Pre-service Education on FP and AYSRH

1. Pre-service Education on FP and AYSRH Session II Topic 1 Combined Oral Contraceptives (COCs)

2. COCs Key Points for Providers and Clients

3. What Are COCs? Traits and Types

4. Effectiveness of COCs More effective Less effective In this progression of effectiveness, where would you place combined oral contraceptives (COCs)? COCs

5. COCs: Mechanism of Action Suppresses hormones responsible for ovulation Thickens cervical mucus to block sperm COCs have no effect on an existing pregnancy.

6. COCs: Characteristics • Safe and more than 99% effective if used correctly • Can be stopped at any time • No delay in return to fertility • Are controlled by the woman • Do not interfere with sex • Have health benefits • Less effective when not used correctly (91%) • Require taking a pill every day • Do not provide protection from STIs/HIV • Have side effects • Have some health risks (rare) Source: Hatcher, 2007; WHO, 2010; CCP and WHO, 2011; Trussell , 2011.

7. Advantages of COCs Advantages of Using COCs. • Safe and more than 99% effective if used correctly • Can be stopped at any time • No delay in return to fertility • Are controlled by the woman • Do not interfere with sex • Have health benefits

8. Non Contraceptive Benefits of COCs • Menstrual related benefits • Decreased amount of flow and fewer days of bleeding; no bleeding (less common) • Regular, predictable menstrual cycles • Reduced pain and cramps during menses • Reduced pain at time of ovulation • Protection from: Ovarian cancer, Endometrial cancer and Symptomatic PID • Reduced risk of: Ovarian cysts, Iron-deficiency anemia • Decreased symptoms of: Endometriosis (pelvic pain, irregular bleeding) and polycystic ovarian syndrome(irregular bleeding, acne, excess hair on face or body)

9. Disadvantages of COCs • Less effective when not used correctly (91%) • Requires taking a pill every day • Does not provide protection from STIs/HIV • Has some side effects • Has some health risks (rare) • COCs may slightly increase risk of blood clots: • Stroke • Heart attack • Risk is concentrated among women who have additional risk factors, such as: • Hypertension • Diabetes • Smoking

10. Possible Side-Effects If a woman chooses this method, she may have some side-effects. They are not usually signs of illness. • But many women do not have any side-effects. • Side-effects often go away after a few months and are not harmful. Most common: • Nausea (upset stomach) • Changes in bleeding patterns (lighter, irregular, infrequent or no monthly bleeding) • Mood changes or headaches • Tender breasts • Dizziness • Slight weight gain or loss

11. COCs Are Safe for Nearly All Women • Almost all women can use COCs safely, including women who: • Have or have not had children • Are not married • Are of any age • Smoke (if under age 35) • Have anemia now or had it in the past • Have varicose veins • Have an STI or HIV/AIDS • Most health conditions do not affect safe and effective use of COCs

12. Who Can and Cannot Use COCs Most women can safely use the pill. But usually cannot use the pill if: • High blood pressure • Smoke cigarettes AND age 35 or older • Gave birth in the last 3 weeks • Breastfeeding 6 months or less • May be pregnant • Some other serious health conditions

13. Who Should Not Use COCs (part 1) My period is late… Breast feeding a baby less than 6 months old Breast feeding a baby less than 6 months old Think they may be pregnant Are pregnant Are pregnant Think they may be pregnant Smoke and are age 35 or older Have or had breast cancer Had a heart attack or stroke Had blood clots in legs or lungs Had blood clots in legs or lungs Had a heart attack or stroke Source: WHO, 2010.

14. Who Should Not Use COCs (part 2) I cannot eat sweets. Take pills for TB, seizures (fits), or HIV Gave birth in last 6 weeks Breast feeding a baby less than 6 months old Have bad headaches with nausea or vision problems Think they may be pregnant Have serious liver disease or gall bladder disease Have high blood pressure Had a heart attack or stroke Have diabetes (high sugar in blood) Have rheumatic disease, such as lupus Had blood clots in legs or lungs Source: WHO, 2010. Source: WHO, 2010; Chu, 2005.

15. Medical Eligibility Criteria What are medical eligibility criteria? Define the categories. Review the job aid.

16. WHO’s Medical Eligibility Criteria Categories for IUDs, Hormonal and Barrier Methods Source: WHO, 2010.

17. WHO’s Medical Eligibility Criteria Categories for IUDs, Hormonal and Barrier Methods WHO’s Medical Eligibility Criteria Categories for IUDs, Hormonal and Barrier Methods Source: WHO, 2010.

18. Category 1 and 2 Examples (not inclusive):Who Can Use COCs Source: WHO, 2010.

19. Category 3 Examples (not inclusive):Who Should Generally Not Use COCs Source: WHO, 2010.

20. Category 4 Examples (not inclusive):Who Should Not Use COCs Source: WHO, 2010; Sekar, 2008.

21. COC Use by Women with HIV • Women with HIV or AIDS can use without restrictions • Women on ARVs can use COCs safely • Should not be used by women who take medications for seizures or rifampacin or rifabutin for tuberculosis (may reduce effectiveness of COCs). • Using low-dose COCs is appropriate • Condom use should be encouraged in addition to COCs Source: WHO, 2010; Sekar, 2008.

22. COC Use by Postpartum Women • Non-breastfeeding women should not initiate COCs before 3 weeks postpartum (3-6 weeks postpartum with VTE risk factors) • Breastfeeding women • Should not use COCs before 6 weeks postpartum • Should not use COCs from 6 weeks to 6 months postpartum unless no other method is available • Can generally initiate COCs at 6 months postpartum Source: WHO, 2010.

23. Group ActivityUnderstanding the Checklist Read questions 1–12 in the checklist. How have you determined medical eligibility in the past? This set of questions identifies women who should not use COCs. This set of questions identifies women who are not pregnant. The checklist also gives instructions about initiating COCs.

24. When to Start COCs (part 1) • Anytime you are reasonably certain the woman is not pregnant • Pregnancy can be ruled out if the woman meets one of the following criteria: • Started monthly bleeding within the past 7 days • Is breastfeeding fully, has no menses and baby is less than 6 months old • Has abstained from intercourse since last menses or delivery • Had a baby in the past 4 weeks • Had a miscarriage or an abortion in the past 7 days • Is using a reliable contraceptive method consistently and correctly • If none of the above apply, pregnancy can be ruled out by pregnancy test, pelvic exam, or waiting until next menses Source: WHO, 2004 (updated 2008).

25. When to Start COCs (part 2) • If starting during the first 5 days of the menstrual cycle, no backup method needed • After day 5 of her cycle, rule out pregnancy and use backup method for the next 7 days • Postpartum • Not breastfeeding: May start 3 to 6 weeks after giving birth, depending on presence of risk factors for blood clots • Breastfeeding: May start 6 months after giving birth Source: WHO, 2004 (updated 2008).

26. When to Start COCs (part 3) • After miscarriage or abortion • If within 5 days after miscarriage or abortion, no backup method needed • If more than 5 days after, rule out pregnancy, use backup method for 7 days • Switching from hormonal method • May start immediately, no backup method needed (with injectables, initiate within reinjection window) • Switching from non-hormonal method • If starting within 5 days of start of menstrual cycle, no backup method needed • If starting after day 5 of cycle, use backup method for 7 days • After using emergency contraceptive pills • Initiate immediately after taking progestin-only ECPs, use backup method for 7 days • After taking ulipristal acetate (UPA) ECPs she can start or restart COCs on the 6th day after taking UPA EPs Source: WHO, 2004 (updated 2008).

27. How to Take COCs The Pill • Take one pill each day, by mouth. • Most important instruction: • Give client her pill pack to hold and look at. • Show how to follow arrows on pack. • Discuss: • Easy to remember to take pills? • “What would help you to remember? What else do you do regularly every day?” • Easiest time to take the pills? At a meal? At bedtime? • Where to keep pills. • What to do if pill supply runs out.

28. How to Take COCs The Pill Caution the client: Waiting too long between packs greatly increases risk of pregnancy. If you use the 28-pill pack: • No waiting between packs. • Once you have finished all the pills in the pack, start new pack on the next day. If you use the 21-pill pack: • 7 days of no pills • Once you have finished all the pills in the pack, wait 7 days before starting new pack. For example: If you finish the old pack on Saturday, take the first pill of the new pack on the following Sunday. 28-pill pack 21-pill pack 21-pill pack

29. Missed Pills Instructions The Pill • Miss 1 or 2 active pills in a row or start a pack 1 or 2 days late: • Always take a pill as soon as possible. • Continue to take one pill every day. • No need for additional protection.

30. Missed Pills Instructions, continued week 3 Inactive pills The Pill Miss 3 or more active pills in a row or start a pack 3 or more days late: • Take a pill as soon as possible, continue taking 1 pill each day, and use condoms or avoid sex for next 7 days OR AND • If these pills missed in week 3, ALSO skip the inactive pills in a 28-pill pack and start a new pack • If inactive pills are missed, throw away the • Missed pills and continue taking pills • 1 each day • If missed pills are in the first week and she had unprotected sex she may wish to use ECPs. Source: WHO, 2004; updated 2008; CCP and WHO, 2011.

31. Key Counseling Topics for COC Users • Safety and efficacy (requires taking pills on time) • How COCs work • Health benefits • Possible side effects • How to take pills and what to do if pills are missed • No protection from STIs/HIV • Inform provider she is taking COCs in case of serious new health problem • Reasons to return: questions, concerns or experiencing any warning signs

32. Correcting Rumors and Misconceptions COCs: Do not build up in a woman’s body. Women do not need a “rest” from taking COCs. Must be taken every day, whether or not a woman has sex that day. Do not make women infertile. Do not cause birth defects or multiple births. Do not change women’s sexual behavior. Do not collect in the stomach. Instead, the pill dissolves each day. Do not disrupt an existing pregnancy.

33. What to Remember See a nurse or doctor if: • Take one pill each day • If you miss pills, you can get pregnant • Side-effects are common but rarely harmful. Come back if they bother you. • Come back for more pills before you run out or if you have problems. • Severe, constant pain in belly, chest, or legs • Very bad headaches • A bright spot in your vision before bad headaches Anything else I can repeat or explain? Any other questions? • Yellow skin or eyes

34. Follow-up for COCs • No fixed schedule; return any time. • Resupply: Give more than 1 cycle of pills, if possible. • Assess for method satisfaction and any health problems or circumstances that may restrict COC use. • Manage and reassure about side effects. • Review correct pill taking and what to do when pills are missed.