Oral Contraceptive Pill ( OCP)J Hassan

IntroductionOCP is widely used in the UK, it can be highly effective in prevention of pregnancy, if used consistently and correctly.It also has non contraceptive benefits includingManaging irregular menstrual cyclesAlleviate dysmenorrhoeaManage endometriosis

2 categoriesCombined oral contraceptive pill (COCP)Progesterone only pill (POP)

Principles of counselling:Why method chosen Efficacy/ Mode of actionPill teach / Potential side effects / reversibilityMenstrual pattern/ full med and sexual hx to elucidate CISafer sex/ leaflet provided

COCPMode of actionOvulation suppressionEndometrial atrophyThickens cervical mucus

EffectivenessFailure rate is 0.2-0.5 per 100 woman years

Classification

BenefitsLess menorrhagia/ dysmenorrhoeaReduction inOvarian / endometrial Cafunctional Ovarian cystsBenign breast lessionsSymptomatic endometriosisRisk of Colon ca Thyroid dxImprovement of acne

RisksVTE- risk inc with age and in those with other risk factorsCervical ca- small inc after 5 yr useBreast ca-Primary liver caHydatidiform mole/ choriocarcinomaMI- increased 3 fold if hyptCVA- Ischaemic increase is about 1.5 fold in normotensive non-smoking COC users and 3 fold in those with hypt.

1st consultationImportant points from the history:Methods used/ length of useLMP / previous pregnancies/recent preg ( associated condn.)/ lactatingAgeCurrent illnesses and txtPast major illness / opsMenstrual hx( cycle length, duration etc)Sexual hx, previous STI, risk behavioursHx of hypt, cardiovascular and risk factors/ DM / VTE/ IHD / CVA

Headaches/migrainesSmoking / no. per dayObesityLiver / Gallbladder dxBreast dxExaminationsBP measurement is essential. If consistently >140/90 then the woman should be advised against use of COCWeight and Height and BMI calculated and documented

Starting Regimes

Missed Pill AdviseIf 1 or 2 of 30-35mcg ethinylestradiol pill or 1of 20mcg Advise to take the most recent pill as soon as remembers, continue taking remaining pill at usual time, she does not require additional contraception or emergency contraceptionIf 3 or more of 30-35 or 2 or more 20mcgAdvise as above, but to use extra method of contraception until pills have been taken for 7 days in a rowIf pill is missed in week 1 ( days1-7)and unprotected sexual intercourse has taken place in pill free week or wk 1 then emergency contraception is neededIf pills missed in wk 3 ( days 15-21), advise to finish pill in pack and start new pack the next day, omitting pill free intervalIf one has missed > 7 consecutive days then consider as stopped COCP

Drug interactionsAntibiotics-( non liver enzyme inducing) Short courses

Side effectsOestrogenicNausea, dizziness, bloating, breast engorgement, vaginal discharge, premenstrual tension, migranesChange to a more progestogenic prep/ Reduce dose of oestrogen and inc dose of progesterone. COC progesterone dominant- Microgynon 30, Loestrin 30 ,Eugynon 30, Norimin, loestrin 20Progestogenic Vaginal dryness, inc wt, reduced libido, acne, mastalgia, depression/lethargy, scanty mensesChange to more osetrogenic eg Ovysmen, Marvelon, femodene, cilest, Trinordiol/ logynon

Follow upReview in 3 months to ensure compliance and acceptability, with further follow up at 12 monthly intervals, encourage pt to seek advise if any worriesBP ant Wt yearlyCheck that COC is taken correctlySought new risk factors/ SEIf pt > 35 yrs, there should be a thorough re-assesment

Progesterone only Pill (POP)Becoming increasingly popular as more women worry about SE and health risk of COCThey can be used with no age limits,in smokers, during lactation and even for women at risk of VTE EfficacyFailure rate of 0.3-5 per 100 woman yearsMode of actionMainly thickening cervical mucusAtrophy of endometrium, hinders implantationInterfere with tubal transport of ovaCerazette however inhibits ovulation

Indications< 21 days post partum. 6wks-6mths postpartum partially or fully BFAge> 35 and smokeBMI> 35Multiple risk for CVSThose at risk of VTE, inc personal hxHypt controlled with medsDM/ CHD/ valvular problemsCIN/ endometrial ca/ ovarian caF Hx Breast caSCD

ContraindicationsUncontrolled hypertensionActive hepatitis/ decompensated cirrhosis/ liver tumoursMal absorptionCurrent DVTUndiagnosed Genital tract bleedingRecent trophoblastic dx with high bHCGCurrent IHD

Current breast CaPast severe side effectsAcute porphyria

Missed pill: pill needs to be taken at same time of day. There is only 3 hour window period for missed pills. Contraception efficacy is restored after 2 days as compared to COCCerazette- has a 12 hour window period.Vomiting within 2 hrs or severe diarrhoea decreases efficacy.Starting regimes- same as COC however additional method is needed for only 48hrsDrug interactions- Pop not affected by broad spectrum abx. However enzyme inducing drugs reduces efficacy.

Thank You

VTE in a first-degree relative under the age of 45 years who, having considered other contraceptive methods, still wish to use COC, then a thrombophilia screen shouldAs Progestogen on its own not demonstrated to have effects on coagulation.