Changes in combined oral contraceptives (OCs) include reduction in the estrogen and progestogen dose and recourse to the third generation, less androgenic progestogens. They retain the efficacy and convenience of OCs while reducing the metabolic and cardiovascular effects and the need to identify contraindications and subjects at risk. OCs sometimes cause menstrual cycle problems: spotting and intercurrent bleeding or bleeding at any time other than menstruation (metrorrhagia). OCs cause loose and edematous stroma in the endometrium where glands maintain a proliferative-like phase throughout the cycle. Many dilated capillaries with hyperplasia of the endothelial cells rise to the surface. Forgetting or failure to take OC pills are often responsible for intercurrent bleeding. It is hard to determine what OCs cause less bleeding than other OCs. The third generation progestogen, gestodene, appears to have better cycle control than the two other third generation progestogens (desogestrel and norgestimate). It is not clear whether triphasic OCs with second generation progestogens are better than monophasic third generation OCs. The OC with low dose ethinyl estradiol (20 mcg) (Mercilon) has as low a bleeding rate as does the OC, Varnoline (30 mcg). Menstrual cycle disturbances rarely happen. Providers must emphasize to new OC users the possibility of spotting or intercurrent bleeding, especially during the first cycle. Providers must also inform them that these disturbances do not affect the effectiveness of the OCs and that they should not stop taking OCs if they are concerned about bleeding. Providers must instruct them what to do if they forget to take a pill(s). Providers should schedule an appointment after a new OC user has completed the third OC packet. They should do a gynecologic exam to search for a genital infection, endo-uterine polyp or fibroma, and hyperplasia of the endometrium. If bleeding persists during the third cycle, the client should change contraception.