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Combined Oral Hormonal Contraceptive (COCP) Review

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COCP Annual Review
  • Update BP & BMI
  • Check that cervical smear is up to date 
    • 25 - 49 years: every three years
    • 50 to 64 years: every 5 years
  • If patient is > 50 years consider lowering dose or stopping
    • continue for one more year following the last spontaneous menstrual period if aged 50 years or over
    • continue for two more years following the last spontaneous menstrual period if aged under 50 years
    • Fit, healthy, non-smoking women may continue the combined oral contraceptive (COC) pill up to the age of 50
    • There may be cardiovascular benefit for older women to use lower dose COCs (20mcg ethinyloestradiol)
  • Check for any drug interactions
  • Are you a smoker?
    • Would you like help giving up?
  • Are you taking the COC correctly and consistently? Discuss:
    • How to take the pill?
    • What to do if you miss a pill?
    • The contraceptive pill may not work if you have diarrhoea have been vomiting
    • The contraceptive pill does NOT protect you from sexually transmitted infections, so you will need to use a condom as well
  • Are you experiencing any side effects?
    • Do you suffer from migraines?
      • If so, do you experience visual symptoms or changes in sensation or muscle power on one side of you body?
  • Are there any changes in your family history?
    • Do you have parents or siblings who have had heart disease or stokes under the age of 45?
    • Do you have parents or siblings that have had a deep vein thrombosis or pulmonary embolous under the age of 45?
    • Do you have any family history of breast cancer under the age of 50?
  • Are there any changes in yor medical history?
    • Do you have diabetes?
    • Have you had a deep vein thrombosis or pulmonary embolus?
    • Do you have any blood clotting illnesses / abnormalities?
  • Consider whether contraception is still required and if the combined pill is still the most appropriate and the safest method
  • Are you aware of the alternatives such as long acting reversible contraception?
    • It is highly effective, with a 98-99 percent success rate over five years of IUD use
    • It can be used by almost any woman including nulliparous
    • Its action lasts for ten years if it is not removed in between
    • The onset of action is immediate
    • It is independent of sexual activity
    • It doesn’t interfere with intercourse
    • It is suitable for lactating women
    • Fertility returns promptly on discontinuation
    • It can be used by women who are on any type of medication
    • It is not associated with cancer of any organ unlike hormonal contraception
    • It does not cause weight gain
    • It does not usually affect mood or sex drive
    • It is also suitable for women who cannot use estrogen-containing contraceptives
    • Would you like to book a consultation with our nurse to discuss or to arrange fitting of a long acting reversible contraceptive

 

  • Give the patient the opportunity to ask questions
  • Tell them to come back if they experience
    • migraines with auras
    • elevated BP 
    • weight gain
    • cahnge in smoking status
    • change in their medical conditions
    • change in their family medical history

MISSED PILLS

Progesterone Only Pills (POP)
  • Check which progestogen-only pill (POP) the woman is taking and the time since the last pill was taken.
  • For the desogestrel pill — a pill is missed if she is more than 12 hours late (that is more than 36 hours since taking the last pill).
  • For all other progestogen-only pills — a pill is missed if she is more than 2 hours late (that is more than 26 hours since taking the last pill).
  • If the woman has missed any POP, she should:
  • Take a pill as soon as possible.
  • Take the next pill at the normal time. This may mean taking two pills in 24 hours (the missed pill and the next one at the usual time).
  • Use a barrier method of contraception (such as condoms) for the next 48 hours, unless she is less than 6 months postpartum, fully breastfeeding, and amenorrhoeic.
  • Consider prescribing emergency contraception if unprotected sexual intercourse has taken place after the missed pill and within 48 hours of restarting the POP.
Combined Oral Contraceptive Pills (COCP) except Qlaira® and Zoely®.
  • If the woman is more than 7 days late restarting the pill after the hormone-free interval (HFI), consider emergency contraception if unprotected sexual intercourse (UPSI) has taken place during the HFI, and advise her to:
  • Take the missed pill as soon as possible.
  • Continue taking the remaining pills at the usual time.
  • Avoid sexual intercourse or use a barrier method of contraception (such as condoms) until 7 consecutive pills have been taken. 
  • Consider a follow up pregnancy test.
  • If one pill has been missed (48–72 hours since the last pill) on week 1 after HFI, advise the woman:
  • That emergency contraception is not required if there was consistent, correct use earlier in week 1 and the 7 days prior to HFI.
  • To take the missed pill as soon as possible.
  • To continue taking the remaining pills at the usual time. This may mean taking two pills in 24 hours (the missed pill and the next one at the usual time).
  • That no additional contraceptive precautions are required if there was consistent, correct use earlier in week 1 and the 7 days prior to HFI.
  • If one pill has been missed (48–72 hours since the last pill) on week 2 or 3 after HFI (or subsequent consecutive weeks continuous pill-taking), advise the woman:
  • That emergency contraception is not required if there was consistent, correct use in the previous 7 days.
  • To take the missed pill as soon as possible.
  • To continue taking the remaining pills at the usual time. This may mean taking two pills in 24 hours (the missed pill and the next one at the usual time).
  • That no additional contraceptive precautions are required if there was consistent, correct use in the previous 7 days.
  • If two or more pills have been missed (72 hours or more since the last pill) in week 1 after HFI, consider emergency contraception if UPSI has taken place during the HFI or week 1, advise the woman to:
  • Take the most recent missed pill as soon as possible. Any earlier missed pills should be ignored.
  • Continue taking the remaining pills at the usual time. This may mean taking two pills in 24 hours (the most recent missed pill and the next one at the usual time).
  • Avoid sexual intercourse or use a barrier method of contraception (such as condoms) until 7 consecutive pills have been taken. 
  • Consider a follow up pregnancy test.
  • If two or more pills have been missed (72 hours or more since the last pill) in week 2 or 3 after HFI (or subsequent consecutive weeks continuous pill-taking), advise the woman:
  • That emergency contraception is not required if there was consistent, correct use in the previous 7 days.
  • To take the most recent missed pill as soon as possible. Any earlier missed pills should be ignored.
  • To continue taking the remaining pills at the usual time. This may mean taking two pills in 24 hours (the most recent missed pill and the next one at the usual time).
  • That if there were two or more missed pills in the 7 days prior to scheduled HFI, to omit the HFI.   
  • To avoid sexual intercourse or use a barrier method of contraception (such as condoms) until 7 consecutive pills have been taken. 
  • This is overcautious, but is a back-up in case of subsequent incorrect use. 
  • If more than seven active COC pills have been missed, advise the woman to restart the COC as a new user. 
  • Also advise the woman that:
  • No more than 2 pills should be taken in any one day.
  • If pills have been missed and no withdrawal bleed occurs at the end of the packet, she should consider the possibility of pregnancy.

ethinyloestradiol desogestrel

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