Combined oral contraceptives

Effectiveness depends on the user: Risk of pregnancy is greatest when a woman starts a new pill pack 3 or more days late, or misses 3 or more pills near the beginning or end of a pill pack.

• As commonly used, about 8 pregnancies yy per 100 women using COCs over the first year. This means that 92 of every 100 women using COCs will not become pregnant.
• When no pill-taking mistakes are made, less than 1 pregnancy per 100 women using COCs over the first year (3 per 1,000 women).

Return of fertility after COCs are stopped: No delay

Protection against sexually transmitted infections (STIs): None

Some users report the following:

• Changes in bleeding patterns including:
  • Lighter bleeding and fewer days of bleeding
  • Irregular bleeding
  • Less frequent bleeding
  • Lack of monthly bleeding

• Headaches
• Dizziness
• Nausea
• Breast tenderness
• Weight change
• Mood changes
• Acne (can improve or worsen, but usually improves)

Other possible physical changes:

• Blood pressure increases a few points (mm Hg). When increase is due to COCs, blood pressure declines quickly after use of COCs stops.

Helps protect against:

• Risks of pregnancy
• Cancer of the lining of the uterus (endometrial cancer)
• Cancer of the ovary
• Symptomatic pelvic inflammatory disease

May help protect against:

• Ovarian cysts
• Iron-deficiency anemia

Reduces:

• Menstrual cramps
• Menstrual bleeding problems
• Ovulation pain
• Excess hair on face or body
• Symptoms of polycystic ovarian syndrome (irregular bleeding, acne, excess hair on face or body)
• Symptoms of endometriosis (pelvic pain, irregular bleeding)

Known Health Risks

Very rare:

• Blood clot in deep veins of legs or lungs (deep vein thrombosis or pulmonary embolism)

Extremely rare:

• Stroke
• Heart attack

Safe and Suitable for Nearly All Women

Nearly all women can use COCs safely and effectively, including women who:

• Have or have not had children
• Are not married
• Are of any age, including adolescents and women over 40 years old
• Have just had an abortion or miscarriage
• Smoke cigarettes - if under 35 years old
• Have anemia now or had in the past
• Have varicose veins
• Are infected with HIV, whether or not on antiretroviral therapy, unless that therapy includes ritonavir

Women can begin using COCs:

• Without a pelvic examination
• Without any blood tests or other routine laboratory tests
• Without cervical cancer screening
• Without a breast examination
• Even when a woman is not having monthly bleeding at the time, if it is reasonably certain she is not pregnant

Combined oral contraceptives:

• Do not build up in a woman’s body. Women do not need a “rest” from taking COCs.
• Must be taken every day, whether or not a woman has sex that day.
• Do not make women infertile.
• Do not cause birth defects or multiple births.
• Do not change women’s sexual behavior.
• Do not collect in the stomach. Instead, the pill dissolves each day.
• Do not disrupt an existing pregnancy.

Problems Reported as Side Effects or Problems With Use:

• Missed pills.
• Irregular bleeding (bleeding at unexpected times that bothers the client)
• No monthly bleeding.
• Ordinary headaches (nonmigrainous).
• Nausea or dizziness.
• Breast tenderness.
• Weight change
• Mood changes or changes in sex drive.
• Acne

New Problems That May Require Switching Methods

• Unexplained vaginal bleeding (that suggests a medical condition not related to the method) or heavy or prolonged bleeding
• Starting treatment with anticonvulsants, rifampicin, rifabutin, or ritonavir
• Migraine headaches
• Circumstances that will keep her from walking for one week or more
• Certain serious health conditions (suspected heart or serious liver disease, high blood pressure, blood clots in deep veins of legs or lungs, stroke, breast cancer, damage to arteries, vision, kidneys, or nervous system caused by diabetes, or gall bladder disease).
• Suspected pregnancy

Contact your doctor if you have any of the problems listed above.

If you forget to administer the pill on time, or delay starting a new leaflet on time, you risk becoming pregnant as the effectiveness of the method decreases. It is important to administer the pill daily, at the same time. It is equally important to start a new leaflet on time, after the 7-day break, if using 21-pill leaflets or not to take a break if using 28-pill leaflets.

1. The risk of an unwanted pregnancy will increase depending on how many pills you forgot to take.
2. If you have forgotten to take a pill, as soon as you remember, take the pill.
   • If you forgot to take 2 or 3 pills:
     • Take the last pill you missed.
     • The previous (first) missed pill should be discarded
     • Use an additional method of contraception within the next 7 days
     • If you have had sexual intercourse in the last 5 days, you can use emergency contraception.

If the above examples do not fit your situation, please contact your doctor, and in the meantime, use an additional barrier method, e.g. condom.

1. Should a woman take a “rest” from COCs after taking them for a time?

No. There is no evidence that taking a “rest” is helpful. In fact, taking a “rest” from COCs can lead to unintended pregnancy. COCs can safely be used for many years without having to stop taking them periodically.

2. If a woman has been taking COCs for a long time, will she still be protected from pregnancy after she stops taking COCs?

No. A woman is protected only as long as she takes her pills regularly.

3. How long does it take to become pregnant after stopping COCs?

Women who stop using COCs can become pregnant as quickly as women who stop nonhormonal methods. COCs do not delay the return of a woman’s fertility after she stops taking them. The bleeding pattern a woman had before she used COCs generally returns after she stops taking them. Some women may have to wait a few months before their usual bleeding pattern returns.

4. Do COCs cause abortion?

No. Research on COCs finds that they do not disrupt an existing pregnancy. They should not be used to try to cause an abortion. They will not do so.

5. Do COCs cause birth defects? Will the fetus be harmed if a woman accidentally takes COCs while she is pregnant?

No. Good evidence shows that COCs will not cause birth defects and will not otherwise harm the fetus if a woman becomes pregnant while taking COCs or accidentally starts to take COCs when she is already pregnant.

6. Do COCs cause women to gain or lose a lot of weight?

No. Most women do not gain or lose weight due to COCs. Weight changes naturally as life circumstances change and as people age. Because these changes in weight are so common, many women think that COCs cause these gains or losses in weight. Studies find, however, that, on average, COCs do not affect weight. A few women experience sudden changes in weight when using COCs. These changes reverse after they stop taking COCs. It is not known why these women respond to COCs in this way.

7. Do COCs change women’s mood or sex drive?

Generally, no. Some women using COCs report these complaints. The great majority of COC users do not report any such changes, however, and some report that both mood and sex drive improve. It is difficult to tell whether such changes are due to the COCs or to other reasons. Providers can help a client with these problems . There is no evidence that COCs affect women’s sexual behavior.

8. What can a provider say to a client asking about COCs and breast cancer?

The provider can point out that both COC users and women who do not use COCs can have breast cancer. In scientific studies breast cancer was slightly more common among women using COCs and those who had used COCs in the past 10 years than among other women. Scientists do not know whether or not COCs actually caused the slight increase in breast cancers. It is possible that the cancers were already there before COC use but were found sooner in COC users .

9. Can COCs be used as a pregnancy test?

No. A woman may experience some vaginal bleeding (a “withdrawal bleed”) as a result of taking several COCs or one full cycle of COCs, but studies suggest that this practice does not accurately identify who is or is not pregnant. Thus, giving a woman COCs to see if she has bleeding later is not recommended as a way to tell if she is pregnant. COCs should not be given to women as a pregnancy test of sorts because they do not produce accurate results.

10. Must a woman have a pelvic examination before she can start COCs or at follow-up visits?

No. Instead, asking the right questions usually can help to make reasonably certain that a woman is not pregnant. No condition that could be detected by a pelvic examination rules out COC use.

11. Can women with varicose veins use COCs?

Yes. COCs are safe for women with varicose veins. Varicose veins are enlarged blood vessels close to the surface of the skin. They are not dangerous. They are not blood clots, nor are these veins the deep veins in the legs where a blood clot can be dangerous (deep vein thrombosis). A woman who has or has had deep vein thrombosis should not use COCs.

12. Can a woman safely take COCs throughout her life?

Yes. There is no minimum or maximum age for COC use. COCs can be an appropriate method for most women from onset of monthly bleeding (menarche) to menopause.

13. Can women who smoke use COCs safely?

Women younger than age 35 who smoke can use low-dose COCs. Women age 35 and older who smoke should choose a method without estrogen or, if they smoke fewer than 15 cigarettes a day, monthly injectables. Older women who smoke can take the progestin-only pill if they prefer pills. All women who smoke should be urged to stop smoking.

14. What if a client wants to use COCs but it is not reasonably certain that she is not pregnant after using the pregnancy checklist?

If pregnancy tests are not available, a woman can be given COCs to take home with instructions to begin their use within 5 days after the start of her next monthly bleeding. She should use a backup method until then.If pregnancy tests are not available, a woman can be given COCs to take home with instructions to begin their use within 5 days after the start of her next monthly bleeding. She should use a backup method until then.

15. Can COCs be used as emergency contraceptive pills (ECPs) after unprotected sex?

Yes. As soon as possible, but no more than 5 days after unprotected sex, a woman can take COCs as ECPs. Progestin-only pills, however, are more effective and cause fewer side effects such as nausea and stomach upset.

16. What are the differences among monophasic, biphasic, and triphasic pills?

Monophasic pills provide the same amount of estrogen and progestin in every hormonal pill. Biphasic and triphasic pills change the amount of estrogen and progestin at different points of the pill-taking cycle. For biphasic pills, the first 10 pills have one dosage, and then the next 11 pills have another level of estrogen and progestin. For triphasic pills, the first 7 or so pills have one dosage, the next 7 pills have another dosage, and the last 7 hormonal pills have yet another dosage. All prevent pregnancy in the same way. Differences in side effects, effectiveness, and continuation appear to be slight.

17. Is it important for a woman to take her COCs at the same time each day?

Yes, for 2 reasons. Some side effects may be reduced by taking the pill at the same time each day. Also, taking a pill at the same time each day can help women remember to take their pills more consistently. Linking pill taking with a daily activity also helps women remember to take their pills.