QuestionSBA
QuestionChoice
Ovarian cancer comes under category 1 in the UK Medical Eligibility criteria (UKMEC), therefore, they recommend unrestricted use
32951
d
History of ovarian cancer
QuestionChoice
This is not a contraindication because the patient is 19. Anyone under 35 who smokes comes under category 2 in the UK Medical Eligibility criteria (UKMEC), therefore, the "benefits generally outweigh the risks"
32950
c
Current smoker, 20 a day
QuestionChoice
Hypertension (with a systolic of more than 160 mmHg or diastolic of more than 95 mmHg) comes under category 4 in the UK Medical Eligibility criteria (UKMEC). However, hypotension is not a contraindication
32952
e
Hypotension
QuestionChoice
Stroke comes under category 4 in the UK Medical Eligibility criteria (UKMEC), which means that prescribing the COCP would lead to a "unacceptable health risk and should not be used". A patients' risk of stroke will increase slightly when prescribed the COCP, therefore, should be avoided in patients who have previously had a stroke
32948
a
History of stroke
QuestionChoice
This is not a contraindication to starting the COCP. Women can in fact extend the cycling of the packets to reduce the number of bleeds they experience
32949
b
Heavy menstrual periods
QuestionComment
According to Quesbook:

Advantages of a contraceptive outweigh the disadvantages (UKMEC 2)
Initiation after current or past history of MI or stroke, multiple risk factors for arterial cardiovascular disease

also, cancer is said to be in UKMEC4 (absolute contraindications)
6233
QuestionComment
**current** breast cancer: UKMEC 4

6466
User
subscriber
Serpiginous Metabolism
User
subscriber
Hypertension Sclerosis
QuestionComment
i read history of "smoke" lol
23619
User
subscriber
richmond
Concept
Chapter
# Summary
 

The combined oral contraceptive pill (COCP) is a long-term contraceptive containing synthetic oestrogen and progestogen. It works by inhibiting ovulation, thickening cervical mucus, and altering the endometrium to prevent fertilisation and implantation. Indications for COCP use include contraception, menstrual cycle regulation, and treatment of dysmenorrhea, menorrhagia, acne, and hirsutism. Contraindications are categorised by UKMEC criteria, detailed in this chapter. 
  
# Definition
 

The combined oral contraceptive pill (COCP) is a long-term contraceptive. It contains synthetic versions of the female hormones oestrogen and progestogen. 
 

# Mechanism of Action
 

* **Inhibition of Ovulation:** The COCP contains synthetic versions of the hormones oestrogen and progestogen. These hormones together suppress the release of gonadotrophins (LH and FSH) from the pituitary gland, preventing the maturation and release of an egg from the ovaries.
 

* **Thickening of Cervical Mucus:** The progestogen component of the COCP increases the viscosity of cervical mucus, making it more difficult for sperm to enter the uterus and fertilise an egg.
 

 * **Alteration of the Endometrium:** The COCP induces changes in the lining of the uterus (endometrium), making it less suitable for the implantation of a fertilised egg.
 

# Indications
 

There are a range of reasons for women to be recommended the oral combined contraceptive pill. For example:
 

* **Contraception:** The COCP works as a long-term contraception. It is taken orally once a day, at around the same time each day. 
 * **Menstrual Cycle Regulation:** The COCP can help regulate irregular menstrual cycles. 
 * **Dysmenorrhea:** The COCP may be used to reduce menstrual cramps. 
 * **Menorrhagia:** The COCP can decrease heavy menstrual bleeding.
 * **Acne and Hirsutism:** The COCP helps in the treatment of acne and excessive hirsutism in women, which may happen in conditions such as polycystic ovary syndrome (PCOS) or other androgen excess conditions.
 * **Premenstrual Syndrome (PMHS**: The COCP can alleviate symptoms of PMS, such as mood swings, bloating, and irritability.
  
# Contraindications 
 
There are numerous contra-indications to the Combined Oral Contraceptive Pill. These can be divided into absolute contraindications, known as ''UKMEC 4'', a situation where the disadvantages outweigh the advantages (UKMEC 3), a situation where the advantages outweigh the disadvantages (UKMEC 2), and a situation whereby there is no limit on that choice of contraception (UKMEC 1).
 

## Absolute Contraindications to Contraception (UKMEC 4)
  
  
  * Known or suspected pregnancy
  * Hypertension with SBP ≥160 mmHg or DBP ≥100 mmHg
  * Smoker over the age of 35 who smokes >15 cigarettes a day 
  * Current and history of ischaemic heart disease
  * History of stroke (including TIA) 
  * Vascular disease
  * History or current VTE
  * Major surgery with prolonged immobilisation
  * Breastfeeding <6 weeks postpartum
  * Not breastfeeding and <3 weeks postpartum with other risk factors for VTE
  * Known thrombogenic mutations 
  * Complicated valvular and congenital heart disease
  * Cardiomyopathy with impaired cardiac function
  * Atrial fibrillation 
  * Migraine with aura (any age)
  * Current breast cancer 
  * Severe (decompensated) cirrhosis 
  * Hepatocellular adenoma and hepatocellular carcinoma
  * Positive antiphospholipid antibodies 
  
  
  
## Disadvantages of a contraceptive outweigh the advantages (UKMEC 3)
  
  * Obesity (BMI ≥35 kg/m2)
  * Multiple risk factors for cardiovascular disease (e.g. smoking, diabetes mellitus, hypertension, obesity, dyslipidaemia) 
  * Well controlled hypertension, and hypertension with SBP >140-159 mmHg or DBP <90-99 mmHg
  * Smoker over age of 35 who smokes <15 cigarettes a day, or anyone over age of 35 who stopped smoking <1 year ago
  * Family history of thrombosis before 45 years old
  * Not breastfeeding and <3 weeks postpartum without other risk factors for VTE
  * Not breastfeeding and between 3-6 weeks postpartum with other risk factors for VTE
  * Organ transplant with complications (e.g. graft failure, rejection) 
  * Immobility (unrelated to surgery)
  * Migraine without aura (any age) [applies to *continuation* of COCP]
  * History (≥5 years ago) of migraine
with aura (any age) 
  * Undiagnosed breast mass or symptoms [applies to *initiation* of COCP] 
  * Carriers of known gene mutations associated with breast cancer
  * Past breat cancer 
  * Diabetes mellitus with nephropathy, retinopathy, neuropathy or other vascular complications 
  * Symptomatic gall bladder disease treated medically or currently active 
  * Past COCP associated cholestasis 
  * Acute viral hepatitis [applies to *initiation* of COCP]
  
  
  
## Advantages of a contraceptive outweigh the disadvantages (UKMEC 2)
  
  * Smokers under the age of 35, and people aged over 35 who stopped smoking over 1 year ago 
  * Obesity (BMI ≥30–34 kg/m2) 
  * Family history of VTE in first-degree relative aged ≥45 years
  * History of raised blood pressure in pregnancy 
  * Breast feeding between 6 weeks-6 months postpartum
  * Not breastfeeding and between 3-6 weeks postpartum without other risk factors for VTE
  * Uncomplicated organ transplant 
  * Known dyslipidaemia 
  * Major surgery without prolonged immobilisation 
  * Superficial venous thrombosis 
  * Uncomplicated valvular and congenital heart disease
  * Cardiomyopathy with normal cardiac function 
  * Long QT syndrome 
  * Non-migrainous headaches [applies to *continuation* of COCP]
  * Migraine without aura [applies to *initiation* of COCP] 
  * Idiopathic intracranial hypertension 
  * Unexplained vaginal bleeding
  * Cervical cancer 
  * Undiagnosed breast mass or symptoms [applies to *continuation* of COCP]
  * Insulin-dependent diabetes mellitus without vascular disease 
  * Symptomatic gall bladder disease treated through cholecystectomy, or asymptomatic gall bladder disease, or history of pregnancy-related cholestasis 
  * Acute viral hepatitis [applies to *continuation* of COCP]
  * Inflammatory bowel disease 
  * Sickle cell disease 
  * Rheumatoid arthritis
  * SLE without antiphospholipid antibodies 
 

 

# Side-effects and Complications
  
**Common Side-Effects:**
 

 * Breast tenderness 
 * Abdominal discomfort, nausea diarrhoea 
 * Headaches
 * Mood changes
 * Reduced libido 
 

**Rare but Serious Side-Effects:**
 

 * Embolism or thrombus, including: DVT and PE, stroke, myocardial infarction
 * Increased risk of breast cancer
 * Increased risk of cervical cancer 
 

 

# Follow-up

Arrange follow up 3 months following initial prescription of a COCP, and annually thereafter.
 

At follow-up, ensure to: 
 

 * Check blood pressure and BMI. 
 * Ask about headaches (including migraine). 
 * Check for risk factors that may be contraindicators to COCP (as per UKMEC criteria). 
 * Enquire about side-effects. 
 * Enquire about how woman is taking the COCP (i.e. adherence). 
 

 

# Missed Pill Rules
 

**Missed One Pill:**
 

* Advise patient to take the pill as soon as possible, even if it means taking two pills in one day.
* * Continue taking the rest of the pack as usual.
No additional contraception needed if this is the only pill missed in the pack.
 

**Missed Two or More Pills in Week 1 (Days 1-7):**
 

 * Advise patient to take the last pill they missed as soon as possible. 
 * Continue taking the rest of the pack as usual.
 * Use additional contraception for the next 7 days.
 * If they had unprotected sex during this week, seek emergency contraception.
 

**Missed Two or More Pills in Week 2 (Days 8-14):**
 

 * Take the last pill they missed as soon as possible. 
 * Continue taking the rest of the pack as usual.
 * No additional contraception needed if they have taken pills correctly for the 7 days prior to the missed pill.
 

**Missed Two or More Pills in Week 3 (Days 15-21):**
 

* Finish the active pills in the current pack, then start a new pack immediately without taking the usual 7-day break.
* No additional contraception needed if they have taken pills correctly for the 7 days prior to the missed pill.
  
# NICE Guidelines 
 

[Click here to view NICE Guidelines on COCP](https://cks.nice.org.uk/topics/contraception-combined-hormonal-methods/management/combined-oral-contraceptive/)
  
  
# References
  
[Click here to see the UKMEC summary sheet on contraception](https://www.fsrh.org/standards-and-guidance/documents/ukmec-2016-summary-sheets/)
2047
2639
Combined Hormonal Contraception
Topic
60
General Practice
6590
A 19-year-old patient visits her GP to talk about different types of contraception. She is keen to start the combined oral contraceptive pill (COCP).

Which of these would be a contraindication for this patient to start the COCP?
a