COMBINED ORAL CONTRACEPTIVE

Contains an oestrogen plus a progestin, the types and quantities of which may vary in different preparations.

Examples include Pilplan, Microgynon

Indications

  • Women <35 years needing highly effective FP method
  • Non-breastfeeding clients, or breastfeeding clients after 6 months postpartum
  • Clients with dysmenorrhoea
  • Clients with heavy periods or ovulation pain
  • Clients concerned by irregular menstrual cycles

Contraindications

  • Diastolic BP >100 mmHg
  • Cardiac disease
  • Thromboembolic disease (e.g. deep vein thrombosis)
  • Active liver disease
  • Within 2 weeks of childbirth
  • When major surgery is planned within 4 weeks
  • Unexplained abnormal vaginal bleeding
  • Known/suspected cervical cancer
  • Undiagnosed breast lumps or breast cancer
  • Pregnancy (known or suspected)

Risk factors


If any 2 of the following, recommend progrestogen-only or non-hormonal FP method

  • Smoking (especially if >10 cigarettes/day)
  • Age >35 years
  • Diabetes

Advantages and other potential health benefits/uses

  • Protects against:
    • Risk of unwanted pregnancy
    • Cancer of the ovary or lining of uterus
    • Symptomatic pelvic inflammatory disease
  • Reduces:
    • Menstrual cramps and bleeding problems
    • Ovulation pain
    • Excess hair on body/face, acne
    • Symptoms of polycystic ovarian syndrome

Disadvantages and common side effects

  • DOES NOT PROTECT AGAINST STIs
  • Spotting, nausea, and vomiting within first few months
  • Changes in bleeding patterns including: fewer days, irregular, lighter, infrequent, or no monthly bleeding
  • May cause headaches, dizziness, weight gain
  • Effectiveness dependent on regular daily dosage
  • Mood changes
  • Breast tenderness
  • Suppresses lactation
  • Medicine interactions reduce effectiveness including:
    • Medicines which increase hepatic enzyme activity, e.g., rifampicin (especially), carbamazepine, griseofulvin, nevirapine, phenytoin, phenobarbital
    • Short courses of some broad spectrum antibiotics, e.g., ampicillin, amoxicillin, doxycycline

An additional FP method must be used during course of treatment with these medicines and for at least 7 days
after completion.

Complications and warning signs

  • Severe headaches, blurred vision
  • Depression
  • Acute severe abdominal pain
  • Chest pain plus dyspnoea (pulmonary embolism)
  • Swelling or pain in calf muscle (Deep vein thrombosis)

INSTRUCTIONS

  • Give 3 cycles of COC and explain carefully:
    • How to take the tablets
    • Strict compliance is essential
    • What to do if doses are missed or there are side effects or warning signs

If starting COC within 5 days of period

  • Supply and show how to use back-up FP method
  • Ask client to return when <7 tablets remain in last cycle

MANAGEMENT OF SIDE EFFECTS OF COCS

Nausea

  • Assess for pregnancy and malaria
  • Suggest taking COCs at bedtime or with food
  • Take pill at same time daily

If symptoms continue:

  • Consider locally available remedies (e.g. eating roasted grains, roasted cassava, boiled greens)

Breast Tenderness

  • Assess for pregnancy
  • Recommend that she wears a supportive bra
  • Examine for cancer symptoms, such as breast infection, lumps, or nipple discharge

If breastfeeding, examine for breast infection

  • If there is infection, use warm compresses. Refer for appropriate evaluation
  • If the examination shows a suspicious lump or discharge, refer for appropriate evaluation
  • Counsel her on non-hormonal FP methods
  • Try hot or cold compresses
  • Suggest ibuprofen, paracetamol, or other pain relievers

Mild Headaches

  • Take proper history (explore when headaches occur, whether she can continue with her daily tasks, what
    medicines relieve her headaches)
  • Take her blood pressure

If blood pressure is normal:

  • Give pain relievers such as ibuprofen or paracetamol
  • If headaches get worse or occur more often, refer for  appropriate evaluation

Palpitations

  • Rule out anaemia and check blood pressure and weight
  • Reassure that this is common in COC users, and usually disappears in a few months
  • Evaluate for other causes unrelated to the method, and refer if necessary

Chest Pain

  • Evaluate for the cause and refer if necessary