Oral Contraceptive Oral Contraceptive Pill ( OCP)Pill ( OCP)

Oral Contraceptive Oral Contraceptive Pill ( OCP)Pill ( OCP)

J HassanJ Hassan

IntroductionOCP is widely used in the UK, it can be highly effective in prevention of pregnancy, if used consistently and correctly.It also has non contraceptive benefits including

• Managing irregular menstrual cycles• Alleviate dysmenorrhoea• Manage endometriosis

• 2 categories• Combined oral contraceptive pill (COCP)• Progesterone only pill (POP)

• Principles of counselling:• Why method chosen • Efficacy/ Mode of action• Pill teach / Potential side effects / reversibility• Menstrual pattern/ full med and sexual hx to elucidate

CI• Safer sex/ leaflet provided

COCPMode of action• Ovulation suppression• Endometrial atrophy• Thickens cervical mucus

EffectivenessFailure rate is 0.2-0.5 per 100 woman years

ClassificationType of progesterone

Monophasic pills Triphasic pills

Levonorgestrel Microgynon 30/EDOvranette (30 EE)Eugynon (30 EE)

TrinodialLogynon/ ED

Norethisterone Ovysmen / Brevinor (35 EE)Norimin( 35)Loestrin 20/30

TrinovumBinovumSynphase

Norgestimate Cilest (35 EE)

Desogestrol Mercilon 20 EeMarvelon 30 EE

Gestogene Femodene (ED/ 30EE)Minulet (30 EE)Femodette(20 EE)

Tri-Minulet

Drospirenone Yasmin (30 EE)

Benefits• Less menorrhagia/ dysmenorrhoea• Reduction in• Ovarian / endometrial Ca• functional Ovarian cysts• Benign breast lessions• Symptomatic endometriosis• Risk of Colon ca • Thyroid dx• Improvement of acne

Risks• VTE- risk inc with age and in those with other risk

factors• Cervical ca- small inc after 5 yr use• Breast ca-• Primary liver ca• Hydatidiform mole/ choriocarcinoma• MI- increased 3 fold if hypt• CVA- Ischaemic – increase is about 1.5 fold in

normotensive non-smoking COC users and 3 fold in those with hypt.

1st consultationImportant points from the history:• Methods used/ length of use• LMP / previous pregnancies/recent preg

( associated condn.)/ lactating• Age• Current illnesses and txt• Past major illness / ops• Menstrual hx( cycle length, duration etc)• Sexual hx, previous STI, risk behaviours• Hx of hypt, cardiovascular and risk factors/ DM /

VTE/ IHD / CVA

• Headaches/migraines• Smoking / no. per day• Obesity• Liver / Gallbladder dx• Breast dx• Examinations• BP measurement is essential. If consistently >140/90

then the woman should be advised against use of COC• Weight and Height and BMI calculated and documented

Starting RegimesMenstruating Ideally start day 1 of cycle can start up to day 5 without

additional contraceptionAnytime if no unprotected intercourse since LMP but additional protection for 7 days

Postpartum Non breast feeding mums- Start Day 21. if after day 21 additional method for 7 daysBreast feeding mums- Start 6 months

Miscarriage/ TOP< 24wks

Same or next day. If started > 7 days after then additional method for 7 days

TOP > 24wks Start on day 21, otherwise if later then additional method for 7 days

Amenorrhoea At any time if no risk of pregnancy, and 7 days additional precautions

Missed Pill Advise• If 1 or 2 of 30-35mcg ethinylestradiol pill or 1of

20mcg • Advise to take the most recent pill as soon as remembers,

continue taking remaining pill at usual time, she does not require additional contraception or emergency contraception

• If 3 or more of 30-35 or 2 or more 20mcg• Advise as above, but to use extra method of contraception until

pills have been taken for 7 days in a row• If pill is missed in week 1 ( days1-7)and unprotected sexual

intercourse has taken place in pill free week or wk 1 then emergency contraception is needed

• If pills missed in wk 3 ( days 15-21), advise to finish pill in pack and start new pack the next day, omitting pill free interval

• If one has missed > 7 consecutive days then consider as stopped COCP

Drug interactions• Antibiotics-( non liver enzyme inducing) Short courses

<3 wks. -Advise to use additional protection while on the treatment and for 7 days afterwards. If pt is taking long term abx, there is no requirement for extra precaution after 3 wks of abx use

• Liver enzyme inducing drugs- advise alternative methods preferably or use high dose of ethinylestradiol eg 50mcg pill, combination of 30 + 20 mcg or 2 30/35mcg, + barrier method and advise tricycling regime with a short pill free interval(4 days) at end of 3 cycles

• Example of drugs – Anticonvulsants, anti TB, Anti fungals, Anti HIV, St Johns Worts,

Side effectsOestrogenicNausea, dizziness, bloating, breast engorgement, vaginal

discharge, premenstrual tension, migranesChange to a more progestogenic prep/ Reduce dose of

oestrogen and inc dose of progesterone. COC progesterone dominant- Microgynon 30, Loestrin 30 ,Eugynon 30,

Norimin, loestrin 20

Progestogenic Vaginal dryness, inc wt, reduced libido, acne, mastalgia,

depression/lethargy, scanty mensesChange to more osetrogenic eg Ovysmen, Marvelon, femodene, cilest,

Trinordiol/ logynon

Follow up• Review in 3 months to ensure compliance and

acceptability, with further follow up at 12 monthly intervals, encourage pt to seek advise if any worries

• BP ant Wt yearly• Check that COC is taken correctly• Sought new risk factors/ SE• If pt > 35 yrs, there should be a thorough re-

assesment

Progesterone only Pill (POP)

• Becoming increasingly popular as more women worry about SE and health risk of COC

• They can be used with no age limits,in smokers, during lactation and even for women at risk of VTE

Efficacy• Failure rate of 0.3-5 per 100 woman yearsMode of action• Mainly thickening cervical mucus• Atrophy of endometrium, hinders implantation• Interfere with tubal transport of ova• Cerazette however inhibits ovulation

Type of progesteron

POP

Norethisterone 350mcg MicronorNoriday

Levonorgestrel 30mcg Microval, Norgeston

Di norgestrel 75mcg Neogest

Etynodiol diacetate 500mcg Femulen

Disogestrel 75mcg Cerazette

Indications• < 21 days post partum. 6wks-6mths postpartum partially or

fully BF• Age> 35 and smoke• BMI> 35• Multiple risk for CVS• Those at risk of VTE, inc personal hx• Hypt controlled with meds• DM/ CHD/ valvular problems• CIN/ endometrial ca/ ovarian ca• F Hx Breast ca• SCD

Contraindications• Uncontrolled hypertension• Active hepatitis/ decompensated cirrhosis/

liver tumours• Mal absorption• Current DVT• Undiagnosed Genital tract bleeding• Recent trophoblastic dx with high bHCG• Current IHD

• Current breast Ca• Past severe side effects• Acute porphyria

• Missed pill: pill needs to be taken at same time of day. There is only 3 hour window period for missed pills. Contraception efficacy is restored after 2 days as compared to COC

• Cerazette- has a 12 hour window period.• Vomiting within 2 hrs or severe diarrhoea decreases

efficacy.• Starting regimes- same as COC however additional

method is needed for only 48hrs• Drug interactions- Pop not affected by broad spectrum

abx. However enzyme inducing drugs reduces efficacy.

Thank You