Recently introduced OCs include those containing drosperidol, more preparations with only 20 μgof EE, new multiphasic preparations, cyclic OCs with 24 days of active medication and 4 days of either placebo or 10 μgof EE, and extended-cycle and continuous cycle preparations plus branded generic versions of most OCs. A combination OC containing estradiol valerate with a new progestin, dienogest, was approved in 2010. There is new evidence that 20 μg EE pills offer reduced risk for venous thrombosis (130). An approach to OC selection for new patients is to begin with a 20 μg EE combination and then adjust depending on the patient’s symptoms after the first 2 to 3 months. As reported in a large systematic review of 20 μg EE OCs compared to 30 to 35 μg EE pills, women taking the lower dose OCs more often report changes in vaginal bleeding, episodes of irregular bleeding and heavy bleeding, and more amenorrhea (210). If a 20 μg pill is offered, the patient should understand that bleeding may be a problem and that she should return if this persists and try a different OC rather than stop the pill. The progestin component may become more important in determining cycle control when 20 μg EE is used. A comparison of 20 μg EE OCS, one containing 100 μgof levonorgestrel, the other with 1 mg of norethindrone acetate (NEA) found the NEA to have about twice as many days of unscheduled vaginal bleeding during the first 3 months, a critical time period for new users, which might be expected to lead to discontinuation (211). In a three-way trial, the 35-μg EE/norgestimate triphasic OC (Tri-Cyclen) was compared with two 20-μg EE pills, one containing 100 μgof levonorgestrel (Alesse), the other containing 150 μg desogestrel, followed by 2 hormone-free days and 5 days of 10 μg EE per day (Mircette) (212). Contraceptive efficacy was not significantly different. In the first two pill cycles more women taking Alesse had breakthrough bleeding and bleeding in the second half of the cycle than those taking the other two OCs in the first two cycles, but thereafter there was little difference. Women taking the higher estrogen Tri-Cyclen consistently experienced more frequent estrogenic side effects—bloating, breast tenderness, and nausea—than did women taking either 20-μg EE OC. These authors concluded that for the specific OCs evaluated, changing to either one of the 20 μg preparations would be beneficial.
For the average patient, the first choice of preparation for contraceptive purposes is a very low estrogen OC (20 μg EE) unless there are other considerations, for example, previous pregnancy while taking the pill. Patients with persistent break-through spotting or bleeding could be offered a pill with the same low estrogen dose, but a more potent progestin, for example levonorgestrel. Patients with apparent weight gain from ﬂuid retention while taking OCs, or with hirsutism or acne that did not respond to other OCs, may benefit from a change to the drospirenone/EE pill. The lower estrogen drospirenone combination is FDA approved for treatment of PMDD and should be considered for women with these symptoms who want hormonal contraception. Women with acne often benefit from the reduction in circulating testosterone that occurs with all combination OCs. Women who experience continuing pelvic pain, dysmenorrhea, or other menstrual triggered symptoms or who simply prefer fewer menstruations may be offered an extended-cycle or continuous cycle-OC regimen.