Combined oral contraceptive

Counselling

Why is she requesting FP? Is she sexually active or is she being pressurised by Parents/Boyfriend /Peers. ?one off/mistake/ non-consensual.

Age - Does not NEED parental permission BUT underage sex is illegal! If a minor and no parent present, encourage her to be open with parents. However, MUST be assured of confidentiality. Explore relationship, stable or multiple partners (possibility of risk taking attitude with an increased risk of STIs). Is she mentally able to cope with sexual relationship and the emotional risks? Any difficulties with remembering to take pills. Does she need a COC or, if a menstrual problem, consider Tranexamic Acid for menorrhagia. If at risk of a pregnancy then should be prescribed a contraception that is best suited to her, and causes minimal risks. Discuss options of other methods of FP. If under-aged, should still be prescribed COC if at risk of pregnancy and is competent.

Risks

Advantages/disadvantages

Decreased risk of ovarian and endometrial Ca
Reliable (if taken correctly) and reversible.
Control of periods and menstrual problems
Improves Acne
Less risk of PID
Increased risk of thrombosis and breast cancer. Has a 0.1% failure rate.
Side effects can include nausea, weight gain, breast tenderness and mood swings.
The WHO has developed a system of risk scoring for COCs combined with certain conditions. The score ranges from 2 (relative contraindication) to 4 (total contraindication). Thus, a girl with uncomplicated and well controlled diabetes has a WHO risk of 3, but add on one additional risk factor, such as smoking, then her risk goes to WHO 4 and therefore unsuitable for 3rd generation COC, but could be suitable for a POP such as Cerazette. Patients with WHO risk of over 2 must be referred to a GP or under 2 if at all concerned.
Further contraindications include severe migraine, >BMI 35, heart disease, IHD, liver disease, hypertension, TIA, Thrombophilias, diabetes, breast Ca, hormone dependent tumours, v. heavy smoker, pregnancy, breast feeding etc.)

History

Is she suitable for COC?

Refer to eBNF for risk scoring as per WHO risks 2 – 4.
BMI - Ht and Wt (BMI >35 WHO 4) (BMI 30 –35 WHO 3)
Smoking (>35 yr. WHO 4 stop COC)
Age
BP (140/90 WHO3) (160/100 WHO4)
General Health and past history of any medical history that might be a contraindication.
Menstrual/Obstetric History (not suitable if breast-feeding) Start 21 days post partum.
Focal Migraine/headache
Liver disease/jaundice
Epilepsy (refer to GP for higher dose COC) or diabetes (Refer to GP)
Medication
Allergies

Family History

Thrombosis, IHD, hypertension, breast cancer, clotting disorders, hypercholesterolemia.

If not suitable, consider other options, including POP – Cerazette.

Action

COC contain 2 hormones – oestrogen and a progestogen, the pills vary by type of synthetic hormone, strength and formulation.
Absorbed by stomach and metabolised by liver.
Acts centrally by inhibiting FSH/LH and thus inhibits ovulation.
Acts peripherally by reducing cervical mucous, increased viscosity and endometrial thinning.
Small therapeutic range and Dose can become sub-therapeutic by interactions with other drugs e.g. antibiotics, anti-epileptics, St John’s Wort etc. Gastric disturbance. Missed pills.

Pill taking – Education

This is MOST important and needs to be done with a PAL and the patient advised to keep the PAL to refer to in the future, with permission to contact nurse if any problems or questions. If the patient thinks she may have problems remembering to stop and start the pill, choose an Every Day ED version (different instructions for missed pill or for missing pill free interval PFI).

Should start COC on day 1 or 2, if later will need to use condoms for 7 days
Usually, a pill is taken every day for 21 days, then pill free for 7 days (or dummy pills with ED). Consult BNF for variations.
To try to take COC at same time of day or at least within 12 hours. If fails to do so – to take due pill (discard missed pills) and use condoms for 7 days. TCA if no period SOS.
MOST dangerous time to miss a pill is at the start of new pack – NEEDS emergency contraception, as well. See Table for more details.
If vomited within 3 hours of having taken pill and/or very severe diarrhoea – use condoms AS WELL, for 7 days.
Antibiotics, particularly broad spectrum, interfere with gut flora and absorption, need to use condoms AS WELL for 14 days. (See BNF for other drugs that affect liver metabolism (enzyme inducers etc).
If additional contraception needed in the last week of active pills (3rd week), then the pill free week should be omitted and to go straight onto a new pack of pills (or dummy pills of 28 pack not taken).
Sexual health – use of condoms reduces risk of STIs.

Choice of COC

The one that contains the lowest dose of oestrogen that is effective and controls the patient’s cycle, with minimal side effects.

Suggestions

Highest dose used contains 50ug of oestrogen – used for patients on anti-epileptic drugs (GP only)
Lowest dose oestrogen contains 20ug (Loestrin 20)
Commonest COC used contains 30ug – Microgynon 30, Microgynon 30 ED, Logynon 30, Logynon 30 ED.
Side effects of weight gain, mood swings – try Mercilon (3rd generation) or Yasmin.
Poor cycle control – try Femodene or Femodene ED, cilest, norimin or ?tricycle regime.
Acne – Marvelon, Dianette or Yasmin.

IF CHANGING BRAND OF COC – should go straight onto new pill without having a pill free week. If changing after pill free week, will need to use condoms as well for 7 days.

Pill Checks

Initially 3 months, then 6 monthly x 2 and then annually, if no problems or risk factors

Check well being ?problems, especially ?headaches.
Any new risk factors?
Menstrual cycle, if irregular consider - ?within 3 months settling in period, STI, cervical disease, irregular taking of pill, intercurrent illness, drug interactions, BTB more common in smokers, ?needs change of COC. ?examination, swabs ?refer.
BP – stop COC if exceeds 160/100 on repeated checks. Refer to GP. Discuss FP options.
Smoking – give advice as necessary. If aged 35 or over. Discuss FP options
Weight – Advise. If BMI 35 or more. Discuss FP options.
The last 3 scenarios are WHO4, and will need to stop COCs and need to consider other methods.
Smear status – perform cervical screening if appropriate.
Check Education
- Knowledge re pill taking, check if aware of ‘7 day rules’ re use of condoms for missed pills, interaction of other drugs, intercurrent illnesses, such as vomiting and diarrhoea.
- Importance of regular pill taking.
- Is she aware of symptoms of thrombosis?
- Aware of risk of STIs and use of condoms
If wanting to conceive, pre-natal advice re smoking, diet and exercise. Also to take OTC folic acid and check rubella status.

Symptoms for which COCs should be stopped immediately

Unusual or severe very prolonged headache
Diagnosis of aura, partial or complete loss of vision.
Speech disturbance
Numbness or weakness suggesting cerebral ischaemia
A severe unexplained fainting attack, vertigo or ataxia
Pain in chest, especially if pleuritic in nature, breathlessness or blood stained sputum
Painful swelling in calf
Focal epilepsy
Severe abdominal pain
Immobilisation due to fracture or major surgery.
Acute jaundice, raised BP, severe skin rash, new risk factor or breast cancer.
Discuss alternatives such as Cerazette, condoms, IUD, implanon, depo etc. Refer to GP.

Emergency contraception when on COC

The COC should still be active as long as she has already taken at least 7 pills

AND has missed 3 pills of 30 – 35 mcg strength
OR has missed 2 pills 20 mcg strength.

But, follow advice of FP leaflet and advise condom use for a week.

However, if the Pill Free Interval is increased by 3 days, then ovulation can occur and she should be prescribed emergency contraception if at all late starting a new pack of pills. (Patients on anti-epileptics need 50% more of emergency contraception - +750mcg.

If in doubt and even if over 72 hours, better to give emergency contraception as no known teratogenic effect. Review and check for pregnancy as necessary.

Missed pill rules

One Active pill missed Days1 - 21	Take missed pill as soon as possible and the next pill at the usual time. No additional barrier required.	No Emergency Contraception (EC) Required
Started a pill pack two or more days late	Start the new pack that day and take pills as usual. Abstain or use condoms for the next 7 days.	NEEDS EC if unprotected intercourse in pill-free week or first 7 days of pack.
Missed any two to four of the first 7 active pills of the pack (Days 1 – 7)	Take the missed pill as soon as possible and the next pill at usual time. Abstain or condoms for next 7 days.	NEEDS EC if has had unprotected sex in pill-free week or in first 7 days of the pack.
Missed any two to four pills of the middle 7 days of pack (Days 8 – 14)	Take the missed pill as soon as possible and the next pill at the usual time. Continue as usual. No need for condoms.	No EC required.
Missed two to four of the last 7 active pills in pack (Days 15 – 21)	Take the missed pill as soon as possible and the next pill at usual time AND go straight onto the next pack. Condoms not required.	No EC required.
Missed five or more pills in a row in any week (Days 1 – 21)	Take the missed pill as soon as possible and the next pill at the usual time AND go straight on to the next pack. Abstain or condoms for 7 days.	NEEDS EC if unprotected intercourse has occurred in the 7 days since missing the fourth pill.
Missed one or more inactive pills in everyday packaging.	Discard the missed pill and continue taking pills as usual.	No extra cover required.

References

Glasier,A Gebbie,A Family Planning and Reproductive Health Churchill Livingstone
Guillebaud,J Contraception Today. Taylor and Francis
www.ffprhc.org.uk