COC is have extra contraceptive benefit

1. Session I, Slide 1
Combined Oral
Contraceptive Pills
(COCs)
Session I:
Characteristics of COCs

2. Session I, Slide 2
COCs Key Points for
Providers and Clients
Take a pill every day.
• Contains both estrogen and progestogen hormones.
• Works mainly by stopping ovulation.
Effectiveness depends
on the user. Can be
very effective.
• “Would you remember to take a pill each day?”
• No need to do anything at time of sexual intercourse.
• Very effective if taken every day. But if woman forgets pills,
she may become pregnant.
• Easy to stop: A woman who stops pills can soon become
pregnant.
Very safe.
• Pills are not harmful for most women’s health and studies
show very low risk for cancer due to pills for almost all women.
The pill can even protect against some types of cancer.
• Serious complications are rare. They include heart attack,
stroke, blood clots in deep veins of the legs or lungs.
Some women have
side-effects at first–
not harmful and often
go away after first 3
months.
• Side-effects often go away after first 3 months.
No protection against
STIs or HIV/AIDS.
• For STI/HIV/AIDS protection, also use condoms.

3. Session I, Slide 3
Relative Effectiveness of
FP Methods
Method
# of unintended pregnancies among
1,000 women in 1st year of typical use
No method 850
Withdrawal 220
Female condom 210
Male condom 180
Pill 90
Injectable 60
IUD (CU-T 380A / LNG-IUS) 8 / 2
Female sterilization 5
Vasectomy 1.5
Implant 0.5
Source: Trussell J., Contraceptive Failure in the United States, Contraception 83 (2011) 397- 404,
Elsevier Inc.

4. Session I, Slide 4
COCs: Mechanism of Action
Thickens
cervical mucus
to block sperm
Suppresses
hormones
responsible for
ovulation
COCs have no effect on an existing pregnancy.

5. Session I, Slide 5
COCs: Characteristics
• Less effective when not used
correctly (91%)
• Require taking a pill every
day
• Do not provide protection
from STIs/HIV
• Have side effects
• Have some health risks
(rare)
• Safe and more than
99% effective if used
correctly
• Can be stopped at any
time
• No delay in return to
fertility
• Are controlled by the
woman
• Do not interfere with sex
• Have health benefits
Source: Hatcher, 2007; WHO, 2010; CCP and WHO, 2011; Trussell , 2011.

6. Session I, Slide 6
COCs: Menstrual-Related Health
Benefits
• Decreased amount of flow and fewer days of
bleeding; no bleeding (less common)
• Regular, predictable menstrual cycles
• Reduced pain and cramps during menses
• Reduced pain at time of ovulation
Source: Davis, 2005.

7. Session I, Slide 7
COCs: Other Health Benefits
Protection from:
• Risks of pregnancy
• Ovarian cancer
• Endometrial cancer
• Symptomatic PID
Reduced risk of:
• Ovarian cysts
• Iron-deficiency anemia
Source: Petitti and Porterfield, 1992; CASH Study, 1987; CCP and WHO, 2011; Belsey, 1988; Davis,
2007.
Decreased symptoms
of endometriosis
(pelvic pain, irregular
bleeding)
Decreased symptoms
of polycystic ovarian
syndrome (irregular
bleeding, acne, excess
hair on face or body)

8. Session I, Slide 8
No Overall Increase in Breast Cancer
Risk for COC Users
Analysis of a large number of studies:
• No overall increase in breast cancer risk among women
who had ever used COCs
• Current use and use within past 10 years: very slight
increase in risk
– May be due to early diagnosis or accelerated growth
of pre-existing tumors
More recent study:
• No increase in breast cancer risk regardless of age,
estrogen dose, ethnicity, or family history of breast
cancer
Source: Collaborative Group on Hormonal Factors in Breast Cancer, 1996; Marchbanks, 2002.

9. Session I, Slide 9
COCs and Cervical Cancer
• Cervical cancer is caused by certain types of human
papillomavirus (HPV)
• Some increase in risk among women with HPV and others
who use COCs more than 5 years
– Risk of cervical cancer goes back to baseline after 10
years of non-use
• Cervical cancer rates in women of reproductive age are
low. Risk of cervical cancer at this age group is low
compared to mortality and morbidities associated with
pregnancy.
Source: Smith, 2003; Appleby, 2007; CCP and WHO, 2011.
COC users should follow the same cervical cancer
screening schedule as other women.

10. Session I, Slide 10
Risk of Blood Clots is Limited
• COCs may slightly increase risk of blood clots:
– Stroke
– Heart attack
• Risk is concentrated among women who have
additional risk factors, such as:
– Hypertension
– Diabetes
– Smoking
Source: World Health Organization Collaborative Study of Cardiovascular Disease and
Steroid Hormone Contraception ,1995; Jick, 2006; WHO, 1998; Farley, 1998.
Stop COCs immediately if a blood clot develops.
– Deep vein thrombosis
– Pulmonary embolism

11. Session I, Slide 11
Possible Side-Effects
If a woman chooses this method, she may have some side-
effects. They are not usually signs of illness.
• But many women do not have any side-effects.
• Side-effects often go away after a few months and are not harmful.
Most common:
• Mood
changes or
headaches
• Tender
breasts
• Changes in
bleeding
patterns (lighter,
irregular,
infrequent or no
monthly
bleeding)
• Slight weight
gain or loss
• Nausea
(upset
stomach)
• Dizziness

12. Session I, Slide 12
Combined Oral
Contraceptive Pills
(COCs)
Session III: Providing COCs

13. Session I, Slide 13
When to Start COCs (part 1)
• Anytime you are reasonably certain the woman is not
pregnant
• Pregnancy can be ruled out if the woman meets one of the
following criteria:
– Started monthly bleeding within the past 7 days
– Is breastfeeding fully, has no menses and baby is less than 6 months old
– Has abstained from intercourse since last menses or delivery
– Had a baby in the past 4 weeks
– Had a miscarriage or an abortion in the past 7 days
– Is using a reliable contraceptive method consistently and correctly
• If none of the above apply, pregnancy can be ruled out by
pregnancy test, pelvic exam, or waiting until next menses
Source: WHO, 2004 (updated 2008).

14. Session I, Slide 14
When to Start COCs (part 2)
• If starting during the first 5 days of the menstrual
cycle, no backup method needed
• After day 5 of her cycle, rule out pregnancy and use
backup method for the next 7 days
• Postpartum
– Not breastfeeding: May start 3 to 6 weeks after
giving birth, depending on presence of risk
factors for blood clots
– Breastfeeding: May start 6 months after giving
birth
Source: WHO, 2004 (updated 2008).

15. Session I, Slide 15
When to Start COCs (part 3)
• After miscarriage or abortion
– If within 5 days after miscarriage or abortion, no backup method needed
– If more than 5 days after, rule out pregnancy, use backup method for
7 days
• Switching from hormonal method
– May start immediately, no backup method needed (with injectables,
initiate within reinjection window)
• Switching from nonhormonal method
– If starting within 5 days of start of menstrual cycle, no backup method
needed
– If starting after day 5 of cycle, use backup method for 7 days
• After using emergency contraceptive pills
– Initiate next day, use backup method for 7 days
Source: WHO, 2004 (updated 2008).

16. Session I, Slide 16
How to Take COCs
• Take one pill each day, by mouth.
• Most important instruction:
– Give client her pill pack to hold and look at.
– Show how to follow arrows on pack.
• Discuss:
– Easy to remember to take pills?
– “What would help you to remember? What else do you do
regularly every day?”
– Easiest time to take the pills? At a meal? At bedtime?
– Where to keep pills.
– What to do if pill supply runs out.
The Pill

17. Session I, Slide 17
How to Take COCs
The Pill
28-pill pack
21-pill pack
If you use the 28-pill pack:
• No waiting between packs.
• Once you have finished all the pills in the
pack, start new pack on the next day.
If you use the 21-pill pack:
• 7 days of no pills
• Once you have finished all the pills in the
pack, wait 7 days before starting new pack.
For example: If you finish the old pack on
Saturday, take the first pill of the new pack on
the following Sunday.
Caution the client: Waiting too long between packs greatly increases risk
of pregnancy.
21-pill pack

18. Session I, Slide 18
Missed Pills Instructions
The Pill
• Miss 1 or 2 active pills in a row or start a
pack 1 or 2 days late:
– Always take a pill as soon as possible.
– Continue to take one pill every day.
– No need for additional protection.

19. Session I, Slide 19
Missed Pills Instructions,
continued
The Pill
Source: WHO, 2004; updated 2008; CCP and WHO,
Miss 3 or more active pills in a row or start a
pack 3 or more days late:
• If these pills missed in week 3, ALSO skip the inactive pills
in a 28-pill pack and start a new pack
• Take a pill as soon as possible, continue taking 1 pill
each day, and use condoms or avoid sex for next 7 days
• If inactive pills are missed, throw away the missed pills and
continue taking pills, 1 each day
OR
week 3
Inactive pills
AND

20. Session I, Slide 20
Key Counseling Topics for COC Users
• Safety and efficacy (requires taking pills on time)
• How COCs work
• Health benefits
• Possible side effects
• How to take pills and what
to do if pills are missed
• No protection from STIs/HIV
• Inform provider she is taking COCs
in case of serious new health problem
• Reasons to return: questions, concerns or
experiencing any warning signs

21. Session I, Slide 21
Correcting Rumors and Misconceptions
COCs:
• Do not build up in a woman’s body. Women do not
need a “rest” from taking COCs.
• Must be taken every day, whether or not a woman has
sex that day.
• Do not make women infertile.
• Do not cause birth defects or multiple births.
• Do not change women’s sexual behavior.
• Do not collect in the stomach. Instead, the pill
dissolves each day.
• Do not disrupt an existing pregnancy.

22. Session I, Slide 22
• Take one pill each day
• If you miss pills, you can
get pregnant
• Side-effects are common
but rarely harmful. Come
back if they bother you.
• Come back for more pills
before you run out or if
you have problems.
What to Remember
Anything else I can
repeat or explain?
Any other
questions?
See a nurse or doctor if:
• Severe, constant
pain in belly, chest,
or legs
• Very bad
headaches
• A bright
spot in your
vision
before bad
headaches • Yellow skin
or eyes

23. Session I, Slide 23
Follow-up for COCs
• No fixed schedule; return any time.
• Resupply: Give more than 1 cycle of pills, if possible.
• Assess for method satisfaction and any health
problems or circumstances that may restrict COC
use.
• Manage and reassure about side effects.
• Review correct pill taking and what to do when pills
are missed.

24. Session I, Slide 24
How can I help you?
• Are you happy using the pill?
• Want more supplies?
• Any questions or problems?
Let’s check:
• For any new health conditions
• When do you take your pills?
• What do you do if you forget a pill?
• Need condoms too?

25. Session I, Slide 25
Management of COC Side Effects
Problem Action/Management
Ordinary
headaches
Reassure client:
usually diminish over
time; take painkillers
If side effects persist
and are unacceptable
to client:
if possible, switch pill
formulations or switch
to another method.
Nausea and
vomiting
Take pills with food or at
bedtime
Breast
tenderness
Recommend supportive
bra; suggest pain
reliever
Counseling and reassurance are key.

26. Session I, Slide 26
Source: CCP and WHO, 2011.
Management of COC Side Effects:
Bleeding Changes
Problem Action/Management
Irregular
bleeding
Reassure client:
reinforce correct pill
taking and review
missed pill instructions;
ask about other drugs
that may interact with
COCs; administer short
course of non-steroidal
anti-inflammatory drugs
If side effects persist
and are unacceptable
to client:
if possible, switch pill
formulations or offer
another method.
Amenorrhea Reassure client: no
medical treatment
necessary.

27. Session I, Slide 27
Advise to stop taking COCs, use a backup method,
and see a health care provider.
Source: Hatcher, 2007.
• Severe, constant pain in belly,
chest, or legs
• Very bad headaches
• A bright spot in your
vision before bad
headaches
• Yellow skin or eyes
When to Return: Warning Signs of Rare
COC Complications

28. Session I, Slide 28
Problems That May Require Stopping COCs or
Switching to Another Method
Source: CCP and WHO, 2011.
Problem Action
Unexplained vaginal
bleeding
• Refer or evaluate by history and pelvic exam
• Diagnose and treat as appropriate
• If an STI or PID is diagnosed, the client may
continue using COCs during treatment
Migraines
• If the client develops migraines with or without
aura, or her migraine headaches worsen, stop
COC use
• Help the client choose a method without
estrogen
Circumstances that
keep her from walking
for one week or more
Tell the client she should:
• Tell her doctors she is using COCs
• Stop taking COCs and use a backup method
• Restart COCs 2 weeks after she can move
about

29. Session I, Slide 29
Problems That May Require Stopping COCs or
Switching to Another Method
Source: CCP and WHO, 2011.
(continued)
Problem Action
Starting treatment with
anti- convulsants or
rifampicin, rifabutin, or
ritonavir
• These drugs make COCs less effective; COCs
may make lamotrigine less effective.
• Advise the client to consider other contraceptive
methods (except progestin-only pills).
Blood clots, heart or
liver disease, stroke, or
breast cancer
• Tell the client to stop COC use
• Give the client a backup method to use
• Refer for diagnosis and care
Suspected pregnancy
• Assess for pregnancy
• If confirmed, tell the client to stop taking COCs
• There are no known risks to a fetus conceived
while a woman is taking COCs

30. Session I, Slide 30
COCs: Summary
• Safe for almost all women
• Effective if used consistently
and correctly
• Fertility returns without a
delay
• Screening and counseling
are essential