Oral Contraception

Oral contraception, commonly known as birth control pills, is a widely used method for preventing pregnancy. These pills contain hormones that regulate a woman’s reproductive system.

  • Types of Oral Contraceptives:
    • Combined Oral Contraceptives (COCs): Contain both estrogen and progestin. They prevent ovulation, thicken cervical mucus to block sperm, and alter the uterine lining to prevent implantation.
      • Ethinyloestradiol/Levonorgestrel oral OD 20/100ug (low dose) 30/150ug (standard dose)
      • Ethinyloestradiol/Drospirenone oral OD  20/3000ug (low dose – Yaz) 30/3000ug (standard dose – Yasmin)
    • Progestin-Only Pills (Mini Pill): Also known as the “mini-pill,” these contain only progestin. Suitable for women who cannot take estrogen.
      • Levonorgestrel 30ug oral OD (must be taken within 3/24 of same time or 2/7 condoms) (Microlut)
      • Drospirenone 4mg oral OD (Slinda)
  • Mechanism of Action:
    • Inhibit Ovulation: Prevent the release of an egg from the ovaries.
    • Thicken Cervical Mucus: Making it more difficult for sperm to enter the uterus.
    • Alter the Endometrium: Reducing the likelihood of implantation of a fertilized egg.
  • Use:
    • Pills are taken daily, ideally at the same time each day.
    • For COCs, a typical cycle includes 21 active pills and 7 placebo pills during which menstrual bleeding occurs.
    • POPs are taken every day with no break and should be taken within the same 3 hour window every day.
  • Benefits:
    • Highly effective when taken correctly.
    • Can regulate menstrual cycles, reduce menstrual cramps, and lighten periods.
    • May reduce the risk of ovarian and endometrial cancers.
  • Side Effects:
    • Nausea, breast tenderness, bloating, and mood changes.
    • Breakthrough bleeding or spotting, especially with POPs.
    • Increased risk of blood clots with COCs.
    • May raise blood pressure in some women.
  • Contraindications :
    • Suspected pregnancy!
    • COCP
      • History of migraine with aura.
      • History of thromboembolic disorders
      • Smoking, especially in women over 35 years of age.
      • History of breast/endometrial/cervical/ovarian/liver cancer
      • Significant liver disease.
      • Severe hypertension.
    • POP
      • breast cancer
      • undiagnosed vaginal bleeding
  • Choosing the Right Contraceptive:
    • Based on individual health, risk factors, and personal preference.
    • Involves shared decision-making.
  • Non-contraceptive Benefits:
    • Management of conditions like polycystic ovary syndrome (PCOS), endometriosis, and anemia due to heavy periods.
    • Reduction in the risk of ovarian cysts.
    • Can improve acne and hirsutism in some women.
  • Considerations:
    • Do not protect against sexually transmitted infections (STIs).
    • Need for alternative contraception in case of missed pills or other interfering medications.
    • Immediate return of fertility after discontinuation.
  • Monitoring:
    • Regular check-ups with a healthcare provider are recommended to monitor for any adverse effects and to ensure that the chosen method continues to be suitable.

Oral contraceptives are a reliable form of birth control with additional health benefits for many women. However, their use should be individualized and regularly reviewed by a healthcare provider to ensure safety and effectiveness.

Detailed Aspects of Contraceptive Management:

  1. Selection Process:
    • The selection of a contraceptive method is a complex decision that involves a thorough understanding of the patient’s medical history, reproductive health, lifestyle factors, personal preferences, and potential risks.
    • Medical History: Clinicians should assess any pre-existing health conditions that might contraindicate certain contraceptive methods. For instance, combined hormonal contraceptives are not recommended for women with a history of thromboembolic disorders or certain types of cancers.
    • Counseling: Detailed counseling sessions should be provided to help patients understand their options, how they work, their effectiveness, side effects, and how to use them.
  2. Initiation Protocols:
    • Check the patient is not pregnant
    • All COCPs will work immediately if an active pill is taken in the first 5 days of the menstrual cycle.
    • If not started in the first 5 days then 7 days of barrier contraception should be used
  3. Monitoring and Adherence:
    1. Ongoing monitoring is key to ensuring the effectiveness of the contraceptive method and managing any side effects.
    2. Side Effects: Common side effects should be discussed in advance. For instance, spotting is common with new hormonal contraceptive use but often resolves within a few months.
    3. Adherence: Strategies to improve adherence, particularly with daily methods like the pill, include setting reminders or linking pill-taking with a daily routine.
  4. Addressing Side Effects:
    • Management of side effects is crucial to encourage continued use of contraception.
    • Nausea: Taking the pill at night or with food may help.
    • Headaches: Monitoring for headaches is essential, especially with estrogen-containing methods, as this could signal more serious complications.
    • Breakthrough Bleeding: Can often be managed by reassurance, as it typically decreases over time, or by adjusting the hormone doses.
  5. Method-Specific Considerations:
    • Each contraceptive method comes with specific considerations:
    • COCPs: Discussing the late/missed pill protocol
      • A late pill is defined as being taken <24 hours late.
        • Take the late hormone pill as soon as possible, then continue taking the pills as usual
        • Two pills can be taken on the same day.
        • No additional contraceptive required.
      • A missed pill is defined as being taken >24 hours late.
        • The most recent pill should be taken and previously missed pills discarded
        • Continue taking the pills as usual (two pills can be taken on the same day).
        • Additional contraceptive methods (eg condoms) or abstinence are required until 7 consecutive active pills are taken
    • POPs: A POP is considered missed if it’s taken more than 3 hours late (or 12 hours if using a desogestrel-containing pill).
      • If < 3 Hours late (12 Hours for Desogestrel):
        • Take the missed pill as soon as possible.
        • The next pill should be taken at the usual time.
        • No additional contraceptive protection is needed.
      • If > 3 Hours Late (12 Hours for Desogestrel):
        • Take the missed pill as soon as remembered, even if it means taking two pills at the same time.
        • Continue taking the remaining pills at the usual time.
        • Use additional contraception (like condoms) or avoid sex for the next 2 days.
      • If Multiple Pills Missed:
        • If more than one pill is missed, the same advice applies – take the most recent missed pill, then continue as normal, with additional contraceptive precautions for the next 2 days.
    • IUDs: Ensuring the patient understands the possibility of expulsion, especially in the first year, and how to check for IUD strings periodically.
    • Implants: Discussing the potential for scar tissue at the insertion site and irregular bleeding patterns.
    • Depot Injections: Addressing potential bone density loss with long-term use and discussing the delay in return to fertility after stopping.
  6. Long-Term Management:
    • Long-term management of contraception may include annual visits to renew prescriptions, assess blood pressure for patients on hormonal methods, and ensure that there are no contraindications for continued use.
    • Weight Gain: While data is mixed, some patients may experience weight gain on certain contraceptives like depo shots; discussing healthy lifestyle choices is important.
    • Bone Health: For users of depot injections, considering bone health is important, and dietary calcium and vitamin D are often recommended.
  7. Transition and Discontinuation:
    1. Patients may decide to switch methods or discontinue contraception due to various reasons like side effects, desire for pregnancy, or reaching menopause.
    2. Switching Methods: Discussing the correct process to switch methods to avoid an unintentional gap in contraceptive coverage.
    3. Preconception Counseling: For those discontinuing contraception to become pregnant, preconception health optimization is important.
  8. Special Populations:
    1. Contraceptive management must be tailored to special populations such as adolescents, perimenopausal women, and those with comorbidities like diabetes or hypertension.
    2. Adolescents: May need additional counseling about STIs and may prefer long-acting reversible contraceptives (LARCs) for convenience and efficacy.
    3. Perimenopausal Women: May still need contraception and could benefit from hormonal methods that can also manage menopausal symptoms.
  9. Regulatory and Ethical Considerations:
    • Providers should be aware of any legal or ethical considerations regarding contraception provision, particularly for minors or in settings with specific regulations.
    • Confidentiality: It’s crucial to maintain patient confidentiality, especially for young or vulnerable populations seeking contraceptive services.
    • Cultural Sensitivity: Being sensitive to and respectful of diverse beliefs and practices regarding family planning is important in delivering care.
  10. Health Promotion and Education:
    1. Educating patients about reproductive health and the importance of STI prevention is an integral part of contraceptive management.
    2. STI Prevention: Emphasizing the importance of condoms, even when using other contraceptive methods, for STI prevention.
    3. Healthy Relationships: Providing information on consent and healthy relationship dynamics, particularly for younger patients.

MEC

The Medical Eligibility Criteria (MEC) for Contraceptive Use is a set of guidelines developed by the World Health Organization (WHO) and adapted by various countries. These guidelines help healthcare providers determine the safety of using different contraceptive methods in the context of specific health conditions and characteristics.

The MEC is organized into four categories, indicating the suitability of a particular contraceptive method for individuals with particular medical conditions or characteristics:

Categories of the MEC:

  1. Category 1: A condition for which there is no restriction for the use of the contraceptive method. It can be used without limitation.
  2. Category 2: A condition where the advantages of using the method generally outweigh the theoretical or proven risks. The method is usually suitable, but careful follow-up may be required.
  3. Category 3: A condition where the theoretical or proven risks usually outweigh the advantages of using the method. The provision of the method is not usually recommended unless other more appropriate methods are not available or acceptable.
  4. Category 4: A condition that represents an unacceptable health risk if the contraceptive method is used. The method should not be used.

Examples of Conditions Evaluated in the MEC:

  • History of deep vein thrombosis or pulmonary embolism
  • Current or history of breast cancer
  • Smoking in women aged over 35
  • Hypertension
  • Diabetes with vascular complications
  • Obesity
  • Migraine headaches, particularly with aura
  • Postpartum period and breastfeeding status
  • Liver disease, including hepatitis
  • HIV/AIDS and other immunocompromising conditions
  • Use of medications that can interact with hormonal contraception

Application of the MEC:

Healthcare providers use the MEC to guide discussions with patients about the most suitable contraceptive options based on their health status. For example:

  • Postpartum Women: Immediate postpartum is Category 1 or 2 for most contraceptive methods, but are Category 4 for the first 21 days postpartum for COCPs due to the risk of thrombosis.
  • Migraine without Aura: For women with migraines without aura, most methods are Category 1 or 2,
  • Migraines with Aura: COCPs are Category 4 due to an increased risk of stroke, but POP (mini-pill) are MEC 2.
  • Women with Breast Cancer: All hormonal methods are generally Category 4 for women with current breast cancer because of concerns about hormone sensitivity of the cancer.

The MEC is an essential tool for the safe provision of contraceptives. It emphasizes individualized contraceptive counseling and helps ensure that people receive effective and safe contraceptive methods that suit their personal medical conditions and life circumstances. It’s important for healthcare providers to stay up-to-date with the MEC guidelines and to apply them in the context of comprehensive reproductive health care, taking into account the patient’s preferences, needs, and values.