Contraceptions ( COC pills,

emergency contraceptive pills, POP)

365 AUNG KAUNG MON

366 AUNG KYAW MIN
367 AUNG KHINE PHYO
 Introduction
• Correct and consistent use of effective methods of contraception
can prevent most unintended pregnancies.
• Abortion is a major consequence of unintended pregnancy.
• Abortion are often performed under unsafe conditions and
result in women dying or suffering serious injuries.
• Unintended pregnancies can also lead to delayed or no antenatal
care which can pose health risks to both mothers and infants.
• These are preventable through contraception.
• The characteristics of the ideal contraceptive method would be
• highly effective
• No side effects or risks
• cheap
• independent of intercourse and requires no regular action on the
part of the user
• non-contraceptive benefits
• acceptable to all cultures and religions
• There is no perfect method of contraception and each method will
have a balance of advantages and disadvantages.
Determinants of Contraceptive Method
Acceptability
• Personal characteristics (e.g. age). • Intrusiveness.
• Fertility intentions. • Non-contraceptive benefits
• Perceptions of effectiveness.
• Perceptions of safety.
• Fear of side-effects.
• Familiarity.
• Experience of others.
• Ease of use and of access.
• Need to see a health professional.
PRACTICAL PRESCRIBING
What a woman needs to know before starting a method of contraception

• How to use the method (pill, patch or ring) and what to do

when misused (e.g. missed pill)
• Typical failure rates
• Common side-effects
• Health benefits
• Fertility return on stopping
• When she requires review
GATHER Approach in Counseling New Clients

• Greet the client politely and warmly.

• Ask the patient about her choices. Ask history including LMP to
exclude pregnancy and contraindications.
• Tell advantages, disadvantages, side-effects, and other methods.
• Help the client to make decision that is the best for her.
• Explain how to use the chosen method
• Return visit should be scheduled.
Combined Oral Contraceptive Pills
Contents of the COC pills
• Most of the commonly used COCPs are “low dose” and contains
oestradiol in a dose of 15-35 micrograms.
• Some newer pills contain oestradiol valerate or oestradiol
hemihydrate.
• The progestrogens that are used in currently available pills are often
referred to as
1. Second generation(levonogestrel, norethisterone)
2. Third generation(gestodene desogestrel) and
3. Fourth generation progestogens(drospirenone and dienogest).
Mechanism of action
• Central action – inhibit the release of FSH and LH from pituitary and
inhibits ovulation
• Peripheral action – causes endometrial atrophy and hostility to an
implanting embryo and cervical mucus thickening to prevent sperm
ascending
Regimens
Traditional preparations:
• Contain 21 pills of combined estrogen progesterone(One pill daily for
21 pills)
• Followed by 7 days pill-free interval or 7 placebo pills(Regular
withdrawal bleeding will occur during pill-free interval)
But there are also:
tricycling(taking three packets without any breaks) for woman with
dysmenorrhoea or headaches during pill-free intervals.
Tailored pills(taking the pills continuously until they want to start a
bleeding episode)
Other preparations:
• Contain 24 days of pills with a shorter pill-free interval.

Preparations are commonly monophasic (i.e. same dose of hormones

throughout) but some are phasic (i.e. dose varies).
Advantages
safe, effective and easy to use
lighter, regular periods with less cramping
can become pregnant again after stopping the pill
don’t interfere with sex
decrease the risk of cancer of endometrium and ovary
reduce the incidence of dysmenorrhoea, fibroids, ectopic
pregnancy, endometriosis, ovarian cysts, premenstrual
syndrome
useful in the treatment of acne *
advancement or postponement of menstruation
Disadvantages

Have some side effects

No protection against STIs *
Failure rate-

 Typical use – 9%
 Perfect use – 0.3%
Side Effects

• CNS -headache, depression, loss of libido, nausea and

vomiting, mood swings
• GI -weight gain, bloating, gall stone, cholestatic jaundice
• GU -cystitis, irregular bleeding, vaginal discharge, growth
of fibroid
• CVS -venous thromboembolism, AMI, stroke, hypertension
• Breast -breast pain, increased risk of breast cancer
• Miscellaneous - leg cramps
Contraindications
Absolute
• Cardiovascular disease
• Acute or severe liver disease
• Estrogen dependent neoplasm particularly breast cancer
• Focal migraine
• Pregnancy

Relative
• Generalized migraine
• long term immobilization
• irregular vaginal bleeding
• less severe risk factors for CVD eg obesity, heavy smoking,
diabetes
• Counsel with GATHER approach.
• Key Instructions should include –
• 1st pill on the 1st day of the menstrual period
• If sure not being pregnant, can start any day of the menstrual
period.
• If more than 5 days, avoid sex or use condoms for 7 days after
taking 1st pill.
• Continue taking one pill each day at the same time in order as
shown in the packing.
• Provide backup method which includes abstinence, male or
female condoms, spermicides and explain to use these methods.
MISSED PILL GUIDELINES
Follow-up
• Return visit back when there is severe constant pain in belly, chest,
very bad head aches, brief loss of vision, seeing flashing lights,
yellow skin or eyes.
• If no problems, come back every 3 or 4 months.
Emergency Contraceptive Pills
What is emergency contraception?

• methods of contraception that can be used to prevent pregnancy

after sexual intercourse.
• recommended for use within 3 – 5 days but are more effective the
sooner they are used after the act of intercourse.
• Methods contains Oral pills and IUD.
• Cu-IUD is the most effective method of emergency contraception
(failure rate 1 in 1,000).
• Should ideally be offered as first choice to women.
• When used for EC, its effect on the endometrium is thought to
prevent implantation if fertilization has occurred.
• The Cu-IUD can be removed once pregnancy has been excluded or
can be left in place for ongoing contraception.
• EC pills prevent around 75% and copper IUDs prevent more than
98% of the pregnancies that would occur if no emergency
contraception were used.
 Emergency Contraceptive Pills
• Often known as the “Morning After Pill”, but actually you can take it up to 3 – 5
days after sex.
• It consists of a hormone progestogen (Levonorgestrel).

• 1.5mg single dose as soon as possible • 2 tablets of levonorgestrel 0.75mg in

after intercourse (preferably within 12 each(1 within 72 hrs and 1 more in
hours but not later than after 72 12hours)
hours)
• If vomiting occurs
Within 2 hrs after taking EC pills, she take another dose.
>2 hrs after taking EC pills, she does not need to take any extra pills.

Alternatives are
0.05mg Ethinyl estradiol, 0.25mg levonorgestrel -2tabs, 2doses, 12hrly
0.03mg Ethinyl estradiol, 0.15mg levonorgestrel -4tabs, 2doses, 12hrly
Mechanism of action

• Work primarily by preventing or delaying the release of eggs from the

ovaries (ovulation).
• Alter endometrial changes
• Alter tubal mobility
• Does not prevent fertilization or disrupt an implanted embryo and
therefore DOES NOT cause an abortion
• Do not work if a woman is already pregnant.
Indications
• Contraceptive failure
Condom split or rupture
Injection method 2 weeks late for injection Depo
1 week late for monthly injection
COCs : missed COCs Pills 3 or more days
starts new pack 3 or more days late
POPs : missed POPs 3 hours late
IUD has come out of place
Couple incorrectly used a fertility awareness method
• Any unprotected sex
• In case of sexual assault
Side Effects
• Changes in bleeding patterns
-slight irregular bleeding 1 to 2 days after
-monthly bleeding starts earlier or later than expected
• In the week after taking ECPs
-nausea, vomiting, abdominal pain
-fatigue
-Headache, Dizziness
-Breast tenderness

EC pills should not be used as regular contraceptive method.

Plan for other contraceptive methods if she needs to prevent unwanted
pregnancy in the future.
Follow Up
• No routine return is needed
• To come back if she thinks she is pregnant
• If she has no monthly bleeding
• If her next monthly bleeding is delayed by more than one week
Progestogen-only Pills
 Progestogen-only Pills (POP)
Pills that contain very low doses of a progestin like the natural hormone
progesterone
• The progestogens that are used in currently available pills are often
referred to as
• - first generations ( ethisterone, norethindrone)
• - second-generation ( Levonorgestrel, Norethisterone)
• - third generation ( Gestodene, Desogestrel) and
• - fourth generation ( Drospirenone and Dienogest)
• Newer third and fourth generations have advantages due to less
androgenic activity but seem to be associated with a higher risk of
venous thrombosis than pills containing second-generation.
2 different types of progestogen-only pill

• 3-hour progestogen-only pill (traditional progestogen-only pill) –

must be taken within 3 hours of the same time each day
• 12-hour progestogen-only pill(desogestrel progestogen-only pill)
– must be taken within 12 hours of the same time each day
Mechanism of action

• Local – endometrium becomes thin and atrophic and hostile to

implantation of embryo, thickening of cervical mucus reducing sperm
permeability and transport.
• Central – in high doses of progesterone, follicular development and
ovulation is inhibited by suppressing the release of pituitary FSH & LH
But low dose of progesterone inhibit ovulation only
Effectiveness
• Failure rate: Typical use – 9%
Perfectly use – 0.3%

Particular indications for POPs

• Breastfeeding mother
• Older age
• Cardiovascular risk factors e.g. high BP, smoking, D.M
Advantages of POPs
• Can be used while breastfeeding
• Can be stopped at anytime without a provider’s help
• Do not interfere with sex
• Acceptable efficacy higher in older women
• Avoidance of estrogen side effects
• Return of fertility more rapid than COC
• Improvement in premenstrual symptoms, mastalgia, dysmenorrhoea
• No harmful effects from overdose
Disadvantages of POPs

• Changes in menstrual patterns including

 frequent bleeding, irregular bleeding, infrequent bleeding ,
prolonged bleeding, no monthly bleeding
 for breastfeeding women, longer delay in return of monthly
bleeding after childbirth (lengthened postpartum amenorrhoea)
• headache, dizziness, mood changes
• breast tenderness, abdominal pain, nausea
• For women not breastfeeding, enlarged ovarian follicles ( ovarian
cysts)
Instructions for POPs
• Can start anytime if it is reasonably certain that she is not pregnant.
• POP needs to be taken continuously.
• Medium-dose pills (e.g. containing desogestrel) inhibit ovulation in
99% of cycles but lower- dose pills inhibit ovulation in less than
one-half of cycles, relying on the cervical mucus effect for
contraception.
• Starting within 5 days of menstruation
• doesn’t need a back-up method.
• If it is more than 5 days of menstruation,back-up method for the
first 2 days of taking pills will he needed.
• Take one pill at the same time each day
• When she finishes one pack, she should take the first pill from the
next pack on the very next day.
• If she is 3 or more hours late taking a pill or misses one completely,
take a missed pill as soon as possible, keep taking pills as usual, on
each day and use extra precautions (e.g. condoms) for the next 48
hours until the progestogen effect on the mucus is built up.
• If unprotected sex occurs during this time, then emergency
contraception is required.
• If she has monthly bleeding , she also should use a back-up method
for the next 2 days.
Side effects of POPs

Erratic or absent menstruation

• Simple, functional ovarian cysts
• Breast tenderness
• Acne
Sickness and diarrhoea
• If you're sick (vomit) within 2 hours of taking a progestogen-only pill,
it may not have been fully absorbed into your bloodstream. Take
another pill straight away and the next pill at your usual time.
• Very severe diarrhoea – 6 to 8 watery stools in 24 hours –the pill
doesn't work properly.
• Keep taking your pill as normal, but use additional contraception,
such as condoms, while you have diarrhoea and for 2 days after
recovering, or 7 days if you're taking a 12-hour pill.
Interaction with other medicines

• There are a number of medicines (some anticonvulsants, antifungals,

antiretrovirals and antibiotics) that induce liver enzymes cytochrome
P450, and will reduce the efficacy of hormonal contraception such as
CHC pills, patch or ring, progestogen-only implant and progestogen-
only pill (POP).
• If a woman using enzyme-inducing medication wishes to use one of
these hormonal methods, then the consistent use of condoms is also
advised.
References

 Gynaecology by Ten Teachers 20th edition

 webs