The Contraceptive Pill in Practice
Dr Helen Dewhirst
Bowling Hall Medical Practice
1/4/2009
1. A 16yr old attends wishing to start the pill.
She has no contraindications to COC use.
When will you tell her to start and how will
you tell her to take it?
2. A 21yr old attends post partum, wanting the
pill again. No contraindications to COC use.
When will you tell her to start it? Will she
need to use condoms and for how long?
3. An 18 yr old student requests the pill for the
first time. She has no contraindications. What
will you tell her about the likelihood of
failure?
4. A 17yr old, at school, taking her A levels this
year, wants reliable contraception. She has
acne and is worried the pill will make it worse.
5. A 17yr old, already on the pill, tells you that
her older sister has recently been in hospital
and has been taking anticoagulants for a leg
thrombosis. What will you advise?
6. A 19 yr old on the COC is due for an
admission for orthopaedic surgery. What will
you advise her about her pills?
7. 21 yr old student , taking microgynon 30 for
18/12.
She says that she is now beginning to feel
depressed and ‘bloated’.
She wants to try another pill. How will you
proceed?
8. A 25yr old woman has just had a termination
as a result of COC failure. She would like to try
the pill again, but is concerned about it failing
again. How could you help?
9. A 30yr old woman is on anti-epileptic therapy.
She has been using condoms but would now
like to try the pill. How would you proceed?
10. A 14yr old who had not started periods but
is sexually active cone requesting the pill. How
would you proceed?
11. A 48yr old woman has been taking
microgynon for the past 18 years and is happy
on it. What are you going to discuss with her?
12. A client attends complaining of headache at
the time of a period. She is on femodene. The
headaches always start two days after
stopping the pill and continue until she starts
the COC again.
13. A 24 yr old complains of BTB on microgynon
30. What are you going to do?
14. A 15 yr old school girl requests COC to
control her period , which are becoming
painful.
15. 20 year old developed migraine after
starting the COC. She last had migraine two
months ago with numbness in her face and
speech difficulty. She wants to continue the
pill. What are you going to discuss with her?
16. A 22 old dislikes taking Cilest as she thinks
they make her feel sick. She has heard about
the contraceptive patch and would like to try
it. What are you going to advise?
17. 25 yr old woman attends for emergency
contraception having forgotten her pill and
had UPSI. What would you discuss with her?
1. A 16yr old attends wishing to start the pill.
She has no contraindications to COC use.
When will you tell her to start and how will
you tell her to take it?
Starting regimes
• Day 1or 2 of cycle. Then no additional contraception is
required.
• Day 3 or later on menses, in which case 7 days extra
precautions required.
• Quick start; This regime allows starting at anytime in
cycle PROVIDED that there has not been a conception
exposure risk that cycle already. 7 days extra
precautions required. This is unlicensed and as such
needs discussing and consent from the patient which
should be documented.
•
Other important information to impart
on first visit
• FPA leaflet. Keep for reference
• Only works if you take it, each new packet should start on
same day of week.
• Even if bleeding, keep taking the pills.
• Never be late to restart
• Only safe in PFI if start the next packet
• Late rules
• Vomiting/ intercurrent illness
• SEs
• STI protection
• How to get help and advice
•
2. A 21yr old attends post partum, wanting the
pill again. No contraindications to COC use.
When will you tell her to start it? Will she
need to use condoms and for how long?
Post partum
• No lactation, day 21( unless severe pregnancy
related hypertension) as ovulation can occur
28 days post partum. No condoms required.
• Lactating, not recommended.
3. An 18 yr old student requests the pill for the
first time. She has no contraindications. What
will you tell her about the likelihood of
failure?
Failure rates
• Failure rates are described per 100 women
years. Perfect usage failure rate is 0.3 per
100wys. Typical use data from USA 8 100wys.
• Age social class, acceptability of contraception
are factors here.
4. A 17yr old, at school, taking her A levels this
year, wants reliable contraception. She has
acne and is worried the pill will make it worse.
Acne
• An oestrogen dominant COC will help with mild acne, such
as marvelon.
• Marvelon which contains desogestrel does however have a
slightly higher risk of VTE ( due to the fact that it is
oestrogen dominant, and this needs to be explained.)
• Yasmin is effective for moderate to severe acne. It is
drospirenone with EE. Drospirinone is antiandrogen as well
as having mineralocorticoid activity.
• Dianette, cryproterone and ethyiylestradiol has not had a
head to head with Yasmin, but Yasmin is thought to be as
good. Dianette has an increased VTE rate yet to be shown
for Yasmin Its duration should be limited due to liver
tumour. It should not therefore have a place for a new user.
5. A 17yr old, already on the pill, tells you that
her older sister has recently been in hospital
and has been taking anticoagulants for a leg
thrombosis. What will you advise?
VTE
• Need to establish whether her sister ( can assume
under 45yrs) had precipitating risk factors for a
VTE, eg surgery or post partum, and whether a
clotting screen has been carried out and results
available.
• WHO 4; FH Factor V Leiden,
• WHO 3; FH thrombosis ,clotting screen not
available no ppts ,
• WHO 2; FH with no ppt and NORMAL clotting.
• These categoroes of risk need to be discussed
further.
6. A 19 yr old on the COC is due for an
admission for orthopaedic surgery. What will
you advise her about her pills?
Surgery
• Risk is for major surgery or leg surgery.
• To stop from at least 2 weeks prior ( best 4
weeks) until 2 weeks afterward.
7. 21 yr old student , taking microgynon 30 for
18/12.
She says that she is now beginning to feel
depressed and ‘bloated’.
She wants to try another pill. How will you
proceed?
Side effects
• Cyclical ‘bloating’ is usually an oestrogen
dominant symptom. Microgynon 30 is
progesterone a dominant pill. A switch to Yasmin
may be helpful here due to mineralocorticoid
activity. Depression is a progesterone dominant
symptom, so the presence of this would again
support the use of Yasmin. Inc risk of VTE to be
discussed, and to check not in fact increased BMI.
Obviously as good GP will look for and screen for
other risk factors for mood disturbance.
•
8. A 25yr old woman has just had a termination
as a result of COC failure. She would like to try
the pill again, but is concerned about it failing
again. How could you help?
Failure of COC
• Many women miss the odd pill, so it would
suggest that she is in the 1/5 of women whose
ovaries show greater return to activity during the
PFI. She could therefore tricycle her pills, taking
3-4 packets back to back and reducing her PFI to
4 days. Some women take a short PFI when BTB
occurs. This method means a greater annual
consumption of EE than with normal regimes. It is
off license. Work is being undertaken looking at
taking Loestrin 20 continuously. This has lower
annual EE than with regular pill taking. Again off
licence.
9. A 30yr old woman is on anti-epileptic therapy.
She has been using condoms but would now
like to try the pill. How would you proceed?
Enzyme inducers
• COC is WHO 3 for women on long term enzyme
inducers. If they are chosen they require to take
50ug EE. One brand available in UK, Norinyl 1.
FPA guidance is to use 2 microgynon, or
femodene and a femodette. This is off licence and
named patient.
• Benefit from tricycling to maintain a steady
hormone state which also helps with the control.
•
10. A 14yr old who had not started periods but
is sexually active cone requesting the pill. How
would you proceed?
Amenorrhoea
• Assuming she is Fraser competent and there
are no child protection issues to resolve a COC
is contraindicated in Primary amenorrhea. She
should use condoms and not start hormonal
contraception until menses occur.
11. A 48yr old woman has been taking
microgynon for the past 18 years and is happy
on it. What are you going to discuss with her?
Age
• WHO 2 In healthy , migraine free, women who
have never smoked, age 35-51 .
• WHO 3 if ex smokers. However BMI is an
independent risk factor. BMI needs to be
below 25.
• Would be appropriate to suggest switching to
a 20ug EE pill , eg Loestrin 20, femodette or
mercilon.
•
12. A client attends complaining of headache at
the time of a period. She is on femodene. The
headaches always start two days after
stopping the pill and continue until she starts
the COC again.
Mood changes
• Important to exclude severe or unusual
headache or migraine with aura. As these
occur regularly in the PFI, she may benefit
from a tricycling regime.
•
13. A 24 yr old complains of BTB on microgynon
30. What are you going to do?
BTB
•
•
•
•
•
•
•
•
Exclude other causes,
a. disease, STI in our population
b. disorder of pregnancy
c. default, missed pills.
d. drugs, enzyme inducers
e. diarrhoea/vomiting
f. duration of use too short.
g. dose
BTB
• Reassure, the dosages to maintain
endometrium is lower than that required to
suppress ovulation. An alternative
progesterone may solve the problem, maybe
higher dosage, or a bi/triphasic preparation
which will have an increasing dosage of
progesterone n second half of the cycle.
•
14. A 15 yr old school girl requests COC to
control her period , which are becoming
painful.
Other Benefits
• The COC is effective in treating dysmenorrhea.
It is an unlicensed indication and therefore the
risk benefit profile is altered.
15. 20 year old developed migraine after
starting the COC. She last had migraine two
months ago with numbness in her face and
speech difficulty. She wants to continue the
pill. What are you going to discuss with her?
Migraine
• Did you feel nauseated or sick to your
stomach?
• Were you bothered by the light a lot more
than when you don’t have a headache?
• Your headaches limited your ability to work,
study or do what you needed to do for at least
1 day?
Migraine
• Answer to 2 out of 3 means a diagnosis of
migraine. Prevalence to this definition can be
as high as 18% in women. The presence of
migraine is a WHO 2 although there is
increasing evidence that the risk in migraine
without aura is not significant. Migraine with
aura is WHO 4. The is an increased risk of
ischaemic stroke. 1 year prevalence is ~ 5%.
Aura
• Timing, Onset before the headache and
duration up to 1 hour.
• Resolution before or with the onset of
headache.
• Symptoms visual (99%) Field effects.
• Description is visible , using a hand to
demonstrate visual features.
WHO 4
• Migraine with aura with or without headache
• Other migraine that are exceptionally severe
and last more than 72hrs with optimal
therapy.
• All migraine treated with ergot derivatives.
• Migraine without aura with multiple other risk
factors, or relevant interacting disease.
16. A 22 old dislikes taking Cilest as she thinks
they make her feel sick. She has heard about
the contraceptive patch and would like to try
it. What are you going to advise?
Evra
• The hormone in EVRA is EE with the active
metabolite of the progesterone in cilest.
• It will therefore share the same SE profile.
May in fact benefit from a progesterone
dominant pill eg microgynon.
17. 25 yr old woman attends for emergency
contraception having forgotten her pill and
had UPSI. What would you discuss with her?
Every time you miss any one pill (late by up to 24 hours)
1
Take a pill as
soon as you
remember
2
Take the
next pill at the
usual time
3
Keep taking the
active pills as
usual, one
each day
If you miss more than 1 pill- meaning anything more than 24 hours have elapsed
since the last time an active pill should have been taken.
4
As well as 1-3,
avoid sex or use an
extra method for 7
days and:
In these special cases, ALSO follow these special rules:
Missed more than
1 of the last 7
active pills?
•Finish all the
active pills in
the pack
•Do not take the
last 7 (inactive)
inactive pills if
it’s a 28-pill
pack
•Do not wait 7days to start
next 21-pill pack
•Start a new
pack
Started pack more
than 7 days late?
Missed more than 2
pills of the first 7
days (days 1-7)?
•Avoid sex or use an extra
method for 7 days
•Plus immediate use of
hormonal emergency
contraception (POEC) if any
exposure preceding PFI
•Return to next day’s active pill
within 24 hours of EC treatment,
and continue
If you miss any of the 7 inactive pills (in a 28 Pill pack only):
Throw
away
missed
pills
Keep
taking 1
pill each
day
Start New
pack as
usual