COC_Counselling_Flashcards

Question 1

What should women considering the combined oral contraceptive pill (COC) be counselled on?

Answer 1

Women considering the combined oral contraceptive pill should be counselled on potential harms and benefits, advice on taking the pill, situations where efficacy may be reduced, and information about STIs.

Question 2

How effective is the combined oral contraceptive pill if taken correctly?

Answer 2

The combined oral contraceptive pill is > 99% effective if taken correctly.

Question 3

What are the potential risks associated with the combined oral contraceptive pill?

Answer 3

The potential risks associated with the combined oral contraceptive pill include a small risk of blood clots, a very small risk of heart attacks and strokes, and an increased risk of breast cancer and cervical cancer.

Question 4

What should women know about taking the COC pill?

Answer 4

Women should be advised that if the COC is started within the first 5 days of the cycle, there is no need for additional contraception. If started at any other point in the cycle, alternative contraception should be used for the first 7 days.

Question 5

When is additional contraception not needed if starting the COC pill?

Answer 5

Additional contraception is not needed if the COC pill is started within the first 5 days of the cycle.

Question 6

When should alternative contraception be used when starting the COC pill?

Answer 6

Alternative contraception should be used for the first 7 days if the COC pill is started at any point other than the first 5 days of the cycle.

Question 7

How should the COC pill be taken daily?

Answer 7

The COC pill should be taken at the same time every day.

Question 8

What is the conventional regimen for taking the COC pill?

Answer 8

The conventional regimen for taking the COC pill is to take it for 21 days and then stop for 7 days, during which a withdrawal bleed similar to menstruation occurs.

Question 9

What major change occurred in the 2019 guidelines regarding the COC pill regimen?

Answer 9

The major change in the 2019 guidelines was the introduction of ‘tailored’ regimes for taking the COC pill, as there is no medical benefit from having a withdrawal bleed.

Question 10

What are the ‘tailored’ regimes for taking the COC pill?

Answer 10

Tailored regimes for taking the COC pill include never having a pill-free interval or ‘tricycling’ - taking three 21-day packs back-to-back before having a 4 or 7 day break.

Question 11

What is the advice regarding intercourse during the pill-free period?

Answer 11

Intercourse during the pill-free period is only safe if the next pack is started on time.

Question 12

In what situations may the efficacy of the COC pill be reduced?

Answer 12

The efficacy of the COC pill may be reduced in situations such as vomiting within 2 hours of taking the pill, medication that induces diarrhoea or vomiting, and taking liver enzyme-inducing drugs.

Question 13

What should be done if vomiting occurs within 2 hours of taking the COC pill?

Answer 13

If vomiting occurs within 2 hours of taking the COC pill, another pill should be taken as soon as possible.

Question 14

How can certain medications affect the effectiveness of oral contraception?

Answer 14

Medications that induce diarrhoea or vomiting, such as orlistat, may reduce the effectiveness of oral contraception.

Question 15

What should women know about concurrent antibiotic use with the COC pill?

Answer 15

For many years, doctors in the UK advised that the concurrent use of antibiotics might interfere with the enterohepatic circulation of oestrogen, making the COC pill ineffective, and advised extra precautions during and for 7 days after antibiotic treatment.

Question 16

What did the 2011 guidelines from the Faculty of Sexual & Reproductive Healthcare say about antibiotics and the COC pill?

Answer 16

The 2011 guidelines from the Faculty of Sexual & Reproductive Healthcare abandoned the approach of advising extra precautions with antibiotics, except for enzyme-inducing antibiotics.

Question 17

What precautions should be taken with enzyme-inducing antibiotics such as rifampicin?

Answer 17

Precautions should still be taken with enzyme-inducing antibiotics such as rifampicin when using the COC pill.

Question 18

What other important discussion should be included in counselling about the COC pill?

Answer 18

Counselling about the COC pill should include a discussion on STIs.

Question 19

A 28-year-old woman presents to her general practitioner wishing to discuss contraception. She is not keen on a long-acting method and would prefer some form of pill. She has no significant past medical history.

After an in-depth discussion with the doctor, she agrees to trial a combined oral contraceptive pill (COCP).

What should she be advised about the pattern of usage?

A pill-free interval is not necessary
A pill-free interval should be taken every month
A pill-free interval should be taken at least every 2 months
A pill-free interval should be taken at least every 3 months
A pill-free interval should be taken at least every 6 months

Answer 19

A pill-free interval is not necessary

There is no medical indication for the pill free interval or withdrawal bleed whilst taking the combined oral contraceptive pill

Traditionally, the COCP has been taken for 21 days in a row followed by a 7-day pill-free interval. This creates a withdrawal bleed that many patients assume is a ‘period’. However, it is an artificial bleed - the body’s response to the withdrawal of hormones. This withdrawal bleed serves no purpose and so more recent guidance from the FSRH discusses taking the COCP continuously, without a pill-free break. They highlight that this method is perfectly safe. As such, the patient should be advised that a pill-free interval is not necessary, should she wish to forgo withdrawal bleeds.

Advising her that a pill-free interval should be taken every month is incorrect. Although this is the traditional method of taking the COCP, withdrawal bleeding serves no physiological purpose and women may prefer to take the pill continuously to avoid such bleeding.

For the same reason, advising her that a pill-free interval should be taken at least every 2 months is incorrect. Some women may wish to have a withdrawal bleed every so often, but it is not necessary.

Having a pill-free interval every 3 months is commonly known as tricycling and has been popular for several years. More recent guidance, however, suggests that even this is unnecessary and the pill can be used safely continuously.

Advising her that a pill-free interval should be taken at least every 6 months is incorrect. This method is safe, and some women may choose to do this, but guidance states that a pill-free interval is not necessary at all.

Question 20

A 19-year-old woman presents to the clinic with concerns about the risks associated with continuous use of the combined oral contraceptive pill (COCP), which she has been taking for 8 months. She has taken consecutive pill packets for the past 3 months to avoid withdrawal bleeding. Apart from a miscarriage at 5 weeks gestation when she was 17, she has no significant medical history and is otherwise well.

What is the most appropriate advice for this patient?

• She can continue to use the pill in this way as there is no medical indication for the pill-free interval or withdrawal bleed
• She should ensure she has a withdrawal bleed at least every 3 months (‘tricycling’)
• She should not skip the pill-free interval or withdrawal bleed for consecutive months as it can increase the risk of blood clots
• She should not skip the pill-free interval or withdrawal bleed for consecutive months as it can increase the risk of breast cancer
• The efficacy of the COCP may reduce over time if it is taken repeatedly without a pill-free interval or withdrawal bleed

Answer 20

She can continue to use the pill in this way as there is no medical indication for the pill-free interval or withdrawal bleed

There is no medical indication for the pill free interval or withdrawal bleed whilst taking the combined oral contraceptive pill

She can continue to use the pill in this way as there is no medical indication for the pill-free interval or withdrawal bleed is correct. It is medically acceptable for this patient to persist in taking her contraceptive pill packets consecutively without a break, as there are no health benefits associated with having a withdrawal bleed. Consequently, clinicians are now encouraged to engage in discussions with patients about ‘tailored’ pill-taking regimens. These may include continuous use without any withdrawal bleeds or ‘tricycling’, which involves taking three 21-day packs back-to-back followed by a 4 or 7-day break. During her consultation, it would be useful to remind her of additional pertinent advice: she ought to take the pill at the same time daily to optimise its efficacy and understand that the COCP does not offer protection against sexually transmitted infections.

She should ensure she has a withdrawal bleed at least every 3 months (‘tricycling’) is incorrect. While ‘tricycling’ is an accepted method of COCP administration, patients don’t need to adopt this regimen. There exists no clinical requirement for a pill-free interval or withdrawal bleed when using the COCP, hence, it is safe for this individual to maintain her current approach.

She should not skip the pill-free interval or withdrawal bleed for consecutive months as it can increase the risk of blood clots is incorrect. The absence of a clinical need for a pill-free interval or withdrawal bleed while on the COCP means that continuing with her present method is safe. However, it must be noted that using the COCP, irrespective of the chosen regimen, does elevate the risk of thrombotic events.

She should not skip the pill-free interval or withdrawal bleed for consecutive months as it can increase the risk of breast cancer is incorrect. The patient’s ongoing method of COCP use is safe since there’s no medical justification for a pill free interval or withdrawal bleed. Nonetheless, all regimens of COCP usage have been associated with an increased risk of both breast and cervical cancers, therefore, acquiring information about personal and familial cancer histories is essential before initiating COCP therapy.

The efficacy of the COCP may reduce over time if it is taken repeatedly without a pill-free interval or withdrawal bleed is incorrect. The effectiveness of the COCP does not diminish with uninterrupted use. However, factors such as vomiting within two hours after taking a dose or concurrent use of liver enzyme-inducing medications could potentially decrease its contraceptive efficacy.