1. Session II, Slide # 1 Combined Oral Contraceptive Pills (COCs) Session II: Who Can and Cannot Use COCs?

2. Session II, Slide # 2 COCs Are Safe for Nearly All Women Almost all women can use COCs safely, including women who: –Have or have not had children –Are not married –Are of any age –Smoke (if under age 35) –Have anemia now or had it in the past –Have varicose veins –Have an STI or HIV/AIDS Most health conditions do not affect safe and effective use of COCs

3. Session II, Slide 3 Who Can and Cannot Use COCs Most women can safely use the pill. But usually cannot use the pill if: High blood pressure Smoke cigarettes AND age 35 or older Breastfeeding 6 months or less May be pregnant Gave birth in the last 3 weeks Some other serious health conditions

4. Session II, Slide 4 Source: WHO, 2010. Breast feeding a baby less than 6 months old Had a heart attack or stroke Had blood clots in legs or lungs Are pregnant My period is late… Think they may be pregnant Who Should Not Use COCs (part 1) Breast feeding a baby less than 6 months old Smoke and are age 35 or older Have or had breast cancer Had a heart attack or stroke Had blood clots in legs or lungs Are pregnant Think they may be pregnant

5. Session II, Slide 5 Source: WHO, 2010. Breast feeding a baby less than 6 months old Had a heart attack or stroke Had blood clots in legs or lungs Think they may be pregnant Who Should Not Use COCs (part 2) Have rheumatic disease, such as lupus Take pills for TB, seizures (fits), or HIV Have high blood pressure I cannot eat sweets. Have diabetes (high sugar in blood) Have serious liver disease or gall bladder disease Have bad headaches with nausea or vision problems Gave birth in last 6 weeks Source: WHO, 2010; Chu, 2005.

6. Session II, Slide # 6 Medical Eligibility Criteria What are medical eligibility criteria? Define the categories. Review the job aid.

7. Session II, Slide # 7 WHO’s Medical Eligibility Criteria Categories for IUDs, Hormonal and Barrier Methods Source: WHO, 2010. CategoryDescription When clinical judgment is available 1No restriction for use Use the method under any circumstances 2 Benefits generally outweigh risks Generally use the method 3 Risks usually outweigh benefits Use of method not usually recommended, unless other methods are not available/acceptable 4Unacceptable health riskMethod not to be used

8. Session II, Slide # 8 WHO’s Medical Eligibility Criteria Categories for IUDs, Hormonal and Barrier Methods Source: WHO, 2010. WHO’s Medical Eligibility Criteria Categories for IUDs, Hormonal and Barrier Methods Category When clinical judgment is available 1 Use the method 2 3 Do not use the method 4

9. Session II, Slide # 9 WHO CategoryConditions (selected examples) Category 1 menarche to 39 yrs; nulliparous; endometriosis; endometrial or ovarian cancer; uterine fibroids; family history of breast cancer; varicose veins; irregular, heavy, or prolonged bleeding; anemia; STI/PID; hepatitis (chronic/carrier) Category 2 ≥40 yrs; breastfeeding ≥6 months postpartum; superficial thrombophlebitis; uncomplicated diabetes; cervical cancer; unexplained vaginal bleeding; undiagnosed breast mass Category 1 and 2 Examples (not inclusive): Who Can Use COCs Source: WHO, 2010.

10. Session II, Slide # 10 WHO CategoryConditions (selected examples) Category 3 Postpartum: Breastfeeding between 6 weeks and 6 months Non-breastfeeding <21 days (if no additional risk factors for blood clots) Vascular conditions: Hypertension (history of or BP 140-159/90–99) Migraine without aura (older than 35 yrs) Gastrointestinal conditions: Symptomatic gall bladder disease (current and medically-treated) Drug interactions: Use of rifampicin, rifabutin, ritonavir Category 3 Examples (not inclusive): Who Should Generally Not Use COCs Source: WHO, 2010.

11. Session II, Slide # 11 WHO CategoryConditions (selected examples) Category 4 Breastfeeding: <6 weeks postpartum Smoking: ≥15 cigarettes/day and ≥ 35 yrs old Vascular conditions: Hypertension (≥160/≥100) Migraines with aura Ischemic heart disease or stroke Diabetes with vascular complications Deep venous thrombosis (history or acute) Pulmonary embolism (history or acute) Liver conditions: Acute hepatitis Severe liver disease and most liver tumors Breast cancer: current or within 5 yrs Category 3 Examples (not inclusive): Who Should Generally Not Use COCs Source: WHO, 2010; Sekar, 2008.

12. Session II, Slide # 12 COC Use by Women with HIV Women with HIV or AIDS can use without restrictions Women on ARVs other than ritonavir can use COCs safely Should not be used by women who take ritonavir (may reduce effectiveness of COCs). Using low-dose COCs is appropriate Condom use should be encouraged in addition to COCs Source: WHO, 2010; Sekar, 2008. WHO Eligibility Criteria ConditionCategory HIV-infected 1 AIDS 1 ARV therapy (which does not contain ritonavir) 2 Ritonavir/ ritonavir- boosted PIs (as part of ARV regimen) 3

13. Session II, Slide # 13 COC Use by Postpartum Women Non-breastfeeding women should not initiate COCs before 3 weeks postpartum (6 weeks postpartum for multiple VTE risk factors) Breastfeeding women –Should not use COCs before 6 weeks postpartum –Should not use COCs from 6 weeks to 6 months postpartum unless no other method is available –Can generally initiate COCs at 6 months postpartum Source: WHO, 2010. WHO Eligibility Criteria ConditionCategory Non- breastfeeding <3 weeks 3 Breastfeeding <6 weeks 4 Breastfeeding >6 weeks and < 6 months 3 Breastfeeding ≥6 months 2

14. Session II, Slide # 14 Group Activity Understanding the Checklist Read questions 1–12 in the checklist. How have you determined medical eligibility in the past? The checklist also gives instructions about initiating COCs. This set of questions identifies women who should not use COCs. This set of questions identifies women who are not pregnant.