ORAL CONTRACEPTIVE PILLS

BREAF IDEA ON PRESCRIBING OCP

1. Oral contraceptive Pills
(OCPs)
---Dr. Safikul Hasan,Demonstrator

2. Thecombined oral contraceptive
pill(COCP), often referred to as
thebirth control pillis a type of birth
control that is designed to be taken
orally. It includes a combination of
anestrogen(usuallyethinylestradiol)
and aprogestogen(specifically
aprogestin). When taken correctly, it
works to prevent pregnancy.
Oral contraceptives (OCPs)

3. Oral contraceptives (OCPs)
Approximately 80% of women will use
OCPs during their lifetime
Success rate if instructions followed
perfectly -99.9% first year of use
Any missed pills -success rate 95%
Adolescent’s success rate -85-90%

4. OCPs -Estrogens
Ethinyl estradiol (EE)
Mestranol -50 µg converted to 40 µg of
EE

5. OCPs -Progesterones
Progesterone ClassificationFamily
•Ethynodioldiacetate
•Norethindrone
•Norethindrone
acetate
1
st
Generation Estrane
(short ½ life)
•Levonorgestrel(LNg)
•Norgestrel
2
nd
GenerationGonane
(longer ½ life)
•Desogestrel
•Norgestimate
3
rd
Generation Gonane

6. Mechanisms of action
Estrogen component
Inhibits ovulation by suppressing FSH & LH
Alters secretions & cellular structure of
endometrial lining
Prevents implantation

7. Mechanisms of action
Progesterone component
Inhibits ovulation by suppressing LH
Thickens cervical mucous & impairs sperm
transport
Alters endometrial lining
Prevents implantation

9. TYPES OF OCPS

11. Monophasic pills
Estrogen
Progesterone
Day 21Day 1

12. Biphasic pill (Necon
®
)
Estrogen
Progesterone
Day 11

13. Triphasic pills
Estrogen
Progesterone
Day 8 Day15
Examples –Caziant
®
; Cylessa
®
; Necon 7/7/7
®
; Ortho-
Novum 7/7/7
®
; Ortho Tri-Cyclen
®
; Tri-Sprintec
®
;
TriNessa
®
; Velivet
®

14. Triphasic pills
Estrogen
Progesterone
Day 17 Day 6Day 13
Day 7 Day 12
Day 8
Ex. Tri-Norinyl
®
; Aranell
®
;Leena
®
Ex. TriNessa
®
; TriVora
®
; Enpresse®
Ex. Estrostep
Fe
®
; TriLegest
Fe
®
;Tilia Fe
®

15. Monophasic, Biphasic or
Triphasic?
Biphasic & triphasic pills were developed to
reduce side effects of monophasic pills
Biphasic with norethindrone associated with inferior
cycle control compared to triphasic with
levonorgestrel [Cochrane Review 2005]
Progestin may be more important than phasic type
Monophasic pills give better cycle control
Triphasic pills offer no physiologic advantage
No data to support triphasic over monophasic pills

16. Progestin only pills
Thicken cervical mucous & prevent sperm
ascending through os
Erratic suppression ovulation
Irregular bleeding more common
Daily compliance crucial
Same timeevery day (2-3 hr difference can
cause bleeding, allow ovulation)
Are not contraindicated in smokers over
age 35

17. Progestin only (Plan B
®
)
0.75 mg levonorgestrel –two doses 12
hours apart
Single 1.5 mg pill available (Plan B -
One Step
®
)
Mifepristone single dose 600 mg within
72 hrs
Emergency Contraception

18. OCP general benefits
Decreased
dysmenorrhea
Reduced menstrual
flow
Reduced risk of
anemia
Improves acne
Eliminate
mittelschmerz
Decreased risk of
ectopic pregnancy
Decreased risk of PID
Decreased symtptomss
of PMS
Improvement in
endometriosis
Suppression of ovarian
& breast cyst formation

19. OCP –Benefit
Endometrial cancer reduced
50% reduction if used in prior 12 months
Maximum protection if use continues for
3 years
Protection lasts for 15 + years
High or low dose pills provide protection

20. OCP –Benefit
Ovarian cancer reduced
40% reduction in risk over nonusers
High dose or low dose pills -same benefit
Begins after 3-6 months of use
80% reduction after 10 years of use
Reduced risk with family history ovarian
CA & 4-8 yrs. use

21. OCP Cardiovascular Risks
Increased risk of CVD in smokers over
age 35
Small increased risk MI with 2
nd
generation progesterones
Only with current users –no lingering effect
Slight increased risk of ischemic stroke
2-6 fold increase of ischemic stroke with
history of classic migraine

22. OCP -Risks
Headaches
May increase or decrease
Headaches attributed to initiation of OCP tend
to improve over time
If HA persists with normal BP & no focal deficit
Lower dosage of estrogen, progestin or both
(no evidence effective)
If HA persists with increased BP or focal deficit
Discontinue OCP

23. OCP -Risks
OCP use associated with increased risk
of developing systemic lupus
erythematosus (SLE)
Especially if started recently [Bernier 2009]
However, very low risk overall

24. VTE Risk
VTE Risk
3-6 fold increased risk VTE, highest first 6-12
months of use (SOR B)
Older women have greater risk
> age 39 -100/100,000 person-years
Adolescents -25/100,000 person-years
Obesity doubles the risk

25. VTE Risks
VTE Risk
Risk decreases with longer duration of use
For same estrogen dose -desogestrel &
drospirenone have significantly higher risk
[Lidegaard 2009]
Grapefruit juice can augment bioavailability of
EE [Grande LA 2009]

26. OCP Risks -EBM
Risks (SOR B)
Increase in cervical cancer after 8 or more
years of use after adjusting for HPV infection
Risk of CIN 2 -3 with oncogenic HPV
Decreased with depot-medroxyprogesterone
(DMPA -Depo-Provera
®
)
No association with combination OCPs
[Harris 2009]

27. OCP Risks/Benefits -EBM
No increased risk of weight gain (SOR A)
Weight gain does occur with DMPA –5.1 kg
No increased risk breast cancer (SOR B)
No consistent change in breast milk
production (SOR A)
Or in infant growth or weight (SOR B)
Women who use OCP are not at an
increased risk of death later in life
In fact a net benefit was found

28. OCPs can be used with these
conditions
Diabetes mellitus
< 35 years old
Nonsmoker > age 35
Smokers < 35 years
old
Obese women
Caution > age 39
Controlled hypertensive
Ulcerative colitis
Pituitary adenomas
After gestational
diabetes

29. OCP Contraindications
History of DVT, PE or arterial clotting
Family history clotting or thrombotic events
Family history (FH) if positive is risk factor VTE
Ask if parent or sibling ever had VTE
Positive FH if 1 relative was < 50 yo when VTE
occurred
Positive FH if 2 or more relatives at any age had
VTE [Bezemer 2009]

30. OCP Contraindications
Smoking and ≥ 35 years old
Uncontrolled hypertension
Migraine with aura
Undiagnosed genital bleeding

31. OCP Contraindications
Pregnancy –not harmful, just too late
Sickle cell (SS) or sickle C (SC) disease
not absolutely contraindicated
DMPA may be preferable for SS disease

32. Drug Interactions
Vitamin C
Increases estrogen level
Can induce nausea
Discontinuation of vitamin C may precipitate
bleeding
Decreased estrogen level
Antibiotics
Unclear impact on efficacy

33. Drug Interactions
Anticonvulsants
Advise patients to use a different form of
contraception
Because some anticonvulsants may reduce
efficacy of OCPs
If you & patient decide to use OCP, use pill
with 50 µg EE
If breakthrough bleeding occurs with that pill
Patient should use alternative contraceptive
method

35. Starting OCPs –2 Options

36. Missing pill instructions
First ask which pill(s) were missed:
If placebo pill just skip it
If active pill and < 24 hrs late
Take immediately
If active pill and ≥ 24 but < 48 hrs late
Take both pills at the same time
Additional contraception not required

37. Missing pill instructions
If 2 active pills missed
Double up for 2 days
Use additional contraceptive method for 7 days
Consider emergency contraception if unprotected
intercourse
If ≥ 3 active pills missed
Stop pills and begin new pack
Use additional contraceptive method for 7 days
Consider emergency contraception if unprotected
intercourse
Discuss alternative contraceptive options that do not
require daily compliance

38. Most Dangerous pill to Miss?
Most dangerous pill to miss is
the 1
st
pill of the new pack
Pill free > 7 days increases risk
ovulation
Use additional form of birth
control until taken 7
consecutive active pills
Stress compliance with starting
each new pack

39. OCP -Postpartum
Can begin combination OCP ≥ 3 weeks
postpartum after delivery.
Starting < 3 weeks postpartum associated
with increased risk of VTE
Balance this against risk of unwanted
pregnancy which has greater risk of VTE
For delivery of < 20 weeks gestation -
can begin combination OCP immediately

40. Contraceptive Failure Rate
Method Typical UsePerfect Use
No method 85% 85%
Diaphragm with spermicide 16% 6%
Condom –male 15% 2%
OCPs 8% 0.3%
Transdermal 8% 0.3%
Transvaginal 8% 0.3%
Injectable 3% 0.3%
IUD –copper 0.8% 0.6%
IUD –progesterone 0.2% 0.2%
Implant 0.05% 0.05%

41. Emergency Contraception (EC)
Woman at risk for unwanted pregnancy
Condom broke or slipped
Forced intercourse
Intercourse and no method of BC
Diaphragm or cervical cap dislodged
Two or more OCPs missed or forgotten
> 12 weeks from last depo progesterone
injection
Missed first pill of OCP

42. Mechanism of action -
Inhibits or delays ovulation if prior to ovulation
Interferes with egg/sperm transport
Alters endometrium and prevents implantation
Emergency Contraception

43. Fewer side effects & better efficacy
95% within 24 hrs, 85% within 25-48 hr
Can be used up to 5 days after intercourse
No clinical exam or pregnancy test is
necessary before EC
EC may be used again even if used before
within the same menstrual cycle.
Emergency Contraception

44. Ulipristal (Ella
®
) approved for EC
Selective progesterone receptor modulator
(SPRM) –30 mg single dose
Remains equally effective up to five day after
unprotected intercourse
Possibility it is less effective in women with
BMI > 30
Requires a prescription
No significant side effects but long-term data
is not yet available
Emergency Contraception

45. THANK YOU