Detailed Notes on Oral Contraceptive Pills (OCPs)

History & Exam

  • Obtain a detailed gynecological history including:

    • Height, weight, BMI, blood pressure, temperature, pulse, and respiration

    • Personal gynecologic history: contraceptive methods used? Any problems?

    • Personal and family history of:

    • Dyslipidemia

    • Type 2 Diabetes Mellitus (T2DM)

    • Hypertension (HTN)

    • Migraine

    • Venous thromboembolism (VTE)

    • Document smoking history.

  • Pap smear (per ACOG schedule) and STD testing:

    • Advisable in all patients but not necessary to start OCPs.

    • Patients under 21 usually won’t need a Pap.

  • Important to note:

    • History of premenstrual migraine, acne, dyspareunia.

General Counseling Suggestions

  • Consider informed consent and disclosure sheet for the patient to sign and provide a copy.

  • Include:

    • Information on side effects (SEs) and warning signs (ACHES)

    • Instructions on managing forgotten pills

    • Written reinforcement of instructions is crucial, especially for younger patients.

  • Emphasize contraindicated groups for certain OCPs and inform about drug interactions.

Types of Oral Contraceptive Pills

  1. Combination Pills

    • Includes:

      • Extended-Cycle

      • Triphasic

  2. Progestin-Only Pills

Combined Oral Contraceptives (COCs)

Efficacy

  • Primary mode of action: Suppression of ovulation.

  • Additional functions:

    • Increases viscosity of cervical mucus, thus preventing sperm entry.

    • Reduces endometrial thickness, lowering ovum implantation risks.

  • Effectiveness: 91%.

Advantages

  • Reliable and rapidly reversible.

  • Health benefits:

    • Reduced menstrual flow and dysmenorrhea

    • Improvement in menstrual symptoms and acne

    • Positive effects on bone mass

    • Regularity or cessation of menses

    • Protection against anemia and reduced incidence of:

    • Ovarian cysts

    • Endometrial cancer

    • Colorectal cancer

    • Other gynecologic diseases causing infertility

Disadvantages

  • Must remember to take daily.

  • No STD protection.

  • Potential decrease in milk production.

  • Serious complications:

    • Thrombophlebitis/thromboembolism

    • Hepatocellular adenomas

    • Stroke and gallbladder disease

    • Hypertension

Side Effects

  • Common:

    • Nausea, fatigue, acne, mild headaches

    • Increased appetite, breast fullness/tenderness

    • Cyclic weight gain and fluid retention

    • Breakthrough bleeding especially in the first 3 months

    • Decreased menstrual flow or amenorrhea

  • Cautions: Cigarette smoking escalates cardiovascular risks.

Dose-Related Side Effects

  • Too much estrogen:

    • Nausea, bloating, hypertension

  • Too little estrogen:

    • Early/midcycle breakthrough bleeding, increased spotting

  • Too much progestin:

    • Increased appetite, weight gain, fatigue, mood changes

  • Too little progestin:

    • Late breakthrough bleeding, amenorrhea

Patient Education

Danger Signs (ACHES)

  • A: Severe abdominal pain (may indicate hepatic tumors or thrombosis)

  • C: Severe chest pain or shortness of breath (pulmonary embolism, myocardial infarction, angina)

  • H: Severe headache (potential stroke, migraine or hypertension)

  • E: Eye problems (blurred vision, flashing lights or blindness; thrombosis)

  • S: Severe leg pain (potential inflammation or thrombosis in the leg)

General Recommendations

  • Smoking cessation and maintenance of ideal body weight.

  • Take the pill at the same time daily.

  • Follow-Up: Check weight and BP after 3 months on OCP, then annually.

Starting COCs

  • Start on:

    • First day of the menstrual cycle

    • First Sunday of the cycle

    • Any day of the cycle with backup method for 7 days if starting late.

  • Missing a pill:

    • If no intercourse in 5 days prior, take two pills immediately and use backup for 7 days.

    • If intercourse occurred, offer emergency contraception and use backup for 7 days.

Drug Interactions

  • Medications that decrease OCP efficacy:

    • Phenytoin, carbamazepine, rifampin, St. John’s wort, antiretrovirals (especially ritonavir-boosted protease inhibitors).

Contraindications

Absolute Contraindications

  • Pregnant or <21 days postpartum

  • Thrombophlebitis/thromboembolic disorders (past or present)

  • Stroke or coronary artery disease (CAD)

  • Breast cancer, undiagnosed abnormal vaginal bleeding, or estrogen-dependent cancers

Relative Contraindications

  • Migraine without aura, hypertension, heart or kidney disease.

Risk Factors for Myocardial Infarction (MI)

  • Higher risk relates to:

    • Cigarette smoking, obesity, hypertension, T2DM, hypercholesterolemia.

  • Women aged >35 who smoke and have other risks should consider non-estrogen birth control methods.

Thromboembolic Disease

  • Increased rate of VTE in users. Recommend stopping OCPs if:

    • Developing thromboembolism or at increased risk associated with surgery or fractures.

Cerebrovascular Disease

  • Slight risk increase for strokes. Stop OCPs if severe headache, visual issues, or transient neurologic disorders occur.

Carcinoma and Hypertension

  • Minimal risk of breast cancer; reduced risk of several others.

  • May cause hypertension, particularly in older age and duration of use.

  • Non-estrogen methods should be used if hypertension arises.

Other Risk Factors

  • Migraines, especially with aura, contraindicate COC use. Consider alternatives based on personal health considerations (e.g., history of migraines, hypertension).

Progestin-Only Contraception

  • Mechanism of Action:

    • Suppresses ovulation, creates atrophic endometrium, thickens cervical mucus.

  • Available forms include:

    • Mini-Pill, Medroxyprogesterone Acetate (DMPA), Etonogestrel Implant.

Progestin-Only Pills Efficacy

  • Similar efficacy to combined OCPs but requires strict adherence (taken within same 3-hour window).

Progestin-Only Advantages and Contraindications

  • Pros:

    • Safe for women with estrogen contraindications; ideal for breastfeeding mothers.

  • Cons include potential irregular bleeding and contraindications related to malabsorptive diseases or past ischemic heart disease.

Patient Education for Progestin-Only Pills

  • Inform about irregular menstrual bleeding.

  • Follow-up evaluation after 3 months of use and annual assessments.

  • Missed Pill Instructions:

    • If missed for >3 hours, take as soon as possible and use backup for 48 hours.