Choosing the right oral contraceptive

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Choosing which oral contraceptive to prescribe to a patient should be carefully considered, with multiple factors determining safety and efficacy, according to data presented at the 44th National Conference on Pediatric Health Care on March 17, 2023.

The menstrual cycle is divided into the follicular phase, dominated by estrogen, and the luteal phase, dominated by progesterone. Hormonal contraceptives steadily bring hormones into the body. Types of contraception include implants, injections, patches, hormonal vaginal contraceptive rings, levonorgestrel intrauterine systems, and oral contraception.

Combined oral contraceptives contain estrogen and progestin, with a 7% typical use failure rate. Ethinyl estradiol is used in these contraceptives, with dosage varying based on the patient. Monophasic pills are often preferred to multiphasic pills.

A progestin only pill, also known as a mini pill or POP, has the same failure rate as combined oral contraceptives. Progesterone is based on androgenicity, and doses will differ between patients. Adverse events include hirsutism, anxiety, acne, and weight gain.

POPs are best used in women who want to take an oral pill but have a contraindication for estrogen. Lower efficacy has been reported compared to combined estrogen-progestin pills.

POPs block sperm migration by thickening the cervical mucus. The egg’s movement through the fallopian tubes is slowed, the endometrium thins, and ovulation is suppressed. Adverse events include mood changes and unscheduled bleeding, but weight gain is not associated.

Timing is vital for POPs, and a missed dose is defined as 3 or more hours after schedule. A pill should be taken as soon as possible, with pills taken at the same time daily. If pills have not been taken properly at least 2 days in a row, back-up or abstinence should be applied.

In cases of vomiting or severe diarrhea within 3 hours of taking the pill, another should be taken as soon as possible. Back-up or abstinence should be applied until the condition has been resolved for 2 or more days.

Combined oral contraceptives may lead to abdominal pain, chest pain, headaches, eye symptoms, severe leg pain, breast tenderness, nausea, bloating, and unscheduled bleeding. There is no evidence linking weight gain to combined oral contraceptives.

Contraindications include hypertension, migraine with aura, current breast cancer, venous thromboembolism, hepatocellular adenoma, malignant hepatoma, known ischemic heart disease, complicated valvular heart disease, and stroke.

In cases of excessive uterine bleeding, patients should prioritize stabilizing endometrium and stopping the bleeding. Providers can recommend continuous cycling to reduce yearly withdrawal bleeding.

A late dosage of combined oral contraceptives is under 24 hours since taking the previous pill, while a missed dose is over 48 hours since taking the previous pill. In this instance, backup methods should be considered.

Before prescribing a contraceptive, a medical history and physical examination should occur, evaluating patients for smoking, HTN, diabetes, venous/arterial thromboembolism, migraine with aura, breast cancer, and postpartum status. Breast and pelvic exams are not required.

Routine follow-up visits are not necessary after prescribing oral contraceptives. Patient satisfaction and concerns should be assessed at other routine visits, along with changes in health status. Blood pressure should be evaluated for combined oral contraceptive uses.

Reference

Gallagher M. Pick a pill! oral contraceptive pill prescribing for beginners. Presented at: 44th National Conference on Pediatric Health Care. March 15-19, Orlando, Florida.