Managing adverse effects of combined hormonal contraception

Evidence to guide choice of formulation of combined hormonal contraception for individuals experiencing adverse effects is limited.

To manage symptoms where the causal link with combined hormonal contraception is uncertain (eg headaches, nausea, breast tenderness, bloating, mood changes, loss of libido, weight gain) consider whether other factors, such as life circumstances, could be the cause, particularly if they develop after the first 3 months of use. If troublesome symptoms persist, consider an alternative method of contraception. A suggested approach to management is given in Suggested approach to managing adverse effects of combined hormonal contraception.

Table 1. Suggested approach to managing adverse effects of combined hormonal contraception
[NB1]
Symptom	Action
headache [NB2]	reduce estrogen or progestogen dose if headache occurs in hormone-free interval, consider a tailored regimen
nausea [NB3]	reduce estrogen dose take COC at night change to another method of contraception
breast tenderness	reduce estrogen or progestogen dose change progestogen; consider using a COC containing drospirenone
bloating and fluid retention	reduce estrogen or progestogen dose change progestogen; consider using a COC containing drospirenone (has a mild diuretic effect)
breakthrough bleeding	address underlying causes [NB4] if using a COC containing 20 micrograms of ethinylestradiol, change to a COC with a higher dose of estrogen [NB5] change progestogen change to vaginal ring if using continuously, consider a 4-day hormone-free break when breakthrough bleeding occurs
vaginal discharge	exclude infection if using vaginal ring, change to COC
weight gain [NB6]	address other causes
mood changes [NB7]	medical review if new or worsening mood symptoms address other causes consider a tailored regimen consider a COC containing drospirenone if symptoms exacerbated premenstrually
acne	change formulation; however, insufficient evidence to guide choice of contraceptive—see Contraception in individuals with acne
reduced libido	change formulation; however, insufficient evidence to guide choice of contraceptive
Note: COC = combined oral contraceptive; LNG-IUD = levonorgestrel-releasing intrauterine contraceptive device NB1: Many symptoms resolve within 3 months of starting combined hormonal contraception; if other causes have been excluded, consider waiting 2 to 3 months before changing contraceptive. NB2: If migraine develops for the first time while taking combined hormonal contraception, seek expert advice on ongoing contraception; see Contraception in individuals with migraine. NB3: Persistent nausea should be investigated with a pregnancy test. NB4: Causes of bleeding include pregnancy, sexually transmitted infections (eg chlamydia), missed or late pills, altered schedule of the vaginal ring, drugs that induce liver enzymes, and vaginal, cervical or uterine pathology. NB5: Do not use COCs containing 50 micrograms of ethinylestradiol or mestranol for contraception because they pose an unacceptable risk of venous thromboembolism. NB6: Weight gain has not been shown to be causally linked to use of combined hormonal contraception. NB7: An association between first prescription of an antidepressant and use of hormonal contraception has been seen, but a causal link is not proven.