Combined hormonal contraceptive Flashcards
What are combined hormonal contraceptives?
Contiain oestrogen and a progestogen either in fixed ratio or varying though the month
Pills, vaginal ring, transdermal patch
What does a COCP contain?
Oestrogen:
Ethinylestradiol
standard strength is 30-35mcg
Low strength contains 20mch and used if there are risk factors for circulatory disease or oestrogen side effects
Use phased preparations for women who have bleeding problems with monophonic products
Progestogens
Levonorgestrel and norethisterone
What advice for starting and taking COCP?
If started within first 5 days of cycle, no need for additional contraception
If started at any other point, additional contraception for first 7 days
Take at same time every day
Taken for 21 days then 7d break giving a withdrawal bleed
Or - tailor as no medical benefit from having withdrawal bleed - never have pill-free interval or tricycling - taking three 21d packs before having 4 or 7d break
Intercourse during pill free period is only safe if next pack started on time
What are short term side effects of combined hormonal contraceptives?
Oestrogen:
Breast tenderness, nausea, cyclical weight gain, bloating, vaginal discharge
Progestogenic:
Mood swings, PMS, vaginal dryness, sustained weight gain, decreased libido, acne
Headache
- advice to report increase in headache or development of focal symptoms
Breakthrough bleeding
- common in first 6 months
If persists > 3 months, check compliance, exclude diarrhoea/vomiting, check gynaecological causes
Screen for chlamydia, check cervix,c heck smear, exclude prenancy
What are risks of combined hormonal contraception?
VTE risk doubled
Ischaemic stroke increased risk
Breast and cervical cancer increased risk (disappears <10y after stopping)
Mood changes
BC
What are benefits of combined hormonal contraception?
Improvement in acne
Reduced menorrhagia/dysmenorrhoea
Reduced risk of ovarian, endometrial and bowel cancer
Reduced menopausal symptoms
OEB
When may the COCP have reduced efficacy?
Womiting within 2 hours of taking pill
Medication that induce diarrhoea or vomiting may reduce effectiveness of oral contraception
Liver enzyme inducing drugs
When should pill be stopped?
Sudden severe chest pain Sudden breathlessness Severe calf pain Unexplained leg swelling Severe stomach pain Unusual severe prolonged headache, sudden visual loss, collapse, dysphasia, hemi-motor/sensory loss, 1st seizure Hepatitis, jaundice or liver enlargement BP > 160/95 4 weeks before leg or major surgery
What should be done if 1 pill is missed?
Take the last pill even if it means taking two pills in one day
Then continue taking pills daily
No need for additional contraceptive protection
What hold be advised if 2 or more pills missed?
What if pills missed in week 1?
Week 2?
Week 3?
Take the last pill even if it means taking two pills in one day
Leave any earlier missed pills and continue taking pills daily, one each day
MAX 2 PILLS one day
Use condoms or abstain until she has taken pills for 7d in a row
IF pills are missed in week 1 emergency contraception should be considered if she had unprotected sex in pill-free interval or in week 1
If pills are missed in week 2, after seven consecutive days of taking COC there is no need for emergency contraception
If pills are missed in week 3, she should finish the pill in current pack and start new pack next day, omiting pill free interval
What are absolute contraindications to COCP?
More than 35yo and smoking more than 15/day
Migraine with aura
Migraine without aura and > 1 risk factor for stroke
Severe migraine/>72hrs
Migraine treated with ergot
History of thromboembolic disease or thombogenic mutation
History of stroke or IHD
CVS disease, peripheral vascular disease, hypertensive retinopathy
Breast feeding < 6 weeks post partum
Uncontrolled HTN
Current breast cancer
Major surgery with prolonged immobilisation
DM with renal/retinal/vascular/neurological complications
If taking rifampicin
When should COCP be avoided?
More than 35yo and smoking less than 15/day
BMI > 35kg/m2
FHx of thromboembolic disease in first degree relatives < 45 years
Controlled HTN
Immobility - wheelchair
Carrier of known gene mutations associated with breast cancer (BRCA1/BRCA2)
What is the problem with giving COCP in migraine?
ISchaemic stroke
- migraine is risk factor
- with Combined contraception, ischaemic stroke increases in incidence
Other risk factors: >35yo HTN Obesity DM Deslipidaemia FHx Artery disease < 45yrs
CI: Migraine with aura Migraine without aura and > 1 risk factor for stroke Severe migraine/>72hrs Migraine treated with ergot
What are oestrogen side effects?
Breast tenderness, nausea, cyclical weight gain, bloating, vaginal discharge
What are progestagenic side effects?
Mood swings PMS Vaginal druness Sustained weight gain Decreased libido Acne
