Contraceptive Pearl: Combined oral contraceptives

Washington State Health Care Authority sent this bulletin at 01/23/2026 08:00 AM PST

January 23, 2026

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Combined oral contraceptives

This bulletin is being sent by the Health Care Authority (HCA) in partnership with the Reproductive Health Access Project (RHAP).

Written by Marielle Jamgochian, MD

Combined oral contraceptives (COCs) are one of the most common birth control methods used today.¹ There are dozens of formulations of COCs, all of which contain an estrogen and a progestin. For pregnancy prevention, COC efficacy is similar across all formulations. Thus, choice of pill can be guided by the patient's preferences, medical comorbidities, and cost. Those with anemia may benefit from a COC with added iron, but those with constipation may wish to avoid added iron. Those with heavy menstrual bleeding, who wish to time their bleeding, or who prefer no monthly bleeding may benefit from extended cycle formulations. There are also options for chewable or oral disintegrating tablets for patients who have trouble swallowing pills.

Hormone dosages vary in different pill formulations. Estrogen formulation is commonly ethinyl estradiol or estradiol valerate.² Dosage of ethinyl estradiol generally varies from 10 mcg (ultralow dosing) to 50 mcg (high dose). Generally, higher dose estrogens carry a higher risk of estrogen-related adverse effects, namely, risk of venous thromboembolism (VTE). However, there are no randomized controlled trials that demonstrate that there is a difference in rates of VTE between low doses (under 30 mcg), though risk of VTE in >50mcg doses is higher than doses <50mcg.³ In general, risk of VTE in any COC is lower than risk of VTE in pregnancy and postpartum.^4-6* Data supports use of 30 mcg dose or higher for adolescents as lower doses of ethinyl estradiol have been associated with impaired bone acquisition.⁷ Estradiol valerate may have lower risk of VTE though absolute risk of VTE in both groups is low.² Lower estrogen doses may confer increased risk of breakthrough bleeding, which may lead to discontinuation in some patients.⁸

Side effect profiles can differ by type of progestin. A newer progestin, drospirenone, is derived from spironolactone and structurally has anti-androgen and anti-mineralocorticoid effects.⁹ In a retrospective analysis of 2147 patients, patients reported greatest acne improvement on drospirenone-containing COC compared to other progestins.¹⁰ There is a potential increased risk of VTE with drospirenone.¹¹

Monophasic pills have one dose of hormone throughout. Biphasic, triphasic, and quadphasic formulations are also available with differing levels of hormone by week. Multiphasic formulations generally do not have any proven advantage over monophasic pills, however, they may make it more difficult to skip withdrawal bleeding. Other disadvantages include difficulty if a tablet is missed or if a pill pack is lost or damaged in the middle of a cycle.⁸

Traditional pills contain 21 days of active pills and 7 days of placebo, but other formulations are available, for example, shortened or no placebo pills, or placebo pills after extended cycle of active pill. Withdrawal bleeding was built into COCs to mimic a period when a patient takes placebo pills. There is no medical reason to have withdrawal bleeding while on COCs other than patient preference.^8,12 Extended cyclic formulations have placebo pills every 3 months or every year for withdrawal bleeding. Monophasic pill packs can also be used for continuous dosing, though a patient will need extra pill packs to make up for skipped placebo pills. Continuous dosing may increase the chance of unexpected/unplanned breakthrough bleeding or spotting.¹²

In summary, COCs offer reliable pregnancy prevention with flexibility to tailor formulations based on individual preferences, comorbidities, and side effect profiles. Understanding the differences in estrogen and progestin components allows clinicians to optimize tolerability for each patient. In general, most patients do not need a specially-chosen COC and can do well with any formulation.

*Range of 5-7/10,000 to 8-11/10,000 per woman-year for COC vs 20/10,000 per woman-year for pregnancy.

References

See RHAP's original post for sources.

About HCA and RHAP partnership

HCA and RHAP are partnering to support the reproductive health provider community’s access to accurate evidence-based clinical information.

If you are an enrolled Apple Health provider, HCA will pay to print items from the RHAP resource library.

Materials such as the birth control choices fact sheet or MEC for initiating contraception chart are available for bulk printing.

To order bulk printing

Email: Brandy Bautista
Include the following information:

"Washington Health Care Authority" in the body of the email
Items you'd like to order
Quantities
Business address
Delivery address (if different than your business address)

Contact

Email: Andrea Estes, Sexual and Reproductive Health Programs Innovation Manager at HCA, with questions regarding this partnership.

About the Health Care Authority (HCA)

Functioning as both the state's largest health care purchaser and its behavioral health authority, the Washington State Health Care Authority (HCA) is a leader in ensuring Washington residents have the opportunity to be as healthy as possible.

There are three pillars of our work: Apple Health (Medicaid); the Public Employees Benefits Board (PEBB) and School Employees Benefits Board (SEBB) programs; and behavioral health and recovery. Under these pillars, HCA purchases health care, including behavioral health treatment for more than 2.7 million Washington residents and provides behavioral health prevention, crisis, and recovery supports to all Washington residents.

Please do not reply directly to this message. For more information, visit the HCA website, where you'll also find contact information.

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