This document provides guidelines on oral contraception eligibility and practical issues. It categorizes medical conditions into WHO categories 1 through 4 for determining contraceptive use, with category 4 conditions representing unacceptable health risks. It outlines category 3 and 4 conditions such as smoking over 15 cigarettes per day after age 35, poorly controlled hypertension, history of breast cancer or DVT. Practical issues discussed include typical versus perfect use efficacy, formulations, instructions, drug interactions and emergency contraception.

1. ORAL CONTRACEPTION :
1.WHO ELLIGIBILITY CRITERIA
2. PRACTICAL ISSUES
DR NAZIMAH IDRIS
O& G
HOSPITAL ALOR SETAR

2. WHO Medical Eligibility Criteria
for Starting Contraceptive
Methods

3. CATEGORIES
• WHO 1 : Use the method. No
restrictions.
• WHO 2 : Can use the method. Benefits
outweighs risk.
• WHO 3 : Should not use the method.
Risk
outweighs advantages.
• WHO 4 : Do not use the method.
Unacceptable health risk.

4. Simplified 2-category system
(with Limited Clinical Judgment)
• WHO 1 & 2 : USE the method
• WHO 3 & 4 : DO NOT USE the
method

5. CRITERIA

6. Personal Characteristics &
Reproductive History
• Age : <40 yrs, >40 yrs
• Parity
• Breastfeeding : <6weeks postpartum, 6weeks
to 6 mths, >6mths postpartum
• Postpartum : <21days, >21days
• Smoking : age <35yrs, age >35yrs <15
cig/day, age >35yrs >15cig/day
• Obesity : BMI >30 kg/m2

7. Cardiovascular disease
• Multiple risk factors for CAD (older age,
smoking, diabetes, HPT)
• Hypertension : BP control, vascular disease
• Hypertension during pregnancy, now normal
• DVT/Pulmonary Embolism : Current or past,
surgery with/without prolonged
immobilization, Family history

8. Cardiovascular disease
• Superficial venous thrombosis
• Ischemic Heart Disease : Current or
past
• Stroke : Current or past
• Hyperlipidemia
• Valvular Heart Disease :
complicated/uncomplicated

9. Neurologic conditions
• Epilepsy
• Headaches :
–
–
–
–
Non-migraine (mild or severe)
Migraine <35, no focal neuro symptoms
Migraine >35, no focal neuro symptoms
Migraine with focal neuro symptoms, any
age

10. Reproductive Tract Infections
& Disorders
•
•
•
•
•
•
Irregular menses
Unexplained vaginal bleeding
Ovarian tumours (benign/malignant)
Endometrial cancer
Uterine fibroids
Gestational Trophoblastic Disease
(benign/malignant)

11. Reproductive Tract Infections
& Disorders
•
•
•
•
Cervical cancer/CIN
Breast disease : benign/undiagnosed
Breast cancer : current/past
Pelvic inflammatory disease :
current/past
• Sexually transmitted infections :
current/past

12. Endocrine conditions
• History of Gestational diabetes
• Insulin/Non-insulin dependant diabetes
: non-vascular disease
• Diabetis with
nephropathy/retinopathy/neuropathy
• Other microangiopathy, diabetes
>20yrs
• Thyroid disorders

13. Gastrointestinal conditions
• Gall bladder disease : with or no symptoms,
medical or surgical treatment
• History of pregnancy-related cholestasis
• Past COC-related cholestasis
• Viral hepatitis : active/carrier
• Cirrhosis
• Liver tumour : benign/malignant

14. In summary…

15. CATEGORY 4
•
•
•
•
Breastfeeding <6weeks postpartum
Smoking at age >35yrs >15 cig/day
Multiple risk factors for CAD
Poorly controlled hypertension, vascular
disease
• DVT/PE, major surgery with prolonged
immobilization
• Ischemic Heart Disease

16. CATEGORY 4 (cont.)
• Cerebrovascular accident
• Complicated valvular heart disease
• Migraine with focal neurological
symptoms
• Current breast cancer
• Diabetes with angiopathy
• Active viral hepatitis, liver tumour

17. CATEGORY 3
•
•
•
•
•
Postpartum <21days
Lactation 6 weeks to 6 mths
Undiagnosed vaginal/uterine bleed
Age >35yrs smoke >15cig/day
History of breast cancer, no recurrence past
5 yrs
• Interacting drugs
• Gallbladder disease

18. CATEGORY 2
• Headache after OCP, not migraine
• Diabetes, no complications
• Major surgery, no prolonged
immobilization
• Mild hypertension
• Undiagnosed breast mass
• Cervical cancer/CIN

19. OCP – PRACTICAL ISSUES

20. ISSUES
• Patterns of use & Efficacy rates
• Drawbacks & Fears of OCP use
• Formulations of OCP – which type to
choose?
• Instructions on use
• Drug Interactions
• Emergency contraception

21. Patterns of use & Efficacy rates
• Typical user vs perfect user
• Perfect user – never misses taking a
pill, takes at the same time everyday,
never vomits or has diarrhoea.
Pregnancy rate: 1 in 1000/year.
• Typical user – Pregnancy rate: 50 in
1000/year

22. Drawback & Fears
• No protection against infection
• Systemic side effects – nausea,
vomiting, headache, breast tenderness,
acne, ?weight gain
• More serious events - myocardial
infarct, ischemic stroke, hemorrhagic
stroke
• Fears of side effects – premature
discontinuation

23. Formulations
• Estrogen : dosage : 150ug -> 50ug ->
35ug
->25ug ->20ug
• Progestogen : 1st/2nd/3rd generation

24. Factors to consider in
starting/switching OCP
OBJECTIVE
ACTION
Lower VTE risk
Lower E dose
Reduce nausea,
breast tenderness,
headache
Lower E dose
Minimise abnormal
bleed
Higher E, more
potent P
Minimise
androgenic effects
3rd generation P
Avoid dyslipidemia
3rd generation P

25. Instructions on use – missed pill
• <24H : take immediately, cont. others
• 24H : take the missed and scheduled
pill together
• >24H (2 or more missed pills) : take last
missed pill, discard other missed pill,
take next pill on time, use additional
contraception for remainder of cycle

26. Instructions on use – additional
contraceptive method
• 1st 7 days after start of use
• Use for 7 days if >12H late in taking
OCP
• Use while taking interacting drug + 7
days thereafter
•
Adapted from Hatcher et al. Contraceptive Technology. 17 th rev.ed. New York: Ardent
Media, 1998: 451-3.

27. Drug Interactions
• Drug decreases effectiveness of OCP:
– Anti-epileptic : Carbamazepine, Dilantin,
Phenobarbitone – 40%. Others: Valproate,
Gabapentin – no effect.
– Antibiotics : Rifampicin. Others: Amoxycillin
Metronidazole – weak association

28. Emergency contraception
• Pre-treatment with oral anti-emetic 1
hour before each OCP dose
• First dose of OCP within 72 hours of
unprotected intercourse, repeat after 12
hours
• Dosage: 500ug of levonorgestrel +
100ug of ethinyl estradiol
• Reduces pregnancy rate by 75%

29. Thank You