Editing Combined oral contraceptive pill (section)

==Medical use==
[[File:pillpacketopen.jpg|frame|Half-used blister pack of LevlenED]]

=== Contraceptive use ===
Combined oral contraceptive pills are a type of oral medication that were originally designed to be taken every day at the same time of day in order to prevent pregnancy.<ref name=":0">{{cite web|url=https://www.plannedparenthood.org/learn/birth-control/birth-control-pill/how-do-i-use-the-birth-control-pill|title=How to Use Birth Control Pills|website=Planned Parenthood|access-date=29 November 2017|archive-date=6 December 2017|archive-url=https://web.archive.org/web/20171206140038/https://www.plannedparenthood.org/learn/birth-control/birth-control-pill/how-do-i-use-the-birth-control-pill|url-status=live}}</ref><ref name=":13">{{cite book | vauthors = Callahan TL, Caughey AB |title=Blueprints obstetrics & gynecology |date=2013|publisher=Lippincott Williams & Wilkins |isbn=978-1-4511-1702-8 |edition=6th |location=Baltimore, MD |oclc=800907400 }}</ref> There are many different formulations or brands, but the average pack is designed to be taken over a 28-day period (also known as a cycle).{{cn|date=December 2024}} For the first 21 days of the cycle, users take a daily pill that contains two hormones, estrogen and progestogen.{{cn|date=December 2024}} During the last 7 days of the cycle, users take daily [[placebo]] (biologically inactive) pills and these days are considered hormone-free days.{{cn|date=December 2024}} Although these are hormone-free days, users are still protected from pregnancy during this time.{{medcn|date=December 2024}}

Some combined oral contraceptive pill packs only contain 21 pills and users are advised to take no pills for the last 7 days of the cycle.<ref name=":02"/> Other combined oral contraceptive pill formulations contain 91 pills, consisting of 84 days of active hormones followed by 7 days of placebo ([[Seasonale]]).<ref name=":0" /> Combined oral contraceptive pill formulations can contain 24 days of active hormone pills followed by 4 days of placebo pills (e.g. Yaz 28 and Loestrin 24 Fe) as a means to decrease the severity of placebo effects.<ref name=":02"/> These combined oral contraceptive pills containing active hormones and a placebo/hormone-free period are called cyclic combined oral contraceptive pills. Once a pack of cyclical combined oral contraceptive pill treatment is completed, users start a new pack and new cycle.<ref>{{cite web| url = https://youngwomenshealth.org/birth-control-pills-all-guides/| title = Birth Control Pills All Guides| date = October 2014| access-date = 20 October 2018| archive-date = 31 May 2023| archive-url = https://web.archive.org/web/20230531032622/https://youngwomenshealth.org/birth-control-pills-all-guides/| url-status = live}}</ref>

Most monophasic combined oral contraceptive pills can be used continuously such that patients can skip placebo days and continuously take hormone active pills from a combined oral contraceptive pill pack.<ref name=":02">{{cite journal | vauthors = Teal S, Edelman A | title = Contraception Selection, Effectiveness, and Adverse Effects: A Review | journal = JAMA | volume = 326 | issue = 24 | pages = 2507–2518 | date = December 2021 | pmid = 34962522 | doi = 10.1001/jama.2021.21392 | s2cid = 245557522 | doi-access = free | title-link = doi }}</ref> One of the most common reasons users do this is to avoid or diminish [[Extended cycle combined hormonal contraceptive|withdrawal bleeding]]. The majority of women on cyclic combined oral contraceptive pills have regularly scheduled withdrawal bleeding, which is vaginal bleeding mimicking users' menstrual cycles with the exception of lighter menstrual bleeding compared to bleeding patterns prior to combined oral contraceptive pill commencement. As such, a study reported that out of 1003 women taking combined oral contraceptive pills approximately 90% reported regularly scheduled withdrawal bleeds over a 90-day standard reference period.<ref name=":02" /> Withdrawal bleeding usually occurs during the placebo, hormone-free days.{{medcn|date=December 2024}} Therefore, avoiding placebo days can diminish withdrawal bleeding among other placebo effects.{{medcn|date=December 2024}}

=== Regimen ===
This section demonstrates the overall rationalisation of [[Route of administration|dosing route]] and intervals of hormonal oral contraceptives, please seek advice and follow instructions from [[Health professional|healthcare professionals]] in administering specific hormonal oral contraceptives. Considering the menstrual cycle as a 28-day cycle, hormonal oral contraceptives are available in packages of 21, 28, or 91 tablets.<ref name=":2a" />  These pills have typically undergone unit dose optimisation so that they follow the administration pattern of once daily, every day or almost every day on a regular basis.<ref name=":2a" /> Since they are formulated into daily doses, it is recommended that the medication should be taken at the same time every day to maximise [[Efficacy (pharmacology)|efficacy]].<ref name=":2a" />
[[File:Package of Lutera Birth Control Pills.jpg|thumb|173x173px|28-tablet pack]]
For 21-tablet packs, the general instruction is to take one tablet daily for 21 days, followed by a 7-day blank interval without taking hormonal oral contraceptives before initiating another 21-tablet pack.<ref name=":2a" /> For 28-tablet packs, the 1st tablet from a new pack should be taken on the next day when the 28th tablet from an old pack was finished.<ref name=":2a" /> While the 7-day blank period does not apply to 28-tablet packs, they will likely include tablets in distinctive colours indicating that they have an alternate amount of active ingredients, otherwise inactive ingredient or [[folate]] supplement only.<ref name=":2a" /> The instruction for 91-tablet pack follows that of 28-tablet packs with some colour-distinguishable tablets which contain different amounts of medicine or supplement.<ref name=":2a" />

To acquire immediate contraceptive effects, the initiation of hormonal oral contraceptive dosing is recommended within the 1st-5th day from menstruation in order to discard other means of [[Birth control|contraception]].<ref name=":4a">{{Cite web |date=2017-12-21 |title=Combined pill |url=https://www.nhs.uk/conditions/contraception/combined-contraceptive-pill/ |access-date=2024-02-28 |website=nhs.uk }}</ref> Specific to Progesterone only pills, even if dosing is initiated within five days, backup contraception is suggested in the first 48 hours since the first pill.<ref name=":0a" /> In the case of dosing initiated after the 5th day from menstruation, effects usually take place after seven days and other contraceptive methods should remain in place until then.<ref name=":4a" />

==== Effectiveness ====
If used exactly as instructed, the estimated risk of getting pregnant is 0.3% which means that about 3 in 1000 women on combined oral contraceptive pills will become pregnant within one year.<ref name=":22">{{cite book |title=Selected practice recommendations for contraceptive use |publisher=World Health Organization | vauthors = ((World Health Organization)) |isbn=978-92-4-156540-0 |edition=Third |location=Geneva |pages=150 |oclc=985676200 |year=2016 |hdl=10665/252267 |hdl-access=free | author-link = World Health Organization }}</ref> However, typical use of combined oral contraceptive pills by users often consists of timing errors, forgotten pills, or unwanted side effects. With typical use, the estimated risk of getting pregnant is about 9% which means that about 9 in 100 women on combined oral contraceptive pills will become pregnant in one year.<ref name="pmid27467196" /> The perfect use failure rate is based on a review of pregnancy rates in clinical trials, and the typical use failure rate is based on a weighted average of estimates from the 1995 and 2002 US National Surveys of Family Growth (NSFG), corrected for underreporting of abortions.<ref>{{cite journal | vauthors = Trussell J | title = Understanding contraceptive failure | journal = Best Practice & Research. Clinical Obstetrics & Gynaecology | volume = 23 | issue = 2 | pages = 199–209 | date = April 2009 | pmid = 19223239 | pmc = 3638203 | doi = 10.1016/j.bpobgyn.2008.11.008 | series = Contraception and Sexual Health }}</ref><ref>{{cite journal | vauthors = Trussell J | title = Contraceptive failure in the United States | journal = Contraception | volume = 83 | issue = 5 | pages = 397–404 | date = May 2011 | pmid = 21477680 | pmc = 3638209 | doi = 10.1016/j.contraception.2011.01.021 }}</ref>

Several factors account for typical use effectiveness being lower than perfect use effectiveness:

# Mistakes on part of those providing instructions on how to use the method
# Mistakes on part of the user
# Conscious user non-compliance with instructions

For instance, someone using combined oral contraceptive pills might have received incorrect information by a health care provider about medication frequency, forgotten to take the pill one day or not gone to the pharmacy in time to renew a combined oral contraceptive pill prescription.

Combined oral contraceptive pills provide effective contraception from the very first pill if started within five days of the beginning of the [[menstrual cycle]] (within five days of the first day of [[menstruation]]). If started at any other time in the menstrual cycle, combined oral contraceptive pills provide effective contraception only after 7 consecutive days of use of active pills, so a backup method of contraception (e.g. [[condom]]s) must be used in the interim.<ref name="Speroff 20052">{{cite book|title=A Clinical Guide for Contraception| vauthors = Speroff L, Darney PD |publisher= Lippincott Williams & Wilkins|year=2005|isbn=978-0-7817-6488-9|edition=4th|location=Philadelphia|pages=21–138|chapter=Oral Contraception}}</ref><ref name="FFPRHC COC2">{{cite web|url=http://www.ffprhc.org.uk/admin/uploads/FirstPrescCombOralContJan06.pdf|title=Clinical Guidance: First Prescription of Combined Oral Contraception|author=FFPRHC|year=2007|archive-url=https://web.archive.org/web/20070704044305/http://www.ffprhc.org.uk/admin/uploads/FirstPrescCombOralContJan06.pdf|archive-date=4 July 2007|url-status=dead|access-date=26 June 2007|author-link=Royal College of Obstetricians and Gynaecologists}}</ref>

The effectiveness of combined oral contraceptive pills appears to be similar whether the active pills are taken continuously or if they are taken cyclically.<ref name="Continuous or extended cycle vs. cy">{{cite journal | vauthors = Edelman A, Micks E, Gallo MF, Jensen JT, Grimes DA | title = Continuous or extended cycle vs. cyclic use of combined hormonal contraceptives for contraception | journal = The Cochrane Database of Systematic Reviews | issue = 7 | pages = CD004695 | date = July 2014 | volume = 2014 | pmid = 25072731 | pmc = 6837850 | doi = 10.1002/14651858.CD004695.pub3 }}</ref> Contraceptive efficacy, however, could be impaired by numerous means. Factors that may contribute to a decrease in effectiveness:<ref name="Speroff 20052" />

# Missing more than one active pill in a packet,
# Delay in starting the next packet of active pills (i.e., extending the pill-free, inactive pill or placebo pill period beyond 7 days),
# [[Intestine|Intestinal]] [[malabsorption]] of active pills due to [[vomiting]] or [[diarrhea]],
# Drug-drug interactions among combined oral contraceptive pills and other medications of the user that decrease contraceptive estrogen and/or progestogen levels.<ref name="Speroff 20052" />

In any of these instances, a backup contraceptive method should be used until hormone active pills have been consistently taken for 7 consecutive days or drug-drug interactions or underlying illnesses have been discontinued or resolved.<ref name="Speroff 20052" /> According to the US [[Centers for Disease Control and Prevention]] (CDC) guidelines, a pill is considered "late" if a user takes the pill after the user's normal medication time, but no longer than 24 hours after this normal time. If 24 hours or more have passed since the time the user was supposed to take the pill, then the pill is considered "missed".<ref name=":22" /> CDC guidelines discuss potential next steps for users who missed their pill or took it late.<ref>{{cite journal | vauthors = Curtis KM, Jatlaoui TC, Tepper NK, Zapata LB, Horton LG, Jamieson DJ, Whiteman MK | title = U.S. Selected Practice Recommendations for Contraceptive Use, 2016 | journal = MMWR. Recommendations and Reports | volume = 65 | issue = 4 | pages = 1–66 | date = July 2016 | pmid = 27467319 | doi = 10.15585/mmwr.rr6504a1 | doi-access = free | title-link = doi }}</ref>

===Role of placebo pills===
The role of the [[placebo]] pills is two-fold: to allow the user to continue the routine of taking a pill every day and to simulate the average [[menstrual cycle]]. By continuing to take a pill every day, users remain in the daily habit even during the week without hormones. Failure to take pills during the placebo week does not impact the effectiveness of the pill, provided that daily ingestion of active pills is resumed at the end of the week.{{citation needed|date=July 2023}}

The placebo, or hormone-free, week in the 28-day pill package simulates an average menstrual cycle, though the hormonal events during a pill cycle are significantly different from those of a normal ovulatory menstrual cycle. Because the pill suppresses ovulation (to be discussed more in the [[#Mechanism of action|Mechanism of action section]]), birth control users do not have true menstrual periods. Instead, it is the lack of hormones for a week that causes a withdrawal bleed.<ref name=":13"/> The withdrawal bleeding that occurs during the break from active pills has been thought to be reassuring, a physical confirmation of not being pregnant.<ref name="gladwell2">{{cite magazine| vauthors = Gladwell M |date=10 March 2000|title=John Rock's Error|url=http://www.gladwell.com/2000/2000_03_10_a_rock.htm|magazine=The New Yorker|archive-url=https://web.archive.org/web/20130511133811/http://www.gladwell.com/2000/2000_03_10_a_rock.htm|archive-date=11 May 2013|access-date=4 February 2009}}</ref> The withdrawal bleeding is also predictable. Unexpected breakthrough bleeding can be a possible side effect of longer term active regimens.<ref>{{cite web|url=http://www.mayoclinic.com/health/birth-control-pill/WO00098|title=Birth control pill FAQ: Benefits, risks and choices|last=Mayo Clinic staff|publisher=Mayo Clinic|access-date=1 February 2013|archive-date=26 December 2012|archive-url=https://web.archive.org/web/20121226060838/http://www.mayoclinic.com/health/birth-control-pill/WO00098|url-status=live}}</ref>

Since it is not uncommon for menstruating women to become anemic, some placebo pills may contain an [[iron]] supplement.<ref>{{cite web|url=http://www.patentstorm.us/patents/6451778/description.html|title=US Patent:Oral contraceptive:Patent 6451778 Issued on September 17, 2002 Estimated Expiration Date: July 2, 2017.|publisher=PatentStorm LLC|archive-url=https://web.archive.org/web/20110613020809/http://www.patentstorm.us/patents/6451778/description.html|archive-date=13 June 2011|url-status=dead|access-date=19 November 2010}}</ref><ref name="pmid11683548">{{cite journal | vauthors = Hercberg S, Preziosi P, Galan P | title = Iron deficiency in Europe | journal = Public Health Nutrition | volume = 4 | issue = 2B | pages = 537–545 | date = April 2001 | pmid = 11683548 | doi = 10.1079/phn2001139 | doi-access = free | title-link = doi }}</ref> This replenishes iron stores that may become depleted during menstruation. As well, birth control pills, such as combined oral contraceptive pills, are sometimes fortified with [[Folate|folic acid]] as it is recommended to take folic acid supplementation in the months prior to pregnancy to decrease the likelihood of [[neural tube defect]] in infants.<ref>{{cite journal | vauthors = Viswanathan M, Treiman KA, Kish-Doto J, Middleton JC, Coker-Schwimmer EJ, Nicholson WK | title = Folic Acid Supplementation for the Prevention of Neural Tube Defects: An Updated Evidence Report and Systematic Review for the US Preventive Services Task Force | journal = JAMA | volume = 317 | issue = 2 | pages = 190–203 | date = January 2017 | pmid = 28097361 | doi = 10.1001/jama.2016.19193 }}</ref><ref>{{cite journal | vauthors = Lassi ZS, Bhutta ZA | title = Clinical utility of folate-containing oral contraceptives | journal = International Journal of Women's Health | volume = 4 | pages = 185–190 | date = April 2012 | pmid = 22570577 | pmc = 3346209 | doi = 10.2147/IJWH.S18611 | doi-access = free | title-link = doi }}</ref>

===No or less frequent placebos===
{{Main|Extended cycle combined oral contraceptive pill}}
If the pill formulation is monophasic, meaning each hormonal pill contains a fixed dose of hormones, it is possible to skip withdrawal bleeding and still remain protected against conception by skipping the placebo pills altogether and starting directly with the next packet. Attempting this with bi- or tri-phasic pill formulations carries an increased risk of [[breakthrough bleeding]] and may be undesirable. It will not, however, increase the risk of getting pregnant.

Starting in 2003, women have also been able to use a three-month version of the pill.<ref>{{cite web|url=https://www.fda.gov/bbs/topics/ANSWERS/2003/ANS01251.html|title=FDA Approves Seasonal Oral Contraceptive|website=U.S. [[Food and Drug Administration]] (FDA) |date=25 September 2003|archive-url=https://web.archive.org/web/20061007101134/https://www.fda.gov/bbs/topics/ANSWERS/2003/ANS01251.html <!-- Bot retrieved archive -->|archive-date=7 October 2006|access-date=9 November 2006}}</ref> Similar to the effect of using a constant-dosage formulation and skipping the placebo weeks for three months, [[Seasonale]] gives the benefit of less frequent periods, at the potential drawback of breakthrough bleeding. Seasonique is another version in which the placebo week every three months is replaced with a week of low-dose estrogen.

A version of the combined pill has also been packaged to eliminate placebo pills and withdrawal bleeds. Marketed as Anya or Lybrel, studies have shown that after seven months, 71% of users no longer had any breakthrough bleeding, the most common side effect of going longer periods of time without breaks from active pills.

While more research needs to be done to assess the long term safety of using combined oral contraceptive pills continuously, studies have shown there may be no difference in short term adverse effects when comparing continuous use versus cyclic use of birth control pills.<ref name="Continuous or extended cycle vs. cy"/>

===Non-contraceptive use===
The hormones in the pill have also been used to treat other medical conditions, such as [[polycystic ovary syndrome]] (PCOS), [[endometriosis]], [[adenomyosis]], acne, hirsutism, [[amenorrhea]], menstrual cramps, [[menstrual migraine]]s, menorrhagia (excessive menstrual bleeding), menstruation-related or fibroid-related anemia and [[dysmenorrhea]] (painful menstruation).<ref name="pmid27467196" /><ref>{{cite web|url=http://www.youngwomenshealth.org/med-uses-ocp.html|title=Medical Uses of the Birth Control Pill|last=CYWH Staff|access-date=1 February 2013|date=18 October 2011|archive-date=5 February 2013|archive-url=https://web.archive.org/web/20130205071228/http://www.youngwomenshealth.org/med-uses-ocp.html|url-status=dead}}</ref> Besides acne, no oral contraceptives have been approved by the US FDA for the previously mentioned uses despite extensive use for these conditions.<ref>{{cite web|url=https://www.fda.gov/Drugs/ResourcesForYou/Consumers/ucm450624.htm|title=Information for Consumers (Drugs) - Find Information about a Drug|website=U.S. [[Food and Drug Administration]] (FDA)|access-date=13 December 2017|archive-date=14 November 2017|archive-url=https://web.archive.org/web/20171114004746/https://www.fda.gov/Drugs/ResourcesForYou/Consumers/ucm450624.htm|url-status=dead}}</ref>

==== PCOS ====
The cause of PCOS, or polycystic ovary syndrome, is multifactorial and not well-understood. Women with PCOS often have higher than normal levels of luteinizing hormone (LH) and androgens that impact the normal function of the ovaries.<ref>{{cite web |title=Patient education: Polycystic ovary syndrome (PCOS) (Beyond the Basics) |url=https://www.uptodate.com/contents/polycystic-ovary-syndrome-pcos-beyond-the-basics |access-date=15 September 2022 |website=UpToDate |archive-date=15 September 2022 |archive-url=https://web.archive.org/web/20220915125817/https://www.uptodate.com/contents/polycystic-ovary-syndrome-pcos-beyond-the-basics |url-status=live }}</ref> While multiple small follicles develop in the ovary, none are able to grow in size enough to become the dominant follicle and trigger ovulation.<ref>{{cite journal |last1=Dumesic |first1=Daniel A. |last2=Lobo |first2=Rogerio A. |date=August 2013 |title=Cancer risk and PCOS |journal=Steroids |volume=78 |issue=8 |pages=782–785 |doi=10.1016/j.steroids.2013.04.004 |issn=1878-5867 |pmid=23624028|s2cid=10185317 }}</ref> This leads to an imbalance of LH, follicle stimulating hormone, estrogen, and progesterone. Without ovulation, unopposed estrogen can lead to endometrial hyperplasia, or overgrowth of tissue in the uterus.<ref>{{cite web |title=Polycystic Ovary Syndrome (PCOS) |url=https://www.acog.org/en/womens-health/faqs/polycystic-ovary-syndrome-pcos |access-date=15 September 2022 |website=American College of Obstetricians and Gynecologists |archive-date=15 September 2022 |archive-url=https://web.archive.org/web/20220915125811/https://www.acog.org/en/womens-health/faqs/polycystic-ovary-syndrome-pcos |url-status=live }}</ref> This endometrial overgrowth is more likely to become cancerous than normal endometrial tissue.<ref>Barakat RR, Park RC, Grigsby PW, et al. Corpus: Epithelial Tumors. In: Principles and Practice of Gynecologic Oncology, 2nd, Hoskins WH, Perez CA, Young RC (Eds), Lippincott-Raven Publishers, Philadelphia 1997. p.859</ref> Thus, although the data varies, it is generally agreed upon by most gynecological societies that due to the unopposed estrogen, women with PCOS are at higher risk for endometrial cancer.<ref>{{cite journal | vauthors = Hardiman P, Pillay OC, Atiomo W | title = Polycystic ovary syndrome and endometrial carcinoma | journal = Lancet | volume = 361 | issue = 9371 | pages = 1810–2 | date = May 2003 | pmid = 12781553 | doi = 10.1016/s0140-6736(03)13409-5 | s2cid = 27453081 }}</ref>

To reduce the risk of endometrial cancer, it is often recommended that women with PCOS who do not desire pregnancy take hormonal contraceptives to prevent the effects of unopposed estrogen. Both combined oral contraceptive pills and progestin-only methods are recommended.{{citation needed|date=July 2023}} It is the progestin component of combined oral contraceptive pills that protects the endometrium from hyperplasia, and thus reduces a woman with PCOS's endometrial cancer risk.<ref>{{cite web |title=Can birth control pills cure PCOS |url=https://www.acog.org/en/womens-health/experts-and-stories/ask-acog/can-birth-control-pills-cure-pcos |access-date=18 September 2022 |website=American College of Obstetricians and Gynecologists |archive-date=20 September 2022 |archive-url=https://web.archive.org/web/20220920171751/https://www.acog.org/en/womens-health/experts-and-stories/ask-acog/can-birth-control-pills-cure-pcos |url-status=live }}</ref> Combined oral contraceptive pills are preferred to progestin-only methods in women who also have uncontrolled acne, symptoms of hirsutism, and androgenic alopecia, because combined oral contraceptive pills can help treat these symptoms.<ref name=":13" />

==== Acne and hirsutism ====
Combined oral contraceptive pills are sometimes prescribed to treat symptoms of androgenization, including acne and hirsutism.<ref>{{cite journal |vauthors=Huber J, Walch K |date=January 2006 |title=Treating acne with oral contraceptives: use of lower doses |journal=Contraception |volume=73 |issue=1 |pages=23–9 |doi=10.1016/j.contraception.2005.07.010 |pmid=16371290}}</ref> The estrogen component of combined oral contraceptive pills appears to suppress androgen production in the ovaries. Estrogen also leads to increased synthesis of sex hormone binding globulin, which causes a decrease in the levels of free testosterone.<ref>{{cite web |title=Hormonal Contraceptives and Acne: A Retrospective Analysis of 2147 Patients |url=https://jddonline.com/articles/hormonal-contraceptives-and-acne-a-retrospective-analysis-of-2147-patients-S1545961616P0670X/ |access-date=15 September 2022 |website=JDDonline - Journal of Drugs in Dermatology |archive-date=19 May 2022 |archive-url=https://web.archive.org/web/20220519125904/https://jddonline.com/articles/hormonal-contraceptives-and-acne-a-retrospective-analysis-of-2147-patients-S1545961616P0670X/ |url-status=live }}</ref>

Ultimately, the drop in the level of free androgens leads to a decrease in the production of sebum, which is a major contributor to development of acne.{{citation needed|date=July 2023}} Four different oral contraceptives have been approved by the US FDA to treat moderate acne if the patient is at least 14 or 15 years old, has already begun menstruating, and needs contraception. These include [[Ortho Tri-Cyclen]], [[Estrostep]], [[Beyaz (drug)|Beyaz]], and [[Drospirenone|YAZ]].<ref>{{cite web |title=Birth Control of Acne |url=http://www.webmd.com/skin-problems-and-treatments/acne/birth-control-for-acne-treatment |access-date=1 February 2013 |publisher=WebMD, LLC |vauthors=Chang L |archive-date=26 January 2013 |archive-url=https://web.archive.org/web/20130126051445/http://www.webmd.com/skin-problems-and-treatments/acne/birth-control-for-acne-treatment |url-status=live }}</ref><ref>{{cite web |title=DailyMed - ORTHO TRI CYCLEN- norgestimate and ethinyl estradiol ORTHO CYCLEN- norgestimate and ethinyl estradiol |url=https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=384e7a40-dcbd-4908-bf5e-65abc9932973#section-1.1 |access-date=13 December 2017 |website=dailymed.nlm.nih.gov |archive-date=14 December 2017 |archive-url=https://web.archive.org/web/20171214072204/https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=384e7a40-dcbd-4908-bf5e-65abc9932973#section-1.1 |url-status=live }}</ref><ref>{{cite web |title=Beyaz Package Insert |url=https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/022532s004lbl.pdf |website=U.S. [[Food and Drug Administration]] (FDA) |access-date=6 August 2019 |archive-date=15 April 2023 |archive-url=https://web.archive.org/web/20230415183259/https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/022532s004lbl.pdf |url-status=live }}</ref>

Hirsutism is the growth of coarse, dark hair where women typically grow only fine hair or no hair at all.<ref>{{cite web |title=Patient education: Hirsutism (excess hair growth in females) (Beyond the Basics) |url=https://www.uptodate.com/contents/hirsutism-excess-hair-growth-in-women-beyond-the-basics |access-date=18 September 2022 |website=UpToDate |archive-date=20 September 2022 |archive-url=https://web.archive.org/web/20220920171546/https://www.uptodate.com/contents/hirsutism-excess-hair-growth-in-women-beyond-the-basics |url-status=live }}</ref> This hair growth on the face, chest, and abdomen is also mediated by higher levels or action of androgens. Therefore, combined oral contraceptive pills also work to treat these symptoms by lowering the levels of free circulating androgens.<ref>{{cite web |title=Hirsutism: What It Is, In Women, Causes, PCOS & Treatment |url=https://my.clevelandclinic.org/health/diseases/14523-hirsutism |access-date=18 September 2022 |website=Cleveland Clinic |archive-date=19 September 2022 |archive-url=https://web.archive.org/web/20220919044547/https://my.clevelandclinic.org/health/diseases/14523-hirsutism |url-status=live }}</ref>

Studies have shown that combined oral contraceptives are effective in reducing both [[Inflammation|inflammatory]] and non-inflammatory facial acne lesions.<ref name=":12a">{{Citation |last1=Arowojolu |first1=Ao |title=Combined oral contraceptive pills for treatment of acne |date=2004-07-19 |journal=Cochrane Database of Systematic Reviews |editor-last=The Cochrane Collaboration |url=https://doi.wiley.com/10.1002/14651858.CD004425.pub2 |access-date=2024-02-28 |place=Chichester, UK |publisher=John Wiley & Sons, Ltd |doi=10.1002/14651858.cd004425.pub2 |last2=Gallo |first2=Mf |last3=Grimes |first3=Da |last4=Garner |first4=Se|issue=3 |pages=CD004425 |pmid=15266533 }}</ref> However, comparisons between different combined oral contraceptives have not been studied to understand if any brand is superior than the others.<ref name=":12a" /> Oestrogen decreases [[sebum]] production by shrinking the [[sebaceous gland]], increasing [[Sex hormone-binding globulin]] (SHBG) production to reduce unbound [[testosterone]], and regulating LH and FSH levels.<ref>{{Cite journal |last=Frances E. Casey |first=M. D. |date=January 2023 |title=Contraception and its impact on acne |url=https://www.contemporaryobgyn.net/view/contraception-acne |journal=GYN Journal |series=Vol 68 No 01 |volume=68 |issue=1}}</ref> Studies have not shown that POPs are effective against acne lesions.{{cn|date=December 2024}}

==== Endometriosis ====
For pelvic pain associated with endometriosis, combined oral contraceptive pills are considered a first-line medical treatment, along with NSAIDs, GnRH agonists, and aromatase inhibitors.<ref>{{cite web|url=https://www.acog.org/Patients/FAQs/Endometriosis#treated|title=ACOG Endometriosis FAQ|access-date=3 March 2019|archive-date=1 February 2020|archive-url=https://web.archive.org/web/20200201032951/https://www.acog.org/Patients/FAQs/Endometriosis#treated|url-status=live}}</ref> Combined oral contraceptive pills work to suppress the growth of the extra-uterine endometrial tissue. This works to lessen its inflammatory effects.<ref name=":13"/> Combined oral contraceptive pills, along with the other medical treatments listed above, do not eliminate the extra-uterine tissue growth, they just reduce the symptoms. Surgery is the only definitive treatment. Studies looking at rates of pelvic pain recurrence after surgery have shown that continuous use of combined oral contraceptive pills is more effective at reducing the recurrence of pain than cyclic use.<ref>{{cite journal | vauthors = Zorbas KA, Economopoulos KP, Vlahos NF | title = Continuous versus cyclic oral contraceptives for the treatment of endometriosis: a systematic review | journal = Archives of Gynecology and Obstetrics | volume = 292 | issue = 1 | pages = 37–43 | date = July 2015 | pmid = 25644508 | doi = 10.1007/s00404-015-3641-1 | s2cid = 23340983 }}</ref>

==== Adenomyosis ====
Similar to endometriosis, adenomyosis is often treated with combined oral contraceptive pills to suppress the growth the endometrial tissue that has grown into the myometrium. Unlike endometriosis however, levonorgestrel containing IUDs are more effective at reducing pelvic pain in adenomyosis than combined oral contraceptive pills.<ref name=":13"/>

====Menorrhagia====

In the average menstrual cycle, a woman typically loses 35 to 40 milliliters of blood.<ref>{{cite web |title=Heavy Menstrual Bleeding |url=https://www.acog.org/en/womens-health/faqs/heavy-menstrual-bleeding |access-date=18 September 2022 |website=American College of Obstetricians and Gynecologists |archive-date=20 September 2022 |archive-url=https://web.archive.org/web/20220920170333/https://www.acog.org/en/womens-health/faqs/heavy-menstrual-bleeding |url-status=live }}</ref> However, up to 20% of women experience much heavier bleeding, or menorrhagia.<ref>{{cite journal |last1=Apgar |first1=Barbara S. |last2=Kaufman |first2=Amanda H. |last3=George-Nwogu |first3=Uche |last4=Kittendorf |first4=Anne |date=15 June 2007 |title=Treatment of Menorrhagia |url=https://www.aafp.org/pubs/afp/issues/2007/0615/p1813.html |journal=American Family Physician |volume=75 |issue=12 |pages=1813–1819 |pmid=17619523 |access-date=15 September 2022 |archive-date=6 October 2022 |archive-url=https://web.archive.org/web/20221006155406/https://www.aafp.org/pubs/afp/issues/2007/0615/p1813.html |url-status=live }}</ref> This excess blood loss can lead to anemia, with symptoms of fatigue and weakness, as well as disruption in their normal life activities.<ref>{{cite web |title=Patient education: Heavy or prolonged menstrual bleeding (menorrhagia) (Beyond the Basics) |url=https://www.uptodate.com/contents/heavy-or-prolonged-menstrual-bleeding-menorrhagia-beyond-the-basics/print |access-date=15 September 2022 |website=UpToDate |archive-date=15 September 2022 |archive-url=https://web.archive.org/web/20220915132011/https://www.uptodate.com/contents/heavy-or-prolonged-menstrual-bleeding-menorrhagia-beyond-the-basics/print |url-status=live }}</ref> Combined oral contraceptive pills contain progestin, which causes the lining of the uterus to be thinner, resulting in lighter bleeding episodes for those with heavy menstrual bleeding.<ref>{{cite web |title=Noncontraceptive Benefits of Birth Control Pills |url=https://www.reproductivefacts.org/news-and-publications/patient-fact-sheets-and-booklets/documents/fact-sheets-and-info-booklets/noncontraceptive-benefits-of-birth-control-pills/ |access-date=15 September 2022 |website=American Society for Reproductive Medicine (ASRM) |archive-date=13 September 2022 |archive-url=https://web.archive.org/web/20220913013344/https://www.reproductivefacts.org/news-and-publications/patient-fact-sheets-and-booklets/documents/fact-sheets-and-info-booklets/noncontraceptive-benefits-of-birth-control-pills/ |url-status=dead }}</ref>

==== Amenorrhea ====
Although the pill is sometimes prescribed to induce menstruation on a regular schedule for women bothered by irregular menstrual cycles, it actually suppresses the normal menstrual cycle and then mimics a regular 28-day monthly cycle.

Women who are experiencing menstrual dysfunction due to [[female athlete triad]] are sometimes prescribed oral contraceptives as pills that can create menstrual bleeding cycles.<ref name="AMSSMfive2">{{Citation|title=Five Things Physicians and Patients Should Question|date=24 April 2014|url=http://www.choosingwisely.org/doctor-patient-lists/american-medical-society-for-sports-medicine/|author1=American Medical Society for Sports Medicine|author1-link=American Medical Society for Sports Medicine|work=[[Choosing Wisely]]: an initiative of the [[ABIM Foundation]]|publisher=American Medical Society for Sports Medicine|access-date=29 July 2014|archive-date=29 July 2014|archive-url=https://web.archive.org/web/20140729224526/http://www.choosingwisely.org/doctor-patient-lists/american-medical-society-for-sports-medicine/|url-status=live}}</ref> However, the condition's underlying cause is energy deficiency and should be treated by correcting the imbalance between calories eaten and calories burned by exercise. Oral contraceptives should not be used as an initial treatment for female athlete triad.<ref name="AMSSMfive2" />

=== Menstrual suppression ===
Menstrual bleeding is not necessary in women who do not wish to conceive, therefore menstrual suppression may be implemented in women who do not want to have menstrual bleeding for convenience, [[Gynaecology|gynecologic disorders]], bleeding disorders or other medical conditions.<ref name=":7a">{{Cite web |title=Hormonal contraception for menstrual suppression |url=https://www.uptodate.com/contents/hormonal-contraception-for-menstrual-suppression |access-date=2024-02-28 |website=www.uptodate.com}}</ref>

In the two types of hormonal oral contraceptives, only combined oral contraceptives can achieve [[amenorrhea]], while POPs can only reduce the amount of blood.<ref>{{Cite journal |last1=Irvine |first1=G. A. |last2=Campbell-Brown |first2=M. B. |last3=Lumsden |first3=M. A. |last4=Heikkilä |first4=A. |last5=Walker |first5=J. J. |last6=Cameron |first6=I. T. |date=June 1998 |title=Randomised comparative trial of the levonorgestrel intrauterine system and norethisterone for treatment of idiopathic menorrhagia |url=https://pubmed.ncbi.nlm.nih.gov/9647148/ |journal=British Journal of Obstetrics and Gynaecology |volume=105 |issue=6 |pages=592–598 |doi=10.1111/j.1471-0528.1998.tb10172.x |issn=0306-5456 |pmid=9647148}}</ref> The method of using combined oral contraceptives for menstrual suppression is to skip the 7 [[placebo]] pills and continue taking active pills after the 21 active pills.<ref name=":8a">{{Cite journal |last1=Jacobson |first1=Janet C. |last2=Likis |first2=Frances E. |last3=Murphy |first3=Patricia Aikins |date=2012 |title=Extended and continuous combined contraceptive regimens for menstrual suppression |url=https://pubmed.ncbi.nlm.nih.gov/23217068/ |journal=Journal of Midwifery & Women's Health |volume=57 |issue=6 |pages=585–592 |doi=10.1111/j.1542-2011.2012.00250.x |issn=1542-2011 |pmid=23217068}}</ref> This can be used in extended method or continuous method.<ref name=":8a" /> For extended method, patients who take active pills for 3, 4, or 6 months and then take placebo pills for a period of time will more likely experience withdrawal bleeding.<ref name=":8a" /> The interval can be decided by the patients according to their own preferences.<ref name=":8a" /> For continuous method, people can take combined oral contraceptives for a year continuously without any placebo pills.<ref name=":8a" /> In the first few months of extended or continuous use of combined oral contraceptives, unscheduled bleeding or spotting may occur.<ref name=":9a">{{Cite journal |last1=Sulak |first1=P. J. |last2=Scow |first2=R. D. |last3=Preece |first3=C. |last4=Riggs |first4=M. W. |last5=Kuehl |first5=T. J. |date=February 2000 |title=Hormone withdrawal symptoms in oral contraceptive users |url=https://pubmed.ncbi.nlm.nih.gov/10674591/ |journal=Obstetrics and Gynecology |volume=95 |issue=2 |pages=261–266 |doi=10.1016/s0029-7844(99)00524-4 |issn=0029-7844 |pmid=10674591}}</ref> However, the bleeding or spotting is expected to resolve after a few months of use.<ref name=":9a" />

Menstrual suppression is commonly used for convenience especially when women go on vacation.<ref name=":7a" /> It is also used for gynecologic disorders such as [[dysmenorrhea]] (commonly known as menstrual pain), symptoms related to premenstrual hormone change and excessive bleeding related to [[uterine fibroid]]s. Patients can also benefit from menstrual suppression for bleeding disorders or chronic [[anemia]].<ref name=":7a" />

=== Menstrual migraine ===
Patients with menstrual Oestrogen-related [[migraine]], but without aura and additional risk factors to stroke, can be benefited from combined oral contraceptives.<ref name=":10a">{{Cite journal |last1=Loder |first1=Elizabeth W. |last2=Buse |first2=Dawn C. |last3=Golub |first3=Joan R. |date=March 2005 |title=Headache and Combination Estrogen-Progestin Oral Contraceptives: Integrating Evidence, Guidelines, and Clinical Practice |url=https://headachejournal.onlinelibrary.wiley.com/doi/10.1111/j.1526-4610.2005.05049.x |journal=Headache: The Journal of Head and Face Pain |volume=45 |issue=3 |pages=224–231 |doi=10.1111/j.1526-4610.2005.05049.x |pmid=15836597 |issn=0017-8748}}</ref><ref name=":11a">{{Cite journal |last=Silberstein |first=Stephen D. |date=September 1999 |title=Menstrual Migraine |url=http://www.liebertpub.com/doi/10.1089/jwh.1.1999.8.919 |journal=Journal of Women's Health & Gender-Based Medicine |volume=8 |issue=7 |pages=919–931 |doi=10.1089/jwh.1.1999.8.919 |pmid=10534294 |issn=1524-6094}}</ref> However, older women and those with a strong family history of problematic headaches may find that using hormonal oral contraceptives worsens their headache.<ref name=":10a" /><ref name=":11a" />