Benefits of Family Planning,

WHO tools and publications

Combined Oral
Contraceptive Pills

Adapted by Dr Rodica Comendant, based on

Training Resource Package for Family
Planning: https://www.fptraining.org/

Session I, Slide 1
Defining Contraception and Family
Planning
What is the definition of contraception?
Contraception is the intentional prevention of
pregnancy by artificial or natural means.
What is the definition of family planning?
Family planning allows individuals and couples to
anticipate and attain their desired number of children
and the spacing and timing of their births. It is
achieved through use of contraceptive methods and
the treatment of involuntary infertility.
– World Health Organization,
Department of Reproductive Health and Research

Session I, Slide 2
Family Planning Saves Lives
Region/ Number of Lifetime risk of
country maternal deaths maternal death 1 in:
Sub-Saharan Africa 162,000 39
Southern Asia 83,000 160
These 2 regions account for 85% of maternal deaths worldwide
Developed regions 1,700 4,300

• Over 287,000 women per year die in pregnancy or childbirth

• 47,000 women per year die from complications of unsafe abortion
• Complications of pregnancy and childbirth are the leading cause of
death in young women
94,000 maternal deaths could be prevented if all women who said
they want to avoid pregnancy were able to stop childbearing.
Sources: WHO, UNICEF, UNFPA and The World Bank, 2010; WHO 2009;
Guttmacher Institute, 2010. Session I, Slide 3
Family Planning and Human Rights

All individuals and couples have the right:

“…to decide freely and responsibly the
number, spacing and timing of their children
and to have the information, education, and
means to do so, and the right to attain the
highest standard of sexual and reproductive
health...”
– ICPD Programme of Action

Source: United Nations, 1995. Session I, Slide 4

Benefits of Providing FP Services

Improves well-being
of families and
Helps achieve the communities
healthiest outcomes
Allow women and for women and their
couples to delay, children
space, and limit
pregnancies

FP services are most effective when clients are free to

make informed choices.
Session I, Slide 5
 WHO’s Family Planning
Guidance Documents and
Job Aids

Session I, Slide 6
Medical Eligibility Criteria for
Contraceptive Use
• Evidence-based
recommendations
• Use by policy-makers and
program managers to improve
access to, and quality of,
family planning services
• 19 contraceptive methods
• Variety of medical conditions
and client characteristics
• Periodic reviews and updates
Session I, Slide 7
Selected Practice Recommendations
for Contraceptive Use
• Evidence-based recommendations
on safe and effective use
• 33 questions related to
contraceptive methods
• Range of issues including initiation,
continuation, incorrect use,
treatment of side effects, and
some programmatic issues
• Use by policy-makers and program
managers
• Periodic reviews and updates;
latest update 2008 Session I, Slide 8
Family Planning:
A Global Handbook for Providers
• Essentials needed to provide
family planning clients with
good-quality care
• Latest guidance for delivering
19 contraceptive methods
appropriately and effectively
• Use by clinical providers
• Periodic reviews and updates;
latest update 2011

Session I, Slide 9
WHO’s Medical Eligibility Criteria
Categories for IUDs, Hormonal and Barrier Methods

When clinical
Category Description judgment is
available
No restriction for Use the method under
1
use any circumstances

Benefits generally Generally use the

2
outweigh risks method

Use of method not

usually recommended,
Risks usually
3 unless other methods
outweigh benefits
are not
available/acceptable
Unacceptable
4 Method not to be used
health risk

Source: WHO, 2010.

Session I, Slide 10
 Combined Oral
Contraceptive Pills
(COCs)
Session I:
Characteristics of COCs

Session I, Slide 11
Combined Oral Contraceptives
Objectives
Participants will be able to:
• Describe the characteristics of COCs in a manner that clients
can understand
• Demonstrate how to screen clients for eligibility for COC use
• Describe when to initiate COCs
• Explain how to use COCs, what to do when pills are missed,
and when to return
• Address common concerns, misconceptions, and myths
• Explain how to manage side effects
• Identify conditions that require switching to another method
• Identify clients in need of referral for COC-related complications
Session I, Slide 12
 COCs Key Points for
Providers and Clients
• Contains both estrogen and progestogen hormones.
Take a pill every day. • Works mainly by stopping ovulation.
• “Would you remember to take a pill each day?”
Effectiveness depends • No need to do anything at time of sexual intercourse.
• Very effective if taken every day. But if woman forgets pills,
on the user. Can be she may become pregnant.
very effective. • Easy to stop: A woman who stops pills can soon become
pregnant.
• Pills are not harmful for most women’s health and studies
show very low risk for cancer due to pills for almost all women.
Very safe. The pill can even protect against some types of cancer.
• Serious complications are rare. They include heart attack,
stroke, blood clots in deep veins of the legs or lungs.
Some women have
side-effects at first–
not harmful and often • Side-effects often go away after first 3 months.
go away after first 3
months.
No protection against • For STI/HIV/AIDS protection, also use condoms.
STIs or HIV/AIDS. Session I, Slide 13
What Are COCs? Traits and Types

Combination of two hormones: estrogen

Content
and progestin
Monophasic, biphasic, triphasic (in the
Phasic
past)
Low-dose: 30-35 µg of estrogen
Dose (common), 20 µg or less (rare in most
places)
21: all active pills
Pills per (7-day break between packs)
pack 28: 21 active + 7 inactive pills
(no break between packs)

Session I, Slide 14
Effectiveness of COCs
In this progression of effectiveness, where would
you place combined oral contraceptives (COCs)?
Implants
More
effective Male Sterilization
Female Sterilization
Intrauterine Devices
Progestin-Only Injectables COCs
Male Condoms
Standard Days Method
Female Condoms
Less
effective
Spermicides
Session I, Slide 15
Relative Effectiveness of
FP Methods
# of unintended pregnancies among
Method 1,000 women in 1st year of typical use
No method 850
Withdrawal 220
Female condom 210
Male condom 180
Pill 90
Injectable 60
IUD (CU-T 380A / LNG-IUS) 8/2
Female sterilization 5
Vasectomy 1.5
Implant 0.5
Source: Trussell J., Contraceptive Failure in the United States, Contraception 83 (2011) 397- 404,
Elsevier Inc.

Session I, Slide 16
COCs: Mechanism of Action

Suppresses
hormones
responsible for
ovulation

Thickens
cervical mucus
to block sperm

COCs have no effect on an existing pregnancy.

Session I, Slide 17
COCs: Characteristics
• Safe and more than • Less effective when not used
99% effective if used correctly (91%)
correctly • Require taking a pill every
• Can be stopped at any day
time
• Do not provide protection
• No delay in return to from STIs/HIV
fertility
• Are controlled by the • Have side effects
woman • Have some health risks
• Do not interfere with sex (rare)
• Have health benefits

Source: Hatcher, 2007; WHO, 2010; CCP and WHO, 2011; Trussell , 2011. Session I, Slide 18
COCs: Menstrual-Related Health
Benefits
• Decreased amount of flow and fewer days of
bleeding; no bleeding (less common)

• Regular, predictable menstrual cycles

• Reduced pain and cramps during menses

• Reduced pain at time of ovulation

Source: Davis, 2005.

Session I, Slide 19
COCs: Other Health Benefits

Protection from: Decreased symptoms

• Risks of pregnancy of endometriosis
• Ovarian cancer (pelvic pain, irregular
bleeding)
• Endometrial cancer
• Symptomatic PID Decreased symptoms
of polycystic ovarian
Reduced risk of: syndrome (irregular
• Ovarian cysts bleeding, acne, excess
• Iron-deficiency anemia hair on face or body)

Source: Petitti and Porterfield, 1992; CASH Study, 1987; CCP and WHO, 2011; Belsey, 1988; Davis, 2007.
Session I, Slide 20
No Overall Increase in Breast Cancer
Risk for COC Users
Analysis of a large number of studies:
• No overall increase in breast cancer risk among women
who had ever used COCs
• Current use and use within past 10 years: very slight
increase in risk
– May be due to early diagnosis or accelerated growth
of pre-existing tumors
More recent study:
• No increase in breast cancer risk regardless of age,
estrogen dose, ethnicity, or family history of breast
cancer
Source: Collaborative Group on Hormonal Factors in Breast Cancer, 1996; Marchbanks, 2002.
Session I, Slide 21
COCs and Cervical Cancer
• Cervical cancer is caused by certain types of human
papillomavirus (HPV)
• Some increase in risk among women with HPV and others
who use COCs more than 5 years
– Risk of cervical cancer goes back to baseline after 10
years of non-use
• Cervical cancer rates in women of reproductive age are
low. Risk of cervical cancer at this age group is low
compared to mortality and morbidities associated with
pregnancy.
COC users should follow the same cervical cancer
screening schedule as other women.
Source: Smith, 2003; Appleby, 2007; CCP and WHO, 2011. Session I, Slide 22
Risk of Blood Clots is Limited
• COCs may slightly increase risk of blood clots:
– Stroke – Deep vein thrombosis
– Heart attack – Pulmonary embolism

• Risk is concentrated among women who have

additional risk factors, such as:
– Hypertension
– Diabetes
– Smoking
Stop COCs immediately if a blood clot develops.
Source: World Health Organization Collaborative Study of Cardiovascular Disease and
Steroid Hormone Contraception ,1995; Jick, 2006; WHO, 1998; Farley, 1998. Session I, Slide 23
 Possible Side-Effects
If a woman chooses this method, she may have some side-
effects. They are not usually signs of illness.
• But many women do not have any side-effects.
• Side-effects often go away after a few months and are not harmful.

Most common:

• Nausea • Changes in • Mood • Tender • Dizziness

(upset bleeding changes or breasts
stomach) patterns (lighter, headaches • Slight weight
irregular, gain or loss
infrequent or no
monthly
bleeding) Session I, Slide 24
 Combined Oral
Contraceptive Pills
(COCs)
Session II:
Who Can and Cannot Use COCs?

Session I, Slide 25
 COCs Are Safe for Nearly All Women

• Almost all women can use COCs safely, including

women who:
– Have or have not had children
– Are not married
– Are of any age
– Smoke (if under age 35)
– Have anemia now or had it in the past
– Have varicose veins
– Have an STI or HIV/AIDS
• Most health conditions do not affect safe and effective
use of COCs

Session I, Slide 26
 Who Can and Cannot Use COCs

Most women can safely use the pill.

But usually cannot use the pill if:

• Smoke • High blood • Gave birth • Breastfeeding • May be • Some

cigarettes pressure in the last 3 6 months pregnant other
AND weeks or less serious
age 35 or health
older conditions

Session I, Slide 27
 Who Should Not Use COCs (part 1)
My period
is late… Breast
Breast
feeding
Are Think they feeding
Are a baby
may be a baby
pregnant pregnant less
pregnant Think they less
than 6
may be than 6
pregnant months
months
old
old

Smoke and
Hada aheart
heart HadHadblood Have or had
are age 35 or Had blood
attackoror clots in legs
clots breast cancer
older attack
Source: WHO, 2010.
stroke
stroke or lungs
in legs or
lungs Session I, Slide 28
 Who Should Not Use COCs (part 2)

Have bad Take pills for Gave birth in last

headaches Breast
TB, seizures 6 weeks
with nausea (fits), or HIV feeding
or vision a baby
problems Think they less
may be than 6
pregnant
months
I cannot
eat
old
sweets.
Have serious
liver disease or
gall bladder
disease
Have high blood
Have diabetes (high pressure Have rheumatic
sugar in blood) Had a heart disease, such as
Had blood
attack or lupus
clots
Source:WHO,
Source: WHO,2010;
2010.Chu, 2005.
stroke in legs or
lungs Session I, Slide 29
 Medical Eligibility Criteria

What are medical

eligibility criteria?

Session I, Slide 30
WHO’s Medical Eligibility Criteria
Categories for IUDs, Hormonal and Barrier Methods

When clinical judgment

Category Description
is available
Use the method under any
1 No restriction for use
circumstances

Benefits generally outweigh

2 Generally use the method
risks
Use of method not usually
Risks usually outweigh recommended, unless other
3
benefits methods are not
available/acceptable

4 Unacceptable health risk Method not to be used

Source: WHO, 2010.

Session I, Slide 31
WHO’s Medical Eligibility Criteria
Categories for IUDs, Hormonal and Barrier Methods

When clinical judgment

Category
is available

1
Use the method
2

3
Do not use the method
4

Source: WHO, 2010.

Session I, Slide 32
Category 1 and 2 Examples (not inclusive):
Who Can Use COCs

WHO Category Conditions (selected examples)

menarche to 39 yrs; nulliparous; endometriosis;
endometrial or ovarian cancer; uterine fibroids;
Category 1 family history of breast cancer; varicose veins;
irregular, heavy, or prolonged bleeding; anemia;
STI/PID; hepatitis (chronic/carrier)

≥40 yrs; breastfeeding ≥6 months postpartum;

superficial thrombophlebitis; uncomplicated diabetes;
Category 2 cervical cancer; unexplained vaginal bleeding;
undiagnosed breast mass

Source: WHO, 2010.

Session I, Slide 33
Category 3 Examples (not inclusive):
Who Should Generally Not Use COCs

WHO Category Conditions (selected examples)

Category 3 Postpartum:
• Breastfeeding between 6 weeks and 6 months
• Non-breastfeeding <21 days (if no additional
risk factors for blood clots)
Vascular conditions:
• Hypertension (history of or BP 140-159/90–99)
• Migraine without aura (older than 35 yrs)
Gastrointestinal conditions:
• Symptomatic gall bladder disease (current and
medically-treated)
Drug interactions:
• Use of rifampicin, rifabutin, ritonavir

Source: WHO, 2010.

Session I, Slide 34
Category 3 Examples (not inclusive):
Who Should Generally Not Use COCs
WHO Category
Category 4
Source: WHO, 2010; Sekar, 2008.
Conditions (selected examples)
Breastfeeding: <6 weeks postpartum
Smoking: ≥15 cigarettes/day and ≥ 35 yrs old
Vascular conditions:
•Hypertension (≥160/≥100)
•Migraines with aura
•Ischemic heart disease or stroke
•Diabetes with vascular complications
•Deep venous thrombosis (history or acute)
•Pulmonary embolism (history or acute)
Liver conditions:
•Acute hepatitis
•Severe liver disease and most liver tumors
Breast cancer: current or within 5 yrs
Session I, Slide 35
 COC Use by Women with HIV

WHO Eligibility Criteria • Women with HIV or AIDS can

use without restrictions
Condition Category
• Women on ARVs other than
HIV-infected 1 ritonavir can use COCs safely
AIDS 1 • Should not be used by women
ARV therapy
who take ritonavir (may reduce
(which does not 2 effectiveness of COCs).
contain ritonavir)

Ritonavir/
• Using low-dose COCs is
ritonavir- appropriate
boosted PIs 3
(as part of ARV • Condom use should be
regimen) encouraged in addition to COCs
Source: WHO, 2010; Sekar, 2008.
Session I, Slide 36
 COC Use by Postpartum Women

WHO Eligibility Criteria • Non-breastfeeding women should

Condition Category not initiate COCs before 3 weeks
postpartum (6 weeks postpartum
Non- for multiple VTE risk factors)
breastfeeding 3
<3 weeks • Breastfeeding women
Breastfeeding – Should not use COCs before
<6 weeks 4 6 weeks postpartum
Breastfeeding – Should not use COCs from
>6 weeks and 3 6 weeks to 6 months postpartum
< 6 months unless no other method is
available
Breastfeeding
≥6 months 2 – Can generally initiate COCs at
6 months postpartum
Source: WHO, 2010.
Session I, Slide 37
Group Activity
Understanding the Checklist
Read questions
This set of
1–12 in the questions
identifies
checklist. women
who
should not
How have you use COCs.

determined
medical eligibility
This set of
in the past? questions
identifies
women
The checklist also who are
gives instructions not
about initiating pregnant.
COCs.

Session I, Slide 38
 Combined Oral
Contraceptive Pills
(COCs)
Session III: Providing COCs

Session I, Slide 39
 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).
Session I, Slide 40
 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).

Session I, Slide 41
 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 nonhormonal 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 next day, use backup method for 7 days
Source: WHO, 2004 (updated 2008).
Session I, Slide 42
 The Pill

How to Take COCs

• 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.
Session I, Slide 43
 The Pill

How to Take COCs

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.
28-pill pack

If you use the 21-pill pack:

• 7 days of no pills

21-pill
• Once you have finished all the pills in the
21-pillpack
pack
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.
Session I, Slide 44
The Pill

Missed Pills Instructions

• 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.

Session I, Slide 45
The Pill
Missed Pills Instructions,
continued
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

AND OR

• If these pills missed in week 3, ALSO skip the inactive pills

in a 28-pill pack and start a new pack
week 3
Inactive pills

• If inactive pills are missed, throw away the missed pills and
continue taking pills, 1 each day
Source: WHO, 2004; updated 2008; CCP and WHO, 2011.
Session I, Slide 46
 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
Session I, Slide 47
 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. Session I, Slide 48
 What to Remember

• Take one pill each day See a nurse or doctor if:

• If you miss pills, you can
• Severe, constant • Very bad
get pregnant pain in belly, chest, headaches
or legs
• Side-effects are common
but rarely harmful. Come
back if they bother you.
• Come back for more pills
before you run out or if
• A bright
you have problems. spot in your
vision
before bad
Anything else I can headaches • Yellow skin
repeat or explain? or eyes
Any other
questions?
Session I, Slide 49
 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.

Session I, Slide 50
 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?

Session I, Slide 51
 Management of COC Side Effects

Counseling and reassurance are key.

Problem Action/Management
Ordinary Reassure client: If side effects persist
headaches usually diminish over and are unacceptable
time; take painkillers to client:
if possible, switch pill
Nausea and Take pills with food or at
formulations or switch
vomiting bedtime
to another method.

Breast Recommend supportive

tenderness bra; suggest pain
reliever

Session I, Slide 52
Management of COC Side Effects:
Bleeding Changes
Problem Action/Management
Irregular Reassure client: If side effects persist
bleeding reinforce correct pill and are unacceptable
taking and review to client:
missed pill instructions; if possible, switch pill
ask about other drugs
formulations or offer
that may interact with
COCs; administer short
another method.
course of non-steroidal
anti-inflammatory drugs
Amenorrhea Reassure client: no
medical treatment
necessary.

Source: CCP and WHO, 2011.

Session I, Slide 53
When to Return: Warning Signs of Rare
COC Complications
• Severe, constant pain in belly, • Very bad headaches
chest, or legs

• A bright spot in your • Yellow skin or eyes

vision before bad
headaches

Advise to stop taking COCs, use a backup method,

and see a health care provider.
Source: Hatcher, 2007.

Session I, Slide 54
Problems That May Require Stopping COCs or
Switching to Another Method

Problem Action
Unexplained vaginal • Refer or evaluate by history and pelvic exam
bleeding • Diagnose and treat as appropriate
• If an STI or PID is diagnosed, the client may
continue using COCs during treatment
• If the client develops migraines with or without
aura, or her migraine headaches worsen, stop
Migraines COC use
• Help the client choose a method without
estrogen
Tell the client she should:
Circumstances that • Tell her doctors she is using COCs
keep her from walking • Stop taking COCs and use a backup method
for one week or more • Restart COCs 2 weeks after she can move
about
Source: CCP and WHO, 2011.
Session I, Slide 55
Problems That May Require Stopping COCs or
Switching to Another Method
(continued)

Problem Action
Starting treatment with • These drugs make COCs less effective; COCs
anti- convulsants or may make lamotrigine less effective.
rifampicin, rifabutin, or • Advise the client to consider other contraceptive
ritonavir methods (except progestin-only pills).

Blood clots, heart or • Tell the client to stop COC use

liver disease, stroke, or • Give the client a backup method to use
breast cancer • Refer for diagnosis and care

• Assess for pregnancy

• If confirmed, tell the client to stop taking COCs
Suspected pregnancy
• There are no known risks to a fetus conceived
while a woman is taking COCs

Source: CCP and WHO, 2011.

Session I, Slide 56
 COCs: Summary

• Safe for almost all women

• Effective if used consistently
and correctly
• Fertility returns without a
delay
• Screening and counseling
are essential

Session I, Slide 57