Types
| Monophasic: |
All 21 active pills contain the same amount of
estrogen/progestin (E/P)
|
| Biphasic: |
The 21 active pills contain 2 different E/P
combinations (10/11)
|
| Triphasic: |
The 21 active pills contain 3 different E/P combinations (6/5/10)
|
Mechanisms of Action
- Suppress ovulation
- Thicken cervical mucus, preventing sperm penetration
- Change endometrium, making implantation less likely
- Reduce sperm transport in upper genital tract (fallopian tubes)
Benefits
Contraceptive
- Highly effective when taken daily (0.1–8 pregnancies per 100 women during the first
year of use)
- Effective immediately
- Pelvic examination not required prior to use
- Do not interfere with intercourse
- Few side effects
- Convenient and easy to use
- Client can stop use
- Can be provided by trained nonmedical staff
Noncontraceptive
- Decrease menstrual flow (lighter, shorter periods)
- Decrease menstrual cramps
- May improve anemia
- May lead to more regular menstrual cycles
- Protect against ovarian and endometrial cancer
- Decrease benign breast disease and ovarian cysts
- Prevent ectopic pregnancy
- Protect against some causes of PID
Limitations
- User-dependent (require continued motivation and daily use)
- Some nausea, dizziness, mild breast tenderness or headaches as well as spotting or light
bleeding (usually disappear within 2 or 3 cycles)
- Effectiveness may be lowered when certain drugs for epilepsy (phenytoin and
barbiturates) or tuberculosis (rifampin) are taken
- Can delay return to fertility
- Forgetfulness increases failure
- Serious side effects (e.g., heart attack, stroke, blood clots in lung or brain, liver
tumors), though rare, are possible
- Resupply must be available
- Do not protect against STDs (e.g., HBV, HIV/AIDS)
Who Can Use COCs
- Women of any reproductive age
- Women of any parity including nulliparous women
- Women who want highly effective protection against pregnancy
- Women who are breastfeeding (6 months or more postpartum)
- Women who are postpartum and not breastfeeding
- Women who are postabortion
- Women with anemia
- Women with severe menstrual cramps
- Women with irregular menstrual cycles
- Women with histories of ectopic pregnancy
Conditions Requiring Precautions
CONDITION |
RECOMMENDATION |
| High blood pressure |
Initiate and resupply after careful evaluation of
condition. Women with BP <160/100 can use COCs. |
| Diabetes |
COCs can be used with uncomplicated diabetes or
diabetes of less than 20 years duration. |
| Migraines |
If no focal neurological symptoms are associated with
the headaches, COCs can be used. |
| Taking drugs for epilepsy or tuberculosis |
Provide higher estrogen (50 µg ethinyl estradiol)
pills or help client choose another method. |
Who Should Not Use COCs
- Women who are pregnant (known or suspected)
- Women who are breastfeeding and fewer than 6–8 weeks postpartum
- Women with unexplained vaginal bleeding (until evaluated)
- Women with active liver disease (viral hepatitis)
- Women over age 35 who smoke
- Women with a history of heart disease, stroke or high blood pressure (>180/110)
- Women with a history of blood clotting problems or diabetes > 20 years
- Women with breast cancer
- Women with migraines and focal neurologic symptoms
- Women who cannot remember to take a pill every day
When to Start
- Anytime during the menstrual cycle when you can be reasonably sure the client is not
pregnant
- Days 1 to 7 of the menstrual cycle
- Postpartum:
- after 6 months if using LAM
- after 3 weeks if not breastfeeding
- Postabortion (immediately or within 7 days)
Management of Common Side Effects
SIDE EFFECT |
MANAGEMENT |
Amenorrhea
(absence of vaginal bleeding or spotting) |
Clients using 21-day packs may forget to leave a
pill-free week for menses. If pills are taken continuously, she may not have any periods.
This is not harmful. Check for pregnancy.
If not pregnant and client is taking COCs correctly, reassure.
Explain that absent menses are most likely due to lack of buildup of uterine lining.
If not pregnant, no treatment is required except counseling and
reassurance. If she continues low-dose estrogen COCs (30–35 µg EE), amenorrhea
usually will persist. Advise client to return to clinic if amenorrhea continues to be a
concern or switch to a high-dose estrogen (50 µg EE) pill if available and no conditions
requiring precaution exist.
If intrauterine pregnancy is confirmed, counsel client regarding options.
If pregnancy will be continued, stop use and assure her that the small dose of estrogen
and progestin in the COCs will have no harmful effect on the fetus. |
High blood pressure
(> 160/100) |
If BP increases in a client with normal BP who is
using COCs, follow closely. If any warning signs (severe headaches, chest pain, blurred
vision) occur or BP > 160/100, the method should be stopped. If COCs
are stopped, help client choose another (nonestrogen) method. Tell her that high BP due to
COCs usually goes away after 1–3 months. Take BP monthly to be sure it returns to
normal. If after 3 months it has not, refer for further evaluation. |
| Nausea/Dizziness/ Vomiting |
Check for pregnancy. If pregnant, manage as above. If not,
advise taking pill with evening meal or before bedtime. Reassure that symptoms usually
decrease after first three cycles of use. |
| Vaginal bleeding/ Spotting |
Check for pregnancy or other gynecological conditions.
Advise taking pills at the same time each day. Reassure that spotting/light menstrual
bleeding is common during first 3 months of use and then decreases. If it persists,
provide higher dose estrogen (50 µg EE) pills or help client choose another method. |
Client Instructions
- Take 1 pill each day, preferably at the same time of day.
- Take the first pill on the first to the seventh day (first day is preferred)
after the beginning of your menstrual period.
- Some pill packs have 28 pills. Others have 21 pills. When the 28-day pack is empty, you
should immediately start taking pills from a new pack. When the 21-day pack is empty, wait
1 week (7 days) and then begin taking pills from a new pack.
- If you vomit within 30 minutes of taking a pill, take another pill or use a
backup method if you have sex during the next 7 days.
- If you forget to take 1 pill, take it as soon as you remember, even if it means taking 2
pills in 1 day.
- If you forget to take 2 or more pills, you should take 2 pills every day until you are
back on schedule. Use a backup method (e.g., condoms) or else do not have sex for 7 days.
- If you miss 2 or more menstrual periods, you should come to the clinic to check to see
if you are pregnant.
General Information
- Some nausea, dizziness, mild breast tenderness and headaches as well as spotting or
light bleeding are common during the menstrual cycle (usually disappear within 2 or 3
cycles).
- Certain drugs (rifampin and most anti-epilepsy drugs) may reduce the effectiveness of
COCs. For this reason, the client should tell her health care provider if she starts any
new drugs.
- COCs do not provide protection against STDs, including the AIDS virus. If either partner
is at risk, they should use condoms as well as COCs.
WARNING SIGNS
FOR COMBINED ORAL CONTRACEPTIVE (COC) USERS
- Severe chest pain or shortness of breath.
- Severe headaches or blurred vision.
- Severe leg pain.
- Absence of any bleeding or spotting during pill-free week (21-day pack) or while
taking 7 inactive pills (28-day pack) may be a sign of pregnancy.
Contact health care provider or clinic if you develop any of the
above problems. |
Who Can Provide
- Physicians
- Nurses, Midwives, Paramedics
- Community-based Workers
- Pharmacists
Where They Can Be Provided
- Hospitals
- Clinics
- Health Posts
- Community-based Distribution Programs
- Pharmacies
- Private Offices
 
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