Contraceptive Pills Lisa Coulter

Combined Oral Contraceptive Pill

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

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

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

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

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

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)

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

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

Progestogen Only Contraceptive Pill

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

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

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

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

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

Emergency Contraception

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

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

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

References Faculty of family planning NICE guidance October 2005