Combined oral contraceptives (COCs) have many uses in dermatology, but dermatologists often underutilize COCs and don’t feel comfortable prescribing them. In this special resident takeover of the podcast, three dermatology residents — Dr. Daniel Mazori, Dr. Elisabeth Tracey, and Dr. Julie Croley — review the basics of prescribing COCs for dermatologic conditions. Beginning at 8:36, they discuss assessment of patient eligibility and selection of COCs, proper use of COCs, and management of risks and side effects.
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Things you will learn in this episode:
- Acne is the main indication for COCs in dermatology, but other off-label uses include hidradenitis suppurativa, hirsutism, female pattern hair loss, and autoimmune progesterone dermatitis.
- When prescribing COCs, it is important to consider absolute and relative contraindications such as cardiovascular disease, postpartum status, women 35 years and older and smoking more than 15 cigarettes per day, migraine with aura, and history of diabetes for more than 20 years, plus others.
- Rule out pregnancy prior to starting COCs via a urine or serum pregnancy test. Dr. Croley points out, “A pelvic exam is not required to start combined oral contraceptives, as is sometimes thought by providers.”
- Monophasic formulations are considered first-line therapy.
- For patients who are concerned about symptoms associated with a hormone-free interval during treatment, choose a COC that does not include placebo pills, or encourage the patient to skip the placebo pills altogether and start the next pack earlier.
- Estrogen-related side effects are a consideration when prescribing COCs. “In general, the lowest possible dose of estrogen that is effective and tolerable should be prescribed,” Dr. Libby advises.
- Combined oral contraceptives can be started on any day of the patient’s menstrual cycle, but patients should be counseled to use backup contraception for 7 days if the COC is started more than 5 days after the first day of their most recent period.
- At least 3 months of therapy can be expected to evaluate the effectiveness of COCs for acne, potentially up to 6 months.
- Breakthrough bleeding is the most common side effect of COCs and can be minimized by taking the COC at about the same time every day and avoiding missed pills. If breakthrough bleeding persists after 3 cycles, consider increasing the estrogen dose or referring the patient to an obstetrician/gynecologist.
- Discuss the risk of venous thromboembolism with patients using the 3-6-9-12 model.
Hosts: Elizabeth Mechcatie, Terry Rudd
Guests: Daniel R. Mazori, MD (State University of New York Downstate Medical Center, Brooklyn); Elisabeth "Libby" Tracey, MD (Cleveland Clinic Foundation, Ohio); Julie Ann Amthor Croley, MD (The University of Texas Medical Branch at Galveston).
Show notes by Alicia Sonners, Melissa Sears, and Elizabeth Mechcatie.
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