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Contraception - Management
Which combined oral contraceptive (COC) should I offer first-line?

  • For a woman receiving her first prescription of a combined oral contraceptive (COC), the recommended first-line option is a monophasic preparation containing 30 micrograms of ethinylestradiol (standard strength) with norethisterone or levonorgestrel (first-line progestogens).
  • However, there are no COCs that cannot be used first-line after counselling, and the preference of the woman should be taken into consideration when prescribing a COC.
Clarification / Additional information
  • Combined oral contraceptives marketed in the UK are listed in Available types.
Basis for recommendation
  • Few direct comparative data are available to identify the best, first-line combined oral contraceptives (COCs) [FFPRHC, 2007b].
  • The recommendation to offer a monophasic COC containing 30 micrograms of ethinylestradiol combined with norethisterone or levonorgestrel first-line is based on guidance issued by the Faculty of Sexual and Reproductive Healthcare (FSRH), formerly the Faculty of Family Planning and Reproductive Healthcare (FFPRHC) [FFPRHC, 2007b]. The guidelines take account of Cochrane systematic reviews and other evidence.
  • CKS does not recommend the following as first-line options:
    • Biphasic or triphasic COCs:
      • This recommendation is based on guidance issued by FFPRHC [FFPRHC, 2007b]. The two relevant Cochrane systematic reviews have been updated since drafting of the FFPRHC guideline, but their conclusions have not changed from the earlier versions.
      • Monophasic COCs compared with biphasic COCs: a Cochrane review compared the efficacy, adverse effects, cycle control, and continuity rates of monophasic and biphasic COCs and found no important differences in bleeding patterns between biphasic and monophasic preparations. The strength of the evidence is limited by the identification of only one trial, the methodological shortcomings of that trial, and the absence of data on accidental pregnancies. The authors of the review concluded that because no clear rationale supports the use of biphasic pills, and because extensive evidence is available for monophasic pills, the latter are preferred [van Vliet et al, 2006a].
      • Monophasic COCs compared with triphasic COCs: a Cochrane systematic review compared triphasic COCs with monophasic COCs in terms of efficacy, cycle control, and discontinuation owing to adverse effects. Twenty-one trials were found. Meta-analysis was generally not possible because of differences in measuring and reporting the cycle disturbance data and in progestogen type and hormone dosages. The available evidence is insufficient to determine whether triphasic COCs differ from monophasic COCs in effectiveness, bleeding patterns, or discontinuation rates. The authors concluded that because triphasic-pill regimens are more complex and are often more expensive, monophasic pills should be the first-line choice [van Vliet et al, 2006b].
    • COCs containing desogestrel and gestodene:
      • Norethisterone- and levonorgestrel-containing COCs may have a lower risk of venous thromboembolism than COCs containing desogestrel and gestodene [FFPRHC, 2007b].
      • Guidelines from the Department of Health state that, provided women are informed of the very small risks of venous thromboembolism associated with desogestrel and gestodene, the decision about which pill to use should be made jointly by the woman and her doctor or other family planning professional [DH, 1999].
    • COCs with 20 micrograms of ethinylestradiol:
      • In general, a lower dose of a drug is preferred to a higher dose, if this does not compromise efficacy, because the lower dose usually minimizes adverse effects. Although similar efficacy is found for COCs with 20 and 30 micrograms of ethinylestradiol, women taking 20 micrograms are more likely to have unscheduled bleeding.
      • A Cochrane review found no difference in contraceptive effectiveness between COCs containing =< 20 micrograms of ethinylestradiol and those containing > 20 micrograms [Gallo et al, 2005]. However, several COCs containing 20 micrograms of ethinylestradiol resulted in higher rates of early trial discontinuation (overall and due to adverse events, such as irregular bleeding) and increased risk of bleeding disturbances (amenorrhoea/infrequent bleeding; irregular, prolonged, frequent bleeding; or breakthrough bleeding or spotting) than their higher-oestrogen comparison pills.
    • Yasmin® (ethinylestradiol 30 micrograms and drospirenone 3 mg):
      • The Scottish Medicines Consortium did not recommend Yasmin® for use within NHS Scotland because it found no evidence that Yasmin® is superior to other standard strength COCs with respect to acne, premenstrual symptoms, or well-being, and it is substantially more expensive than alternative products [Scottish Medicines Consortium, 2003a].
      • A more recent review found no good evidence to suggest that Yasmin is superior to other COCs (including co-cyprindiol) with regard to acne or premenstrual symptoms [MeReC, 2006]. The review identified a small trial (n = 128) which found Yasmin® and co-cyprindiol to have a similar effect on reducing median total acne lesion count in those with mild to moderate acne. However, co-cyprindiol is only licensed for severe acne that has not responded to oral antibiotics (or for moderately severe hirsutism). For severe acne, it is not known how effective Yasmin® would be compared to co-cyprindiol.
    • COCs with higher doses of levonorgestrel or norethisterone:
      • There is no evidence of any advantages over COCs with lower doses of these progestogens.
    • Co-cyprindiol (cyproterone acetate [anti-androgen] and ethinylestradiol):
      • Co-cyprindiol is not licensed for use solely as a contraceptive. It should be reserved for selected women requiring treatment for severe acne, those refractory to prolonged antibiotic therapy, and those with moderately severe hirsutism [ABPI Medicines Compendium, 2004a]. Co-cyprindiol is useful in these women who also wish to receive oral contraception [BNF 53, 2007].
      • The Committee on the Safety of Medicines warned of the increased incidence of venous thromboembolism in users of co-cyprindiol compared with women who use low dose oestrogen COCs [CSM, 2002].
      • For further information on its use in the treatment of acne vulgaris, see the CKS topic on Acne vulgaris.
    • Every-day (ED) preparations:
      • These are not routinely used in the UK but can be useful to women who have difficulty starting the next packet at the correct time.
  • The FFPRHC guidelines recommend as good practice that there are no COCs that cannot be used first-line after counselling and that the preference of the woman should be taken into consideration when prescribing a COC [FFPRHC, 2007b].

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