Prescribing the oral contraceptive pill: key considerations for primary care physicians

Article Figures & Data

Table 1.

Summary of patient characteristics and medical conditions more suitable for POP compared with COCP

Patient characteristics	Age	>45 years old
	BMI	>30
	Smoking	Age >35 years old and >15 cigarettes a day
	Breastfeeding	<6 weeks post-delivery
Medical conditions	Cardiac	Impaired cardiac function
	Cardiac	Cardiac arrhythmias
	Neurological	Migraine with aura
	Haematological	Personal or strong family history of VTE
	Vascular disease
	Organ transplant

BMI = body mass index. COCP = combined oral contraceptive pill. POP = progestogen-only pill. VTE = venous thromboembolism.

Table 2.

Summary of characteristics of synthetic progestogens and indications for use^a

Generation	Progestogen	COCP preparation		Available as POP	Physiological activity	Best formulation for use

		Monophasic	Multiphasic
1st	Medroxyprogesterone	✓	✗	✓	Moderate androgenic	Irregular or missed periods
	Medroxyprogesterone	✓	✗	✓	Minor glucocorticoid	Irregular or missed periods

	Norethisterone	✓	✓	✓	Moderate progestogenic	Menorrhagia, adenomyosis
	Norethisterone	✓	✓	✓	Mild androgenic	Menorrhagia, adenomyosis

2nd	Levonorgestrel	✓	✓	✓	Strongly progestogenic	Menorrhagia, adenomyosis
2nd	Levonorgestrel	✓	✓	✓	Strongly androgenic	Menorrhagia, adenomyosis

3rd	Desogestrel	✓	✗	✓	Strongly progestogenic	Dysmenorrhoea, endometriosis

	Norgestimate	✓	✗	✗	Medium progestogenic	Moderate acne
	Norgestimate	✓	✗	✗	Weakly androgenic	Moderate acne

	Gestodene	✓	✗	✗	Strongly progestogenic	Dysmenorrhoea
	Gestodene	✓	✗	✗	Mildly androgenic	Dysmenorrhoea

4th	Drospirenone	✓	✗	✗	Anti-androgenic	Acne, PCOS, PMS
	Drospirenone	✓	✗	✗	Anti-mineralocorticoid	Acne, PCOS, PMS

	Dienogest	✗	✓	✓	Anti-androgenic	Endometriosis
	Dienogest	✗	✓	POP not licensed for contraceptive purposes in UK

	Nomegestrol	✓	✗	✗	Targeted anti-oestrogenic at endometrium	Menorrhagia, PCOS, PMS
	Nomegestrol	✓	✗	✗	Partial anti-androgenic	Menorrhagia, PCOS, PMS

↵a The indications for use apply regardless of whether the progestogen is prescribed in combination with oestrogen or if available, as the POP. COCP = combined oral contraceptive pill. PCOS = polycystic ovarian syndrome. PMS = pre-menstrual syndrome. POP = progestogen-only pill.

Table 3.

Indications for use according to COCP regimen

Regimen type	Pattern of COCP use	Indications
Traditional	21 days on pill	For women keen to maintain a regular bleed and are symptom free during their periods
Traditional	7 days off pill

Tailored use	24 days on pill	Shorter bleeding time and suitable for women keen to reduce symptoms from their periods but who wish to maintain a regular withdrawal bleed
Tailored use	4 days off pill

Extended	3 months on pill	Ideal for those with severe pain or mood swings in the lead up to or during their periods, for example, endometriosis, PMS
Extended	7 days off pill

Continuous	Continuous use with no pill-free days	Ideal for those with severe pain or mood swings in the lead up to or during their periods, for example, endometriosis, PMS
Continuous	Continuous use with no pill-free days	May be associated with unscheduled bleeding

Table 4.

Side effects of progestogens in relation to physiological activity

Physiological activity	Side effects
Progestogenic	Breast tenderness, change in bowel activity, bloating, increased appetite, tiredness, mood changes, skin changes
Androgenic	Oily skin, acne, hirsutism, weight gain, mood changes
Glucocorticoid	Mood swings, increased appetite, water retention
Mineralocorticoid	Water retention, bloating