Combined Oral Contraceptives Pills
• COCs are packaged with either 21 or 28 pills per pack. The 21-pill pack contains only active pills and requires women to take a seven-day break between packs. The 28-pill pack contains 21 active pills and seven inactive or hormone-free pills. These inactive pills are included to minimize the risk of women forgetting to start a new pack of pills on time after a seven-day break. The seven-day period, during which no active pills are taken, is called the “hormone-free interval.” Most women have their menstrual bleeding during this hormone-free interval.
The recommendations on COCs in this guidance refer to low-dose COCs containing ≤ 35 μg ethinyl estradiol, combined with a progestogen. Recommendations in this guidance are the same for all COC formulations, irrespective of their progestogen content.
The patch releases 20 μg of ethinyl estradiol and 150 μg of norelgestromin daily.
The CVR releases 15 μg of ethinyl estradiol and 120 μg of etonogestrel daily.
Contradictions of combined oral contraceptives (WHO/FRM/FPP-2001)
(A) Circulatory diseases (past or present) Thromboembolic disorder (current or past)
• Arterial or venous thrombosis
• Severe hypertension, stroke
• Valvular heart disease, Ischemic heart disease, Angina
• Diabetes with vascularcomplications
• Focal migraine.
(B) Diseses of the liver
• Active liver disease
• Liver adenoma,carcinoma
• Liver tumors.
• Undiagnosed genitaltract bleeding
• Estrogen dependent neoplasm e.g. breast cancer
• Breast feeding (within 6 weeks postpartum)
• Major surgery or prolonged immobilization.
• Age > 40 years
• Smoker or < 35 years
• History of jaundice
• Gall bladder disease
• Hyper lipidemia
• Post breast cancer
• Breast feeding (postpartum 6 weeks to6 months)
• Sickle cell disease
Initiation of COCs
Having menstrual cycles
• Within 5 days after the start of menstrual bleeding: COCs, the patch and the CVR can be initiated. No additional contraceptive protection is needed.
• More than 5 days since the start of menstrual bleeding: COCs, the patch and the CVR can be initiated if it is reasonably certain that the woman is not pregnant. She will need to abstain from sex or use additional contraceptive protection for the next 7 days.
• COCs, the patch and the CVR can be initiated at any time if it is reasonably certain that the woman is not pregnant. She will need to abstain from sex or use additional contraceptive protection for the next 7 days. Postpartum (breastfeeding)
• Less than 6 weeks postpartum and primarily breastfeeding: The woman should not use COCs, the patch or the CVR (MEC category 4).
• 6 weeks to 6 months postpartum and primarily breastfeeding: Use of COCs, the patch or the CVR is generally not recommended unless other more appropriate methods are not available or not acceptable (MEC category 3).
• More than 6 months postpartum and amenorrhoeic: COCs, the patch and the CVR can be initiated as advised for other amenorrhoeic women.
• More than 6 months postpartum and menstrual cycles have returned: COCs, the patch and the CVR can be initiated as advised for other women having menstrual cycles. Postpartum (non-breastfeeding)
• Less than 21 days postpartum: Use of COCs, the patch or the CVR is generally not recommended unless other more appropriate methods are not available or not acceptable (MEC category 3). It is highly unlikely that a woman will ovulate and be at risk of pregnancy during the first 21 days postpartum. However, for programmatic reasons (i.e. depending on national, regional and/or local programme protocols), some contraceptive methods may be provided during this period.
• 21 or more days postpartum: For women with no other risk factors for venous thromboembolism, COCs, the patch and the CVR can generally be initiated (MEC category 2).
• Medically eligible and menstrual cycles have not returned: COCs, the patch and the CVR can be initiated immediately if it is reasonably certain that the woman is not pregnant. She will need to abstain from sex or use additional contraceptive protection for the next 7 days.
• Medically eligible and menstrual cycles have returned: COCs, the patch and the CVR can
be initiated as advised for other women having menstrual cycles.
• COCs, the patch and the CVR can be initiated immediately post-abortion. No additional contraceptive protection is needed.
Advantages of COCs
Contraceptive benefits: (i) Protection against unwanted pregnancy (failure rate – 0.1 per 100 women year) (ii) Convenient to use (iii) Not intercourse related (iv) Reversibility (v) Improving maternal and child health care.
Non-contraceptive benefits: Improvement of menstrual abnormalities—(1) Regulation of menstrual cycle (2) Reduction of dysmenorrhea (40 percent) (3) Reduction of menorrhagia (50 percent) (4) Reduction of premenstrual tension syndrome (PMS) (5) Reduction of Mittelschmerz’s syndrome (6) Protection against irondeficiency anemia.
Protection against health disorders — (7) Pelvic inflammatory disease (thick cervical mucus) (8) Ectopic pregnancy (9) Endometriosis (10) Fibroid uterus (11) Hirsutism and acne (12) Functional ovarian cysts (13) Benign breast disease (14) Osteopenia and postmenopausal osteoporotic fractures (15) Autoimmune disorders of thyroid (16) Rheumatoid arthritis.
Prevention of malignancies—(17) Endometrial cancer (50 percent) (18) Epithelial ovarian cancer (50 percent) (19) Colorectal cancer (40 percent).
• Nausea, vomiting, headache (OGN) and leg cramps (PGN) — These are transient and often subside following continuous use for 2–3 cycles.
• Mastalgia (OGN + PGN) — Heaviness or even tenderness in the breast is often transient.
• Weight gain (PGN) — Though progestins have got an anabolic effect due to its chemical relation to testosterone, use of low dose COCs does not cause any increase in weight.
• Chloasma (OGN) and acne (PGN) are annoying for cosmetic reasons. Low dose oral contraceptives improves acne as levonorgestrel preparations are less androgenic.
INDICATIONS FOR WITHDRAWAL
While the majority tolerates the combined pill, in some susceptible individuals, gross adverse symptoms develop which necessitate its withdrawal. The indications for withdrawal of the pill are:
(1) Severe migraine;
(2) Visual or speech disturbances;
(3) Sudden chest pain;
(4) Unexplained fainting attack or acute vertigo;
(5) Severe cramps and pains in legs;
(6) Excessive weight gain;
(7) Severe depression;
(8) Prior to surgery (it should be withheld for at least 6 weeks to minimize postoperative vascular complications) and
(9) Patient wanting pregnancy.
Management of Missed Pill:
When a woman forgets to take one pill (late up to 24 hours), she should take the missed pill at once and continue the rest as schedule. There is nothing to worry. When she misses two pills in the first week (days 1–7), she should take 2 pills on each of the next 2 days and then continue the rest as schedule. Extra precaution has to be taken for next 7 days either by using a condom or by avoiding sex.
If 2 pills are missed in the third week (days 15–21) or if more than two active pills are missed at any time, another form of contraception should be used as back up for next 7 days as mentioned above. She should start the next pack without a break.
If she misses any of the 7 inactive pills (in a 28-day pack only) she should throw away the missed pills. She should take the remaining pills one a day and start the new pack as usual.
Drug interactions: Effectiveness of some drugs (Aspirin, oral anticoagulants, oral hypoglycemics) are decreased and that for some other drugs (beta blockers, corticosteroids, diazepam, aminophylline) are increased by oral contraceptives.