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What is the MoA of COCs?

Contain low dose oestrogen and moderate dose progestogen. Inhibition of hypothalamic and pituitary function leading to anovulation.


What are the norethisterone group of progestogens?

-norethisterone acetate
-ethynodiol acetate
Converted to norethisterone (NET) before exerting any contraceptive activity


What is the preferred progestogen? WHY?

Levonorgestrel. 10x more potent than NET, has less effect on the coagulative pathway.


What are the gestogens?

3rd gen progestogens
-cyproterone acetate
Less androgenic than NET and LNG


What is the aim of COC commencement?

Provide good cycle control and effective contraception with the least side effects using a pill of the lowest dose


What is a suitable first choice COC?

Monophasic pill containing 30mcg ethinyloestradiol (EO) with levonorgestrel or norethisterone e..g Level ED, Nordette


What should high dose monophonic be reserved for?

50mcg oestrogen, high dose COC reserved for:
-breakthrough bleeding on low dose
-control or menorrhagia
-concomitant use of enzyme using drugs
-low dose pill failure


COC in epilepsy?

Use COC with high dose oestrogen (e.g. 50mcg)


COC in hirsute women?

Less androgenic preparation e.g. Diane-35, Estelle-35


COC in women 35+?

-Low dose monophonic (unless smoker)
-Controls hot flushes of perimenopause if continued until ~30y
-Cease pill around 51y, wait several weeks and check FSH/oestradiol
-if FSH high and oestradiol low, presume menopause


Absolute contraindications to COC?

-First 2 weeks post partum
-Hx of thromboembolic disease / thrombophilia
-Cerebrovascular disease
-Focal migraine
-Coronary artery disease
-Oestrogen dependent tumours
-Active liver disease


Relative contraindications to COC?

-Heavy smoking
->35 + smoking / other CV RFx
-Undiagnosed abnormal vaginal bleeding
-4 weeks before surgery, 2 weeks post
-GB/liver disease
-HTN / DM / hyperlipidemia
-Severe depression


Circulatory disorders linked with COC use?

Venous: DVT, PE (+rare = mesenteric, hepatic, renal thrombosis)
Arterial: MI, thromboembolic/haemorrhagic stroke (+rare = retinal and mesenteric thrombosis)


What causes increased circulatory d/o risk in COCs?

Oestrogen content. Now reduced as doses have been reduced to 20mcg etc


Which cancers may be influenced by COC use?

Very low risk: cervix, breast
Protective: endometrial, epithelial ovarian


Mx breakthrough bleeding on low dose COC?

Usual to have breakthrough bleeding in first 2 months. If minor, continue. If major, cease and start new pill, usually with 50mcg ethinyloestradiol


Advice when starting pill?

-Periods often become shorter and lighter
-No break is necessary
-Drugs that may affect pill: antacids, purgatives, vitamin C, antibiotics, anticonvulsants
-D/V may reduce effectiveness: if vomits within 2h taking pill, take another active pill
-Return yearly for review


Advice re missed pills?

Just keep going: take a pill as soon as possible then resume usual schedule
IF >2x20 or >3x30 EO pills are missed, use condoms / abstinence for 7 days


7 day rule for missed or late pill?

-take forgotten pill asap, even if you take 2 the next day
-if >12h late, increased risk of pregnancy so use another contraceptive method for 7 days
-if these 7d run beyond last hormone pill in pack, miss the inactive pills and start next pack
-you may miss a period (at least 7 hormone tablets should be taken)


Delaying a period?

Skip sugar pills, continue taking hormone pills until end of next pack


What is the mini pill?

Progestogen only pill e.g. levonorgestrel 30mcg/day


Side effects mini pill?

No serious AEx. Compliance a problem due to cycle irregularity, irregular bleeding.
Often decreases cycle length


Indications for POP?

-smokers 45y+
-CIx to or intolerance of oestrogen (migraines, DM, chloasma, lactation, HTN)


What is the injectable contraceptive?

Depo-provera. Only IM contraceptive in Aus.
150mg injection every 12 weeks


What is the implanon?

Subdermal contraceptive implant containing etonogestrel (progestogen). Inhibits ovulation and has anti mucous effect.
3y system


Absolute IUD contraindications?

-Known or suspected pregnancy
-Active PID
-Undiagnosed genital tract bleeding
-Previous ectopic
-Severe uterine cavity distortion


Problems with IUD?

-Pregnancy / ectopic pregnancy
-Extrusion, perfortaion or uterus, translocation