Combined Oral Contraceptive Pill

Eg. Microgynon

Mechanism of Action
Prevents conception by acting on:
Hypothalamic-pituitary axis
o Suppresses synthesis + secretion of FSH and LH
o Inhibits development of ovarian follicles and ovulation
Cervical mucus
o Thickens mucus to prevent penetration of sperm
Endometrium
o Inhibits blastocyst implantation

Advantages

Non-invasive
Effective + easy to reverse
Menses tend to become regular, lighter and less painful
Some find it improves acne
Shown to reduce risk of ovarian, endometrial and colorectal cancer

Disadvantages

User-dependent relies on patient to remember to take it regularly

Side effects
o Breakthrough bleeding
Commonly in first few months
o Weight gain
o Mood changes
o Breast tenderness, nausea, headaches
o If they do not settle over the first 3 months, alternative COCP or
contraception can be tried.
Increased risk of VTE + MI + Stroke + Breast cancer
Does not protect against STI must use condoms too

Types

Dose variability
o Monophasic constant oestrogen/progesterone dose
o Phasic dose varies through cycle (biphasic, triphasic,
quadriphasic)
Strength
o Oestrogen 30-35micrograms
Pill free interval
o 7 days where pill is not needed
o Either no pill is taken or dummy pill taken (for concordance)

Eligibility
Category 1 + 2 = no restriction to use

Category 3 + 4 = not recommended

Common conditions which are category 3/4:
BMI is 35+
Breastfeeding (6 months post natal)
Smokers aged 35+
Cardiovascular disease or risk factors (smoking, diabetes, hypertension,
obesity)
Hypertension
History of VTE
Diabetes with complications
Migraine with aura
Medications anticonvulsants

Treatment Course
Start on 1st day of menstrual bleeding (if started at any other time, use condom
for 7 days)
Taken every day at the same time for 3 weeks then 1 week free (or placebo
tablets)
Missed pill:
If within 48hrs take pills as soon as possible (even if 2 in one day)
no emergency contraception needed
If after 48hrs take pills but extra steps are required
in 1st week = emergency contraception considered if
unprotected sex
in 2nd week = continue as normal
in 3rd week = continue but omit pill-interval (no placebo
pills)

Diarrhoea + Vomiting = missed pill

Vomiting within 2 hours of pill = take another pill

Follow up after 3 months

Check BP

Progesterone Only Pill

Eg. minipil, Cerazette

Mechanism of Action

Cervical mucus
o More viscous + impenetrable to sperm
Thins endothelium

Advantages

Effective + safe (used when Combined is contra-indicated)

o Breastfeeding, VTE/Cardiovascular risk factors, Diabetes, High BMI
(35+), Heavy smokers, Hypertension

Disadvantages

Strict schedule (taken at same time each day)

o Usually within 3 hours
o Newer progesterone tablets (Desogestrel) have a 12hr window
Eg. Cerazette
Does not control menstrual cycle as effectively as Combined
Side effects:
o Irregular menstrual bleeding

Contraindications

Breast cancer/ past history

Liver tumours/ cirrhosis

Treatment Schedule

Start on first day on cycle

If started on any other day (use contraception for 48hrs)
Changing from Combined to Progesterone start as straight after end of
Combined

Missed Pills

Missed pill should be taken as soon as possible

No more than 2 pills a day
Additional contraception until pills have been taken correctly for 2 days

Follow-Up

Review after 3 months

Check BP

Progesterone Injection

Eg. Depo, Sayana, Noristerat

Mechanism of Action

Suppresses ovulation
Makes endometrium unsuitable for implantation (thins it)
Increases viscosity of cervical mucus less sperm penetration

Advantages

No need to remember to take pills

Reversible

Disadvantages

Side effects:
o Irregular bleeding
o Delayed return to fertility (at least 3 months, sometimes up to 1 yr)
Contraindications
o Breast cancer +history of breast cancer
o Deranged LFTs

Treatment Course

Injections started on or before day 5 of cycle

o If after day 5, check patient is not pregnant then start (+7 day
contraception)
Site is usually Gluteal muscle
Lasts 3 months

Progesterone Implant
Subdermal insertion into the upper arm
4cm flexible rod
Lasts for 3yrs

Intra-Uterine Device (IUD)

Copper T anchored to myometrium at the fundus

Mechanism of Action

Sets up a cytotoxic inflammatory reaction in the endometrium

spermicidal
Cooper concentration inhibits sperm motility

Duration

Either 5yrs or 10yrs dependent on patient choice

If over 40 can be left in until menopause confirmed (even if after 5yrs)

Advantages

Rapid return of fertility

Convenience
No hormonal content
Can be used as emergency contraception
o If unprotected sex was 72hrs-5days ago

Disadvantages

Heavier + more painful periods

Discomfort during fitting
Increased risk of pelvic infection

Contraindications

History of PID
Recent exposure to STI
Gynae cancer
Small uterus (less than 5.5cm)

Intra-Uterine System
(IUS)
Mirena coil
Releases levonorgestrel (LNG)

Mechanism of Action

Reduces endometrial growth (atrophy) + prevent implantation

viscosity of cervical mucus
No effect on ovulation

Advantages

Very effective, convenient and reversible

Reduced risk of PID compared to IUD
Lasts for 5 years

Mechanism of Action

Insertion can be unpleasant

Menstrual irregularities in first 6months (bleeding + spotting)
Side effects (typical of progesterone)
o Headache, breast tenderness, mood changes