Choosing the Right Oral

C o n t r a c e p t i v e P i l l fo r
Tee ns
Anne Powell, MD

KEYWORDS
 Oral contraceptive pill (OCP)  Combined oral contraceptive (COC)
 Progestin-only contraceptive (POP)  Venous thromboembolism (VTE)
 US medical eligibility criteria (US MEC)

KEY POINTS
 Oral contraceptive pills provide effective and safe contraception for adolescents when
taken correctly.
 Oral contraceptive pills include 2 broad categories: progestin-only pills (POPs) and com-
bined oral contraceptives (COCs).
 COCs lead to an increased risk of venous thromboembolism (VTE), so clinicians should
perform a thorough assessment of any contraindications to estrogen before prescribing.
 COCs provide many noncontraceptive health benefits, including treatment of dysmenor-
rhea, excessive uterine bleeding, acne, and polycystic ovary syndrome.

INTRODUCTION

In 1960, the first oral contraceptive pill (OCP), Enovid, was approved by the US Food
and Drug Administration.1 Since that time, OCPs available to US women have
changed dramatically, with decreased hormone concentrations and increased variety
in formulations. As detailed in other articles in this publication, the American Academy
of Pediatrics and American College of Obstetricians and Gynecologists advocate that
long-acting reversible contraceptives (LARCs) be recommended as first-line contra-
ceptive options for sexually active adolescents2 (See Suzanne Allen and Erin Barlow’s
article, “LARC Methods,” in this issue). Although trends are shifting in terms of
increasing LARC use, OCPs continue to be the most common form of prescription
contraception accessed by US adolescents.3

Disclosure: The author has no financial or commercial relationships or interests to disclose.

There were no funding sources for this article.
Division of Adolescent Medicine, University of Massachusetts Medical School, 55 Lake Avenue
North, Worcester, MA 01655, USA
E-mail address: [email protected]

Pediatr Clin N Am 64 (2017) 343–358

http://dx.doi.org/10.1016/j.pcl.2016.11.005 pediatric.theclinics.com
0031-3955/17/ª 2017 Elsevier Inc. All rights reserved.
344 Powell

TYPES OF ORAL CONTRACEPTIVE PILLS, MECHANISM OF ACTION, AND EFFICACY

There are 2 broad categories of OCPs: progestin-only pills (POPs) and combined oral
contraceptives (COCs). POPs function primarily through thickening the cervical
mucus and thereby preventing sperm penetration. In addition, POPs inhibit ovulation
to variable degrees, reduce cilia activity in the fallopian tubes, and alter the endome-
trium.1 COCs, which contain both estrogen and progesterone, function primarily
though inhibiting ovulation via feedback in the hypothalamic-pituitary-ovarian axis
and thickening cervical mucus. When discussing efficacy of OCPs, it is crucial to
distinguish perfect use from typical use. There is a significant discrepancy between
these rates due to challenges with patient adherence to daily dosing. With perfect
use, oral contraceptives have a 0.3% failure rate in the first year of use4; however,
with typical use, oral contraceptives have a failure rate of 8% in the first year of
use.4 Although OCPs offer excellent pregnancy protection with proper use, they
do not offer protection from sexually transmitted infections (STIs). As such, all pa-
tients using OCPs for contraception should also be counseled to use condoms
consistently for STI protection (See Zoon Wangu and Gale R. Burstein’s article,
“Adolescent Sexuality: Updates to the Sexually Transmitted Infection Guidelines,”
in this issue).
Both POPs and COCs require daily dosing; however, POPs require more exact
dosing to maintain contraceptive efficacy. For adolescents, daily dosing in general
can be problematic. When counseling an adolescent about OCPs for birth control, it
is important for clinicians to speak openly with patients about the challenges of daily
dosing and explore whether the adolescent feels that she is capable of adherence.
Many adolescents find using an alarm in their cell phones to be a useful tool in helping
them remember to take their pills. Because POPs require exact dosing in terms of the
hour taken each day, most clinicians try to avoid this method as a primary form of birth
control in adolescents. However, POPs may be the only option available for certain pa-
tients. With such patients, counseling must be very direct about the necessity of exact
dosing, as well as the strong recommendation for consistent condom use, as both STI
protection and back-up contraception.

ADDRESSING COMMON CULTURAL MYTHS ABOUT ORAL CONTRACEPTIVE PILLS

Many patients have preconceived notions about the efficacy, safety, and side
effects of OCPs. It is very useful to explore a patient’s current understanding and
knowledge of OCPs before prescribing so that common cultural “myths” can be
dispelled. A common myth is that taking OCPs will impair a patient’s future fertility.
Generally, OCPs do not adversely affect fertility. For most patients, menstrual cycles
return promptly to the same pattern that existed before starting OCPs.1 Some
women may experience some delay before menstrual cycles resume, but most
do not.
Some patients may be concerned because menstrual flow is lighter than usual than
what they experienced before starting OCPs. Some patients think that menstrual
blood is “backing up” in their bodies. It is helpful to educate such patients about
how OCPs prevent excessive build-up of the uterine lining, so infrequent menses, or
light menses, while on OCPs does not pose a health risk.
Many patients believe that OCPs lead to significant weight gain. For some patients,
this is a major reason to avoid OCPs, so it is important to address this concern in the
early stages of contraceptive counseling. Patients will be reassured to know that mul-
tiple double-blind studies have shown no association between low-dose COC use and
weight gain.5
 The Right Oral Contraceptive Pill for Teens 345

Patients may also hold the belief that birth control is “artificial” and unsafe, whereas
pregnancy represents a natural, safe condition. It can be useful to educate such pa-
tients that negative health issues associated with being pregnant and postpartum
are far more common than with OCPs.

DECIDING BETWEEN PROGESTIN-ONLY PILLS AND COMBINED ORAL CONTRACEPTIVES

COCs are generally favored over POPs as a form of contraception because of the
strict dosing schedule required by POPs. When deciding if an adolescent is an appro-
priate candidate for COCs, it is necessary to determine if the patient has a contraindi-
cation to estrogen-containing medications. The Centers for Disease Control and
Prevention (CDC) recently published updated guidelines regarding medical eligibility
for contraceptive use. This document, the US Medical Eligibility Criteria for Contracep-
tive Use (US MEC), is designed to assist clinicians to counsel patients about contra-
ceptive method choice4 and was adapted from global guidance provided by the
World Health Organization (WHO). The US MEC includes recommendations for using
specific contraceptive methods in patients with specific medical conditions and can
be accessed through the CDC Web site.
When assessing a patient’s safety profile regarding use of COCs, much of the
decision-making revolves around the increased risk of venous thromboembolism
(VTE) associated with estrogen. The relative risk of VTE in patients taking COCs is 3
to 5 times higher than in women who are not taking COCs.3 Certain patient character-
istics, such as smoking and obesity, also contribute to increased VTE risk. Although
the relative risk is increased, the absolute risk of VTE remains very low. Estimates
regarding the prevalence of nonfatal VTE in the general population are highly variable.
At baseline, a general estimate of a young, healthy woman’s risk of developing a VTE is
4 of 100,000 women per year.3 This risk increases to approximately 10 to 30 of
100,000 women per year when a patient is on a low-dose COC.3 However, when
explaining this increased risk to patients, it is important to remind them that the risk
of VTE when on a COC is still much lower than the risk of a VTE during pregnancy. Dur-
ing pregnancy, a woman’s risk of VTE increases to approximately 60 of 100,000
women per year.3
As detailed in the US MEC, the WHO classifies medical eligibility criteria for contra-
ception into 4 main categories, summarized in Table 1.4
When prescribing a COC, it is important to screen for common category 3 and 4
conditions that may pose contraindications to estrogen use. A clinician should inquire
about personal and family history of VTE, history of migraine with aura, and history of
hypertension. Patients who have underlying thrombophilias, such as Factor V Leiden
deficiency, are not appropriate candidates for COC therapy. Common category 3 and
4 conditions are summarized in Table 2. Please note that this list is not comprehen-
sive; the US MEC has a more thorough description of medical contraindications to
COC treatment.

Table 1
World Health Organization categories of medical eligibility criteria for contraceptive use

Category 1 Condition for which there is no medical restriction to use method

Category 2 Advantages of using contraceptive method generally outweigh the risks
Category 3 Theoretic or proven risks usually outweigh advantages of contraceptive
method
Category 4 Unacceptable health risk if contraceptive method used
346 Powell

Table 2
Common category 3 and 4 medical conditions from 2016 US medical eligibility criteria
recommendations for COC use

Category 3 conditions (use of method  Adequately controlled hypertension

generally not recommended)  Superficial venous thrombosis (acute or
history)
 History of deep venous thrombosis (DVT)
with low-risk recurrence DVT/pulmonary
embolism (PE)
 Use of certain anticonvulsants
 Antiretroviral (ARV) treatment with
Fosamprenavir (all other ARVs are cate-
gories 1 and 2)
Category 4 conditions (health risk associated  Known thrombogenic mutation
with using method is unacceptable)  Acute DVT
 History of DVT, higher risk of recurrent
DVT/PE
 Postpartum <21 d
 Migraine with aura
 Uncontrolled hypertension
 Lupus with positive or unknown antiphos-
pholipid antibody
 Major surgery with prolonged
immobilization
 Hepatocellular adenoma
 Personal history of stroke
 Complicated valvular heart disease

SMOKING AND COMBINED ORAL CONTRACEPTIVE USE

In adolescents, smoking does not represent an absolute contraindication to using

COCs. Smoking alone increases the risk of VTE and this effect is compounded by
COC use. Smoking itself causes 1.4 to 3.3 times risk increase in VTE.6 The combina-
tion of COC use and smoking compounds this risk further, leading to an 8.8 times risk
increase in VTE.6 In patients younger than 35, smoking is classified as a category 2
condition.4 In patients ages 35 or older, smoking becomes a category 3 or 4 condition
depending on the number of cigarettes smoked per day.4 Adolescent patients who
smoke should be counseled about the increased risk of VTE and smoking cessation
should be encouraged.

PRESCRIBING THE PROGESTIN-ONLY PILL

If a patient has a medical contraindication to estrogen or wishes to avoid estrogen for

personal reasons, there are several nonhormonal methods and progestin-only
methods available. As detailed in other articles of this issue, intrauterine devices are
available in nonhormonal and progestin-only forms. Also, Nexplanon and Depo-
Provera are highly effective contraceptive methods that contain progesterone only
(See article, “LARC Methods,” in this issue). Patients who have medical contraindica-
tions to estrogen should be counseled about these other contraceptive methods.
Alternatively, patients can be offered the POP.
Most clinicians try to avoid the use of the POP as a primary method of contraception
due to difficulties many patients have with the exact daily dosing that this medication
requires. POPs contain the active ingredient norethindrone at a concentration of
 The Right Oral Contraceptive Pill for Teens 347

0.35 mg. The POP pack contains 28 days of active hormonal pills. Many patients are
familiar with the traditional packaging of estrogen-containing COCs; most have 3
consecutive weeks of active hormonal pills followed by 7 days of placebo pills. Pa-
tients being prescribed a POP should be clearly counseled that these pills do not
have a placebo week and it is crucial that they take every pill in a pack to maintain con-
traceptive efficacy. Common side effects of POPs include intermittent amenorrhea
and irregular spotting. POPs also have several health benefits, including improved
dysmenorrhea and possible protection against endometrial cancer.1

QUICK START METHOD

The “traditional” way to initiate OCP use was to advise a patient to wait until her men-
strual period and then start the OCP. This method is problematic in that many adoles-
cents have irregular menses. Waiting for the onset of menses could result in significant
delay in starting the OCP and could lead to an undesired “window of opportunity” for
unintended pregnancy. Such reasoning supports the use of the “quick start method.”
The quick start method applies to all types of OCPs, both POPs and COCs.
With the quick start method, the patient starts the OCP medication as soon as it is
prescribed. In all sexually active patients, it is recommended to check a urine preg-
nancy test before giving an OCP prescription. If the pregnancy test is negative and
the patient’s last menstrual period (LMP) was within the past 5 days, the patient
may start the OCP on the day the script is provided. Back-up contraception is not
necessary in this situation, although condoms are always recommended for STI
protection.1
If the patient’s LMP was more than 5 days ago, urine pregnancy test negative, and she
has NOT had unprotected intercourse since LMP, the OCP can be started that day. In
this situation, patients require back-up contraception for the first week of OCP use.
If the patient’s LMP was more than 5 days ago and she has had unprotected inter-
course, then she should be counseled about the potential for an early pregnancy that
would not necessarily be reflected in a urine pregnancy test. Use of a POP or COC is
not associated with teratogenic effects or adverse pregnancy outcomes.1 Therefore,
even if pregnancy cannot be definitively excluded, patients can be given the option to
start an OCP and return for follow-up pregnancy testing within 2 to 3 weeks. If a patient
has had unprotected intercourse within the past 5 days, she should be offered emer-
gency contraception (EC) (See Ellen S. Rome and Veronica Issac’s article, “Emergency
Contraception,” in this issue). If she chooses, the patient should take EC as soon as
possible and then start the OCP that same day. The patient should be advised to use
back-up contraception for 1 week and should return for follow-up pregnancy testing in
2 weeks.
Some patients may not be comfortable starting a contraceptive method when preg-
nancy cannot be definitively excluded and do not choose EC. Such patients can be
provided with a script for the OCP and advised to use barrier contraception until their
next menses. Patients should be advised to start the OCP on the first day of menses or
the first Sunday following menses and should also be encouraged to return for preg-
nancy testing if menses is late.

PRESCRIBING COMBINED ORAL CONTRACEPTIVES

Just as with POPs, the quick start method is effective. COCs contain both estrogen
and progesterone and function primarily through inhibiting ovulation and thickening
cervical mucus. Benefits and risks associated with COCs and differences among
COC formulations are discussed in the following sections.
348 Powell

NONCONTRACEPTIVE HEALTH BENEFITS OF COMBINED ORAL CONTRACEPTIVES

In addition to providing birth control, COCs offer several other health benefits noted in
Table 3. COCs can provide menstrual regulation, decreased menstrual flow, and
improved dysmenorrhea. Many patients opt to use COCs for treatment of irregular,
heavy, or painful menses (See Sheryl A. Ryan’s article, “The Treatment of
Dysmenorrhea and Excessive Uterine Bleeding,” in this issue). COCs can help prevent
and treat iron-deficiency anemia associated with menorrhagia. Long-term (>5 years)
COC use offers some protective effects against endometrial and ovarian cancer.7
COC use can prevent ovarian cyst formation due to inhibition of ovulation. Certain for-
mulations improve acne and hirsutism, which are discussed later.

SIDE EFFECTS AND MEDICAL RISKS ASSOCIATED WITH COMBINED ORAL

CONTRACEPTIVES

One of the most common side effects associated with COC use is irregular, break-
through menstrual bleeding. Breakthrough bleeding (BTB) typically resolves within
the first 3 cycles of COC use and patients should be counseled proactively about
this possible side effect. Management of persistent BTB is discussed later. Some pa-
tients may experience nausea after taking COCs. For such patients, taking the COC
with food or in the evening can be helpful.
Among the greatest concerns related to COC therapy is increased incidence of VTE.
Risk of VTE is most prominent during the first year of use, particularly during the first
3 months of use.3 Depending on the age and medical profile of the patient, other
serious, but uncommon risks include myocardial infarction, stroke, hypertension,
and benign liver tumors.1 These side effects and medical risks are summarized in
Table 4.
When initiating COC therapy, it is crucial to counsel patients about the increased
VTE risk and educate them about concerning symptoms. The ACHES mnemonic
may help patients remember symptoms related to VTE complications:
A bdominal pain
C hest pain
H eadaches
E ye symptoms (such as vision changes)
S evere leg pain

Table 3
Noncontraceptive health benefits of combined oral contraceptives (COCs)

Menstrual-related  Improved dysmenorrhea

 Decreased menstrual blood flow
 Regulation of menstrual cycle
 Reduction in premenstrual syndrome symptoms (PMS)
 Reduction in premenstrual dysphoric disorder (PMDD) symptoms
Hematologic  Decreased iron-deficiency anemia
Cancer prevention  Decreased risk of endometrial cancer
 Decreased risk of ovarian cancer
Dermatologic  Improved acne (with certain COC formulations)
 Improved hirsutism (with certain COC formulations)
Ovarian  Prevention of ovarian cysts
 Relief of Mittelschmerz (ovulatory pain)
 The Right Oral Contraceptive Pill for Teens 349

Table 4
Side effects and medical risks associated with combined oral contraceptive use

Common side effects  Breakthrough bleeding

 Intermittent amenorrhea
 Nausea
 Breast tenderness
 Headaches
Serious medical risks  Venous thromboembolism
 Pulmonary embolus
 Myocardial infarction
 Stroke
 Hypertension
 Gallbladder disease
 Cholestatic jaundice
 Benign liver tumors
 Melasma/chloasma (increased melanocyte activity, patchy facial
discoloration)
 Slight increase in risk of cervical dysplasia and cervical carcinoma

OBESITY AND COMBINED ORAL CONTRACEPTIVES

There has been increasing concern about the safety and efficacy of COCs in obese
women. Women who are obese and taking estrogen are at even higher risk of VTE
than are women with normal body mass index (BMI) who are taking comparable doses
of estrogen. The US MEC classifies obesity as a category 2 condition for women of any
age. Obese patients being prescribed COCs should be counseled that achieving a
healthier BMI can help decrease their VTE risk.
Studies have been conflicting regarding whether or not COCs have slightly lower ef-
ficacy rates in obese women. Peak hormone concentrations achieved in obese women
taking COCs have been found to be less than in women with BMIs in the normal range.8
However, the potential differences in peak hormone levels have not been shown to affect
breakthrough ovulation.9 Several studies have suggested that obese women have
higher failure rates of COCs.10 Other studies have been reassuring that elevated BMI
does not compromise COC efficacy.11 The Society of Family Planning has concluded
that overweight and obese patients using COCs appear to be at similar or slightly higher
risk of pregnancy compared with women who have a normal-range BMI.12
Bariatric surgery is becoming more common in the adolescent population. History
of bariatric surgery, both restrictive and malabsorptive procedures, is considered to
be category 1 and does not pose a contraindication to COC use.13

BREAST CANCER RISK AND COMBINED ORAL CONTRACEPTIVES

The topic of whether the risk of breast cancer increases with COC use can be
confusing. This question has been reviewed in the medical literature extensively. In
a 2002 study published in the New England Journal of Medicine, current or former
oral contraceptive use was found NOT to be associated with increased risk of breast
cancer.14 Similarly, a large-scale prospective study published in Contraception in
2013 found no association between oral contraceptive use and overall breast cancer
risk.13 The Collaborative Group on Hormonal Factors in Breast Cancer synthesized
and reanalyzed the epidemiologic data on the relationship between COCs and breast
cancer on a worldwide, large-scale level.15 That group concluded that there is a small
increase in the risk of having breast cancer diagnosed while taking COCs and in the
350 Powell

10 years after COC discontinuation.15 Cancers diagnosed in this group tended to be

much less clinically advanced than in women not taking COCs.15 Results of the study
also found, however, that there is no significantly excess risk of having breast cancer
diagnosed in women more than 10 years after COC discontinuation.15 In general,
COCs are considered to be safe and effective in young women, even if there is a family
history of breast cancer.14

MEDICATION INTERACTIONS AND COMBINED ORAL CONTRACEPTIVES

It is important to review all medications that a patient is taking to screen for potential
medication interactions. A common misconception is that broad-spectrum antibiotics
compromise the efficacy of COCs. It is true that antibiotics can alter hepatic meta-
bolism and lead to decreased levels of circulating estrogen in patients taking COCs;
however, this decreased estrogen level is not clinically significant in that it does not
impair COC efficacy. The vast majority of antibiotics, antifungals, and antiparasitic
medications are classified as category 1 (no medical restriction to use method). Ex-
ceptions to this are rifampin and rifabutin, which are classified as category 3 (risks
generally outweigh benefits).
Certain anticonvulsants, some of which are also used as mood stabilizers, can
interact negatively with COCs and compromise COC efficacy. These include
phenytoin, barbiturates, carbamazepine, primidone, topiramate, and oxcarbazepine.4
Also, it is notable that pharmacokinetic studies show that levels of lamotrigine
decrease significantly with concurrent COC use.4 For a patient taking lamotrigine
(Lamictal) as a monotherapy for seizure disorders, COC use would not be recommen-
ded. Table 5 summarizes the US eligibility criteria for commonly used medications.4

DIFFERENCES AMONG COMBINED ORAL CONTRACEPTIVE FORMULATIONS

In the United States, COC formulations differ in the following ways: (1) estrogen con-
centration, (2) type and concentration of progesterone, (3) monophasic versus multi-
phasic formulations, and (4) ratio of inactive to active hormonal pills.

Table 5
Common medications and combined oral contraceptive use

Broad-spectrum antibiotics Category 1

Antifungal medications Category 1
Antiparasitic medications Category 1
Rifampin or rifabutin therapy Category 3
Certain anticonvulsants Category 3
 Phenytoin
 Barbiturates
 Carbamazepine
 Oxcarbazepine
 Primidone
 Topiramate
 Lamotrigine
St John’s Wart Category 2
Selective serotonin reuptake inhibitors Category 1
Antiretroviral therapy EXCEPT for fosamprenavir Categories 1 and 2
Antiretroviral Therapy with fosamprenavir Category 3
 The Right Oral Contraceptive Pill for Teens 351

The 2 types of estrogen available in COC formulations are ethinyl estradiol and
mestranol. Mestranol is available in a few 50 mg COCs and is uncommonly used; these
pills are discussed in this article. COCs containing ethinyl estradiol (EE) are far more
commonly used. Concentrations of EE in COCs range from 10 to 50 mg. Most COCs
contain 20 to 35 mg of estrogen and there is only 1 COC available that has 10 mg of
EE. In general, it is recommended to initiate COC treatment with a dose of EE that
is in the 20-mg to 35-mg range. Doses of EE greater than 35 mg are associated with
higher risk of VTE.
Variations in estrogen concentrations in the 10-mg to 35-mg range lead to differences
in other side effects. Lower-estrogen pills are associated with decreased levels of
nausea, gastrointestinal upset, and breast tenderness, but can be associated with
higher levels of breakthrough bleeding.1 So, for a patient with heavy menstrual
bleeding, a clinician would favor a COC pill with 30 to 35 mg of estrogen. Conversely,
for a patient with a sensitive stomach concerned about nausea, a clinician would favor
a COC pill with 20 mg of estrogen.

COMBINED ORAL CONTRACEPTIVES AND PROGESTINS

COCs differ in the concentration and type of progestin in their formulations. Progestins
vary in terms of prothrombotic effect, potency of endometrial stabilization, and antian-
drogenic activity. When selecting a COC for a particular patient, it is useful to match
certain patient characteristics with specific progestin effects. Patient characteristics
to consider include history of excessive uterine bleeding, acne, hirsutism, and polycy-
stic ovary syndrome (PCOS). The types of progestins in COCs are norethindrone, le-
vonorgestrel, norgestrel, desogestrel, and drospirenone.

PROGESTINS AND CLOTTING RISK

The VTE risk associated with COCs is related primarily to effects of estrogen. In recent
years, there has been controversy in the medical community and the media about the
possibility of certain progestins leading to increased clotting risk. COCs containing
desogestrel include product labeling with information about a potential increased
risk of VTE. This warning was based on international studies from the 1990s that sug-
gested COCs containing desogestrel were associated with a higher VTE risk than
COCs containing levonorgestrel and norgestrel.16 Validity of these results is controver-
sial and desogestrel-containing COCs remain widely prescribed.1 However, more
recent studies support the finding that desogestrel-containing COCs are associated
with relatively increased risk of VTE compared with levonorgestrel-containing pills.6
There has also been controversy about the safety of the progestin drospirenone.
Studies have been conflicting about whether drospirenone is associated with elevated
VTE risk compared with levonorgestrel. A recent Cochrane Systematic Review article
concluded that, as expected, all COCs investigated were associated with an increased
risk of VTE.17 However, the risk of VTE was found to vary depending on type of pro-
gestin. COCs containing desogestrel and drospirenone were associated with an
approximately 50% to 80% higher VTE risk than with levonorgestrel-containing
COCs.17 But the absolute risk of VTE associated with COCs with these progestin com-
ponents remains low and desogestrel and drospirenone remain widely prescribed.

PROGESTINS AND ANTIANDROGENIC EFFECTS

Certain progestin components have stronger antiandrogenic properties than others.

Antiandrogenic effects are useful in treating patients with acne, hirsutism, and/or
352 Powell

PCOS. Progestins that have strong antiandrogenic benefits are norgestimate, drospir-
enone, and desogestrel. This is summarized in Fig. 1.

CHOOSING AN INITIAL COMBINED ORAL CONTRACEPTIVE FOR PATIENTS WITHOUT

EXCESSIVE UTERINE BLEEDING, ACNE, HIRSUTISM, OR POLYCYSTIC OVARY
SYNDROME

In patients who require only contraception and/or dysmenorrhea, it is not necessary to

start with an antiandrogenic progestin. The progestins norethindrone, levonorgestrel,
and norgestrel are all appropriate in this patient profile. Estrogen concentration should
be started at a concentration of 35 mg or less. Some common COCs that contain the
aforementioned progestins and also have 35 mg or less of estrogen are listed in
Table 6.

CHOOSING AN INITIAL COMBINED ORAL CONTRACEPTIVE FOR PATIENTS WITH

MENORRHAGIA AND/OR EXCESSIVE UTERINE BLEEDING

When selecting a COC for a patient with menorrhagia and/or excessive uterine
bleeding, the priority is to stabilize the endometrium and cease bleeding as quickly
and safely as possible. The progestin norgestrel is highly effective at stabilizing the
endometrium. Oral contraceptives with this progestin are excellent choices for pa-
tients with menorrhagia. In patients with menorrhagia, patients can often benefit
from having fewer menstrual periods per year. COCs can be prescribed to provide
continuous cycling, which is discussed further later in this article. In patients who
have menorrhagia and/or excessive bleeding but also need antiandrogenic effects
for treatment of acne and PCOS, a clinician should opt for a norgestimate-
containing COC.

CHOOSING AN INITIAL COMBINED ORAL CONTRACEPTIVE FOR PATIENTS WITH ACNE,

HIRSUTISM, AND/OR POLYCYSTIC OVARY SYNDROME

Patients with acne, hirsutism and/or PCOS benefit from COCs that offer a combination
of antiandrogenic effect, menstrual regulation, and contraception. The progestins nor-
gestimate, desogestrel, and drospirenone all offer strong antiandrogenic properties.
COCs with antiandrogenic progestins are summarized in Table 7. As discussed, the
potential for increased clotting risk with drospirenone and desogestrel remains
controversial. Norgestimate is a progestin that offers excellent antiandrogenic effect
with a VTE risk that has been consistently shown to be similar to levonorgestrel.6 In
initial selection of a COC for a patient needing strong antiandrogen effect, it is very
reasonable to select a norgestimate-containing pill. Fig. 2 summarizes the basic
approach to choosing an initial OCP depending on patient characteristics.

Fig. 1. Progestins and antiandrogenic properties.

 The Right Oral Contraceptive Pill for Teens 353

Table 6
Common combined oral contraceptives (COCs) containing norethindrone, levonorgestrel, and
norgestrel categorized by concentration of ethinyl estradiol (EE)

35 mg EE 30 mg EE 20–25 mg EE
Norethindrone-containing COCs Ortho-Novum 1/35 Lo-estrin 1/5/30 Lo-estrin 1/20
Necon 0.5/35 Junel 1.5/30 Junel 1/20
Microgestin 1/5/30 Microgestin 1/20
Levonorgestrel-containing COCs Nordette Aviane
Portia Alesse
Levlen
Levora
Seasonale
Quasense
Jolessa
Norgestrel-containing COCs Lo-Ovral
Cryselle
Low-Ogestrel

MONOPHASIC VERSUS MULTIPHASIC COMBINED ORAL CONTRACEPTIVE

FORMULATIONS

In monophasic COCs, there is the same concentration of estrogen and progesterone

in every active hormonal pill in the pack. In contrast, concentrations of hormone vary
over the course of the pill pack in multiphasic formulations. There are no benefits asso-
ciated with multiphasic COCs compared with monophasic COCs with comparable
hormone concentrations.18

EXTENDED AND CONTINUOUS CYCLING

For both personal and medical reasons, minimizing the number of menses per year is
highly desirable for many women. Certain menstrual-related medical issues, such as
dysmenorrhea, endometriosis, premenstrual dysphoric disorder (PMDD), and menor-
rhagia, can be helped by reducing the number of cycles per year. Although some

Table 7
Common COCs containing norgestimate, desogestrel, and drospirenone categorized by
concentration of ethinyl estradiol (EE)

20 mg EE 30 mg EE 35 mg EE
Norgestimate-containing COCs Ortho-cyclen
Sprintec
MonoNessa
Previfem
Desogestrel-containing COCs Mircette Desogen
Kariva Reclipsen
Mercilon Ortho-cept
Apri
Drospirenone-containing COCs YAZ Yasmin
BEYAZ Zarah
Gianvi Ocella
Vestura Safyral
Yasminelle
354 Powell

Fig. 2. Algorithm for choosing an initial COC.

patients may feel reassured by having a monthly menses, there is no medical reason
why patients need to have monthly withdrawal bleeds while taking COCs. Extended
and continuous cycling with COCs is safe and effective. Safety profile and efficacy
rates are comparable among cyclic, continuous, and extended cycling COC use.19
A recent Cochrane Review found that, in 11 of the 12 studies examined, bleeding pat-
terns were equivalent among cyclic, continuous, and extended cycling groups.19
Certain formulations of COCs are packaged with a higher ratio of active to inactive
pills. For example, in Seasonale and its generic equivalents, there are 84 active pills
and 7 inactive pills. Such formulations allow for patients to have a menstrual period
approximately 4 times per year. Any monophasic COC formulation can be manipu-
lated to provide extended cycling. If a traditional 28-day COC is prescribed and a pa-
tient requires or desires extended cycling, the patient is instructed to take the active
hormonal pills for 3 weeks, discard the placebo week, and proceed directly to the
next pack. When prescribed in this way, it can be useful for the prescription to indicate
that the patient should be provided 2 packs as a 1 month supply. Patients may elect to
have a “scheduled” withdrawal bleed every few months, which means they would take
the placebo week every third or fourth pill pack if desired.
With continuous cycling, the patient takes active hormonal pills daily without any
scheduled withdrawal bleeding. Lybrel is a COC that is designed specifically for
continuous cycling. Lybrel contains 90 mg levonorgestrel and 20 mg EE per pill with
no inactive pills. Similar to extended cycling, patients may also use any monophasic
 The Right Oral Contraceptive Pill for Teens 355

COC formulation to provide continuous cycling. Patients simply take the active pills
continuously, skipping the placebo week, until menstrual bleeding occurs. Once
bleeding occurs, the patient allows a pill-free interval between 3 and 7 days and
then resumes taking continuous active pills.

GENERAL FOLLOW-UP AND TROUBLESHOOTING SIDE EFFECTS

After starting on OCPs, patients should be seen for follow-up within 3 months to check
up on medication adherence and side effects. Blood pressure should be monitored
and STI testing may also be considered. Clinicians should inquire about the develop-
ment of migraine headaches with aura or neurologic symptoms, which is an indication
to discontinue estrogen use. Also, the “ACHES” symptoms associated with VTE
should be reviewed.
Nausea and breast tenderness are common side effects associated with COC use.
Typically, these side effects resolve within the first few cycles of use. If nausea and/or
breast tenderness persist, clinicians may consider switching to a lower-estrogen COC
formulation.
One of the most common side effects associated with COC use is BTB. Patients
should be counseled proactively that BTB is very common during the first few months
of COC use. It is not uncommon for adolescents to overestimate the severity of their
menstrual blood loss. It may be useful to check a patient’s hemoglobin and hematocrit
when the degree of menstrual bleeding is in question. It is not recommended to switch
a COC formulation solely in response to BTB within the first 3 cycles, unless the patient
finds the side effect completely intolerable or unless there is true menorrhagia and/or
anemia associated with COC use. In general, light to moderate BTB typically resolves
after 3 months of COC use.
If BTB persists after 3 months, clinicians have several options to offer patients. If a
patient is on an OCP with an estrogen concentration less than 35 mg, then increasing
the dose of estrogen may help to stabilize the endometrium. If the dose of estrogen is
already maximized at 35 mg, then the COC formulation can be changed to a more
potent progestin component. Progestins that are particularly potent in terms of stabi-
lizing the endometrium include norgestrel and norgestimate.

MANAGING MISSED PILLS

Missing pills is a very common occurrence, and patients should be counseled proac-
tively about how to handle this situation. Recommendations on how to manage
missed pills vary in level of complexity and can at times be difficult for patients to un-
derstand. The most recent edition of Contraceptive Technology offers a simplified
approach to managing missed pills, which is summarized in Table 8.1

MANAGING PILL DOSING WITH VOMITING AND/OR DIARRHEA

If a patient vomits within 2 hours of taking a COC, she should proceed as if the pill were
missed and use back-up contraception until she has had 7 days of taking active pills
successfully.1 Similarly, if a patient has severe vomiting and diarrhea for 2 days or
more, she should be managed as if pills were missed.1

PATIENTS WITH CHRONIC MEDICAL CONDITIONS AND COMBINED ORAL

CONTRACEPTIVE USE

Adolescents with chronic medical issues require special care and consideration when
it comes to contraception. Many chronic medical issues, such as cystic fibrosis (CF),
356 Powell

Table 8
Simplified management of missed pills

Emergency
Catch-up Dosing Contraception (EC)? Back-up Contraception?
Missed 1 pill, <12 h  Take missed pill ASAP Not needed Not needed
late  Resume usual dosing
Missed 1 pill, >12 h  Take missed pill ASAP Not needed Yes, condoms or
late  Resume usual dosing abstinence  7 d
Missed 2 or more  Take forgotten pill Take EC if Yes, condoms or
pills, has at least and today’s pill (2 pills unprotected abstinence  7 d
7 active pills on same day) intercourse in
remaining in pill  Resume usual dosing past 7 d
pack
Missed 2 or more  Take forgotten pill Take EC if Yes, condoms or
pills, has 7 or and today’s pill (2 pills unprotected abstinence until she
fewer active pills on same day) intercourse in has taken 7 active pills
remaining in pack:  Resume usual dosing past 7 d in the NEXT PACK
OPTION 1
Missed 2 or more  Take forgotten pill Take EC if Yes, condoms or
pills, has 7 or and today’s pill (2 pills unprotected abstinence  7 d
fewer active pills on same day) intercourse in
remaining in pack:  Take the rest of the past 7 d
OPTION 2 active pills in the pack
 Skip placebo pills and
proceed directly to
next pack

Adapted from Hatcher RA. Contraceptive technology. New York: Ardent Media; 2011.

are associated with increased risk of adverse health events as a result of pregnancy,
making effective contraception especially important. Some chronic medical issues,
such as migraine headaches with aura, place patients at increased risk of medical
complications associated with estrogen use. As such, clinicians should consult up-
to-date guidelines in the US MEC when prescribing contraception to adolescents
with chronic health conditions. The relationship between select common chronic
health issues in adolescents and COC use is discussed in this section.
In the most recent US MEC guidelines, CF is classified as a category 1 condition with
regard to COC use4; however, patients with CF are at increased risk of liver disease,
gallbladder disease, and VTE associated with central venous catheters. The safety
categories assigned to these other medical conditions are the same as for women
who do not have CF. The category 1 classification for CF is based on the assumption
that these other medical conditions are NOT present. Furthermore, certain medica-
tions used to treat CF can decrease the effectiveness of COCs, so clinicians should
check potential medication interactions before prescribing a COC to a patient with CF.
Infection with human immunodeficiency virus (HIV) is classified as a category 1 con-
dition. As with CF, a clinician should consider the potential for medication interaction
when prescribing COCs to a patient with HIV. Most antiretroviral medications are clas-
sified as categories 1 or 2, making COCs an appropriate choice for most patients with
HIV.4 However, the antiretroviral agent fosamprenavir (FPV) is classified as category 3,
and COCs should be avoided in in patients taking FPV.4
For most adolescent patients with insulin-dependent and non–insulin-dependent
diabetes mellitus (DM), COCs are classified as category 2, making COCs an
 The Right Oral Contraceptive Pill for Teens 357

appropriate option for teens with DM.4 However, if patients with DM also have neurop-
athy, retinopathy, other vascular disease, or have had DM for more than 20 years, the
safety classification for COCs changes to categories 3/4.4
In patients with inflammatory bowel disease (IBD), COCs are classified as categories
2/3. For patients with IBD and no other risk factors for VTE, COC use is considered
category 2 and benefit generally outweighs the risks. However, in patients with IBD
and an increased risk of VTE, such as extensive disease, surgery, and/or immobiliza-
tion, COCs change to category 3 and risks generally outweigh benefits.20 In patients
with mild ulcerative colitis and no or small ileal resection, absorption of COCs appears
intact.20 It is possible that absorption may be impaired in patients with Crohn disease
or extensive bowel resection.20 LARCs are classified as category 1 for patients with
IBD and may provide a safe and effective alternative for teen patients with IBD.4
For patients with systemic lupus erythematosus (SLE), safety classification for COC
use depends on whether the patient has antiphospholipid antibodies. In patients with
SLE who have positive or unknown antiphospholipid antibodies, COCs are classified
as category 4 and represent an unacceptable health risk.4 For patients with SLE and
negative antiphospholipid antibodies, COCs are classified as category 2.4

REFERRING TO ADOLESCENT MEDICINE OR GYNECOLOGY

Many primary care providers are comfortable managing OCPs in uncomplicated

adolescent patients. In certain situations, it may be advisable to have an adolescent
medicine specialist or gynecologist involved. Referrals to subspecialists should be
considered in patients with structural gynecologic anomalies, patients with menor-
rhagia that has caused anemia, and in patients with complicated medical comorbid-
ities. Patients with known or suspected endometriosis may benefit from establishing
a long-term relationship with a gynecologist. Subspecialty consultation also may be
considered in patients who have persistent side effects or BTB on OCP treatment.

SUMMARY

In summary, OCPs provide effective and safe contraception for adolescents when
taken correctly. OCPs include 2 broad categories: POPs and COCs. Both POPs
and COCs require daily dosing, although POPs require more exact dosing to maintain
efficacy. Daily dosing can be challenging for adolescents, and strategies to improve
adherence should be discussed proactively. COCs lead to an increased risk of VTE,
so clinicians should perform a thorough assessment of any contraindications to estro-
gen before prescribing. The US MEC provides comprehensive guidelines about which
contraceptive methods are appropriate for patients depending on their medical pro-
files. COCs provide many noncontraceptive health benefits, including treatment of
dysmenorrhea, excessive uterine bleeding, acne, and PCOS. All sexually active ado-
lescents should be counseled to use condoms consistently for prevention of STIs.

REFERENCES

1. Hatcher RA. Contraceptive technology. New York: Ardent Media; 2011.

2. Committee on Adolescent Health Care Long-Acting Reversible Contraception
Working Group, The American College of Obstetricians and Gynecologists. Com-
mittee opinion no. 539: adolescents and long-acting reversible contraception: im-
plants and intrauterine devices. Obstet Gynecol 2012;120(4):983–8.
3. Emans SJH, Laufer MR. Emans, Laufer, Goldstein’s pediatric and adolescent gy-
necology. Philadelphia: Lippincott, Williams and Wilkins; 2012.
358 Powell

4. Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Con-
traceptive Use, 2016. MMWR Recomm Rep 2016;65(3):1–103.
5. Kharbanda EO, Parker ED, Sinaiko AR, et al. Initiation of oral contraceptives and
changes in blood pressure and body mass index in healthy adolescents.
J Pediatr 2014;165(5):1029–33.
6. Trenor CC, Chung RJ, Michelson AD, et al. Hormonal contraception and throm-
botic risk: a multidisciplinary approach. Pediatrics 2011;127(2):347–57.
7. Hannaford PC, Selvaraj S, Elliott AM, et al. Cancer risk among users of oral con-
traceptives: cohort data from the Royal College of General Practitioner’s oral
contraception study. BMJ 2007;335(7621):651.
8. Westhoff CL, Torgal AH, Mayeda ER, et al. Pharmacokinetics of a combined oral
contraceptive in obese and normal-weight women. Contraception 2010;81(6):
474–80.
9. Westhoff CL, Torgal AH, Mayeda ER, et al. Ovarian suppression in normal-weight
and obese women during oral contraceptive use: a randomized controlled trial.
Obstet Gynecol 2010;116(2 Pt 1):275–83.
10. Holt VL, Cushing-Haugen KL, Daling JR. Body weight and risk of oral contracep-
tive failure. Obstet Gynecol 2002;99(5 Pt 1):820–7.
11. Kaneshiro B, Edelman A, Carlson N, et al. The relationship between body mass
index and unintended pregnancy: results from the 2002 National Survey of Family
Growth. Contraception 2008;77(4):234–8.
12. Society of Family Planning, Higginbotham S. Contraceptive considerations in
obese women: release date 1 September 2009, SFP Guideline 20091. Contra-
ception 2009;80(6):583–90.
13. Vessey M, Yeates D. Oral contraceptive use and cancer: final report from the
Oxford-Family Planning Association contraceptive study. Contraception 2013;
88(6):678–83.
14. Marchbanks PA, McDonald JA, Wilson HG, et al. Oral contraceptives and the risk
of breast cancer. N Engl J Med 2002;346(26):2025–32.
15. Breast cancer and hormonal contraceptives: further results. Collaborative Group
on Hormonal Factors in Breast Cancer. Contraception 1996;54(3 Suppl):1S–106S.
16. Spitzer WO, Lewis MA, Heinemann LA, et al. Third generation oral contraceptives
and risk of venous thromboembolic disorders: an international case-control study.
Transnational research group on oral contraceptives and the health of young
women. BMJ 1996;312(7023):83–8.
17. de Bastos M, Stegeman BH, Rosendaal FR, et al. Combined oral contraceptives:
venous thrombosis. Cochrane Database Syst Rev 2014;(3):CD010813.
18. Van Vliet HA, Grimes DA, Helmerhorst FM, et al. Biphasic versus monophasic oral
contraceptives for contraception. Cochrane Database Syst Rev 2006;(3):CD002032.
19. Edelman A, Micks E, Gallo MF, et al. Continuous or extended cycle vs. cyclic use
of combined hormonal contraceptives for contraception. Cochrane Database
Syst Rev 2014;(7):CD004695.
20. Curtis KM, Tepper NK, Marchbanks PA. U.S. medical eligibility criteria for contra-
ceptive use, 2010. J Womens Health (Larchmt) 2011;20(6):825–8.