Combined oral contraceptive (COC)
93% effective
What — oral pill with oestrogen and progestogen hormones
Types — several equally effective hormone combinations, different cost and side effects
- Start woman on PBS or S100 available version — less than 35microgram ethinylestradiol with LNG or NE (see packet)
How it works — prevents ovulation. Regulates cycle with artificial periods
Prescription — must be prescribed by eligible practitioner. Some are on the PBS
Timing — 1 pill taken every 24 hours. Best taken at same time each day
Fertility return — rapid
Packet
- LNG/NE has 28 tablets
- 21 active pills
- AND 7 inactive ('sugar') pills
- Always start with active pill
- Finish 1 pack before starting next
- Some newer types of COC have more active pills (24+) and are more expensive
Suitable for Quick Start — yes, see Contraception — general principles
- Take 1 active pill every day for 7 days to give contraception
Missed pill — Figure 7.9
Who benefits
- Women who are good pill-takers, want period control or less pain/bleeding
- Some women find some COCs help improve acne and mood
- May be helpful for symptoms of PCOS, endometriosis, premenstrual syndrome
Do not use COC if
Special issues
Not as effective as LARC (COC 92%, LARC 99+%)
Menstruation
COC allows women to safely skip periods (by missing or reducing the inactive or ‘sugar’
pills)
- Skipping periods may help reduce or avoid unwanted side effects experienced with the
artificial period bleed (eg headache, mood changes, period pain)
- Possible with COC with same dose per active pill — not possible on triphasic packs
Diarrhoea/vomiting
- Contraceptive effectiveness could be reduced if person vomits within 3 hours of taking
COC or has severe diarrhoea for more than 24 hours
- Manage as per missed pills
- Advise no sex or use condoms until after 7 days of active pill taking (after they
are better)
- Consider need for emergency contraception
Surgery
- Stop COC and switch to alternate contraception 4 weeks before major elective surgery or expected
period of immobility
- Medical consult
Side effects
- May increase BP
- Uncommon — headache, sore breasts, mood changes, decreased sex drive, nausea, bloating,
weight gain, breakthrough bleeding
- Can try different COC or alternate method — medical consult
Caution with clot risk
- COC causes small increase in risk of blood clot. Not first choice in people with multiple
clot risks
- Use progestogen-only, LARC or non-hormonal contraception
- Medical consult if concerned
Follow-up
Vaginal ring
93% effective. Expensive
What
- Plastic ring with oestrogen and progestogen (combined hormones) similar to COC pills (eg NuvaRing)
- Has less frequent issues with breakthrough bleeding than COC
How it works — prevents ovulation. Regulates cycle with artificial periods
Prescription — must be prescribed by eligible practitioner. Not available on PBS and expires 4 months after dispensing
Timing — new ring inserted by woman every 3–4 weeks
Who benefits — woman wanting relative advantages of CHC method but
- Unable to remember to take daily COC
- Have issues with malabsorption
Special issues
Same issues as COC
Progestogen-only pill (POP)
93% effective
What — oral pill with progestogen hormone
Type — 2 types
- LNG 30microgram
- NE 350microgram
Prescription — must be prescribed by eligible practitioner. Available on PBS
How it works
- Primary effect — thickens cervical mucus preventing sperm penetration
- Prevents ovulation in 60% of cycles. Can vary between patients
Timing — 1 pill taken at same time (within 3 hours) every day
Fertility return — rapid
Packet — 28 tablets, all identical and active. Start anywhere
Suitable for Quick Start — yes, see Contraception — general principles
- 1 pill every day for 3 days to give contraception
Missed pill
- If more than 3 hours late — take missed pill straight away, then next pill at correct
time
- Advise no sex or use condoms until 1 pill taken each day for 3 days
- Offer ECP
Who benefits
- Women who can't tolerate or have contraindications to oestrogen in COC
- Women with high cardiovascular risk
- Breastfeeding mothers
Do not use POP if
Special issues
- Not as effective as LARC due to strict timing
- Some women not able to manage routine, even though it suits them in theory (eg tired
breastfeeding mothers, young women)
Bleeding
- Variable
- Frequent and irregular bleeding more common than no bleeding or prolonged bleeding
Diarrhoea/vomiting
- Only important in severe diarrhoea or if they vomit less than 2 hours after taking
POP
- If vomiting within 2 hours of taking a pill — take another pill
- If this second pill is more than 3 hours late — advise no sex or use condoms until
1 pill a day taken for 3 days in a row (after they are better)
Side effects
- Uncommon — headaches, mood change, weight gain, breast tenderness, loss of libido,
acne
Follow-up
- Medical follow up every year and offer regular Adult health check, STI check — woman, young person
- Always ask woman on POP about missed pills and bleeding
- Does she know what to do if she misses a pill
- Is it still best method for her