5.3 COCP

Question 1

What does COCP contain?

Answer 1

oestrogen and progesterone

Question 2

Effectiveness of COCP

Answer 2

> 99% but 91% with typical use

Question 3

At what age can you use COCP?

Answer 3

Up to 50 year old

• fine in under 20s
• UKMEC 2 at 6 weeks post birth

Question 4

Mechanism of action of COCP?

Answer 4

• Preventing OVULATION (this is the primary mechanism of action)
• Progesterone thickens the cervical mucus
• Progesterone inhibits proliferation of the endometrium, reducing the chance of successful implantation

Oestrogen and progesterone inhibit GnRH, FSH and LH so ovulation cannot occur.

Question 5

What is breakthrough and withdrawal bleeding?

Answer 5

COCP maintains endometrium, when pill is stopped there is “withdrawal bleed”.

When extended use without a pill free period you get “breakthrough bleeding”

Question 6

Whats the difference between multi- and mono- phasic COCPs?

Answer 6

• Monophasic pills contain the same amount of hormone in each pill
• Multiphasic pills contain varying amounts of hormone to match the normal cyclical hormonal changes more closely

Everyday formulations (e.g. Microgynon 30 ED) are monophasic pills, but the pack contains seven inactive pills, making it easier for women to keep track by simply taking the pills in order every day.

Question 7

Name 5 monophasic COCPs?

Answer 7

Microgynon
Loestrin
Cilest
Yasmin
Marvelon

(vary in amount of oestrogen and type of progesterone)

Question 8

What hormones does Microgynon contain?

Answer 8

Microgynon contains ethinylestradiol and levonorgestrel

Question 9

What hormones does Loestrin contain?

Answer 9

Loestrin contains ethinylestradiol and norethisterone

Question 10

What hormones does Cilest contain?

Answer 10

Cilest contains ethinylestradiol and norgestimate

Question 11

What hormones does Yasmin contain?

Answer 11

Yasmin contains ethinylestradiol and drospirenone

Question 12

What hormones does Marvelon contain?

Answer 12

Marvelon contains ethinylestradiol and desogestrel

Question 13

What hormone combo is NICE first line?

Answer 13

ethinylestradiol with:

• levonorgestrel or
• norethisterone

(lower VTE risk)

Question 14

Which COPC are NICE first line?

Answer 14

Microgynon or Leostrin

ethinylestradiol with:

• levonorgestrel (Microgynon) or
• norethisterone (Loestrin)

(lower VTE risk)

Question 15

Which COCP is first line for PMS?

Answer 15

Yasmin / drospirenone for PMS

Drospirenone has anti-mineralocorticoid and anti-androgen activity, helps symptoms of:

• bloating,
• water retention and
• mood changes

Continuous use more effective for PMS

Question 16

What type of COCP pills could be used if someone suffers from acne?

Answer 16

COCPs containing cyproterone acetate

Question 17

Name a COCP containing cyproterone acetate and what it could help with?
Use?

Answer 17

Dianette / cyproterone acetate can be used for:

• acne
• hirsutism

More oestrogen mean 2x great VTE risk. Stop 3 months after acne is controlled.

Question 18

What 3 COCP regimes are there?

Answer 18

• 21 days on and 7 days off
• 63 days on (three packs) and 7 days off (“tricycling“)
• Continuous use without a pill-free period

Question 19

8 side effects of COCPs?

Answer 19

• Unscheduled bleeding is common in the first three months and should then settle with time
• Breast pain and tenderness
• Mood changes and depression
• Headaches
• Hypertension
• VTE (the risk is much lower for the pill than pregnancy)
• Small increased risk of BREAST and CERVICAL cancer, returning to normal ten years after stopping
• Small increased risk of MI and stroke

Question 20

5 benefits of COCPs?

Answer 20

• Effective contraception
• Rapid return of fertility after stopping
• Improvement in premenstrual symptoms, menorrhagia (heavy periods) and dysmenorrhoea (painful periods)
• Reduced risk of ENDOMETRIAL, OVARIAN and COLON cancer
• Reduced risk of benign ovarian cysts

Question 21

What are COCP UKMEC 4 contraindications?

Answer 21

COCP is UKMEC 4:

• Uncontrolled HTN (particularly ≥160 / ≥100)
• Migraine with aura (risk of stroke)
• History of VTE
• Aged >35 and smoking more than 15 cigarettes per day
• Major surgery with prolonged immobility
• Vascular disease or stroke
• Ischaemic heart disease, cardiomyopathy or AF
• Liver cirrhosis and liver tumours
• SLE and antiphospholipid syndrome
• note BMI >35 is UKMEC 3

Question 22

When and how should you start the pill?

Answer 22

Start on 1st day of cycle (or within 5days) and no extra contraception needed.

If start after day 5 you need condoms for 7 days.
(ensure not pregnant - reliable use before)

Question 23

Advice for switching between contraceptive pills?

Answer 23

Between COCPs finish one finish one pack, start the new pill pack without the pill-free period.

Traditional progesterone-only pill (POP), they can switch at any time but 7 days of extra contraception (i.e. condoms).

Desogestrel (progesterone-only), can switch immediately, and no additional contraception is required. This differs from a traditional POP because desogestrel inhibits ovulation.

Question 24

Important things to cover in a combined contraception pill OSCE / consultation?
(long answer)

Answer 24

• Different contraceptive options, including long-acting reversible contraception (LARC)
• Contraindications
• Adverse effects
• How to take
• Missed pills
• Factors on efficacy (e.g. D&V, enzyme inducers)
• Sexually transmitted infections (this pill is not protective)
• Safeguarding concerns (particularly in those under 16)

Screen for contraindications by discussing and documenting:

• Age
• Weight and height (BMI)
• Blood pressure
• Smoker or non-smoker
• Past medical history (particularly migraine, VTE, cancer, cardiovascular disease and SLE)
• Family history (particularly VTE and breast cancer)

Question 25

What is an COCP " one missed pill"?

Answer 25

When is it more than 24 hrs late, so 48 hrs since the last pill was taken but less than 72 hrs.

Question 26

What should you do when you miss one pill?

Answer 26

- Take the missed pill as soon as possible (even if this means taking two pills on the same day) - No extra protection

Question 27

What happens if you miss more than one pill?

Answer 27

ie 72hrs since last pill 1. Take the most recent missed pill as soon as possible (ie two in one day) 2. CONDOMS for until they have taken pill straight for 7 DAYS 3. depending on day of packet, if day: - 1-7; emergency contraception - 8-14 no emergency - 15-21 no emergency but back to back the next pack (skip pill free period) (and condoms 7 days) (technically it takes 7 days to work, and 7 days to not work, break periods are the riskiest times)

Question 28

What do you do if you have D&V?

Answer 28

This counts as a missed pill!

Question 29

Name a medicine that reduces COCP effectiveness?

Answer 29

Rifampicin ``` and other enzyme inducers PC BRAS: - phenytoin - carbamazepine - barbiturates - rifampicin - alcohol chronic - sulphonylureas (and: smoking, St Johns Wort, griseofulvin) ```

Question 30

Should COCP be stopped before surgery?

Answer 30

Yes, four weeks before a major operation (great than 30mins) or anything that needs limb immobilised.