Contraceptive Counselling Flashcards
What are the potential harms of the combined oral contraceptive pill?
small risk of blood clots
very small risk of heart attacks and strokes
increased risk of breast cancer and cervical cancer
What is the relevant advice regarding how to take the pill?
Think of the sequence of numbers; 1,21/7,3,0,5
1= Take once a day at the same time every day
21/7=Typically people take the pill for 21 days then have a 7 day pill free period
3= ‘Tailored’ regimes should now be discussed with women. This is because there is no medical benefit from having a withdrawal bleed. Options include never having a pill-free interval or ‘tricycling’ - taking three 21 day packs back-to-back before having a 4 or 7 day break
0 = When on the pill free period it is okay to continue having sex, however the next pack has to be started on time
5= There is no need to have additional cotnraception when the pill is started on the first 5 days of the cycle, however if the packet is started at any other point of the cycle then additional contraception needs to be added.
When might the effectiveness of the pill be reduced?
if vomiting within 2 hours of taking COC pill
medication that induce diarrhoea or vomiting may reduce effectiveness of oral contraception (for example orlistat)
if taking liver enzyme-inducing drugs
What are the contraindications to the combined oral contraceptive pill?
UKMEC (UK Medical Eligibility Criteria)
UKMEC 3: disadvantages generally outweigh the advantages
UKMEC 4: represents an unacceptable health risk
Examples of UKMEC 3 conditions include:
more than 35 years old and smoking less than 15 cigarettes/day
BMI > 35 kg/m^2*
- family history of thromboembolic disease in first degree relatives < 45 years
- controlled hypertension
- immobility e.g. wheel chair use
- carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
- current gallbladder disease
Examples of UKMEC 4 conditions include
- more than 35 years old and smoking more than 15 cigarettes/day
- migraine with aura
- history of thromboembolic disease or thrombogenic mutation
- history of stroke or ischaemic heart disease
- breast feeding < 6 weeks post-partum
- uncontrolled hypertension
- current breast cancer
- major surgery with prolonged immobilisation
Diabetes diagnosed over 20 years ago is classified as UKMEC 3 or 4 depending on severity.
If 1 pill is missed:
- take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
- no additional contraceptive protection needed
If 2 or more pills are missed
- take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
- the women should use condoms or abstain from sex until she has taken pills for 7 days in a row.
Week 1 (1-7): take emergency contraception
Week 2 (8-14): Take pills for seven days before having sex. No emergency contraception is needed.
Week 3 (15-21): Omit pill free interval
What are the advantages of the oral contraceptive pill?
- highly effective (failure rate < 1 per 100 woman years)
- doesn’t interfere with sex
- contraceptive effects reversible upon stopping
- usually makes periods regular, lighter and less painful
- reduced risk of ovarian, endometrial cancer - this effect may last for several decades after cessation
- reduced risk of colorectal cancer
- may protect against pelvic inflammatory disease
- may reduce ovarian cysts, benign breast disease, acne vulgaris
What are the disadvantages of the combined oral contraceptive pill?
- people may forget to take it
- offers no protection against sexually transmitted infections
- increased risk of venous thromboembolic disease
- increased risk of breast and cervical cancer
- increased risk of stroke and ischaemic heart disease (especially in smokers)
- temporary side-effects such as headache, nausea, breast tenderness may be seen
What are adverse effects of the progesterone only pill?
irregular vaginal bleeding is the most common problem
When does protection begin after taking the progesterone only pill?
- if commenced up to and including day 5 of the cycle it provides immediate protection, otherwise additional contraceptive methods (e.g. condoms) should be used for the first 2 days
- if switching from a combined oral contraceptive (COC) gives immediate protection if continued directly from the end of a pill packet (i.e. Day 21)
What should you do if you miss a dose of the progesterone only pill?
- if < 3 hours* late: continue as normal
- if > 3 hours*: take the missed pill as soon as possible, continue with the rest of the pack, extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
Other potential problems of POP
- diarrhoea and vomiting: continue taking POP but assume pills have been missed - see above
- antibiotics: have no effect on the POP**
- liver enzyme inducers may reduce the effectiveness
What are the domains to cover in contraceptive counselling?
Potential contraindications
Advantages/disadvantages (including risks and side effects)
How to take
Missed pill
Vomitting/diarrhoea
