Title: Combined oral contraceptives (COC)
Course: Level 3 - Family Planning > Section: Oral contraceptive methods

Combined oral contraceptives (COCs) are pills that are taken once a day to prevent pregnancy. They contain the hormones estrogen and progestin. Combined oral contraceptives (COCs) are also called "the Pill," low-dose combined pills, OCPs, and OCs.There are many different brands, and they come in packs of 21 or 28 pills (Figure 6.1).

Two brands, microgynon and Leo-femenal, both in packs of 28 pills, are the most popular ones in Ethiopia. One pill is taken every day. The first 21 pills have a combination of synthetic oestrogen and progesterone hormones. The last seven pills of a 28-day pack have no hormones and are called spacer pills. They are usually different in colour, and some brands contain iron. The iron in the pill can be taken as a supplement to avoid iron deficiency.

Fig 6.1. Combined oral contraceptive with spacer pills in the bottom row.

How effective are COCs?:

Effectiveness depends on the user. It is 99.9% effective if used correctly and consistently. There is no delay in Return of fertility after COCs are stopped but don't protect against sexually transmitted infections (STIs) including HIV/AIDS

Side effects (that are temporary and not dangerous):

Changes in bleeding patterns including: lighter bleeding and fewer days of bleeding, irregular bleeding, infrequent bleeding, no monthly bleeding, headaches, dizziness, nausea, breast tenderness, weight change, mood changes, acne (can improve or worsen, but usually improves), blood pressure increases a few points.

Who can use COCs?:

Women of any reproductive age or parity including women who:

- Have or have not had children.
- Are not married.
- Are of any age, including adolescents and women over 40 years old.
- Have just had an abortion or miscarriage.
- Smoke cigarettes-if under 35 years old.
- Have anemia now or had in the past.
- Have varicose veins.
- Are infected with HIV, whether or not taking antiretroviral medications.

Who can not use COCs?:

Women who have the following conditions (contraindications):

- Pregnancy (but no proven negative effects on the fetus if taken accidentally).
- Fully or nearly fully breastfeeding a baby less than 6 months old.
- Has had a baby in the last 3 weeks.
- Current or history of breast cancer.
- A liver tumor, liver infection or cirrhosis or has developed jaundice while using COCs.
- Age 35 or older and smoking.
- Blood pressure 140/90 mmHg or higher.
- Diabetes for more than 20 years or damage to arteries, vision, kidneys or nervous system caused by diabetes.
- Current gallbladder disease.
- Current or history of stroke, blood clot in legs or lungs, heart attack or serious heart problems.
- Migraines with aura or migraines without aura at age 35 or older.
- Taking medications for seizures (barbiturates, carbamazepine, oxcarbazepine, phenytoin, primidone, topiramate, or rifampicin).
- Planning major surgery that will keep her from walking for one week.

When to start using COCs?:

- Anytime (during the menstrual cycle) it is reasonably sure that the client is not pregnant.
- Within 5 days after the start of her monthly bleeding.
- Immediately when stopping IUD or another hormonal method. No need to wait for her next monthly bleeding.
- Postpartum:
  - Six months after giving birth if using LAM.
  - At least, after three weeks if not breastfeeding (on days 21 -28).
  - Beyond those dates, pregnancy has to be ruled out.
  - Post abortion (after abortion or miscarriage) immediately or within seven days.

Procedure for using COCs:

- Give your client, at least, one packet of the same pills that she will use, even if she will be getting her pills elsewhere later.
- Show her which kind of pill container you are giving her (21 pills or 28 pills).If the pack has 28 pills, point out that the last seven "remainder" pills. are a different color and do not contain hormones.
- Instruct her to follow the direction of the arrows on the packet to take the rest of the pills, one each day (including the remainder pills).
- Give her essential instructions on starting the first packet, starting the next pack, and what to do if she misses a pill.
- Ask her to repeat the most important instructions, and show you how she will take her pills, using the pill packet.
- Ask her if she has any questions, fears or concerns, and answer her questions.

Advantages of COCs:

- COCs are very effective contraceptives, giving women control over their fertility when taken consistently and correctly.
- Fertility returns soon after stopping COC pills, which makes them an excellent option for females who want to become pregnant in the near future.
- Combined oral contraceptive pills decrease menstrual flow significantly in women with a normal uterus. Therefore, pill users are less likely to develop iron deficiency anaemia. Pills also reduce menstrual cramps and pain.

Disadvantages of COCs:

Although they are advantageous in many cases, COCs have some disadvantages, and you should inform your clients about these disadvantages in order to help them choose from all available methods. One of the main disadvantages of COCs is that they are not recommended for breastfeeding women, because they affect the quality and quantity of milk. Very rarely, COCs can also cause strokes, blood clots in deep veins of the legs, or heart attacks. Those at highest risk are women with high blood pressure and women who are aged 35 years or older. Also bear in mind that the pills do not protect against STIs, including AIDS.