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PocketGuide for Family Planning Service Providers
Combined Combined (Estrogen/Progestin) Contraceptives

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Management of Other Problems

Acne | Breast Fullness or Tenderness | Chest Pain | Depression | Headache | Jaundice | COCs: Diarrhea or Vomiting | COCs: Missed Active Pills | COCs: Missed Inactive Pills | CICs: Presents Early for Next Injection | CICs: Presents Late for Next Injection | Starting COCs or a CIC after Day 7 of Menstrual Cycle
PROBLEM Acne
ASSESSMENT Ask how and how often she cleans her face. Ask if she is currently under great stress.
MANAGEMENT Acne usually is improved with use of COCs or CICs; however, in some clients it can worsen or remain the same. Recommend cleaning face twice a day and avoiding use of heavy facial creams. Counsel as appropriate. If condition is not tolerable, help client choose another (nonhormonal) method.

 

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PROBLEM Breast fullness or tenderness (mastalgia)
ASSESSMENT Check for pregnancy.
MANAGEMENT If pregnant, manage as above (see Amenorrhea).

If not pregnant, breast tenderness usually improves within 3 months of starting COCs or a CIC.
ASSESSMENT Check breasts for:
  • Lumps or cysts
  • Discharge or galactorrhea (leakage of milk-like fluid), if not breastfeeding

Ask whether client notices fullness only at a certain time of the month (e.g., just before menses).
MANAGEMENT If physical examination shows lump or discharge suspicious for cancer (e.g., firm, nontender or fixed and which does not change during the menstrual cycle), refer to appropriate source for diagnosis. If no abnormality, reassure.

Advise client to avoid caffeine, chocolate, etc., and counsel her that cyclic changes in breast fullness or tenderness are related to the estrogen/progestin but are not a problem. If taking a COC, switch to a lower estrogen pill if not already on lowest estrogen COC. If the symptomatic management is not helpful, help client choose another method.
ASSESSMENT If she is breastfeeding and breast(s) is tender, examine for breast infection.
MANAGEMENT If breast(s) is not infected, recommend a bra that provides additional support.

If breast infection, use warm compresses, advise to continue breastfeeding and give antibiotics as appropriate.

 

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PROBLEM Chest pain (especially if it occurs with exercise)
ASSESSMENT Assess for possible cardiovascular disease (CVD). Also, check:
  • Blood pressure
  • Heart for irregular beats (arrhythmias)
MANAGEMENT If evidence of CVD, refer for further evaluation. Consider stopping COCs or CIC and help client choose another method.

 

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PROBLEM Depression (mood change or loss of libido)
ASSESSMENT Discuss changes in mood or libido.
MANAGEMENT Depression or loss of libido may be related to the progestin in COCs and CICs. If COCs or CICs have not caused depression to worsen or libido to decrease, they can be continued. If the client thinks her depression has worsened or libido decreased while using COCs or CICs, help her choose another method.

 

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PROBLEM Headache (especially with blurred vision)
ASSESSMENT Ask if there has been a change in pattern or severity of headaches since beginning the COCs or CIC.

Perform physical examination, measure blood pressure.

Examine as appropriate:

  • Eyes (fundoscopic)
  • Neurologic system
MANAGEMENT If headaches are mild, treat with analgesics and reassure. Re-evaluate after 1 month if mild headaches persist.

If headaches have changed since starting the COCs or CIC (e.g., numbness or tingling accompanied by loss of speech, visual changes or blurred

vision), stop COCs or CIC and help client choose another (nonhormonal) method.

 

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PROBLEM Jaundice
ASSESSMENT If jaundice occurs after starting COCs or a CIC, check for:
  • Active liver disease (hepatitis)
  • Gall bladder disease
  • Benign or malignant liver tumors
MANAGEMENT The hormones (estrogen and progestin) in COCs and CICs have little effect on liver function. If client has jaundice due to viral hepatitis, stop COCs or the CIC and help client choose another method until she is fully recovered (i.e., either 3 months after becoming asymptomatic or when normal liver function returns).

If jaundice is due to gall bladder disease, stop COCs or the CIC and help client choose another method unless other methods are not available or acceptable.

If jaundice is due to a liver tumor or cirrhosis, stop COCs or the CIC and refer for further evaluation. Help client choose another method.

 

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PROBLEM COCs: Diarrhea or vomiting (for more than 24 hours)
ASSESSMENT Ask if it has lasted for more than 24 hours (then 2 pills will have been missed).
MANAGEMENT Acute vomiting and diarrhea may interfere with the effectiveness of the pill. In these cases, a backup method should be used until the client has taken 7 active pills.

 

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PROBLEM COCs: Missed active pills
ASSESSMENT Has client missed only 1 pill?
MANAGEMENT Advise client to take the missed pill when she remembers, even if it means taking 2 pills in the same day, and complete pack as usual. No backup method is necessary.
ASSESSMENT Has client missed 2 or more consecutive pills?
MANAGEMENT Advise client to take 2 pills per day until she is back on schedule and to use a backup method if she has sex during the next 7 days. (If she has started bleeding, advise her to stop taking pills and start a new pack 7 days later.)

 

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PROBLEM COCs: Missed inactive ("reminder") pills (28-day pack only)
ASSESSMENT Has client missed reminder pills in week 4?
MANAGEMENT Advise client to throw away missed pills and complete pack as usual. No backup method is necessary for clients who miss any of the "reminder" pills in week 4 (28-day packs only).

 

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PROBLEM CICs: Presents early for next injection
ASSESSMENT Is she more than 3 days early?
MANAGEMENT Giving injections early is not ideal but can be done when necessary. Reschedule the next injection for 30 days from current injection.

 

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PROBLEM CICs: Presents late for next injection
ASSESSMENT Is she more than 3 days late?
MANAGEMENT It is acceptable to give CICs up to 3 days late. If the client is more than 3 days late but the possibility of pregnancy can be ruled out, give next injection. Reschedule the next injection for 30 days from current injection. If pregnancy cannot be ruled out, ask her to use a barrier method until her next menses.

 

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PROBLEM Starting COCs or a CIC after day 7 of the menstrual cycle
ASSESSMENT Check for pregnancy by symptoms, physical examination or pregnancy test, if indicated and available.
MANAGEMENT Advise client that her regular bleeding pattern may be altered. She should use a backup method if she has sex during the next 7 days. Suppression of follicular development does not occur until 7 days after receiving an injection of a CIC or starting a COC.

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