Combined oral contraceptive pill (Complete) Flashcards
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What does the combined oral contraceptive pill contain?
Progesterone
Oestrogen
Combined oral contraceptive pill is also referred to as?
Combined hormonal contraception (CHC)
What are the 3 main routes of administration for CHC?
Orally
Transdermally
Intravaginally
What is the mechanisms of action of CHC?
Involves:
Thickening the cervical mucus
Thinning the endometrium
Inhibiting ovulation
What are the contraindictions for taking CHC?
Anything that increases risk of venous thromboembolism such as:
Migarine with aura
Less than 6 weeks post-partum for breastfeeding woman
Cardiomyopathy
AF
Active breast cancer
Antiphospholipid antibodies
Age >35 years and smoking >15 cigarettes a day
Hypertension ( ≥160 mmHg systolic or ≥100 mmHg diastolic)
Vascular disease
IHD
Hx of CVA (e.g. TIA)
Hx VTE
Major surgery with prolonged immobilisation
Known thrombogenic disorders (E.g. factor V lieden)
Complex valvular heart disease (e.g. pulmonary hypertension, history of subacute bacterial endocarditis)
Severe liver cirrhosis
Hepatocellular adenoma or carcinoma
Why is CHC contraindicted in breast-feeding woman less than 6 weeks post-partum?
Due to:
Increased risk of thromboembolism post-partum
Reduction in lactation
Can be transferred to milk
Why is migraine with aura a contraindiction for CHC?
Migraine with aura involves neurogenic inflammation and activation of thrombotic pathways
What are the three main types of combined oral contraceptive pill? (COCP)
Monophasic: Each pill contains same dose
Phasic: Pills contain differing amounts of hormones and must be taken in the correct order
Every day pills: contain 21 hormone-containing pills, and 7 hormone-free pills
What regimens are available for CHC?
Traditional
Extended
Continuous use
Flexible-extended use
What is the traditional regiment for CHC?
Pill: One pill per day for 3 weeks followed by 7 day hormone free interval (HFI)
Patch: One patch per week for 3 weeks followed by 7 day HFI
Intravaginal: one vaginal ring for 3 weeks followed by 7-day HFI
What is extended use regimen for CHC?
Used for a period of nine weeks (3 months), followed by a 7-day HFI, also known as “tricycling”
What is continous use regimen for CHC?
Used continuously without any HFI
What is flexible extended use regimen?
Method used until breakthrough bleed followed by 4-day HFI
What information needs to be relayed to the patient when starting COCP?
If started on first day of period will provide immediate contraceptive protection.
If started at any other time in cycle, need 7 days of additional protection (e.g. condoms).
Postpartum patients can begin 21 days after giving birth unless they are breastfeeding which would be 6 weeks.
What are the advantages of CHC? (8)
- Effective (failure rate < 1 per 100 woman years)
- Doesn’t interfere with sex
- Contraceptive effects revisible upon stopping
- Makes periods regular, lighter and less painful
- Reduces risk of ovarian and endometrial cancers which can last for decades affter stopping.
- Reduces risk of colorectal cancer
- Can protect against PID (pelvic inflammatory disease)
- Reduces ovarian cysts, benign breast disease and acne vulgaris
What are disadvantages of CHC? (5)
Increased risk of breast and cervical cancer
Increased risk of stroke and ischaemic heart disease (especially in smokers)
Increased risk of VTE
People may forget to take it
Offers no protection against sexually transmitted infections
What are some side effects associated with CHC? (3)
Breast tenderness
Headaches
Nausea and vomitting
Mood and libido changes
Irregular menstrual bleeding, spotting or amenorrhoea
Ovarian cysts
How should patients who’ve missed one pill at any time of the cycle be managed?
Take the last missed pill as soon as you remember. (You might need to take two pills in one day)
Continue taking one pill each day as usual
Do not require any additional protection during sex (E.g. condom)
What should be advised to patients who have missed 2 or more pills within the first week (start of pack)?
1) Take the last missed pill as soon as you remember. (You might need to take two pills in one day)
2) Leave any earlier missed pills
3) Continue taking one pill each day as usual
Will require additional protection (E.g. condom) up until 7 days of using pill correctly.
If they had sex during missed pill interval or week 1, will require emergency contraception.
How should patients who had unprotected sex within pill free interval during week 1 be managed?
Require emergency contraception
What should be advised to patients who have missed > 1 pill within the 2nd week (day 8-14)?
After seven consecutive days of taking the COC there is no need for emergency contraception
What should be advised to patients who have missed > 1 pill within the 3rd week (day 15-21)?
She should finish the pills in her current pack and start a new pack the next day.
Because of this theyre omitting the pill free interval
How should woman on COCP be advised to continue management if experiencing episodes vomitting (e.g. gastroenteritis)?
Patients should take another pill straight away if previous COCP taken within 3 hours of vomitting
(2 hours for progesterone only pill)
N.B. Due to vomitting it probably will not have been absorbed by their body.
Woman on COCP should be monitored annually for?
Hypertension
N.B. Shown to have 2% risk of hypertension when taking so should have BP measured annually
What guideline should be referred to when advising children <16 about contraception and sexual health without breaking confidentiality?
Fraiser guidelines
What criteria from the fraiser guidelines must be met for a child to be deemed ‘Fraiser competent’?
Must meet ALL of the following:
1) Sufficienct maturity and intelligence to understand what the treatment is and its implications.
2) Cannot be persuaded to tell their parents or have a doctor tell them
3) Very likely to continue having sexual intercourse even without contraception
4) Physical and/or mental health likely to suffer if advice or treament not initiated.
5) Advice/treatment is in the patients overall best interest
