Fully funded:

1st generation

  • norethisterone 500µg + ethinylestradiol 35µg

    • Brevinor (no sugar)

    • Norimin

  • norethisterone 1mg + ethinylestradiol 35µg

    • Brevinor-1

2nd generation

  • Levonorgestrel 100 + ethinylestradiol 20

    • Ava20

    • Microgynon

  • Levonorgestrel 125µg + ethinylestradiol 50ug

    • Microgynon 50

  • Levonorgestrel 150µg + ethinylestradiol 50µg

    • Ava 30

    • Levlen ED

    • Microgynon 30 (SA)

    • Monofeme

    • Nordette

    • Roxanne (SA)

3rd generation

  • cyproterone acetate 2mg + ethinylestradiol 35µg:

    • Ginet

      • use contraceptive (code = “O”)

      • can then use 6 months supply

  • drosgestrel 150µg + ethinylestradiol 20µg

    • Mercilon (part)

  • drosgestrel 150µg + ethinylestradiol 30µg

    • Marvelon (part)

Vaginal ring

  • Ethinylestradiol 15µg/24hrs + etonogestrel 120/24hrs

    • NuvaRing

      • can have 4 rings

      • keep at room temp

Mechanism of action

  • inhibit ovulation: HPO axis

    • decrease LH & FSH via -ve feedback

  • + change cervical mucous & endometrium

  • 1st 7 pills inhibit ovulation

  • remaining 14 maintain ovulation

  • 7 placebo -> withdrawal bleed

    • endometrial shedding

  • safe for extended use

    • tricycling

    • 7 pill free after 3rd packet

Efficacy

  • failure rate = 0.3% with perfect use

  • typical use = 9% failure rate

  • COC effective regardless of BMI

  • unscheduled bleeding less common with CHC than with progestogen-only

  • cycle control better with COC containing 30-35

History and exam

  • assess medical eligibility

  • migraine

  • cardiovascular risk factors:

    • smoking

    • obesity

    • HTN

    • thombophilia

    • VTE

    • dyslipidaemia

  • BP, weight, BMI: for first prescription

UKMEC - UK Medical Eligibility Criteria

Migraine

  • COC contraindicated in migraine with aura

    • discontinued if develop migraine with aura

  • if develop migraine without aura while on COC

    • should be stopped

    • especially ≥35yo

  • Pre-existing migraine without aura \<35 not CI to COC

VTE

  • higher risk of VTE

  • CI current/past history

  • avoid:

    • obesity

    • smoking

    • fhx ≤45

Smokers
  • heavy smokers ≥35yo not advised

Starting pill

  • conception most likely = Day of ovulation or preceeding 24hours

  • risk of pregnancy in 1st 3/7 very unlikely

  • started up to and including D5 without need for additional contraception

  • beyond D5 can start if reasonably certain not pregnant

    not pregnant:

  • no symptoms or signs pregnancy + any:

  • has not had intercourse since last menses

    • using reliable method of contraception (reliably + correct)

    • within first 7 days of a normal menstrual period

    • within 4 weeks post-partum for non-lactating women

    • wihin first 7 days post-abortion or miscarriage

    • full/nearly fully breastfeeding, amenorhoeic, and less than 6/12 post partum

  • pregnancy test adds weight but only if ≥3 weeks since last UPSI

  • additional precautions for next 7 days

  • post partum and not breast feeding:

    • start d21 if no VTE rxfx

Quick starting

if pregnancy excluded/reasonably certain not pregnant

Extra contraception:

D 1-5: no

D ≥ 6 or after Progesterone only emergency contraceptive: 7d

After ulipristal EC: 14d

Switching pills

  • COC - COC:

    • start on day after last active pill

    • no extra

  • POP/LNG-IUS:

    • started imediately

    • 7 day rule

  • implant/depot

    • start any time up to when repeat injection/implant due

    • no extra

    • COC suppresses ovulation by time inhibition of 1st method worn off

Missed pills

  • pill that is completely omitted

    • >24 hours passed since pill was due(48hours since last pill)

  • ovulation may occur as inhibitory effects on ovary reduced

  • 7 consecutive pills prevents ovulation

    • therefore if 7 taken: theoretically up to 7 can be missed without any effect on contracptive efficacy

  • weeks 2/3 are unlikely to result in loss of efficacy

  • follicular activity resumes during pill free week

One pill being missed:

  • missed pill taken as soon as remembered

  • remaining pills continued at usual time

  • EC not usually required

    • consider if pills have been missed earlier in the packet or in the last week of previous packet

Two or more pills missed (>72h since last pill, >48hrs late):

  • most recent missed pill should be taken ASAP

  • remianing pills ocntinued

  • 7 day rule

    • over cautious in 2/3 week
Minimising risk of pregnancy
First week: 1-7

  • EC should be considered if unprotected sex ocured in:

    • pill-free interval or

    • in the first week of pill-taking

Second week: 8-14
  • no indication for EC if pills in preceeding 7 days have been taken
Third week: 15-21
  • omit the pills-free interval

Drug interactions

Antibiotics:

  • additional precautions are not required when using non-enzyme inducint abx

  • unless vomiting or diarrhoea

  • however: BPAC

    • colonic bacterial disturbance may inhibit enterohepatic circulation of oestrogen (progestegen not affected)

    • evidence = weak

    • short courses \<3w use additional for 7d after abx stopped and 7 active pills

    • after 3w gut flora resistance means that safe

Enzyme inducing drugs:

  • increase the metabolism of oestrogens/progesterogens

  • reduce contraceptive efficacy

  • ideally switch to method that is unaffected

  • additional precautions

  • COC ≥ 30µg EE

  • consider omitting/shortening pill-free or ≥ 50µg for short term use

  • use alternative method

Lamotrigine:

  • serum levels of lamotrigine are reduced by CHC

  • increased sideeffects on cessation of CHC

  • increase lamotrigine levels during pill-free week

Risks

VTE:

risks per 100 000

  • Non contracetive and not pregnant: 5/year

  • COC (1st gen = norethsterone, 2nd gen = levonorgestrel): 15/year

  • COC (desogestrel, drospirenone, cypterone): 25/year

  • Pregnancy: 60/year

  • Immediate post-partum: 300-400

  • 4-5/10 000 women-years in those who do not use oral contraceptives

  • risk = twice that == 9-10/10 000 women-years

  • desogestrel, cyproterone > levonorgestrel, orethisterone

  • greatest in first few months of starting

  • returns to that of non-users wihin weeks of discontinuation

  • pregnancy = 29/10 000 women-years

  • immediate post partum = 300-400/10 000 women-years

  • family history = poor indicator

    • first degree relative with VTE \< 45 as UKMEC 3

Cardiovascular disease and stroke:

  • women ≥35 who smoke \<15 = UKMEC 3

  • women ≥35 who smoke >15 = UKMEC 4

  • ≥ 1 year after giving up ≥ 35 then risk UKMEC 2

  • risk of stroke increased in COC with migraine compared to without migraine

  • migraine with aura

    • COC increases risk of ischaemic stroke

  • hypertension

    • ≥150mmHg sBP or ≥95mmHg dBP = UKMEC4

    • controlled = UKMEC3

  • Obesity

    • UKMEC3 for BMI ≥35

Breast cancer:

  • with family history:

    • increased risk of breast cancer compared to women with no fhx

    • background risk increased

      • not sufficiently extra with COC

    • family history doens’t restrict use COC - UKMEC 1

  • BRCA mutations

    • conflicting evidence

    • currently UKMEC 3

  • Current breast cancer

    • represents unacceptable risk

  • Past/no evidence of disease

    • UKMEC 3

Cervical cancer

  • risk increase with duration of COC use

  • no recommendations to change

Benefits

Mortality

  • 12% reduction all cause mortality

  • no overal increased risk cancer

Ovarian and endometrial cancer

  • COC reduced risk of ovarian and endometrial cancer

    • every 5yrs approx. 20% reduction in risk ovarian

    • 50% endometrial

  • continues for several decades after stopping

Acne

  • effective reducing inflammatory and non-inflammatory acne

  • especially cyproterone acetate

Bone health

  • no effect

Colorectal cancer

  • reduction in risk

Dysmenorrhoea and heavy menstrual bleeding

  • limited evidence from RCT that COC can improve pain or reduce menstrual blood loss compared to other treatments

  • COC treat pain associated with endometriosis

Menopause:

  • COC may reduce menopausal symptoms

Side effects:

Unscheduled bleeding

  • 20% of COC have irregular bleeding

  • usually settles with time

  • contine COC for 3/12 before considering changing

  • likely cuases:

    • missed pills

    • STI

    • pregnancy

    • malabsorption (vomiting within 2 hours)

Mood changes:

  • no evidence causes depression

Weight gain:

  • no causal association between COC and weight gain

Strategies:

Acne

  • increase oestrogen

  • decrease progestogen

  • change to less adrogenic progestogen (Cypertone)

Ginet

Amenorrhoea

  • increase oestrogen

  • decrease progestogen

microgynon 50

Breakthrough bleeding

  • early-mid cycle

    • increase oestrogen

microgynon 50

  • late cycle

    • increase progestogen or change type

Brevinor-1

Breast soreness

  • decrease oestrogen

  • decrease progestogen

Ava 20

depression, moodiness, irritability

  • decrease progestogen

Ava 20, Microgynon 20, Loette

Headaceh in pill-free week

  • tri-cycle pills

Menstrual cramps

  • increase progestogen

  • tricycle

Brevinor-1

Nausea

  • decrease oestrogen

Ava 20

Weight gain

  • decrease oestrogen

  • decrease progestogen

Ava 20