Oral Contraceptives Mike Williams GPST2
Curriculum Mechanism Efficacy Advantages/Disadvantages Starting Continuing Problems/complications
Contraception: effectiveness rates, risks, benefits and appropriate selection of patients for all methods; safe provision of all methods of oral contraception... Refer to the UK Medical Eligibility Criteria for Contraceptive Use
Feedback inhibition of hormone axis
3 pregnancies per 1,000 women per year (when used correctly) 80 pregnancies per 1,000 women per year.
Non-invasive Modifies periods Timing COCP reduces risk of ovarian, endometrial, colorectal cancer No effect on intercourse
Increase risk of VTE STI's Breakthrough bleeding Compliance Interactions
VTE absolute risk small and less than that of pregnancy unless further risk factors Slight increase in breast cancer risk - contraindicated in current breast cancer and risk>benefits COCP if known BRAC1 COCP- cervical cancer - 2 x risk at 10years. NOT a contraindication
Category 1 - no contraindication Category 2 - benefits outweigh the risks Category 3 - risks outweigh the benefits Category 4 - unacceptable risk
Personal history? Current VTE (on anticoagulants)? First degree relative <45 years old? First degree relative >45 years old?
Age <35 years? Age >35years and... <15 cigarettes/day? >15 cigarettes/day? Stopped smoking <1year ago? Stopped smoking >1year ago?
http://www.fsrh.org/pdfs/ukmecsum marysheets2009.pdf
Initial Consultation
Current and previous medical conditions Medications Family history
BMI BP Pregnancy test if appropriate
NICE recommends all forms of contraception are discussed to enable an informed decision COCP vs POP - individual preference or led by factors in history If no contraindications discuss advantages and disadvantages
Drug interactions
Antibiotics ok unless enzyme inducers e.g. Rifampicin, Rifabutin St John's Wort Anticonvulsants e.g.carbamazepine, oxcarbazepine, eslicarbazepine, phenobarbital, phenytoin, primidone and topiramate Antiretrovirals
No additional contraceptive required for non enzyme inducing antibiotics. Short course of enzyme inducers (<2months) - use additional precautions during and for a month afterwards, & tricycle packs. Long course of enzyme inducers (>2months) - choose alternative, preferably non-hormonal method. Lamotrigine - increased seizure risk unless concurrent non enzyme inducing anticonvulsant.
Which pill?
Better control of cycle Lighter bleeding Greater leeway for missed pills Decreased risk of ovarian, endometrial, colorectal ca.
Suitable with a large number of conditions e.g. VTE, smoking, increased BMI, migraine Can be used during breastfeeding Suitable if undergoing major surgery
Dose of oestrogen and progesterone remains the same Phased may have two, three or four different doses throughout pack. 21 pill cycle with or without 7 dummy pills (Zoely 4, Qlaira 2)
No actual recommended first line Monophasic Lowest dose that balances good cycle control with side effects. E.g. MICROGYNON Others include Cilest, Yasmin, Loestrin.
Contains different progestogens- levonorgestrel, norethisterone. E.g. MICRONOR, NORIDAY, NORGESTON Newer POP - desogestrel. E.g. CERAZETTE
First day of menstrual bleeding - but can be started up to day 5 without additional protection (unless Qlaira or Zoely) If required - use for 7 days (Qlaira - 9days), or 2 days if POP. Start directly after emergency contraception but will need 7days additional precautions for Levonelle and 14 for EllaOne. Or until next period if on POP.
Missed Pills
Up to 24 hours - take missed pill and carry on as usual Two missed pills - take the most recent missed pill, 7 days additional precautions and contact GP or practice nurse
If 0-3 hours - take missed pill ASAP and carry on as normal (unless desogestrel 0-12 hours) If outside that window - use additional precautions for 48 hours and phone for advice (or refer to pill leaflet)
Monitoring and follow up
First at 3 months then 6-12 monthly intervals Check BMI, BP. Enquire about new developments in medical/social history e.g. Smoking, medications, age. Any BTB? Regularity of menses? Still the most appropriate method? LARC? Still required? Adverse effects?
menorrhagia cervical ectopy breast fullness migraine type headaches fluid retention, weight gain (fluid) tiredness, irritability nausea bloating
scanty menses leukorrhoea breast tenderness dull type of headache - often of pill withdrawal appetite increase, weight gain premenstrual depression leg cramps, softening of ligaments acne, greasy hair vaginal dryness low mood low libido especially if associated with low mood
Scenario
Plan appointment ahead e.g. PILS etc. UKMEC Start lowest dose, and titrate to SE s, control of bleeding etc. Multiple exceptions refer to product literature F/u 3 months and then 6-12 months Be vigilant to other causes of BTB e.g. infection