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

2. 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 >.

3. 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.

4. 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)

5. 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

6. 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) , Elsevier Inc.

7. 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.

8. 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.

9. 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.

10. 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.

11. 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.

12. 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.

13. 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.

14. 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.