Combined oral contraceptive pill (Complete)

Question 1

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What does the combined oral contraceptive pill contain?

Answer 1

Progesterone

Oestrogen

Question 2

Combined oral contraceptive pill is also referred to as?

Answer 2

Combined hormonal contraception (CHC)

Question 3

What are the 3 main routes of administration for CHC?

Answer 3

Orally

Transdermally

Intravaginally

Question 4

What is the mechanisms of action of CHC?

Answer 4

Involves:

Thickening the cervical mucus

Thinning the endometrium

Inhibiting ovulation

Question 5

What are the contraindictions for taking CHC?

Answer 5

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

Question 6

Why is CHC contraindicted in breast-feeding woman less than 6 weeks post-partum?

Answer 6

Due to:

Increased risk of thromboembolism post-partum

Reduction in lactation

Can be transferred to milk

Question 7

Why is migraine with aura a contraindiction for CHC?

Answer 7

Migraine with aura involves neurogenic inflammation and activation of thrombotic pathways

Question 8

What are the three main types of combined oral contraceptive pill? (COCP)

Answer 8

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

Question 9

What regimens are available for CHC?

Answer 9

Traditional

Extended

Continuous use

Flexible-extended use

Question 10

What is the traditional regiment for CHC?

Answer 10

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

Question 11

What is extended use regimen for CHC?

Answer 11

Used for a period of nine weeks (3 months), followed by a 7-day HFI, also known as “tricycling”

Question 12

What is continous use regimen for CHC?

Answer 12

Used continuously without any HFI

Question 13

What is flexible extended use regimen?

Answer 13

Method used until breakthrough bleed followed by 4-day HFI

Question 14

What information needs to be relayed to the patient when starting COCP?

Answer 14

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.

Question 15

What are the advantages of CHC? (8)

Answer 15

• 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

Question 16

What are disadvantages of CHC? (5)

Answer 16

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

Question 17

What are some side effects associated with CHC? (3)

Answer 17

Breast tenderness

Headaches

Nausea and vomitting

Mood and libido changes

Irregular menstrual bleeding, spotting or amenorrhoea

Ovarian cysts

Question 18

How should patients who’ve missed one pill at any time of the cycle be managed?

Answer 18

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)

Question 19

What should be advised to patients who have missed 2 or more pills within the first week (start of pack)?

Answer 19

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.

Question 20

How should patients who had unprotected sex within pill free interval during week 1 be managed?

Answer 20

Require emergency contraception

Question 21

What should be advised to patients who have missed > 1 pill within the 2nd week (day 8-14)?

Answer 21

After seven consecutive days of taking the COC there is no need for emergency contraception

Question 22

What should be advised to patients who have missed > 1 pill within the 3rd week (day 15-21)?

Answer 22

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

Question 23

How should woman on COCP be advised to continue management if experiencing episodes vomitting (e.g. gastroenteritis)?

Answer 23

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.

Question 24

Woman on COCP should be monitored annually for?

Answer 24

Hypertension

N.B. Shown to have 2% risk of hypertension when taking so should have BP measured annually