Estradiol 1.5 mg / Nomegestrol 2.5 mg Combined Oral Contraceptive in Women of Reproductive Age with ADHD and Comorbid Anxiety‑Depressive Disorders

1. Indication and First‑line Recommendation

• The estradiol‑nomegestrol acetate combined oral contraceptive is specifically recommended as a first‑line option for contraception in young women, including those with psychiatric conditions. 1
• Because the formulation uses natural 17β‑estradiol rather than ethinylestradiol, it is theorised to provide a more favourable hormonal profile. 2

2. Dosage and Formulation

• The standard low‑dose preparation (1.5 mg estradiol + 2.5 mg nomegestrol acetate) is considered the appropriate effective dose for this population. 1

3. Pre‑initiation Assessment

• Pregnancy must be reasonably excluded before starting the contraceptive. 3

4. Initiation Timing and Backup Contraception

• Initiation should occur within the first five days of the menstrual cycle to avoid the need for backup contraception. 3
• If initiation occurs after day 5, backup contraception must be used for seven consecutive days. 3, 4

5. Structured Monitoring (First 3–6 Months)

• Monthly clinic visits during the first three months are advised to assess mood, anxiety, and irritability. 5, 6
• Irregular bleeding is common in the first three to six months and generally not harmful; it should be monitored. 5, 6

6. Ongoing Follow‑up (After 6 Months)

• Weight should be monitored because weight changes can affect contraceptive efficacy. 4

7. Management of Missed Pills

a. One missed pill (< 48 h)

• Take the missed pill as soon as remembered, continue the remaining pills at the usual time, and no backup contraception is required. 7, 8, 4

b. Two or more missed pills (≥ 48 h)

• Take the most recent missed pill immediately, discard the others, and use backup contraception for seven consecutive days.
• If the missed pills occur in the first week and unprotected intercourse happened within the preceding five days, consider emergency contraception.
• If the missed pills occur in the last week, omit the hormone‑free interval and start a new pack immediately. 7, 8, 4

8. ADHD Medication Considerations

• Continuation of ADHD stimulant medication is recommended while using the estradiol‑nomegestrol oral contraceptive. 9
• No known contraindications exist for the combined use of stimulant ADHD drugs and hormonal contraceptives. 9
• Although no direct pharmacologic interactions have been demonstrated, clinicians should monitor for potential mood effects. 5, 6, 9

9. Alternative Contraceptive Options (When Oral Formulation Is Not Appropriate)

• Non‑oral reversible long‑acting contraceptives (e.g., hormonal or copper IUD, sub‑dermal implant) are viable alternatives with a lower risk of mood‑related adverse effects in women with ADHD. 4
• The copper IUD is an effective non‑hormonal option when oral contraceptives are unsuitable. 4