OCP!

ORAL CONTRACEPTIVE PILLS (OCPs)

OCPs include combined oral contraception (COC) and the progestin-only pill (POP).

  • Efficacy: 91% effective with typical use.

Start OCP at any time. No backup contraception is needed if OCP is initiated within 5 days of menses onset; otherwise, provide backup contraception for 7 days for COC and 5 days for POP. 

Non-contraceptive benefits:

  • Reduction in cancer risk: ovarian, endometrial, colorectal
  • Improve dysmenorrhea and irregular menses
  • Decrease risk of PID and ectopic pregnancy
  • Improve acne for most users
  • Treat androgen excess in women with PCOS
  • Maintain bone density in anovulatory women

Adverse drug effects (ADE):

  • Estrogen-related: nausea, breast tenderness, headache, bloating, melasma, increased BP, spotting, breakthrough bleeding
  • Progestin-related: breast tenderness, headache, fatigue, mood changes, breakthrough bleeding
  • Androgen-related: weight gain, acne, hirsutism, increased LDL, decreased HDL
    • less of an issue with 3rd/4th-generation progestins (see below)

Check out the CDC’s US Medical Eligibility Criteria (MEC) app for more information!

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COMBINED ORAL CONTRACEPTION (COC)

Most popular form of contraception overall.

Contraindications: thromboembolic disorder, migraine with aura, HTN, tobacco use over age 35yo, breast cancer history, etc

  • Risk of MI increases 12 fold for women with even well-controlled HTN
  • Check out the CDC’s MEC chart for a full list!

Multiple types:

  • Ethinyl estradiol (EE) in combination with different generations of progestin:
    • 1st generation: norethindrone, norenthindrone acetate, ethynodiol diacetate (Loestrin, Loestrin-Fe)
    • 2nd: levonorgestrel, norgestrel (Aviane, Levora)
    • 3rd: norgestimate, desogestrel (Orthocyclen, Sprintec, Desogen)
    • 4th: drospirenone (Yaz, Yasmin)
      • Note that drospirenone has anti-mineralocorticoid effects that can predispose to hyperkalemia
  • Extended-cycle COC
      • Seasonale and Seasonique are prescribed for 12 weeks for continuous use followed by one week of inactive pill
        • Advantages: fewer periods
        • Disadvantages: spotting, possible heavier periods

Key point: The dose of sex steroids in COCs has been reduced dramatically since they first became available, allowing for the same efficacy with fewer ADEs. COCs contain both estrogen and progestin, but are progestin-dominant. Regarding estrogen content, low-dose COCs containing 30 or 35 micrograms of estrogen are most common; ultra low-dose formulations containing only 20 micrograms of estrogen are also available, which in theory should be safer but several Cochrane reviews have failed to detect any significant differences; nevertheless, the reviews did not detect any inferiority in contraceptive efficacy but did find a higher rate of breakthrough bleeding on the ultra low-dose pills.

What if your patient misses a dose?

  • 1 dose late or missed: take missed pill ASAP, then take next pill at regular time
  • ≥2 missed doses: take the most recent missed pill and continue rest at usual time. Use backup contraception for 7 days or abstain from intercourse until having taken 7 consecutive hormonal pills. If in the last week of pack, skip placebo pills, start a new pack. And always consider the need for emergency contraception (but not ulipristal–residual hormone from hormonal contraception will interfere with its MOA)!

PROGESTIN-ONLY PILL (POP)

Efficacy: 87% effective with typical use, but must be taken at the same time everyday!

Contraindications: breast cancer history, hepatic tumors, cirrhosis, hepatitis, etc

Multiple types (see generations above): norethindrone (Camila, Errin, Nor-QD), drospirenone (Slynd)

What if your patient misses a dose?

  • Remember that POP must be taken at the same time everyday, thus a missed dose is any more than 3 hours from regular time. In this case, take the dose ASAP then continue at same time each day. Use backup contraception or abstain from intercourse for 2 days. And always consider the need for emergency contraception (but not ulipristal–residual hormone from hormonal contraception will interfere with its MOA)!

SUMMARY!

  • COC and POP are effective when taken correctly. No backup contraception is needed if started <5 days after menses onset.
  • Migraine with aura and tobacco use in patients ≥35yo are important contraindications to remember. Check the CDC’s MEC app before prescribing!
  • Start COC with low dose EE, generally <35 mcg
  • Use 3rd/4th-generation progestin for patients with acne or PCOS

*Blog post based on Med-Peds Forum talk by Sybil Cineas, MP Core Faculty