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Combined Oral Contraceptive Pills (COCs). Session III: Providing COCs. 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
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Combined OralContraceptive Pills(COCs) Session III: Providing COCs
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 Source: WHO, 2004 (updated 2008).
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 Source: WHO, 2004 (updated 2008).
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 Source: WHO, 2004 (updated 2008).
How to Take COCs 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.
How to Take COCs The Pill Caution the client: Waiting too long between packs greatly increases risk of pregnancy. 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. 28-pill pack 21-pill pack 21-pill pack
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.
Missed Pills Instructions, continued week 3 Inactive pills The Pill Miss 3 or more active pills in a row or start a pack 3 or more days late: • Take a pill as soon as possible, continue taking 1 pill each day, and use condoms or avoid sex for next 7 days OR AND • 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. Source: WHO, 2004; updated 2008; CCP and WHO, 2011.
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
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.
What to Remember See a nurse or doctor if: • 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. • Severe, constant pain in belly, chest, or legs • Very bad headaches • A bright spot in your vision before bad headaches Anything else I can repeat or explain? Any other questions? • Yellow skin or eyes
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.
The Pill Return Visit • How can I help you? • Are you happy using the pill? • Want more supplies? • Any questions or problems? • Let’s check: • For any new health conditions • When do you take your pills? • What do you do if you forget a pill? • Need condoms too?
Management of COC Side Effects Counseling and reassurance are key.
Management of COC Side Effects:Bleeding Changes Source: CCP and WHO, 2011.
When to Return: Warning Signs of Rare COC Complications • Very bad headaches • Severe, constant pain in belly, chest, or legs • A bright spot in your vision before bad headaches • Yellow skin or eyes Advise to stop taking COCs, use a backup method, and see a health care provider. Source: Hatcher, 2007.
Problems That May Require Stopping COCs or Switching to Another Method Source: CCP and WHO, 2011.
Problems That May Require Stopping COCs or Switching to Another Method (continued) Source: CCP and WHO, 2011.
COCs: Summary • Safe for almost all women • Effective if used consistently and correctly • Fertility returns without a delay • Screening and counseling are essential