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What is the contraceptive patch - Evra?


Evra is the first contraceptive patch. It contains 150microg norgestromin + 20 microg. Ethinyl Oestradiol. It’s a sticky patch you put on your skin, and it releases two hormones that stop you from getting pregnant. It’s light pink in colour, and just under 2 inches by 2 inches (5cm by 5 cm).This patch is applied once-weekly for three weeks wand for the next week no patch is applied.

This patch should be applied to the back of the shoulder, low down on the abdomen, upper arm or buttock. Once applied pressure should be applied for ten seconds. There is no need to remove it when bathing. At each change of patch a different site should be used.

Evra is a useful contraceptive introduced in the early years of this century. It’s now used by about one per cent of women of child-bearing age in Britain. The arrival of a new mode of administration in contraception should be welcomed although it will take a while before we learn how well it will be received. It provides an option for those who have had problems with a variety of oral preparations. Its success will be measured by the number of women who wish to try it on recommendation of their friends and relatives.

As 80% of the hormone is still present after 7days it is advised that the patch should not be flushed as there is a risk of water contamination.

Picture of an Evra contraceptive patch applied to the right upper arm.

How fail-safe is Evra?

Evra is just as effective as the combined oral contraceptive pills.

What side effects may I expect with this contraceptive patch?

Symptoms associated with the combined pill such as mastalgia, and breakthrough bleeding may be more common in early cycles than with combined oral contraceptive pills.

When should the Evra contraceptive patch be applied?

When first used an Evra patch should be applied on the first day of your period and it will provide immediate protection.

If you forget to change the patch after seven days in the middle of a course but you remember within 48 hours then you may change the patch and no further action is required. If there is more than a 48 hour delay then you should apply a new patch and use a barrier method for the next seven days.

What are the risks with Evra?

Evra is like a ‘skin’ version of the contraceptive pill, and it may well have similar long-term side-effects to the Pill.

We don’t yet know what the exact risk of thrombosis (clotting) is. However, it’s important you realise this risk exists.

The pharmaceutical company has a Web site that provides further information that might interest you:-

www.orthoevra.com

In one study, ring users preferred the ring to the oral contraceptive (P<.001), and patch users preferred the oral contraceptive to the patch.0801

Related Medical Abstracts - Click on the paper title:-

Benefits and Risks of Evra Contraceptivee Patch

It is generally assumed that the overall risks and benefits of Evra will be similar to the combined oral contraceptive pill but more long-term data is required.

What are the benefits of birth control pills?

The combined birth control pill suppresses the natural hormone cycle providing:

The additional benefits include:

  • improvement of acne (Q5.10).
  • oestrogen for those with amenorrhoea (absent periods) and low oestrogen levels (Q6.21).
  • reduction of excess body hair (hirsutism - hirsutism treatment).
  • reduced incidence of functional ovarian cysts (3).
  • improvement in endometriosis (Q15.19 and Q15.20).

The four-weekly bleeds that occur whilst taking the combined birth control pill are not periods (menstruation) but withdrawal bleeds. Menstruation is a bleed that occurs each month spontaneously and not in women who are taking hormonal treatment such as the combined birth control pill.

Will the birth pill improve my periods?

The majority of patients report reduced flow and less period pain. There are occasional exceptions so that a few ladies with light periods find their menstrual flow increased by the combined birth control pill. During early pill cycles in particular there may be some breakthrough bleeding. Some women do not have a withdrawal bleed during the combined oral contraceptive pill-free interval. If this happens for two consecutive cycles a pregnancy test should be considered. Absence of the withdrawal bleed is not detrimental to health. When the combined oral contraceptive pill is discontinued, the periods may take a few months to return to normal. Premenstrual syndrome is less common whilst taking the combined oral contraceptive pill although there may still be some symptoms for the last few days of the cycle.

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Could the birth pill alter my libido?

Relieved of the stress of possible unwanted pregnancy, some women report increased initiation of sexual activity. Others find their libido reduced, perhaps as there is some sub-conscious wish to have a child. If libido is reduced, vaginal discomfort due to infection should be excluded. Otherwise a change to a less progestogenic pill may help.

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What are the risks of taking the birth pill?

Thromboembolism (blood clots): The early combined oral contraceptive pills contained 150 mg of the oestrogen mestranol together with norethynodrel which is a progestogen. The first report of thromboembolism (a blood clot forming in a vein within the leg or pelvis and then travelling to the lungs) in association with the combined oral contraceptive pill came soon after the combined oral contraceptive pills were introduced. The pharmaceutical industry has made enormous efforts to reduce the risks associated with the oral contraceptive pills whilst maintaining their contraceptive effectiveness. Essentially there have been two avenues that have been explored. Firstly, the amount of oestrogen in the combined oral contraceptive pill has been reduced and secondly newer progestogens have been developed.

The oestrogen in the combined oral contraceptive pill reduces LH and FSH production and therefore suppresses follicular development and ovulation (Q 2.3). There has been concern that reducing the amount of oestrogen in the combined oral contraceptive pills could lead to contraceptive failure. Over the years it has been found that the lowest dose of oestrogen that remains effective is much lower than originally contemplated. The original 150 mg was reduced to 100mg then 50mg. The majority of pills prescribed today have less than 50mg of ethinyl oestradiol and two have just 20mg (Loestrin 20 – Parke Davis; Mercilon – Organon). At this level, the oestrogen content is only a little more than that found in hormone replacement therapy (HRT). HRT does not suppress follicular development or ovulation and it therefore follows that the 20mg oestrogen pills will be the minimum effective dose.

Mortality risks are negligible.

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What side effects could I have whilst taking the birth pill?

The vast majority of patients taking the combined oral contraceptive pill feel very well but, as with any medicine that has benefits, some minor side effects are occasionally reported. These include:

  • altered body weight (some gain a few pounds and others lose a little).
  • nausea (feeling sick) and vomiting.
  • mastalgia (breast tenderness).
  • headaches (the combined oral contraceptive pill should be stopped if they become severe).
  • altered libido (sex drive - Q15.5) with many women noticing an increase and others a reduction.
  • depression.
  • reduced or absent menstrual flow (Q15.4 ;24.17A).

These side effects usually settle within two or three months.


What is the effect of birth pills on body weight?

All of us are intermittently gaining or losing weight.

Inevitably some patients find that they gain weight around the time of starting the combined oral contraceptive pill but others observe a weight loss.

In a personal computer search of the medical literature from 1966 to date I found exactly fifty papers (articles in medical journals) where weight change in relation to the combined oral contraceptive pill had been studied.

  • Thirty-six papers indicated no change, eleven found an increase varying from 0.3kg to 2.4Kg.
  • Three papers found weight loss with the combined oral contraceptive pill for women who were overweight or who had polycystic ovaries.

Related Medical Abstracts - Click on the paper title:-

 

Will the birth pill increase my vaginal discharge?

Cervical ectopy (erosion - cervical erosion) appears to be more common in women taking the combined oral contraceptive pill although the newer lower dose pill seem to cause this less frequently. Cervical ectopy only requires treatment if there are persistent significant symptoms after excluding other problems such as infection. Contrary to popular belief, there is no evidence that the combined oral contraceptive pill increases the incidence of candida (thrush).

Does the birth pill increase my chance of pelvic infections?

There is no increase in the incidence of Candida infection in pill users. The incidence is the same as in women with intrauterine devices and those using no contraception. Bacterial infections that gain entry to the pelvis through the cervix are less common in pill users as the progestogen makes the cervical mucus thick. However, there is no protection against viruses or chlamydia.

Related Medical Abstracts - Click on the paper title:-

What is the relationship between the birth pill and fibroids?

Surprisingly, studies show that the combined oral contraceptive pill reduces the chance of fibroid development. It is a surprise because both oestrogen and progesterone are factors in fibroid development so fibroids shrink after the menopause (HRT-Add-Back). The current presumption is that the total of these hormones provided by the combined oral contraceptive pill in a month must be less than the natural hormone output by the ovaries.

Related Medical Abstracts - Click on the paper title:-

Will the birth pill increase my blood pressure?


For the majority of women, the blood pressure increases on the combined oral contraceptive pill by an average of 1mm Hg (a tiny amount). An increase of 5-10mm Hg may be of clinical importance but 1mm really does not matter. This is an example of a statistical (mathematical) proven increase that has no consequence from the medical point of view.

The international recommendation is that the combined oral contraceptive pill should not be started or continued if your blood pressure is 160/100 or higher. High blood pressure can be a factor in heart disease and strokes and as a few women (about 1%) may develop clinically significant raised blood pressure, checks should be carried out periodically. Your blood pressure should be measured before you start the combined oral contraceptive pill and three months later. If your blood pressure is normal it should be reviewed at six months intervals and after two years it can be reviewed annually.

Related Medical Abstracts - Click on the paper title:-

Does the birth pill have any effect on the blood?

All chemicals in the blood are eventually removed and eliminated from the body. The liver plays a key role in this process and this is true for oestrogens and progestogens. The oestrogen and progestogens in the combined oral contraceptive pill results in a slight alteration in the fat chemistry of the blood. There is a rise in low-density cholesterol (Q 27.4) and triglycerides and a reduction of high-density cholesterol. These changes have been reduced by the more modern pills.

When we cut ourselves a blood clot forms to seal the wound and stop the bleeding.

  • This involves a cascade of chemical reactions in the blood that lead to the clot forming.
  • Some people are particularly prone to inappropriate blood clots, which occur within the veins usually in the legs or pelvis.
  • If such a blood clot, which is called a deep venous thrombosis, becomes dislodged it can travel to the lungs and causes a pulmonary embolism, which is a serious life threatening condition.
  • The combined oral contraceptive pills do have a slight adverse effect on the clotting mechanism. Again, the new low oestrogen dose preparations are less likely to lead to problems.

What is the relationship between the birth pill and thromboembolism (blood clots)?

Deep venous thrombosis and pulmonary embolism are uncommon if you are young (Figure 15.1). There is a slight increased risk of these problems if you are taking a combined oral contraceptive pill and the risk is further increased for those who are overweight or who smoke. The newer and lower oestrogen dose pills probably cause fewer problems. To put the risk in context, a woman taking the combined oral contraceptive pill is more likely to be hospitalised as a result of an accident than from a complication associated with her pill.

Figure 15.1

A study by the World Health Organisation (WHO) published in 1995 provided evidence that the newer pills with their lower oestrogen content are associated with lower incidence of thromboembolism than the earlier higher oestrogen dose pills. This study also brought attention to the relationship between the progestogen in the combined oral contraceptive pill and thromboembolism.

There have been three “generations” of progestogens used in oral contraceptives. The WHO study found that the second generation progestogen, levonorgestrel, was only half as likely to be associated with thromboembolism compared to the third generation progestogens desogestrel and gestodene. Essentially, the WHO study demonstrated that the second generation progestogens were associated with a lower incidence of thromboembolism than had been previously believed. The third generation progestogens were not found to be associated with higher risks than anticipated.

In October 1995, the Committee on Safety of Medicines issued an alert to doctors and the media recommending that women taking third generation combined oral contraceptive pills should change to second generation preparations.

  • The presentation of the information was such that many women were inappropriately led to believe that the combined oral contraceptive pill was associated with high risk of mortality.
  • There was a 10,000 increase in the number of pregnancy terminations in the next nine months. Some Hospitals reported a 25% increase in births in July and August of 1996.
  • There are risks of mortality with pregnancy termination and with childbirth. The emotional trauma of pregnancy termination is not easilyQuantified.

Table 15.1 puts the risk of deaths from thromboembolism in perspective.

Table 15. 1 Deaths per million women. 

Risk

 Deaths per million women
Second generation pill

 approximately 2

Third generation pill

 approximately 3

Pregnancy and childbirth

 60

Road traffic accidents

 80

Scuba diving

220

Smoker (aged 35)

1670

A change from a third generation pill to a second generation would be expected to prevent the death of one women in every million taking the combined oral contraceptive pill. There are risks in most aspects of life. We cannot be complacent but every effort should be made to ensure that when clinical information is presented to the public, it is presented in perspective. One death in a million is a tiny risk but for any family (and doctor) involved it is a disaster of the most enormous proportion. There has been an indication that third generation progestogens may have been safer in relation to heart disease.

The latest evaluation of the third generation of the combined oral contraceptive pill has concluded that these pills can be prescribed as a first choice preparation. There are a number of factors to be taken into account when assessing risk and the tiny risks involved probably make it virtually impossible to distinguish risks between second and third generation pills.

Related Medical Abstracts - Click on the paper title:-

What is the relationship between the combined oral contraceptive pill and heart attacks?

The combined oral contraceptive pill has slight adverse effects on the lipids (“fat” chemicals) in the blood and these changes are known risk factors for heart disease. Heart attacks before the menopause are rare. Studies of patients on the early high dose preparations of the combined oral contraceptive pill found a five-fold increase in the incidence of heart attacks. Further studies demonstrated that there are usually confounding (additional) factors contributing to the attacks. In particular, smoking increases the risks. With the more modern low dose pills the risks are probably lower. The latest evidence suggests that there is no increased risk of heart attacks for oral contraceptive users.

The current recommended advice is that smokers should discontinue the combined oral contraceptive pill at the age of 35years. The best advice is that smokers should stop smoking.

Related Medical Abstracts - Click on the paper title:-

What is the relationship between the birth pill and strokes?

Strokes are uncommon in young women but there is a marginal statistical increase in those who have taken the combined oral contraceptive pill. Strokes may involve haemorrhage (bleeding) within the brain or reduced blood supply (ischaemia) to part of the brain. In young women it is the bleed variety of stroke that is the more common. One study in Europe found no significant increase in the chance of the bleed variety of stroke in association with the combined oral contraceptive pill. Smoking and high blood pressure are more important risk factors and these confuse any analysis of the risks of the combined oral contraceptive pill.

Related Medical Abstracts - Click on the paper title:-

Does the birth pill affect the breasts?

Many women find that their breasts are slightly larger when taking the combined oral contraceptive pill. Breast discomfort (mastalgia) may respond to vitamin B 6 (pyridoxine) 50 mg once or twice daily. Otherwise a change of pill should be considered. Should milk production occur (galactorrhoea) investigation of the prolactin hormone level is indicated (hyperprolactinaemia). Benign breast disease (Q 27.16) tends to improve when the combined oral contraceptive pill is taken.

 

Could I feel depressed as a result of taking the birth pill?

A few women describe a little depression when taking the combined oral contraceptive pill. The pill does not cause severe depression. If a change of pill does not solve the problem, pyridoxine (Vitamin B6) 50mg daily may be beneficial but it can take up to two months to be effective.

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What is the relationship between the birth pill and cancer of the ovary?


Several studies have provided convincing evidence that ovarian cancer is less likely to occur in women who have taken the combined oral contraceptive pill. Your risk of ovarian cancer is reduced by about 50% if you have taken the combined oral contraceptive pill for at least five years. The protection continues for about 15 to 20 years after you stop taking the combined oral contraceptive pill. This protection appears to be independent of the brand of pill used. It is likely that the combined oral contraceptive pill needs to have been taken for a minimum of two years to achieve this protection. The incidence of ovarian cancer seems to be falling and this is likely to be related to this benefit of the combined oral contraceptive pill.

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What is the relationship between the combined oral contraceptive pill and cancer of the uterus?


Progesterone and progestogens protect against endometrial (lining of the womb) cancer. The combined oral contraceptive pill provides progestogen for 21 days each month. Studies indicate a 40% reduction in the incidence of endometrial cancer when the combined oral contraceptive pill has been taken for more than five years. Protection continues for more than fifteen years after the combined oral contraceptive pill is discontinued.

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What is the relationship between the combined oral contraceptive pill and cancer of the cervix?

Sexual activity and number of partners are the factors that have large impacts on the incidence of pre-malignant and malignant conditions of the cervix (neck of the womb - Q32.16). The sheath (condom) provides mechanical protection not only against pregnancy but also against sexually transmitted disease. It prevents transmission of the human papilloma virus believed to be responsible for cervical cancer. It may be that the early studies suggesting that the combined oral contraceptive pill increased the risk were only reflecting the prevention of transmission of the virus with the barrier method.

There has been a suggestion that the combined oral contraceptive pill may increase the chance of pre-malignant conditions of the cervix developing in women at risk but this remains an area of debate requiring more data. There is no reason to stop the combined oral contraceptive pill if you have been found to have an abnormal smear test provided appropriate investigations and treatment are undertaken (Pap Test).

Related Medical Abstracts - Click on the paper title:-

What is the relationship between the birth pill and cancer of the breast?

This question is discussed in Q32.43.

Support Groups

Members of a support group, provide each other with various types of help and information for a particular shared difficulty.

The support may take the form of providing relevant information,

  • relating personal experiences,
  • listening to others' experiences,
  • providing sympathetic understanding and
  • establishing social networks.

A support group may also provide ancillary support, such as serving as a voice for the public or engaging in advocacy.

Support groups maintain interpersonal contact among their members in a variety of ways.

Support groups also maintain contact through printed information rich newsletters, telephone chains, internet forums, and mailing lists.

Support groups offer companionship and information for people coping with diseases or disabilities. Support groups may not be appropriate for everyone, and some find that a support group actually adds to their stress rather than relieving it.

Evaluation of the quality of Web sites is discussed in (internet information). You may find that several general women's health sites may help you (internet information). The following are more specialised relevant Web sites:-

This page was updated 30th January 2007

Whilst I am taking the combined oral contraceptive pill, what monitoring should I receive?

Medical opinion varies as to how often patients on the combined oral contraceptive pill should be checked.

At your first visit the doctor will need to review your medical history and to undertake a general and pelvic examination.

A further review will be undertaken about three months later to ensure that the chosen pill is acceptable.

Many family planning clinics have specialist nurses to undertake some of these routine assessments.

The blood pressure is checked at each subsequent visit to the clinic, which will probably be at three to six monthly intervals. A persistent blood pressure of 160/100mm Hg or more would be an indication to stop the combined oral contraceptive pill and to consider medication to reduce your blood pressure.

Pelvic examination and cervical smears every three years are probably ade quate unless you develop symptoms. More frequent monitoring may be indicated for those with risk factors.

Product information for oral contraceptives currently includes the recommendation that all women should have breast and pelvic examination before starting the combined oral contraceptive pill and at regular intervals whilst taking it.

The Committee on Safety of Medicines and the Faculty of Family Planning and Reproductive Health Care in the UK now believe that it is unnecessary for all women taking the combined oral contraceptive pill to have routine breast and pelvic examinations either before or whilst taking the combined oral contraceptive pill.

Blood pressure should always be measured but other physical examination should only be performed if considered appropriate by the clinician.

One of my family has had a blood clot (thromboembolism). Should I have any special tests?

Thromboembolism may occur during immobilisation particularly after a major operation. If your relative had a thromboembolism in such circumstances we would not anticipate that you are at increased risk.

Some families have disorders of the blood clotting mechanism, which predisposes them to thrombosis (thrombophilia). If several of your relatives have been affected, particularly when the blood clots have occurred spontaneously without an obvious cause, we would need to consider thrombophilia. There are blood tests that may detect these abnormalities but they are extremely expensive. In these circumstances, it may be appropriate to seek advice from a haematologist (blood disorder specialist).

Does an aeroplane journey increase the risks of taking the combined oral contraceptive pill?

Modern commercial aeroplanes are pressurised. The increased risks of venous and arterial thrombosis associated with high altitude are therefore eliminated.

There have been reports of circulatory complications after a flight but this is e qually true for those not taking the combined oral contraceptive pill. Underlying dehydration, following sunbathing, alcohol or a gastro-intestinal upset increases the risk.

Many airline stewardesses take the combined oral contraceptive pill. They know the importance of ensuring ade quate fluid intake and they will take a little walk every hour or so to keep their circulation going.

It has been suggested that Aspirin 75mg daily should be considered before the flight and for a few days afterwards.

There is one concern about flights for women taking the combined oral contraceptive pill particularly if they are travelling West as they may inadvertently take a pill late. It may be prudent to keep one watch set at the time of your home and use this to guide you on when you should be taking your pills.

Are there times when the combined oral contraceptive pill should be prescribed only with special caution?

Yes, there are times when a patient has medical problems such that the combined oral contraceptive pill can be prescribed but only with special caution. More careful monitoring is required. Examples are:

  • moderately elevated blood pressure (hypertension) requiring medication (patients with a history of high blood pressure in pregnancy can be given the combined oral contraceptive pill but again the blood pressure should be checked more frequently).
  • obesity (greater than 50% above ideal weight for height) is a reason for caution. Calorie control and exercise should be encouraged with a view to ensuring weight loss.
  • hormones may, on occasion, aggravate depression.
  • sickle cell disease (an inherited cause of anaemia found generally in people of Afro-Caribbean origin); this was regarded as a contraindication for the combined oral contraceptive pill as there is an increased risk of thrombosis; some authorities now suggest that the combined oral contraceptive pill can be given with caution. It may be prudent to discontinue the combined oral contraceptive pill during any episodes of immobilisation.

  • some medical conditions when they are mild but not if they are severe. Examples are diabetes, systemic lupus (SLE), Crohn's disease and renal disease.

    Varicose vein problems are not a contraindication for the combined oral contraceptive pill. Varicose veins are more frequently found in association with obesity and this would be a reason for caution. The pill should be stopped if you need injection treatment.

    When a woman has a medical problem that may be affected by the combined oral contraceptive pill, the doctors involved in her care will usually liaise to ensure consistency of advice. Ultimately it is for the doctors caring for the woman to provide her with the information that she requires to make an informed choice.

The more common contraindications to the combined oral contraceptive pill include:-

  • pregnancy.
  • a history of arterial or venous thrombosis.
  • cardiomyopathy (an inflammatory condition of the heart).
  • ischaemic heart disease (heart attacks or angina).
  • familial conditions associated with thrombosis.
  • severe migraine.
  • strokes.
  • diabetes.
  • liver diseases.
  • gall stones (the combined oral contraceptive pill can be taken after surgical removal of the gall bladder).
  • porphyria (an inherited condition affecting the break down process of red blood cells)
  • very high blood pressure.
  • smoking at age 35 years or more.
  • severe systemic lupus (SLE) requiring steroid treatment.
  • cancer of the breast or uterus.

     As with any medication, your doctor will check to see if there is any specific medical reason contraindicating the combined oral contraceptive pill.

On which day of my menstrual cycle should I start my first course of the combined oral contraceptive pill?

Nowadays, we recommend that it should be started on thefirst day of a period as this provides immediate contraceptive cover. The next period will occur after 23 days but subsequent periods will be at 28 day intervals.

Following childbirth, the combined pill can be taken if the baby is not being breast-fed; breast feeding combined with progestogen-only pills provides excellent contraception. During pregnancy and for the first two weeks after childbirth there is an increased risk of thromboembolism (blood clot problems - surgery risks) and this may be further increased by the combined oral contraceptive pill (Q15.14).

  • The pill should be commenced no earlier than 21 days after childbirth.
  • If there has been a high blood pressure problem associated with pregnancy or there is a tendency to obesity, the combined oral contraceptive pill should be further delayed.
  • If the combined oral contraceptive pill is commenced more than 21 days after childbirth, additional contraceptive precautions are required for the first seven days. The combined oral contraceptive pill can be commenced immediately after early miscarriage or pregnancy termination.

If periods are absent or infrequent, and this problem has been appropriately investigated (Q6.6), a course of progestogen tablets will usually provide a withdrawal bleed and the combined oral contraceptive pill can be commenced on the first day of bleeding.

Can I start the combined oral contraceptive pill whilst I am breast-feeding?

The combined oral contraceptive pill is likely to reduce the quantity and quality of your milk which will contain a relatively large amount of hormones. If oral contraception is required the combination of a progestogen-only pill with breast-feeding will provide highly effective contraception for you.

Can I take the combined oral contraceptive pill if I have had episodes when I did not see my periods (amenorrhoea)?

  • The amenorrhoea should be investigated, before the combined oral contraceptive pill is prescribed, and treated if a specific cause is found (Q6.21).
  • If pregnancy has been excluded there is no reason why the combined oral contraceptive pill cannot be prescribed.
  • When the combined oral contraceptive pill is subsequently discontinued the menstrual cycle will return to the pattern that would have occurred if the combined oral contraceptive pill had not been taken.

This means that the amenorrhoea may recur and fertility medication may be required if a pregnancy is planned.

Can I start the combined oral contraceptive pill if I am not currently seeing my periods?

Absence of periods (amenorrhoea) needs to be investigated (Q6.6). Provided that both pregnancy and a problem requiring treatment have been excluded, amenorrhoea is not a contraindication to the combined oral contraceptive pill.

Does it matter if I do not see a period whilst taking the combined oral contraceptive pill?

A withdrawal bleed ('period' whilst taking the combined oral contraceptive pill) does not have to occur with every pill-free interval.

Provided you have taken the combined oral contraceptive pill correctly, a pregnancy is very unlikely.

If you do not see a withdrawal bleed it usually means that the lining of your womb is not building up sufficiently to result in a bleed. This reflects the way that the womb is responding to the combined oral contraceptive pill and does not indicate what will happen when the combined oral contraceptive pill is stopped if you wish to have a baby.

From the medical point of view there is no reason to change the combined oral contraceptive pill if the problem continues and there is no need to run any tests.

If you are unhappy that you do not see a withdrawal bleed, a different pill may suit you better. One of the phasic pills could be tried if you are on a monophasic variety

A girl of 13 had extremely heavy and painful periods which were controlled for two years with a monophasic pill (Microgynon). At the age of sixteen she returned to my clinic as she kept missing withdrawal bleeds. She had not started sexual activity but was worried that she would lose her fertility. We reassured her that medically there was no anxiety. After discussion she was started on a phasic pill (Trinovum) and withdrawal bleeds occurred.

Some women find that when they stop the combined oral contraceptive pill they do not see their periods. Until twenty years ago this was called 'post-pill amenorrhoea'. Research then showed that, with few exceptions, patients with amenorrhoea after discontinuing the combined oral contraceptive pill had infrequent or absent periods before they commenced the combined oral contraceptive pill. The pill had simply masked an underlying problem and was not the cause.

What is the advice when my changing combined oral contraceptive pill preparation?

The simplest guide is that the current combined oral contraceptive pill should be taken until the course is completed and the new pill should commence on the first day of the withdrawal bleed; no additional contraception is required but the first cycle on the new pill will be just 23 days.

     

What should be done if breakthrough bleeding occurs whilst I am taking the combined oral contraceptive pill?

The first course of action is to check that there is no cause for the bleeding other than the combined oral contraceptive pill preparation. A missed pill, antibiotics or gastro-intestinal upset may have occurred. There may be a local cause such as vaginitis (inflammation of the vagina), a cervical polyp (cervical polyps) or other cervical disease. These can be assessed by medical examination. A bleed early in pregnancy can be mistaken for break-through bleeding.

Light breakthrough bleeding may be acceptable for perhaps three months and is likely to settle. Otherwise a change of pill preparation is appropriate. If the oestrogen content is very low increasing this may be the first line of approach. Increasing the progestogen content (Table 16.1) or changing from a monophasic to a bi-phasic or tri-phasic pill (Table 16. 2) are other possible remedies.

Can my combined oral contraceptive pill withdrawal bleed be planned to avoid weekends?

If a pill packet is commenced on a Sunday, the withdrawal bleed should occur on weekdays. When starting the combined oral contraceptive pill for the first time, if you delay to the next Sunday rather than commence on the first day of the period, additional contraception is required for the first seven days. For those on monophasic pills (Table 16.1) who wish to convert to a Sunday start, it is probably best to take two packets back-to-back and then finish the second packet on the Saturday. The third packet is commenced on the following Sunday. The other option would be to continue taking the combined oral contraceptive pill from a spare pack until the next Sunday. This spare packet can be kept in reserve for similar cycle adjustments when required. 


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