1. Contraceptive Pills
Lisa Coulter

2. Combined Oral Contraceptive Pill

3. Mode Of Action Affect negative feedback suppressing FSH and LH
No follicles develop
No ovulation

4. Absolute Contraindications to COCP
Smoker 15 per day and >35
BMI >40
BP 160/95
VTE/IHD/CVA
Current breast ca
Viral hepatitis/cirrhosis
DM plus nephropathy/retinopathy/neuropathy

5. Starting COCP Day 1-5 menstrual cycle – no condoms
Post TOP/miscarriage – if start within 7d of TOP/miscarriage <24 gestation, no condoms
Post partum (not breast feeding) – start day 21of cycle, no condoms
Post partum (breast feeding) – not recommended; if >6m pp and menstruating, as for other cycling women
After other contraception
Depo: start 12w and 5d after last depo, no condoms
From POP: change anytime, no condoms
From implanon: any time prior to removal, or on day of removal, no condoms

6. Missed COCP Pills
If <12h late and UPSI – take pill and continue as normal
If >12h late and UPSI:
In pill free wk/first 7 pills: (if miss 2x20mcg or 3x30mcg pills) need EC
Middle 7 pills: take missed pill, condoms for 7d, no EC
Last 7 pills: take missed pill, start next packet without break, condoms 7d, no EC

7. COCP and D&V
If vomit within 2h of taking pill, take another or follow rules for missed pills
If severe diarrhoea >24h – keep taking pills but follow missed pill instructions for each day of diarrhoea

8. COCP and Broad Spectrum Abx
Penicillins, ampicillin, tetracyclines and cephalosporins may affect enterohepatic recirculation of ethinylestradiol
Continue pills, condoms during and for 7d after abx
Emergency contraceptive if UPSI during/7d after abx
Women established on non-enzyme inducing abx, i.e. >3w use do not require condoms (effects on bowel flora subside after 3w)

9. COCP and Enzyme Inducers
Women should be offered regime containing 50mcg ethinylestradiol
Condoms should be used during use of enzyme inducers and for 4w after stopping

10. When to Discontinue COCP
At least 4w before major surgery
First onset of migraine with aura
Pain or swelling in legs
Chest pain with breathlessness or haemoptysis
Cigarette smoker >35y
Age 50y

11. Progestogen Only Contraceptive Pill

12. Generations of POP 1st: norethindrone
2nd: norethisterone (micronor), levenorgesterol (microval)
3rd: desorgestrel (cerazette), gestodene

13. Mode of Action Cervical mucus changes Endometrial changes
Variable effect on ovulation

14. Who is Eligible for POP? Lactation Older women and smokers
Diabetes/obesity
Hypertension
Women’s choice
Oestrogen related contraindications

15. When to Start POP
First Use: day 1-5 of cycle no condoms, otherwise condoms required for 2d
Post partum and breast feeding: ideally on day 21 of cycle, no condoms
Post TOP: If started >7d after TOP, condoms for 2d

16. Missed POP Traditional POP (>3h late)
take missed pill, continue daily pill taking, condoms for 2d
Desorgestrel-only pill (>12h late)
Take missed pill, continue daily pill taking, condoms for 2d

17. Emergency Contraception

18. Specific indications Unprotected SI Potential barrier failures
Potential COCP failure
2x20mcg or 3x30mcg and UPSI in pill free wk/wk 1
Potential POP failure
1 or more missed and UPSI in next 2d
Potential IUD/IUS failure
expelled/removed and UPSI in previous 7d
Potential injectable failure
>14w depot and UPSI
Enzyme inducers and OCPs/implants during or within 28d of use and UPSI

19. Methods Levonelle 1500 Levonorgestrel 1500mcg within 72h of UPSI
Affects sperm migration/ function and endometrial receptivity
Variable effect on ovulation
Efficacy: 95%<24h, 85% 24-48h, 58% 48-72h
CI: pregnancy, hypersensitivity
SE: N&V, menstrual disturbance, breast tenderness
Double dose if taking enzyme inducers

20. Methods IUD Copper IUD within 5d of UPSI Inhibits implantation
Failures <1:1000
CI: possible implanted pregnancy, Recent PID

21. References
Faculty of family planning
NICE guidance October 2005