7.3.1 Combined hormonal oral contraceptives

Monophasic standard-strength combined oral contraceptives

ChoiceDrugDosage
1st choiceRigevidon® (ethinylestradiol 30micrograms, levonorgestrel 150micrograms) (21 day preparation)Dose: 1 daily for 21 days; subsequent courses repeated after a 7 day pill-free interval
2nd choiceCilique® (ethinylestradiol 35micrograms, norgestimate 250micrograms)Dose: 1 daily for 21 days; subsequent courses repeated after a 7 day pill-free interval
Or
Gedarel® 30/50 (ethinylestradiol 30micrograms,desogestrel 150microgramsDose:
1 daily for 21 days; subsequent courses repeated after a 7 day pill-free interval
Or
Millinette® 30/75 (ethinylestradiol 30micrograms, gestodene 75micrograms) (21day preparationDose:
1 daily for 21 days; subsequent courses repeated after a 7 day pill-free interval

Monophasic low-strength combined oral contraceptives

ChoiceDrugDosage
1st choiceGedarel® 20/150 (ethinylestradiol 20micrograms, desogestrel 150micrograms) (21 day preparation)Dose:
1 daily for 21 days; subsequent courses repeated after a 7 day pill-free interval
OR
Millinette® 20/75 (ethinylestradiol 20micrograms, gestodene 75micrograms) (21 day preparation)Dose:
1 daily for 21 days; subsequent courses repeated after a 7 day pill-free interval

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 link below for further details and useful tools, e.g. prescribing checklist and information for women. 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. Lucette® (not for peanut or soya hypersensitivity), Dretine® , Yacella® or Yiznell.®
  • 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

  • Women with acne often benefit from the oestrogen component of combined hormonal contraception. If acne is a particular problem, choose a pill containing a less androgenic progestogen (e.g. desogestrel (Gedarel® 30/150) or consider co-cyprindiol 2000/35.
  • Co–cyprindiol 2000/35 (composed of cyproterone acetate 2mg and ethinylestradiol 35micrograms) is a treatment for severe acne that has not responded to oral antibiotics or for moderately severe hirsutism. Only in those patients may it also be used as an oral contraceptive (see section 13.6.2). Most acne improves with any COC.
  • Women taking co-cyprindiol for acne require at least 3 months of treatment to relieve symptoms, and prolonged treatment might be needed. The need to continue treatment should be evaluated periodically by the treating physician. The risk of venous thromboembolism is rare, but healthcare professionals and patients should remain vigilant for signs and symptoms of this important side effect. See MHRA for further information.
  • In women with severe hyperandrogenism, symptoms usually recur when treatment with co-cyprindiol is stopped. In these women treatment may be continued until the symptoms are judged unlikely to recur. The decision of when to stop should be judged on a case by case basis.

Missed pill rules for COCs

Caution

While evidence suggests that combined oral contraceptives (COCs) have a higher risk of venous thromboembolism (VTE), the absolute risk of VTE is small. The incidence of VTE in healthy, non-pregnant women who are not taking an oral contraceptive is about 5–10 cases per 100,000 women per year. For those using combined oral contraceptives containing second-generation progestogens this incidence is about 20 per 100,000 women per year of use. Some studies have reported a greater risk of VTE in women using combined oral contraceptives containing the third-generation progestogens desogestrel and gestodene; the incidence in these women is about 40 per 100 000 women per year of use. Any increase in risk is greatest in the first year of use. However the absolute risk is considerably smaller than that associated with pregnancy. Provided that this is made clear to the user, there is no restriction on prescription of these pills. See MHRA.