Patient Management Guide - Oral Contraceptive Care - Know Your Contraceptives
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Oral Contraceptive Care Patient Management Guide
CONSULTATION CHECKLIST
Factors to discuss during initial consultation:
Consult UK Medical Eligibility Criteria for contraceptive use
Patient suitability for contraceptive care:
• Age • Personal & family medical history
• BMI • History of Depression
• Blood pressure • Migraine with aura
• Smoking status • Other medications
Patients’ personal preferences • Allergies (e.g. soya/peanuts)
Contraceptive pill information:
• What is the pill and what does it do
• How to take the pill correctly
• Pill effectiveness
• Please encourage your patient to read the Patient Information Leaflet
Missed pill guidance:
• What to do if a pill is missed
For missed pill guidance visit www.knowyourcontraceptives.ie
Sexual Health & the risks of unprotected sex
CONSULTATION CHECKLISTCONSULTATION CHECKLIST
Factors to discuss during review consultation:
Consult UK Medical Eligibility Criteria for contraceptive use
Has anything changed?
• Age • Personal & family medical history
• BMI • Migraine with aura
• Blood pressure • Depressive Symptoms
• Smoking status • Other medications
Patients’ satisfaction:
• Side effects (please refer to Side Effects Management section for reporting)
• Compliance
• Cost
Missed pill guidance:
• What to do if a pill is missed
For missed pill guidance visit www.knowyourcontraceptives.ie
Sexual health & the risks of unprotected sex
CONSULTATION CHECKLISTEMERGENCY CONTRACEPTION
• If restarting regular hormonal contraception • The length of time a barrier method is required
immediately after emergency contraception, for protection depends on the method of
patients should use a barrier method emergency contraception used.
(condoms) or avoidance of sex should
be advised.
Warnings & Precautions for use of Emergency Contraception 1,2
• If vomiting occurs within 3 hours of taking an • E mergency contraception does not prevent
Emergency Contraceptive tablet, another a pregnancy in every instance
tablet should be taken immediately • Women who present for repeated courses
• Emergency contraception is an occasional of emergency contraception should be
method. It should in no instance replace a advised to consider long-term methods of
regular contraceptive method contraception
• Concomitant use of UPA or LNG in one • Use of emergency contraception does not
menstrual cycle is not recommended replace the necessary precautions against
sexually transmitted diseases
Levonorgestrel LNG
• L evonorgestrel LNG prevents ovulation and • L NG does not contraindicate the continuation
fertilisation if intercourse has taken place in of regular hormonal contraception
the preovulatory phase, when the likelihood of • After taking LNG it is recommended to use
fertilisation is the highest barrier methods or abstain from sex until the
next menstrual period starts
EMERGENCY CONTRACEPTIONEMERGENCY CONTRACEPTION
Ulipristal acetate UPA
• Ulipristal acetate (UPA) is a selective progesterone-receptor modulator. Its mechanism of action
is to delay ovulation until sperm from unprotected sex are no longer viable 3
nlike Levonorgestrel (LNG) UPA binds to progesterone receptors & may reduce the efficacy of
• U
progestogen-containing contraceptives 4
fter taking UPA, a patient should not start a hormonal contraceptive method for at least 5 days
• A
& should use barrier methods or abstain from sex until effective hormonal contraceptive cover
has been achieved 3 – see guidance below:
Requirement for additional
Methods
contraceptive cover
Combined oral contraceptive pill (except Qlaira®) 7 Days
UPA then Qlaira® Combined oral contraceptive pill 9 Days
wait at 7 days
Combined vaginal ring/ transdermal patch
least 5
days Progestogen-only pill (traditional/ desogestrel) 2 Days
Progestogen-only implant or injectable 7 Days
EMERGENCY CONTRACEPTIONYour Patient’s SEXUAL HEALTH
• Correct use of hormonal contraceptive care helps to prevent unintended pregnancy
however they do not protect against sexually transmitted infections5-9
• The incidence of sexually transmitted infections (STIs) are on the rise in Ireland 10
• STIs are passed on from infected partner(s) during unprotected sex including
vaginal, anal & oral sex 11
• Most STIs have no obvious11symptoms, so your patient may not be aware that they or
their partner(s) is infected
• Certain STIs can cause long-term health problems if they are not treated, such as
infertility, complications in pregnancy and pelvic inflammatory disease 11
Advise your patient to reduce the risk of contracting an STI by:
sing condoms correctly
U
L imiting the number of sexual partners your patient has – the more partners one has,
the greater the chance of coming into contact with an infected person
Talking to your patient about STIs & practicing safer sex
dvising your patient to get regular sexual health check-ups including STI screening,
A
smear tests & being breast aware
SEXUAL HEALTHPRESCRIBING GUIDE 12
Oestrogen dosage
No Synthetic
Generation 20mcg 30mcg 35mcg 1.5mg Phasic
oestrogen progestogen
1st Generation NORIDAY 350mcg Norethisterone ANDROGENICITY
OVREENA
150mcg Levonorgestrel
OVRANETTE HIGH
VIOLITE
2nd Generation MICROLITE 100mcg Levonorgestrel
LEONORE
30/75/125mcg
LOGYNON Levonorgestrel
MINULET 75mcg Gestodene
MEDIUM
MERCILON MARVIOL 150mcg Desogestrel
3rd Generation
AZALIA
75mcg Desogestrel
CERAZETTE
CILIQUE 250mcg Norgestimate
ZOELY 2.5mg Nomegestrol
LOW
QLAIRA 2/3mcg Dienogest
4th Generation
ELVINETTE
ELVINA
YASMINELLE 3mg Drospirenone
YASMIN
YAZ
PRESCRIBING GUIDEVENOUS THROMBOEMBOLISM
Risk of developing a blood clot (VTE) in a given year 13,14
Women not using a combined hormonal contraception (CHC)
About 2 out of 10,000 women
and are not pregnant
Women who are pregnant About 29 per 10,000 women
Women who are postpartum About 300–400 per 10,000 women
Women using a CHC containing levonorgestrel, norethisterone
About 5-7 out of 10,000 women
or norgestimate
Women using a CHC containing drospirenone, gestodene
About 9-12 out of 10,000 women
or desogestrel
Women using a CHC containing dienogest or nomegestrol Not yet known*
Does not appear to be associated
Women using progestogen-only methods of contraception
with an increased risk of VTE
*Further studies are ongoing or planned to collect sufficient data to estimate the risk
Conditions that increase the risk of VTE 5-9
Lifestyle Factors Medical History Current Medical Status
Increasing age Personal/Family history of VTE CHC use
Smoking Inherited blood clotting disorders Pregnancy/Postpartum
Obesity Cancer Major surgery
Other medical conditions
Immobilisation & High Altitude Major trauma
associated with VTE
• The risk of VTE is highest in first year of CHC use
• The risk of VTE is increased when a CHC is re-started after a break in use of 4 weeks or more
VTE RISKMISSED PILL
Missed Pill Management
COMBINED ORAL CONTRACEPTIVE PILLS 5,6,8,9
If the patient is less than 12 hours late in taking any tablet, contraceptive protection is not
reduced. The patient should take the tablet as soon as she remembers & take further tablets at
the usual time.
If she is more than 12 hours late in taking any tablet, contraceptive protection may be reduced.
The management of missed tablets can be guided by the following two basic rules:
1. Tablet-taking must never be discontinued for longer than 7 days;
2. 7 days of uninterrupted tablet-taking are required to attain adequate suppression of the
hypothalamic-pituitary-ovarian-axis
Missed 1 pill more than 12 hours late
Missed pill in Week 1 of pack Missed pill in Week 2 of pack Missed pill in Week 3 of pack
• T ake the forgotten pill now, • T ake the forgotten pill now, • Take the forgotten pill now,
even if it means taking 2 pills even if it means taking 2 even if it means taking 2 pills
in 1 day pills in 1 day in 1 day
• Take remaining pills as usual • Take remaining pills as • Take remaining pills as usual
• Use barrier method (e.g. usual • Instead of a pill free week
condom) for next 7 days • You are protected start your next pack
to ensure protection • You are protected
OR
• Stop this pack immediately
IMPORTANT:
• Begin the pill free week (not
If you’ve had unprotected longer than 7 days including
sex in the previous 7 days, the forgotten pill)
the possibility of pregnancy
should be considered • Then start your next pack
• You are protectedMISSED PILL
Missed Pill Management
COMBINED ORAL CONTRACEPTIVE PILLS 15
Missed 2 pills in a row
If you’ve missed two pills anywhere in the pack or started a new pack two days late, your protection
against pregnancy will be affected. Please consult with your doctor or nurse for further advice.
You will need to use a barrier method (e.g. a condom) for the next 7 days
to ensure you remain protected.
Missed 2 pills in Missed 2 pills in Missed 2 pills in
Week 1 of pack Week 2 of pack Week 3 of pack
• Take the forgotten pill now, • Take the forgotten pill now, • Take the forgotten pill now,
even if it means taking 2 pills even if it means taking even if it means taking 2 pills
in 1 day 2 pills in 1 day in 1 day
• Leave any earlier missed pills • Leave any earlier missed • Leave any earlier missed pills
pills
• Take remaining pills as usual • Take remaining pills as usual
• Take remaining pills
• Use barrier method (e.g. • Instead of a pill free week
as usual
condoms) for next 7 days start your next pack
• Use barrier method (e.g.
• Use barrier method (e.g.
condoms) for next 7 days
condoms) for next 7 days
IMPORTANT:
If you’ve had unprotected
sex in the previous 7 days,
the possibility of pregnancy
should be consideredMissed Pill Management
MISSED PILL PROGESTOGEN ONLY PILLS
containing 75mcg desogestrel 7,16
ontraceptive protection may be reduced if more than 36 hours have elapsed between
• C
two tablets.
• If the patient is less than 12 hours late in taking any tablet, she should take the tablet as soon
as she remembers & take further tablets at the usual time.
• If she is more than 12 hours late, she should use barrier method of contraception for the next
7 days.
• If tablets were missed in the first week & intercourse took place in the week before the tablets
were missed, the possibility of pregnancy should be considered.
Missed 1 pill more than 12 hours late
• T ake the forgotten pill now, even if it means
taking 2 pills in 1 day
• Take remaining pills as usual
• Use barrier method (e.g. condom) for next
7 days to ensure protection
IMPORTANT:
If you’ve had unprotected sex in
the previous 7 days, the possibility of
pregnancy should be consideredMissed Pill Management
MISSED PILL PROGESTOGEN ONLY PILLS
containing 75mcg desogestrel 15
Missed 2 pills in a row
If you’ve missed two pills anywhere in the pack or started a new pack two or more days late, you
are not protected against pregnancy. Please consult with your doctor or nurse for further advice.
You will need to use a barrier method (e.g. a condom) for the next 7 days
to ensure you remain protected for the duration of the pack.
Missed 2 pills in Missed 2 pills in
Week 1 of pack anywhere else in the pack
• Take the forgotten pill now, even if it • Take the forgotten pill now, even
means taking 2 pills in 1 day if it means taking 2 pills in 1 day
• Leave any earlier missed pills • Leave any earlier missed pills
• Take remaining pills as usual • Take remaining pills as usual
• Use barrier method (e.g. condoms) • Use barrier method (e.g. condoms)
for next 7 days for next 7 days
IMPORTANT:
If you’ve had unprotected sex in
the previous 7 days, the possibility of
pregnancy should be consideredSIDE EFFECT MANAGEMENT
• Side effects usually diminish within 3 months with continued use of same method 17
SIDE EFFECT
•R
eassure & educate patients to help establish realistic expectations & decrease
the chance of unanticipated side effects 17
• Identify which component is likely to be at fault, but it can be difficult to ascertain
which portion (either the oestrogen or progestogen or both) is responsible
Oestrogen Related Side Effects Progestogen Related Side Effects
The oestrogen used in COCs (usually Degree of androgenicity is likely to
ethinylestradiol) is linked to some minor cause negative side effects
side effects
A higher amount of oestrogen helps to
To resolve, lower the oestrogen dose reduce androgen related side effects
Change to a more dominant Change type of progestogen to one
progestogen with lower androgenic properties
Try progestogen only options that do Increase the oestrogen strength
not contain oestrogen
Most common side effects: acne,
Most common side effects: nausea, vaginal dryness, sustained weight
headache, thrush, excess bleeding, increase & low mood
fluid retention, breast tenderness
Adverse events & product complaints should be reported to
the Health Products Regulatory Authority. Reporting forms & information
can be found at www.hpra.ie.
Reproduced with the kind permission of Dr. Deirdre LundyPRESCRIBING GUIDE 12
Oestrogen dosage
No Synthetic
Generation 20mcg 30mcg 35mcg 1.5mg Phasic
oestrogen progestogen
1st Generation NORIDAY 350mcg Norethisterone ANDROGENICITY
OVREENA
150mcg Levonorgestrel HIGH
OVRANETTE
VIOLITE
2nd Generation MICROLITE 100mcg Levonorgestrel
LEONORE
30/75/125mcg
LOGYNON
Levonorgestrel
MINULET 75mcg Gestodene MEDIUM
MERCILON MARVIOL 150mcg Desogestrel
3rd Generation
AZALIA 75mcg Desogestrel
CERAZETTE
CILIQUE 250mcg Norgestimate
ZOELY 2.5mg Nomegestrol
LOW
QLAIRA 2/3mcg Dienogest
4th Generation
ELVINETTE
ELVINA
YASMINELLE 3mg Drospirenone
YASMIN
YAZACNE
• Generally mediated through progestogen
•M ore common side effect of 2nd generation pills – switch to a 4th generation pill
• f patient is on 4th generation pill & acne is persistent, increase oestrogen dose
I
ACNE
WHICH
CAUSE ACTION CONTRACEPTIVE?
Elvina • Elvinette • Qlaira
Too much progestagenic Try less progestagenic
Yasmin • Yasminelle • Yaz
potency 4th generation brands
Zoely
Too much androgenic Try less androgenic brands
Marviol • Mercilon
potency containing desogestrel
Increase oestrogen Minulet • Ovreena • Ovranette
Too little oestrogen • Logynon • Cilique
to a higher dose
Reproduced with the kind permission of Dr. Deirdre LundyPRESCRIBING GUIDE 12
Oestrogen dosage
No Synthetic
Generation 20mcg 30mcg 35mcg 1.5mg Phasic
oestrogen progestogen
1st Generation NORIDAY 350mcg Norethisterone ANDROGENICITY
OVREENA
150mcg Levonorgestrel HIGH
OVRANETTE
VIOLITE
2nd Generation MICROLITE 100mcg Levonorgestrel
LEONORE
30/75/125mcg
LOGYNON
Levonorgestrel
MINULET 75mcg Gestodene MEDIUM
MERCILON MARVIOL 150mcg Desogestrel
3rd Generation
AZALIA
75mcg Desogestrel
CERAZETTE
CILIQUE 250mcg Norgestimate
ZOELY 2.5mg Nomegestrol
LOW
QLAIRA 2/3mcg Dienogest
4th Generation
ELVINETTE
ELVINA
YASMINELLE 3mg Drospirenone
YASMIN
YAZBREAK THROUGH BLEEDING
• Generally caused by irregular pill taking and lack of patient compliance
• Can result from a change in sexual partner – therefore it is important to rule out a STI
• May improve with an increase in oestrogen or a change in progestogen
BREAK WHICH
CAUSE ACTION CONTRACEPTIVE?
THROUGH
BLEEDING
Counsel patient on correct
Irregular pill taking No change
usage
Undiagnosed STI Sexual history STI screen No change
Increase oestrogen Minulet • Ovreena • Ovranette
Too little oestrogen
to a higher dose • Logynon • Cilique
Too much progestagenic Try less progestagenic
Elvina • Qlaira • Yasmin • Zoely
potency 4th generation brands
Reproduced with the kind permission of Dr. Deirdre LundyPRESCRIBING GUIDE 12
Oestrogen dosage
No Synthetic
Generation 20mcg 30mcg 35mcg 1.5mg Phasic
oestrogen progestogen
1st Generation NORIDAY 350mcg Norethisterone ANDROGENICITY
OVREENA
150mcg Levonorgestrel HIGH
OVRANETTE
VIOLITE
2nd Generation MICROLITE 100mcg Levonorgestrel
LEONORE
30/75/125mcg
LOGYNON
Levonorgestrel
MINULET 75mcg Gestodene MEDIUM
MERCILON MARVIOL 150mcg Desogestrel
3rd Generation
AZALIA 75mcg Desogestrel
CERAZETTE
CILIQUE 250mcg Norgestimate
ZOELY 2.5mg Nomegestrol
LOW
QLAIRA 2/3mcg Dienogest
4th Generation
ELVINETTE
ELVINA
YASMINELLE 3mg Drospirenone
YASMIN
YAZBLOATING / BREAST TENDERNESS
• Bloating is usually a progestogen side effect – change progestogen or increase oestrogen dose
• Breast tenderness is usually due to oestrogen – reduce oestrogen dose
• Consider copper coil as it’s hormone free
WHICH
CAUSE ACTION CONTRACEPTIVE?
BLOATING
BLOATING /
BREAST Too much progestagenic Try less progestagenic Elvina • Elvinette • Qlaira
TENDERNESS potency 4th generation brands Yasmin • Yasminelle • Yaz • Zoely
BREAST TENDERNESS
Reduce oestrogen Elvinette • Leonore • Mercilon
to a lower dose Microlite • Violite • Yasminelle • Yaz
Try non oestrogen
Too much oestrogen Azalia • Cerazette • Noriday
medicines
Copper coil • Implanon
Consider non oral options
Jaydess • Mirena • Nuvaring
Reproduced with the kind permission of Dr. Deirdre LundyPRESCRIBING GUIDE 12
Oestrogen dosage
No Synthetic
Generation 20mcg 30mcg 35mcg 1.5mg Phasic
oestrogen progestogen
1st Generation NORIDAY 350mcg Norethisterone ANDROGENICITY
OVREENA
150mcg Levonorgestrel HIGH
OVRANETTE
VIOLITE
2nd Generation MICROLITE 100mcg Levonorgestrel
LEONORE
30/75/125mcg
LOGYNON
Levonorgestrel
MINULET 75mcg Gestodene MEDIUM
MERCILON MARVIOL 150mcg Desogestrel
3rd Generation
AZALIA 75mcg Desogestrel
CERAZETTE
CILIQUE 250mcg Norgestimate
ZOELY 2.5mg Nomegestrol
LOW
QLAIRA 2/3mcg Dienogest
4th Generation
ELVINETTE
ELVINA
YASMINELLE 3mg Drospirenone
YASMIN
YAZHEADACHES / HEADACHES DURING PILL FREE WEEK
• Ensure it is not migraine with aura
• Timing of the headache is the most important thing to establish
• If headache persists throughout the pill pack – likely cause is too much oestrogen
• If it’s during pill free week – lower oestrogen dose or reduce pill free interval
WHICH
CAUSE ACTION CONTRACEPTIVE?
HEADACHES THROUGHOUT PILL PACK
Reduce oestrogen Elvinette • Leonore • Mercilon
to a lower dose Microlite • Violite • Yasminelle • Yaz
Too much oestrogen Try non oestrogen brands Azalia • Cerazette • Noriday
HEADACHES Copper coil • Implanon
Consider non oral options
Jaydess • Mirena • Nuvaring
HEADACHES DURING PILL FREE WEEK
Reduce oestrogen Elvinette • Leonore • Mercilon
strength to a lower dose Microlite • Violite • Yasminelle • Yaz
Too much
of a hormone drop Shorten or omit pill
Logynon • Qlaira • Yaz • Zoely
free interval
Reproduced with the kind permission of Dr. Deirdre LundyPRESCRIBING GUIDE 12
Oestrogen dosage
No Synthetic
Generation 20mcg 30mcg 35mcg 1.5mg Phasic
oestrogen progestogen
1st Generation NORIDAY 350mcg Norethisterone ANDROGENICITY
OVREENA
150mcg Levonorgestrel
OVRANETTE HIGH
VIOLITE
2nd Generation MICROLITE 100mcg Levonorgestrel
LEONORE
30/75/125mcg
LOGYNON
Levonorgestrel
MINULET 75mcg Gestodene MEDIUM
MERCILON MARVIOL 150mcg Desogestrel
3rd Generation
AZALIA 75mcg Desogestrel
CERAZETTE
CILIQUE 250mcg Norgestimate
ZOELY 2.5mg Nomegestrol
LOW
QLAIRA 2/3mcg Dienogest
4th Generation
ELVINETTE
ELVINA
YASMINELLE 3mg Drospirenone
YASMIN
YAZIRRITABILITY / DEPRESSION / LOSS OF LIBIDO
• Progestogen is a mood suppressant – change progestogen
• Loss of libido – linked to androgen activity. If decrease in libido – try more androgenic pill
• Can happen with any combination of oestrogen/progestogen
• Consider copper coil as it is hormone free
• Depressed mood and depression are well known side effects of hormonal contraceptive
care. If a patient develops depression while on the pill, consideration should be given to
prescribing a non-hormonal alternative.
WHICH
CAUSE ACTION CONTRACEPTIVE?
Too much Try less progestagenic Elvinette • Qlaira • Yasmin
progestagenic potency 4th generation brands Yasminelle • Yaz • Zoely
IRRITABILITY / Try levonorgestrel
Too little androgenic Leonore • Microlite • Violite
DEPRESSION brands with androgenic
properties Ovreena • Ovranette • Logynon
/ LIBIDO LOSS properties
Increase oestrogen to Minulet • Ovreena • Ovranette
Too little oestrogen
a higher dose Logynon • Cilique
Reproduced with the kind permission of Dr. Deirdre LundyPRESCRIBING GUIDE 12
Oestrogen dosage
No Synthetic
Generation 20mcg 30mcg 35mcg 1.5mg Phasic
oestrogen progestogen
1st Generation NORIDAY 350mcg Norethisterone ANDROGENICITY
OVREENA
150mcg Levonorgestrel
OVRANETTE HIGH
VIOLITE
2nd Generation MICROLITE 100mcg Levonorgestrel
LEONORE
30/75/125mcg
LOGYNON
Levonorgestrel
MINULET 75mcg Gestodene MEDIUM
MERCILON MARVIOL 150mcg Desogestrel
3rd Generation
AZALIA 75mcg Desogestrel
CERAZETTE
CILIQUE 250mcg Norgestimate
ZOELY 2.5mg Nomegestrol
LOW
QLAIRA 2/3mcg Dienogest
4th Generation
ELVINETTE
ELVINA
YASMINELLE 3mg Drospirenone
YASMIN
YAZNAUSEA
• Can be caused by too much oestrogen – reduce oestrogen dose
• Can also be caused by both oestrogen and progestogen
• Advise patient to take pill in the evening time after food
WHICH
CAUSE ACTION CONTRACEPTIVE?
Elvinette • Leonore • Mercilon
Reduce oestrogen to a
lower dose
Microlite • Violite • Qlaira
Yasminelle • Yaz • Zoely
Too much oestrogen Try non oestrogen brands Azalia • Cerazette • Noriday
Copper coil • Implanon • Jaydess
Consider non oral options
NAUSEA Mirena • Nuvaring
Reproduced with the kind permission of Dr. Deirdre LundyPRESCRIBING GUIDE 12
Oestrogen dosage
No Synthetic
Generation 20mcg 30mcg 35mcg 1.5mg Phasic
oestrogen progestogen
1st Generation NORIDAY 350mcg Norethisterone ANDROGENICITY
OVREENA
150mcg Levonorgestrel HIGH
OVRANETTE
VIOLITE
2nd Generation MICROLITE 100mcg Levonorgestrel
LEONORE
30/75/125mcg
LOGYNON
Levonorgestrel
MINULET 75mcg Gestodene MEDIUM
MERCILON MARVIOL 150mcg Desogestrel
3rd Generation
AZALIA 75mcg Desogestrel
CERAZETTE
CILIQUE 250mcg Norgestimate
ZOELY 2.5mg Nomegestrol
LOW
QLAIRA 2/3mcg Dienogest
4th Generation
ELVINETTE
ELVINA
YASMINELLE 3mg Drospirenone
YASMIN
YAZTHRUSH
• Can be caused by too much oestrogen – reduce oestrogen dose
• Consider non oral options such as the copper intrauterine device
WHICH
CAUSE ACTION CONTRACEPTIVE?
Elvinette • Leonore
Reduce oestrogen to a
Mercilon • Microlite • Violite
lower dose
Yasminelle • Yaz
Too much oestrogen Try non oestrogen brands Azalia • Cerazette • Noriday
Copper coil • Implanon
Consider non oral options
Jaydess • Mirena
THRUSH
Reproduced with the kind permission of Dr. Deirdre LundyPRESCRIBING GUIDE 12
Oestrogen dosage
No Synthetic
Generation 20mcg 30mcg 35mcg 1.5mg Phasic
oestrogen progestogen
1st Generation NORIDAY 350mcg Norethisterone ANDROGENICITY
OVREENA
150mcg Levonorgestrel HIGH
OVRANETTE
VIOLITE
2nd Generation MICROLITE 100mcg Levonorgestrel
LEONORE
30/75/125mcg
LOGYNON
Levonorgestrel
MINULET 75mcg Gestodene MEDIUM
MERCILON MARVIOL 150mcg Desogestrel
3rd Generation
AZALIA 75mcg Desogestrel
CERAZETTE
CILIQUE 250mcg Norgestimate
ZOELY 2.5mg Nomegestrol
LOW
QLAIRA 2/3mcg Dienogest
4th Generation
ELVINETTE
ELVINA
YASMINELLE 3mg Drospirenone
YASMIN
YAZWEIGHT GAIN
• There is insufficient evidence to suggest CHCs can lead to weight gain
• Patients starting CHCs may find they have an increased appetite which can lead to weight gain
•C yclical weight gain may be oestrogen related due to fluid retention – use low dose oestrogen pill
WHICH
CAUSE ACTION CONTRACEPTIVE?
FLUID RETENTION
Elvinette • Leonore •
Reduce oestrogen to a
Mercilon • Microlite • Violite
lower dose
Yasminelle • Yaz
Too much oestrogen
Try non oestrogen brands Azalia • Cerazette • Noriday
Reproduced with the kind permission of Dr. Deirdre Lundy
WEIGHT
GAINPRESCRIBING INFORMATION
Combined Abbreviated Prescribing Information – for full malignancies (e.g. of the genital organs or the breasts). Ovreena & one are associated with the lowest risk of VTE. Other products may have
Violite: Presence or history of venous or arterial thrombosis (e.g. deep up to twice this level of risk. The decision to use any product other than
and contra- indications, see relevant Summary of Product venous thrombosis, pulmonary embolism, myocardial infarction (MI) or one with the lowest VTE risk should be taken only after a discussion with
Characteristics (SmPC). cerebrovascular disorder), the presence of severe or multiple risk factors the woman to ensure she understands the risk of VTE, how her current
for venous or arterial thrombosis, previous prodromal symptoms of
thrombosis (e.g. transient cerebral ischaemia or angina pectoris), ever year of use. There is also some evidence that the risk is increased
coated tablets: 75 micrograms desogestrel. Cilique 250/ 35 cardiovascular disorders (e.g. cardiac diseases, valvulopathy, arrhythmic when a CHC is re-started after a break in use of 4 weeks or more. The risk
microgram tablets: 250 micrograms of norgestimate and 35 micrograms disturbances), severe hypertension, diabetes mellitus with vascular of arterial thromboembolic complications or of a cerebrovascular accident
of ethinylestradiol Elvina 0.03mg/3mg Film-coated Tablets: 0.03 mg involvement, ocular disorder of vascular origin, known or suspected in CHC users increases in women with risk factors. If a woman has more
ethinylestradiol and 3 mg drospirenone. Elvinette 0.02mg/3mg than one risk factor, it is possible that the increase in risk is greater than
0.02 mg ethinylestradiol and 3 mg drospirenone. breast)present or history of benign or malignant liver tumours, the sum of the individual factors - in this case her total risk should be
Ovreena 30 micrograms/150 micrograms coated tablets: 150 migraine with focal neurological symptoms. Violite is contraindicated for
micrograms levonorgestrel and 30 micrograms ethinylestradiol, Violite concomitant use with the medicinal products containing ombitasvir/pari- negative a CHC should not be prescribed. Please refer to the relevant
100/20: 100 mg levonorgestrel and 20 mg ethinylestradiol. Please refer taprevir/ritonavir, and dasabuvir, glecaprevir/pibrentasvir and SmPC for a list of risk factors and symptoms for VTE and ATE. CHC users
to the relevant Summary of Product Characteristics (SmPC) for a full list of sofosbuvir/velpatasvir/voxilaprevir Warnings and Precautions:
excipients. Indication: Contraception. Administration: Azalia: 1 tablet Azalia:
taken every day at about the same time, without taking any notice of possible risks for each individual woman. The risk of breast cancer is COC use should be discontinued. Azalia & Cilique contain lactose.
possible bleeding. Each new pack to be started directly after the previous slightly increased with COC use, but for POPs the evidence is less Tumours: A possible increased risk of cervical cancer has been reported
with long-term COC use. A slightly increased risk of breast cancer has
bleeding. For details of usage, especially if changing from another been observed in COC users, although direct causation has not been
contraceptive method or where a patient either misses a dose or has referred to a specialist if acute or chronic disturbances of liver function shown. Hepati c tumours (benign and malignant) have also been
vomiting/diarrhoea, please refer to the SmPC. Elvina, Elvinette, occur. Azalia should be discontinued in the event of a thrombosis and reported. Other conditions: Possible increased risk of pancreatitis in
Ovreena, Violite & Cilique: The tablets must be taken every day at women with a history of thromboembolic disorders should be made women with family history of, or current, hypertriglyceridemia. Clinically
about the same time in the order shown on the blister pack. One tablet is aware of the possibility of a recurrence. Discontinuation should also be relevant increases in blood pressure may rarely occur and require
to be taken daily for 21 consecutive days. Each subsequent blister started considered if there is long-term immobilization. Diabetic patients should discontinuation of COC use. If pre-existing or emergent elevated blood
after a 7-day tablet-free interval, during which time a withdrawal bleed pressure does not respond adequately to antihypertensive therapy, the
usually occurs. This bleeding usually starts on day 2-3 after the last tablet COC must be withdrawn, and may be resumed if normotensive values are
and may not have stopped before the next pack is started. For details of achieved. The following conditions may arise or worsen during use of
usage, especially if changing from another contraceptive method or not adequately respond to antihypertensive therapy, consider COCs although evidence of a relationship is inconclusive: Jaundice and/or
where a patient either misses a dose or has vomiting/diarrhoea, please discontinuing use. Ectopic pregnancy should be included in the pruritus associated with cholestasis, gallstones, porphyria, system lupus
refer to the relevant the SmPC. Contraindications: Hypersensitivity to erythematosus, haemolytic uraemic syndrome, Sydenham’s chorea,
the active substances or any of the excipients, undiagnosed vaginal Chloasma may occasionally occur, and women with a tendency to this herpes gestationis, hearing loss due to otosclerosis. Liver function
bleeding, presence or history of sever e hepatic disease (whilst liver should avoid exposure to the sun or UV radiation whilst taking Azalia. disturbance (acute or chronic) may require COC discontinuation until liver
function tests are abnormal). Or with the medicines containing The following conditions have been reported during sex steroid use:
ombitasvir/paritaprevir/ritonavir and dasabuvir Azalia: Active venous jaundice and/or pruritus related to cholestasis; gallstone formation; peripheral insulin resistance and glucose tolerance; diabetics should be
thromboembolic disorder; known or suspected sex-steroid sensitive porphyria; systemic lupus erythematosus; haemolytic uraemic closely monitored, particularly in the early stage of COC use. Worsening of
malignancies; Cilique: Presence or risk of venous thromboembolism syndrome; Sydenham’s chorea; herpes gestationis; otosclerosis-related endogenous depression, epilepsy, Crohn’s disease and ulcerative colitis
(VTE); or arterial thromboembolism (ATE); high risk of arterial hearing loss; (hereditary) angioedema. Lactation Azalia: There have have been reported during COC use. Women with a tendency to chloasma
thromboembolism due to multiple risk factors or to the presence of one been reports of a decrease in breast milk production while using Azalia. should avoid exposure to the sun or ultraviolet radiation while taking
serious risk factor such as (a) diabetes mellitus with vascular symptoms, Small amounts of etonogestrel are excreted in the breast milk. As a result, COCs. With all COCs, irregular bleeding may occur, especially during the
(b) severe hypertension (c) severe dyslipoproteinaemia. Elvina & 0.01 - 0.05 microgram etonogestrel per kg body weight per day may be
Elvinette: Hypersensitivity to peanut or soya, presence or risk of VTE, ingested by the child (based on an estimated milk ingestion of 150 considered after approximately three cycles. If bleeding irregularities
presence or risk of arterial thromboembolism (ATE), severe renal ml/kg/day) Cilique, Elvina, Elvinette, Ovreena & Violite: Circulatory occur after previously regular cycles, further diagnostic procedures should
disorders: The use of any CHC increases the risk of VTE compared with no be considered. Please refer to the relevant SmPC for further information
use. Products that contain levonorgestrel, norgestimate or norethister- regarding cycle control. Azalia, Cilique, Violite, Ovreena, Elvina &Elvinette: Depression can be serious and is a well-known risk factor for two months of treatment, bleeding tends to become less frequent. The pain, papanicolaou smear suspicious, libido decreased, edema, asthenia, suicidal behavior and suicide. Women should be advised to contact their following adverse reactions have been reported: Common (≥1/100 to pain, excessive thirst, sweating increased, weight decrease; Rare ( ≥ physician in case of mood changes and depressive symptoms, including
References:
1. www.hpra.ie 10. National Medicines Information Centre (2012) Update on Sexually Transmitted Infections Volume 18 Number 2
2. ellaOne® Summary of Product Characteristics Available at www.medicines.ie 11. http://www.thinkcontraception.ie/Sexually-Transmitted-Infections-STIs.3.1.aspx Last accessed: 31/08/15
3. 12. Adapted from MIMS Ireland (June 2016) Contraception pp. 317 - 319. MPI Media Ltd, Dublin.
hormonal contraception after use of ulipristal acetate 30mg (ellaOne®) for emergency contraception” 13. Adapted from Faculty of Sexual & Reproductive Healthcare Statement Venous Thromboembolism (VTE) and
September 2015 Hormonal Contraception November 2014
4. 14.
outweigh risks – CHMP endorses PRAC recommendation November 2013 EMA/709120/2013
5. Elvina Summary of Product Characteristics Available at www.medicines.ie 15.
6. Elvinette Summary of Product Characteristics Available at www.medicines.ie Recommendations” May 2011
7. Azalia Summary of Product Characteristics Available at www.medicines.ie 16. Cerazette Summary of Product Characteristics Available from www.medicines.ie
8. Ovreena Summary of Product Characteristics Available at www.medicines.ie 17.
9. Violite Summary of Product Characteristics Available at www.medicines.ie 2010 Dec 15;82(12):1499-1506. University of California, Los Angeles: California
For further information and patient support visit www.knowyourcontraceptives.ie
Acknowledgements
We sincerely thank Dr. Deirdre Lundy, Bray Womens Health Centre, for sharing the
We sincerely thank the Irish HCPs with a special interest in contraceptive care, who assisted
Consilient Health with the development of sections 1 - 5 of this Patient Management Guide.
IE-OCS-405a(1), Date of Preparation: May 2021You can also read
