Combined Oral Contraception

Question 1

Effectiveness?

Answer 1

93%

Question 2

Acne?
Weight Gain?
VTE Risk?

Answer 2

Decreases
Neutral
2-3X- increase risk

Question 3

Bleeding:
Cycle Control?
Withdrawal Bleeding or spotting?

Answer 3

Yes
Generally both decrease after first 3 months.
Depends on type. Low E general has more spotting
higher estrogen has less
Extended cycle has less of both over time and continuous use has high spotting in first 3 months but usually amenorrhea at 1 year

Question 4

AE

Answer 4

Breast tenderness, nausea bloating - tend to resolve with time

Question 5

Drug Interactions

Answer 5

Decrease in hormone levels with CYP34A inducers - anticonvulsants and some antivirals
Antibiotics ( if they induce diarrhea ) may decrease potency ( some people say to use contraception for 48 hours after any diarrhea)

Question 6

Return to Fecundity

Answer 6

For most resumes in 1 month
99% ovulate within 3-6 months

Question 7

Additional Comments

Answer 7

Option for continuous dosing can help alleviate PMS
May decrease risk of ovarian, endometrial and colorectal cancer
May increase risk of cervical and breast cancer
Adjustable dosing for Adverse effects or for non-contraceptive use

Question 8

What are the regimes for extended use?

Answer 8

consecutive administration of active pills for 3-6-12 months with a 4-7 day hormone free interval

Question 9

Advantages to Extended or Continuous use?

Answer 9

Decrease PMS symptoms
- Endometriosis
- Anemia
- PCOS
Increased adherence and convenience

Question 10

Disadvantages of extended or continuous use?

Answer 10

no long term safety data
intially breakthrough ble3eding but decreases with time
possible delay in pregnancy recognition

Question 11

What dose of EE is approved to be used with continuous or extedned dosing?

Answer 11

<50 mcg

Question 12

Managing AE ( most will resolve after 3 months)
Breakthrough bleeding ?
Breast Tenderness ?
Nausea?
Headache?
Acne?
Cholasma?

Answer 12

• Can increase dose of estrogen if the bleeding is early or increase the dose of progestin if the bleeding is late in the cycle.
• Change to contraception with less estrogen
• Take at night with food or lower estrogen content
• If happens with HFI - can switch to extended or continuous or do shorter hormone free interval
• Decrease androgenic CHC ( desogestrel, norgestimate, drospirenone)
• Avoid sunlight, sunscreen and decrease estrogen

Question 13

Missed Dose
Week 1
What do you do?
Do I need EC?
Back up contraception?

Answer 13

Take 1 pill ASAP and continue to use as usual ( even if 2 pills in one day)
Yes if you have had unprotected sex in last 5 days
Yes for 7 days

Question 14

Missed Dose
Week 2
What do you do?
Do I need EC?
Back up contraception?

Answer 14

• Take 1 pill ASAP and continue as usual
• if 3 or more days missed and unprotected sex in the last 5 days then yes
• if 3 days missed then yes you need back up for 7 days

Question 15

Missed dose
Week 3
What do you do?
Do I need EC?
Back up contraception?

Answer 15

• Start a new cycle of pills WITHOUT a hormone free interval
• if 3 or more days missed and unprotected sex in the last 5 days then yes
• if 3 days missed then yes you need back up for 7 days

Question 16

Missed dose AFTER cycle ( you didn’t start a new pack on time after a hormone free interval)
What do you do?
Do I need EC?
Back up contraception?

Answer 16

Resume active pill asap
If unprotected sex in last 5 days and new active pill cycle delayed then yes
backup for 7 days IF EC is indicated

Question 17

Benefits ( 3 )

Answer 17

1. Simple and Highly Effective
2. Reduces Menstrual Symptoms and irregularity ( alleviates hot flashes and menorrhagia in perimenopause)
3. Decrease in PID, Endometriosis, Salpingitis, Endometrial CA, Ovarian CA, Ovarian Cysts, Colorectal Cancer, Benign Breast disease, Osteoporosis, ectopic pregnancy, Acne and Hirsutism

Question 18

Risks

Answer 18

1. VTE ( risk is still much higher in pregnancy)
2. MI/Stroke no significant risk over baseline in non smokers
   3.Breast Cancer increase X 1.3 - back to baseline at 10 years
3. BMD in COC with less than 20 mcg and in youth decreases
4. May contribute to HTN, HF, Db, Raynauds, Gallbladder/liver/pancreatitis dx, LSE, migraine, Depression, Gerd, Vaginal yeast infections, Increase Triglycerides

Question 19

what do you do if you have had vomiting or diarrhea for more than 48 hours?

Answer 19

treat as a missed pill and consider back up contraception for 7 days and EC if you have had unprotected sex within 5 days ( esp. in first week of cycle)