Session I, Slide 1

Combined OralContraceptive Pills

(COCs)Session I:

Characteristics of COCs

Session I, Slide 2

Combined Oral Contraceptives

Objectives

Participants will be able to:

• Describe the characteristics of COCs in a manner that clients can understand

• Demonstrate how to screen clients for eligibility for COC use

• Describe when to initiate COCs

• Explain how to use COCs, what to do when pills are missed, and when to return

• Address common concerns, misconceptions, and myths

• Explain how to manage side effects

• Identify conditions that require switching to another method

• Identify clients in need of referral for COC-related complications

Session I, Slide 3

COCs Key Points for Providers and Clients

Take a pill every day.• Contains both estrogen and progestogen hormones.• Works mainly by stopping ovulation.

Effectiveness depends on the user. Can be very effective.

• “Would you remember to take a pill each day?”• No need to do anything at time of sexual intercourse.• Very effective if taken every day. But if woman forgets pills,

she may become pregnant.• Easy to stop: A woman who stops pills can soon become

pregnant.

Very safe.

• Pills are not harmful for most women’s health and studies show very low risk for cancer due to pills for almost all women. The pill can even protect against some types of cancer.

• Serious complications are rare. They include heart attack, stroke, blood clots in deep veins of the legs or lungs.

Some women have side-effects at first–not harmful and often go away after first 3 months.

• Side-effects often go away after first 3 months.

No protection against STIs or HIV/AIDS.

• For STI/HIV/AIDS protection, also use condoms.

Session I, Slide 4

What Are COCs? Traits and Types

ContentCombination of two hormones: estrogen and progestin

Phasic Monophasic, biphasic, triphasic

DoseLow-dose: 30-35 µg of estrogen (common), 20 µg or less (rare in most places)

Pills per pack

21: all active pills(7-day break between packs)

28: 21 active + 7 inactive pills (no break between packs)

Session I, Slide 5

Effectiveness of COCs

In this progression of effectiveness, where would you place combined oral contraceptives (COCs)?

Implants

Male Sterilization

Female Sterilization

Intrauterine Devices

Progestin-Only Injectables

Male Condoms

Standard Days Method

Female Condoms

Spermicides

Less effective

More effective

COCs

Session I, Slide 6

Relative Effectiveness of FP Methods

Method # of unintended pregnancies among1,000 women in 1st year of typical use

No method 850

Withdrawal 220

Female condom 210

Male condom 180

Pill 90

Injectable 60

IUD (CU-T 380A / LNG-IUS) 8 / 2

Female sterilization 5

Vasectomy 1.5

Implant 0.5Source: Trussell J., Contraceptive Failure in the United States, Contraception 83 (2011) 397- 404, Elsevier Inc.

Session I, Slide 7

COCs: Mechanism of Action

Thickens cervical mucus to block sperm

Suppresseshormonesresponsible forovulation

COCs have no effect on an existing pregnancy.

Session I, Slide 8

COCs: Characteristics

• Less effective when not used correctly (91%)

• Require taking a pill every day

• Do not provide protection from STIs/HIV

• Have side effects

• Have some health risks (rare)

• Safe and more than 99% effective if used correctly

• Can be stopped at any time

• No delay in return to fertility

• Are controlled by the woman

• Do not interfere with sex• Have health benefits

Source: Hatcher, 2007; WHO, 2010; CCP and WHO, 2011; Trussell , 2011.

Session I, Slide 9

COCs: Menstrual-Related Health Benefits

• Decreased amount of flow and fewer days of bleeding; no bleeding (less common)

• Regular, predictable menstrual cycles

• Reduced pain and cramps during menses

• Reduced pain at time of ovulation

Source: Davis, 2005.

Session I, Slide 10

COCs: Other Health Benefits

Protection from: • Risks of pregnancy• Ovarian cancer• Endometrial cancer• Symptomatic PID

Reduced risk of:• Ovarian cysts• Iron-deficiency anemia

Source: Petitti and Porterfield, 1992; CASH Study, 1987; CCP and WHO, 2011; Belsey, 1988; Davis, 2007.

Decreased symptoms of endometriosis (pelvic pain, irregular bleeding)

Decreased symptoms of polycystic ovarian syndrome (irregular bleeding, acne, excess hair on face or body)

Session I, Slide 11

No Overall Increase in Breast Cancer Risk for COC Users

Analysis of a large number of studies:

•No overall increase in breast cancer risk among women who had ever used COCs

•Current use and use within past 10 years: very slight increase in risk

– May be due to early diagnosis or accelerated growth of pre-existing tumors

More recent study:

•No increase in breast cancer risk regardless of age, estrogen dose, ethnicity, or family history of breast cancer

Source: Collaborative Group on Hormonal Factors in Breast Cancer, 1996; Marchbanks, 2002.

Session I, Slide 12

COCs and Cervical Cancer

• Cervical cancer is caused by certain types of human papillomavirus (HPV)

• Some increase in risk among women with HPV and others who use COCs more than 5 years

– Risk of cervical cancer goes back to baseline after 10 years of non-use

• Cervical cancer rates in women of reproductive age are low. Risk of cervical cancer at this age group is low compared to mortality and morbidities associated with pregnancy.

Source: Smith, 2003; Appleby, 2007; CCP and WHO, 2011.

COC users should follow the same cervical cancer screening schedule as other women.

Session I, Slide 13

Risk of Blood Clots is Limited

• COCs may slightly increase risk of blood clots: – Stroke– Heart attack

• Risk is concentrated among women who have additional risk factors, such as: – Hypertension– Diabetes– Smoking

Source: World Health Organization Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception ,1995; Jick, 2006; WHO, 1998; Farley, 1998.

Stop COCs immediately if a blood clot develops.

– Deep vein thrombosis– Pulmonary embolism

Session I, Slide 14

Possible Side-Effects

If a woman chooses this method, she may have some side-effects. They are not usually signs of illness.

•But many women do not have any side-effects.

•Side-effects often go away after a few months and are not harmful.

Most common:

• Mood changes or headaches

• Tender breasts

• Changes in bleeding patterns (lighter, irregular, infrequent or no monthly bleeding)

• Slight weight gain or loss

• Nausea (upset stomach)

• Dizziness