Combined oral contraceptives (COCs)

Recovery of fertility

After stopping the COC, the normal functioning of the hypothalamic-pituitary-ovary system is quickly restored. More than 85-90% of women are able to become pregnant within 1 year, which corresponds to the biological level of fertility. Admission of COCs prior to the beginning of the conception cycle does not adversely affect the fetus, course and outcome of pregnancy. Accidental reception of COC in early stages of pregnancy is not dangerous and is not the basis for abortion, but at the first suspicion of pregnancy a woman should immediately stop taking COC.

Short-term reception of COC (within 3 months) causes an increase in the sensitivity of the receptors of the hypothalamus-pituitary-ovary system, so when the COC is abolished, ejection of tropic hormones and stimulation of ovulation occur. This mechanism is called "rebound-effect" and is used for some forms of anovulation.

In rare cases, after withdrawal of COC, amenorrhea is observed. It can be a consequence of atrophic changes in the endometrium, developing when taking COC. Menstruation occurs when the functional layer of the endometrium is restored independently or under the influence of therapy with zestrogens. Approximately 2% of women, especially in the early and late fertility periods, after stopping the COC, amenorrhea lasting more than 6 months (the so-called post-pill amenorrhoea - hyperdrug syndrome) is observed. The nature and causes of amenorrhea, as well as the response to therapy in women using COCs, do not increase the risk, but can mask the development of amenorrhea by regular menstrual bleeding.

Rules for the individual selection of combined oral contraceptives

COCs are selected strictly for a woman, taking into account the features of the somatic and gynecological status, the data of individual and family history. The selection of the COC takes place according to the following scheme.

• Targeted interrogation, assessment of the somatic and gynecological status and definition of the category of acceptability of the method of combined oral contraception for this woman in accordance with WHO eligibility criteria.
• The choice of a specific drug, taking into account its properties and, if necessary, therapeutic effects; advising a woman on the method of combined oral contraception.
• Observing a woman for 3-4 months, assessing the tolerability and acceptability of the drug; if necessary, a decision to change or cancel the COC.
• Clinical follow-up of a woman during the entire period of use of COCs.

A woman's survey is aimed at identifying possible risk factors. It necessarily includes the following series of aspects.

• Character of the menstrual cycle and gynecological anamnesis.
  • When there was a last menstruation, whether it was normal (it is necessary to exclude pregnancy now).
  • Is the menstrual cycle regular. Otherwise, a special examination is necessary to identify the causes of the irregular cycle (hormonal disorders, infection).
  • The course of previous pregnancies.
  • Abortions.
• Previous use of hormonal contraceptives (oral or other):
  • whether there were side effects; if so, which;
  • for what reasons the patient stopped using hormonal contraceptives.
• Individual history: age, blood pressure, body mass index, smoking, medication, liver disease, vascular disease and thrombosis, presence of diabetes, oncological diseases.
• Family history (illness in relatives who developed before the age of 40): arterial hypertension, venous thrombosis or hereditary thrombophilia, breast cancer.

In accordance with the conclusion of the WHO, the following survey methods are not relevant for assessing the safety of the use of COCs.

• Examination of mammary glands.
• Gynecological examination.
• Examination for the presence of atypical cells.
• Standard biochemical tests.
• Tests for inflammatory diseases of the pelvic organs, AIDS. The drug of the first choice should be a monophasic COC with an estrogen content of no more than 35 μg / day and a low androgenic gestagen. Such COCs include Logest, Femoden, Zhanin, Yarina, Mersilon, Marvelon, Novinet, Regulon, Belara, Miniziston, Lindineth, Silest ".

Three-phase COCs can be considered as reserve drugs when there are signs of estrogen deficiency against a background of monophasic contraception (poor control of the cycle, dryness of the vaginal mucosa, decreased libido). In addition, three-phase drugs are indicated for primary use in women with signs of estrogen deficiency.

When choosing a drug should also take into account the state of health of the patient.

In the first months after the onset of COC intake, the body adapts to hormonal reorganization. During this period, intermenstrual smearing or, more rarely, breakthrough bleeding may occur (in 30-80% of women), as well as other side effects associated with hormonal imbalance (in 10-40% of women). If unwanted events do not occur within 3-4 months, it is possible that the contraceptive should be changed (after excluding other causes - organic diseases of the reproductive system, skipping tablets, drug interactions). It should be emphasized that at present the selection of COC is large enough to select them for the majority of women who are shown this method of contraception. If the woman is not satisfied with the drug of the first choice, the drug of the second choice is selected taking into account the specific problems and side effects that the patient has.

Choosing a COC

Basic principles of monitoring patients using COCs

• Annual gynecological examination, including colposcopy and cytological examination.
• Once or twice a year, the examination of the mammary glands (in women who have a history of benign breast tumors and / or breast cancer in the family), once a year, mammography (in patients in perimenopause).
• Regular measurement of blood pressure. With an increase in diastolic blood pressure to 90 mm Hg. Art. And the reception of the COC is stopped.
• Special examinations for indications (with the development of side effects, the appearance of complaints).
• With violations of menstrual function - the exclusion of pregnancy and transvaginal ultrasound scanning of the uterus and its appendages. If intermenstrual bleeding persists for more than three cycles or appears with further administration of COC, the following recommendations should be adhered to.
  • Eliminate the error in taking COC (skipping tablets, non-compliance with the reception scheme).
  • Exclude pregnancy, including ectopic pregnancy.
  • Exclude organic diseases of the uterus and appendages (myoma, endometriosis, hyperplastic processes in the endometrium, cervical polyps, cervical cancer or uterine body).
  • Exclude infection and inflammation.
  • If you exclude these reasons - change the drug in accordance with the recommendations.
  • In the absence of bleeding cancellation should be deleted:
    • COC reception without 7-day breaks;
    • pregnancy.
  • If these reasons are excluded, the most likely cause of the absence of bleeding cancellation is endometrial atrophy, caused by the influence of progestogen, which can be detected with ultrasound of the endometrium. This condition is called "mute menstruation", "pseudoamenorrhea". It is not associated with hormonal disorders and does not require the withdrawal of COCs.

Rules for the reception of COCs

Women with a regular menstrual cycle

• Primary reception of the drug to begin within the first 5 days after the onset of menstruation - in this case, the contraceptive effect is provided already in the first cycle, additional measures of protection from pregnancy are not necessary. Reception of monophasic COCs starts with a tablet with the label of the corresponding day of the week, multiphase COCs - from a tablet labeled "start of reception." If the first tablet is taken later than 5 days after the onset of menstruation, in the first cycle of COC intake an additional method of contraception for 7 days is needed.
• Take 1 tablet (pills) daily at about the same time of day for 21 days. In case of missing the tablet, follow the "Rules of forgotten and missed tablets" (see below).
• After taking all (21) tablets from the package, make a 7-day break, during which there is a bleeding withdrawal ("menstruation"). After the break, the taking of tablets from the next package begins. For a reliable contraception, the interval between receiving cycles should not exceed 7 days!

All modern COCs are issued in "calendar" packages, designed for one cycle of reception (21 tablets - 1 per day). There are also packages with 28 tablets; in this case, the last 7 tablets do not contain hormones ("pacifiers"). In this case, the break between the packages does not: it is replaced by taking placebo, since in this case the patients are less likely to forget to start receiving the next package on time.

Women with amenorrhea

• To start reception at any time under condition of reliably excluded pregnancy. In the first 7 days, use an additional method of contraception.

Breastfeeding women

• Earlier than 6 weeks after childbirth COC is not appointed!
• The period from 6 weeks to 6 months after birth, if a woman is breastfeeding, use the COC only in case of emergency (the method of choice is mini-saws).
• More than 6 months after childbirth:
  • with amenorrhea the same as in the section "Women with amenorrhea";
  • with the restored menstrual cycle.

"Rules of forgotten and missed tablets"

• If you missed 1 tablet.
  • Delay in the intake of less than 12 hours - take the missed tablet and continue taking the drug until the end of the cycle according to the previous scheme.
  • Delay in the reception for more than 12 hours - the same actions as in the previous paragraph, plus:
    • when a pill is missed at week 1, use a condom for the next 7 days;
    • when a tablet is skipped during the second week, there is no need for additional means of protection;
    • when you miss a pill at the 3rd week, after completing one package, the next start without interruption; There is no need for additional means of protection.
• If you missed 2 tablets or more.
  • Take 2 tablets a day until the reception goes into the regular schedule, plus use additional methods of contraception within 7 days. If after the missed tablets bloody discharge begins, it is better to stop the taking of tablets from the current package and start a new package after 7 days (counting from the beginning of the missing tablets).

Rules for assigning COCs

• Primary appointment - from the 1st day of the menstrual cycle. If the reception is started later (but no later than the 5th day of the cycle), then in the first 7 days it is necessary to use additional methods of contraception.
• The appointment after the abortion - immediately after the abortion. Abortion in I, II trimesters, and also septic abortion belong to the category 1 states (there are no restrictions to using the method) for the designation of COCs.
• Appointment after childbirth - in the absence of lactation begin taking COC no earlier than the 21st day after giving birth (category 1). If there is lactation, the COC should not be prescribed, minipills should be used no earlier than 6 weeks after the delivery (category 1).
• Transition from high-dose COCs (50 μg EE) to low-dose (30 μg EE or less) - without a 7-day break (so that the hypothalamic-pituitary system is not activated due to dose reduction).
• Transition from one low-dose COC to another - after an ordinary 7-day break.
• The transition from mini-drank to COC - on the 1 st day of the next bleeding.
• The transition from an injection to a COC is the day of the next injection.

Recommendations for patients taking COCs

• It is advisable to reduce the number of cigarettes smoked or to stop smoking altogether.
• Observe the regimen of the drug: do not skip the pills, strictly adhere to the 7-day break.
• The drug should be taken at the same time (in the evening before going to bed) with a small amount of water.
• Have the "Rules of forgotten and missed tablets" at hand.
• In the first months of taking the drug, intermenstrual bloody discharge of varying intensity is possible, usually disappearing after the third cycle. With ongoing intermenstrual bleeding at a later date, you should consult your doctor to determine their cause.
• In the absence of a menstrual-like reaction, you should continue taking the pill according to the usual schedule and urgently seek medical attention to exclude pregnancy; When confirming pregnancy, immediately stop taking COC.
• After discontinuation of the drug, pregnancy may occur already in the first cycle.
• Simultaneous use of antibiotics, as well as anticonvulsants, leads to a decrease in the contraceptive effect of COCs.
• When vomiting occurs (within 3 hours after taking the drug), one more pill should be taken additionally.
• Diarrhea that lasts for several days requires the use of an additional contraceptive method before another menstrual reaction.
• With sudden localized severe headache, migraine attack, chest pain, acute visual impairment, shortness of breath, jaundice, increased blood pressure above 160/100 mm Hg. Art. Immediately stop taking the drug and consult a doctor.