Combined Oral Contraceptives for Premenstrual Syndrome Management

Initiation and Management of COCs

The American Academy of Pediatrics recommends starting adolescents and women with less severe symptoms on a monophasic pill containing 30-35 μg of ethinyl estradiol with a progestin such as levonorgestrel or norgestimate 1, 2
COCs can be initiated at any time if it is reasonably certain that the woman is not pregnant, with additional contraceptive protection needed for 7 days if started >5 days after menstrual bleeding began 3
Blood pressure measurement is recommended before initiation of COCs 3

Extended or continuous cycle regimens may be beneficial for PMS symptoms, providing decreased menstrual cramping and blood loss, improved management of conditions exacerbated cyclically, and optimized ovarian suppression 1, 2
The most common adverse effect of extended-cycle regimens is unscheduled bleeding 2
Regular blood pressure monitoring is important for all COC users, with an increased risk of venous thromboembolism in young women using COCs, approximately 3-4 per 10,000 woman-years 2, 5

If one pill is late (<24 hours), take the late pill as soon as possible and continue the remaining pills at the usual time, while if one pill is missed (24-48 hours), take the missed pill immediately and continue the pack 4
If two or more consecutive pills are missed (≥48 hours), take the most recent missed pill, continue the pack, and use backup contraception for 7 days 4
Seven days of continuous combined hormonal contraceptive use is necessary to reliably prevent ovulation 4
For women who frequently miss pills, consider alternative methods less dependent on user compliance, and if PMS symptoms persist despite COC use, counsel on alternative contraceptive methods 4, 6