Expand knowledge base on combined pills

In discussing birth control options with a patient, she tells you she is interested in taking the Pill, but is concerned that it might be dangerous due to “all the risks.” What’s your next move?

Remind women that in general, contraceptives pose few serious health risks.1

When considering combined oral contraceptives (OCs), the use of the Pill is generally safer than unintended pregnancy, says Anita Nelson, MD, professor in the Obstetrics and Gynecology Department at the David Geffen School of Medicine at the University of California in Los Angeles.

Pregnancy-related mortality in the United States from 1998 to 2005 was higher than any other period in the prior 20 years2, says Nelson, who provided an OC update at the recent Contraceptive Technology: Quest for Excellence conference.3 To compare the risks of death, the risk of death from pregnancy and delivery is about 1 in 8,700, lower than the annual risk of death from an automobile accident. For healthy, nonsmoking women ages 15-34, the chance of dying from oral contraceptive use is less than 1 in 1 million.4

Women have an underestimation of fertility risk, an under-appreciation of the health risks of pregnancy, and an over-estimation of the risks of contraception, says Nelson.

In a recent survey conducted to assess women’s knowledge of the health risks of pregnancy and how their assessment of pregnancy risks compared to their estimates of the risks of oral contraceptives, more than 75% of respondents rated birth control pills as more hazardous to a woman’s health than pregnancy.5 Less than half knew that risks of venous thromboembolism (VTE), diabetes, and hypertension increase in pregnancy.

Oral contraceptives are safe and well-tested, says Nelson. They are the best-studied medication in history, with more than 50 years of clinical experience logged in the United States, she notes. (Remind women of the Pill’s noncontraceptive benefits; see the list, below.)

Non-contraceptive Health Benefits of OCs

Proven reduction in risk:

  • Ovarian cancer
  • Endometrial cancer
  • Pelvic inflammatory disease
  • Ectopic pregnancy
  • Benign breast disease
  • Menorrhagia
  • Dysmenorrhea
  • Iron deficiency anemia
  • Low bone density

Possible reduction in risk:

  • Cardiovascular disease
  • Uterine fibroids
  • Endometriosis
  • Rheumatoid arthritis

Source: Nelson AL. Combined oral contraceptives: update 2012. Presented at the Contraceptive Technology: Quest for Excellence conference. Atlanta; November 2012.

There are often stories in the news challenging the safety of birth control pills, Nelson notes. She offers the following messages to present to patients if the evening news carries such a story:

  • Do not stop your pill until we talk.
  • Whatever pill you are taking is safer than pregnancy.
  • When you stop taking your pill for only four weeks and then restart it, you experience the risks that happen at the time of pill initiation.
  • Keep on letting your pill work for you until the dust settles.

Check extended cycle

How many women in your practice use pills in an extended regimen? While research indicates that extended cycle OCs have demonstrated safety, with less blood loss than standard 21/7 pills, their use has not been popular, says Nelson.6

However, recent surveys show that many women would prefer to bleed less frequently than once a month.3 To help patients considering extended cycle pills, Nelson offers the following counseling points:

  • Validate the patient’s beliefs in need for monthly menses without hormonal contraception.
  • Menses represents reproductive failure. It’s a cleanup operation to prepare for better luck next cycle.
  • Dispel patients’ concerns proactively. Explain that in extended cycle, a woman’s blood is not building up, and her ovaries are not swelling. When she chooses to discontinue the method, her fertility will return, if she is not menopausal.
  • Use of extended regimen pills does not increase a woman’s cancer risk.

Up OC access, success

How can your clinic streamline prescribing practices to improve access and success with combined OCs? Nelson reviews the following key points:

  • No pelvic exam is needed prior to prescription.7 The American College of Obstetricians and Gynecologists (ACOG) and the World Health Organization (WHO) require only a check of weight, blood pressure, and health history.
  • If there is a need to screen for sexually transmitted infections (STIs), use urine tests.
  • Be sure to use Same Day/Quick Start protocols. Advise the patient to take her first pill at the time of the office visit or within the next 12 hours. Unless she has started the pills within five days of starting her period, counsel her to use a backup method, such as condoms, for at least seven days.
  • A pregnancy test is indicated only if the patient has had unprotected intercourse since her last menstrual period. Provide her with emergency contraception (EC) immediately if she has had unprotected intercourse in last five days.
  • If possible, provide several months’ supply of pills. Dispensing a year’s supply of pill cycles is associated with higher method continuation and lower costs than dispensing fewer cycles per visit.8
  • Provide a supply of condoms for use if the patient decides to stop using pills. Provide a demonstration of proper condom use.

“Give EC by advance prescription,” advises Nelson. “Accidents will happen.”

Remember that noncompliance is cited in 86% of unintended pregnancies with combined oral contraceptives, says Robert Hatcher, MD, MPH, professor of gynecology and obstetrics at Emory University School of Medicine in Atlanta. “This can be avoided by prescribing pills continuously instead of 21/7, 21/7, 21/7, the dual use of OCs with condoms, or by quickly switching women from OCs to long-acting reversible contraception if they are missing pills each month,” says Hatcher.


  1. Trussell J. Choosing a contraceptive: efficacy, safety, and personal considerations. In: Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology: 20th revised edition. New York: Ardent Media; 2011.
  2. Berg CJ, Callaghan WM, Syverson C, et al. Pregnancy-related mortality in the United States, 1998 to 2005. Obstet Gynecol 2010; 116(6):1,302-1,309.
  3. Nelson AL. Combined oral contraceptives: update 2012. Presented at the Contraceptive Technology: Quest for Excellence conference. Atlanta; November 2012.
  4. Trussell J, Jordan B. Reproductive health risks in perspective. Contraception 2006; 73(5):437-439.
  5. Nelson AL, Rezvan A. A pilot study of women’s knowledge of pregnancy health risks: implications for contraception. Contraception 2012; 85(1):78-82.
  6. Edelman AB, Gallo MF, Jensen JT, et al. Continuous or extended cycle vs. cyclic use of combined oral contraceptives for contraception. Cochrane Database Syst Rev 2005; (3):CD004695.
  7. Stewart FH, Harper CC, Ellertson CE, et al. Clinical breast and pelvic examination requirements for hormonal contraception: Current practice vs evidence. JAMA 2001; 285(17):2,232-2,239.
  8. Foster DG, Parvataneni R, de Bocanegra HT, et al. Number of oral contraceptive pill packages dispensed, method continuation, and costs. Obstet Gynecol 2006; 108(5):1,107-1,114.