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What are the mechanisms of contraception in the COCP

inhibit ovulation.

inhibit proliferation of the endometrium, creating unfavourable conditions for implantation

increases the thickness of cervical mucus, preventing passage of sperm.


How does the COCP inhibit ovulation

negative feedback effect of the oestrogen and progesterone on the hypothalamo-pituitary axis prevents the surge in LH
thus preventing ovulation


What is the difference between monophasic and phasic COCP

Monophasic pills: every pill contains the same levels of oestrogen and progesterone.

Phasic pills: the level of oestrogen and progesterone in the pills changes throughout the cycle.


What are the advantages of the COCP

Non-invasive method.
Menses tend to become regular, lighter and less painful.
Running packets together allows control of timing of menses for events such as holidays, exams, and sporting competitions.
improves acne.
It may help symptoms of premenstrual syndrome (PMS).
reduce the risk of ovarian, endometrial and colorectal cancer
It may reduce risk of ovarian cysts.
Normal fertility returns immediately after stopping usage


What are the disadvantages of the COCP

User-dependent - relies on remembering to take it regularly
Side effects - headaches, breast tenderness and mood changes
increased risk VTE
May cause an increase in blood pressure.
Breakthrough bleeding (BTB) may occur, particularly in the first few months of use.


Who should not take the COCP

BMI greater than 35
Breast feeding
Smoking >15 per day over the age of 35
History of or family history of venous thromboembolisms
Prolonged immobility due to surgery or disability
Diabetes mellitus with complications e.g. retinopathy
History of migraines with aura
Breast cancer or primary liver tumours
Heart disease - IHD, Valvular or congenital heart disease with complications. Also cardiomyopathy with impaired cardiac function, Atrial fibrillation.


What are some side effects of the COCP

Breakthrough bleeding.
Weight gain and Mood changes - but no evidence
breast tenderness,


How is the COCP taken?

The COC pill should be started on the first day of menstrual bleeding, but can be started up to day 5 without the need for extra protection.

When started at any other time in the cycle, additional contraceptive precautions (eg, condoms) should be used for seven days

taken for 21 consecutive days, at approximately the same time of day

followed by seven pill-free days (or seven days of neutral tablets) to allow endometrial shedding and a withdrawal bleed. Contraception is still provided during the hormone-free interval.

Explain that only the first pill is taken on the first day of the woman's period. Future packets will all be started on the same day of the week as the first packet, following a strict 28-day cycle.


What counts as a missed COCP?

If they take it more than 48 hours after the last pill (ie more than 24 hours late) it counts as a missed pill.


What is the advice given for a single missed COCP

The last pill missed should be taken now, even if it means taking two pills in one day.
The rest of the pack should be taken as usual.
No additional contraception is needed.
The seven-day break is taken as normal.


What is the advice given for two or more missed COCP

The last pill missed should be taken now, even if it means taking two pills in one day.
Any earlier missed pills should be left.
The rest of the pack should be taken as usual and additional precautions (eg, condoms or abstinence) should be taken for the next seven days.

If the pills are missed in the first week of a pack (pills 1-7): emergency contraception should be considered if the patient had unprotected sex in the pill-free interval or the first week of the pill packet. She should finish the packet and have the usual pill-free interval.

If the pills are missed in the second week of a pack (pills 8-14): there is no need for emergency contraception as long as the pills in the preceding seven days have been taken correctly. The packet should be finished and the usual pill-free interval taken.

If the pills are missed in the third week of a pack (pills 15-21): the next pack of pills should be started without a break - ie the pill-free interval is omitted. If taking a packet with dummy/placebo pills, these should be discarded, and the new packet started. Emergency contraception is not required.


How often should a woman taking the COCP be followed up?

After the first prescription, review at 3 months.
If all is well, follow up at 6- to 12-month intervals.
Supplies of up to a year may be issued.


How is the COCP managed around the time of surgery?

discontinued 4 weeks before elective major surgery
restarted on day one of the next period, occurring at least 2 weeks after mobilisation.

Progestogen-only contraception can be offered as an alternative during this time.

Women requiring emergency surgery should receive subcutaneous heparin and compression stockings.


What is the mechanism of action of the POCP

thickens the cervical mucus due to the high levels of progesterone. This prevents the entry of sperm and thereby fertilisation of the oocyte.

suppression ovulation (60% of cycles with pills containing levonorgestrel, 97% of cycles with desogestrel)

thinning of the endometrium which inhibits implantation.


What are the advantages of the POCP compared to the COCP

It is an effective and safe form where oestrogens are contra-indicated

It contains an even lower dose of progestogen than low-dose combined contraceptives and no oestrogen.

It can be used during breast-feeding.

It is suitable for women about to undergo major surgery or surgery on their legs.

There is no evidence that the POCP is associated with an increased risk of VTE


What are the disadvantages of the POCP

It has to be taken meticulously at the same time each day. (three hours window for traditional, 12 hours in newer with desogestrel)

It is just as susceptible to substances that cause enzyme induction, like rifampicin, many anticonvulsants and St John's wort.

It does not control the menstrual cycle as effectively as the COCP - causes irregular menstruation or amenorrhoea.

There may be minor side-effects such as breast tenderness, skin changes, and headaches. These usually improve with time.

There is an increased risk of ovarian cysts, perhaps up to 30%.

There may be a small increased risk of breast cancer for women taking the POCP.


What are some contraindications to the POCP

Past history of breast cancer.
Severe cirrhosis.
Liver tumours.
Stroke and coronary heart disease
Systemic lupus erythematosus (SLE) with positive antiphospholipid antibodies.
Those on medication, including antiretroviral therapy, enzyme-inducing anticonvulsants (but not lamotrigine which is contra-indicated with the COCP), and enzyme-inducing antibiotics such as rifampicin and rifabutin.


How should the POCP be started?

on the first day of menstruation, giving immediate contraceptive cover

If started any day up to the fifth day from the start of menstruation, no additional contraceptive precautions are required.

If started at any other time in the cycle, pregnancy should be excluded first, and additional contraceptive precautions should be used for 48 hours (eg, condoms or abstinence).


What should a woman do if she misses her POCP

She should take the missed pill as soon as she remembers and resume her usual pill-taking schedule - even if this means taking two pills on the same day, ie one when she remembers and the next pill on time.

In addition, if the pill is more than three hours late (12 hours for desogestrel pills such as Cerazette®) other contraceptive precautions are required (eg, condoms) or abstinence for the next 48 hours.

Consider emergency contraception if there was unprotected sexual intercourse 2-3 days prior to the missed pills, or there has been intercourse since the missed pill(s).


What are the common side effects of POCP

Irregular menstrual bleeding patterns


Which drugs are liver enzyme inducers and therefore alter the effectiveness of the pill?

Anticonvulsants such as carbamazepine, oxcarbazepine, phenytoin, barbiturates, primidone, and topiramate.
NB: Lamotrigine does not affect the POCP.

Antibiotics - rifabutin and rifampicin (potent enzyme inducers).

St John's wort.

Antiretrovirals - particularly ritonavir-boosted protease inhibitors.


How does the IUD work?

It releases copper, which makes the uterus an unfavourable environment for sperm.

creates an endometrial inflammatory reaction, inhibiting implantation if fertilisation has already occurred.


How soon does the IUD work as a contraceptive?



What are the advantages of the IUD

Rapid return of fertility post-removal.
Convenience (long-lasting method that is independent of intercourse).
No hormonal content.


What are the disadvantages of the IUD

heavier and more painful menstruation
discomfort of fitting.


What are absolute contraindications to using the IUD

History of pelvic inflammatory disease (PID) or purulent cervicitis in prev 3 months
Recent exposure to sexually transmitted infection (STI).
Septic abortion or postpartum endometritis in the previous 3 months.

Current pregnancy.
Between 48 hours and 4 weeks postpartum.

Uterine factors
Uterine abnormality distorting the uterine cavity - eg, fibroids, bicornuate uterus.
Uterus less than 5.5 cm in length on sounding. (The device may be expelled, but may also be less effective eg, if placed in one horn of bicornuate uterus)

Gynaecological cancers
Ovarian, cervical or endometrial cancer.
Malignant trophoblastic disease.
Undiagnosed irregular vaginal bleeding/suspicion of genital malignancy.

Adverse reactions to copper
Copper allergy or Wilson's disease.

Other factors
Previous history of bacterial endocarditis after prosthetic valve replacement.
Significant immunosuppression.


What are the side effects of the IUD

prolonged, heavier and more painful periods

There is a sixfold increase in risk of PID in the first 20 days following insertion.

Ectopic pregnancy is increased relative to normal pregnancies where copper devices are used.

Failure of insertion

Syncope at insertion

Suspected perforation at insertion

Cramping after insertion



Lost threads


What is the mechanism of action of the IUS

suppressant effect on the endometrium, which prevents implantation

There is an increase in endometrial phagocytic cells which also prevents implantation.

Decreased sperm penetration of cervical mucus and impaired sperm migration.


What are the advantages of the IUS

Rapid return of fertility post-removal.
Reduced menstrual loss and dysmenorrhoea.
Convenience (long-lasting method that is independent of intercourse).
Lack of significant interactions with hepatic enzyme-inducing drugs.
Compared to long-acting injectable depot contraceptives there is no demonstrable effect on bone mineral density (BMD),


What are the disadvantages of the IUS

Initial menstrual irregularities.

Fitting an IUS is technically more difficult (in view of its larger diameter) than fitting an IUCD, particularly in nulliparous or perimenopausal women.