QuestionSBA
QuestionChoice
Mastitis does cause breast pain, however, examination would reveal inflammatory changes such as erythema and warmth. Mastitis is common among those breastfeeding, but it can also occur in smokers.
62384
b
Mastitis
QuestionChoice
A patient under the age of 30 with bilateral breast pain and normal examination is unlikely to have breast cancer.
The guidance for urgent referral on the suspected cancer pathway is:

*  30 years or over with unexplained breast lump with or without pain, or
* 50 years and over with unilateral nipple changes such as discharge or retraction

A referral can be considered for those with skin changes to the breast or those 30 years and over with an unexplained lump in the axilla.
[Click here for NICE CKS on Breast cancer - recognition and referral] (https://cks.nice.org.uk/topics/breast-cancer-recognition-referral/)
62385
c
Breast malignancy
QuestionChoice
Fat necrosis often occurs after trauma to the breast tissue. A lump with overlying bruising would be found on examination.
62386
d
Fat necrosis of the breat
QuestionChoice
Fibroadenomas are benign tumours of the breast originating from fibrous and epithelial tissue. Whilst this patient is a typical age for fibroadenomas, she does not present with a lump. Fibroadenomas present with a firm, non tender lump which is highly mobile.
62387
e
Fibroadenoma of the breast
QuestionChoice
Breast tenderness is a common side effect of the combined oral contraceptive pill. This can often be managed with simple analgesia such as paracetamol, however, alternative contraception can be offered if symptoms continue.
62383
a
Side effect of the combined oral contraceptive pill
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
12538
A 24 year old female attends her GP surgery with bilateral breast tenderness for the past two weeks. Examination of the breasts shows no abnormalities.

Her past medical history includes asthma.

She currently takes a salbutamol inhaler and the combined oral contraceptive pill.

Which of the following is the most likely explanation for this patient’s symptoms?
a