3 DECEMBER 2021 ausdoc . com . au no other contraindications , COCPs can be useful in managing androgenic symptoms and regulating cycles in patients with PCOS . Note that the TGA has only approved cyproterone-containing COCPs for treating severe acne and hirsutism , and advises that in these patients they can additionally provide contraception . These pills should not be routinely prescribed for patients without severe androgen-related symptoms .
HMB and dysmenorrhoea All COCPs can reduce menstrual losses and dysmenorrhoea . The EV / dienogest pill ( Qlaira ) is licensed for HMB , although superiority in this regard over other pills is not clear . Some pills have high rates of amenorrhoea during the hormone-free break ( occurring in up to 30 % of users for estradiol / nomegestrol pills ).
Extended or continuous hormone-pill use of any monophasic pill ( by running pill packs together or using an extended cycle COCP ) can be helpful in reducing withdrawal bleeds and pelvic pain , including pain associated with endometriosis .
Premenstrual syndrome and premenstrual dysphoric disorder Limited evidence suggests that all COCPs may improve premenstrual symptoms and the severe form of premenstrual syndrome ( PMS ) called premenstrual dysphoric disorder ( PMDD ), especially if hormone-free intervals are avoided with an extended or continuous cycle regimen . The 20 µ g EE / 3mg drospirenone pill ( Yaz ) is licensed for the management of PMDD , but not PMS .
This recommendation is based on research showing it is more effective than placebo over three months . This effect may relate to the shortened hormone-free break and spironolactone-like properties of drospirenone . However , the data demonstrates a large placebo effect , and it is unclear if the effect of drospirenone formulations was superior to other COCPs or persisted beyond three months .
COCP side effects
Concerns regarding side effects , such as weight gain , mood changes and lowered libido , are often attributed to hormonal contraception ; however , there is limited evidence to prove causation and to guide
Table 3 . Androgenicity of progestogens in COCPs Category Less androgenic
Anti-androgenic
Table 4 . Managing side effects with COCPs 33
Symptom
Headache *
Nausea #
Breast tenderness #
Bloating
Breakthrough bleeding
Weight gain Mood changes ‡
Acne
Reduced libido
Progestogen
Gestodene , desogestrel , nomegestrol acetate , norethisterone ( balanced by oestrogenic receptor activity )
Dienogest , drospirenone , cyproterone
Strategy
Consider minimising the hormone-free break if headaches occur during this time Reduce oestrogen or progestogen dose
Reduce oestrogen dose Take pill at night
Reduce oestrogen or progestogen dose Change progestogen ; consider using a COCP with drospirenone
Reduce oestrogen or progestogen dose Change progestogen ; consider using a COCP with drospirenone ( has a mild diuretic effect )
Exclude underlying causes Increase oestrogen dose ( max 35mcg EE ) Change progestogen Change to vaginal ring If using COCP continuously , consider a 4-day hormone-free break when breakthrough bleeding occurs
Consider other causes , as no evidence it is caused by combined oral contraception
Medical review if new or worsening mood symptoms Address other causes Consider a tailored regimen Consider a COCP containing drospirenone if symptoms exacerbated premenstrually
Change formulation ; however , insufficient evidence to guide choice of contraceptive
Change formulation ; however , insufficient evidence to guide choice of contraceptive
* Exclude new-onset migraine or migraine with aura ( MEC 3 and MEC 4 conditions )
#
Consider excluding pregnancy ‡ An association between first prescription of an antidepressant and use of hormonal contraception has been seen , but a causal link is not proven
Reproduced with permission from ‘ Managing adverse effects of combined hormonal contraception ’ ( published 2020 Dec , amended 2021 Mar ). In Therapeutic Guidelines [ digital ]. Melbourne : Therapeutic Guidelines Limited ; 2021 Mar . tg . org . au
changes of pill type .
While it is essential to acknowledge that these effects may be related to hormonal contraception and validate concerns , it is also important to consider whether other
factors may be contributing . Unscheduled bleeding is also common in the first months of use .
Persisting with a particular COCP for three months may allow side effects to
settle . If unwanted symptoms , such as PMS , headaches or pelvic pain occur in the hormone-free break , it can be useful to trial skipping these breaks with extended or continuous COCP use . Other strategies for managing side effects are listed in table 4 . If symptoms persist , consider an alternative COCP formulation or different contraceptive method .
PROGESTOGEN-ONLY PILLS
POPs may be an alternative oral method when a contraindication to oestrogen precludes use of combined hormonal contraception .
Traditional POPs Traditional POPs in Australia ( also known as “ mini-pills ”) are PBS-listed , and contain a small continuous daily dose of either levonorgestrel or norethisterone ( table 5 ). These mini-pills primarily work by thickening the cervical mucus and have a variable effect on suppression of ovulation .
Evidence to guide choice between these POPs is lacking . While their efficacy is the same as the COCP , their narrow three-hour missed pill window may result in a higher likelihood of failure , especially in young women with high fertility .
Drospirenone 4mg POP From August 2021 a new POP containing drospirenone 4mg became available . Each cycle contains 24 hormone pills and four hormone-free pills , with similar efficacy in trials to other oral contraceptives . Unlike traditional POPs , the drospirenone 4mg POP reliably inhibits ovulation , and has a 24-hour rather than three-hour missed pill window . It is not covered by the PBS , so costs more to patients than traditional POPs .
Safe POP prescribing
Both the traditional POPs and the new drospirenone 4mg POP are not associated with increased cardiovascular risks and have few contraindications and precautions .
The only absolute contraindication ( UKMEC 4 ) to POPs is current breast cancer . UKMEC 3 conditions for POPs include past breast cancer , severe ( decompensated ) cirrhosis , hepatocellular adenoma or malignant liver tumour and CV disease that
Got a question about O & G ? Introducing our new Women ’ s Health Group leader Professor Steve Robson
Professor Robson is an internationally recognised leader in women ’ s health with 25 years ’ experience in obstetrics and gynaecology . He has specific expertise in gynaecological surgery and birth procedures and will act as group leader alongside our sexual health expert Dr Terri Foran .
Both are keen to hear and respond to your women ’ s health questions , so please jump into the group and fire away .
AusDoc Women ’ s Health Group Chairperson Professor Steve Robson
AusDoc Women ’ s Health Group Chairperson Dr Terri Foran
Join a group at ausdoc . com . au / groups