7.3.1 Combined hormonal oral contraceptives

Monophasic standard-strength combined oral contraceptives

Monophasic low-strength combined oral contraceptives

Prescribing Notes

• Contraceptive pills should not be prescribed generically.
• The doses in the table above refer to the licensed standard COC regimen. However the FSRH recommends women should be given information about both standard and tailored COC regimens to broaden contraceptive choice. Tailored (continuous or extended) regimens offer an acceptable alternative for many women as they can reduce the frequency of withdrawal bleeds and can reduce withdrawal symptoms associated with the hormone-free interval. Women should be advised that the use of tailored CHC regimens is outside the manufacturer’s license but is supported by the FRSH. For further information see FSRH
• The risk of blood clots with all low-dose COCs is small. COCs that contain levonorgestrel, norethisterone, or norgestimate have the lowest risk of venous thromboembolism.  See MHRA for further information.
• Millinette^® 30/75 and Gedarel^® 30/150 are third generation pills; since the progestogen is different, individual women may experience fewer, or different, side–effects.
• COCs containing ethinylestradiol 30micrograms / drospirenone 3mg e.g. Yasmin^® are not recommended as first choice contraceptives: they have similar contraceptive effectiveness to other COCs in routine use, no significant advantages in adverse event profile, and cost significantly more. If this combination is deemed necessary, prescribe a less costly brand e.g. Dretine^®  or Yacella^® 
• Triphasic and biphasic COCs have no real benefits and are more complicated to use.
• Millinette^® 20/75 (ethinylestradiol 20micrograms,   gestodene 75micrograms) and Gedarel^® 20/150 (ethinylestradiol 20micrograms, desogestrel 150micrograms) contain a lower dose of oestrogen and may be associated with a better side–effect profile in women complaining of oestrogenic symptoms such as nausea or breast enlargement/mastalgia.
• EVRA^® is a standard strength transdermal contraceptive containing norelgestromin and ethinylestradiol. EVRA^® patches should be restricted for use in women who are likely to comply poorly with COCs. Side effects, risks and benefits are likely to be the same as those for the COC pill. Evidence suggests that the transdermal route for COC may have an increased risk of VTE compared to standard oral COCs. This is in contrast to Hormone Replacement Therapy (HRT) preparations, where the risk of VTE is thought to be lower with the transdermal route.
• Women taking enzyme-inducing drugs such as carbamazepine: Consider an alternative method of contraception. If a COC is used, a high dose COC containing at least 50micrograms of oestrogen such as Norinyl-1^® (mestranol 50micrograms, norethisterone 1mg) will be required. An alternative approach [but unlicensed] is to provide two tablets of Rigevidon^® (levonorgestrel 150 micrograms, ethinylestradiol 30micrograms). A tricycling regimen (i.e. taking three pill packets together without a break) and shortening the pill free interval to four days has also been advised [unlicensed]. For women taking rifampicin or rifabutin, an alternative method of contraception should be sought.
• Women aged up to 50 years can be advised that no contraceptive method is contraindicated by age alone and that combined hormonal contraception can be used unless there are co-existing diseases or risk factors. It is recommended that COCs are not continued beyond 50 years of age since more suitable alternatives exist.
• Women prescribed COCs should be reviewed annually. This is an opportunity to assess any changes to medical, family and sexual health history together with checking blood pressure and weight.
• Latest recommendations are that no additional contraceptive precautions are required when combined oral contraceptives are used with antibacterials that do not induce liver enzymes, unless diarrhoea or vomiting occurs. Antibacterials that induce liver enzymes include rifampicin and rifabutin – see BNF for further details.

Acne

• Oral contraceptives are not first line for acne treatment, see section 13.6.
• If a person receiving treatment for acne wishes to use hormonal contraception, consider using the combined oral contraceptive pill (COC) in preference to the progestogen-only pill. Consider a COC containing a less androgenic progestogen such as desogestrel (e.g. Gedarel^® 30/150).
• In women with PCOS refer to 7.1.7.
• COCs (if not contraindicated) in combination with topical agents can be considered as an alternative to systemic antibiotics in women.
• Co-cyprindiol (Dianette®) or other ethinylestradiol/cyproterone acetate-containing products may be considered in moderate to severe acne where other treatments have failed but require careful discussion of the risks and benefits with the patient. Use should be discontinued 3 months after acne has been controlled and prescription guided by the UK Medical Eligibility Criteria for Contraceptive Use and the Summary of Product Characteristics for the individual product.

Missed pill rules for COCs

• Refer to FSRH guide on missed pills.

Caution

• While evidence suggests that combined oral contraceptives (COCs) have a higher risk of venous thromboembolism (VTE), the absolute risk of VTE is small. There is good evidence that the risk of venous thromboembolism (VTE) may vary between products, depending on the progestogen – CHCs that contain levonorgestrel, norethisterone, or norgestimate have the lowest risk of VTE – the benefits of any CHC far outweigh the risk of serious side effects – prescribers and women should be aware of the major risk factors for thromboembolism, and of the key signs and symptoms. See MHRA.