When talking about CHC it should not be forgotten that in addition to providing contraception this contraceptive method is associated with additional

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Philip Warren
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3 When talking about CHC it should not be forgotten that in addition to providing contraception this contraceptive method is associated with additional health benefits. These benefits can be used to treat gynaecological problems and disorders. 3

4 1. Endrikat J. et al.: A twelve-month comparative clinical investigation of two low-dose oral contraceptives containing 20 micrograms ethinylestradiol/75 micrograms gestodene and 20 micrograms ethinylestradiol/150 micrograms desogestrel, with respect to efficacy, cycle control and tolerance. Contraception 1995;52: Endrikat J. et al.: A twelve-month comparative clinical investigation of two low-dose oral contraceptives containing 20 micrograms ethinylestradiol/75 micrograms gestodene and 30 micrograms ethinylestradiol/75 micrograms gestodene, with respect to efficacy, cycle control, and tolerance.contraception 1997;55: Foidart J.-M. et al.: A comparative investigation of contraceptive reliability, cycle control and tolerance of two monophasic oral contraceptives containing either drospirenone or desogestrel. European Journal of Contraception and Reproductive Health Care 2000;5: Mansour, D. et al.: Efficacy and tolerability of a monophasic combined oral contraceptive containing nomegestrol acetate and 17β-oestradiol in a 24/4 regimen, in comparison to an oral contraceptive containing ethinylestradiol and drospirenone in a 21/7 regimen.european Journal of Contraception and Reproductive Health Care 2011;16: There are no visible differences between pills containing 30 µg or 20 µg EE with regard to these side effects. 4

1. Redmond G et al. Use of placebo controls in an oral contraceptive trial: methodological issues and adverse event incidence. Contraception 1999; 60: 81 5.

5 1. Redmond G et al. Use of placebo controls in an oral contraceptive trial: methodological issues and adverse event incidence. Contraception 1999; 60: When discussing harmless side effects after starting a CHC, inform the patient that typically those symptoms will disappear within 3 months of use. Placebocontrolled studies found similar numbers of women with nausea, headache or breast discomfort in both the placebo and treatment groups. Side effects can be troublesome in daily life and should therefore be treated. Most recommendations for the treatment of side effects are based on clinical experience. 5

6 1. Endrikat J. et al.: A twelve-month comparative clinical investigation of two low-dose oral contraceptives containing 20 micrograms ethinylestradiol/75 micrograms gestodene and 20 micrograms ethinylestradiol/150 micrograms desogestrel, with respect to efficacy, cycle control and tolerance. Contraception 1995;52: Endrikat J. et al.: A twelve-month comparative clinical investigation of two low-dose oral contraceptives containing 20 micrograms ethinylestradiol/75 micrograms gestodene and 30 micrograms ethinylestradiol/75 micrograms gestodene, with respect to efficacy, cycle control, and tolerance.contraception 1997;55: Foidart J.-M. et al.: A comparative investigation of contraceptive reliability, cycle control and tolerance of two monophasic oral contraceptives containing either drospirenone or desogestrel. European Journal of Contraception and Reproductive Health Care 2000;5: Mansour, D. et al.: Efficacy and tolerability of a monophasic combined oral contraceptive containing nomegestrol acetate and 17β-oestradiol in a 24/4 regimen, in comparison to an oral contraceptive containing ethinylestradiol and drospirenone in a 21/7 regimen.european Journal of Contraception and Reproductive Health Care 2011;16: Taubert H. and Kuhl,H.: Kontrazeption mit Hormonen: 2.nd edition 1995:Thieme Verlag Stuttgart:p158 6

7 Unscheduled bleeding (defined as bleeding/spotting episodes not starting in the pill-free interval) is common in CHC newstarters and decreases with longer duration of use. COC with 20 µg EE are associated with more breakthrough bleeding than those with 30 µg EE. In COCs containing natural estrogens, breakthrough bleeding is common even in long-term users. If pills have been taken correctly, unscheduled bleeding does not indicate decreased efficacy. In long-term users with a normal bleeding pattern, new breakthrough bleeding may indicate chlamydia infection. 6

8 Unscheduled bleeding is uncomfortable and irritating. You should therefore discuss changing to another CHC after other causes of breakthrough bleeding have been excluded. The vaginal ring has a very stable bleeding pattern. 7

9 1. Macìas G et al.:effects of a combined oral contraceptive containing oestradiol valerate/dienogest on hormone withdrawal-associated symptoms: results from the multicentre, randomised, double-blind, active-controlled HARMONY II study. J Obstet Gynaecol Aug;33(6):

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11 Breast tenderness and ovarian cysts in users of very-low-dose pills can be caused by diminished suppression of follicular activity in the ovary. Estrogens produced in the ovary combine with estrogens in the pill to cause breast tenderness. 10

12 If vaginal dryness is a problem a lubricant may help. 11

13 1. Häni,D. Merki-Feld G.S.: Weight gain due to hormonal contraception: myth or truth? Gynäkologische Rundschau 2008;

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1. Lidegaard et al.: Venous thrombosis in users of non-oral hormonal contraception: follow-up study, Denmark 2001-10. BMJ 2012;344 2. Van Hlyckama Vlieg et al.

16 1. Lidegaard et al.: Venous thrombosis in users of non-oral hormonal contraception: follow-up study, Denmark BMJ 2012; Van Hlyckama Vlieg et al.; The venous thrombotic risk of oral contraceptives, effects of oestrogen dose and progestogen type: results of the MEGA case-control study. BMJ 2009.: Martinelli et al.: Duration of oral contraceptive use and the risk of venous thromboembolism. A case-control study.thrombosis Research 2016:

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1. Source: European Medicines Agency: Information for patients: When taking CHCs, you should be alert for the signs and symptoms of blood clots, which may include severe pain or swelling in the legs,

18 1. Source: European Medicines Agency: Information for patients: When taking CHCs, you should be alert for the signs and symptoms of blood clots, which may include severe pain or swelling in the legs, sudden unexplained breathlessness, rapid breathing or cough, chest pain, and weakness or numbness of the face, arm or leg. If you develop any of these signs and symptoms you should seek medical advice immediately. 17

1. N.Tepper et al.: Blood pressure measurement prior to initiating hormonal contraception: a systematic review. Contraception 2013;87:631-8.

19 1. N.Tepper et al.: Blood pressure measurement prior to initiating hormonal contraception: a systematic review. Contraception 2013;87: Conclusion Ref 1: Fair-quality evidence from five reports showed that women who did not have their blood pressure measured prior to COC initiation had a higher risk of acute MI and ischaemic stroke compared with women who did have their blood pressure measured. One study with fair-quality evidence showed no increased risk of haemorrhagic stroke based on whether or not blood pressure was measured. Studies that examined hormonal contraceptive methods other than COCs were not identified. Reasons to recommend a follow-up visit especially in new users include the opportunity to: Establish that the patient is using the pill correctly Discuss any problems with pill use Discuss any ongoing side effects (to encourage continuation) Check blood pressure Talk about STIs and condoms Check for warning signs such as new migraine 18

QUESTIONS AND ANSWERS ON COMBINED HORMONAL CONTRACEPTIVES: LATEST INFORMATION FOR WOMEN

QUESTIONS AND ANSWERS ON COMBINED HORMONAL CONTRACEPTIVES: LATEST INFORMATION FOR WOMEN Why is new information being made available now? A recent Europe wide review looked at the benefits and risks of