5.3 COCP Flashcards
What does COCP contain?
oestrogen and progesterone
Effectiveness of COCP
> 99% but 91% with typical use
At what age can you use COCP?
Up to 50 year old
- fine in under 20s
- UKMEC 2 at 6 weeks post birth
Mechanism of action of COCP?
- Preventing OVULATION (this is the primary mechanism of action)
- Progesterone thickens the cervical mucus
- Progesterone inhibits proliferation of the endometrium, reducing the chance of successful implantation
Oestrogen and progesterone inhibit GnRH, FSH and LH so ovulation cannot occur.
What is breakthrough and withdrawal bleeding?
COCP maintains endometrium, when pill is stopped there is “withdrawal bleed”.
When extended use without a pill free period you get “breakthrough bleeding”
Whats the difference between multi- and mono- phasic COCPs?
- Monophasic pills contain the same amount of hormone in each pill
- Multiphasic pills contain varying amounts of hormone to match the normal cyclical hormonal changes more closely
Everyday formulations (e.g. Microgynon 30 ED) are monophasic pills, but the pack contains seven inactive pills, making it easier for women to keep track by simply taking the pills in order every day.
Name 5 monophasic COCPs?
Microgynon Loestrin Cilest Yasmin Marvelon
(vary in amount of oestrogen and type of progesterone)
What hormones does Microgynon contain?
Microgynon contains ethinylestradiol and levonorgestrel
What hormones does Loestrin contain?
Loestrin contains ethinylestradiol and norethisterone
What hormones does Cilest contain?
Cilest contains ethinylestradiol and norgestimate
What hormones does Yasmin contain?
Yasmin contains ethinylestradiol and drospirenone
What hormones does Marvelon contain?
Marvelon contains ethinylestradiol and desogestrel
What hormone combo is NICE first line?
ethinylestradiol with:
- levonorgestrel or
- norethisterone
(lower VTE risk)
Which COPC are NICE first line?
Microgynon or Leostrin
ethinylestradiol with:
- levonorgestrel (Microgynon) or
- norethisterone (Loestrin)
(lower VTE risk)
Which COCP is first line for PMS?
Yasmin / drospirenone for PMS
Drospirenone has anti-mineralocorticoid and anti-androgen activity, helps symptoms of:
- bloating,
- water retention and
- mood changes
Continuous use more effective for PMS
What type of COCP pills could be used if someone suffers from acne?
COCPs containing cyproterone acetate
Name a COCP containing cyproterone acetate and what it could help with?
Use?
Dianette / cyproterone acetate can be used for:
- acne
- hirsutism
More oestrogen mean 2x great VTE risk. Stop 3 months after acne is controlled.
What 3 COCP regimes are there?
- 21 days on and 7 days off
- 63 days on (three packs) and 7 days off (“tricycling“)
- Continuous use without a pill-free period
8 side effects of COCPs?
- Unscheduled bleeding is common in the first three months and should then settle with time
- Breast pain and tenderness
- Mood changes and depression
- Headaches
- Hypertension
- VTE (the risk is much lower for the pill than pregnancy)
- Small increased risk of BREAST and CERVICAL cancer, returning to normal ten years after stopping
- Small increased risk of MI and stroke
5 benefits of COCPs?
- Effective contraception
- Rapid return of fertility after stopping
- Improvement in premenstrual symptoms, menorrhagia (heavy periods) and dysmenorrhoea (painful periods)
- Reduced risk of ENDOMETRIAL, OVARIAN and COLON cancer
- Reduced risk of benign ovarian cysts
What are COCP UKMEC 4 contraindications?
COCP is UKMEC 4:
- Uncontrolled HTN (particularly ≥160 / ≥100)
- Migraine with aura (risk of stroke)
- History of VTE
- Aged >35 and smoking more than 15 cigarettes per day
- Major surgery with prolonged immobility
- Vascular disease or stroke
- Ischaemic heart disease, cardiomyopathy or AF
- Liver cirrhosis and liver tumours
- SLE and antiphospholipid syndrome
- note BMI >35 is UKMEC 3
When and how should you start the pill?
Start on 1st day of cycle (or within 5days) and no extra contraception needed.
If start after day 5 you need condoms for 7 days.
(ensure not pregnant - reliable use before)
Advice for switching between contraceptive pills?
Between COCPs finish one finish one pack, start the new pill pack without the pill-free period.
Traditional progesterone-only pill (POP), they can switch at any time but 7 days of extra contraception (i.e. condoms).
Desogestrel (progesterone-only), can switch immediately, and no additional contraception is required. This differs from a traditional POP because desogestrel inhibits ovulation.
Important things to cover in a combined contraception pill OSCE / consultation?
(long answer)
- Different contraceptive options, including long-acting reversible contraception (LARC)
- Contraindications
- Adverse effects
- How to take
- Missed pills
- Factors on efficacy (e.g. D&V, enzyme inducers)
- Sexually transmitted infections (this pill is not protective)
- Safeguarding concerns (particularly in those under 16)
Screen for contraindications by discussing and documenting:
- Age
- Weight and height (BMI)
- Blood pressure
- Smoker or non-smoker
- Past medical history (particularly migraine, VTE, cancer, cardiovascular disease and SLE)
- Family history (particularly VTE and breast cancer)
What is an COCP “ one missed pill”?
When is it more than 24 hrs late, so 48 hrs since the last pill was taken but less than 72 hrs.
What should you do when you miss one pill?
- Take the missed pill as soon as possible (even if this means taking two pills on the same day)
- No extra protection
What happens if you miss more than one pill?
ie 72hrs since last pill
- Take the most recent missed pill as soon as possible (ie two in one day)
- CONDOMS for until they have taken pill straight for 7 DAYS
- depending on day of packet, if day:
- 1-7; emergency contraception
- 8-14 no emergency
- 15-21 no emergency but back to back the next pack (skip pill free period)
(and condoms 7 days)
(technically it takes 7 days to work, and 7 days to not work, break periods are the riskiest times)
What do you do if you have D&V?
This counts as a missed pill!
Name a medicine that reduces COCP effectiveness?
Rifampicin
and other enzyme inducers PC BRAS: - phenytoin - carbamazepine - barbiturates - rifampicin - alcohol chronic - sulphonylureas (and: smoking, St Johns Wort, griseofulvin)
Should COCP be stopped before surgery?
Yes, four weeks before a major operation (great than 30mins) or anything that needs limb immobilised.
