QuestionSBA
QuestionChoice
BMI should be recorded and documented prior to initiating combined hormonal contraception in all women, even those who do not appear overweight. Women with a BMI ≥35 kg/m<sup>2</sup> generally should not use combined hormonal contraception.
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a
Height and weight
QuestionChoice
Cervical screening starts at age 25 in the UK. Prior to age 25, cervical smears should not be performed.
49808
b
Cervical smear test for primary screening for high-risk human papillomavirus infection
QuestionChoice
As she has been using condoms reliably, there is no need to perform a pregnancy test prior to initiating combined hormonal contraception.
49811
e
High-sensitivity urinary pregnancy test
QuestionChoice
Routine checks for diabetes and impaired glucose tolerance are not required for initiation of combined hormonal contraception, even if there is a family history.
49809
c
Check HbA1c level
QuestionChoice
The use of combined hormonal contraception is acceptable for women with a family history of breast cancer, and genetic tests are not required.
49810
d
Screening for BRCA1 and BRCA2 genes
QuestionComment
her family history of maternal breast cancer entirely excludes the option of the COCP?
17995
QuestionComment
FxHx is UKMEC 1, carrying BRCA mutation is 3, current cancer is 4 and past is 5. Technically she is eligible, it’s also likely that her mother would be aware of BRCA mutations that might need screening, I believe patients are normally told about such potentially hereditary conditions.

25629
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Pleomorphic Adenoma
QuestionComment
Probably a typo, but past breast cancer would be UKMEC 3
26185
User
subscriber
Acute Body
User
subscriber
Jargon Tachycardia
QuestionComment
BMI >35 is UKMEC3 though.
27818
User
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Relapse CT
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# 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.

# Administration

* Taken orally once daily, ideally at the same time each day
* Can be taken for 21 days with a 4 or 7 day hormone-free interval (HFI), or tricycled (9 weeks consecutive use with 4 or 7 day HFI)

# 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
 * Personal history of 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 in first-degree relative 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 breast 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/)
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Contraception request/advice
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Obstetrics and gynaecology
A 22-year-old woman attends her general practitioner seeking contraception. She is entering her final year at university and does not wish to become pregnant while studying. She has read a little about contraception and thinks she would like to take a combined oral contraceptive pill. She is currently using condoms every time she has intercourse.

She has a past medical history of asthma, atopic dermatitis and has recently recovered from a COVID-19 infection. She takes salbutamol as required. She does not appear overweight.

Her mother has type 2 diabetes and recently underwent a left mastectomy for a lobular breast cancer in situ. Her father recently died age 59 of bowel cancer.

Which of the following should be performed before prescribing the combined oral contraceptive pill?
a