Lisa Coulter

Contraceptive Pills

Combined Oral Contraceptive Pill

Mode Of ActionAffect negative feedback suppressing FSH

and LH

No follicles develop

No ovulation

Absolute Contraindications to COCP Smoker 15 per day and >35

BMI >40

BP 160/95

VTE/IHD/CVA

Current breast ca

Viral hepatitis/cirrhosis

DM plus nephropathy/retinopathy/neuropathy

Starting COCP Day 1-5 menstrual cycle – no condoms

Post TOP/miscarriage – if start within 7d of TOP/miscarriage <24 gestation, no condoms

Post partum (not breast feeding) – start day 21of cycle, no condoms

Post partum (breast feeding) – not recommended; if >6m pp and menstruating, as for other cycling women

After other contraceptionDepo: start 12w and 5d after last depo, no condoms From POP: change anytime, no condomsFrom implanon: any time prior to removal, or on day of

removal, no condoms

Missed COCP Pills If <12h late and UPSI – take pill and continue as normal

If >12h late and UPSI:

In pill free wk/first 7 pills: (if miss 2x20mcg or 3x30mcg pills) need EC

Middle 7 pills: take missed pill, condoms for 7d, no EC

Last 7 pills: take missed pill, start next packet without break, condoms 7d, no EC

COCP and D&VIf vomit within 2h of taking pill, take another or

follow rules for missed pills

If severe diarrhoea >24h – keep taking pills but follow missed pill instructions for each day of diarrhoea

COCP and Broad Spectrum AbxPenicillins, ampicillin, tetracyclines and

cephalosporins may affect enterohepatic recirculation of ethinylestradiol

Continue pills, condoms during and for 7d after abx

Emergency contraceptive if UPSI during/7d after abx

Women established on non-enzyme inducing abx, i.e. >3w use do not require condoms (effects on bowel flora subside after 3w)

COCP and Enzyme InducersWomen should be offered regime containing

50mcg ethinylestradiol

Condoms should be used during use of enzyme inducers and for 4w after stopping

When to Discontinue COCPAt least 4w before major surgery

First onset of migraine with aura

Pain or swelling in legs

Chest pain with breathlessness or haemoptysis

Cigarette smoker >35y

Age 50y

Progestogen Only Contraceptive Pill

Generations of POP1st: norethindrone

2nd: norethisterone (micronor), levenorgesterol (microval)

3rd: desorgestrel (cerazette), gestodene

Mode of ActionCervical mucus changes

Endometrial changes

Variable effect on ovulation

Who is Eligible for POP?Lactation

Older women and smokers

Diabetes/obesity

Hypertension

Women’s choice

Oestrogen related contraindications

When to Start POPFirst Use: day 1-5 of cycle no condoms,

otherwise condoms required for 2d

Post partum and breast feeding: ideally on day 21 of cycle, no condoms

Post TOP: If started >7d after TOP, condoms for 2d

Missed POPTraditional POP (>3h late)

take missed pill, continue daily pill taking, condoms for 2d

Desorgestrel-only pill (>12h late)Take missed pill, continue daily pill taking,

condoms for 2d

Emergency Contraception

Specific indications Unprotected SI

Potential barrier failures

Potential COCP failure2x20mcg or 3x30mcg and UPSI in pill free wk/wk 1

Potential POP failure 1 or more missed and UPSI in next 2d

Potential IUD/IUS failure expelled/removed and UPSI in previous 7d

Potential injectable failure>14w depot and UPSI

Enzyme inducers and OCPs/implants during or within 28d of use and UPSI

Methods Levonelle 1500

Levonorgestrel 1500mcg within 72h of UPSI

Affects sperm migration/ function and endometrial receptivity

Variable effect on ovulation

Efficacy: 95%<24h, 85% 24-48h, 58% 48-72h

CI: pregnancy, hypersensitivity

SE: N&V, menstrual disturbance, breast tenderness

Double dose if taking enzyme inducers

MethodsIUD

Copper IUD within 5d of UPSI

Inhibits implantation

Failures <1:1000

CI: possible implanted pregnancy, Recent PID

ReferencesFaculty of family planningNICE guidance October 2005