Combined Oral Contraceptive (Follow-up and Common Problems)

oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

  • When the patient attends for follow-up ask:
    • Has she found it easy to use?
    • Has she noticed any adverse effects?
    • Does she understand how to take it?
    • Does she know how to manage missed pills?[1]
    • Has the pattern of withdrawal bleeds been regular?
    • Has there been any breakthrough bleeding (BTB)?
  • At future appointments, eg annual review, consider whether contraception is still required and if the combined pill is still the most appropriate and safest method:
    • Have there been developments in her medical history, eg new medication, or social history, eg age and smoking, which need to be considered.
    • Check blood pressure.
    • Check whether cervical screening is due.
    • Give the patient the opportunity to ask questions.

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Breakthrough bleeding

See separate article Breakthrough Bleeding with Combined Hormonal Contraception.[2] Women should be advised that this can occur with the combined oral contraceptive pill (COCP), most commonly in the first few months. If there has been no vomiting or diarrhoea and no missed pills, it has not been shown to indicate reduced efficacy.

Drug interactions

There are many commonly used drugs which can affect the efficacy of the pill. Women should be advised to carry out a pregnancy test and seek medical advice if there is a very light or no withdrawal bleed:

  • Antibacterials - enzyme inducers only, eg rifampicin, rifabutin.
  • Antidepressants - St John's wort (which can be bought over-the-counter).
  • Anticonvulsants - carbamazepine, oxcarbazepine, phenobarbital, phenytoin, primidone and topiramate.
  • Antifungals - griseofulvin.
  • Antivirals - nelfinavir, nevirapine, ritonavir.
  • Modafinil (used in the treatment of narcolepsy and fatigue).
Category of drug Advice given
Non-enzyme-inducing antibacterial. Should be advised that no additional contraception is required.
Short course (less than 7 days) of rifamycin. Women are advised to continue taking the combined oral contraceptive pill (COCP) and omit any pill-free interval that would have occurred during the course or the 7 days following it. Additional contraception should be continued for 28 days after stopping the rifamycin.
Long-term course of rifamycin. Should be advised to use an alternative, non-hormonal method where possible.
Enzyme-inducing drugs, including anticonvulsants, St John's wort, etc. Should be encouraged to use alternative methods of contraception. If, having considered alternatives, they still choose the COCP, the patient should be advised of the increased risk of pregnancy. Should use a preparation containing at least 50 micrograms of oestrogen. Tricycling the packs, with no withdrawal bleed for 3-4 packs and then a reduced pill-free interval of only 4 days, is also recommended. If BTB occurs on 50 micrograms, the dose should be increased to 80-100 micrograms.

Women on lamotrigine monotherapy should be advised that due to the risk of reduced seizure control whilst on combined hormonal contraception (CHC), and the potential for toxicity in the CHC-free week, the risks of using CHC may outweigh the benefits.[3]

Diarrhoea and vomiting

  • Vomiting within 2 hours of taking the pill, or very severe diarrhoea, can affect the absorption of the pill.
  • The advice for women who suffer vomiting or diarrhoea for more than 24 hours is to follow the same advice as if they had missed pills.

Surgery

For any woman on the COCP about to undergo major elective operation, or leg surgery, the risk of thromboembolism needs to be balanced with the risk of unwanted pregnancy.[4]

There are 2 choices:
  • Continue the COCP and administer thromboprophylaxis in the peri-operative period. This involves subcutaneous heparin and graduated compression stockings.
  • Discontinue the pill 4 weeks prior to surgery. Restart the pill on day one of the next period, occurring at least 2 weeks after mobilisation. Discuss effective alternatives eg depot injection and provide as appropriate. Restart pill before next injection is due.

Women requiring emergency surgery should receive subcutaneous heparin and compression stockings.

Amenorrhoea

  • There can be amenorrhoea following cessation of using the COCP. This is usually due to the pill's withdrawal bleeds masking an underlying problem.
  • Any amenorrhoea lasting more than 6 months after stopping the pill should be investigated as for secondary amenorrhoea.

Mature women

This is detailed in Contraception and the Mature Woman.

Menorrhagia

  • In women with heavy, painful menses the combined pill has been shown to reduce the amount of pain and bleeding.[5][6]
  • It can also make the cycle more manageable by running together packs, and avoiding the pill-free week, women can avoid the withdrawal bleed. This is particularly useful for travel, but also for athletes. It is good practice to advise women that they can manipulate their cycle in this way as research has suggested that 78% of women are not aware of this potential and 58% of women would be interested in using this option.[7]

Polycystic ovarian disease

  • Women who have polycystic ovarian disease (PCOS) are often oligo-amenorrhoeic.
  • Endometrial cystic hyperplasia is associated with prolonged periods of anovulation, as found in PCOS.
  • There is an association between endometrial carcinoma in young women, aged less than 40 years and PCOS.[8] They should be offered protective therapy from prolonged exposure to relatively unopposed oestrogen. The COCP does this effectively, as well as providing contraception.

Acne

  • Randomised controlled trials have shown significant improvements in acne vulgaris whilst using the COCP.
  • This evidence is specific for preparations containing the progestogens levonorgestrel and norethisterone. There is no evidence to support the use of Cilest® or Yasmin® for this purpose. Dianette® is also indicated for use in acne or moderately severe hirsutism. It should be withdrawn if there is no improvement after 3 months of use. Dianette® carries a four times higher risk of VTE than other COCPs and should not be used indefinitely.

Risk of ovarian or endometrial cancer

  • The pill has been shown to reduce the risk of ovarian or endometrial cancer in those considered to be at risk because of family history.
  • The risk is reduced by 50% in ovarian cancer if the COCP is used for more than 5 years, or 50% in endometrial cancer if used for more than 1 year.

Further reading & references

  1. Missed Pill Recommendations, Faculty of Sexual and Reproductive Healthcare (2011)
  2. Management of Unscheduled Bleeding in Women Using Hormonal Contraception; Faculty of Sexual and Reproductive Healthcare (2009)
  3. Drug Interactions with Hormonal Contraception, Faculty of Sexual and Reproductive Healthcare (2011)
  4. D'Souza R, Guillebaud J; Venous thromboembolism and oral contraceptives. Lancet. 1999 Oct 23;354(9188):1469; author reply 1469-70.
  5. Hendrix SL, Alexander NJ; Primary dysmenorrhea treatment with a desogestrel-containing low-dose oral contraceptive. Contraception. 2002 Dec;66(6):393-9.
  6. Iyer V, Farquhar C, Jepson R; The oral contraceptive pill for heavy menstrual bleeding. (2005) (Cochrane Review) The Cochrane Library. (Issue 4). Oxford Update Software.
  7. Andrist LC, Arias RD, Nucatola D, et al; Women's and providers' attitudes toward menstrual suppression with extended use of oral contraceptives. Contraception. 2004 Nov;70(5):359-63.
  8. Nisker JA, Ramzy I, Collins JA; Adenocarcinoma of the endometrium and abnormal ovarian function in young women. Am J Obstet Gynecol. 1978 Mar 1;130(5):546-50.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Hayley Willacy
Current Version:
Peer Reviewer:
Dr Hannah Gronow
Last Checked:
28/09/2011
Document ID:
482 (v5)
© EMIS