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PatientPlus articles are written for doctors and so the language can be technical. However, some people find that they add depth to the articles found in the other sections of this website which are written for non-medical people.

Combined Oral Contraceptive (Follow Up and Common Problems)

What to do in the follow-up consultation
  • When the patients attend for follow-up ask whether she has found it easy to use and if she has noticed any adverse effects. Check she understands how to take it and that she knows how to manage missed pills.1 Has the pattern of withdrawal bleeds been regular? Has there been any breakthrough bleeding?
  • At future appointments e.g. annual review consider whether contraception is still required and if the combined pill is still the most appropriate and safest method. Has there been developments in her medical history e.g. new medication, or social history e.g. age and smoking, which need to be considered.
  • Check blood pressure.
  • Check whether cervical screening is due.
  • Give the patient opportunity to ask questions.
Common problems

Breakthrough bleeding

See separate article on breakthrough bleeding. Women should be advised that this can occur with the combined oral contraceptive pill, 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.
If a patient presents with breakthrough bleeding (BTB) consider the following before a change of pill:

  • Test for chlamydia. Chlamydial cervicitis is the most common cause of BTB in young sexually active women.2
  • Look for local causes (examine the cervix).
  • Has there been any missed pills? BTB may start 2-3 days after a missed pill.
  • Is the patient taking any other medicines? Enzyme inducers e.g. rifampicin, carbamazepine.
  • Does the patient drink? People who drink heavily are more likely to miss pills and less likely to remember that they have.
  • Is there any reason to suggest an absorption problem? Has there been diarrhoea or vomiting?
  • Is the patient pregnant or recently lost a pregnancy?
  • Does the patient have a bleeding tendency?

Bleeds or spotting at times other than the expected withdrawal bleed which persists for more than 3 months, should be managed by changing the type of pill.
There is limited data to suggest that BTB is more common with preparations containing 20 micrograms of oestrogen rather than 30 or higher. A Cochrane review found little evidence supporting bi-phasic or tri-phasic preparations, and suggested that choice of progestogen may be more important.3

A suitable strategy would therefore be:

  1. Increase oestrogen content if on low-dose preparation.
  2. Change progestogen.
  3. Increase progestogen.
  4. Try phased preparation.

Drug interactions

There are many commonly used drugs which can effect the efficacy of the pill:4

  • Antibacterials - Rifamycins, amoxicillin and tetracyclines
  • Antidepressants - St John's Wort, which can be bought over the counter
  • Anti-convulsants - carbamazepine, oxcarbazepine, phenobarbital, phenytoin, primidone and topiramate
  • Anti-fungals - griseofulvin
  • Anti-virals - nelfinavir,nevirapine, ritonavir
  • Modafinil - used in the treatment of narcolepsy
Category of drug Advice given
Less than 3 week course of non enzyme inducing broad spectrum antibiotic Should be advised to use additional contraception during the course and for 7 days afterwards. To omit the pill-free interval, if the 7 days runs beyond the end of the packet. Omit the inactive tablets if using an everyday preparation.
Short course( less than 7 days) of rifamycin. Women are advised to continue taking the COC pill and omit any pill free interval that would have occurred during the course or the 7 days following it.
Long term course of rifamycin Should be advised to use alternative, non-hormonal method where possible.
Enzyme inducing drugs, incl anti- convulsants, St john's Wort etc Should be encouraged to use alternative methods of contraception. If having considered alternatives they still choose the COC pill 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.5

Erythromycin, co-trimoxazole and sulphonamides are thought not to interact with the pill.
Long-term antibiotics are less likely to effect pill use as resistant gut flora emerge after 3 weeks.
The anti-convulsants sodium valproate and lamotrigine are also thought to have little effect on pill efficacy.

Diarrhoea and vomiting

  • Vomiting within 2 hours of taking the pill or very severe diarrhoea can effect 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.
  • Women should be advised to return for a pregnancy test if there is a very light or no withdrawal bleed.

Surgery6

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

There are 2 choices:

  1. Continue the COC pill and administer thromboprophylaxis in the peri-operative period. This involves subcutaneous heparin and graduated compression stockings.
  2. 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 e.g. 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 COC pill. 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

Advice for Women over 40 years of age (see related article COC - first prescription).

  • Women should be advised that although natural fertility declines after 37 years of age, effective contraception is still required.
  • No contraceptive method is contraindicated by age alone.
  • The COC pill can be used unless there are coexisting diseases or risk factors.
  • Women who have no other risk factors, and have stopped smoking more than 1 year ago, may use the COC pill.
  • Clinicians prescribing the pill to women over 40 years should consider a monophasic pill, with less than, or equal to 30 micrograms of oestrogen and a low dose of norethisterone or levonorgestrel as the first choice.
  • There is debate over evidence showing a potential protective effect against osteoporosis. Low dose preparations with 30-35 micrograms of oestrogen may positively effect bone mineral density.

Other uses for the combined hormonal contraceptive pill.

  • In women with heavy, painful menses the combined pill has been shown to reduce the amount of pain and bleeding.7,8 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.9
  • Women who have polycystic ovarian disease (PCOS) are often oligo-amenorrheic. 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.10 They should be offered protective therapy from prolonged exposure to relatively unopposed oestrogen. The COC pill does this effectively, as well as providing contraception.
  • Randomised controlled trials have shown significant improvements in acne vulgaris whilst using the COC pill. 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 COC pills and should not be used indefinitely.
  • Reduction of 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 COC is used for more than 5 years, or 50% in endometrial cancer if used for more than 1 year.

Document References
  1. Missed Pills, Faculty of Family Planning and Reproductive Health Care RCOG (2005)
  2. FFPRHC; Faculty of Family Planning and Reproductive Health Care Clinical Effectiveness Unit; Contraceptive Choices for Young People.
  3. Van Vliet HA, Grimes DA, Helmerhorst FM, et al; Biphasic versus triphasic oral contraceptives for contraception.; Cochrane Database Syst Rev. 2003;(2):CD003283. [abstract]
  4. British National Formulary British Medical Association and Royal Pharmaceutical Society of Great Britain. London.
  5. FFPRHC; Faculty of Family Planning and Reproductive Health Care Clinical Effectiveness Unit - Drug Interactions; [pdf download]
  6. D'Souza R, Guillebaud J; Venous thromboembolism and oral contraceptives.; Lancet. 1999 Oct 23;354(9188):1469; author reply 1469-70.
  7. Hendrix SL, Alexander NJ; Primary dysmenorrhea treatment with a desogestrel-containing low-dose oral contraceptive.; Contraception. 2002 Dec;66(6):393-9. [abstract]
  8. 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.
  9. 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. [abstract]
  10. 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.
AcknowledgementsEMIS is grateful to Dr Hayley Willacy for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2007.
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Document Version: 1
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Last Updated: 6 Sep 2007
Review Date: 5 Sep 2008






















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