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

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This article provides primary care physicians with key considerations for prescribing combined or progestogen-only oral contraceptives, including patient selection criteria and estrogen dose optimization.

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This review article outlines key considerations for primary care physicians when prescribing combined oral contraceptive pills and progestogen-only pills, focusing on patient selection, estrogen dosage, regimen type, and progestogen generation. The authors highlight that while extended or continuous regimens are recommended for managing severe pain associated with conditions like endometriosis, they carry a higher risk of unscheduled bleeding compared to traditional cyclical use. Specific progestogens such as desogestrel and dienogest are identified in summary tables as having indications for treating dysmenorrhea and endometriosis, respectively. Relevance to endometriosis: listed as one indication for certain COCP preparations, though the paper's main focus is general contraceptive prescribing guidelines.

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Conclusion

With up to 50% of women discontinuing the oral contraceptive within the first year of its use, 5 being aware of the different preparations, as well as their availability, is important for PCPs. While the purpose of this article was not to ‘name’ every single type of contraceptive pill that is currently available — which would be difficult considering the amount of research and change that is ongoing in this area — the aim instead was to provide PCPs with a set of key considerations. By doing so, it will not only enable a more individualised approach to be delivered but also, more importantly, provide reassurance for women. Funding There was no additional internal or external funding for this project. Provenance Freely submitted; externally peer reviewed. Competing interests The authors have declared no competing interests. Discuss this article Contribute and read comments about this article: bjgp.org/letters

References

1. Kuhl H. Pharmacology of estrogens and progestogens: influence of different routes of administration. Climacteric 2005; 8(Suppl 1: 3-63. DOI: 10.1080/13697130500148875. 2. Faculty of Sexual and Reproductive Healthcare of the Royal College of Obstetrics and Gynaecology. UK medical eligibility criteria for contraceptive use . 2016 (amended 2019). https://www.fsrh.org/documents/ukmec-2016/ (accessed 4 Oct 2021). 3. Faculty of Sexual and Reproductive Healthcare of the Royal College of Obstetrics and Gynaecology. Progestogen only pills . 2015 (amended 2019). https://www.fsrh.org/ standards-and-guidance/documents/cec- ceu-guidance-pop-mar-2015/ (accessed 4 Oct 2021). 4. Gallo MF, Nanda K, Grimes DA, et al . 20 µg versus >20 µg estrogen combined oral contraceptives for contraception. Cochrane Database Syst Rev 2013; (8): CD003989. DOI: 10.1002/14651858.CD003989.pub5. 5. UpToDate. Combined estrogen–progestin oral contraceptives: patient selection, counselling and use . 2021. https://www.uptodate.com/ contents/combined-estrogen-progestin-oral- contraceptives-patient-selection-counseling- and-use (accessed 4 Oct 2021). 6. Yu Q, Zhou Y, Suturina L, et al . Efficacy and safety of estradiol valerate/dienogest for the management of heavy menstrual bleeding: a multicenter, double-blind, randomized, placebo-controlled, phase III clinical trial. J Womens Health (Larchmt) 2018; 27(10): 1225–1232. DOI: 10.1089/jwh.2017.6522. Epub 2018 Jun 29. 7. National Institute for Health and Care Excellence. Combined oral contraception: nomegestrol/estradiol (Zoely). Evidence summary. ESNM28 . London: NICE, 2013. https://www.nice.org.uk/advice/esnm28/ chapter/Key-points-from-the-evidence (accessed 4 Oct 2021). 8. Legro RS, Pauli JG, Kunselman AR, et al . Continuous versus cyclical oral contraception: a randomized controlled trial. J Clinic Endocrinol Metab 2008; 93(2): 420–429. DOI: 10.1210/jc.2007-2287. 9. Mansour D. Use of the new progestogens in contraception and gynaecology. Obstetrician and Gynaecologist 2006; 8: 229–234. DOI: https://doi.org/10.1576/toag.8.4.229.27272. 10. Shahnazi M, Bayatipayan S, Khalili AF, et al . Comparing the effects of the second-and third-generation oral contraceptives on sexual functioning. Iran J Nurs Midwifery Res 2015; 20(1): 47–55. 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

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MeSH descriptors

Physicians, Primary Care Contraception Contraceptives, Oral Female Humans

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