Combined hormonal contraception

Question 1

Combined hormonal contraceptives (CHC) usually contain?

Answer 1

a low-dose oestrogen and a moderate dose of progestogen.

They are available as:

• a combined oral contraceptive pill (COC)
• vaginal ring

Question 2

A suitable first choice is?

Answer 2

a monophasic pill containing 30 or 35 mcg ethinyloestradiol (EE) with levonorgestrel or norethisterone e.g.

• Nordette
• Microgynon
• Monofeme
• Levlen ED, Brevinor

Question 3

Cover starts immediately if active pills started on?

Answer 3

day 1 of cycle

Question 4

Formulations containing 50 mcg EE

Answer 4

are no longer recommended because:

• there is no known additional benefit from their use and
• they are associated with an increased risk of venous thromboembolism (VTE)

Question 5

Acne

Answer 5

The oestrogen in any CHC may improve acne.

COCs containing an anti-androgenic progestogen e.g.

• Diane 35 ED

can be used second-line if acne remains a problem.

Question 6

Important advice for the patient

Answer 6

No break from the pill is necessary

Liver enzyme-inducing drugs that interact with the pill include:

• the older anti-epileptics (e.g. phenytoin, carbamazapine)
• St John’s wort and protease inhibitors
• rifampicin
• anticonvulsants (except sodium valproate)

Most antibiotics do not interact with CHC, only exceptions:

• rifabutin
• rifampicin

D&V may reduce the effectiveness of the pill

Yearly return visits are recommended

In the absence of contraindications, the pill can be safely used up to age 50

Question 7

The 7-day rule for the missed pill (>24 h late)

Answer 7

The golden rule is ‘just keep going’

Take the forgotten pill as soon as possible, even if it means taking 2 pills in one day. Take the next pill at the usual time and finish the course.

If you forget to take it for more than 24 hrs after the usual time, there is an increased risk of pregnancy so use condoms or abstinence for 7 d

If these 7 d run beyond the last hormone pill in your packet, then miss out on the inactive pills (or 7-d gap) and proceed directly to the first hormone pill in your next packet. You may miss a period. (At least 7 hormone tablets should be taken.)

–If <7 active pills were taken before the missed pill, consider emergency contraception if unprotected sex took place in the past 5 days. If ulipristal acetate emergency contraception is used, wait 5 days before restarting the pill.

–This advice does not apply to the quadriphasic pill Qlaira and the product information should be consulted.