This site is intended for healthcare professionals.

First COCP Consultation

Mechanism of action –COCP contains ethinyloestradiol ( EE ) , oestradiol valerate , or oestradiol and one of a range of progestogens
Ethinyloestradiol is the most common oestrogen Works on the hypothalamic-pituitary-ovarian axis to suppress the synthesis and secretion of FSH and the mid-cycle LH surge – thus inhibiting ovulation progestin also makes implantation less likely as it causes thickening of cervical mucus , a decrease in tubal motility and the inhibition of endometrial proliferation Very effective over 99 % if used correctly
and easily reversible

Types –Monophasic – every pill has same levels of oestrogen and progesterone throughout the cycle
○ most common types
○ Microgynon is an example
 Phasic pills – levels of oestrogen and progesterone vary through the cycle.
○ these can be biphasic , triphasic or quadraphasic
○ important that these are taken in correct order

Phasic pills are thought to reduce the incidence of side effects and complications related to oral contraception. The idea is to reduce the hormone levels to the minimum amount necessary

Advantages –Non-invasive and more effective than barrier methods Can regulate periods- make them regular , lighter and less painful Can improve acne in some women Help with symptoms of premenstrual syndrome Reduce cancer risk ovarian , endometrial and colorectal cancer and of functional ovarian cysts and benign ovarian tumours Fertility returns nearly immediately after stopping May also reduce risk of benign breast disease and osteoporosis ( evidence is conflicting )

Disadvantages- User dependent Side effects VTE risk ( small ↑ in risk ) Breast cancer ↑ ed risk Cervical cancer ↑ ed risk related to duration of use May cause small risk ↑ in BP , MI and stroke Changes in lipid metabolism Does not provide STI protection Breakthrough bleeding may happen in first few months of use Mood changes- depressed mood , depression No evidence that it causes
○ weight gain or
○ change in libido

Suitability-Exclude pregnancy Establish safety using the UKMEC criteria
see the UKMEC summary sheet under links History- focus on aspects which may influence the choice
○ breastfeeding ?
○ menorrhagia ?
○ fibroids ?
○ previous ectopics
○ diabetes ?
○ epilepsy ?
○ headache ? migraine ?
○ CVD risk factors
○ obesity
○ gall bladder disease ?
○ smoking
○ hypertension ?
○ h.o STIs or PID
○ venous thromboembolism
○ smear status ( if applicable )

Is she taking any medications ? Liver enzyme inducing meds

see under links FSRH leaflet : Clinical guidance : Drug Interaction with Hormonal Contraception
 If unsure – advice patient that you will check and come back to her , a COCP request is not an emergency scenario

UKMEC category 1 – no restriction to use UKMEC category 2 – advantages generally outweigh risks UKMEC 3 risks generally outweigh advantages – use not recommended UKMEC 4 unacceptable risk to health

BNF Contraindications –Acute porphyrias Gallstones Heart disease associated with pulmonary hypertension or risk of embolus History during pregnancy of 
○ cholestatic jaundice
○ chorea 
○ pemphigoid gestationis
○ pruritus H/O breast cancer
○ can be used after 5 yrs if no evidence of disease and 
non-hormonal methods unacceptable H/O haemolytic uraemic syndrome Migraine with aura Personal h/o of venous or arterial thrombosis Sclerosing treatment for varicose veins Severe or multiple risk factors for venous throboembolism SLE with ( or unknown ) antiphospholipid antibodies Transient cerebral ischaemic attacks without headaches Undiagnosed vaginal bleeding

Risk factors Venous Thromboembolism –family h/o VTE in 1st degree relative under 45 yrs 
○ avoid contraceptive containing desogestral or gestodene OR
○ avoid if known prothrombotic coagulation abnormality 
e.g Factor V Leiden or antiphospholipid antibodies ( including 
lupus anticoagulant ) obesity ; body mass index > = 30 kg/m2 
( avoid if BMI >= 35 unless no suitable alternative )
○ in adolescents , caution if obese according to BMI ( adjusted 
for age and gender )
○ in those who are markedly obese , avoid unless no suitable alternative long term immobilization e.g in wheelchair 
avoid if confined to bed or leg in plaster cast H/O superficial thrombophlebitis age over 35 ( avoid if over 50 ) smoking

Risk Factors arterial disease –family h/o arterial disease in 1st degree relative aged under 45 yrs
○ avoid if atherogenic lipid profile diabetes mellitus- avoid if diabetes complications present hypertension ; BP above systolic 140 or diastolic 9-
○ avoid if BP above systolic 160 or diastolic 95
○ in adolescents , avoid if BP very high smoking – avoid if smoking > 40 / day age over 35 yrs ( avoid if > 50 yrs ) obesity – avoid if BMI > 35 unless no suitable alternative
○ in adolescents caution if obese according to BMI ( adjusted for 
age and gender )
○ in those who are markedly obese , avoid unless no suitable alternative migraine without aura 
○ avoid if migraine with aura ( focal symptoms ) OR
○ severe migraine frequently lasting over 72 hrs despite treatment OR
○ migraine treated with ergot derivatives

when to start –First day of menstrual bleeding Can be started up to day 5 without the need for extra contraception If starting at any other point in the cycle additional contraceptive methods should be used for 7 days ( 9 days for Qlaira ) If switching from other methods- refer to appropriate literature to advice find under links and reference FSRH CEU Guidance : Switching or Starting Methods of Contraception Missed pills – print info ( under links )

Side effects –Most side effects mild and transient May improve by changing to another pill formulation Most common is breakthrough bleeding Other complains may include nausea , headaches , abdominal cramping , breast tenderness and an ↑ in vaginal discharge

Less than 16 or > 40 Women age < 16 consider
○ sexual risk assessment
○ confidentiality
○ legal issues
○ ability to consent e.g Fraser competence
○ any child protection issues Women > 40
○ ↑ ed risk of health conditions 
○ assess carefully risk VTE and CVD
○ consider testing for e.g lipid profile , glucose or thrombophilia screen if a sig family h/o thromboembolic disease is evident or the woman has a 1st degree relative with known thrombophilia

Follow up and prescription –Provide written information The first COCP consultation can be over whelming A monophasic COC is considered as a good first choice Missed pills- provide written info
Find it under links and resources Follow up should be in 3 months but she should come earlier if she becomes concerned
The duration may vary from 3-4 months ( 1st f/u ) between countries Check BP in the f/u visit If changing preparations consider atleast 3 months before another change

Aim is issue a pill –which has the lowest dose of oestrogen and progestogen to provide good cycle control and effective contraception is well tolerated has best safety profile is affordable offers other additional non-contraceptive benefits if desired

 

LINKS AND RESOURCES

PATIENT INFORMATION

A complete information resource from FPA UK– 20 page leaflet https://www.fpa.org.uk/sites/default/files/the-combined-pill-your-guide.pdf

The Family Planning Association has a collection of booklets -it is very unlikely that your meets would not be met here http://www.fpa.org.uk/professionals/resources/leaflet-and-booklet-downloads

A colourful printable foldable leaflet for young people from Comecorrect. org http://www.comecorrect.org.uk/ContraceptiveGuide.pdf

Brook – contraceptive advice for  patients under 25 – an excellent resource with helpful videos https://www.brook.org.uk/topics/contraception/

Excellent work from BPAS- So you want to know about contraception 36 pages – ask the young person to take a photo or copy the URL https://www.bpas.org/media/1211/young-persons-guide-to-contraception.pdf

A leaflet from FPA summarising all common available methods https://www.fpa.org.uk/sites/default/files/your-guide-to-contraception.pdf

Planned parenthood for patients in US – fabulous resource https://www.plannedparenthood.org/learn/birth-control

RESOURCES FOR HCP’s

The Faculty of Sexual and Reproductive Healthcare of the Royal College of Obstetricians & Gynaecologists – produce guidelines which are used in  the UK for all matters related to contraception. The website starts an auto-download as soon as you get to the link.  You will need to search for individual publications – the UKMEC link is https://www.fsrh.org/ukmec/

Switching or Starting Methods of Contraception is here ( auto-download ) when clicked https://www.fsrh.org/standards-and-guidance/documents/fsrh-ceu-switching-document-feb-2019/

Gillick and Fraser competency guidelines from NSPCC https://learning.nspcc.org.uk/research-resources/briefings/gillick-competency-and-fraser-guidelines/

Under 16s – consent and confidentiality in sexual health services from FPA http://www.fpa.org.uk/factsheets/under-16s-consent-and-confidentiality-sexual-health-services#ewni

Prescribing contraception in under 16s from MDU https://www.themdu.com/guidance-and-advice/guides/prescribing-contraception-to-under-16s

The Royal Australian and New Zealand Collge of Obstetricians and Gynaecologists guidance on COCP https://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women’s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Combined-hormonal-contraceptives-(C-Gyn-28)-Review-March-2016.pdf?ext=.pdf

A recent update from FSRH- that there is no benefit from seven day hormone free interval https://pcwhf.co.uk/news/updated-fsrh-guidance-on-combined-hormonal-contraception-chc/

ACOG Long acting reversible contraception Program https://www.acog.org/About-ACOG/ACOG-Departments/Long-Acting-Reversible-Contraception

 

 References

  1. Contraception combined hormonal methods CKS NHS
  2. NICE BNF Ethinylestradiol with Lenonorgestrel via
https://bnf.nice.org.uk/drug/ethinylestradiol-with-levonorgestrel.html#contraIndications
  3. Faculty of Sexual & Reproductive Healthcare of the Royal College of Obstetricians & Gynaecologists Combined Oral Contraceptive Pill
  4. Contraceptive Pill First Prescription by Dr Mary Harding Patient UK November 2014
  5. Choosing a combined oral contraceptive pill Australian Prescriber Feb 2015
  6. Phasic approach to oral contraceptive Am J Obstet Gynecol. 1987 Ocr;157 (4 Pt 2); 1052-8 ( Abstract )
  7. Website Amboss COCP section accessed via 
https://www.amboss.com/us/knowledge/Hormonal_contraceptives

 

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