Information Sheet for Candidates

Your next patient in a general practice is an 18 year old,

Marianne, who seeks your advice regarding the oral
contraceptive pill. She has been with her current boyfriend
for about 4 months and they are thinking about starting a
sexual relationship. She has thought about all the other
contraceptive methods but believes that the OCP is the
most convenient for her.
Your tasks are to:
Take a short history and perform a relevant
examination
Explain the advantages and disadvantages of the OCP
to the patient
Answer any questions

HOPC: as above
PHx.: unremarkable, especially no DVT, no cardiovascular disease, no migraine, no
blood disorder, no liver problem.
FHx. NAD, especially no hyperlipidaemia
EXAMINATION: BP 115/65, P 68 + reg., RR 18, T 37.0
No abnormalities
Advice:
The normal cycle:
The hypothalamus releases gonadotrophin-releasing hormone (GnRH) which stimulates
the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the
pituitary gland. These influence the ovaries, inducing the secretion of oestrogen (from
theca granuloas cells) and progesterone (formed in the luteinised theca cells, corpus
luteum!) with a feedback loop to the hypothalamus and pituitary gland.
THE COMBINED ORAL CONTRACEPTIVE (COC) contains oestrogen (usually less
than 50 mcg of ethinyl oestradiol) and progesterone (progestogens: norethisterone,
levonorgestrel, gestogens (less androgenic)). They are either:
Monophasic = the amount of hormones in the tablet is constant throughout the
cycle
Triphasic = varying doses with less total progestogen but a bit more total
oestrogen, thus less negative effect on lipid metabolism (less decrease in HDL
lipids)
The most commonly prescribed COC are:
monophasic: Nordette, Microgynon30, Levlen ED
biphasic: Sequilar
triphasic: Triquilar
The COC offers a high degree of pregnancy prevention (only 1-3% failure rate).
CONTRA-INDICATIONS:
Hx. of arterial or venous thrombosis
Severe HPT
Migraine
Oestrogen dependent tumours

IHD
familial hyperlipidaemia
liver disease
polycythaemia

OTHER BENEFITS:
Reduction of most menstrual cycle disorders (menorrhagia, dysmennorrhoea, PMT)
Reduction of pelvic infections (PID)
Reduction in benign breast disease and benign breast tumours
Reduction in functional ovarian cysts
Reduction in uterine myomas and endometriosis
Reduction in endometrial and ovarian CAs

SIDE-EFFECTS:
1. Thrombembolism (arterial and venous) use low dose COCs!
2. Cancer risk: not proven but possibly increased risk of cervical CA, therefore the
patient should have yearly PAP-smear! Breast Ca not known but self examination
recommended!
3. ACNE: oestrogen seems to improve acne, whilst progestogen aggravates it.
Change over to Diane ED
4. Amenorrhoea: increase oestrogen or decrease progestogen
5. Breakthrough bleeding (BTB) and spotting: usually setlles, take pill at the same
time every day!
6. CHLOASMA: hyperpigmentation of the skin in rare cases, change to progestogen
only pill and avoid sunlight exposure.
7. GALLBLADDER disease can be accelerated in higher oestrogen pills
8. Headaches and migraine: discontinue and change to different method of
contraception.
9. Mood changes and depression: switch to monophasic pill or change progestogen
10. Nause and vomiting: usually settles, try to change oestrogen.
11. Sexual desire: libido can decrease, increase oestrogen
12. weight gain: decrease or change porgestogen
DRUG-INTERACTION:
1. ANTIOBIOTICS: during the time and up to seven days after finishing antibiotics
the absorption of the pill is reduced and pregnancy may occur! Other methods
should be used!
2. ANTICONVULSANTS: carbamazepine and phenytoin increase the hepatic
enzyme activity, which in turn increases the metabolism of contraceptive steroids
and reduces their efficacy!!!
3. Vit. C interacts as well!
4. Griseofulvin !
DIARRHOEA AND VOMITING: can change the absorption of the COC dramatically!
YEARLY follow-up examination, incl. PAP smear!!!
THE SEVEN DAY RULE:
If the patient misses or takes a pill late (more than 12 hours):
Take the pill asap, even if it means to take 2 tablets on one day and continue your
pack, although there have to be at least 7 hormone containing tablets. If not, leave
the inactive tablets out and continue straight with the hormone containing tablets.
This usually means that youll miss a period.
Use alternate contraception, e.g. condoms, for 7 days
The OCP does not protect against STDs!!!