Oral Contraceptive Pill ( OCP) J Hassan

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

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

COCP Mode of action Ovulation suppression Endometrial atrophy Thickens cervical mucus Effectiveness Failure rate is 0.2-0.5 per 100 woman years

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)

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

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.

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

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

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

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 30-35 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

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 30 + 20 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,

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

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

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 0.3-5 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.

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

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

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

Current breast Ca Past severe side effects Acute porphyria

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.

Thank You