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

History

Is she suitable for COC?

Family History

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

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

Action

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).

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

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

Symptoms for which COCs should be stopped immediately

Emergency contraception when on COC

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

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