth noting that other forms of contraception, such as intrauterine devices and barrier methods, may be suitable alternatives for some women, as discussed in the 2013 U.S. selected practice recommendations for contraceptive use 1. However, for oral contraceptives specifically, the progestin-only pill is generally considered the safest option due to its low risk of estrogen-related complications.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Safest Oral Contraceptive Options
The safest oral contraceptive option is often a matter of debate, and the answer can vary depending on individual circumstances. However, based on available evidence, here are some key points to consider:
- Oral contraceptive pills are the most commonly used reversible method of contraception, with a pregnancy rate of 4% to 7% per year 2.
- Estrogen-containing methods, such as combined oral contraceptive pills, increase the risk of venous thrombosis, whereas progestin-only and nonhormonal methods are associated with rare serious risks 2.
- Low-dose oral contraceptives, such as those containing 20 micrograms of ethinyl estradiol, may be a safer option, with fewer side effects and comparable cycle control to higher-dose pills 3, 4.
- Extended-cycle oral contraceptives, which provide a low-dose, combined active pill containing levonorgestrel and ethinyl estradiol, may also be a safe and effective option, with a similar efficacy and adverse effect profile to other extended-regimen OCs 4.
Factors to Consider
When choosing an oral contraceptive, several factors should be considered, including:
- The patient's tolerance for risk of pregnancy, menstrual bleeding changes, and other risks 2.
- The patient's personal values and preferences, including the desire for a low-dose or extended-cycle regimen 2, 5.
- The potential benefits of hormonal contraceptives, such as improved medical conditions associated with hormonal changes related to the menstrual cycle, such as acne, endometriosis, and premenstrual dysphoric disorder 2.
Specific Oral Contraceptives
Some specific oral contraceptives that may be considered safe and effective include:
- Those containing levonorgestrel or norethisterone in combination with ethinyloestradiol 35 microgram or less, which are considered first-line options 5.
- Those containing drospirenone, a unique progestin that provides a new contraceptive option with safety equivalent to that of other oral contraceptive formulations 6.