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CF CLINICAL FOCUS 47
at inconvenient times , and symptoms of PMS , withdrawal headaches or pelvic pain in the hormone-free break .
Patients may choose to tricycle three packs at a time followed by a four-day break or use the COCP continuously . Breakthrough bleeding with extended use generally improves over time as the endometrium stabilises . Although no studies of continuous use beyond 12 months are available , no safety concerns have been identified . A pre-packaged extended cycle pill ( Seasonique ) is available , providing three consecutive months of COCP followed by seven days of a 10 µ g EE ( see table 1 ).
There is limited evidence for side effects such as weight gain , mood changes and lowered libido with hormonal contraception .
Table 2 . Higher-risk medical eligibility criteria ( MEC ) for COCP use
VTE / CV risk factors
Relatively strong contraindications ( MEC 3 ) Absolute contraindications ( MEC 4 )
History ( ≥5 years ago ) of migraine with aura Develops migraine without aura during use Age ≥35 years and smoking < 15 cigarettes / day or stopped smoking < 1 year ago BMI ≥35 kg / m 2 Multiple risk factors for CV disease Adequately controlled hypertension Cardiomyopathy with impaired cardiac function Atrial fibrillation Diabetes with nephropathy , retinopathy , neuropathy or other vascular disease First-degree relative with VTE age < 45 years Immobility ( unrelated to surgery ), eg , wheelchair use
Migraine with aura in the past 5 years Age ≥35 years and smoking ≥15 cigarettes per day Hypertension and vascular disease Uncontrolled hypertension ( systolic ≥160mmHg or diastolic
≥100mmHg ) Current or history of ischaemic heart disease or stroke History of VTE or current VTE Major surgery with prolonged immobilisation Known thrombogenic mutation Complicated valvular or congenital heart disease
Phasic COCPs Triphasic COCPs have three different doses of LNG / EE throughout the pack followed by a seven-day hormone-free break . These are no longer commonly used , as they are not amenable for extended or continuous use , and lack evidence of benefit over other COCPs .
A quadriphasic COCP with EV / dienogest ( Qlaira ) was designed with oestrogen step-down and progestogen step-up dosing to reduce menstrual blood loss and has an indication for use in HMB as well as contraception . It has complex instructions for managing missed pills .
Breast cancer
Post-partum
Past breast cancer Undiagnosed mass / breast symptoms ( to initiate
COCP ) Carriers of known gene mutations associated with breast cancer ( eg , BRCA1 / BRCA2 )
Less than 3 weeks post-partum in non-breastfeeding women without VTE risk factors
3-6 weeks post-partum in non-breastfeeding women with other VTE risk factors
Liver Acute flare viral hepatitis ( to initiate COCP ) Past combined oral contraception-related cholestasis Gallbladder disease ( medically treated or current )
Other Complicated organ transplant : graft failure , rejection , cardiac allograft vasculopathy
Current breast cancer
Less than 6 weeks post-partum in breastfeeding women Less than 3 weeks post-partum in non-breastfeeding women with other VTE risk factors
Severe ( decompensated ) cirrhosis Hepatocellular adenoma Malignant liver tumour
Positive antiphospholipid antibodies
Safe COCP prescribing
The medical eligibility criteria ( MEC ) of the UK Royal College of Obstetricians and Gynaecologists ’ Faculty of Sexual and Reproductive Healthcare provides guidance for safe contraceptive prescribing . Contraindications for COCP use include migraine with aura , hormonally related cancers and severe liver disease , as well as risk factors for , or past history of , VTE or arterial vascular disease ( table 2 ).
Liver enzyme-inducing medications reduce the effectiveness of COCPs , and
MEC 3 = a condition where the risks usually outweigh the advantages
an IUD ( hormonal or copper ) or depot medroxyprogesterone injectable is recommended instead .
The only routine examination recommended for people requesting the COCP is blood pressure and body mass index ( BMI ). However , these consultations also provide an opportunity to offer broader sexual and reproductive healthcare , such as cervical screening , screening for sexually transmitted infections and providing safe sex advice . When initiating a new COCP , it is important to provide sufficient repeats for a 12-month supply to reduce the risk of running out of pills and unintended pregnancy .
COCP non-contraceptive benefits
Acne and hirsutism The oestrogen in all COCPs can improve acne by increasing sex hormone-binding globulin levels , and thereby reducing free testosterone . While COCPs with anti-androgenic or less-androgenic progestogens ( table 3 ) may be theoretically most helpful for acne and hirsutism , there is insufficient evidence to suggest superiority of any COCP , and a PBS-listed COCP with either LNG or NET can be a useful first choice . Nevertheless , if after 3-6 months there is insufficient response to one COCP , changing to another with a less androgenic progestogen may be trialled . Provided there are