OCP

Question 1

How does the OCP work?

4 points

Answer 1

COCs prevent ovulation by providing level of E and P in the blood inhibiting the Pituitary release of LH and FSH, thicken cervical mucus to inhibit sperm penetration of the upper reproductive tract and alter the endometrial lining to make implantation less likely.

Question 2

What is the efficacy of the OCP

Answer 2

Perfect use

2/1000 actual use 9/100

Question 3

What is the discontinuation of the OCP

Answer 3

OCP discontinuation rate 60% at 6 moths 34% because of side effects

Question 4

What is the return of fertility of the OCP

Answer 4

• may be a delayed for the first several months after stopping 97% spontenously menstrated 90 days after stopping.79% of getting pregnant in the year after stopping the pill, similar to general population

Question 5

What are other benefits

Answer 5

Limit the development of functional cysts
can be a treatment for pelvic pain as causes endometrial atrophy
Increasing SHBG - reduce free androgen concentrations and improve acne and hirsutism

Question 6

Side effects

Answer 6

• In the first few months woman may have breast tenderness, nausea and headahces, these often settle
• Unscheduled bleeding 50% in their first cycle of use and improving from there - associated with lower estrogen doses (20mcg ethinyl estradiol) and 24/4 regimes
• Amenorrhoea - Can be intentional if running the pill packs together. The low dose estrogens are inadequate in stimulating endometrial proliferation

Question 7

What are the cardiovascular affects of the OCP

Answer 7

• Older age - older then 35 and tobacco use increase mortality in CHC users
• COCs cause a mild raise in BP within the normal range

Question 8

What is the VTE risk

Answer 8

• 3-5X increased RR VTE in COC users - the risk is low it is 0.06/100 pill years
• VTE risk higher in the first few months of use

Question 9

What is the stroke risk
baseline risk in a population
risk on the OCP

Answer 9

• Absolute risk of stroke in a young woman 5 per 100 000 - being on the COC doubles the risk
• Absolute risk is less then in pregnancy or the post partum period
• COC users are 1.6X more likely to have an arterial thombus
• This is likely due to the higher estrogen dosing and did not vary with progesterone types
• COC is ok with a stroke unless there is evidence of microvascular disease including nephropathy retinopathy or neuropathy or atherosclerosis - low dose estrogen or progesterone only has been recommended

Question 10

How does the OCP affect your lipids

Answer 10

• COC can negatively affect lipid metabolism but not in a clinically relavent way
• COC raise Triglycerides 25mg/dL / 6 months of use
• Woman with dyslipidaemia who start the OCP may have an increased risk in cardiovascular events and VTE but the evidence is poor
• COC increases plasma insulin and reduces insulin sensitivity but actually not clinically relevant - no increased risk of developing diabetes

Question 11

How does the OCP affect cancer development

Answer 11

• OCPs reduce the risk of ovarian (RR 0.5) endometrial (RR0.6) and colorectal cancers
• Breast and cervical cancer risk is temporarily increased with rcurrent or recent OCP use with that risk has disappeared within 5 years of discontinuation - 10 years for cervical cancer
• Positive protective impact lasted for over 30 years
• OCPs can be used as chemoprevention against BRCA mutations

Question 12

What are the absolute contraindications to the pill?

Answer 12

• 35 or over and smoking
• 2 or more risk factors for arterial cardiovascular disease - older, smoking, diabetes, HTN
• HTN 140/90
• VTE - hx or acute event
• Thrombogenic mutations - factor V leiden, Protein C or S deficiency, antithombin
• Hx stroke
• Valvular heart disease
• Breast cancer
• cirrhosis
• migrane with aura
• Hepatocellular adenoma or malignant hepatoma
• Care with major elective surgery associated with prolonged immobility - stopped 4 weeks before and restarted two weeks after mobilisation

Question 13

How do headaches affect OCP prescription

Answer 13

• Consider tension cluster and migraine headaches
• Migranes and exogenous estrogen increases the risk for stroke and they compound this together 2-4X
• If new headaches while on the OCP start then consider stopping it

Question 14

How does antiepileptics affect contraception choice ?

Answer 14

• Enzyme inducing antiepileptics can increase the metabolism for contraception reducing their efficacy - the metabolism is accelerated and alters the protein binding
• Ideally LARCs are best - IUDs or depot
• Strong inducers include phenytoin, carbamezapine
• A higher dose COCP maybe appropriate if a LARC is not wanted - at least 50 mcg of estrogen
• Lamotrigine should have IUCD or jadelle

Question 15

How does the OCP affect the risk for inflammatory bowel disease ?

Answer 15

• COC is associated with an increased risk of inflammatory bowel disease UC and Chrons 1.7X maybe due to thromobotic effects on microvasculature
• lower or no estrogen containing compounds are preferred
• The year following bariatric surgery is contraindicated as the risk of malabsortion

Question 16

When can the OCP started post partum

Answer 16

BPAC says COCP can be used from 6 weeks postpartum if breastfeeding and feeding is well established or from 3 weeks if not breastfeeding - if there is no other VTE risks (these include LSCS, PPH, PET, smoking, immobility, blood transfusion or BMI over 30)

Question 17

If the patient develops…
acne
what can you do to help?

Answer 17

Increase oestrogen or decrease progesterone
and / OR
Select a less androgenic progesterone eg drospirenone or cyproterone

Question 18

If the patient develops…
bloating
what can you do to help?

Answer 18

Decrease estrogen

and or change progesterone to one with a mild diuretic effect eg drospirenone

Question 19

If the patient develops…
breakthrough bleeding
what can you do to help?

Answer 19

Increase the estrogen

Change the progesterone

Question 20

If the patient develops…
headache, breast tenderness,
what can you do to help?

Answer 20

Decrease oestrogen

Change progestogen eg levonorgestrel

Question 21

If the patient develops…
nausea
what can you do to help?

Answer 21

Decrease estrogen
take the pill at night
Change to POP

Question 22

What is the value in tricycling?

Answer 22

This method is a useful way to minimise bleeding. Extended use can also be useful to:
• Decrease the risk of break-through ovulation associated with missed pills in women who forget pills
regularly.37 Another method not relying on daily intake is preferred for these women.
• Avoid withdrawal headaches, in the hormone free week.38-40
• Avoid PMS.39, 40
• Avoid unacceptably heavy or painful withdrawal bleeds.
• Decrease the risk of breakthrough ovulation in women taking liver enzyme inducers.

Question 23

What are the relative contraindications with the OCP that are strongly cautioned as the risk of VTE is so high

Answer 23

Family history of VTE in a first-degree relative aged < 45 years
Immobile for a prolonged period due to illness or disability, i.e. without the added risk of VTE associated with surgery
Aged ≥ 35 years and smoke < 15 cigarettes per day or stopped smoking less than one year ago
Obesity (body mass index [BMI] ≥ 35 kg/m2)

Question 24

What is the VTE risk in:
Pregnancy and post partum
COC users
Woman not taking the COC

Answer 24

VTE risk per 10,000

Not on COC 2-4
On COC 7-10
Pregnant 20-30

Question 25

What is the advice around breast cancer risk and who to not prescribe to

Answer 25

current breast cancer and use is strongly cautioned against in those with a history of breast cancer or who are known carriers of gene mutations associated with breast cancer, e.g. BRCA1 or BRCA2.1

Question 26

How old is too old?

Answer 26

The use of COCs is not recommended in those aged ≥ 50 years due to the risks outweighing the benefits.13