QuestionSBA
QuestionChoice
While deep-vein thromboses are a well-known adverse effect of taking oestrogen-containing contraception, it is not necessary to rule out an existing DVT prior to starting contraception
34412
c
Venous doppler ultrasound
QuestionChoice
Hypertension is a common adverse effect of the combined oral contraceptive pill and it is recommended that blood pressure should be checked before and while taking the COCP
34410
a
Blood pressure
QuestionChoice
A D-dimer is a specific blood test that is useful in helping to guide clinical diagnosis of a DVT. It is not necessary to perform one prior to starting contraception
34413
d
D-dimer
QuestionChoice
It is not necessary to perform an ECG prior to starting contraception
34411
b
ECG
QuestionChoice
It is recommended to monitor the blood pressure and weight prior to starting and while taking the COCP
34414
e
No routine monitoring is required
QuestionComment
there are no monitoring requirements for blood pressure. Where is that?

17586
QuestionComment
you do have to measure BP once per year
61349
User
subscriber
Vaccine Complement
User
subscriber
Fungal Tyrosine
QuestionComment
its before starting not necessarily monitored
36709
User
subscriber
Serotonin Dorsal
QuestionComment
Is this on the BNF somewhere? I can't find it
39649
User
subscriber
Just Another Med Student
QuestionComment
found in oral contraceptives treatment summary, not the drug page
61469
User
subscriber
Suture Retrograde
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
2772
Combined Oral Contraceptive Pill
Topic
76
Obstetrics and Gynaecology
6893
A 15 year old girl attends her GP to ask for the combined oral contraceptive pill. During the consultation, her GP is satisfied that there are no safeguarding concerns regarding her partner and that she meets the Fraser guidelines. She is prescribed ethinylestradiol with desogestrel 1 tablet daily for 21 days and a 7-day pill free break.


Question: Select the most appropriate monitoring option required before starting her contraception.
a