1. Pre-service Education on FP and AYSRH
Session II Topic 1 Combined Oral Contraceptives (COCs)

2. 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.
Explain: The key points to remember about COCs are that: one pill must be taken every day; effectiveness depends on the user; COCs are very safe, they help reduce menstrual bleeding and cramps, some women have side effects at first (these are not harmful); and COCs don’t provide protection against STIs or HIV/AIDS.

3. What Are COCs? Traits and Types
Content
Combination of two hormones: estrogen and progestin
Phasic
Monophasic, biphasic, triphasic
Dose
Low-dose: 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)
Ask the participants: What are some traits that differ among combined oral contraceptive pills? <allow participants to answer; click the mouse to reveal the following traits>
• COCs can differ in hormone content, dosage, and number of pills per pack. All combined oral contraceptive pills contain ethinyl estradiol, which is a synthetic estrogen, and one of the various types of progestin. The most common type of combined pill is monophasic, in which the hormone content is constant in all 21 active pills.
• COCs are also available as biphasic and triphasic pills, in which the ratio of estrogen to progestin varies among the active pills two or three times during the cycle. There are no clinically significant differences in effectiveness or safety between multiphasic and monophasic pills.
• Both the type and the amount of hormone contained in each formulation of pill are related to its potential for side effects. The low-dose pills used today generally contain 30 to 35 micrograms (µg) of ethinyl estradiol and have a much lower potential for side effects than older high-dose pills containing 50 µg of estrogen (commonly used until the late 1970s and now used primarily for emergency contraception). Some types of low-dose pills contain as little as 20 µg of estrogen, but they are rare in most places.
• COCs are packaged with either 21 or 28 pills per pack. The 21-pill pack contains only active pills and requires women to take a seven-day break between packs. The 28-pill pack contains 21 active pills and seven inactive or hormone-free pills. These inactive pills are included to minimize the risk of women forgetting to start a new pack of pills on time after a seven-day break. The seven-day period, during which no active pills are taken, is called the “hormone-free interval.” Most women have their menstrual bleeding during this hormone-free interval.
•Ask the students: Which brands of pills are they familiar with. Allow students to answer and add to the students’ responses as needed.
Show some of the brands that are available in the country

4. 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
The purpose of this activity is to emphasize the effectiveness of combined oral contraceptives.
• Inform: The list on these slides categorizes contraceptive methods from most effective to least effective as commonly used. In this list, spermicides are the least effective method and the most effective methods are contraceptive implants, sterilization, and IUDs.
COCs

5. COCs: Mechanism of Action
Suppresses
hormones
responsible for
ovulation
Illustration credit: Salim Khalaf/FHI
Ask students to brainstorm ideas about how to explain how COCs work to prevent pregnancy, using simple language the client will understand. For example, “Your body stops producing eggs for as long as you take the pill so you cannot get pregnant.” Encourage students to use pages or illustrations from counseling tools to help with their explanations.
Thickens
cervical mucus to block sperm
COCs have no effect on an existing pregnancy.

6. 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)
Ask students to brainstorm what they know about Combined Oral Contraceptives (COCs)
Write their responses on the flip chart
Show the slide and compare it to their responses
Source: Hatcher, 2007; WHO, 2010; CCP and WHO, 2011; Trussell , 2011.

7. Advantages of COCs Advantages of Using COCs.
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
Ask students to brainstorm the advantages of COCs
Write their responses on the flip chart
Show the slide on advantages of COCs and compare to those listed on the flip chart.

8. Non Contraceptive Benefits of COCs
Menstrual related 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
Protection from: Ovarian cancer, Endometrial cancer and Symptomatic PID
Reduced risk of: Ovarian cysts, Iron-deficiency anemia
Decreased symptoms of: Endometriosis (pelvic pain, irregular bleeding) and polycystic ovarian syndrome (irregular bleeding, acne, excess hair on face or body)
Show the slide on the non-contraceptive benefits of COCs and discuss.

9. Disadvantages of COCs Less effective when not used correctly (91%)
Requires taking a pill every day
Does not provide protection from STIs/HIV
Has some side effects
Has some health risks (rare)
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
Ask students to brainstorm the disadvantages of COCs
Write their responses on the slip chart
Show the slide on advantages of COCs and compare to those listed on the flip chart.

10. 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.
Remind participants that as with many contraceptive methods, there are some side effects associated with COCs that are not harmful but may be unpleasant.
Women’s preferences for certain methods are often related to side effects. Ask the students: What side effects of COCs, have you heard about?
As we have acknowledged, some women who take COCs experience certain side effects. These side effects may include nausea, dizziness, headaches, breast tenderness, and mood swings. COCs may also cause bleeding changes.
Most women experience a reduction in the amount of menstrual bleeding. The majority of women have regular menstrual bleeding while taking COCs; however, some women may experience amenorrhea while others have breakthrough bleeding, or irregular bleeding between periods. This bleeding ranges from spotting to light bleeding episodes.
Because some cultures or religions restrict sexual and religious activities during menstruation, breakthrough bleeding may interfere with a woman’s daily life. Breakthrough bleeding is generally not harmful to a woman’s health.
Studies show COCs have no negative effect on hemoglobin or iron levels and may even help prevent iron-deficiency anemia.
It is important to remember that many COC users do not experience any side effects. Those who do experience side effects may experience one or two of these side effects, but not all of them.
Typically, side effects diminish within a few months after a woman begins COC use.
Because these side effects may have an important impact on users’ experience with COCs, they should be addressed during counseling and follow-up visits.

11. COCs Are Safe for Nearly All Women
Almost all women can use COCs safely, including women who:
Have or have not had children
Are not married
Are of any age
Smoke (if under age 35)
Have anemia now or had it in the past
Have varicose veins
Have an STI or HIV/AIDS
Most health conditions do not affect safe and effective use of COCs
Use slides to show women who can safely use COCs:
• Nearly all women can use COCs safely and effectively.
• Most health conditions do not affect safe and effective use of COCs and only few conditions or situations may affect a woman’s eligibility to use COCs.
• The WHO medical eligibility criteria were developed to reassure providers about conditions that do not interfere with safe use of contraceptives and highlight all the conditions that affect a woman’s eligibility to use any given contraceptive method.

12. Who Can and Cannot Use COCs
Most women can safely use the pill.
But usually cannot use the pill if:
Adapted from WHO’s Decision-making tool for family planning clients and providers.
Explain that most women can safely use the pill as mentioned in the previous slide. Use slides to show who should not use COCs
High blood pressure
Smoke cigarettes AND age 35 or older
Breastfeeding 6 months or less
May be pregnant
Gave birth in the last 3 weeks
Some other serious health conditions

13. Who Should Not Use COCs (part 1)
5/25/2012
My period is late…
Breast
feeding a baby less than 6 months old
Breast
feeding a baby less than 6 months old
Are
pregnant
Think they may be pregnant
Are
pregnant
Think they may be pregnant
Illustration credit: Ambrose Hoona-Kab.
Adapted from WHO’s Decision-making tool for family planning clients and providers.
Smoke and are age 35 or older
Had a heart attack or stroke
Had blood clots in legs or lungs
Have or had breast cancer
Had a heart attack or stroke
Had blood clots
in legs or lungs
Source: WHO, 2010.

14. Who Should Not Use COCs (part 2)
5/25/2012
Have rheumatic disease, such as lupus
Take pills for TB, seizures (fits), or HIV
Have high blood pressure
I cannot eat sweets.
Have diabetes (high sugar in blood)
Have serious
liver disease or
gall bladder disease
Have bad headaches with nausea or vision problems
Gave birth in last 6 weeks
Breast
feeding a baby less than 6 months old
Think they may be pregnant
Illustration credit: Ambrose Hoona-Kab.
Adapted from WHO’s Decision-making tool for family planning clients and providers.
Had a heart attack or stroke
Had blood clots
in legs or lungs
Source: WHO, 2010; Chu, 2005.
Source: WHO, 2010.

15. Medical Eligibility Criteria
5/25/2012
Medical Eligibility Criteria
What are medical eligibility criteria? Define the categories. Review the job aid.
Brainstorming (10 min.)
This activity has two purposes:
To give participants an opportunity to share what they know about the eligibility criteria used in their national family planning guidelines or the WHO medical eligibility criteria (WHO MEC) so that the facilitator can determine whether the participants understand the criteria and how they are used or whether they need additional background information before proceeding.
To introduce job aids that help participants understand eligibility criteria (and that they may also use at their worksites), such as the WHO Medical Eligibility Criteria Wheel for Contraceptive Use. The WHO MEC Wheel can be downloaded from:
Explain the 4 categories:
Category 1: For women with these conditions or characteristics, the method presents no risk and can be used without restrictions.
Category 2: For women with these conditions or characteristics, the benefits of using the method generally outweigh the theoretical or proven risks. Women with Category 2 conditions generally can use the method, but careful follow-up may be required.
Category 3: For women with these conditions or characteristics, the theoretical or proven risks of using the method usually outweigh the benefits. Women with Category 3 conditions generally should not use the method. However, if no better options for contraception are available or acceptable, the provider may judge that the method is appropriate, depending on the severity of the condition. In such cases, ongoing access to clinical services and careful follow-up will be required.
Category 4: For women with these conditions or characteristics, the method presents an unacceptable health risk and should not be used.
In some cases, a particular condition or characteristic is assigned to one category for initiation and another for continuation of the method. In other words, the category may depend on whether a woman with the condition wishes to initiate the contraceptive method or was already using that method when she developed the condition.

16. When clinical judgment is available
WHO’s Medical Eligibility Criteria
Categories for IUDs, Hormonal and Barrier Methods
Category
Description
When clinical judgment is available 1
No restriction for use
Use the method under any circumstances 2
Benefits generally outweigh risks
Generally use the method 3
Risks usually outweigh benefits
Use of method not usually recommended, unless other methods are not available/acceptable 4
Unacceptable health risk
Method not to be used
Source: WHO, 2010.

17. When clinical judgment is available
WHO’s Medical Eligibility Criteria
Categories for IUDs, Hormonal and Barrier Methods
WHO’s Medical Eligibility Criteria
Categories for IUDs, Hormonal and Barrier Methods
Category
When clinical judgment is available 1
Use the method 2 3
Do not use the method 4
Explain that in situations where clinical judgment is limited, the four-category classification framework can be simplified into two categories. When simplified for these situations, categories 1 and 2 indicate that the method can be used, while categories 3 and 4 indicate that the woman is not medically eligible to use the method.
Demonstrate how to use the WHO MEC Wheel. Explain that COCs are safe for the overwhelming majority of women. Use slides 9-11 to provide an overview of the medical eligibility criteria for COCs.
List medical criteria on a flip chart. Ask participants to find the appropriate category on the WHO MEC Wheel. If time allows, this exercise can be made into a game using teams to determine the correct answers. Ask several participants to share one thing that they know about the eligibility criteria in their national FP/RH guidelines (if they exist) or the WHO MEC.
Answer any questions that participants have about general medical eligibility issues or how to use the MEC Wheel before moving on to medical eligibility for COCs.
Source: WHO, 2010.

18. Conditions (selected examples)
Category 1 and 2 Examples (not inclusive): Who Can Use COCs
WHO Category
Conditions (selected examples)
Category 1
menarche to 39 yrs; nulliparous; endometriosis; endometrial or ovarian cancer; uterine fibroids; family history of breast cancer; varicose veins; irregular, heavy, or prolonged bleeding; anemia; STI/PID; hepatitis (chronic/carrier)
Category 2
≥40 yrs; breastfeeding ≥6 months postpartum; superficial venous thrombosis; dyslipidaemias without other cardiovascular risk factors; uncomplicated diabetes; cervical cancer; unexplained vaginal bleeding; undiagnosed breast mass
Source: WHO, 2010.

19. Conditions (selected examples)
Category 3 Examples (not inclusive): Who Should Generally Not Use COCs
WHO Category
Conditions (selected examples)
Category 3
Postpartum:
Breastfeeding between 6 weeks and 6 months
Non-breastfeeding and less than 3 weeks if no additional risk factors for deep vein blood clots (VTE)
Non-breastfeeding 3-6 weeks with additional risk of VTE
Vascular conditions:
Hypertension (history of or BP /90–99)
Migraine without aura (older than 35 yrs)
Gastrointestinal conditions:
Symptomatic gall bladder disease (current and medically-treated)
Drug interactions:
Use of seizure medications or rifampicin or rifabutin
Source: WHO, 2010.

20. Conditions (selected examples)
Category 4 Examples (not inclusive): Who Should Not Use COCs
WHO Category
Conditions (selected examples)
Category 4
Breastfeeding: <6 weeks postpartum
Non-Breastfeeding:<3 weeks with risk factors for VTE
Smoking: ≥15 cigarettes/day and ≥ 35 yrs old
Vascular conditions:
Hypertension (≥160/≥100)
Migraines with aura
Ischemic heart disease or stroke
Diabetes with vascular complications
Deep venous thrombosis (history or acute)
Pulmonary embolism (history or acute)
Liver conditions:
Acute hepatitis
Severe liver disease and most liver tumors
Breast cancer: current or within 5 yrs
Source: WHO, 2010; Sekar, 2008.

21. COC Use by Women with HIV
WHO Eligibility Criteria
Condition
Category
HIV-infected 1
AIDS
ARV therapy
(which does not contain ritonavir) 2
Ritonavir/ ritonavir-boosted PIs
(as part of ARV regimen) 3
Women with HIV or AIDS can use without restrictions
Women on ARVs can use COCs safely
Should not be used by women who take medications for seizures or rifampacin or rifabutin for tuberculosis (may reduce effectiveness of COCs).
Using low-dose COCs is appropriate
Condom use should be encouraged in addition to COCs
Summary: Can women taking antiretroviral (ARV) therapy use COCs? What advice would you give to women taking rifampicin or rifabutin ? What advice would you give women taking medications for seizures?
Ask participants: Let us take a closer look at the conditions and categories pertaining to clients with HIV or AIDS.
Use slides to present the following:
Women with HIV who may or may not have AIDS can use COCs without any restrictions—category 1.
According to WHO, women with AIDS who are on antiretroviral (ARV) therapy generally can use COCs.
Women who are taking medicines for seizures (such as barbiturates, carbamazepine, lamotrigine, oxcarbazepine, phenytoin, primidone, topiramate) or medication for tuberculosis such as rifampicin,or rifabutin should not take COCs. These medications can make COCs less effective.
A sensible approach may be to use condoms consistently as a backup method of contraception while taking low-dose COCs.
Regardless of the method chosen, counseling on condom use should be an integral part of contraceptive counseling for women with HIV.
Source: WHO, 2010; Sekar, 2008.

22. COC Use by Postpartum Women
WHO Eligibility Criteria
Condition
Category
Non-breastfeeding <3 weeks 3
Breastfeeding <6 weeks 4
Breastfeeding >6 weeks and < 6 months
Breastfeeding ≥6 months 2
Non-breastfeeding women should not initiate COCs before 3 weeks postpartum (3-6 weeks postpartum with VTE risk factors)
Breastfeeding women
Should not use COCs before 6 weeks postpartum
Should not use COCs from 6 weeks to 6 months postpartum unless no other method is available
Can generally initiate COCs at 6 months postpartum
• Ask participants: Let us take a closer look at the conditions and categories pertaining to postpartum clients.
• Use slides to present the following:
O Nonbreastfeeding women generally should not initiate COCs before three weeks postpartum due to the increased risk of blood clots in the immediate postpartum period―category 3.
O Some of these women may have additional risk factors for thrombosis. In this case they should not be given COCs under any circumstances before 3 weeks postpartum, a category 4 condition, and generally should not use COCs before 6 weeks postpartum, a category 3 condition. These recommendations come from a 2010 WHO technical consultation on the use of combined hormonal contraceptives during the postpartum period.
O Women who are not breastfeeding and less than 3 weeks since giving birth, without additional risk that she might develop a blood clot in a deep vein (VTE) generally should not use COCs
O Women who are not breastfeeding and between 3 and 6 weeks postpartum with additional risk that she might develop a blood clot in a deep vein (VTE) generally should not use COCs
O Women who are not breastfeeding and between 3 and 6 weeks postpartum without additional risk that she might develop a blood clot in a deep vein (VTE) can use COCs
O Breastfeeding women should avoid COCs until six months postpartum.
O It is particularly important not to use COCs during the first six weeks postpartum, the period when milk production is established, because COCs can reduce the amount of breastmilk produced.
O Women can generally initiate COCs at six months postpartum when breastmilk is not the sole source of the infant’s nutrition.
O Consider using this slide if the participants will be offering services to postpartum clients. It provides a concise overview of medical eligibility issues related to COC use by women during the postpartum period.
O Refer participants to the 2015 WHO document, Medical Eligibility Criteria for Contraceptive Use, 5th Edition, for the latest WHO update on medical eligibility issues for COCs during postpartum
Source: WHO, 2010.

23. Read questions 1–12 in the checklist.
Group Activity Understanding the Checklist
Read questions 1–12 in the checklist.
How have you determined medical eligibility in the past?
The checklist also gives instructions about initiating COCs.
This set of questions identifies women who should not use COCs.
This set of questions identifies women who are not pregnant.
The purpose of this activity is to introduce participants to the Checklist for Screening Clients Who Want to Initiate Combined Oral Contraceptives, to provide an overview of its purpose, and to show how to use it.
• Distribute a COC checklist to each participant.
• When introducing the checklist, note that it should be used by providers to determine whether a client is medically eligible to use the method that she selected during an informed decision-making process.
• The questions on the checklist identify women who have health conditions—WHO category 3 or 4—that make it unsafe for them to use COCs. The checklist also incorporates questions that allow a provider to determine with reasonable certainty that a client is not pregnant.
• To use the checklist, providers ask the questions on the checklist and follow the instructions based on the client’s responses. Explain that the medical eligibility questions, questions 1–12, are at the top of the checklist.
• Ask participants:
O To pair up with the person sitting next to them and take turns reading questions 1–12 on the checklist as if they were asking a client each question.
O How have you determined a client’s medical eligibility for COCs in the past? If so, how might the checklist facilitate that process?
• Accept responses from several participants and discuss any concerns that participants may raise.
• Ask participants to read questions 13–18. Emphasize that providers should follow the instructions for this set of questions to identify women who are not pregnant or those who might be pregnant and should either wait till next menses or have a pregnancy test in order to rule out pregnancy.
Refer to Session Plan for Exercise on Using the Checklist

24. When to Start COCs (part 1)
Anytime you are reasonably certain the woman is not pregnant
Pregnancy can be ruled out if the woman meets one of the following criteria:
Started monthly bleeding within the past 7 days
Is breastfeeding fully, has no menses and baby is less than 6 months old
Has abstained from intercourse since last menses or delivery
Had a baby in the past 4 weeks
Had a miscarriage or an abortion in the past 7 days
Is using a reliable contraceptive method consistently and correctly
If none of the above apply, pregnancy can be ruled out by pregnancy test, pelvic exam, or waiting until next menses
Ask participants the following question: If a woman is medically eligible and wants to use COCs, when can she start them? <participants call out responses; accept responses from several participants>. Let us compare your responses with the information on the next several slides.
Use the slides to present the following:
A woman can start taking COCs anytime a provider is reasonably certain that she is not pregnant.
A provider can be reasonably certain that a woman is not pregnant if any of these situations apply:
Her monthly bleeding started within the past seven days.
The woman is fully breastfeeding, has no menses, and her baby is less than six months old.
She has abstained from intercourse since her last menses or since delivery.
She had a baby in the past four weeks.
She had a miscarriage or an abortion in the past seven days.
She has been using a reliable contraceptive method consistently and correctly.
If none of these situations apply, a provider can conduct a urine pregnancy test or a bimanual pelvic exam if appropriate to determine if the woman is pregnant.
If no other means to rule out pregnancy are available, a provider can ask a woman to come back at the time of her next menses and to use a backup contraceptive method in the meantime.
Providers may give a pack of COCs to the client with instructions to begin using them when her menses starts. This is known as advance provision.
Remind participants that questions 13–18 in the Checklist for Screening Clients Who Want to Initiate Combined Oral Contraceptives are used to rule out pregnancy as part of the screening process for starting COCs.
See Session Plan for Group Activity
Source: WHO, 2004 (updated 2008).

25. When to Start COCs (part 2)
If starting during the first 5 days of the menstrual cycle, no backup method needed
After day 5 of her cycle, rule out pregnancy and use backup method for the next 7 days
Postpartum
Not breastfeeding: May start 3 to 6 weeks after giving birth, depending on presence of risk factors for blood clots
Breastfeeding: May start 6 months after giving birth
Use the slides to present the following:
If a woman initiates COC use during the first five days after the onset of her menstrual period, it is not necessary to use a backup method, such as condoms.
Because it takes time for COCs to become fully effective, starting use during the first five days allows the hormones to fully inhibit follicular development in the ovaries and prevent ovulation, ensuring that there is virtually no danger of pregnancy.
If a woman starts COCs after the fifth day of her menstrual cycle it is necessary to rule out pregnancy. She should also use a backup method for seven days as there is a chance she may ovulate before COCs become fully effective.
You can be reasonably certain a woman is not pregnant if she is starting within seven days after the start of her menses. If it is more than seven days, you should ask the other pregnancy-related questions on the checklist to rule out pregnancy.
A woman who is not breastfeeding may begin COCs three weeks after delivery, when the increased risk of blood clots associated with pregnancy subsides. This interval is extended to 6 weeks after delivery for women with additional risk factors for blood clots.
If a non-breastfeeding woman wishes to initiate COCs after four weeks postpartum, it is necessary to first rule out pregnancy.
If fully or nearly fully breastfeeding, a woman may begin COCs at six months postpartum.
COCs may be provided in advance so that a breastfeeding woman can initiate the method when it is appropriate for her situation.
Remind participants that the instruction boxes below the questions on the Checklist for Screening Clients Who Want to Initiate Combined Oral Contraceptives also provide guidance about when to initiate COCs for women who are eligible.
Source: WHO, 2004 (updated 2008).

26. When to Start COCs (part 3)
After miscarriage or abortion
If within 5 days after miscarriage or abortion, no backup method needed
If more than 5 days after, rule out pregnancy, use backup method for 7 days
Switching from hormonal method
May start immediately, no backup method needed (with injectables, initiate within reinjection window)
Switching from non-hormonal method
If starting within 5 days of start of menstrual cycle, no backup method needed
If starting after day 5 of cycle, use backup method for 7 days
After using emergency contraceptive pills
Initiate immediately after taking progestin-only ECPs, use backup method for 7 days
After taking ulipristal acetate (UPA) ECPs she can start or restart COCs on the 6th day after taking UPA EPs
Use the slides to present the following:
• A woman can start COCs immediately or within the first five days after a first- or second-trimester miscarriage or abortion without the need for a backup method. However, if she wishes to start COCs more than five days after a miscarriage or abortion, rule out pregnancy and instruct the woman to use a backup method, such as condoms, for seven days.
• When switching from hormonal methods, COCs can be started immediately with no need for a backup method.
• If the woman is switching from injectables to COCs, she can initiate anytime during the reinjection window.
• When switching from nonhormonal methods, COCs can be started during the first five days of the menstrual cycle with no need for a backup method. After day five of the menstrual cycle, instruct the woman to use a backup method for the next seven days.
• If the woman is switching from an IUD to COCs after day five of her cycle, the IUD can be left in place as backup method for the next seven days or until her next menses. If an IUD user has had intercourse since her last menses, it is particularly important to keep the IUD in place for at least seven days after starting COCs.
• If a woman has taken progestin-only emergency contraceptive pills, she should begin taking COCs the she can start or restart COCs immediately after she takes the ECPs. No need to wait for her next monthly bleeding. day after she takes her final dose of ECPs. She should also use a backup method for the first seven days. If she does not start immediately, but returns for COCs, she can start at any time she is reasonably certain she is not pregnant. If a woman has taken ulipristal acetate (UPA) ECPs she can start or restart COCs on the 6th day after taking UPA ECPs. All women will need to use a backup method method for the first 7 days after taking pills.
Source: WHO, 2004 (updated 2008).

27. How to Take COCs Take one pill each day, by mouth.
The Pill
Take one pill each day, by mouth.
Most important instruction:
Give client her pill pack to hold and look at.
Show how to follow arrows on pack.
Discuss:
Easy to remember to take pills?
“What would help you to remember? What else do you do regularly every day?”
Easiest time to take the pills? At a meal? At bedtime?
Where to keep pills.
What to do if pill supply runs out.
Adapted from WHO’s Decision-making tool for family planning clients and providers.
Discussion (5 min.)
• Ask participants the following questions:
O What instructions do you give women about how to take COCs? <accept responses from several participants>
O Why is it important that women follow these instructions and take COCs consistently and correctly? <accept responses from several participants>
O Let us compare your responses with the information on the next few slides. <click the mouse to reveal each bullet on the slides>
• Use the slides to present the following:
O After a woman starts taking COCs, she should take one pill each day until the pack is empty. Failing to take the pill daily increases the risk of pregnancy.
O Women using the 21-pill pack take a seven-day break from pill taking each month. The 28-pill pack users take seven inactive pills during the hormone-free interval and do not take a break between pill packs.

28. How to Take COCs
The Pill
28-pill pack
21-pill pack
If you use the 28-pill pack:
No waiting between packs.
Once you have finished all the pills in the pack, start new pack on the next day.
If you use the 21-pill pack:
7 days of no pills
Once you have finished all the pills in the pack, wait 7 days before starting new pack. For example: If you finish the old pack on Saturday, take the first pill of the new pack on the following Sunday.
Caution the client: Waiting too long between packs greatly increases risk of pregnancy.
Adapted from WHO’s Decision-making tool for family planning clients and providers.
Give women advice about what to do if they forget to take a pill.
For pills containing 30–35 μg ethinyl estradiol
Missed 1 or 2 active (hormonal) pills in a row, or starts a pack 1 or 2 days late: The woman should take an active (hormonal) pill as soon as possible and then continue taking pills daily, 1 each day.
If the woman misses 2 or more active (hormonal) pills in a row, she can take the first missed pill and then either continue taking the rest of the missed pills (1 each day) or discard them to stay on schedule.
Depending on when the woman remembers that she missed the pill(s), she may take 2 pills on the same day (one at the moment of remembering, and the other at the regular time) or even at the same time. No additional contraceptive protection is needed.
Missed 3 or more active (hormonal) pills in a row, or starts a pack 3 or more days late: the woman should take an active (hormonal) pill as soon as possible and then continue taking pills daily, 1 each day.
Depending on when the woman remembers that she missed the pill(s), she may take 2 pills on the same day (one at the moment of remembering, and the other at the regular time) or even at the same time.
The woman should also use condoms or abstain from sex until she has taken active (hormonal) pills for 7 days in a row.
If the woman missed the pills in the third week, she should finish the active (hormonal) pills in her current pack and start a new pack the next day. She should not take the 7 inactive pills.
If the woman missed the pills in the first week and had unprotected sex, she may wish to consider the use of emergency contraception.
21-pill pack

29. Missed Pills Instructions
The Pill
Miss 1 or 2 active pills in a row or start a pack 1 or 2 days late:
Always take a pill as soon as possible.
Continue to take one pill every day.
No need for additional protection.
Adapted from WHO’s Decision-making tool for family planning clients and providers.
For pills containing up to 20 μg of ethinyl estradiol
Missed 1 active (hormonal) pill or starts a pack 1 day late:
The woman should follow the guidance above for “Missed 1 or 2 active (hormonal) pills in a row, or starts a pack 1 or 2 days late”.
Missed 2 or more active (hormonal) pills in a row, or starts a pack 2 or more days late:
The woman should follow the guidance above for “Missed 3 or more active (hormonal) pills in a row, or starts a pack 3 or
more days late”.

30. Missed Pills Instructions, continued
The Pill
Source: WHO, 2004; updated 2008; CCP and WHO, 2011.
Miss 3 or more active pills in a row or start a pack 3 or more days late:
If these pills missed in week 3, ALSO skip the inactive pills in a 28-pill pack and start a new pack
If inactive pills are missed, throw away the
Missed pills and continue taking pills
1 each day
If missed pills are in the first week and she had unprotected sex she may wish to use ECPs.
Take a pill as soon as possible, continue taking 1 pill each day, and use condoms or avoid sex for next 7 days OR
week 3
Inactive pills
AND
Adapted from WHO’s Decision-making tool for family planning clients and providers.
See Session Plan for Instructions on Missed Pills

31. Key Counseling Topics for COC Users
Safety and efficacy (requires taking pills on time)
How COCs work
Health benefits
Possible side effects
How to take pills and what to do if pills are missed
No protection from STIs/HIV
Inform provider she is taking COCs
in case of serious new health problem
Reasons to return: questions, concerns or experiencing any warning signs
Photo credit: Karl Grobl
•Ask participants: What are the key counseling topics for new COC users? <allow participants to respond, affirm correct responses and click mouse to reveal the list>
•Introduce the WHO counseling tool- Decision Making Tool for Family Planning Clients and Providers: The Pill. Explain that this section is part of a much larger flip chart which contains information on all methods. The tool is an excellent resource for counseling.
•Use slides to present the following:
oAfter a client makes an informed choice to use COCs, and you determine that she has no known conditions that would prohibit use, you and the client should discuss in greater detail how to use COCs and address any additional questions or misconceptions that the client may have about the characteristics of COCs.
oSpecifically, you should discuss how safe and effective COCs are, how efficacy is affected by a woman’s ability to take pills on time, how COCs work, health benefits, possible side effects, how to take pills correctly and what to do when pills are missed. Encourage the client to examine the pill pack and point out the order in which to take the pills. Ask the client several “what if” questions about missed pills, side effects, and other common misconceptions to ensure that she understands.
oYou should also discuss the fact that COCs do not protect against STIs/HIV.
oDuring counseling, help the client to assess her risk of acquiring or transmitting infection and discuss the benefits and feasibility of condom use to reduce that risk. Explain how to use condoms correctly and consistently and, if needed, help women develop and practice strategies to negotiate condom use with their partners.
oTell the client that if she is diagnosed with any serious new health problem she should inform her health care provider she is taking COCs.
oFinally, discuss when to return, and tell the client about the warning signs of possible complications. We will discuss the warning signs in a few moments.
See Session Plan for Roleplay

32. Correcting Rumors and Misconceptions
COCs:
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.
click the mouse to reveal the list>
•Explain that Rumors are unconfirmed stories that are transferred from one person to another by word of mouth. In general, rumors arise when:
O an issue or information is important to people, but it has not been clearly explained.
O there is nobody available who can clarify or correct the incorrect information.
O the original source is perceived to be credible.
O clients have not been given enough options for contraceptive methods.
O people are motivated to spread them for political reasons.
• A misconception is a mistaken interpretation of ideas or information. If a misconception is imbued with elaborate details and becomes a fanciful story, then it acquires the characteristics of a rumor.
O Discuss methods for counteracting rumors and misinformation (see Session Plan)

33. Anything else I can repeat or explain? Any other questions?
What to Remember
Take one pill each day
If you miss pills, you can get pregnant
Side-effects are common but rarely harmful. Come back if they bother you.
Come back for more pills before you run out or if you have problems.
See a nurse or doctor if:
Severe, constant pain in belly, chest, or legs
Very bad headaches
A bright spot in your vision before bad headaches
Yellow skin or eyes
Adapted from WHO’s Decision-making tool for family planning clients and providers.
Use slides to present the following:
Key messages that clients remember.
Scheduled follow-up visits are not necessary for COC users, but clients should be advised to return to the clinic anytime they have questions or concerns.
Contact with the client within the first two to six months may improve continuation among women experiencing side effects, because this is when such problems are most likely to occur. A follow-up visit is also a good time to replenish a woman’s supply of pills and her backup method, if needed.
If supplies are available, the provider should give a woman as many packs as allowed by national policy, which could range from two packs to up to a year’s supply of pills, and advise her to return for resupply before she runs out.
During follow-up visits, the provider should ask if the client is satisfied with the method and if she has noticed any health problems that developed since she began taking COCs. Conditions that preclude continuation of COCs include breast cancer, liver disease, complicated diabetes, high blood pressure, and other conditions classified as category 3 or 4 in the WHO medical eligibility criteria.
Circumstances that may restrict COC use include certain drug regimens that may reduce COC effectiveness or initiating smoking at an older age.
The provider should also ask whether the client’s reproductive goals have changed, as she may want to become pregnant or desire a long-acting or permanent method.
If the client reports or complains about side effects, the provider should assess her symptoms and, if appropriate, reassure her that the side effects are not harmful and discuss ways to manage them.
The provider should also determine whether a client is taking pills correctly and reinforce instructions on what to do when she forgets to take one or more pills.
If the client has developed any conditions that are contraindications for continuing to use COCs, or if the client finds side effects unacceptable, the provider should help her choose another method.
Anything else I can repeat or explain? Any other questions?

34. Follow-up for COCs No fixed schedule; return any time.
Resupply: Give more than 1 cycle of pills, if possible.
Assess for method satisfaction and any health problems or circumstances that may restrict COC use.
Manage and reassure about side effects.
Review correct pill taking and what to do when pills are missed.
Ask participants to share any strategies that they have developed to support method continuation among their clients.