The ABCs of COCs: A Guide for Dermatology Residents on Combined Oral Contraceptives
Despite the number of on-label and off-label uses for combined oral contraceptives (COCs) in dermatology, research suggests that dermatologists underprescribe COCs. With the intention of familiarizing dermatology residents with COCs, this article discusses ways to assess patient eligibility, select a COC, counsel on use, and manage risks and side effects.
Resident Pearls
- Screen for contraindications to combined oral contraceptives (COCs) by taking a medical history, measuring a baseline blood pressure, and excluding pregnancy. A baseline pelvic examination is unnecessary.
- Characteristics to consider when selecting a COC include the formulation, hormone-free interval, estrogen dose, and progestin type.
- Combined oral contraceptives can be initiated on any day of the menstrual cycle, with the need for backup contraception based on the number of days since the first day of the patient’s most recent period.
- Management of risks and side effects includes simple lifestyle changes, skipping the hormone-free interval, switching the COC, and referring to an obstetrician/gynecologist.
Monophasic vs Multiphasic
All the hormonally active pills in a monophasic formulation contain the same dose of estrogen and progestin; however, these doses change per pill in a multiphasic formulation, which requires that patients take the pills in a specific order. Given this greater complexity and the fact that multiphasic formulations often are more expensive and lack evidence of superiority, a 2011 Cochrane review recommended monophasic formulations as first line.6 In addition, monophasic formulations are preferred for autoimmune progesterone dermatitis because of the stable progestin dose.
Hormone-Free Interval
Some COCs include placebo pills during which hormone withdrawal symptoms such as bleeding, pelvic pain, mood changes, and headache may occur. If a patient is concerned about these symptoms, choose a COC with no or fewer placebo pills, or have the patient skip the hormone-free interval altogether and start the next pack early7; in this case, the prescription should be written with instructions to allow the patient to get earlier refills from the pharmacy.
Estrogen Dose
To minimize estrogen-related side effects, the lowest possible dose of ethinyl estradiol that is effective and tolerable should be prescribed7,8; 20 μg of ethinyl estradiol generally is the lowest dose available, but it may be associated with more frequent breakthrough bleeding.9 The International Planned Parenthood Federation recommends starting with COCs that contain 30 to 35 μg of estrogen.10 Synthesizing this information, one option is to start with 20 μg of ethinyl estradiol and increase the dose if breakthrough bleeding persists after 3 cycles.
Progestin Type
First-generation progestins (eg, norethindrone), second-generation progestins (eg, norgestrel, levonorgestrel), and third-generation progestins (eg, norgestimate, desogestrel) are derived from testosterone and therefore are variably androgenic; second-generation progestins are the most androgenic, and third-generation progestins are the least. On the other hand, drospirenone, the fourth-generation progestin available in the United States, is derived from 17α-spironolactone and thus is mildly antiandrogenic (3 mg of drospirenone is considered equivalent to 25 mg of spironolactone).
Although COCs with less androgenic progestins should theoretically treat acne better, a 2012 Cochrane review of COCs and acne concluded that “differences in the comparative effectiveness of COCs containing varying progestin types and dosages were less clear, and data were limited for any particular comparison.”11 As a result, regardless of the progestin, all COCs are believed to have a net antiandrogenic effect due to their estrogen component.1
Counsel on Use
Combined oral contraceptives can be started on any day of the menstrual cycle, including the day the prescription is given. If a patient begins a COC within 5 days of the first day of her most recent period, backup contraception is not needed.4 If she begins the COC more than 5 days after the first day of her most recent period, she needs to use backup contraception or abstain from sexual intercourse for the next 7 days.4 In general, at least 3 months of therapy are required to evaluate the effectiveness of COCs for acne.1
Manage Risks and Side Effects
Breakthrough Bleeding
The most common side effect of breakthrough bleeding can be minimized by taking COCs at approximately the same time every day and avoiding missed pills. If breakthrough bleeding does not stop after 3 cycles, consider increasing the estrogen dose to 30 to 35 μg and/or referring to an obstetrician/gynecologist to rule out other etiologies of bleeding.7,8
