PocketGuide: Combined Contraceptives - Management of Side Effects

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PocketGuide for Family Planning Service Providers

Combined (Estrogen/Progestin) Contraceptives

Management of Side Effects

Amenorrhea | High Blood Pressure | Nausea/Dizziness/Vomiting | Bleeding/Spotting

SIDE EFFECT	Amenorrhea (absence of vaginal bleeding or spotting)
ASSESSMENT	COCs: Ask how she has been taking her pills. Has she missed any pills in the cycle?
MANAGEMENT	Missed pills or pills taken late increase risk of pregnancy. Clients using 21-day packs may forget to leave a pill-free week for menses. If pills are taken continuously, amenorrhea may result. This is not harmful. If the client is not satisfied, switch to a high-dose estrogen pill (50 ľg EE) if available and no conditions requiring precaution exist.
ASSESSMENT	Check for pregnancy (intrauterine or ectopic) by history, checking symptoms and performing a pelvic examination (speculum and bimanual) or a pregnancy test, if indicated and available. Is she using a low-dose pill (30–35 ľg EE)? Has she stopped taking the pill?
MANAGEMENT	If not pregnant, no treatment is required except counseling and reassurance. Explain that blood does not build up inside her uterus or body with amenorrhea. The continued action of small amounts of progestin shrinks the endometrium, leading to decreased menstrual bleeding and, in some women, no bleeding at all. If she continues low-dose COCs (30–35 ľg EE), amenorrhea usually will persist. Advise client to return to clinic if amenorrhea continues to be a concern. If intrauterine pregnancy is confirmed, counsel client regarding options.⁴ If pregnancy will be continued, stop use of COCs and assure her that the small dose of estrogen and progestin in the COCs will have no harmful effect on the fetus. If client is taking COCs correctly, reassure. Explain that absent menses is most likely due to lack of buildup of uterine lining. If the client is not satisfied, switch to a high-dose estrogen (50 ľg EE) pill if available and no conditions requiring precaution exist.
ASSESSMENT	CICs: Check for pregnancy by history, checking symptoms and performing a pelvic examination (speculum and bimanual) or a pregnancy test, if indicated and available.
MANAGEMENT	If intrauterine pregnancy is confirmed, counsel client regarding options.⁴ If pregnancy will be continued, stop the CIC and assure her that the small dose of estrogen and progestin in the CIC will have no harmful effect on the fetus. If not pregnant, no treatment is required except counseling and reassurance. Advise client to return to clinic if amenorrhea continues to be a concern.

SIDE EFFECT	High blood pressure (> 160/100)
ASSESSMENT	Ask if this is the first time anyone has told her that she has high blood pressure. Allow 15 minutes rest, then repeat BP reading.
MANAGEMENT	If BP increases in a client with normal BP who is using COCs or CICs, follow closely. If any warning signs (severe headaches, chest pain, blurred vision) occur or BP > 160/100, the method should be stopped. If COCs or CICs are stopped, help client choose another (nonestrogen) method. Tell her that high BP due to COCs or CICs usually goes away within 1 to 3 months. Take BP monthly to be sure it returns to normal. If after 3 months it has not, refer for further evaluation.

SIDE EFFECT	Nausea/Dizziness/Vomiting
ASSESSMENT	If taking COCs, find out if pills are taken in morning or on an empty stomach.
MANAGEMENT	Advise client to take pill with evening meal or before bedtime.
ASSESSMENT	Check for pregnancy.
MANAGEMENT	If pregnant, manage as above (see Amenorrhea).
ASSESSMENT	No cause found.
MANAGEMENT	Counsel that it will probably decrease over the first 3 months of COC or CIC use. If she is using a COC and symptoms persist, switch to a lower-dose estrogen pill (20 ľg EE) if available. If problem is intolerable, stop COC or CIC and help client choose another (nonestrogen) method.

SIDE EFFECT	Bleeding/Spotting (See Figure 10. Management of Bleeding/Spotting for COCs in this chapter and definitions of bleeding and spotting in the Client Assessment chapter)
ASSESSMENT	Has client recently begun COCs or a CIC?
MANAGEMENT	If yes, reassure. Advise that breakthrough bleeding/spotting (BTB/S) is common during the first 3 months of COC or CIC use and decreases markedly in most women by the fourth month of use. If BTB/S persists and is bothersome, switch to another COC or help client choose another method (COC or CIC).
ASSESSMENT	Check for gynecologic conditions (e.g., intrauterine or ectopic pregnancy, incomplete abortion, PID).
MANAGEMENT	If gynecologic problems are present, refer or manage according to clinic guidelines.
ASSESSMENT	Is client taking a new drug (e.g., rifampin)?
MANAGEMENT	If yes, give client a higher dose COC (50 ľg EE) or help her choose another method (COC or CIC).
ASSESSMENT	COCs: Ask if she has missed 1 or more pills or if she takes pills at a different time every day.
MANAGEMENT	If yes, review instructions. If she continues to miss pills, she may need to switch methods to minimize risk of pregnancy. (See Missed Pills in this chapter.)

4 If pregnancy cannot be confirmed by pelvic exam (and pregnancy testing is not available), either refer the client for a pregnancy test or ask her to return in 2–4 weeks for repeat examination.

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