Combined oral contraceptives (COCs), also known as birth control pills, contain low doses of synthetic estrogen and progestins similar to natural hormones. They work by preventing ovulation, thickening cervical mucus, and thinning the uterine lining. COCs are highly effective, easy to use, and can be provided by non-clinical staff without an exam. Potential benefits include preventing pregnancy and reducing risks of certain cancers and diseases. Side effects may include nausea, spotting, headaches, and weight changes. Nearly all women can safely use COCs, but those with certain medical conditions should use them carefully or avoid use. Providers should counsel clients on correct use, potential side effects, and warning signs requiring medical attention.

1. COMBINED ORAL CONTRACEPTIVES
(COCs)
29th September 2022
Dr. Ali M. Ibrahim

2. WHAT ARE THEY?
• Combined Oral Contraceptives are pills that
contain low doses of synthetic oestrogen and
progestins similar to the natural hormones in a
woman’s body.
• Combined orals contraceptives (COCs) are also
called “the pill”

3. HOW DO THEY WORK?
• Prevention of ovulation.
• Thickening of cervical mucus.
• Thinning of the endometrial lining.

4. ADVANTAGES (BENEFITS)
Contraceptive Benefits:
• Highly effective
• Effective immediately –when started
within 7 days of menses
• Easy to use
• Can be provided by a non-clinical service
providers
• Pelvic examination is not essential to
initiate use

5. KNOWN HEALTH BENEFITS
Help protect against :
• Risk of Pregnancy
• Endometrial cancer
• Cancer of the ovary
• Symptomatic pelvic inflammatory disease
May protect against
• Ovarian cysts
• Iron –deficiency anemia

6. CONT’’
COCs reduce:
• Menstrual cramps
• Menstrual bleeding problems
• Ovulation pains
• Excess hair on the face or body
• Symptoms of polycystic ovarian syndrome

7. SIDE EFFECTS
Minor side effects:
• Nausea
• Spotting or bleeding in between periods
• Mild headache
• Breast tenderness
• Slight weight gain.
• Mood changes or changes in sex drive.

8. CONT’’
Major Side effects
They are rare, though possible
• DVT/pulmonary embolism
• Myocardial infarction
• Stroke
• Heart attack

9. CONT’’
Effectiveness may be lowered by:
• Anti -TB drugs
• Anti- epileptic
• Anti- retroviral drugs
• Gastroenteristis, vomiting and diarrhoea
NB: COCs offer no protection against
STI/HBV/HIV/AIDS- ensure dual
protection

10. WHO CAN USE COCS?
Nearly all women can use COCs safely and
effectively including women who:
• Have or have not had children
• Are not married
• Are of RH age
• Have just had an abortion or miscarriage
• Are smoker <35yrs
• Have anemia
• Have varicose veins
• Are HIV+
• Breasting feeding women after 6 months

11. SITUATIONS TO USE WITH CARE
• Women over 40 years
• Women with unexplained vaginal bleeding
• Women with migraine
• Women gallbladder disease
• Women with breast lumps
• Women with sickle cell disease
• Diabetes

12. WHO SHOULD NOT USE
• Breastfeeding mothers <6 months postpartum
• Women with history of blooding clotting disorders
• Women with ischaemic heart disease or complicated
valvular heart disease
• Women with active liver disease
• Women with hypertension( BP-140-159/90-99 or equal
to r more than 160/100
• Women with diabetes complicated by heart disease

13. CONT”
• Women who are smokers and are 35 yrs or older
• Women with history or current breast cancer
• Women with gall bladder disease
• Women receiving treatment with drugs that affect liver
enzymes:
Rifampcin (TB), phenytoin ,carbamazepine,
barbiturates, primidone, topiramate and
oxcarbazipine (epilepsy) and certain ARVs
(HIV) e.g. Nevirapine, Ritonavir,Nelfinavir, Lopinavir
(with Ritonavir (Kaletra)

14. WHEN TO START COCS
• Having menstrual period or switching from a non
hormonal method
• Switching from a hormonal method
• Breastfeeding above six months
• After abortion or miscarriage
• After taking emergency contraceptive pills
• Any time of the menstrual cycle when your are
reasonably sure that the client is not pregnant

15. EXPLAINING HOW TO USE COCS
• Give pills: as many as possible- a years supply
• Explain pill pack: show on the pack where to begin
• Give key instruction: take one pill each day –same until
pack is empty
• Explain starting next pack: explain when to begin next
the next pack-28 or 21-pill pack
• Provide backup and explain use: some times she many
need a backup; explain e.g. in missed pills

16. WARNING SIGNS
A: Abdominal pain (severe)
C: Chest Pain (severe), cough, with shortness of
breath
H: Headaches (severe), dizziness, weakness,
numbness
E: Eye problems (vision loss or blurring), speech
problems
S: Severe leg pain (calf or thigh)
If any of the above signs are noticed, STOP COC
and report to health facility immediately.

17. KEY POINTS FOR PROVIDERS AND CLIENTS
• Take one pill every day
• Bleeding changes are common but not
harmful
• Take any missed pills as soon as possible
• Can be given to women at any time to
start later

18. Thank You.