QuestionSBA
QuestionChoice
A levonorgestrel-releasing intrauterine system (IUS) such as Mirena® is a coil that elutes levongesterel. It is used as contraception as well as a treatment for menorrhagia when dysfunctional intrauterine bleeding has been diagnosed. NICE guidance suggests initiating treatment for heavy menstrual bleeding without further investigation when the patient is low risk for fibroids or uterine cavity abnormalities, such as this patient.
The coil should be offered first line and disucssed with the patient to see if it aligns with their wishes in terms of contraception. The patient should also be counselled on the IUS causing menstrual irregularities for the first 6 months.
62203
a
A Levonorgestrel-releasing intrauterine system
QuestionChoice
An intrauterine device (IUD) is also known as the copper coil. It is a form of contraception. It is not recommended in menorrhagia as the IUD can cause periods to be heavier.
62207
e
Intrauterine device
QuestionChoice
An ultrasound is recommended if there is a suspicion of fibroids eg a mass felt on examination, age of over 30 or dysmenorrhea.
62204
b
Pelvic ultrasound
QuestionChoice
Whilst this can be used as a treatment option for menorrhagia secondary to dysfunctional uterine bleeding, it is contraindicated for this patient due to her history of migraines with aura.
62205
c
Combined oral contraceptive pill
QuestionChoice
Tranexamic acid can be offered to treat menorrhagia for those who find the IUS unsuitable. It can also be beneficial to those who are suspected to have fibroids as it can be used in the interim before investigations have been arranged.
62206
d
Tranexamic acid
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
12502
A 25 year old female attends her GP surgery with heavy periods for the past 6 months. Due to this she is struggling to go to work when menstruating. Her periods are regular with no intermenstrual bleeding.
She has a past medical history of migraines with aura for which she takes sumitriptain.

An examination reveals no abnormalities. Blood tests are carried out which show a mild anaemia and a normal clotting screen.

Which of the following is the best next step in the management of this patient?
a