2 Combined Oral Contraceptives Objectives Participants will be able to:Describe the characteristics of COCs in a manner that clients can understandDemonstrate how to screen clients for eligibility for COC useDescribe when to initiate COCsExplain how to use COCs, what to do when pills are missed, and when to returnAddress common concerns, misconceptions, and mythsExplain how to manage side effectsIdentify conditions that require switching to another methodIdentify clients in need of referral for COC-related complicationsThe learning objectives for this module are based on input from various stakeholders <insert who provided input: participants, supervisors, health officials>.The objectives of this module are as follows: By the end of this training session, participants will be able to: <click the mouse to advance through the objectives, reading each objective aloud >.
3 COCs Key Points for Providers and Clients Take a pill every day.Contains both estrogen and progestogen hormones.Works mainly by stopping ovulation.Effectiveness depends on the user. Can be very effective.“Would you remember to take a pill each day?”No need to do anything at time of sexual intercourse.Very effective if taken every day. But if woman forgets pills, she may become pregnant.Easy to stop: A woman who stops pills can soon become pregnant.Very safe.Pills are not harmful for most women’s health and studies show very low risk for cancer due to pills for almost all women. The pill can even protect against some types of cancer.Serious complications are rare. They include heart attack, stroke, blood clots in deep veins of the legs or lungs.Some women have side-effects at first–not harmful and often go away after first 3 months.Side-effects often go away after first 3 months.No protection against STIs or HIV/AIDS.For STI/HIV/AIDS protection, also use condoms.Adapted from WHO’s Decision-making tool for family planning clients and providers.
4 What Are COCs? Traits and Types ContentCombination of two hormones: estrogen and progestinPhasicMonophasic, biphasic, triphasicDoseLow-dose: µg of estrogen (common), 20 µg or less (rare in most places)Pills per pack21: all active pills (7-day break between packs)28: 21 active + 7 inactive pills (no break between packs)
5 Effectiveness of COCsIn this progression of effectiveness, where would you place combined oral contraceptives (COCs)?Less effectiveMore effectiveImplantsMale SterilizationFemale SterilizationIntrauterine DevicesProgestin-Only InjectablesMale CondomsStandard Days MethodFemale CondomsSpermicidesAsk participants: Where would you put combined oral contraceptives on this list?After participants respond, click the mouse to reveal the answerCOCs
6 Relative Effectiveness of FP Methods # of unintended pregnancies among1,000 women in 1st year of typical useNo method850Withdrawal220Female condom210Male condom180Pill90Injectable60IUD (CU-T 380A / LNG-IUS)8 / 2Female sterilization5Vasectomy1.5Implant0.5Source: Trussell J., Contraceptive Failure in the United States, Contraception 83 (2011) , Elsevier Inc.
7 COCs: Mechanism of Action Suppresseshormonesresponsible forovulationIllustration credit: Salim Khalaf/FHIThickenscervical mucus to block spermCOCs have no effect on an existing pregnancy.
8 COCs: Characteristics Safe and more than 99% effective if used correctlyCan be stopped at any timeNo delay in return to fertilityAre controlled by the womanDo not interfere with sexHave health benefitsLess effective when not used correctly (91%)Require taking a pill every dayDo not provide protection from STIs/HIVHave side effectsHave some health risks (rare)Source: Hatcher, 2007; WHO, 2010; CCP and WHO, 2011; Trussell , 2011.
9 COCs: Menstrual-Related Health Benefits 5/25/2012COCs: Menstrual-Related Health BenefitsDecreased amount of flow and fewer days of bleeding; no bleeding (less common)Regular, predictable menstrual cyclesReduced pain and cramps during mensesReduced pain at time of ovulationSource: Davis, 2005.
10 COCs: Other Health Benefits Protection from:Risks of pregnancyOvarian cancerEndometrial cancerSymptomatic PIDReduced risk of:Ovarian cystsIron-deficiency anemiaDecreased symptoms of endometriosis (pelvic pain, irregular bleeding)Decreased symptoms of polycystic ovarian syndrome (irregular bleeding, acne, excess hair on face or body)Source: Petitti and Porterfield, 1992; CASH Study, 1987; CCP and WHO, 2011; Belsey, 1988; Davis, 2007.
11 No Overall Increase in Breast Cancer Risk for COC Users Analysis of a large number of studies:No overall increase in breast cancer risk among women who had ever used COCsCurrent use and use within past 10 years: very slight increase in riskMay be due to early diagnosis or accelerated growth of pre-existing tumorsMore recent study:No increase in breast cancer risk regardless of age, estrogen dose, ethnicity, or family history of breast cancerSource: Collaborative Group on Hormonal Factors in Breast Cancer, 1996; Marchbanks, 2002.
12 COCs and Cervical Cancer Cervical cancer is caused by certain types of human papillomavirus (HPV)Some increase in risk among women with HPV and others who use COCs more than 5 yearsRisk of cervical cancer goes back to baseline after 10 years of non-useCervical cancer rates in women of reproductive age are low. Risk of cervical cancer at this age group is low compared to mortality and morbidities associated with pregnancy.COC users should follow the same cervical cancer screening schedule as other women.Source: Smith, 2003; Appleby, 2007; CCP and WHO, 2011.
13 Risk of Blood Clots is Limited COCs may slightly increase risk of blood clots:StrokeHeart attackRisk is concentrated among women who have additional risk factors, such as:HypertensionDiabetesSmokingDeep vein thrombosisPulmonary embolismStop COCs immediately if a blood clot develops.Source: World Health Organization Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception ,1995; Jick, 2006; WHO, 1998; Farley, 1998.
14 Possible Side-Effects If a woman chooses this method, she may have some side- effects. They are not usually signs of illness.But many women do not have any side-effects.Side-effects often go away after a few months and are not harmful.Most common:Mood changes or headachesTender breastsChanges in bleeding patterns (lighter, irregular, infrequent or no monthly bleeding)Slight weight gain or lossNausea (upset stomach)DizzinessAdapted from WHO’s Decision-making tool for family planning clients and providers.