2. INTRODUCTION
• OCP is widely used world wide.
• Primary used: to prevent pregnancy.
- Highly effective if used consistently & correctly.
• Secondary used:
Managing heavy & irregular menses
Alleviate dysmenorrhoea
Endometriosis
PCOS
DUB
3. TYPES
COMBINED OCP
• Most effective
• Formulation may be :
Monophasic
Biphasic
Triphasic
PROGESTOGEN ONLY
PILL
• Must take daily without
interruption.
Norethisterone
Levonogestrel (LNG)
Ethynodiol
4. PRINCIPLE OF COUNSELLING
• Why method chosen.
• Efficacy & mode of action.
• Pill teach/ irreversibility/potential side
effect
• Menstrual pattern/ full medical and sexual
history to elucidate contra indication
• Safer sex /leaflet provided.
7. HOW EFFECTIVE?
• COCs are very effective when taken correctly
and consistently.
• Correct and consistent use taking one pill
every day, starting a new pack of pills on time,
and following instructions for missed pills.
• The pregnancy rate (Over the 1st year):
< 1 /100 women (for correct & consistent )
9 /100 women (commonly used).
8. EFFICACY
• A Cochrane review :
– With perfect use (following directions for
use) the failure rate is 0.3%
– With typical use (actual use including
inconsistent or incorrect use) is 9%.
9. MODE OF ACTION
• Suppression of ovulation
– By prevention of ovarian follicular
maturation
– By interrupting the oestrogen-mediated
positive feedback on the hypothalamic-
pituitary axis thus preventing LH surge
• Thicken the cervical mucus
– reduce sperm penetrability
• Alteration of the endometrium
– reducing likelihood of implantation
10. COMMON ADVERSE EFFECTS
• Changes of bleeding pattern
• Headache / Giddiness/ Nausea
• Breast tenderness
• Weight gain
• Mood changes depress/ irritable
• Acne / pigmentation
12. ADVANTAGES
• High efficacy
– Failure rate 0.1-3/100 woman years
• Reversible
– Prompt return to ovulation with 70% of women
ovulating in the 1st cycle and 98% by the 3rd
cycle
• Not related to intercourse
• in menstrual blood flow
– Reduced the menstrual blood flow by 50% thus
reducing the incidence of iron deficiency
anaemia
13. ADVANTAGES
• Less dysmenorhoea
– Reduce menstrual prostaglandin release thus
reducing uterine contractility and
dysmenorrhoea
• Predictability of menses
• Fewer PMS
• Reduction in benign breast disease
• Reduction in functional ovarian cyst
• Reduction in colorectal cancer
14. ADVANTAGES
• Reduction in ectopic pregnancy rate
– All forms of contraception reduce the incidence of
ectopic pregnancy
– Risk of ectopic pregnancy in COCP users is 0.005
per 1000 woman yrs.
• Reduction in ovarian and endometrial cancer
– COCP use for 4 and 8 years associated with 40%
and 51% reduction in risk of ovarian cancer
respectively
– COCP use for 4 and 8 years associated with 54%
and 66% reduction in risk of endometrial cancer
respectively
15. CONTRA INDICATIONS
• Allergy to any component of product
• H/O blood clot disorder
• H/O stroke /heart disease
• Severe Hypertension
• Poorly controlled DM
• Migraines
• Breast Cancer
16. Disadvantages
• Thromboembolic dz
– Venous thromboembolism
• Normal : 4–5/10 000 woman-years
• COC : 9–10/10 000
• Pregnancy : 29/10 000
– Myocardial infarction : in smoker
– Stroke : in migraine with aura.
• Breast cancer
– RR: 1.24 in current user
– Small risk, and will reduce with time after stopping
• Cervical cancer
– Increased with increasing duration of use
– Small risk.
17. Drug interactions
• Enzyme-inducing drugs :
1. Antiepileptic drugs Carbamazepine or
Phenytoin.
Increase the metabolism of estrogens and
progestogens : reduce the contraceptive
efficacy
Should ideally switch to a method that is
unaffected (e.g. intrauterine methods or the
progestogen-only injectable).
18. Drug interactions
2. For women using the COC in conjunction with
enzyme inducers (except rifampicin or
rifabutin) : increase the dose to at least 50 μg
EE (maximum 70 μg EE) and to shorten (4
days)/omit their pill-free interval.
• Women using Rifampacin or Rifabutin should
use condoms in the short term or switch to a
method unaffected by enzyme-inducing drugs.
19. Assessments for the First
Time?
• Detailed history :
– Medical conditions : Migraine, Drug use,
Family medical history and Lifestyle
factors such as smoking,
# should recheck the history at least
annually.
• Examination
– Blood pressure
– BMI
20. When in the Menstrual Cycle can
COC be Started?
• Conception is most likely to occur :
Following unprotected sexual intercourse on
the day of ovulation or in the preceding 24
hours
• If started up to and including Day 5 : no need
for additional contraception.
21. When in the Menstrual Cycle can
COC be Started?
• Beyond Day 5 : a woman may start COC at any
other time if it is reasonably certain she is not
pregnant .
– When starting COCs after Day 5 women should
use additional precautions such as condoms or
avoid sex for the next 7 days.
• estradiol valerate/dienogest-containing pill
(Qlaira) should be started on Day 1, with
additional precautions used for 9 days if
starting any time after this.
22. Criteria to exclude pregnancy
• Has not had intercourse
since last normal menses
• Has been correctly and
consistently using a
reliable method of
contraception
• Is within the first 7
days of the onset of a
normal menstrual
period
• Is within the first 7
days post miscarriage
• Is within 4 weeks
postpartum for non-
lactating women
• Is fully or nearly fully
breastfeeding,
amenorrhoeic, and less
than 6 months
postpartum.
A UPT, adds weight to the exclusion but
only if ≥ 3 weeks since last UPSI
23. When to start?
Situation When to start Backup?
Fully or nearly fully
Breastfeeding
> 6 mths after birth
If her menstrual cycle has
not return, start any time it
is reasonable certain she’s
not pregnant.
(take COCs during her next
menses)
1st 7 days
Partially Breastfeeding
< 6 weeks
> 6 weeks
Start taking 6 weeks
after delivery,
Anytime if menses has
not return, &
reasonably certain she
is not pregnant.
If menses return, start
as usual
Until 6 weeks post
delivery if menses
return before this time.
1st 7 days of taking pill
24. When to start?
Situation When to start Backup?
Not Breastfeeding
< 4 weeks
> 4 weeks
Start anytime on day
21-28 after delivery,
Anytime if menses has
not return, &
reasonably certain she
is not pregnant.
If menses return, start
as usual
No
1st 7 days.
Irregular bleeding not
related to pregnancy
Anytime it is reasonably
not pregnant
1st 7 days
25. When to start?
Situation When to start Backup?
After 1st / 2nd trimester
miscarriage
Immediately
If within 7 days after
miscarriage
If > than 7 days,
anytime it is reasonably
certain she is not
pregnant.
No
1st 7 days
9 days for estradiol
valerate/dienogest pill)
If you cannot be reasonably certain
that the woman is not pregnant,
give COCs & tell her to take them during her next monthly bleeding
26. MISSED PILL
• A pill that is completely omitted more than
24 hours have passed since the pill was
due OR 48 hours since last pill taken.
• Evidence : taking hormonally active pills
for 7 consecutive days prevents ovulation.
• Therefore as long as seven pills have been
taken, theoretically up to seven can be
missed without any effect on
contraceptive efficacy.
27. MISSED 1 PILL……….
If ONE pill has been missed
(48–72 hours since last pill or
24 – 48 hours late starting first pill
in new packet)
The missed pill
should be taken
as soon as it is
remembered
The remaining pills
should be
continued at the
usual time.
28. MISSED 2 PILLS…….
If TWO OR
MORE pills have
been missed
(>72 hours since
last pill in
current packet
or
>48 hours late
starting first pill
in new packet)
1. The most recent
missed pill should
be taken as soon
as possible.
2. The remaining
pills should be
continued at the
usual time.
3. Condoms
should be used or
sex avoided until
7 consecutive
active pills have
been taken.
29. Missed 2 pills…..
• If pills are missed in the 1st week
(Pills 1–7)
EC should be considered if unprotected sex
occurred in the pill-free interval or in the
first week of pill-taking.
• If pills are missed in the second week
(Pills 8–14)
No indication for EC if the pills in the
preceding 7 days have been taken consistently
and correctly
30. • If pills are missed in the third week
(Pills 15–21)
OMIT THE PILL-FREE INTERVAL by
finishing the pills in the current pack
(or discarding any placebo tablets) and
starting a new pack the next day.
32. • Contain low dose of Progestin like the natural
Progesterone.
• No Estrogen, so, estrogen related side effect
are avoided.
• Common user:
Breastfeeding mother.
Women who cannot use estrogen
can be used in patient with HPT & overweight
33. MODE OF ACTION
• Thickening the cervical mucus.
• Interfere with ova transport
• Prevent ovulation – desogestrel pill,
Cerazette.
97% of menstrual cycle
34. EFFECTIVENESS
• Depend on the user.
• > 99% effective if taken correctly.
• Breastfeeding:
Commonly used: 1/100 women get pregnant
Taken everyday: 3/1000 women
• Not breastfeeding:
Commonly used: 3-10/100
Taken everyday: 9/1000 women
35. SIDE EFFECTS
• Altered bleeding patterns is the most
common reason given by women for stopping
POPs.
– 20% will be amenorrhoeic
– 40% will bleed regularly
– 40% will have erratic bleeding.
• Weight change
• Mood change
• Headache/Dizziness/Nausea
• Cardiovascular disease (MI, VTE and
stroke) and breast cancer – no evidence
36. How to take the POP?
• One tablet daily taken on day 1 of cycle and
taken continuously without a break.
• Should be taken at the same time every day
and within 3 hrs ( within 12 H for Qlaira)
• If pill missed for more than 3 hrs, additional
precautions needed for following 2 days
• An estimated 48hrs of POP use was deemed
necessary to achieve the contraceptive effects on
cervical mucus
37. When to start POPs?
• Woman can start using POPs anytime she
wants if it is reasonably certain she is not
pregnant.
• Can be started up to and including Day 5.
If started after this time condoms or
abstinence are advised for 48 hours.
38. When to start POPs?
• Up to and including Day 21 postpartum.
If started after this time condoms or abstinence
are advised for 48 hours.
• Can be started at the time of miscarriage or
within 5 days.
If started after this time condoms are required
for the next 48 hours.
39. MISSED PILLS
• Traditional pill : > 3 hours late
• DESOGESTREL –ONLY (Cerazette®) : > 12
hrs late
Take the last pill as soon as remembered.
If more than one pill has been missed just
take one pill.
Take the next pill at the usual time. This
may mean taking two pills in one day.
40. MISSED PILLS
Use additional contraception for 2 days
after missing the 3 hour pills.
It take 2 days for the effect on cervical
mucus to be re-established after missing a
pill.
Use additional contraception for 7 days if
missing the 12-hour pill.
It take 7 days for the effect on ovulation
to be re-established after a missed pill.
41. DRUGS INTERACTIONS
• Women using liver enzyme-inducing
medications short term should be advised to
use condoms in addition to progestogen-only
pills and for at least 4 weeks after the liver
enzyme-inducer is stopped.
• Women using liver enzyme-inducing
medications long term should be advised that
the efficacy of progestogen-only pills is
reduced and an alternative contraceptive
method should be considered.
42. DISADVANTAGES
• Strict adherence to the rules of pill taking is
essential
• Pattern of bleeding is unpredictable.
• Associated with increased incidence of
ovarian follicular cysts
43. CONCLUSION
• Almost everyone can safely use almost any
method & providing methods is usually not
complicated.
• Family planning methods can be effective
when properly provided.
• Know your clients & assist them on the
method chosen to ensure effectiveness &
continuing contraceptive use.
59. Implanon- timing of insertion
• Day 1 to day 5 of natural menses. If
later than day 5, recommend
additional contraception till day 7. If
after day 7, must make sure
abstinence.
• Immediate after 1st trimester
abortion
• Day 21 after 2nd trimester abortion
or delivery
• During breast feeding
60. Implanon- advantages & benefits
• Feature of ‘forgetability’
• Long action plus high continuation
rates
• Absence of the initial peak dose
• Steady blood levels that minimized
metabolic changes
• Oestrogen free- usable in past VTE,
excellent choice for many diabetics
• Unchanged blood pressure
• Can use in past ectopics
• Rapidly reversible- after removal
44/47 women will ovulate within 3
weeks
61. Implanon- problems &
disadvantages
• Altered bleeding pattern
• Minor general side effects – acne,
headache, abdominal pain, breast
pain, dizziness, mood changes,
reduced libido and hair loss
• Body weight – slight increase
• Possible hypo-oestrogenism
• Local adverse effects – discomfort,
expulsion, migration and scarring
62.
63.
64. Implanon -
contraindications
• Absolute include progestogen
dependant tumour, current severe
hepatic disease, pregnancy,
undiagnosed vaginal bleeding, severe
hypersensitivity and acute porphyria
• Relative include previous ectopic
pregnancies and liver cirrhosis
