Oral Contraceptive Pill

( OCP)
J Hassan

Introduction

OCP is widely used in the UK, it can be highly

effective in prevention of pregnancy, if used
consistently and correctly.
It also has non contraceptive benefits including
Managing irregular menstrual cycles
Alleviate dysmenorrhoea
Manage endometriosis

2 categories
Combined oral contraceptive pill (COCP)
Progesterone only pill (POP)

Principles of counselling:
Why method chosen
Efficacy/ Mode of action
Pill teach / Potential side effects / reversibility
Menstrual pattern/ full med and sexual hx to elucidate CI
Safer sex/ leaflet provided

COCP
Mode of action
Ovulation suppression
Endometrial atrophy
Thickens cervical mucus
Effectiveness
Failure rate is 0.2-0.5 per 100 woman years

Type of
progesterone
Levonorgestrel

Classification

Norethisterone

Monophasic pills

Triphasic pills

Microgynon 30/ED

Trinodial

Ovranette (30 EE)

Logynon/ ED

Eugynon (30 EE)

Ovysmen / Brevinor (35
EE)

Trinovum

Norimin( 35)

Synphase

Norgestimate

Loestrin 20/30
Cilest (35 EE)

Desogestrol

Mercilon 20 Ee

Gestogene

Femodene (ED/ 30EE)

Binovum

Marvelon 30 EE
Minulet (30 EE)
Femodette(20 EE)

Tri-Minulet

Benefits

Less menorrhagia/ dysmenorrhoea

Reduction in
Ovarian / endometrial Ca
functional Ovarian cysts
Benign breast lessions
Symptomatic endometriosis
Risk of Colon ca
Thyroid dx
Improvement of acne

Risks

VTE- risk inc with age and in those with other risk factors
Cervical ca- small inc after 5 yr use
Breast caPrimary liver ca
Hydatidiform mole/ choriocarcinoma
MI- increased 3 fold if hypt
CVA- Ischaemic increase is about 1.5 fold in
normotensive non-smoking COC users and 3 fold in those
with hypt.

1st consultation

Important points from the history:

Methods used/ length of use
LMP / previous pregnancies/recent preg ( associated
condn.)/ lactating
Age
Current illnesses and txt
Past major illness / ops
Menstrual hx( cycle length, duration etc)
Sexual hx, previous STI, risk behaviours
Hx of hypt, cardiovascular and risk factors/ DM /
VTE/ IHD / CVA

Headaches/migraines
Smoking / no. per day
Obesity
Liver / Gallbladder dx
Breast dx
Examinations
BP measurement is essential. If consistently >140/90 then
the woman should be advised against use of COC
Weight and Height and BMI calculated and documented

Starting Regimes
Menstruating

Postpartum
Miscarriage/
TOP< 24wks
TOP > 24wks
Amenorrhoea

Ideally start day 1 of cycle can start up to day 5 without

additional contraception
Anytime if no unprotected intercourse since LMP but
additional protection for 7 days
Non breast feeding mums- Start Day 21. if after day 21
additional method for 7 days
Breast feeding mums- Start 6 months
Same or next day. If started > 7 days after then additional
method for 7 days
Start on day 21, otherwise if later then additional method for
7 days
At any time if no risk of pregnancy, and 7 days additional
precautions

Missed Pill Advise

If 1 or 2 of 30-35mcg ethinylestradiol pill or 1of 20mcg

Advise to take the most recent pill as soon as remembers, continue

taking remaining pill at usual time, she does not require additional
contraception or emergency contraception

If 3 or more of 30-35 or 2 or more 20mcg

Advise as above, but to use extra method of contraception until

pills have been taken for 7 days in a row
If pill is missed in week 1 ( days1-7)and unprotected sexual
intercourse has taken place in pill free week or wk 1 then
emergency contraception is needed
If pills missed in wk 3 ( days 15-21), advise to finish pill in pack and
start new pack the next day, omitting pill free interval
If one has missed > 7 consecutive days then consider as stopped
COCP

Drug interactions
Antibiotics-( non liver enzyme inducing) Short courses <3
wks. -Advise to use additional protection while on the
treatment and for 7 days afterwards. If pt is taking long
term abx, there is no requirement for extra precaution
after 3 wks of abx use
Liver enzyme inducing drugs- advise alternative methods
preferably or use high dose of ethinylestradiol eg 50mcg
pill, combination of 30 + 20 mcg or 2 30/35mcg, + barrier
method and advise tricycling regime with a short pill free
interval(4 days) at end of 3 cycles
Example of drugs Anticonvulsants, anti TB, Anti fungals,
Anti HIV, St Johns Worts,

Side effects
Oestrogenic
Nausea, dizziness, bloating, breast engorgement, vaginal
discharge, premenstrual tension, migranes
Change to a more progestogenic prep/ Reduce dose of
oestrogen and inc dose of progesterone.

COC progesterone dominant- Microgynon 30, Loestrin 30 ,Eugynon 30, Norimin,

loestrin 20

Progestogenic
Vaginal dryness, inc wt, reduced libido, acne, mastalgia,
depression/lethargy, scanty menses

Change to more osetrogenic eg Ovysmen, Marvelon, femodene, cilest,

Trinordiol/ logynon

Follow up
Review in 3 months to ensure compliance and
acceptability, with further follow up at 12 monthly
intervals, encourage pt to seek advise if any
worries
BP ant Wt yearly
Check that COC is taken correctly
Sought new risk factors/ SE
If pt > 35 yrs, there should be a thorough reassesment

Progesterone only Pill

(POP)
Becoming increasingly popular as more women worry about
SE and health risk of COC
They can be used with no age limits,in smokers, during
lactation and even for women at risk of VTE
Efficacy
Failure rate of 0.3-5 per 100 woman years
Mode of action
Mainly thickening cervical mucus
Atrophy of endometrium, hinders implantation
Interfere with tubal transport of ova
Cerazette however inhibits ovulation

POP

Type of progesteron
Norethisterone

350mcg

Micronor
Noriday

Levonorgestrel

30mcg

Microval,
Norgeston

Di norgestrel

75mcg

Neogest

Etynodiol diacetate

500mcg

Femulen

Disogestrel

75mcg

Cerazette

Indications

< 21 days post partum. 6wks-6mths postpartum partially or fully BF

Age> 35 and smoke
BMI> 35
Multiple risk for CVS
Those at risk of VTE, inc personal hx
Hypt controlled with meds
DM/ CHD/ valvular problems
CIN/ endometrial ca/ ovarian ca
F Hx Breast ca
SCD

Contraindications
Uncontrolled hypertension
Active hepatitis/ decompensated cirrhosis/ liver
tumours
Mal absorption
Current DVT
Undiagnosed Genital tract bleeding
Recent trophoblastic dx with high bHCG
Current IHD

 Current breast Ca
Past severe side effects
Acute porphyria

 Missed pill: pill needs to be taken at same time of day.

There is only 3 hour window period for missed pills.
Contraception efficacy is restored after 2 days as
compared to COC
Cerazette- has a 12 hour window period.
Vomiting within 2 hrs or severe diarrhoea decreases
efficacy.
Starting regimes- same as COC however additional method
is needed for only 48hrs
Drug interactions- Pop not affected by broad spectrum abx.
However enzyme inducing drugs reduces efficacy.

Thank You