WHEN TO START ORAL CONTRACEPTIVES ?

Sunday start: Take the first

Quick start: Take the first
COC tablet as soon as possible
regardless of cycle day.
Day 1 start: Take the first
tablet in the COC pack on the
first day of menses
tablet in the COC pack on the
first Sunday after the
beginning of menstruation. If
menses begins on Sunday,
start that day.
Noncontraceptive Benefits of Combination Oral Contraceptives

1. Reduction in the Risk of Endometrial Cancer

• 1 year of COC use decreases the risk by 40 %
• 10 years of use decreases the risk by 80%
• The reduced risk may persist for up to 20 years following
discontinuation of oral contraceptives
Noncontraceptive Benefits of Combination Oral Contraceptives

2. Reduction in the Risk of Ovarian Cancer

• Women who have used oral contraceptives for up to 4 years are 30%
less likely to develop ovarian cancer
Noncontraceptive Benefits of Combination Oral Contraceptives
3. Improved Regulation of Menstruation and Reduction in the Risk of
Anemia
• Women who take oral contraceptives typically experience more
regular menstrual cycles, less cramping and dysmenorrhea

• Some COC formulations contain iron, which may also minimize the
risk for anemia

• OCs use decreases overall monthly menstrual flow by 60% (beneficial

in anemic women)
Noncontraceptive Benefits of Combination Oral Contraceptives

4. Reduction in the Risk of Fetal Neural Tube Defects

• some COC formulations contain a source of folate in every pill
• While COCs are not 100% effective at preventing pregnancy, it is
possible that a woman may conceive while taking a COC. In addition,
many women may become pregnant very soon after discontinuing a
COC.
Noncontraceptive Benefits of Combination Oral Contraceptives
5. Relief from Symptoms Associated with Premenstrual Dysphoric
Disorder
• Current evidence suggests that these agents are most effective at
targeting the physical symptoms associated with PMDD
• Yaz, carries an FDA-approved indication for PMDD
Noncontraceptive Benefits of Combination Oral Contraceptives

6. Relief of Benign Breast Disease

Women who use OC:
• are less likely to develop benign breast cysts or fibroadenomas
• have less progression of such conditions
Noncontraceptive Benefits of Combination Oral Contraceptives

7. Prevention of Ovarian Cysts

• Because OC suppress ovarian stimulation, women who take them are
less likely to develop ovarian cysts
Noncontraceptive Benefits of Combination Oral Contraceptives

8. Decrease in Symptoms Related to Endometriosis

• In endometriosis, the extended-cycle COCs may provide the most
effective relief from menstrual pain by reducing the total number of
painful episodes per year
Noncontraceptive Benefits of Combination Oral Contraceptives
9. Improvement in Acne Control
• All COCs can improve acne by increasing the quantity of sex hormone–
binding globulin (SHBG) and thereby decreasing free testosterone
concentrations

• Ortho Tri-Cyclen (EE and norgestimate), Estrostep Fe (EE and

norethindrone acetate), Yaz, and Beyaz (EE and drospirenone) each carry
an FDA-approved indication for the treatment of acne
Progestin-only pills
• Progestins thicken cervical mucus, delay sperm transport, and induce
endometrial atrophy
• They also block the LH surge and thus inhibit ovulation
• Progestin-only “minipills” (28 days of active hormone per cycle) are available
options.
• Progestin-only OCs are less effective than combination OCs and are associated
with irregular and unpredictable menstrual bleeding
Progestin-only pills
• Minipills must be taken every day of the menstrual cycle at
approximately the same time to maintain contraceptive efficacy
• If a progestin-only OC is taken more than 3 hours late, patients should
use a backup method of contraception for 48 hours
• Minipills may not block ovulation (nearly 40% of women continue to
ovulate normally), so the risk of ectopic pregnancy is higher with their
use than with other hormonal contraceptives.
Progestin-Only Pills
• Progestin-only products have not shown the same
thromboembolic risk as estrogen-containing products
• Therefore, women at increased risk for or with a history of
thromboembolism may be good candidates for progestin-only oral
contraceptives
Progestin-Only Pills
• can minimize menses, many women have amenorrhea after six to
nine cycles

• safe to use in lactating women

• spotting does not subside in some women, and this is a common

cause for discontinuation
Progestin-Only Pills
• Indications: Those who cannot use or tolerate combined hormonal contraceptives or those
seeking long-term contraception
1. History of or current MI, stroke, DVT, cardiovascular disease
2. Atrial fibrillation
3. BP 160/100 mm Hg
4. Smoker age 35 or older
5. Breast cancer within 5 years
6. Active, symptomatic liver disease
7. Benign or malignant liver tumors
8. History of cholestasis because of OCs
9. Migraine headache with neurologic impairment or aura or migraine without aura in
women 35 years or older
10. Retinopathy or neuropathy because of diabetes
11. Surgery within the past 4 weeks
12. Breastfeeding
Progestin-Only Pills
• Components: One of the following progestins
• 1. Depot medroxyprogesterone acetate (DMPA [Depo-Provera
injectable/Depo-Provera subcutaneously])
• 2. Norethindrone 0.35 mg (Micronor, Nor-QD)
• 3. Norgestrel 0.075 mg (Ovrette)
• 4. Levonorgestrel 0.03 mg (Microlut)
Progestin-Only Pills
• C. Mechanisms of Action
• 1. Thickens cervical mucus, prevents sperm movement
• 2. Thins uterus lining
• 3. Suppresses midcycle peak of LH and FSH, inhibits ovulation
(minimal with oral progestin pills)
Post-partum contraception use
• According to the American Academy of Pediatrics and the American
College of Obstetricians and Gynecologists (2012), POPs and DMPA may be
initiated prior to discharge regardless o breastfeeding status

• For the etonogestrel implant, insertion is delayed until 4 weeks postpartum

or those exclusively breastfeeding but can be inserted anytime for those
not nursing

• Combination hormone contraception may begin at 6 weeks following

delivery, if breast feeding is well established and the infant’s nutritional
status is surveilled
 Postpartum Use of CHCs
• The CDC (2011) revised the US MEC guidelines regarding the use of combined
hormonal contraception during the puerperium due to the higher risk of venous
thromboembolism (VTE) during these weeks.

• In the postpartum phase, there is concern about use of CHCs because of the
mother’s hypercoagulability and the effects on lactation

• In the first 21 days postpartum (when the risk of thrombosis is higher),

estrogen-containing hormonal contraceptives should be avoided

• If contraception is required during this period, progestin-only contraceptive

methods may be acceptable alternatives
Postpartum Use of CHCs
• It is recommended that women who are breast-feeding avoid CHCs for
the first 42 days postpartum in those with risk factors for VTE and for
30 days in those without risk factors.

• In those women who are not breast-feeding, CHCs should be avoided

for up to 42 days postpartum in those with risk factors for VTE

• After 42 days postpartum, there is no restriction to the use of CHCs.

To delay menses
• Already on COCs: continue with no pill free weeks
• Not on COCs: cidulot nor, steronate nor (1 tablet daily starting 5 days before
menses and continue). Menses occur 2-4 days after discontinuation
To induce menses
Use high dose of progesterone