Important Safety Information for Combined Oral Contraceptives

Combined oral contraceptives, also called COCs or combined pills, contain an estrogen and a progestin. They are used to prevent pregnancy and may also be prescribed for menstrual cycle control, menstrual symptoms, acne, or other hormone-related concerns when appropriate.

Combined pills are not suitable for everyone. Because they contain estrogen, they may increase the risk of serious cardiovascular side effects in some patients.

FDA labeling for combined oral contraceptives warns that cigarette smoking increases the risk of serious cardiovascular events from COC use, especially in women over 35 years old, and COCs should not be used by women over 35 who smoke.

What combined oral contraceptives are used for

Combined oral contraceptives may be used for:

  • Preventing pregnancy
  • Regulating menstrual cycles
  • Reducing menstrual cramps or heavy menstrual bleeding
  • Helping with acne or hormone-related symptoms, depending on the specific product and doctor assessment

Use only as prescribed or approved by your doctor.

Who should not use combined oral contraceptives

You may not be eligible for combined pills if you:

  • Are over 35 years old and smoke
  • Have or have had blood clots in the legs, lungs, or eyes
  • Have a history of stroke or heart attack
  • Have certain heart valve or heart rhythm problems
  • Have uncontrolled high blood pressure
  • Have migraine with aura
  • Have diabetes with blood vessel complications
  • Have known clotting disorders
  • Have breast cancer or a history of breast cancer
  • Have liver disease, liver tumors, or jaundice related to previous contraceptive use
  • Have unexplained vaginal bleeding
  • Are pregnant or think you may be pregnant
  • Are scheduled for major surgery with prolonged immobilization

CDC guidance also classifies combined hormonal contraception as not recommended for certain higher-risk conditions, including migraine with aura.

How to take combined pills

Take your pill exactly as directed on the product label or as instructed by your doctor.

General reminders:

  • Take one pill daily.
  • Try to take it at the same time each day.
  • Follow the order of pills in your pack.
  • Do not skip active pills.
  • Check whether your pack contains active and inactive/placebo pills.
  • Ask your doctor or pharmacist if you are unsure which pills are active.

Missed pill information

If you miss pills, your chance of pregnancy may increase.

For combined oral contraceptives, CDC guidance generally recommends taking the most recent missed active pill as soon as possible and continuing the remaining pills at the usual time. If two or more consecutive active pills are missed, backup contraception may be needed.

Ask a doctor or pharmacist if:

  • You missed more than one active pill
  • You missed pills during the first week of the pack
  • You had unprotected sex after missed pills
  • You are unsure whether the missed pill was active or placebo
  • You vomited or had severe diarrhea after taking a pill

Talk to a doctor before use

Before using combined pills, tell your doctor if you:

  • Smoke or vape nicotine
  • Have high blood pressure or have not checked your blood pressure recently
  • Have migraine or severe headaches
  • Recently gave birth or are breastfeeding
  • Have a personal or family history of blood clots
  • Have diabetes, high cholesterol, or obesity
  • Have liver, gallbladder, kidney, or adrenal problems
  • Take anti-seizure medicines, tuberculosis medicines, HIV medicines, hepatitis C medicines, or herbal supplements
  • Are taking medicines that may affect potassium levels

Blood pressure should be assessed before starting combined hormonal contraception, according to CDC selected practice recommendations.

Special precaution for drospirenone-containing pills

Some combined pills contain drospirenone, such as Yaz-type or Yasmin-type products. FDA labeling for drospirenone-containing contraceptives includes warnings related to potassium levels and states that these products should not be used in patients with conditions that predispose them to hyperkalemia, such as renal impairment, hepatic impairment, or adrenal insufficiency.

Tell your doctor if you take medicines that may increase potassium, such as certain blood pressure medicines, diuretics, NSAIDs used long-term, or potassium supplements.

Warning signs and emergency care

Stop use and seek emergency medical care immediately if you experience:

  • Chest pain or pressure
  • Sudden shortness of breath
  • Coughing blood
  • Severe headache that is new or unusual
  • Vision changes or vision loss
  • Weakness or numbness on one side of the body
  • Severe pain, swelling, warmth, or redness in one leg
  • Severe abdominal pain
  • Fainting
  • Severe allergic reaction symptoms, such as swelling of the face, lips, tongue, or throat

Do not wait for an online consultation if you have emergency symptoms.

Common side effects

Common side effects may include:

  • Nausea
  • Breast tenderness
  • Headache
  • Spotting or breakthrough bleeding
  • Changes in menstrual flow
  • Mood changes
  • Bloating
  • Acne changes

Some side effects may improve after the first few months. Contact a doctor if symptoms are severe, persistent, or concerning.

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This page is for general educational purposes only and does not replace medical advice, diagnosis, or treatment.