Hormonal Contraception III- Chapter 16:

Q 16. 1 What are the different types of combined oral contraceptive pills?

All combined oral contraceptive pills contain oestrogen and progestogen (Tables 16.1 & 16.2). Pills may be either fixed dose or phasic. All phasic pills have varying amounts of progestogen and the oestrogen content may also change during the course. With the exception of two pills, which have mestranol as the oestrogens, estrogens, all combined pills in the UK contain ethinyl oestradiol as the oestrogen. There are a variety of progestogens that have been developed and we have three “generations” of the pill. In 2002 a new pill called Yasmin® has been launched in the UK. This is the first combined pill to contain a new progestin called drospirenone that affects the salt and water balance in your body. It has been claimed that this new pill is even less likely to affect your weight than its predecessors. The pill is generally taken for twenty-one days with a seven day gap between courses. Some “every day pills” are marketed with seven placebo (blank) pills. These packages are not popular in the UK as the placebo may be taken at the incorrect time occasionally resulting in pill failure but in some countries the majority of packages are of the every day variety.

Q 16. 1 What are the different types of combined oral contraceptive pills?

Q 16. 1a What is the new Evra® Patch?

Q 16. 2 What are the benefits and problems of the phasic pills?

Q 16. 3 How will my doctor help me to decide which is likely to be the best pill for me?

Q 16. 4 Whilst I am taking the pill, what monitoring should I receive?

Q 16. 5 A member of my family has a history of a deep venous thrombosis (DVT) or pulmonary embolism (thromboembolism). Should I have a screening blood test?

Q 16. 6 Does an aeroplane journey increase the risks of taking the combined oral contraceptive pill?

Q 16. 7 Are there times when the combined oral contraceptive pill should be prescribed only with special caution?

Q 16. 8 Are there any contraindications to taking the combined oral contraceptive pill?

Q 16. 9 On which day of my menstrual cycle should I start my first course of the pill?

Q 16. 10 Can I start the combined oral contraceptive pill whilst I am breast-feeding?

Q 16. 11 Can I take the pill if I have had episodes when I did not see my periods (amenorrhoea)?

Q 16. 12 Can I start the pill if I am not currently seeing my periods?

Q 16. 13 Does it matter if I do not see a period whilst taking the pill?

Q 16. 14 What is the advice when my changing pill preparation?

Q 16. 15 What should be done if breakthrough bleeding occurs whilst I am taking the pill?

Q 16. 16 Can my pill withdrawal bleed be planned to avoid weekends?

Q 16. 17 Can I take the pill without a seven-day pill-free gap?

Q 16. 18 What should be done if a pill is missed?

Q 16. 19 Could I conceive whilst I am taking the pill?

Q 16. 20 Can combined oral contraceptive pills interact with other medication?

Q 16. 21 I am taking the combined oral contraceptive pill. Will this reduce my future fertility?

Q 16. 22 I have been on the pill for sometime. Is there any need to take a break from it?

Q 16. 23 I am due to have an operation. Should I stop taking my pill?

Q 16. 24 What is the advice with regard to third generation combined oral contraceptive pills?

Q 16. 25 Until what age can I take the pill?

Q 16. 26 I have taken the pill. Will this change the time when I will go through the menopause?

Q 16. 27 I am taking the pill. How will I know if I have reached my menopause?

Q 16. 28 In what circumstances should the pill be stopped immediately?

Q 16. 29 What symptoms are commonly associated with taking the oral contraceptive pill?

Q 16. 30 Should the pill be discontinued if I develop headaches?

Q 16. 31 If I have varicose veins can I take the pill?

Q 16. 32 I have developed vomiting and diarrhoea. How does this affect my pill taking?

Q 16. 33 How long before starting a pregnancy should I stop taking the pill?

Q 16. 34 Where can I obtain further information about contraception?

Q 16. 35 Could I have some Web sites?

Women’s Health – Home Page

Q 16. 1a What is the new EvraŽ Patch?

•This is the first contraceptive patch. It contains 150microg norgestromin + 20 microg. Ethinyl Oestradiol. This patch is applied once-weekly for three weeks with one week with no patch applied.

Evra is just as effective as the combined oral contraceptive pills.

•As 80% of the hormone is still present after 7days it is advised that the patch should not be flushed as there is a risk of water contamination.

Symptoms associated with the combined pill such as mastalgia dysmenorrhoea and breakthrough bleeding may be more common in early cycles than with COP.

This patch should be applied to the back of the shoulder, low down on the abdomen, upper arm or buttock. Once applied pressure should be applied for ten seconds. There is no need to remove it when bathing. At each change of patch a different site should be used.

When first used an Evra patch should be applied on the first day of your period and it will provide immediate protection. If you forget to change the patch after seven days in the middle of a course but you remember within 48 hours then you may change the patch and no further action is required. If there is more than a 48 hour delay then you should apply a new patch and use a barrier method for the next seven days.

The arrival of a new mode of administration in contraception should be welcomed although it will take a while before we learn how well it will be received. It provides an option for those who have had problems with a variety of oral preparations. Its success will be measured by the number of women who wish to try it on recommendation of their friends and relatives.

The pharmaceutical company has a Web site that provides further information that might interest you:

Q 16. 1 What are the different types of combined oral contraceptive pills?

Q 16. 2 What are the benefits and problems of the phasic pills?

Q 16. 3 How will my doctor help me to decide which is likely to be the best pill for me?

Q 16. 4 Whilst I am taking the pill, what monitoring should I receive?

Q 16. 5 A member of my family has a history of a deep venous thrombosis (DVT) or pulmonary embolism (thromboembolism). Should I have a screening blood test?

Q 16. 6 Does an aeroplane journey increase the risks of taking the combined oral contraceptive pill?

Q 16. 7 Are there times when the combined oral contraceptive pill should be prescribed only with special caution?

Q 16. 8 Are there any contraindications to taking the combined oral contraceptive pill?

Q 16. 9 On which day of my menstrual cycle should I start my first course of the pill?

Q 16. 10 Can I start the combined oral contraceptive pill whilst I am breast-feeding?

Q 16. 11 Can I take the pill if I have had episodes when I did not see my periods (amenorrhoea)?

Q 16. 12 Can I start the pill if I am not currently seeing my periods?

Q 16. 13 Does it matter if I do not see a period whilst taking the pill?

Q 16. 14 What is the advice when my changing pill preparation?

Q 16. 15 What should be done if breakthrough bleeding occurs whilst I am taking the pill?

Q 16. 16 Can my pill withdrawal bleed be planned to avoid weekends?

Q 16. 17 Can I take the pill without a seven-day pill-free gap?

Q 16. 18 What should be done if a pill is missed?

Q 16. 19 Could I conceive whilst I am taking the pill?

Q 16. 20 Can combined oral contraceptive pills interact with other medication?

Q 16. 21 I am taking the combined oral contraceptive pill. Will this reduce my future fertility?

Q 16. 22 I have been on the pill for sometime. Is there any need to take a break from it?

Q 16. 23 I am due to have an operation. Should I stop taking my pill?

Q 16. 24 What is the advice with regard to third generation combined oral contraceptive pills?

Q 16. 25 Until what age can I take the pill?

Q 16. 26 I have taken the pill. Will this change the time when I will go through the menopause?

Q 16. 27 I am taking the pill. How will I know if I have reached my menopause?

Q 16. 28 In what circumstances should the pill be stopped immediately?

Q 16. 29 What symptoms are commonly associated with taking the oral contraceptive pill?

Q 16. 30 Should the pill be discontinued if I develop headaches?

Q 16. 31 If I have varicose veins can I take the pill?

Q 16. 32 I have developed vomiting and diarrhoea. How does this affect my pill taking?

Q 16. 33 How long before starting a pregnancy should I stop taking the pill?

Q 16. 34 Where can I obtain further information about contraception?

Q 16. 35 Could I have some Web sites?

Women’s Health – Home Page

Q 16. 2 What are the benefits and problems of the phasic pills?

Phasic pills (Table 16.2) claim to provide better cycle control than monophasic pills providing the same amount of hormone each month.

Great care is needed to ensure that each pill is taken on the correct day. Some women report premenstrual syndrome like symptoms as the hormone levels change. Phasic pills do not readily lend themselves to postponing the withdrawal bleed or omitting the pill-free interval. This problem can be overcome when required by moving on to a monophasic pill with the same hormone content as the last part of the phasic pill (e.g. Binovum to Norimin).

Q 16. 1 What are the different types of combined oral contraceptive pills?

Q 16. 1a What is the new Evra® Patch?

Q 16. 2 What are the benefits and problems of the phasic pills?

Q 16. 3 How will my doctor help me to decide which is likely to be the best pill for me?

Q 16. 4 Whilst I am taking the pill, what monitoring should I receive?

Q 16. 5 A member of my family has a history of a deep venous thrombosis (DVT) or pulmonary embolism (thromboembolism). Should I have a screening blood test?

Q 16. 6 Does an aeroplane journey increase the risks of taking the combined oral contraceptive pill?

Q 16. 7 Are there times when the combined oral contraceptive pill should be prescribed only with special caution?

Q 16. 8 Are there any contraindications to taking the combined oral contraceptive pill?

Q 16. 9 On which day of my menstrual cycle should I start my first course of the pill?

Q 16. 10 Can I start the combined oral contraceptive pill whilst I am breast-feeding?

Q 16. 11 Can I take the pill if I have had episodes when I did not see my periods (amenorrhoea)?

Q 16. 12 Can I start the pill if I am not currently seeing my periods?

Q 16. 13 Does it matter if I do not see a period whilst taking the pill?

Q 16. 14 What is the advice when my changing pill preparation?

Q 16. 15 What should be done if breakthrough bleeding occurs whilst I am taking the pill?

Q 16. 16 Can my pill withdrawal bleed be planned to avoid weekends?

Q 16. 17 Can I take the pill without a seven-day pill-free gap?

Q 16. 18 What should be done if a pill is missed?

Q 16. 19 Could I conceive whilst I am taking the pill?

Q 16. 20 Can combined oral contraceptive pills interact with other medication?

Q 16. 21 I am taking the combined oral contraceptive pill. Will this reduce my future fertility?

Q 16. 22 I have been on the pill for sometime. Is there any need to take a break from it?

Q 16. 23 I am due to have an operation. Should I stop taking my pill?

Q 16. 24 What is the advice with regard to third generation combined oral contraceptive pills?

Q 16. 25 Until what age can I take the pill?

Q 16. 26 I have taken the pill. Will this change the time when I will go through the menopause?

Q 16. 27 I am taking the pill. How will I know if I have reached my menopause?

Q 16. 28 In what circumstances should the pill be stopped immediately?

Q 16. 29 What symptoms are commonly associated with taking the oral contraceptive pill?

Q 16. 30 Should the pill be discontinued if I develop headaches?

Q 16. 31 If I have varicose veins can I take the pill?

Q 16. 32 I have developed vomiting and diarrhoea. How does this affect my pill taking?

Q 16. 33 How long before starting a pregnancy should I stop taking the pill?

Q 16. 34 Where can I obtain further information about contraception?

Q 16. 35 Could I have some Web sites?

Women’s Health – Home Page

Q 16. 3 How will my doctor help me to decide which is likely to be the best pill for me?

The objective is to choose an effective pill, with the lowest side-effects and the lowest possible hormone content. A pill with 30 or 35mg ethinyl oestradiol is now the usual first choice. If this proves to be too low to prevent break-through bleeding the next preparation up the ladder (Table 16.1) may overcome the problem. A 50mg pill may be recommended for women on some anti-epileptic drugs (Q16.20).

If a friend has recommended her brand of pill to you there is unlikely to be a reason why you should not try it. Similarly, if you are about to recommence oral contraception and have been happy with one preparation in the past, it would seem reasonable for you to try it again.

Q 16. 1 What are the different types of combined oral contraceptive pills?

Q 16. 1a What is the new Evra® Patch?

Q 16. 2 What are the benefits and problems of the phasic pills?

Q 16. 3 How will my doctor help me to decide which is likely to be the best pill for me?

Q 16. 4 Whilst I am taking the pill, what monitoring should I receive?

Q 16. 5 A member of my family has a history of a deep venous thrombosis (DVT) or pulmonary embolism (thromboembolism). Should I have a screening blood test?

Q 16. 6 Does an aeroplane journey increase the risks of taking the combined oral contraceptive pill?

Q 16. 7 Are there times when the combined oral contraceptive pill should be prescribed only with special caution?

Q 16. 8 Are there any contraindications to taking the combined oral contraceptive pill?

Q 16. 9 On which day of my menstrual cycle should I start my first course of the pill?

Q 16. 10 Can I start the combined oral contraceptive pill whilst I am breast-feeding?

Q 16. 11 Can I take the pill if I have had episodes when I did not see my periods (amenorrhoea)?

Q 16. 12 Can I start the pill if I am not currently seeing my periods?

Q 16. 13 Does it matter if I do not see a period whilst taking the pill?

Q 16. 14 What is the advice when my changing pill preparation?

Q 16. 15 What should be done if breakthrough bleeding occurs whilst I am taking the pill?

Q 16. 16 Can my pill withdrawal bleed be planned to avoid weekends?

Q 16. 17 Can I take the pill without a seven-day pill-free gap?

Q 16. 18 What should be done if a pill is missed?

Q 16. 19 Could I conceive whilst I am taking the pill?

Q 16. 20 Can combined oral contraceptive pills interact with other medication?

Q 16. 21 I am taking the combined oral contraceptive pill. Will this reduce my future fertility?

Q 16. 22 I have been on the pill for sometime. Is there any need to take a break from it?

Q 16. 23 I am due to have an operation. Should I stop taking my pill?

Q 16. 24 What is the advice with regard to third generation combined oral contraceptive pills?

Q 16. 25 Until what age can I take the pill?

Q 16. 26 I have taken the pill. Will this change the time when I will go through the menopause?

Q 16. 27 I am taking the pill. How will I know if I have reached my menopause?

Q 16. 28 In what circumstances should the pill be stopped immediately?

Q 16. 29 What symptoms are commonly associated with taking the oral contraceptive pill?

Q 16. 30 Should the pill be discontinued if I develop headaches?

Q 16. 31 If I have varicose veins can I take the pill?

Q 16. 32 I have developed vomiting and diarrhoea. How does this affect my pill taking?

Q 16. 33 How long before starting a pregnancy should I stop taking the pill?

Q 16. 34 Where can I obtain further information about contraception?

Q 16. 35 Could I have some Web sites?

Women’s Health – Home Page

Q 16. 4 Whilst I am taking the pill, what monitoring should I receive?

Medical opinion varies as to how often patients on the pill should be checked. At your first visit the doctor will need to review your medical history and to undertake a general and pelvic examination. A further review will be undertaken about three months later to ensure that the chosen pill is acceptable. Many family planning clinics have specialist nurses to undertake some of these routine assessments. The blood pressure is checked at each subsequent visit to the clinic, which will probably be at three to six monthly intervals. A persistent blood pressure of 160/100mm Hg or more would be an indication to stop the pill and to consider medication to reduce your blood pressure. Pelvic examination and cervical smears every three years are probably adequate unless you develop symptoms. More frequent monitoring may be indicated for those with risk factors.

Product information for oral contraceptives currently includes the recommendation that all women should have breast and pelvic examination before starting the pill and at regular intervals whilst taking it. The Committee on Safety of Medicines and the Faculty of Family Planning and Reproductive Health Care in the UK now believe that it is unnecessary for all women taking the pill to have routine breast and pelvic examinations either before or whilst taking the pill. Blood pressure should always be measured but other physical examination should only be performed if considered appropriate by the clinician.

Q 16. 1 What are the different types of combined oral contraceptive pills?

Q 16. 1a What is the new Evra® Patch?

Q 16. 2 What are the benefits and problems of the phasic pills?

Q 16. 3 How will my doctor help me to decide which is likely to be the best pill for me?

Q 16. 4 Whilst I am taking the pill, what monitoring should I receive?

Q 16. 5 A member of my family has a history of a deep venous thrombosis (DVT) or pulmonary embolism (thromboembolism). Should I have a screening blood test?

Q 16. 6 Does an aeroplane journey increase the risks of taking the combined oral contraceptive pill?

Q 16. 7 Are there times when the combined oral contraceptive pill should be prescribed only with special caution?

Q 16. 8 Are there any contraindications to taking the combined oral contraceptive pill?

Q 16. 9 On which day of my menstrual cycle should I start my first course of the pill?

Q 16. 10 Can I start the combined oral contraceptive pill whilst I am breast-feeding?

Q 16. 11 Can I take the pill if I have had episodes when I did not see my periods (amenorrhoea)?

Q 16. 12 Can I start the pill if I am not currently seeing my periods?

Q 16. 13 Does it matter if I do not see a period whilst taking the pill?

Q 16. 14 What is the advice when my changing pill preparation?

Q 16. 15 What should be done if breakthrough bleeding occurs whilst I am taking the pill?

Q 16. 16 Can my pill withdrawal bleed be planned to avoid weekends?

Q 16. 17 Can I take the pill without a seven-day pill-free gap?

Q 16. 18 What should be done if a pill is missed?

Q 16. 19 Could I conceive whilst I am taking the pill?

Q 16. 20 Can combined oral contraceptive pills interact with other medication?

Q 16. 21 I am taking the combined oral contraceptive pill. Will this reduce my future fertility?

Q 16. 22 I have been on the pill for sometime. Is there any need to take a break from it?

Q 16. 23 I am due to have an operation. Should I stop taking my pill?

Q 16. 24 What is the advice with regard to third generation combined oral contraceptive pills?

Q 16. 25 Until what age can I take the pill?

Q 16. 26 I have taken the pill. Will this change the time when I will go through the menopause?

Q 16. 27 I am taking the pill. How will I know if I have reached my menopause?

Q 16. 28 In what circumstances should the pill be stopped immediately?

Q 16. 29 What symptoms are commonly associated with taking the oral contraceptive pill?

Q 16. 30 Should the pill be discontinued if I develop headaches?

Q 16. 31 If I have varicose veins can I take the pill?

Q 16. 32 I have developed vomiting and diarrhoea. How does this affect my pill taking?

Q 16. 33 How long before starting a pregnancy should I stop taking the pill?

Q 16. 34 Where can I obtain further information about contraception?

Q 16. 35 Could I have some Web sites?

Women’s Health – Home Page

Q 16. 5 A member of my family has a history of a deep venous thrombosis (DVT) or pulmonary embolism (thromboembolism). Should I have a screening blood test?

Thromboembolism may occur during immobilisation particularly after a major operation. If your relative had a thromboembolism in such circumstances we would not anticipate that you are at increased risk.

Some families have disorders of the blood clotting mechanism, which predisposes them to thrombosis (thrombophilia). If several of your relatives have been affected, particularly when the blood clots have occurred spontaneously without an obvious cause, we would need to consider thrombophilia. There are blood tests that may detect these abnormalities but they are extremely expensive. In these circumstances, it may be appropriate to seek advice from a haematologist (blood disorder specialist).

Q 16. 1 What are the different types of combined oral contraceptive pills?

Q 16. 1a What is the new Evra® Patch?

Q 16. 2 What are the benefits and problems of the phasic pills?

Q 16. 3 How will my doctor help me to decide which is likely to be the best pill for me?

Q 16. 4 Whilst I am taking the pill, what monitoring should I receive?

Q 16. 5 A member of my family has a history of a deep venous thrombosis (DVT) or pulmonary embolism (thromboembolism). Should I have a screening blood test?

Q 16. 6 Does an aeroplane journey increase the risks of taking the combined oral contraceptive pill?

Q 16. 7 Are there times when the combined oral contraceptive pill should be prescribed only with special caution?

Q 16. 8 Are there any contraindications to taking the combined oral contraceptive pill?

Q 16. 9 On which day of my menstrual cycle should I start my first course of the pill?

Q 16. 10 Can I start the combined oral contraceptive pill whilst I am breast-feeding?

Q 16. 11 Can I take the pill if I have had episodes when I did not see my periods (amenorrhoea)?

Q 16. 12 Can I start the pill if I am not currently seeing my periods?

Q 16. 13 Does it matter if I do not see a period whilst taking the pill?

Q 16. 14 What is the advice when my changing pill preparation?

Q 16. 15 What should be done if breakthrough bleeding occurs whilst I am taking the pill?

Q 16. 16 Can my pill withdrawal bleed be planned to avoid weekends?

Q 16. 17 Can I take the pill without a seven-day pill-free gap?

Q 16. 18 What should be done if a pill is missed?

Q 16. 19 Could I conceive whilst I am taking the pill?

Q 16. 20 Can combined oral contraceptive pills interact with other medication?

Q 16. 21 I am taking the combined oral contraceptive pill. Will this reduce my future fertility?

Q 16. 22 I have been on the pill for sometime. Is there any need to take a break from it?

Q 16. 23 I am due to have an operation. Should I stop taking my pill?

Q 16. 24 What is the advice with regard to third generation combined oral contraceptive pills?

Q 16. 25 Until what age can I take the pill?

Q 16. 26 I have taken the pill. Will this change the time when I will go through the menopause?

Q 16. 27 I am taking the pill. How will I know if I have reached my menopause?

Q 16. 28 In what circumstances should the pill be stopped immediately?

Q 16. 29 What symptoms are commonly associated with taking the oral contraceptive pill?

Q 16. 30 Should the pill be discontinued if I develop headaches?

Q 16. 31 If I have varicose veins can I take the pill?

Q 16. 32 I have developed vomiting and diarrhoea. How does this affect my pill taking?

Q 16. 33 How long before starting a pregnancy should I stop taking the pill?

Q 16. 34 Where can I obtain further information about contraception?

Q 16. 35 Could I have some Web sites?

Women’s Health – Home Page

Q 16. 6 Does an aeroplane journey increase the risks of taking the combined oral contraceptive pill?

Modern commercial aeroplanes are pressurised. The increased risks of venous and arterial thrombosis associated with high altitude are therefore eliminated. There have been reports of circulatory complications after a flight but this is equally true for those not taking the pill. Underlying dehydration, following sunbathing, alcohol or a gastro-intestinal upset increases the risk. Many airline stewardesses take the pill. They know the importance of ensuring adequate fluid intake and they will take a little walk every hour or so to keep their circulation going. It has been suggested that Aspirin 75mg daily should be considered before the flight and for a few days afterwards.

There is one concern about flights for women taking the pill particularly if they are travelling West as they may inadvertently take a pill late. It may be prudent to keep one watch set at the time of your home and use this to guide you on when you should be taking your pills.

Q 16. 7 Are there times when the combined oral contraceptive pill should be prescribed only with special caution?

Yes, there are times when a patient has medical problems such that the pill can be prescribed but only with special caution. More careful monitoring is required. Examples are:

• moderately elevated blood pressure (hypertension) requiring medication (patients with a history of high blood pressure in pregnancy can be given the pill but again the blood pressure should be checked more frequently.

• obesity (greater than 50% above ideal weight for height) is a reason for caution. Calorie control and exercise should be encouraged with a view to ensuring weight loss.

• hormones may on occasion aggravate depression.

• sickle cell disease (an inherited cause of anaemia found generally in people of Afro-Caribbean origin); this was regarded as a contraindication for the pill as there is an increased risk of thrombosis; some authorities now suggest that the pill can be given with caution. It may be prudent to discontinue the pill during any episodes of immobilisation.

• some medical conditions when they are mild but not if they are severe. Examples are diabetes, systemic lupus (SLE), Crohn’s disease and renal disease.

Varicose vein problems are not a contraindication for the pill. Varicose veins are more frequently found in association with obesity and this would be a reason for caution. The pill should be stopped if you need injection treatment.

When a woman has a medical problem that may be affected by the pill, the doctors involved in her care will usually liaise to ensure consistency of advice. Ultimately it is for the doctors caring for the woman to provide her with the information that she requires to make an informed choice.

Q 16. 1 What are the different types of combined oral contraceptive pills?

Q 16. 1a What is the new Evra® Patch?

Q 16. 2 What are the benefits and problems of the phasic pills?

Q 16. 3 How will my doctor help me to decide which is likely to be the best pill for me?

Q 16. 4 Whilst I am taking the pill, what monitoring should I receive?

Q 16. 5 A member of my family has a history of a deep venous thrombosis (DVT) or pulmonary embolism (thromboembolism). Should I have a screening blood test?

Q 16. 6 Does an aeroplane journey increase the risks of taking the combined oral contraceptive pill?

Q 16. 7 Are there times when the combined oral contraceptive pill should be prescribed only with special caution?

Q 16. 8 Are there any contraindications to taking the combined oral contraceptive pill?

Q 16. 9 On which day of my menstrual cycle should I start my first course of the pill?

Q 16. 10 Can I start the combined oral contraceptive pill whilst I am breast-feeding?

Q 16. 11 Can I take the pill if I have had episodes when I did not see my periods (amenorrhoea)?

Q 16. 12 Can I start the pill if I am not currently seeing my periods?

Q 16. 13 Does it matter if I do not see a period whilst taking the pill?

Q 16. 14 What is the advice when my changing pill preparation?

Q 16. 15 What should be done if breakthrough bleeding occurs whilst I am taking the pill?

Q 16. 16 Can my pill withdrawal bleed be planned to avoid weekends?

Q 16. 17 Can I take the pill without a seven-day pill-free gap?

Q 16. 18 What should be done if a pill is missed?

Q 16. 19 Could I conceive whilst I am taking the pill?

Q 16. 20 Can combined oral contraceptive pills interact with other medication?

Q 16. 21 I am taking the combined oral contraceptive pill. Will this reduce my future fertility?

Q 16. 22 I have been on the pill for sometime. Is there any need to take a break from it?

Q 16. 23 I am due to have an operation. Should I stop taking my pill?

Q 16. 24 What is the advice with regard to third generation combined oral contraceptive pills?

Q 16. 25 Until what age can I take the pill?

Q 16. 26 I have taken the pill. Will this change the time when I will go through the menopause?

Q 16. 27 I am taking the pill. How will I know if I have reached my menopause?

Q 16. 28 In what circumstances should the pill be stopped immediately?

Q 16. 29 What symptoms are commonly associated with taking the oral contraceptive pill?

Q 16. 30 Should the pill be discontinued if I develop headaches?

Q 16. 31 If I have varicose veins can I take the pill?

Q 16. 32 I have developed vomiting and diarrhoea. How does this affect my pill taking?

Q 16. 33 How long before starting a pregnancy should I stop taking the pill?

Q 16. 34 Where can I obtain further information about contraception?

Q 16. 35 Could I have some Web sites?

Women’s Health – Home Page

Q 16. 8 Are there any contraindications to taking the combined oral contraceptive pill?

The more common contraindications to the pill include:-

• pregnancy.

• a history of arterial or venous thrombosis.

• cardiomyopathy (an inflammatory condition of the heart).

• ischaemic heart disease (heart attacks or angina).

• familial conditions associated with thrombosis.

• severe migraine.

• strokes.

• diabetes.

• liver diseases.

• gall stones (the pill can be taken after surgical removal of the gall bladder).

• porphyria (an inherited condition affecting the break down process of red blood cells)

• very high blood pressure.

• smoking at age 35 years or more.

• severe systemic lupus (SLE) – requiring steroid treatment.

• cancer of the breast or uterus.

As with any medication, your doctor will check to see if there is any specific medical reason contraindicating the combined oral contraceptive pill.

Q 16. 1 What are the different types of combined oral contraceptive pills?

Q 16. 1a What is the new Evra® Patch?

Q 16. 2 What are the benefits and problems of the phasic pills?

Q 16. 3 How will my doctor help me to decide which is likely to be the best pill for me?

Q 16. 4 Whilst I am taking the pill, what monitoring should I receive?

Q 16. 5 A member of my family has a history of a deep venous thrombosis (DVT) or pulmonary embolism (thromboembolism). Should I have a screening blood test?

Q 16. 6 Does an aeroplane journey increase the risks of taking the combined oral contraceptive pill?

Q 16. 7 Are there times when the combined oral contraceptive pill should be prescribed only with special caution?

Q 16. 8 Are there any contraindications to taking the combined oral contraceptive pill?

Q 16. 9 On which day of my menstrual cycle should I start my first course of the pill?

Q 16. 10 Can I start the combined oral contraceptive pill whilst I am breast-feeding?

Q 16. 11 Can I take the pill if I have had episodes when I did not see my periods (amenorrhoea)?

Q 16. 12 Can I start the pill if I am not currently seeing my periods?

Q 16. 13 Does it matter if I do not see a period whilst taking the pill?

Q 16. 14 What is the advice when my changing pill preparation?

Q 16. 15 What should be done if breakthrough bleeding occurs whilst I am taking the pill?

Q 16. 16 Can my pill withdrawal bleed be planned to avoid weekends?

Q 16. 17 Can I take the pill without a seven-day pill-free gap?

Q 16. 18 What should be done if a pill is missed?

Q 16. 19 Could I conceive whilst I am taking the pill?

Q 16. 20 Can combined oral contraceptive pills interact with other medication?

Q 16. 21 I am taking the combined oral contraceptive pill. Will this reduce my future fertility?

Q 16. 22 I have been on the pill for sometime. Is there any need to take a break from it?

Q 16. 23 I am due to have an operation. Should I stop taking my pill?

Q 16. 24 What is the advice with regard to third generation combined oral contraceptive pills?

Q 16. 25 Until what age can I take the pill?

Q 16. 26 I have taken the pill. Will this change the time when I will go through the menopause?

Q 16. 27 I am taking the pill. How will I know if I have reached my menopause?

Q 16. 28 In what circumstances should the pill be stopped immediately?

Q 16. 29 What symptoms are commonly associated with taking the oral contraceptive pill?

Q 16. 30 Should the pill be discontinued if I develop headaches?

Q 16. 31 If I have varicose veins can I take the pill?

Q 16. 32 I have developed vomiting and diarrhoea. How does this affect my pill taking?

Q 16. 33 How long before starting a pregnancy should I stop taking the pill?

Q 16. 34 Where can I obtain further information about contraception?

Q 16. 35 Could I have some Web sites?

Women’s Health – Home Page

Q 16. 9 On which day of my menstrual cycle should I start my first course of the pill?

Nowadays, we recommend that it should be started on the first day of a period as this provides immediate contraceptive cover. The next period will occur after 23 days but subsequent periods will be at 28 day intervals.

Following childbirth, the combined pill can be taken if the baby is not being breast-fed; breast feeding combined with progestogen-only pills provides excellent contraception. During pregnancy and for the first two weeks after childbirth there is an increased risk of thromboembolism (blood clot problems – Q4.21) and this may be further increased by the pill (Q15.14). The pill should be commenced no earlier than 21 days after childbirth. If there has been a high blood pressure problem associated with pregnancy or there is a tendency to obesity, the pill should be further delayed. If the pill is commenced more than 21 days after childbirth, additional contraceptive precautions are required for the first seven days. The combined oral contraceptive pill can be commenced immediately after early miscarriage or pregnancy termination.

If periods are absent or infrequent, and this problem has been appropriately investigated (Q6.6), a course of progestogen tablets will usually provide a withdrawal bleed and the pill can be commenced on the first day of bleeding.

Q 16. 1 What are the different types of combined oral contraceptive pills?

Q 16. 1a What is the new Evra® Patch?

Q 16. 2 What are the benefits and problems of the phasic pills?

Q 16. 3 How will my doctor help me to decide which is likely to be the best pill for me?

Q 16. 4 Whilst I am taking the pill, what monitoring should I receive?

Q 16. 5 A member of my family has a history of a deep venous thrombosis (DVT) or pulmonary embolism (thromboembolism). Should I have a screening blood test?

Q 16. 6 Does an aeroplane journey increase the risks of taking the combined oral contraceptive pill?

Q 16. 7 Are there times when the combined oral contraceptive pill should be prescribed only with special caution?

Q 16. 8 Are there any contraindications to taking the combined oral contraceptive pill?

Q 16. 9 On which day of my menstrual cycle should I start my first course of the pill?

Q 16. 10 Can I start the combined oral contraceptive pill whilst I am breast-feeding?

Q 16. 11 Can I take the pill if I have had episodes when I did not see my periods (amenorrhoea)?

Q 16. 12 Can I start the pill if I am not currently seeing my periods?

Q 16. 13 Does it matter if I do not see a period whilst taking the pill?

Q 16. 14 What is the advice when my changing pill preparation?

Q 16. 15 What should be done if breakthrough bleeding occurs whilst I am taking the pill?

Q 16. 16 Can my pill withdrawal bleed be planned to avoid weekends?

Q 16. 17 Can I take the pill without a seven-day pill-free gap?

Q 16. 18 What should be done if a pill is missed?

Q 16. 19 Could I conceive whilst I am taking the pill?

Q 16. 20 Can combined oral contraceptive pills interact with other medication?

Q 16. 21 I am taking the combined oral contraceptive pill. Will this reduce my future fertility?

Q 16. 22 I have been on the pill for sometime. Is there any need to take a break from it?

Q 16. 23 I am due to have an operation. Should I stop taking my pill?

Q 16. 24 What is the advice with regard to third generation combined oral contraceptive pills?

Q 16. 25 Until what age can I take the pill?

Q 16. 26 I have taken the pill. Will this change the time when I will go through the menopause?

Q 16. 27 I am taking the pill. How will I know if I have reached my menopause?

Q 16. 28 In what circumstances should the pill be stopped immediately?

Q 16. 29 What symptoms are commonly associated with taking the oral contraceptive pill?

Q 16. 30 Should the pill be discontinued if I develop headaches?

Q 16. 31 If I have varicose veins can I take the pill?

Q 16. 32 I have developed vomiting and diarrhoea. How does this affect my pill taking?

Q 16. 33 How long before starting a pregnancy should I stop taking the pill?

Q 16. 34 Where can I obtain further information about contraception?

Q 16. 35 Could I have some Web sites?

Women’s Health – Home Page

Q 16. 10 Can I start the combined oral contraceptive pill whilst I am breast-feeding?

The combined oral contraceptive pill is likely to reduce the quantity and quality of your milk which will contain a relatively large amount of hormones. If oral contraception is required the combination of a progestogen-only pill with breast-feeding will provide highly effective contraception for you.

Q 16. 11 Can I take the pill if I have had episodes when I did not see my periods (amenorrhoea)?

The amenorrhoea should be investigated, before the pill is prescribed, and treated if a specific cause is found (Q6.21). If pregnancy has been excluded there is no reason why the pill cannot be prescribed. When the pill is subsequently discontinued the menstrual cycle will return to the pattern that would have occurred if the pill had not been taken. This means that the amenorrhoea may recur and fertility medication may be required if a pregnancy is planned.

Q 16. 12 Can I start the pill if I am not currently seeing my periods?

Absence of periods (amenorrhoea) needs to be investigated (Q6.6). Provided that both pregnancy and a problem requiring treatment have been excluded, amenorrhoea is not a contraindication to the pill.

Q 16. 13 Does it matter if I do not see a period whilst taking the pill?

A withdrawal bleed (‘period’ whilst taking the pill) does not have to occur with every pill-free interval. Provided you have taken the pill correctly, a pregnancy is very unlikely. If you do not see a withdrawal bleed it usually means that the lining of your womb is not building up sufficiently to result in a bleed. This reflects the way that the womb is responding to the pill and does not indicate what will happen when the pill is stopped if you wish to have a baby. From the medical point of view there is no reason to change the pill if the problem continues and there is no need to run any tests.

If you are unhappy that you do not see a withdrawal bleed, a different pill may suit you better. One of the phasic pills (Table 16.2) could be tried if you are on a monophasic variety

A girl of 13 had extremely heavy and painful periods which were controlled for two years with a monophasic pill (Microgynon). At the age of sixteen she returned to my clinic as she kept missing withdrawal bleeds. She had not started sexual activity but was worried that she would lose her fertility. We reassured her that medically there was no anxiety. After discussion she was started on a phasic pill (Trinovum) and withdrawal bleeds occurred.

Some women find that when they stop the pill they do not see their periods. Until twenty years ago this was called “post-pill amenorrhoea”. Research then showed that, with few exceptions, patients with amenorrhoea after discontinuing the pill had infrequent or absent periods before they commenced the pill. The pill had simply masked an underlying problem and was not the cause.

Q 16. 1 What are the different types of combined oral contraceptive pills?

Q 16. 1a What is the new Evra® Patch?

Q 16. 2 What are the benefits and problems of the phasic pills?

Q 16. 3 How will my doctor help me to decide which is likely to be the best pill for me?

Q 16. 4 Whilst I am taking the pill, what monitoring should I receive?

Q 16. 5 A member of my family has a history of a deep venous thrombosis (DVT) or pulmonary embolism (thromboembolism). Should I have a screening blood test?

Q 16. 6 Does an aeroplane journey increase the risks of taking the combined oral contraceptive pill?

Q 16. 7 Are there times when the combined oral contraceptive pill should be prescribed only with special caution?

Q 16. 8 Are there any contraindications to taking the combined oral contraceptive pill?

Q 16. 9 On which day of my menstrual cycle should I start my first course of the pill?

Q 16. 10 Can I start the combined oral contraceptive pill whilst I am breast-feeding?

Q 16. 11 Can I take the pill if I have had episodes when I did not see my periods (amenorrhoea)?

Q 16. 12 Can I start the pill if I am not currently seeing my periods?

Q 16. 13 Does it matter if I do not see a period whilst taking the pill?

Q 16. 14 What is the advice when my changing pill preparation?

Q 16. 15 What should be done if breakthrough bleeding occurs whilst I am taking the pill?

Q 16. 16 Can my pill withdrawal bleed be planned to avoid weekends?

Q 16. 17 Can I take the pill without a seven-day pill-free gap?

Q 16. 18 What should be done if a pill is missed?

Q 16. 19 Could I conceive whilst I am taking the pill?

Q 16. 20 Can combined oral contraceptive pills interact with other medication?

Q 16. 21 I am taking the combined oral contraceptive pill. Will this reduce my future fertility?

Q 16. 22 I have been on the pill for sometime. Is there any need to take a break from it?

Q 16. 23 I am due to have an operation. Should I stop taking my pill?

Q 16. 24 What is the advice with regard to third generation combined oral contraceptive pills?

Q 16. 25 Until what age can I take the pill?

Q 16. 26 I have taken the pill. Will this change the time when I will go through the menopause?

Q 16. 27 I am taking the pill. How will I know if I have reached my menopause?

Q 16. 28 In what circumstances should the pill be stopped immediately?

Q 16. 29 What symptoms are commonly associated with taking the oral contraceptive pill?

Q 16. 30 Should the pill be discontinued if I develop headaches?

Q 16. 31 If I have varicose veins can I take the pill?

Q 16. 32 I have developed vomiting and diarrhoea. How does this affect my pill taking?

Q 16. 33 How long before starting a pregnancy should I stop taking the pill?

Q 16. 34 Where can I obtain further information about contraception?

Q 16. 35 Could I have some Web sites?

Women’s Health – Home Page

Q 16. 14 What is the advice when my changing pill preparation?

The simplest guide is that the current pill should be taken until the course is completed and the new pill should commence on the first day of the withdrawal bleed; no additional contraception is required but the first cycle on the new pill will be just 23 days.

Q 16. 15 What should be done if breakthrough bleeding occurs whilst I am taking the pill?

The first course of action is to check that there is no cause for the bleeding other than the pill preparation. A missed pill, antibiotics or gastro-intestinal upset may have occurred. There may be a local cause such as vaginitis (inflammation of the vagina), a cervical polyp (Q21.2) or other cervical disease. These can be assessed by medical examination. A bleed early in pregnancy can be mistaken for break-through bleeding. Light breakthrough bleeding may be acceptable for perhaps three months and is likely to settle. Otherwise a change of pill preparation is appropriate. If the oestrogen content is very low increasing this may be the first line of approach. Increasing the progestogen content (Table 16.1) or changing from a monophasic to a bi-phasic or tri-phasic pill (Table 16. 2) are other possible remedies.

Q 16. 16 Can my pill withdrawal bleed be planned to avoid weekends?

If a pill packet is commenced on a Sunday, the withdrawal bleed should occur on weekdays. When starting the pill for the first time, if you delay to the next Sunday rather than commence on the first day of the period, additional contraception is required for the first seven days. For those on monophasic pills (Table 16.1) who wish to convert to a Sunday start, it is probably best to take two packets back-to-back and then finish the second packet on the Saturday. The third packet is commenced on the following Sunday. The other option would be to continue taking the pill from a spare pack until the next Sunday. This spare packet can be kept in reserve for similar cycle adjustments when required.

Table 16. 1 Monophasic combined oral contraceptive pills:

Preparation

Ethinyl Oestradiol (mg)

mg / Progestogen

Manufacturer

Loestrin® 20

20

1 norethisterone acetate

Parke Davis

Loestrin® 30

30

1.5 norethisterone acetate

Parke Davis

Brevinor®

Ovysmen®

35

35

0.5 norethisterone

0.5 norethisterone

Searle

Jannsen-Cilag

Norimin®

35

1 norethisterone

Searle

Norinyl®-1

Ortho-Novin® 1/50

50 (mestranol)

1 norethisterone

Searle

Janssen-Cilag

Microgynon® 30

Ovranette®

30

30

levonorgestrel

0.15 levonorgestrel

Schering

Wyeth

Eugynon® 30

Ovran® 30

30

30

levonorgestrel

0.25 levonorgestrel

Schering

Wyeth

Ovran®

50

0.25 levonorgestrel

Wyeth

Cilest®

35

0.25 norgestimate

Janssen-Cilag

3rd GENERATION:

Mercilon®

20

0.15 desogestrel

Organon

Marvelon®

30

0.15 desogestrel

Organon

Femodene®

Minulet®

30

30

0.075 gestodene

0.075

Schering

Wyeth

Femodette®

20

0.075

Schering

Yasmin®

Evra® Patch

30

(see 16-01a)

3 drospirenone

Schering

Janssen-Cilag

Table 16. 2 Phasic combined oral contraceptive pills:

Preparation

Ethinyl Oestradiol (mg)

mg / Progestogen

Manufacturer

Binovum®

35

0.5/1 norethisterone

Janssen-Cilag

Trinovum®

35

0.5/0.75/1 norethisterone

Janssen-Cilag

Synphase®

35

0.5/1/0.5 norethisterone

Searle

Logynon®

Trinordiol®

30/40/30

30/40/30

0.05/0.075/0.125 levonorgestrel

0.05/0.075/0.125 levonorgestrel

Schering

Wyeth

3rd GENERATION

Triadene®

30/40/30

0.05/0.07/0.1

Schering

Tri-Minulet®

30/40/30

0.05/0.07/0.1

Wyeth

Q 16. 1 What are the different types of combined oral contraceptive pills?

Q 16. 1a What is the new Evra® Patch?

Q 16. 2 What are the benefits and problems of the phasic pills?

Q 16. 3 How will my doctor help me to decide which is likely to be the best pill for me?

Q 16. 4 Whilst I am taking the pill, what monitoring should I receive?

Q 16. 5 A member of my family has a history of a deep venous thrombosis (DVT) or pulmonary embolism (thromboembolism). Should I have a screening blood test?

Q 16. 6 Does an aeroplane journey increase the risks of taking the combined oral contraceptive pill?

Q 16. 7 Are there times when the combined oral contraceptive pill should be prescribed only with special caution?

Q 16. 8 Are there any contraindications to taking the combined oral contraceptive pill?

Q 16. 9 On which day of my menstrual cycle should I start my first course of the pill?

Q 16. 10 Can I start the combined oral contraceptive pill whilst I am breast-feeding?

Q 16. 11 Can I take the pill if I have had episodes when I did not see my periods (amenorrhoea)?

Q 16. 12 Can I start the pill if I am not currently seeing my periods?

Q 16. 13 Does it matter if I do not see a period whilst taking the pill?

Q 16. 14 What is the advice when my changing pill preparation?

Q 16. 15 What should be done if breakthrough bleeding occurs whilst I am taking the pill?

Q 16. 16 Can my pill withdrawal bleed be planned to avoid weekends?

Q 16. 17 Can I take the pill without a seven-day pill-free gap?

Q 16. 18 What should be done if a pill is missed?

Q 16. 19 Could I conceive whilst I am taking the pill?

Q 16. 20 Can combined oral contraceptive pills interact with other medication?

Q 16. 21 I am taking the combined oral contraceptive pill. Will this reduce my future fertility?

Q 16. 22 I have been on the pill for sometime. Is there any need to take a break from it?

Q 16. 23 I am due to have an operation. Should I stop taking my pill?

Q 16. 24 What is the advice with regard to third generation combined oral contraceptive pills?

Q 16. 25 Until what age can I take the pill?

Q 16. 26 I have taken the pill. Will this change the time when I will go through the menopause?

Q 16. 27 I am taking the pill. How will I know if I have reached my menopause?

Q 16. 28 In what circumstances should the pill be stopped immediately?

Q 16. 29 What symptoms are commonly associated with taking the oral contraceptive pill?

Q 16. 30 Should the pill be discontinued if I develop headaches?

Q 16. 31 If I have varicose veins can I take the pill?

Q 16. 32 I have developed vomiting and diarrhoea. How does this affect my pill taking?

Q 16. 33 How long before starting a pregnancy should I stop taking the pill?

Q 16. 34 Where can I obtain further information about contraception?

Q 16. 35 Could I have some Web sites?

Women’s Health – Home Page

Q 16. 17 Can I take the pill without a seven-day pill-free gap?

From the medical point of view, there is no benefit in having the gap, and if you are taking a fixed, rather than a phasic pill, you can take the pill back-to-back without pill free days. This may avoid a bleed during a social event or a vacation. The bleed that occurs during the gap we call a withdrawal bleed and not a period. The pharmaceutical companies produce the packaging with the pill-free interval as women understandably feel that it is normal to have a monthly bleed. The only real advantage is that it provides an indication that there is no pregnancy. The phasic pills do not readily lend themselves to a pill-free interval although your doctor can usually provide appropriate advice (Q16.2) If a pill is missed less than seven days before the pill-free interval, the pill-free interval should be avoided (Q16.18). The pill-free interval can be avoided for social convenience such as a vacation. Some women have cyclical symptoms around the time of the pill-free interval. If there are problems with headaches, heavy or painful periods the pill can be taken “back-to-back”. We generally recommend three packets at a time leading to a withdrawal bleed every ten weeks. The combined oral contraceptive pill is a treatment option for endometriosis and we may recommend avoiding the pill-free interval for several months (Q23.21).

Q 16. 18 What should be done if a pill is missed?

If a pill is taken more than 12 hours late we regard it as missed. The missed pill can be taken and the course continued at the appropriate time. Additional precautions (usually condoms) should be used for the next seven days. If there are less than seven pills remaining in the course, the next packet should be commenced without a seven-day gap; if you are on an ED (every day) regimen, the seven inactive pills should be omitted. The risks of pregnancy are highest when the missed pill is at the beginning or end of a cycle.

Q 16. 19 Could I conceive whilst I am taking the pill?

There are few failures associated with the pill provided that the pill has been taken correctly. Ideally, the pill should be taken at the same time each day. There is a maximum safety limit of 12 hours. If the pill is taken more than 12 hours late additional precautions are essential (Q 16.18). The seven pill-free days allow the natural hormone cycle to begin. If the gap is inadvertently increased, ovulation (egg release) can occur and pregnancy may ensue. During a gastro-intestinal upset (vomiting or severe diarrhoea) the pill may not be absorbed and additional precautions are required. The additional precautions should be continued for at least seven days after the bowel has settled. Similarly, some antibiotics reduce the absorption of the pill and the same precautions would apply.

Q 16. 20 Can combined oral contraceptive pills interact with other medication?

Some medications, such as those used in the treatment of epilepsy, increase the rate that the liver breaks down chemicals including the oestrogen and progestogen in the pill. Rifampicin, used for a short course for those at risk of meningococcal meningitis, is so powerful at speeding up chemical breakdown pathways that although given for only 2 days, its effects may last for 4 weeks; additional contraceptive precautions are advisable to cover this. Rifampicin may also be prescribed for several months during treatment of tuberculosis. This may make the lower dose pills in particular less effective and breakthrough bleeding more likely. Higher dose pills (e.g. 50mg ethinyl oestradiol), in these circumstances, achieve similar hormone levels to lower dose pills taken by women not taking the anti-epileptic treatment. Some broad-spectrum antibiotics (effective against a wide variety of bacteria) can reduce the absorption of oestrogen. Break-through bleeding may occur if the hormone levels fall below a threshold. For those on long-term broad spectrum antibiotics (e.g. for treatment of acne) the bacteria in the intestine become resistant to the antibiotic and after the first two weeks there is no need for additional contraception. The combined oral contraceptive pills may interfere with treatment for diabetes, depression and high blood pressure; appropriate adjustments may be required.

Q 16. 1 What are the different types of combined oral contraceptive pills?

Q 16. 1a What is the new Evra® Patch?

Q 16. 2 What are the benefits and problems of the phasic pills?

Q 16. 3 How will my doctor help me to decide which is likely to be the best pill for me?

Q 16. 4 Whilst I am taking the pill, what monitoring should I receive?

Q 16. 5 A member of my family has a history of a deep venous thrombosis (DVT) or pulmonary embolism (thromboembolism). Should I have a screening blood test?

Q 16. 6 Does an aeroplane journey increase the risks of taking the combined oral contraceptive pill?

Q 16. 7 Are there times when the combined oral contraceptive pill should be prescribed only with special caution?

Q 16. 8 Are there any contraindications to taking the combined oral contraceptive pill?

Q 16. 9 On which day of my menstrual cycle should I start my first course of the pill?

Q 16. 10 Can I start the combined oral contraceptive pill whilst I am breast-feeding?

Q 16. 11 Can I take the pill if I have had episodes when I did not see my periods (amenorrhoea)?

Q 16. 12 Can I start the pill if I am not currently seeing my periods?

Q 16. 13 Does it matter if I do not see a period whilst taking the pill?

Q 16. 14 What is the advice when my changing pill preparation?

Q 16. 15 What should be done if breakthrough bleeding occurs whilst I am taking the pill?

Q 16. 16 Can my pill withdrawal bleed be planned to avoid weekends?

Q 16. 17 Can I take the pill without a seven-day pill-free gap?

Q 16. 18 What should be done if a pill is missed?

Q 16. 19 Could I conceive whilst I am taking the pill?

Q 16. 20 Can combined oral contraceptive pills interact with other medication?

Q 16. 21 I am taking the combined oral contraceptive pill. Will this reduce my future fertility?

Q 16. 22 I have been on the pill for sometime. Is there any need to take a break from it?

Q 16. 23 I am due to have an operation. Should I stop taking my pill?

Q 16. 24 What is the advice with regard to third generation combined oral contraceptive pills?

Q 16. 25 Until what age can I take the pill?

Q 16. 26 I have taken the pill. Will this change the time when I will go through the menopause?

Q 16. 27 I am taking the pill. How will I know if I have reached my menopause?

Q 16. 28 In what circumstances should the pill be stopped immediately?

Q 16. 29 What symptoms are commonly associated with taking the oral contraceptive pill?

Q 16. 30 Should the pill be discontinued if I develop headaches?

Q 16. 31 If I have varicose veins can I take the pill?

Q 16. 32 I have developed vomiting and diarrhoea. How does this affect my pill taking?

Q 16. 33 How long before starting a pregnancy should I stop taking the pill?

Q 16. 34 Where can I obtain further information about contraception?

Q 16. 35 Could I have some Web sites?

Women’s Health – Home Page

Q 16. 21 I am taking the combined oral contraceptive pill. Will this reduce my future fertility?

The short answer is no. At one time it was thought that the pill could cause “post-pill amenorrhoea” (absent periods after stopping the pill – Q16.13) and this was associated with anovulatory (failure of egg release) infertility. Subsequent studies showed that those who developed post-pill amenorrhoea had similar cycle problems before commencing the pill. The pill was not the cause but it had been masking the underlying problem. It seems likely that, if anything, the pill may conserve fertility by reducing the incidence of pelvic inflammatory disease (Q20.2) and endometriosis (Q9.11). Pregnancy termination (abortion), which should be prevented by the pill, can have complications leading to infertility (Q19.14).

Modern contraceptive methods are extremely effective. There is a danger that one can assume that when the pill is discontinued a pregnancy will occur quickly. With increasing age, fertility decreases – if you want a child, you should not leave it too long (Q9.6).

Q 16. 22 I have been on the pill for sometime. Is there any need to take a break from it?

There is no medical advantage in taking a break from the pill. All too frequently, an unplanned pregnancy will occur. The concept that the pill should only be taken for five or ten years at a time is based in mythology.

Q 16. 23 I am due to have an operation. Should I stop taking my pill?

One of the potential complications following an operation is a blood clot in one of the veins in the legs or pelvis (Q4.21) and we surgeons try to reduce the risk as far as possible. As the combined pill is also associated with a tiny risk of blood clot problems (Q15.14) we need to consider whether the pill should be stopped before we operate. Ideally, the pill should be discontinued four weeks before major surgery or any operation on the legs. The pill can be recommenced on the first day of the next period provided that this occurs at least 14 days after the operation. If there is need for a major operation when the pill has not been discontinued, your surgeon may recommend injections of heparin for a few days to thin the blood a little. There is no reason to discontinue the pill for minor operations or intermediate operations such as laparoscopy (Q23.24). There is no recommendation to stop progestogen-only pills or other progestogen contraception for surgery.

Q 16. 24 What is the advice with regard to third generation combined oral contraceptive pills?

The latest evidence is that third generation combined oral contraceptive pills are safe and may be offered as a first choice.

References:

The 1995 pill scare revisited: Anatomy of a non-epidemic (1997-2060)

Q 16. 25 Until what age can I take the pill?

The official recommendation for women with no risk factors is that there is no upper age limit for taking the pill.

Women who smoke should stop the pill by the age of 35 years as they are at increased risk of heart disease. The best medical advice is to stop smoking.

Q 16. 26 I have taken the pill. Will this change the time when I will go through the menopause?

The pill does not change the time of the menopause. Each egg appears to behave as if it has a timer which determines when it will go into an active phase (Q2.3). If the hormone environment is not appropriate, the active phase is cut short and that egg fails to develop. One of the important ways that the pill works is that it creates a hormone environment that prevents further development of the eggs that are going into the active phase. The pill does not stop eggs from going into the early active phase (otherwise the menopause would be delayed in pill users).

Q 16. 27 I am taking the pill. How will I know if I have reached my menopause?

As you approach the age of 50 there is an increasing chance that you will be reaching your menopause but withdrawal bleeds will continue for however long the pill is taken. There is no test that can absolutely define when the menopause has occurred even for a woman who is not taking the pill and seems to have stopped her periods although a blood test for FSH and oestradiol levels (Q26.14) can be a useful guide. If you want to know if you are likely to have reached yourmenopause, the blood test should be scheduled for the last day of the pill-free interval.

References:

Fertility & Sterility. Vol 66(1) (pp 101-104), (1996-1459)

Q 16. 28 In what circumstances should the pill be stopped immediately?

The pill should be discontinued and urgent medical advice sought if any of the following occur:-

• Severe headache accompanied by visual disturbance.

• Sudden visual disturbance or difficulty with speech.

• Weakness or numbness in one part of the body.

• Severe pain in a calf.

• Unexplained shortness of breath.

• Severe chest or abdominal pain.

• Jaundice.

Q 16. 29 What symptoms are commonly associated with taking the oral contraceptive pill?

Many women experience mild symptoms that are a nuisance or inconvenience although they are not damaging to their general health. Many of these symptoms occur frequently amongst non-pill takers so the pill may not be responsible. Anxiety that the pill may be causing major problems frequently leads the patient back to her doctor. The more common symptoms include breast discomfort, bloating, headaches, vaginal discharge, aches in the legs and weight change. After checking that all is well, your doctor will probably only need to reassure you. Frequent change of pill prescription is rarely indicated.

Q 16. 30 Should the pill be discontinued if I develop headaches?

Migraine involves a headache with visual disturbance. If severe migraine starts, the pill should be stopped immediately and not recommenced. The progestogen-only pill is not contraindicated. If mild migraine occurs, the pill should be stopped but it may be tried again later with careful monitoring and advice from your doctor. Headaches by themselves are not a contraindication to the pill. If they occur around the time of the pill-free interval, the pill may be taken for nine weeks without a break before a pill-free interval reducing the symptom from 13 to 5 times each year.

Q 16. 31 If I have varicose veins can I take the pill?

Varicose veins are not a contraindication against taking the pill.

Q 16. 32 I have developed vomiting and diarrhoea. How does this affect my pill taking?

If you have taken a pill within two hours and you do not think that another will stay down, you should recommence the pill as soon as possible and use additional contraception until seven days after the vomiting has settled. The pill should be continued rather than omitted for the seven pill free days if they would occur during this time. Mild to moderate diarrhoea does not interfere with pill absorption.

Q 16. 33 How long before starting a pregnancy should I stop taking the pill?

There is no evidence of any increased risk of abnormality for the baby in women who conceive soon after stopping the pill. The underlying risk of congenital abnormality (a structural defect of one or more parts of the body present at birth) is 2% of all babies. Even when pregnancy occurs accidentally in women taking the pill, the risk of congenital abnormality is not increased above this 2% level. At one time, one of the most common problems facing obstetricians was determination of the duration of pregnancy. Only if the menstrual cycle was normal and the mother was certain about the date of the first day of the last menstrual period (L.M.P.) could the obstetrician be reasonably confident about the expected time for delivery (expected date of delivery – E.D.D). Knowing the ‘dates’ is critical either when there is a possible need to induce labour, plan an elective Caesarean section or stop premature labour. Periods may be delayed or irregular for a few months after stopping the pill, reducing the accuracy of determining dates in a pregnancy. Ultrasound, which has been available for more than twenty years, can be reasonably accurate in the first half of pregnancy in determining dates usually overcoming this potential difficulty.

There is some evidence that folic acid supplementation reduces the risk of the spina bifida group of defects when taken before pregnancy and for a few weeks after conception. We now recommend folic acid supplements to all women contemplating pregnancy.

Q 16. 34 Where can I obtain further information about contraception?

Some your useful sources of further information can be found at Q13.27.

Q 16. 35 Could I have some Web sites?

Evaluation of the quality of Web sites is discussed in Q4.27. You may find that several general women’s health sites may help you (Q4.28). The following are more specialised Web sites on topics found in this chapter:-

Q 16. 1 What are the different types of combined oral contraceptive pills?

Q 16. 1a What is the new Evra® Patch?

Q 16. 2 What are the benefits and problems of the phasic pills?

Q 16. 3 How will my doctor help me to decide which is likely to be the best pill for me?

Q 16. 4 Whilst I am taking the pill, what monitoring should I receive?

Q 16. 5 A member of my family has a history of a deep venous thrombosis (DVT) or pulmonary embolism (thromboembolism). Should I have a screening blood test?

Q 16. 6 Does an aeroplane journey increase the risks of taking the combined oral contraceptive pill?

Q 16. 7 Are there times when the combined oral contraceptive pill should be prescribed only with special caution?

Q 16. 8 Are there any contraindications to taking the combined oral contraceptive pill?

Q 16. 9 On which day of my menstrual cycle should I start my first course of the pill?

Q 16. 10 Can I start the combined oral contraceptive pill whilst I am breast-feeding?

Q 16. 11 Can I take the pill if I have had episodes when I did not see my periods (amenorrhoea)?

Q 16. 12 Can I start the pill if I am not currently seeing my periods?

Q 16. 13 Does it matter if I do not see a period whilst taking the pill?

Q 16. 14 What is the advice when my changing pill preparation?

Q 16. 15 What should be done if breakthrough bleeding occurs whilst I am taking the pill?

Q 16. 16 Can my pill withdrawal bleed be planned to avoid weekends?

Q 16. 17 Can I take the pill without a seven-day pill-free gap?

Q 16. 18 What should be done if a pill is missed?

Q 16. 19 Could I conceive whilst I am taking the pill?

Q 16. 20 Can combined oral contraceptive pills interact with other medication?

Q 16. 21 I am taking the combined oral contraceptive pill. Will this reduce my future fertility?

Q 16. 22 I have been on the pill for sometime. Is there any need to take a break from it?

Q 16. 23 I am due to have an operation. Should I stop taking my pill?

Q 16. 24 What is the advice with regard to third generation combined oral contraceptive pills?

Q 16. 25 Until what age can I take the pill?

Q 16. 26 I have taken the pill. Will this change the time when I will go through the menopause?

Q 16. 27 I am taking the pill. How will I know if I have reached my menopause?

Q 16. 28 In what circumstances should the pill be stopped immediately?

Q 16. 29 What symptoms are commonly associated with taking the oral contraceptive pill?

Q 16. 30 Should the pill be discontinued if I develop headaches?

Q 16. 31 If I have varicose veins can I take the pill?

Q 16. 32 I have developed vomiting and diarrhoea. How does this affect my pill taking?

Q 16. 33 How long before starting a pregnancy should I stop taking the pill?

Q 16. 34 Where can I obtain further information about contraception?

Q 16. 35 Could I have some Web sites?

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