Combined Oral Contraceptives

Combination contraceptives are medications intended for use by women who are sexually active but who do not wish to become pregnant. Combination contraceptives are often used off-label to treat other female reproductive system-related issues such as painful periods, endometriosis-related pelvic pain, menstrual migraines, PMS (premenstrual syndrome), and menstrual cycle irregularities. Combination contraceptives may also be used to improve bone mineral density or to treat acne. Combination contraceptives contain a synthetic estrogen and a synthetic progesterone, two hormones that influence the female reproductive system and suppress ovarian function, potentially impacting endometriosis lesion growth. Because they contain estrogen, these medications carry an increased risk of developing blood clots. Additionally, they may increase a woman's risk of developing abnormal uterine bleeding or impaired liver functioning.1-4

A laparoscopy (a minimally invasive surgical procedure) is the only method of definitively diagnosing endometriosis. Because of this, some providers may treat endometriosis-related symptoms empirically. This means that they are basing their treatment decisions on past experiences and other cases they have seen. If a woman comes in with clear signs of endometriosis, her provider may first recommend combination contraceptives for her pain to see if this provides relief instead of pursuing diagnostic surgery. This may lead to symptom and pain reduction without needing to undergo a procedure. Additionally, a woman may come in with signs of endometriosis who is also wanting to try birth control. Her provider may recommend combination contraceptives to potentially address both issues.5 Combination contraceptives include birth control pills, as well as the vaginal ring (NuvaRing) and the skin patch (Ortho Evra, Xulane) contraceptives.3

What are the ingredients in combination contraceptives?

Each combination contraceptive contains synthetically created estrogen and progesterone hormones. Although the exact synthetic version may vary between each combination contraceptive, they all function in a similar manner, and behave like naturally produced estrogen and progesterone in the body.3,4

How do combination contraceptives work?

Combination contraceptives affect the levels of estrogen and progesterone in the body. Although these hormones are synthetically created in these medications, the body recognizes them in the same manner. Combination contraceptive stops the body from ovulating (the process by which the ovaries release an egg each month). This suppression of ovarian function helps stabilize natural hormone levels in the body, suppressing endometriosis lesion growth. Specifically, the estrogen component reduces or halts the production of two hormones called FSH (follicle stimulating hormone) and LH (luteinizing hormone) which lead to ovulation. The progesterone also reduces the production of LH, as well as limits sperm movement and ability to reach any eggs that may be released. Both estrogen and progesterone affect the endometrium (lining of the uterus) and lighten menstrual flow.1,3,4

All of these mechanisms also suppress endometriosis lesion growth and shedding in other parts of the body, thus, reducing a woman's endometriosis-related pain.

What are the possible side effects of combination contraceptives?

Many clinical trials have evaluated the safety and efficacy of combination contraceptives. The most common side effects of these medications include, but are not limited to:

  • Nausea
  • Vomiting
  • Irregular uterine bleeding
  • Abdominal pain
  • Headache
  • Acne
  • Breast tenderness or pain
  • Anxiety and depression2,4,6

These are not all the possible side effects of combination contraceptives. Talk to your doctor about what to expect or if you experience any changes that concern you during treatment with combination contraceptives.

Things to know about combination contraceptives

Combination contraceptives can increase a woman's risk of developing blot clots. They should not be used before or immediately after a major surgery, or by any woman with a history of blot clots. Combination contraceptives should not be used by women who have a condition that makes them prone to blood clots, such as lupus or hereditary thrombophilia. There is a chance that combination contraceptives may affect the growth of estrogen-related cancers, such as breast cancer. Women with breast cancer or other estrogen-dependent cancers should not take combination contraceptives. Combination contraceptives may also lead to an increase in blood pressure or impact liver functioning. Alert your provider if you notice any of the following:

  • Breast lumps or discharge from the nipple
  • Severe nausea and vomiting
  • Pain in the calf, leg, groin, or chest
  • Pain in the side, abdomen, or stomach
  • Sudden slurring of speech
  • Sudden vision changes
  • Sudden loss of coordination or numbness of the limbs
  • Yellowing of the eyes or skin
  • Sudden shortness of breath2,6

Before starting a combination contraceptive, tell your provider if you:

  • Are over the age of 35
  • Are taking any other medications, vitamins, or supplements
  • Have a history or blood clots or a family history of blood clots
  • Have any liver conditions
  • Have any cardiovascular conditions
  • Have any conditions that could make you prone to developing blood clots
  • Have any mental health-related conditions
  • Are a smoker
  • Are allergic to any medications or ingredients in any medications
  • Could be pregnant
  • Are planning to breastfeed or are currently breastfeeding
  • Have high blood pressure
  • Have diabetes or are pre-diabetic2,6

Dosing information

The dosing information for a combination contraceptive can vary with the type of combination contraceptive used. Most combination contraceptive pills will come in a blister pack with 21 active pills that you can pop out one at a time and take. These pills should be taken at the same time each day. If you forget to take a pill, it is generally recommended that you take the missed pill as soon as you remember. If 24 hours have passed, or you have missed more than one pill, contact your provider on what the next step is based on your medication and situation. A back-up contraceptive such as condoms may be recommended.

There are often seven inactive pills in the pack as well, and after the 21 active pills are taken, the inactive pills will follow. These are taken once a day at the same time, and will trigger a woman's period to begin. There are ways to take the pill and different brands that can prevent a woman's period from happening altogether. Contact your provider to see if this is possible or recommended in your specific situation.3,4

Other non-pill combination contraceptives, such as the ring or the patch, can have different administration schedules. In most cases, the vaginal ring remains in place for three weeks at a time, and is then removed for a week to allow menstruation. After this, a new one is inserted in its place. The patch is changed weekly for three weeks, and is removed for one week to allow menstruation. Your provider will let you know what the dosing schedule will be for the method you are using.

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Written by: Casey Hribar | Last reviewed: February 2021