Combined Oral Contraceptive Pills (COCs) Session I: Characteristics of COCs

Combined Oral Contraceptives Objectives Participants will be able to: Describe the characteristics of COCs in a manner that clients can understand Demonstrate how to screen clients for eligibility for COC use Describe when to initiate COCs Explain how to use COCs, what to do when pills are missed, and when to return Address common concerns, misconceptions, and myths Explain how to manage side effects Identify conditions that require switching to another method Identify clients in need of referral for COC-related complications The learning objectives for this module are based on input from various stakeholders <insert who provided input: participants, supervisors, health officials>. The objectives of this module are as follows: By the end of this training session, participants will be able to: <click the mouse to advance through the objectives, reading each objective aloud >.

COCs Key Points for Providers and Clients Take a pill every day. Contains both estrogen and progestogen hormones. Works mainly by stopping ovulation. Effectiveness depends on the user. Can be very effective. “Would you remember to take a pill each day?” No need to do anything at time of sexual intercourse. Very effective if taken every day. But if woman forgets pills, she may become pregnant. Easy to stop: A woman who stops pills can soon become pregnant. Very safe. Pills are not harmful for most women’s health and studies show very low risk for cancer due to pills for almost all women. The pill can even protect against some types of cancer. Serious complications are rare. They include heart attack, stroke, blood clots in deep veins of the legs or lungs. Some women have side-effects at first–not harmful and often go away after first 3 months. Side-effects often go away after first 3 months. No protection against STIs or HIV/AIDS. For STI/HIV/AIDS protection, also use condoms. Adapted from WHO’s Decision-making tool for family planning clients and providers.

What Are COCs? Traits and Types Content Combination of two hormones: estrogen and progestin Phasic Monophasic, biphasic, triphasic Dose Low-dose: 30-35 µg of estrogen (common), 20 µg or less (rare in most places) Pills per pack 21: all active pills (7-day break between packs) 28: 21 active + 7 inactive pills (no break between packs)

Effectiveness of COCs In this progression of effectiveness, where would you place combined oral contraceptives (COCs)? Less effective More effective Implants Male Sterilization Female Sterilization Intrauterine Devices Progestin-Only Injectables Male Condoms Standard Days Method Female Condoms Spermicides Ask participants: Where would you put combined oral contraceptives on this list? After participants respond, click the mouse to reveal the answer COCs

Relative Effectiveness of FP Methods # of unintended pregnancies among 1,000 women in 1st year of typical use No method 850 Withdrawal 220 Female condom 210 Male condom 180 Pill 90 Injectable 60 IUD (CU-T 380A / LNG-IUS) 8 / 2 Female sterilization 5 Vasectomy 1.5 Implant 0.5 Source: Trussell J., Contraceptive Failure in the United States, Contraception 83 (2011) 397- 404, Elsevier Inc.

COCs: Mechanism of Action Suppresses hormones responsible for ovulation Illustration credit: Salim Khalaf/FHI Thickens cervical mucus to block sperm COCs have no effect on an existing pregnancy.

COCs: Characteristics Safe and more than 99% effective if used correctly Can be stopped at any time No delay in return to fertility Are controlled by the woman Do not interfere with sex Have health benefits Less effective when not used correctly (91%) Require taking a pill every day Do not provide protection from STIs/HIV Have side effects Have some health risks (rare) Source: Hatcher, 2007; WHO, 2010; CCP and WHO, 2011; Trussell , 2011.

COCs: Menstrual-Related Health Benefits 5/25/2012 COCs: Menstrual-Related Health Benefits Decreased amount of flow and fewer days of bleeding; no bleeding (less common) Regular, predictable menstrual cycles Reduced pain and cramps during menses Reduced pain at time of ovulation Source: Davis, 2005.

COCs: Other Health Benefits Protection from: Risks of pregnancy Ovarian cancer Endometrial cancer Symptomatic PID Reduced risk of: Ovarian cysts Iron-deficiency anemia Decreased symptoms of endometriosis (pelvic pain, irregular bleeding) Decreased symptoms of polycystic ovarian syndrome (irregular bleeding, acne, excess hair on face or body) Source: Petitti and Porterfield, 1992; CASH Study, 1987; CCP and WHO, 2011; Belsey, 1988; Davis, 2007.

No Overall Increase in Breast Cancer Risk for COC Users Analysis of a large number of studies: No overall increase in breast cancer risk among women who had ever used COCs Current use and use within past 10 years: very slight increase in risk May be due to early diagnosis or accelerated growth of pre-existing tumors More recent study: No increase in breast cancer risk regardless of age, estrogen dose, ethnicity, or family history of breast cancer Source: Collaborative Group on Hormonal Factors in Breast Cancer, 1996; Marchbanks, 2002.

COCs and Cervical Cancer Cervical cancer is caused by certain types of human papillomavirus (HPV) Some increase in risk among women with HPV and others who use COCs more than 5 years Risk of cervical cancer goes back to baseline after 10 years of non-use Cervical cancer rates in women of reproductive age are low. Risk of cervical cancer at this age group is low compared to mortality and morbidities associated with pregnancy. COC users should follow the same cervical cancer screening schedule as other women. Source: Smith, 2003; Appleby, 2007; CCP and WHO, 2011.

Risk of Blood Clots is Limited COCs may slightly increase risk of blood clots: Stroke Heart attack Risk is concentrated among women who have additional risk factors, such as: Hypertension Diabetes Smoking Deep vein thrombosis Pulmonary embolism Stop COCs immediately if a blood clot develops. Source: World Health Organization Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception ,1995; Jick, 2006; WHO, 1998; Farley, 1998.

Possible Side-Effects If a woman chooses this method, she may have some side- effects. They are not usually signs of illness. But many women do not have any side-effects. Side-effects often go away after a few months and are not harmful. Most common: Mood changes or headaches Tender breasts Changes in bleeding patterns (lighter, irregular, infrequent or no monthly bleeding) Slight weight gain or loss Nausea (upset stomach) Dizziness Adapted from WHO’s Decision-making tool for family planning clients and providers.