Pill ladder for combined pill (COC)

Switching from hormonal contraceptive method to combined hormonal contraception (CHC) (1):

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CHC, combined hormonal contraception; COC, combined oral contraception; CTP, combined transdermal patch; CVR, combined vaginal ring; HFI, hormonal free interval

Oestrogen and Progestogen effects of combined oral contraceptive (COC)

• Oestrogen Effects
  • menorrhagia
  • cervical ectopy
  • breast fullness
  • migraine type headaches
  • fluid retention, weight gain (fluid)
  • tiredness, irritability
  • nausea
  • bloating
    
    
• Try changing to:
  • lower oestrogen or higher progestogen pill or pill with some androgenic activity
    • problems related to a relative oestrogen excess may be helped by prescribing a more progesterone dominant pill such as Microgynon 30 or Ovranette; or Loestrin 30, so moving left across the ladders (see below)
      
      
• Progestogen Effects
  • scanty menses
  • leukorrhoea, dry vagina
  • breast tenderness
  • dull type of headache - often of pill withdrawal
  • appetite increase, weight gain
  • premenstrual depression
  • leg cramps, softening of ligaments
  • acne, greasy hair
  • vaginal dryness
  • low mood
  • low libido especially if associated with low mood
    
    
• Try changing to:
  • lower progestogen pill or less androgenic pill or higher oestrogen pill
    • problems related to a relative progesterone excess may be helped by prescribing a more oestrogen dominant COC such as Cilest, Marvelon, Femodene or Minulet, or Yasmin, so moving right across the ladders (see below)
    • for some of the progestogens (e.g. levonorgestrel) the unwanted effects are due to their androgenicity, so switching does not necessarily only mean trying a more oestrogenic pill, but perhaps switching to a less androgenic progestogen (norgestimate, gestodene, or desogestrel)

The pill ladder

In Table below, the first column is the micrograms of oestrogen. The three left hand columns are more progesterone dominant and the four right hand columns more oestrogen dominant pills:

For LESS oestrogenic activity then move across ladders to the LEFT

For LESS progestogenic activity then move across ladders to the RIGHT

*Abbreviations:

Ethinyloestradiol (EE), Mestranol (M), Levonorgestrel (LNG), Norethisterone (NET), Norgestimate (NGT), Gestodene (GSD), Desogestrel (DSG), Drospirenone (DRSP)

**30 - 40 indicates a variable dose of oestrogen.

** 35 indicates a constant dose of oestrogen, but variable dose of progestogen

You can move up and down, left and right across the pill ladders.

Examples

• if a woman is experiencing acne and mood swings on a progesterone dominant pill such as Microgynon, it is worth moving right across the ladders to a more oestrogen dominant pill such as Cilest
  
  
• if a woman is experiencing nausea and breast tenderness on an oestrogen dominant pill such as Femodene, it is worth moving left across the ladders to a more progesterone dominant pill such as Ovranette. A possible alternative move is to a pill containing less oestrogen but the same progestogen, e.g. Femodene to Femodette
  
  
• in general with breakthrough bleeding, it is worth trying a higher dose of oestrogen (of course pathology such as a cervical problem or a sexually transmitted inf ection (STI) needs to be excluded first). Certain progesterones are associated with better cycle control than others (LNG better than NET, GSD better than DSG) but if a woman finds a particular progesterone suits her, for example DSG, but she experiences beakthrough bleeding with a low dose 20 mcg EE (Mercilon), then you can try moving up the same ladder staying with the same progesterone but increasing to a 30 mcg EE pill (Marvelon)

Notes:

• completely separating unwanted effects of oestrogen and progestogens is very difficult
  • progestogens have varying degrees of progestogenicity (wanted effect, for contraception), androgenicity (unwanted effect , leading to spotty skin, greasy hair and hirsuitism) and oestrogenicity. This can actually add or subtract from the 'apparent' level of oestrogenicity in the combined formulation. So, for example Cilest, although a 35 mcg pill, has, biologically the same long term effects as the 30 mcg pills, because it has very little oestrogenic activity

Reference:

• FSRH (July 2019). Combined Hormonal Contraception
• the Practitioner (1999); 243:462-72.
• Update (1998); 56(8): 751-8.
• Morgan S, Evans A. The Pill Ladder. Avon GP Education (Accessed July 25th 2013).