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7.3.1 Combined oral contraceptives

**New** contraception interaction advice - see "Drug Interactions with Hormonal Contraception"

7.3.1    Combined oral contraceptives

Low strength-oestrogen 20 micrograms
Loestrin 20
Mercilon
Femodette

 

Standard strength-oestrogen 30 micrograms
Loestrin 30
Femodene
Marvelon
Microgynon 30; Microgynon 30 ED

 

Standard strength-oestrogen 35 micrograms
Brevinor
Cilest
Dianette
Phasic preparations
Logynon (ED)

Notes:

Yasmin and Evra have been approved by the Family Planning Service only.

1. Combined oral contraceptives (COCs) containing both oestrogen and progestogen are the most effective. A low hormone content pill should be tried initially and the patient maintained on a preparation with lowest oestrogen and progestogen content consistent with good cycle control and minimal side-effects. Preparations containing the older progestogens levonorgestrel and norethisterone are to be preferred. Family planning recommend ovranette first line, unless acne is a probel where brevinor should be used.

2. Guidance on the incidence of venous thromboembolism associated with COCs has been updated following a review by the European Medicines Agency. There is an increased risk of venous thromboembolic disease in users during the first year and possibly after restarting after a break of four weeks or more. The risk is considerably smaller than that associated with pregnancy (about 60 cases per 100,000 pregnancies). In all cases, the risk of venous thromboembolism increases with age and in the presence of other risk factors e.g. obesity. The risk also depends on the type of progestogen used.   

For further details see the Combined Hormonal Contraception and Risk of Venous Thromboembolism table in BNF section 7.3.1 and the MHRA DSU Feb 2014.

3. Provided that women are fully informed of, and accept, these very small risks and do not have medical contra-indications, it should be a matter of clinical judgement and personal choice which type of oral contraceptives are prescribed.

4. Arterial disease – Arterial disease is rarer but much more serious. It is related to age and the risk is strongly influenced by smoking. Myocardial infarction is increased by a factor of between three and five times compared with non-users. The increased risk is primarily concentrated in older women (>35) and is increased ten times among smokers. Diabetes has not been shown to increase the risk of thromboembolism.

5. Phased preparations were introduced to improve cycle control but there is no good evidence that they do so and they are more complicated to use. They may be useful if a patient is unable to tolerate the progestogenic side effects.

6. Combined oral contraceptives (COCs) have long been thought to be associated with a small increased risk of cervical cancer. Whether this association is due directly to the effect of COCs or whether it reflects, at least partly, confounding effects of other factors such as smoking, number of sexual partners, and age at first intercourse has been unclear. New data1 add to the evidence that COCs have a role in the development of cervical cancer.

The latest report1 has reanalysed data for more than 16 500 women with cervical cancer and found that current use of COCs for 5 years or longer is accompanied by an increased risk of cervical cancer (relative risk 1·90 [95% CI 1·69–2·13]). The baseline risk of cervical cancer increases with age, and the number of extra cases in COC users increases with age. The new report estimates that:

  • Women who use COCs for 5 years from age 20 years have increased cumulative incidence of cervical cancer at age 50 years from 38 cases per 10 000 (in neverusers) to 40 cases per 10 000 (ie, an extra two cases per 10,000).

  • Women who use COCs for 10 years from age 20 years have increased cumulative incidence of cervical cancer at age 50 years from 38 cases per 10 000 (in never-users) to 45 cases per 10 000 (ie, an extra seven cases per 10,000).

Risk falls when COCs are stopped; after about 10 years, risk reaches the same level as that for never-users of COCs. The data suggest that the risk of cervical cancer in users of progestogen-only injectable contraceptives (ie, Depo-Provera and Noristerat) may be similar to that for COC users.

7. No epidemiological data are available for the risk of cervical cancer in users of Evra (a combined hormonal contraceptive patch), NuvaRing, (a combined hormonal intravaginal contraceptive), progestogen-only pills or Mirena (a progestogen-only intrauterine device).

 

For link to BNF section: 7.3.1 Combined hormonal contraceptives