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Combined Oral Contraception

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Combined Oral Contraception

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    1. Combined Oral Contraception It is estimated that more than 60 million women world wide are using COC, most usually called the “pill”, and 200 million are estimated to have used it since it was first introduced (Swarewski and Guillebaud 2002). COC’s have the advantage of high efficacy, rapid reversibility, and additional non-contraceptive benefits. Side effects / Safety - important to put these issues into context.

    2. Sexual Health Matters Prevention of pregnancy Promotion of safer sexual practices Protection of fertility Integrated Contraception and Sexual Health Services – The Sexual Health Strategy?

    3. Patient Information Leaflets

    4. Current Choices Current choices include combined oestrogen and progestogen formulations taken on 21 day cycles. Thirty-four brands of OC are available in the UK with some 24 being different, offering a variety or hormone types and different dosages. Everyday preparations - 28 days. Seasonale is being researched to reduce the number of pill periods (withdrawal bleeds) per year. Designed to be taken for 84 days at a time with a seven day break, giving women only four bleeds a year. Ortho - Evra – contraceptive patch a small patch about the size of a matchbox that releases 20 mcg ethinyl oestradial and 150 mcg progestogen (norelgestromin). It is used three weeks out of four with a new patch being used each week.

    5. Efficacy Rates The combined pill in one of the most researched medicines available and is a most effective method of fertility control. “Perfect use” failure rate is quoted as 0.1% “Typical use” failure rate is quoted as 5% (Hatcher, Trussell et al. 1998) Popularity – used by 25% of women aged 16 – 49 followed by the male condom (20%)

    6. Hormonal Changes during the Fertility Cycle FSH - Development of egg follicles, which produce oestrogen. Oestrogen levels rise - cause a surge in LH. Follicle ruptures and releases the egg at ovulation. Lifespan of egg is up to 24 hours. After ovulation: Ovary produces oestrogen & progesterone causing changes in cervical secretions, BBT & cervix - Indicators of fertility.

    7. Physiology of Menstruation

    8. Mode of action of COC Combined oral contraception provide blood levels of synthetic oestrogen and progestogen to prevent cyclical pituitary release of the Follicle Stimulating Hormone (FSH) and Lutenising Hormone (LH) which prevents ovulation. Other modes of action; Thickening of cervical mucus Thinning of the endometrium reduces the opportunity for implantation to be successful

    9. Pharmokinetics In current practice, low dose COC’s, containing 20-35 microgrammes (ug) ethinyl oestradiol (EE) in combination with a progestogen, have generally replaced older COC’s containing 50 ug (EE). Monophasic preparations are more commonly prescribed.

    10. Medical Eligibility Criteria for Contraceptive Use - WHO In 2000 the World Health Organisation (WHO) published criteria for contraceptive use, divided into four categories: 1. A condition for which there is no restriction for the use of the contraceptive method –unrestricted use. 2. A condition where the advantages of the method generally outweigh the risks – benefits outweigh risks. 3. Conditions where the theoretical or proven risk usually outweighs the advantages of using the method – risks outweigh benefits. 4. A condition that represents an unacceptable health risk if the contraceptive is used – unacceptable health risks.

    11. Sexual Health Assessment A careful family, medical, gynaecological and sexual history should be taken prior to starting the COC to exclude any contraindications to its use. It is important to ask about all medications, drugs or herbal preparations, prescribed, over the counter or illicit, as these could affect absorption and therefore, have implications on efficacy rates. There is no need for pelvic examination, cervical smear, breast examination, haemoglobin or genital examination prior to starting COC.

    12. What do women need to know when considering COC? How can women interpret the risks and benefits of COC? 1995 pill scare! VTE Risk associated with COC’s containing norethisterone or levonorgestrel is less than that for COC’s containing desogestrel and gestodene.

    13. What information do women need to use COC appropriately? Seven consecutive pills are needed to inhibit ovulation and continued pill-taking maintains ovarian quiescence. The usual 7-day pill free interval allows endometrial shedding and most women will have a withdrawal bleed.

    14. When to start COC? Between days 1 – 5 of the menstrual cycle,without the need for additional contraception 21 pill taking days, 7 day pill free interval. Childbirth – 21 days post partum Termination of pregnancy – ideally on the day of termination.

    15. Missed Pills? A COC pill is regarded as missed if it is taken more than 12 hours late. Ideally COC pills should be taken at approximately the same time every day. If the pill is taken more than 12 hours late, contraceptive protection is threatened. Emergency contraception may be indicated.

    16. How can compliance be optimised? Important that the client understands how to take the product effectively. Patient Information Leaflet in support of the consultation. Concordance rather than compliance! Reinforce pill taking regime. Advise how to follow up advice. Review annually

    17. Female Cancer Women with and without a family history of breast cancer may be advised that any increased risk of breast cancer with COC is likely to be small (FFPRHC Grade B) evidence. Cervical cancer – recent evidence suggests increasing duration of COC increases risk.

    18. Examinations and Tests Women with a BP measurement consistently over 140 mmHg systolic and/or 90 mmHg diastolic should be advised against use of COC. Thrombophilia screening is not recommended routinely. STI risk assessment Body Mass Index (BMI) > 40 (constitutes morbid obesity)

    19. How can clinicians help women choose their first COC? General advice – safety VTE risk Contraceptive efficacy Breakthrough bleeding Metabolic effects Price comparisons There are no Coc’s that cannot be used first-line after counselling and women can be advised that they may use COC from menarche to the menopause unless there are medical or other contraindications.

    20. Women aged less than 16 years Consent – The Fraser Guidelines (England and Wales, 1985) established that a clinician can provide contraceptive advice or treatment to patient aged under 16 years provided he or she is satisfied that the patient is competent to consent to the advice or treatment. Competency is a young person’s ability to understand choices and their consequences, including the nature, purpose and possible risk of any treatment. Confidentiality – the duty of confidentiality owed to a patient aged under 16 years is deemed to be as great as that owed to any other patient.

    21. Client Follow-up A follow-up visit 3 months after the initial COC consultation allows further instruction and any assessment of problems. Appropriate written information should support all client consultations. Women should be provided with telephone numbers and national help lines providing advice on contraception and sexual health.

    22. References: FFPRHC Guidance (October 2006) First Prescription of Combined Oral Contraception. Journal of Family Planning and Reproductive Health Care, Volume 29, No. 4, pp 209 – 223. www.ffprhc.org.uk Royal College of Obstetricians and Gynaecologists (2004) Venous Thromboembolism and Hormonal Contraception, Guideline No. 40. Prodigy Clinical Recommedation – Contraception www.prodigy.nhs.org

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