Technical Update on Combined Oral

Contraceptives (COCs) Progestin Only Pills

(POPs) & Emergency Contraceptive Pills
(ECPs)

Family Planning Division

Ministry of Health and Family Welfare
Government of India
 Overview of Oral Contraceptives
• Provides option for delaying, spacing and limiting births.
• Oral contraceptives are safe, effective, reversible methods to
prevent pregnancy and need to be taken regularly.
• Do not disrupt an existing pregnancy and do not interfere with
sexual intercourse.
• Do not protect a woman from HIV or other Sexually
Transmitted Infections (STIs). Women using oral
contraceptives must use condoms to prevent HIV and other
STIs.
 Types of Oral Contraceptives
A. Hormonal
Combined Oral Contraceptive (COC)
Progestin-Only Pill (POP)
Levonorgestrel Emergency Contraceptive Pill
(ECP)
B. Non-hormonal
 Centchroman (Ormeloxifene)
 Contraceptive Effectiveness of Oral
Contraceptives
• Perfect use: Pregnancy rates (failure rates) during
perfect use show how effective a method is when it is
used perfectly, consistently and exactly according to
directions.
• Common (or typical) use: Pregnancy rates (failure
rates) during common (or typical) use show how
effective a method is during actual use by the average
person who does not always use the method
consistently and correctly.
Contraceptive Effectiveness
Combined Oral Contraceptive
Pills (COCs)
 Combined Oral Contraceptive Pills
(COCs)
• Safe and Effective
• Failure rate: Perfect use 0.3 preg/100 women; Typical
use 8 preg/100 women
 Combined Oral Contraceptive Pills
(COCs)…Contd
• Available in public sector as free and ASHA
supply (Mala-N)
• In each strip, 21 are hormonal tablets and 7
non hormonal (iron) tablets
• Each hormonal tablet contains Levonorgestrel
(0.15mg) and Ethinyl estradiol (30
micrograms)
• Should not be given to breastfeeding women
till 6 months postpartum
 Combined Oral Contraceptive Pills
(COCs)…Contd

• Several non-contraceptive benefits – protection

against endometrial and ovarian cancer, iron
deficiency anemia, polycystic ovarian syndrome,
endometriosis, decreases risk of ectopic pregnancy
• Effectiveness depends on regular and correct use
• Can be started any time if it is reasonably certain
that she is not pregnant (Use pregnancy checklist)
 How COCs Work

Works primarily by preventing release of

eggs from ovaries (ovulation) by
suppressing FSH and LH
 When to Start COCs
 Women having menstrual cycle:
 If used within 5 days of menstrual bleeding, back-up
method is not needed
 Anytime after 5 days of menstrual bleeding, if it is
reasonably certain that she is not pregnant. Back up
method (Condom) for first 7 days of pills
 Breastfeeding women more than 6 months after giving
birth:
 In the absence of menstrual bleeding, pills can be started
after ruling out pregnancy and back-up method needed for
7 days
 When to Start COCs (Contd)

 Women not breastfeeding:

 Less than 4 weeks after giving birth: Anytime on days
21-28 after childbirth. No back up method
 More than 4 weeks after giving birth: Anytime, when
reasonably certain that she is not pregnant. Back up
method (condom) for first 7 days.
 After miscarriage or abortion:
 Within 7 days, no back up method
 Beyond 7 days, when reasonably certain that she is not
pregnant, back up method (condom) for first 7 days
 How to Use COC Pills
• Linking pill intake to a daily activity may
help her remember to take the pill daily and
reduce some side effects
• When she finishes one pack, first pill from
the next pack should be taken on the very
next day
• Bleeding occurs when woman is on iron
tablets. However, pills should be continued,
irrespective of bleeding
 COC: Side Effects
• Irregular and unexpected bleeding
• No Monthly Bleeding
• Non migrainous headache
• Nausea and Dizziness
• Breast tenderness
• Weight change
• Mood changes or changes in sex drive
• Acne
 COCs: Managing Missed Pills
1) Missed 1 or 2 pills/ started new pack 1 or 2 days late:
• Take one hormonal pill as soon as possible or two pills at
scheduled time and continue the scheduled pills

2) Missed 3 or more pills in the first or second

week/started new pack 3 or more days late:
• Take one hormonal pill as soon as possible and continue
the scheduled pills
• Backup method for the next 7 days
• Consider taking ECPs, if sex in the past 72 hours
COCs: Managing Missed Pills (Contd..)

3) Missed 3 or more pills in the third week:

• Take one hormonal pill as soon as possible and
finish all hormonal pills in the pack as
scheduled.
• Throw away the 7 non-hormonal pills. Start a
new pack the next day.
• Backup method for the next 7 days
• Consider taking ECPs, if sex in the past 72 hours
COCs: Managing Missed Pills (Contd..)

4) Missed any non- hormonal pills (last 7 pills of Mala-N):

• Discard the missed non-hormonal pill(s).
• Keep taking COCs one each day. Start the new pack as usual
5) Severe vomiting or diarrhea:
• If vomiting within 2 hours after taking a pill, another pill from
pack as soon as possible and continue the scheduled pills
• If vomiting or diarrhea for more than 2 days: Take one
hormonal pill as soon as possible or two pills at scheduled
time and continue the scheduled pills
 Conditions where COCs should be
avoided
• Taking anti-convulsants or Rifampicin
• Migraine
• Non-ambulatory condition (1week or more)
• In certain health conditions:
• Hypertension • Stroke and heart disease
• Deep vein thrombosis or • Liver/Gall bladder disease
Pulmonary embolism
• Long standing diabetes with • Suspected pregnancy
organ damage
COC Quiz: Please open page 79 of Reference
Manual
• Actual/typical use effectiveness of COC is:
- 8 pregnancies/100 women over the first year of use
• Major advantages of COCs include that they:
- Are highly effective if taken correctly
- Protect against ovarian and endometrial cancer
- Decrease the risk of ectopic pregnancy
• COCs are not appropriate for the following women:
• Breastfeeding <6 months • With high BP
postpartum • With breast cancer
• With suspected pregnancy • With DVT
• Who smoke >15 cigarettes/day • With heart disease
and ≥ 35 years of age • With recurrent migraine
• With liver disease • On anticonvulsants
 COC Quiz:
Please open page 79 of Reference Manual
(Contd)

• Common side effects of COCs include:

- Nausea, headache
- Breast tenderness
- Irregular bleeding
- Weight gain
 Progesterone only
Contraceptive Pills (POPs)
 Progestin-only- Pills (POPs)
• Contain very low dose of a synthetic
hormone known as progestin (like
natural hormone Progesterone)
• All 28 pills in a packet are hormone tablets (either
Levonorgestrel or Desogestrel)
• One pill to be taken every day at the same time
without any break
• These are safe for breastfeeding women and can be
started earlier than 6 weeks postpartum
Progestin-only- Pills (POPs) Contd..

• More effective along with breast feeding than

when taken after breast feeding stops
• Bleeding changes are common but not harmful
• Decreases risk of ectopic pregnancy
• Can be taken any time if it is reasonably certain
that she is not pregnant (Use pregnancy checklist)
• New pack to be started on the next day at the same
time as starting a pack late risks pregnancy
 How POPs work

• Thickening cervical mucus (this blocks

sperm from meeting an egg)
• Disrupting the menstrual cycle, including
preventing the release of eggs from the
ovaries (ovulation)
 When to Start POPs
 Women having menstrual cycle:
 If used within 5 days of menstrual bleeding, back-up method
is not needed
 Anytime after 5 days of menstrual bleeding, if it is
reasonably certain that she is not pregnant. Back up method
(Condom) for first 2 days of pills
 Breastfeeding women:
 Less than 6 months:
Anytime or immediately after childbirth. No back up method
 More than 6 months after giving birth:
In the absence of menstrual bleeding, pills can be started after
ruling out pregnancy and back-up method needed for 2 days
 When to Start POPs (Contd)
 Women not breastfeeding:
 Less than 4 weeks after giving birth: Anytime or
immediately after childbirth. No back up method
 More than 4 weeks after giving birth: Anytime, in the
absence of menstrual bleeding, when reasonably certain
that she is not pregnant. Back up method (condom) for
first 2 days.
 After miscarriage or abortion:
 Within 7 days, no back up method
 If more than 7 days, pregnancy to be ruled out and back-
up method (condom) for 2 days
 How to Use POPs?

• One pill to be taken every day and at same

time until the packet is empty
• Linking pill intake to a daily activity may
help her remember to take the pill daily and
reduce some side effects
• When she finishes one pack, first pill from
the next pack should be taken on the very
next day at the same time
 POPs: Managing Missed Pills

1) 3 or more hours late taking a pill or misses

one pill completely:
• Take a pill as soon as possible
• Keep taking pills as usual, one each day

2) If she has monthly bleeding:

• A backup method should be used for the next 2
days
• Can consider taking ECPs, if had sex in the past
72 hours
 POPs: Managing Missed Pills Contd..

3) If she has severe vomiting or diarrhea:

• If vomiting within 2 hours after taking a
pill, another pill to be taken as soon as
possible and continue the scheduled pills
• If her vomiting or diarrhea continues, to
follow the instructions for missed pills
 POPs: Side effects
• No monthly bleeding
• Irregular and unexpected bleeding
• Heavy and prolonged bleeding
• Non migranous headaches
• Mood changes or changes in sex drive
• Breast tenderness
• Severe pain in lower abdomen
• Nausea and dizziness
Conditions where POPs should be
avoided
• Treatment with anticonvulsants or rifampicin
• History of breast cancer
• Deep vein thrombosis or Pulmonary
embolism
• Liver cirrhosis
• Suspected pregnancy
Emergency Contraceptive
Pills (ECPs)
 Emergency Contraceptive Pill (ECP)

• To be used within 72 hours of unprotected sex (accidental

sex or contraceptive accident like condom rupture or missed
pills)
• Sooner it is taken, more effective
• Safe for all women even for those who cannot use regular
hormonal contraceptives, no known health risks
• Not appropriate as a regular contraceptive method due to
less effective than other contraceptives, chances of
menstrual irregularities
• Do not disrupt an existing pregnancy
• Provides an opportunity for women to start using a
regular contraceptive method
 Emergency Contraceptive Pill (ECP)

How to Use ECP

• In national program, EC pill contains only progestin -
Levonorgestrel (1.5 mg per tab) and available as free and
ASHA supply (ezy-pill)
• To be taken immediately after unprotected/accidental
intercourse or as soon as possible within next 3 days
(72 hours)
 How ECP Works

• Works primarily by preventing or delaying

release of eggs from ovaries (ovulation)
• Does not work if woman is already pregnant
 ECP: Side Effects

– Nausea,
– Vomiting
– Bleeding irregularity
ECP: Important Counselling Points
• Counsel to choose a regular FP method
• Most contraceptive methods can be started on the same
day of ECP use
• ECP does not protect from STI/HIV
• ECP will not harm an existing pregnancy
• Advise to return to health care provider, if her next
monthly bleeding:
- Is very light (possible pregnancy)
- Period is delayed beyond one week of expected date
- Is unusually painful (possible ectopic pregnancy)
• Distribute handouts of summary of key
characteristics of COCs, POPs, ECPs. (pages
79, 80, 82 Reference Manual for Oral
Contraceptives)
Thank you