1. Choosing the best COC and POP
Jill Zelin

3. POP
21/7 ED
Qlaira
Persona
21/7
triphasic
Evra
NuvaRing
NFP
levonelle
Silicone
diaphragm
Spermicide
Depo-Provera
ulipristal
Nexplanon
FemCap
Pasante
Unique
Latex
condom
non-latex
condoms
IUS
Femidon
Cu IUDs
Mates Skyn
Avanti Ultima
Essure
Filshie clip

4. DFFP course: COCs
Ovulation inhibited by effects on LH and FSH
MacGregor EA

5. % of women experiencing an unintended pregnancy during the first year of use
Trussell J. In: Hatcher et al. (eds) Contraceptive Technology (20th Edition). New York, Ardent Media 2011

6. DFFP course: COCs
MacGregor EA

7. Key Benefits and Risks BENEFITS Contraceptive efficacy Ovarian cancer
DFFP course: COCs
Key Benefits and Risks
BENEFITS
Contraceptive efficacy
Ovarian cancer
Endometrial cancer
Colorectal cancer
Menstrual problems
Ectopic pregnancy
Ovarian cysts
Benign breast disease
PID
MacGregor EA

8. Key Benefits and Risks RISKS BENEFITS Venous disease
DFFP course: COCs
Key Benefits and Risks
RISKS
Venous disease
Arterial disease
Breast cancer
Cervical cancer
BENEFITS
Contraceptive efficacy
Ovarian cancer
Endometrial cancer
Colorectal cancer
Menstrual problems
Ectopic pregnancy
Ovarian cysts
Benign breast disease
PID
MacGregor EA

9. DFFP course: COCs
Also leads on the slide of benefits of COC which = side effects of not
ie. remember - not being on the pill has side-effects
MacGregor EA

10. COC progestogen ladder
DFFP course: COCs
COC progestogen ladder
cyproterone
drospirenone
gestodene
desogestrel
norgestimate
levonorgestrel
norethisterone
More
oestrogenic by DOSE
Dianette
35mcg
Cilest
Norimin
Brevinor/Ovysmen
30mcg
Yasmin
Femodene/
Katya
Marvelon
Microgynon
Loestrin 30
20mcg
Yaz
Femodette
Sunya
Mercilon
Loestrin 20
Prog-only
Femulen
Cerazette
Norgeston
Noriday/
Micronor
More oestrogenic by function
Less oestrogenic by function
MacGregor EA

11. Risk of venous thromboembolism (VTE) associated with non-use, combined hormonal contraception (CHC) use over the course of 1 year
Risk of VTE per 10,000 healthy
women
Non contraceptive users and not pregnant 2
CHC containing ethinylestradiol plus
levonorgestrel, norgestimate or
Norethisterone
5-7
CHC containing etonogestrel (ring) and
norelgestromin (patch)
6-12
gestodene, desogestrel, drospirenone
9-12
(adapted from
/2013/11/news_detail_ jsp&mid=WC0b01ac058004d5c1)

12. Pharmacokinetics & dynamics
Based on data from various sources, no direct comparative data

13. DFFP course: COCs
VTE per 100,000 women/yr
1% mortality
MacGregor EA

14. VTE per 100,000 women/yr Dinger JC et al. Contraception 2007; 75: 344
DFFP course: COCs
VTE per 100,000 women/yr
Dinger JC et al. Contraception 2007; 75: 344
MacGregor EA

15. EURAS: effect of time on VTE risk
DFFP course: COCs
EURAS: effect of time on VTE risk
Obesity is biggest risk
Risk for all COCs is around 90/100,000
Baseline was 44/100,000 (higher than usual 5/100,000!)
BMI>30 on COC was 230/100,000
Pregnant 290/100,000
Once no safer than preg, no longer have grounds to prescribe COCs
Dinger JC et al. Contraception 2007; 75: 344
MacGregor EA

16. BMI ≥30 EURAS 3X VTE risk vs. normal weight
DFFP course: COCs
EURAS
BMI ≥30
3X VTE risk vs. normal weight
Obesity is biggest risk
Risk for all COCs is around 90/100,000
Baseline was 44/100,000 (higher than usual 5/100,000!)
BMI>30 on COC was 230/100,000
Pregnant 290/100,000
Once no safer than preg, no longer have grounds to prescribe COCs
Dinger JC et al. Contraception 2007; 75: 344
MacGregor EA

17. Arterial Thromboembolism
DFFP course: COCs
Arterial Thromboembolism MI
very small increase in risk in healthy users vs. non users
Ischemic stroke
increased X2 in healthy users vs. non users
MacGregor EA

18. Collaborative Group on Hormonal Factors & Ca Breast 1996
DFFP course: COCs
Collaborative Group on Hormonal Factors & Ca Breast 1996
Meta-analysis of 54 studies from 26 countries
53,297 women with Ca Breast
100,239 women without Ca Breast
Current COC users:RR=1.24[ ]
i.e. 24% increased risk
Lancet 1996; 347:
MacGregor EA

19. Women’s CARE Study 2002 Population-based case-control study in US
DFFP course: COCs
Women’s CARE Study 2002
Population-based case-control study in US
4575 women with Ca breast
4682 controls
Current COC users: RR = 1.0 [ ]
Past COC users: RR = 0.9 [ ]
Marchbanks PA et al. NEJM 2002; 346:
MacGregor EA

20. Why the differences? Surveillance bias Age of population
DFFP course: COCs
Why the differences?
Surveillance bias
Age of population
2002: restricted to women aged 35-64
1996: 9% of women with Ca Breast were <35 years at the time of diagnosis
Are young women with BRCA1 and BRCA2 mutations using COCs at increased risk of Ca Breast?
MacGregor EA

21. Three-Nation Study 2005 Population-based case-control study
DFFP course: COCs
Three-Nation Study 2005
Population-based case-control study
Is COC use a risk factor for early Ca Breast in Caucasian carriers and non-carriers of BRCA1 and BRCA2 mutations?
Low-dose COCs are NOT associated with increased risk of Ca Breast in BRCA1 or BRCA2 carriers, or in non-carriers
Milne RL et al. Cancer Epidemiol Biomarkers Prev 2005; 14: 350-6
MacGregor EA

22. BRCA and Ovarian Cancer
DFFP course: COCs
BRCA and Ovarian Cancer
BRCA mutations associated with increased risk of Ca ovaries
Low-dose COCs may be associated with reduced risk of Ca ovaries in BRCA1&2 carriers
Narod SA et al. NEJM 1998; 339: 424-8
Whittemore AS et al. Br J Cancer 2004; 91:
MacGregor EA

23. FHx Ca Breast: Practical Prescribing
DFFP course: COCs
FHx Ca Breast: Practical Prescribing
Can use CHCs (UKMEC 1)
Counsel about inherent increased background risk
Consider benefits
Reduced Ovarian, Endometrial, Colorectal Ca
Relief from period-related problems
MacGregor EA

24. Cervical cancer DFFP course: COCs
Cervical cancer increased with use of COCs
Effect of HPV - main cause of cervical cancer - not usually taken into account.
Aim: to assess how use of COCs affected risk of cervical cancer in women with HPV in a multicentric case-control study.
Results: long-term use of COCs could be a co-factor that increases risk of cervical cancer by up to 4-fold in women who are positive for cervical HPV DNA. Extra effort should be made to included long-term users of COCs in cervical screening programmes.
MacGregor EA

25. Cervical cancer COC use Smoking HPV DFFP course: COCs
Cervical cancer increased with use of COCs
Effect of HPV - main cause of cervical cancer - not usually taken into account.
Aim: to assess how use of COCs affected risk of cervical cancer in women with HPV in a multicentric case-control study.
Results: long-term use of COCs could be a co-factor that increases risk of cervical cancer by up to 4-fold in women who are positive for cervical HPV DNA. Extra effort should be made to included long-term users of COCs in cervical screening programmes.
MacGregor EA

26. Risk of Cx cancer in women with Cx HPV COC users vs. never users
DFFP course: COCs
Risk of Cx cancer in women with Cx HPV COC users vs. never users
Cervical cancer increased with use of COCs
Effect of HPV - main cause of cervical cancer - not usually taken into account.
Aim: to assess how use of COCs affected risk of cervical cancer in women with HPV in a multicentric case-control study.
Results: long-term use of COCs could be a co-factor that increases risk of cervical cancer by up to 4-fold in women who are positive for cervical HPV DNA. Extra effort should be made to included long-term users of COCs in cervical screening programmes.
Moreno et al. Lancet 2002; 359:
MacGregor EA

27. Ca Cervix: Practical Prescribing
DFFP course: COCs
Ca Cervix: Practical Prescribing
Women using CHCs should be counselled:
Against smoking
Use condoms to protect against STIs
Take up the Cervical Screening Programme
Women with CIN can continue CHCs during treatment
MacGregor EA

28. The pill is pretty safe BUT
DFFP course: COCs
The pill is pretty safe BUT
SOME WOMEN ARE DANGEROUS!
MacGregor EA

29. Practical Prescribing
DFFP course: COCs
Practical Prescribing
Who never?
Who maybe?
special advice/monitoring
MacGregor EA

30. DFFP course: COCs
Assessment
History
MacGregor EA

31. Assessment Examination Blood pressure BMI (weight (kg/m2)/height(m)
DFFP course: COCs
Assessment
Examination
Blood pressure
BMI (weight (kg/m2)/height(m)
MacGregor EA

32. UKMEC Eligibility Because: UKMEC 1: no restriction No associated risks
DFFP course: COCs
UKMEC Eligibility
UKMEC 1: no restriction
UKMEC 2:
UKMEC 3:
UKMEC 4: unacceptable risk
Because:
No associated risks
Benefits > risks
Risks > benefits
Risks >>> benefits
UKMEC 2009
MacGregor EA

33. Absolute contraindications
DFFP course: COCs
Absolute contraindications
< 6 weeks postpartum if breastfeeding
Smoker ≥ age 35 ≥15 cigs/day
BP systolic >160 or diastolic ≥95
Current or past Hx VTE
Known thrombogenic mutations
Major surgery with prolonged immobilization
Systemic Lupus Erythematosus
Current or past Hx IHD/CVA
Diabetes > 20yrs OR with “opathies”
Complicated valvular heart disease
Migraine aura (“focal”)
Current breast cancer
Liver tumours
Liver disease: active hepatitis/severe cirrhosis
MacGregor EA

34. Smokers: Practical Prescribing
DFFP course: COCs
Smokers: Practical Prescribing
CHCs not recommended in smokers >35 years
<15 cigs/day UKMEC 3
≥15 cigs/day UKMEC 4
Healthy, non-smoking women may continue to use CHCs until menopause
MacGregor EA

35. [Insert Lecture Name Here]
‘Quick Start’ Method
Start at any time during menstrual cycle
Use of back-up barrier contraception for 7 days
If following emergency contraception, do urine pregnancy test in 3 weeks
Talking Points:
Start at any time during menstrual cycle
Provider should recommend use of back-up barrier contraception or abstinence for 7 days. If unprotected intercourse occurs days emergency contraception should be considered.
If Quick Start method is used with emergency contraception, it is important to obtain a urine pregnancy test in 3 weeks to ensure that the patient was not already pregnant when the implant was inserted.
- - -
Original content for this slide submitted by Clinical Advisory Committee for New Developments in Contraception: The Single-Rod Implant in July Original funding received from Organon through an unrestricted educational grant. This slide is available at

36. Bridging

37. Oestrogenic and Progestogenic effects
DFFP course: COCs
Oestrogenic and Progestogenic effects
Oestrogenic
Progestogenic
Breast enlargement / tenderness
Acne
Bloating
Greasy hair
Weight gain (water retention)
Hirsutism
Nausea
Weight gain
(increased appetite)
Non-infective vaginal discharge
*these side effects are much less likely with newer pills containing progestogens other than levonorgestrel and norethisterone
Some headaches
Depression
Chloasma
Loss of libido
Photosensitivity
Vaginal dryness
MacGregor EA

38. COC progestogen ladder
DFFP course: COCs
COC progestogen ladder
cyproterone
drospirenone
gestodene
desogestrel
norgestimate
levonorgestrel
norethisterone
More
oestrogenic by DOSE
Dianette
35mcg
Cilest
Norimin
Brevinor/Ovysmen
30mcg
Yasmin
Femodene/
Katya
Marvelon
Microgynon
Loestrin 30
20mcg
Yaz
Femodette
Sunya
Mercilon
Loestrin 20
Prog-only
Femulen
Cerazette
Norgeston
Noriday/
Micronor
More oestrogenic by function
Less oestrogenic by function
MacGregor EA

39. Drug interactions Antibiotics No concerns unless enzyme-inducing
DFFP course: COCs
Drug interactions
Antibiotics
No concerns unless enzyme-inducing
MacGregor EA

40. Drug interactions Enzyme-inducing agents Antibiotics Antifungals
DFFP course: COCs
Drug interactions
Enzyme-inducing agents
Anti-epileptics
Anti-retrovirals
St John’s Wort
Antibiotics
Rifampicin
Antifungals
Griseofulvin
FFPRHC guidance (April 2005) Drug interactions with hormonal contraception
MacGregor EA

41. Enzyme-inducing agents
DFFP course: COCs
Enzyme-inducing agents
CHCs
50 mcg monophasic
Norinyl-1 50 mcg mestranol
OR standard COC (off-licence)
4 day PFI
tricycle/continuous
If seizures occur in PFI consider tricycling
MacGregor EA

42. DFFP course: COCs
MacGregor EA

43. DFFP course: COCs
MacGregor EA

44. Progestogen-only pills currently available in the UK
Brand name
Type of
progestogen
Dose
(µg)
Cerazette®
Desogestrel 75
Noriday®
Norethisterone
350
Micronor®
Norgeston®
Levonorgestrel 30

45. no longer manufactured
POP
Femulen® - Etynodiol diacetate 500µg
no longer manufactured

46. UKMEC 3 Current ischaemic heart disease Stroke while taking POP
Headaches migraine with aura, at any age starting while taking POP
Gestational trophoblastic neoplasia with abnormal hCG
Breast cancer in the past (5 years+)
Viral hepatitis active/Cirrhosis severe (decompensated)/Liver tumours

47. UKMEC 4
Breast cancer current or within the last 5 years

49. Women over 40
Little benefit in using Cerazette – traditional POPs as effective
Failure rates for traditional POPs vary are lower for women aged over 40 compared to younger women

50. POP and weight
There is no evidence that the efficacy of progestogen-only pills is reduced in women weighing >70 kg and therefore the licensed use of one pill per day is recommended.
But I usually give 2!!