Download Combined oral contraception

 Combined oral contraception
Recommend
 See flow chart for missed contraceptive pill
Related topics:
Contraception, page 446
Health check – women, page 384
1.
May present with:

Request for repeat supply of oral contraceptive pill

Request for contraception

Subject raised during a consultation for another reason
2.
Immediate management: not applicable
3.
Clinical assessment:

Initial assessment by nurse practitioner or medical officer

Clinical assessment as per Contraception including
–
contraception needs, method of contraception available
–
choice of contraception, WHO medical eligibility criteria for contraceptive use
WHO category 4
Medical condition
Absolute contraindications:
Conditions which represent
 Breast feeding and less than 6 weeks postpartum
unacceptable health risks
 Ischaemic heart disease of stroke
 Smoking 15 or more cigarettes daily in a woman aged 35 years or more
 BP systolic ≥ 160 or diastolic ≥ 100 mmHg
 Hypertension with vascular disease
 Migraine with aura
 Diabetes mellitus with vascular complications
 Deep vein thrombosis (DVT) / Pulmonary emboli (PE) – past or present
history
 Active viral hepatitis, Benign or malignant liver tumour
 Severe cirrhosis
For compressive list see [2]
WHO category 3
Strong relative contraindication
Conditions where the risk usually
outweigh the advantages which
represent unacceptable health
risks
Medical condition
 Smoking 15 or more cigarettes daily in a woman aged 35 years or more
 BP systolic 140-159 or diastolic 90-99 mmHg
 History of hypertension (where BP cannot be evaluated) or adequately
controlled hypertension, where blood pressure can be evaluated
 Known hyperlipidaemia
 Migraine without aura in a woman aged 35 years or more (if migraine
develops during use of COC’s it becomes a category 4
contraindication)
 Diabetes mellitus with vascular complications
 History of breast cancer with no evidence of disease for the last 5 years
 Breast feeding from 6 weeks to less than 6 months postpartum
 Less than 21 days post partum
For compressive list see [2]
Note: If a woman has more than one of the first five conditions in category 3, which increase the risk of
cardiovascular disease, clinical judgement must be exercised. In most instances, the combined conditions
should be regarded as belonging to category 4 (contraindicated). If the method is provided, record the woman’s
special condition in the clinical record and advise her of warning signs relevant to her condition
WHO category 2
Generally safe to use
Conditions where the
advantages generally outweigh
the risks
Medical condition


Smoking in a woman aged less than 35 years
Migraine without aura in a woman aged less than 35 years (if migraine
develops during use of COC’s it becomes a category 3)
 Diabetes mellitus without vascular complications
 Age ≥ 40 years
 Family history of DVT / PE (in first degree relatives)
 Breast feeding and 6 months or more postpartum
 History of high blood pressure during pregnancy
 Obesity BMI ≥ 30
 Treatment with griseofulvin
 Antiretroviral therapy
For compressive list see [2]
Note: when a woman has more than one of the first three, which increase the risk of cardiovascular disease,
clinical judgement must be exercised. In most instances, the combined conditions should be regarded as
belonging to category 3 (strong relative contraindication). If the method is provided, record the woman’s special
condition in the clinical record and advise her of warning signs relevant to her condition

4.
Interactions
liver enzyme inducing medications which may render the pill and other
hormonal contraceptives less protective:
 most anticonvulsants (not Sodium Valproate or Clonazepam),
Carbamazepine, Rifampacin, Griseofulvin, St John’s Wort (possibly)
see Depression, many antiretroviral medications used for HIV
management
- antibiotics also can temporarily disturb bowel flora affecting circulating
oestrogen levels and reduce the pills effectiveness. Condoms should be
used whilst the antibiotic course is taken and for 7 days after

Detailed information on drug interactions with hormonal contraceptives can be
obtained from Medical Officer / Nurse Practitioner / Family Planning Qld /
Pharmacist or pharmacy websites

Side effects

breakthrough

lowered libido
bleeding

mood changes

nausea

weight gain

breast tenderness

chloasma

acne

bloating

headache
Management:
 Confirm that less than 12 months since last MO / NP assessment for oral
contraceptive pill prescription
Oral Contraceptive Pills
DTP IHW / NP / RIN / SRH
(Combined Pills)
Authorised Indigenous Health Workers must consult MO
Rural and Isolated Practice Endorsed Registered Nurses and Sexual and Reproductive Health
Schedule
4
Endorsed Registered Nurses may proceed
Nurse Practitioners may proceed
Form
Strength
Route of Administration
Tablet
Ethinyloestradiol 30 microgram/ Levonorgestrel 150
Oral
microgram eg Nordette
Ethinyloestradiol 30 microgram/ Levonorgestrel 50
Oral
Tablet
microgram, Ethinyloestradiol 40 microgram/
Levonorgestrel 75 microgram, Ethinyloestradiol 30
microgram/ Levonorgestrel 125 microgram eg Triphasil
Tablet
Ethinyloestradiol 20 microgram / Levonorgestrel 100
Oral
microgram eg Loette
Tablet
Ethinyloestradiol 35 microgram/Northisterone 500
Oral
microgram eg Brevinor
Tablet
Ethinyloestradiol 35 microgram/Northisterone 1 mg
Oral
eg Brevinor 1
Tablet
Ethinyloestradiol 30 microgram / Drosperinone 3mg
Oral
eg Yasmin
The client must be initially assessed by a MO / Nurse Practitioner and prescribed hormonal
contraception
Confirm it is less that 12 months since last MO / NP assessment
Maximum supply at any one time not to exceed 4 months
Provide Consumer Medicine Information if available:
Most problems relate to missed pills, vomiting and diarrhoea, use of broad spectrum antibiotics, poor
cycle control and what to do in the event of surgery.
Side effects such as nausea, breast tenderness, acne and increase in blood pressure require review by
a MO. They may respond to a change of prescription or other interim measures such as anti-emetics. If
the symptoms are severe the pill may be stopped but other forms of contraception will be needed.
Nausea can be helped by taking the pill at night
ESSENTIAL OCP COUNSELLING
Starting Combined Pill
Preferably start the active pill on day 1 of menses as it is then effective immediately.
However, packaging varies and health care providers need to be familiar with the way
different packaging types are “followed” to assist women to commence and continue
taking pills correctly. Active pills can be started day 2-5 but will not be effective until 7
active pills taken. Start at risk clients anytime in the cycle with active pills using the 7 day
rule. Additional methods of contraception should be used for this first 7 days.
Missed Pills
OCP should be taken at around the same time each day. If taken late
 by less than 24 hours then still protected, take missed pill as soon as
remember
 if more than 24 hours – a back up method of contraception is required or
abstinence until seven consecutive active pills have been taken
Diarrhoea and Vomiting
Due to the risk of incomplete absorption, additional methods of contraception should be used
during the illness and for 7 days following. If the vomiting and diarrhoea occurs during the
last 7 active tablets of the packet, take the next packet without the pill free period.
Antibiotics
Due to the risk of incomplete absorption, additional methods of contraception should be used
whilst taking the antibiotics and for 7 days following. If the antibiotics are taken during the last
7 active tablets of the packet, take the next packet without the pill free period.
Poor Cycle Control
As a general rule the lowest dose pill should be used that obtains good cycle control.
Breakthrough bleeding in the first 2 months is common and is likely to settle
spontaneously. However, some women have a continuing problem with breakthrough
bleeding and it may be necessary to change their prescription. In this instance consult
MO and refer the patient to the next MO clinic as necessary. Other causes of abnormal
bleeding, particularly pregnancy, abnormal pap smears or infection related bleeding need
to be considered before assuming bleeding is pill related.
Thromoembolic disease risk
Major surgery with or without prolonged immobilisation
Oral contraceptive pills containing oestrogen should be stopped 4 weeks prior to major
elective surgery and any surgery to the legs. The woman should be recommenced at the
first period so long as this is more than 2 weeks after the surgery.
Other risk factors include: obesity, age, history of thrombophlebitis, family history if VTE in
first degree family, post partum, non-lactating, history of current venous thromboembolic
event (VTE), known thrombogenic mutations
Advise the patient to STOP ORAL CONTRACEPTIVE PILL IMMEDIATELY and consult
MO if any of the following occur:

severe chest pain

severe abdominal pain

sudden onset shortness of

severe prolonged headache
breath

migraines with aura

calf pain
5.
Follow up:
 Patients should be reviewed after the first 3-4 cycles on the pill to check BP,
discuss side effects and review any problems in pill taking
 Patients on the Combined Oral Contraceptive Pill should be followed up every
12 months by a MO
6.
Referral / Consultation:
 Medical Officer / Nurse Practitioner
 Progestogen – Only Pill (“Minipill”)
Recommend
 For women not able to take combined oral contraception
Related topics:
 Combined oral contraception, page 448
1.
May present with:

Postnatal lactating woman

Request for repeat supply of oral contraceptive pill

Request for contraception

Side effects of combined oral contraception
2.
Immediate management: not applicable
3.
Clinical assessment:

Initial assessment by nurse practitioner or medical officer

Clinical assessment as per Contraception including
–
contraception needs
–
method of contraception available
–
choice of contraception
–
WHO medical eligibility criteria for contraceptive use
WHO category 4
Absolute contraindications:
Conditions which represent
unacceptable health risks
Medical condition
 Breast cancer diagnosed within the last 5 years
WHO category 3
Strong relative contraindications
Medical condition
Conditions where the risks usually
outweigh the advantages
 Current DVT / PE, Active viral hepatitis
 Liver tumour (benign or malignant), Severe decompensated
cirrhosis
 History of breast cancer with no evidence of disease for the last 5
years
 Breastfeeding and less than 6 weeks postpartum
 Current liver enzymes including medications
 Unexplained abnormal vaginal bleeding
WHO category 2
Generally safe to use
Conditions where the advantages
generally outweigh the risks
Medical condition
 Current history of ischaemic heart disease or stroke (if either
develops during POP use it becomes a Category 3
 Raised BP systolic ≥ 160 or diastolic ≥ 100 mmHg
 Hypertension with vascular disease
 Migraine with aura or development of migraine without aura at any
stage during POP use, it becomes Category 3
Diabetes with or without complications
History of DVT / PE
Previous ectopic pregnancy
Known hyperlipidaemia
Treatment with griseofulvin
Antiretroviral therapy
For comprehensive list see [2]






4.
Management:

Confirm that less than 12 months since last MO / NP assessment for
progesterone only pill prescription
Oral Contraceptive Pills
DTP
(Progestogen Only Pill)
IHW / NP / Mid / RIN / SRH
Authorised Indigenous Health Workers must consult MO
Rural and Isolated Practice Endorsed Registered Nurses and Sexual and Reproductive Health
Endorsed Registered Nurses may proceed
Midwives may proceed to supply Levonorgestrel only (maximum 8 weeks)
Nurse Practitioners may proceed
Form
Strength
Route of Administration
Tablet
Levonorgestrel 30 microgram eg Microval
Oral
Schedule
Tablet
4
Norethisterone 350 microgram eg Noriday
Oral
The client must be initially assessed by a MO / Nurse Practitioner and prescribed hormonal
contraception at the clinic where patient is currently
It is less that 12 months since last MO / NP assessment
Maximum supply at any one time not to exceed 4 months
Provide Consumer Medicine Information if available:
Essential Progestogen Only Pill information
Starting Progestogen Only Pill
Start on day 1 of menses preferably. If started at any other time, additional methods of
contraception should be used for the first 48 hours until contraception is reliable.
Missed Pills
If you forget a pill, take it as soon as you remember and the next one at the normal time. If
you are more than 3 hours late you are not protected for the next 48 hours and must use
additional methods of contraception during this time.
Lactation
Excreted in breast milk. Dosage to infant is extremely small and not found to affect milk
quality, quantity or infant growth or development. Recommended for breast feeding
women
Diarrhoea and Vomiting
Due to the risk of incomplete absorption, additional methods of contraception should be
used during the illness and for 3 days following.
Interactions – medications which may render the pill less protective
As per OCP
Antibiotics other than Rifampicin do not affect the absorption of the Progestogen Only Pill
Detailed information on drug interactions with hormonal contraceptives can be obtained
from Family Planning QLD
Irregular Vaginal Bleeding
Troublesome spotting occurs in some women. In this instance consult MO and refer the
patient to the next MO clinic as necessary. Exclude infection, abnormal pap smear, poor
pill use and pregnancy
5.
Follow up:
 Clients on the Oral Contraceptive Pill should be followed up every 12 months by
a MO
 Ensure adequate supply of Progestogen Only Pill
6.
Referral / consultation:
 Medical Officer / nurse practitioner
 Long-acting hormonal contraception
“Depo Provera®”
(Depot Medroxyprogesterone Acetate (DMPA)
Recommend
 Lactating women, women who cannot take or tolerate combined oral contraception,
poor combined oral contraception takers
Background
 Works by preventing ovulation and changing the endometrial lining and cervical
mucus
Related topics:
Health Check – women, page 384
Contraception, page 446
1.
May present with

Request for contraception

Request for administration of DMPA

Side effects with other forms of contraception
2.
Immediate management: not applicable
3.
Clinical assessment:


Initial assessment by DTP Sexual and reproductive endorsed nursing officer or
nurse practitioner or medical officer
Clinical assessment as per Contraception including
–
contraception needs
–
method of contraception available
–
choice of contraception
–
WHO medical eligibility criteria for contraceptive use
–
pregnancy test (a negative test does not exclude pregnancy)
–
BP, weight, menstrual pattern
WHO category 4
Absolute contraindications:
Conditions which represent
unacceptable health risks
WHO category 3
Strong relative contraindications
Conditions where the risks
usually outweigh the advantages
Medical condition
 Breast cancer diagnosed within the last 5 years
Medical condition
 Arterial disease including – current or PH of myocardial infarction or
stroke, multiple risk factors for cardiovascular disease, BP > 160
systolic or > 100 diastolic, current DVT/PE, bleeding or coagulation
disorder that precluded IMI
 Diabetes mellitus with vascular complications (including
hypertension, nephropathy, retinopathy, or neuropathy) or of > 20
years duration
 Migraine with aura occurring for the first time, or recurring with DMPA
use
 Past history of breast cancer with no current disease for 5 years




WHO category 2
Generally safe to use
Conditions where the
advantages generally outweigh
the risks

Lactation <6 weeks post partum
Active viral liver disease (not including carriers)
Decompensated cirrhosis
Unexplained abnormal vaginal bleeding
Medical condition












Adequately controlled hypertension
BP, systolic 140-159 or diastolic 90 - 99 mmHg
Migraine without aura
Diabetes < 20 years without vascular complications
Known thrombogenic mutation
History of DVT / PE
Cervical intraepithelial neoplasia
Hyperlipidaemia
Compensated cirrhosis
Gallbladder disease
Treatment with griseofulvin
Antiretroviral therapy
Side effects
 breast tenderness, irregular vaginal bleeding, weight gain, headaches and acne

4.
 delayed return of menstrual cycle, and therefore a delay in the return of fertility.
Average return to previous menstrual pattern is 8 months
 may be at risk of osteoporosis if used for more than 2 years, will be reversible for
most women – important for women <25 years and >46 years of age
The 3 most significant side effects are:
 weight gain
 irregular vaginal bleeding
 delayed return of fertility
Management:



Confirm that less than 12 months since last MO / NP for Depot Medroxyprogesterone Acetate
(DMPA) prescription and initiation of first dose
Prior to administration of 12 weekly injection, check:
 BP, weight, menstrual/bleeding pattern
If more than 14 weeks since last injection do urine pregnancy test (with consent) to exclude
pregnancy
Depo Medroxyprogesterone Acetate
DTP
DMPA
IHW / NP / RIN / SRH
Authorised Indigenous Health Workers must consult MO
Rural and Isolated Practice Endorsed Registered Nurses and Sexual and Reproductive Health Endorsed Registered Nurses
may proceed
Nurse Practitioners may proceed
Form
Strength
Route of Administration
Duration
Ampoule
Medroxyprogesterone acetate 150
IMI upper outer quadrant of buttock or
administered once
mg/mL
deltoid in obese women
every 12 weeks +/14 days.
The client must be initially assessed by a MO / Nurse Practitioner and prescribed hormonal contraception
It is less that 12 months since last MO / NP assessment
Provide Consumer Medicine Information if available:
Schedule


4
“Abnormal” vaginal bleeding is very common with the use of injectable progestogen contraception.
However, menstrual/bleeding history should be checked before each dose is given. If any doubt
about normality of bleeding pattern perform Health Check – women and refer to MO / NP
Some clients may experience side effects such as weight gain, breast tenderness and depression
with injectable hormonal contraception, but their incidence is low. Patients who experience side
effects require review by a MO
5.
Follow up:
 Clients on injectable hormonal contraception should be followed up every 12 months by a MO
 Delayed return of fertility and amenorrhoea may occur after discontinuing treatment. This is normal
and in the vast majority normal fertility and normal periods will return within a year. If in doubt
consult MO / NP or refer to next MO clinic
6.
Referral / consultation:
 Medical officer / nurse practitioner
Sub-Dermal Progestogen Implant (“IMPLANON®”)
Recommend
 Assessment, insertion, follow up and removal must be performed by a MO specifically trained to do so. If
implant is not palpable conduct pregnancy test and advise alternate method until location is confirmed.
Not seen on x-ray, only visible with ultrasound.
Background
 Long-acting contraceptive effect lasting 3 years





Failure rates <0.1%
Important to exclude pregnancy before insertion as amenorrhoea is a common side effect
Effective immediately if inserted at day 1 -5 of the cycle or if currently on reliable contraception, otherwise
requires 7 days
Side effects include change in menses (amenorrhoea, oligomenorrhoea, frequent periods, prolonged
periods or prolonged spotting are all possible), breast tenderness, weight gain, acne and mood changes
Is easily reversible, may be detected by other people