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Recommendations for Contraceptive Use |
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Combined Oral Contraceptives (COCs) |
Classification of Selected
Procedures for Low Estrogen Combined Oral Contraceptives (COCs)
| Procedure |
Class |
Rationale |
| Pelvic examination (speculum and
bimanual) |
C |
- Conditions which would restrict use of COCs should be
identified by history before method initiation.
- A pelvic exam may reveal reproductive tract infections or
reproductive tract malignancies which should be treated for optimal preventive care.
Routine pelvic exam screening for asymptomatic women, in the absence of tests for cervical
cancer, however, is a low yield procedure1.
- A pelvic exam may help evaluate the question of pregnancy:
in this case it is Class A.
- A pelvic exam is not necessary to ensure safe use of COCs
as a contraceptive method.
|
| Blood pressure |
B |
- Due to their estrogen component, COCs have subtle (and
usually insignificant) effects on blood pressure 2. Where possible, for clients
at risk of high blood pressure, blood pressure screening would ideally accompany
initiation of COCs.
- Women with a long history of severe hypertension are at
high risk of vascular disease, and thus arterial thrombosis (clotting), which estrogens
may worsen.
|
| Breast examination |
B |
Lumps that are suspicious for
cancer should be evaluated. While any hormonal treatment may in theory cause such lumps to
grow3, pregnancy causes much higher hormonal levels; therefore, a potential
malignancy of the breast should not be a reason to delay a woman's access to the use of
this contraceptive method. |
| STD screening by lab tests (for
asymptomatic persons) |
C |
For optimal health care, clients
at risk for STDs (by personal history or socio-demographic risk factors) should be offered
STD screening where possible. However, presence of an STD will not affect the safe use of
COCs. |
| Cervical cancer screening |
C |
Cervical cancer screening is
indicated for women at risk of cervical carcinoma, and is recommended (where possible) for
optimal preventive health care for women of reproductive age or beyond (particularly women
at risk of STDs). NOTE:Though causality has
not been established, long-term (more than 5 years) COC use may be associated with a
slight increased risk of cervical cancer4,5. Cervical cancer screening is
advised for optimal preventive care for all women at risk of cervical cancer (e.g.,
smokers, women with partners having multiple partners, women with young age at first
intercourse, etc.4,5). All women at risk should ideally have access to a
practical method of cervical cancer screening, treatment and follow-up. |
| Routine, mandatory lab tests
(e.g., cholesterol, glucose, liver function tests) |
D |
The effects of COCs on
cholesterol, blood glucose and normal liver function are slight, and of no
demonstrated clinical significance6. |
Specific
counseling points for COC use:
- efficacy
- common side effects
- correct use of method (including instructions for missed
pills)
- signs and symptoms for which to see a health provider
- STD protection (when/as appropriate)
|
A |
- Accurate client education is essential for maximum quality
of family planning services.
- Appropriate counseling about common contraceptive side
effects at the time of method selection can lead to improved client satisfaction and
contraceptive continuation7.
|
| Counseling concerning change in
menses, including irregular or absent menstrual bleeding |
A |
Low dose COCs commonly cause
"breakthrough bleeding" (spotting or bleeding during the three weeks of active
pills), especially in the first three months of COC use. Low dose COCs also commonly cause
very light menses, and amenorrhea (absence of withdrawal bleeding) may occur. |
KEY:
Class A = essential and mandatory or otherwise
important in all circumstances, for safe and effective use of the contraceptive method
Class B = medically/epidemiologically rational in
some circumstances to optimize the safe and effective use of the contraceptive method, but
may not be appropriate for all clients in all settings
Class C = may be appropriate for good preventive
health care, but not materially related to safe and effective use of the contraceptive
method
Class D = not materially related to either good
routine preventive health care or to the safe and effective use of the contraceptive
method
Citations:
Huber DH, Huber SC. Screening oral
contraceptive candidates and inconsequential pelvic examinations. Studies in Family
Planning 1975;6(2):49-51.
Task Force on Oral Contraceptives, WHO Special
Programme of Research, Development and Research Training in Human Reproduction. The WHO
Multicentre trial of the vasopressor effects of combined oral contraceptives: Comparisons
with IUD. Contraception 1989;40:129-145.
Droegemueller W. Breast Diseases, in Herbst AL,
Mishell DR, Stenchever MA, Droegemueller W (eds). Comprehensive Gynecology, 2nd
edition. St. Louis, Mosby Year Book, 1992, pp 377-408.
Brinton LA. Oral contraceptives and cervical
neoplasia. Contraception 1991;43(6):581-595.
Schlesselman JJ. Oral contraceptives in
relation to cancer of the breast and reproductive tract - an epidemiological review. British
Journal of Family Planning 1989;15:23-33.
Speroff L, Glass RH and Kase NG. Clinical
Gynecologic Endocrinology and Infertility, 5th edition. Baltimore, Williams and
Wilkins, 1994, pp 726-727.
Cotten N, Standback J, Maidouka H,
Taylor-Thomas JT, Turk T. Early discontinuation of contraceptive use in Niger and The
Gambia. International Family Planning Perspectives 1992;18(4):145-149. |
