ORAL CONTRACEPTION – a guide for trainees
COMBINED ORAL CONTRACEPTION (COC): Normally
Normally, most women can have the following 2nd gen COCs
•	Microgynon  30
•	Ovranette
IF THEY HAVE PROBLEMS:
Figure out whether the problems are due to too much oestrogen or too much progestogen
Oestrogen Effects
Menorrhagia, breast fullness, migraine type headaches, fluid retention, weight gain (fluid), tiredness, irritability, nausea, bloating

Try changing to: lower oestrogen or higher progestogen pill or pill with some androgenic activity
•	pills with a lower oestrogen component e.g. Loestrin 20 (20 micrograms ethinyl oestradiol, 1000 micrograms of norethisterone)
•	pills with a higher progestogen component e.g. Loestrin 30 (30 micrograms ethinyl oestradiol, 1500 micrograms of norethisterone), Eugynon 30 (30 micrograms ethinyl oestradiol, 250 micrograms levenogestrel) 
Progestogen Effects
scanty menses, leucorrhoea: dry vagina, breast tenderness, acne, greasy hair, appetite increase, weight gain, premenstrual depression, dull type of headache - often of pill withdrawal, leg cramps, softening of ligaments

Try changing to:
lower progestogen pill or less androgenic pill or higher oestrogen pill
•	Brevinor and Ovysmen (2nd gen) - both contain 35 micrograms of ethinyl oestradiol and 500 micrograms norethisterone - considered more oestrogenic than many other pills because they have a higher oestrogen component 
•	Cilest (Ethinylestradiol / Norgestimate)
•	Marvelon (3rd gen)- considered more oestrogenic because its progestogen component (150 micrograms desgestrel) has less of a counteractive effect on the actions of the oestrogen (30 micrograms ethinyl oestradiol)
Breakthrough Bleeding with COC
This is a checklist in cases of possible breakthrough bleeding (BTB) occurring in COC takers. BTB bleeding may occur during the first few months after prescribing a new COC. If it persists then a cause must be sought.

History:
•	taking of COC - ? missed pills ? taken at same time
•	medication - ? antibiotics ? enzyme inducers
•	history of gastroenteritis ?
•	is there a possibility of pregnancy or disorder associated with pregnancy e.g. trophoblastic tumour ?
•	factors affecting absorption of pill e.g. ileostomy ?
•	history of post-coital bleeding ? CIN ?

Examination:
pelvic and speculum examination - swabs and cervical smear if indicated

If all possible causes have been excluded then the COC may be changed. Options include:
1.	a user taking a monophasic pill may try a phasic pill
2.	an increased level of progestogen
3.	a different type of progestogen e.g. consider a 3rd generation COC
4.	in some cases a high dose (50 mcg pill) may be considered
5.	
PROGESTOGEN ONLY PILL (POP): Normally
•	Give Micronor
•	Cerazette inhibits ovulation more frequently than does a standard progestogen-only pill.  More recently, cerazette has become the first POP with a missed pill window of 12 hours instead of 3 hours allowed by conventional POPs (2)