Choosing a Hormonal Contraceptive

Full update March 2021

The charts below provide answers to some common questions to help choose and switch to the best hormonal contraceptive for each patient. These charts do NOT offer complete information on long-acting contraceptives (e.g., IUDs, implants), some of which do contain hormones. For additional information, see our charts Comparison of Oral Contraceptives and Non-Oral Alternatives (U.S. subscribers; Canadian subscribers) and Contraception for Women With Chronic Medical Conditions.

Considerations for Choosing a Hormonal Contraceptive

Question

Answer/Pertinent Information

Does the patient have any risk factors for use of a hormonal contraceptive (e.g., drug interactions, comorbidity, etc)?

If yes, continue to the next questions.

If no:

  • for long-acting contraceptives, consider an IUD or an implant.
  • for more short-term contraception, consider starting with a combined oral contraceptive (COC) containing low-dose ethinyl estradiol (≤35 mcg) plus levonorgestrel 0.15 mg or norgestimate 0.25 mg for a good balance of safety and efficacy.1

Are there any drug interactions to consider?

CYP3A4 inducers (e.g., phenytoin, carbamazepine, some HIV drugs, topiramate, rifampin, St. John’s wort) induce the metabolism of estrogen, potentially decreasing efficacy.2

  • The efficacy of oral progestin-only contraceptives and etonogestrel implant may also decrease when used with CYP3A4 inducers.2

If a patient is taking a CYP3A4 inducer:

  • Depot medroxyprogesterone is preferred, or an IUD.2
  • If using a COC, consider a higher estrogen content (≥30 mcg ethinyl estradiol).2

Is the patient obese?

The majority of high-quality studies indicate that the efficacy of COCs is not decreased in patients with obesity. However, reduced efficacy in patients with a BMI over 30 kg/m2 has not been ruled out.3,4

  • Consider an extended-cycle or continuous regimen with 20 to 35 mcg ethinyl estradiol.5
  • The efficacy of progestin implants or depot medroxyprogesterone is NOT decreased in patients who are obese.5

Contraceptive patches may be less effective in patients who are obese.4 See product labeling for specific weight or BMI cutoffs.

Obesity increases the risk of thrombosis. If the patient has additional risk factors for thrombosis (e.g., smoker, ≥35 years), consider a progestin-only contraceptive.2,3

Is there a risk for non-adherence?

If adherence may be challenging, consider an IUD, implant, depot medroxyprogesterone, weekly patch, or monthly vaginal ring.

Avoid progestin-only pills if adherence is an issue. Varying daily administration times by more than three hours can decrease efficacy.2

Is the patient breastfeeding?

For breastfeeding patients:

  • Preferred:2,6 implants, depot medroxyprogesterone, or progestin-only pills.
  • Non-preferred:2 estrogen-containing COCs, patches, and vaginal ring. Avoid these in the first 30 days postpartum (first 42 days if the patient has any risk factors for venous thromboembolism [VTE]).2

Does the patient smoke?

If the patient is ≥35 years old:2,3,7

  • consider a progestin-only contraceptive.5
  • avoid estrogen-containing contraceptives due to an increased risk of cardiovascular disease.
  • if alternatives are limited, a COC can be considered if the patient smokes less than 15 cigarettes/day.

If the patient is <35 years old consider COCs IF there are no other risk factors for thrombosis.7

Does the patient have hypertension?

If blood pressure is controlled below 140/90 mmHg and the patient does not have any other cardiovascular risk factors, any hormonal contraceptive can be considered.7

If SBP 140 to 159 mmHg or DBP 90 to 99 mmHg:

  • consider a progestin-only pill, implant, or levonorgestrel-releasing IUD.2,7
  • avoid estrogen-containing contraceptives unless there is no alternative.7

If SBP ≥160 mmHg or DBP ≥100 mmHg:

  • copper IUD is preferred.2
  • progestin-only options can be considered.2
  • estrogen-containing contraceptives should not be used.7
  • generally, avoid depot medroxyprogesterone due to a theoretical risk of dyslipidemia which could contribute to cardiovascular risk.7

Does the patient have an increased risk of thrombosis (e.g., history of clots, ≥35 years, smoker, severe hypertension, diabetes, high cholesterol)?

Estrogen possibly increases the risk of thrombosis. The risk of thrombosis with COCs is only about half of the risk of thrombosis with pregnancy.7

  • Thrombosis risk is less with <50 mcg ethinyl estradiol.7

For patients with an increased risk of thrombosis:

  • consider a progestin-only contraceptive.2,5,7
  • avoid contraceptive patches and rings.8,9

Does the patient have migraine headaches?

If the patient has migraine headaches with an aura:

  • Avoid estrogen-containing contraceptives as they may increase the risk of stroke in patients with migraine headaches with an aura.7
  • Consider a progestin-only contraceptive.5,7

If the patient has migraine headaches withOUT an aura:

  • Consider an estrogen-containing contraceptive IF the patient is <35 years old, a non-smoker, and does not have hypertension.7

If the patient has menstrual migraines, consider an extended-cycle or continuous COC.10

Does the patient have osteoporosis or risk factors for osteoporosis (e.g., chronic alcohol use, strong family history)?

Avoid depot medroxyprogesterone as it can decrease bone mineral density.11

 

Considerations for Switching Contraceptives (to manage complaints, adverse effects, etc)

Question

Answer/Pertinent Information

Is the patient experiencing breakthrough bleeding?

Breakthrough bleeding is common with all forms of COC especially during the first three months of use.1

Ensure patient is adherent and there are no drug interactions which may reduce estrogen levels.

If the bleeding is early or mid-cycle, there may be too little estrogen.1

  • Switch to a higher estrogen dose formulation.1

If the bleeding is late in the cycle, there may be too little progestin.1

  • Switch to a higher dose progestin, or one with higher progestin activity (e.g., desogestrel, levonorgestrel).1

The contraceptive patch may have less breakthrough bleeding compared to COCs.4

Is the patient experiencing migraines?

If migraines develop in a patient or worsen, estrogen-containing contraceptives should be stopped.3

See above for help choosing an appropriate contraceptive in women with migraines.

Is the patient having vasomotor symptoms of perimenopause?

Estrogen-containing contraceptives generally improve vasomotor symptoms of perimenopause. If the patient is having symptoms during hormone-free days, try an extended-cycle or continuous regimen.12

Is the patient experiencing increased appetite, weight gain, acne, oily skin, hirsutism, and dyslipidemia?

The patient may be getting too much androgen.1

Switch to a progestin with less androgenic activity.

  • Second-generation progestins (norgestrel, levonorgestrel) have the most androgenic activity.a
  • Drospirenone is an anti-androgenic progestin.
  • First- or third-generation progestins (e.g., norethindrone, desogestrel) have lower androgenic activity.a

Is the patient experiencing acne?

COCs in general improve acne.4 Some are FDA- or Health Canada-labeled for acne: Estrostep Fe (U.S.), Ortho Tri-Cyclen (U.S.), Yaz, Yasmin (Canada), and Alesse (Canada).

Consider switching to a COC with a progestin that has lower androgenic activity.1,13

Consider switching to a higher estrogen dose formulation.13

Avoid depot medroxyprogesterone.1

Is the patient experiencing headache, breast tenderness, fatigue, and changes in mood?

The patient may be getting too much progestin.

  • Consider switching to a progestin with less progestin activity (e.g., drospirenone).1

Does the patient have symptoms of nausea, breast tenderness, increased blood pressure, melasma (grey-brown patches on the face), menstrual headache, and bloating?

The patient may be getting too much estrogen, consider switching to a lower-dose estrogen formulation.1

Avoid patches which provides the highest estrogen exposure.

Consider the vaginal ring which provides the lowest estrogen exposure.14

For bloating, consider switching to a formulation containing drospirenone, a progestin that has weak potassium-sparing diuretic effects.1

Is the patient experiencing menstruation-related problems (anemia menorrhagia, bloating, dysmenorrhea, and menstrual headache/migraine)?

Consider an extended-cycle or continuous regimen.10

Does the patient have endometriosis-related menstrual pain?

COCs may reduce the symptoms of endometriosis. An extended-cycle or continuous regimen can be considered if symptoms persist.1

Abbreviations: BMI = body mass index; COC = combined oral contraceptive DBP = diastolic blood pressure; IUD = intrauterine device; SBP = systolic blood pressure.

  1. Definitions:
    • 1st generation progestins: norethindrone, norethindrone acetate, ethynodiol diacetate
    • 2nd generation progestins: levonorgestrel, norgestrel
    • 3rd generation progestins: norgestimate, desogestrel
    • 4th generation progestins: drospirenone, dienogest

References

  1. Nationwide Children’s. Prescribing guidelines for prescription contraceptives. 2019. http://partnersforkids.org/wp-content/uploads/2019/11/W136220_Reproductive-Health-Guidelines_final.pdf. (Accessed February 24, 2021).
  2. CDC. U.S. Medical Eligibility Criteria (US MEC) for Contraceptive Use, 2016. MMWR Recomm Rep 2016;65:1-103.
  3. WHO. Medical eligibility criteria for contraceptive use. 5th ed. Geneva: WHO; 2015. https://www.who.int/reproductivehealth/publications/family_planning/MECguidelinePart-2.pdf?ua=1. (Accessed February 23, 2021).
  4. Black A, Guilbert E, Costescu D, et al. No. 329 - Canadian contraception consensus part 4 of 4 chapter 9: combined hormonal contraception. J Obstet Gynaecol Can 2017;39:229-68.e5.
  5. Black A, Guilbert E, Costescu D, et al. Canadian contraception consensus (part 3 of 4): chapter 7: intrauterine contraception. J Obstet Gynaecol Can 2016;38:182-222.
  6. Tepper NK, Phillips SJ, Kapp N, et al. Combined hormonal contraceptive use among breastfeeding women: an update systematic review. Contraception 2016;94:262-74.
  7. The American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 206. Use of hormonal contraception in women with coexisting medical conditions. Obstet Gynecol 2019;133:e128-50. Erratum in Obstet Gynecol 2019;133:1288.
  8. Product monograph for Evra. Janssen. Toronto, ON M3C 1L9. March 2020.
  9. Product information for Twirla. Agile Therapeutics. Princeton, NJ 08540. February 2020.
  10. Mayo Clinic. Birth control pill FAQ: benefits, risks and choices. May 25, 2019. https://www.mayoclinic.org/healthy-lifestyle/birth-control/in-depth/birth-control-pill/art-20045136. (Accessed February 23, 2021).
  11. Product information for Depo-Provera. Pfizer. New York, NY 10017. December 2020.
  12. Cho MK. Use of combined oral contraceptives in perimenopausal women. Chonnam Med J 2018;54:153-8.
  13. Faculty of Sexual and Reproductive Healthcare Clinical Guidance. Contraceptive choices for young people, clinical effectiveness unit. March 2010 (amended May 2019). https://www.fsrh.org/standards-and-guidance/documents/cec-ceu-guidance-young-people-mar-2010/fsrh-guideline-contraception-young-people-may-2019.pdf. (Accessed February 23, 2021).
  14. Product information for NuvaRing. Merck. Whitehouse Station, NJ 08889. May 2019.

Cite this document as follows: Clinical Resource, Choosing a Hormonal Contraceptive. Pharmacist’s Letter/Prescriber’s Letter. March 2021. [370333]