1. Oral Contraceptive Pill ( OCP)
J Hassan

2. Introduction
OCP 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

3. Principles of counselling: Why method chosen Efficacy/ Mode of action
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

4. COCP Mode of action Ovulation suppression Endometrial atrophy
Thickens cervical mucus
Effectiveness
Failure rate is per 100 woman years

5. Classification Type of progesterone Monophasic pills Triphasic pills
Levonorgestrel
Microgynon 30/ED
Ovranette (30 EE)
Eugynon (30 EE)
Trinodial
Logynon/ ED
Norethisterone
Ovysmen / Brevinor (35 EE)
Norimin( 35)
Loestrin 20/30
Trinovum
Binovum
Synphase
Norgestimate
Cilest (35 EE)
Desogestrol
Mercilon 20 Ee
Marvelon 30 EE
Gestogene
Femodene (ED/ 30EE)
Minulet (30 EE)
Femodette(20 EE)
Tri-Minulet
Drospirenone
Yasmin (30 EE)

6. 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

7. 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.

8. 1st consultation Important 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

9. Weight and Height and BMI calculated and documented
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
VTE in a first-degree relative under the age of 45 years who, having considered other contraceptive methods, still wish to use COC, then a thrombophilia screen should

10. Starting Regimes Postpartum Miscarriage/ TOP< 24wks TOP > 24wks
Menstruating
Ideally start day 1 of cycle can start up to day 5 without additional contraception
Anytime 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 days
Breast 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

11. 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 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

12. 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 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,

13. Side effects Oestrogenic
Nausea, dizziness, bloating, breast engorgement, vaginal discharge, premenstrual tension, migranes
Change 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 menses
Change to more osetrogenic eg Ovysmen, Marvelon, femodene, cilest, Trinordiol/ logynon

14. 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

15. 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 per 100 woman years
Mode of action
Mainly thickening cervical mucus
Atrophy of endometrium, hinders implantation
Interfere with tubal transport of ova
Cerazette however inhibits ovulation
As Progestogen on its own not demonstrated to have effects on coagulation.

16. POP Type of progesteron Norethisterone 350mcg Levonorgestrel 30mcg
Micronor
Noriday
Levonorgestrel
30mcg
Microval, Norgeston
Di norgestrel
75mcg
Neogest
Etynodiol diacetate
500mcg
Femulen
Disogestrel
Cerazette

17. 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

18. 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

19. Current breast Ca
Past severe side effects
Acute porphyria

20. Missed pill: pill needs to be taken at same time of day
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.

21. Thank You