o Severe icirrhosis
o Malignant iliver itumor
Combined iOral iContraceptives
• Combined ioral icontraceptives i(COCs) iare ia icombination iof iestrogen iand iprogestin.
• Most iCOC iformulations inow icontain ibetween i20 ito i35 imcg iof iethinyl iestradiol
iplusione iof i8 iavailable iprogestins.
• A ihigh inumber iof iunintended ipregnancies iare idue ito imisuse ior idiscontinuation
iofiOCs.
• Consider ithe i“quick istart” imethod iwhen iinitiating ioral icontraceptives.
o If ilast imenstrual iperiod i(LMP) iwas iwithin ithe ilast i5 idays, ithe imethod ican
ibeistarted iimmediately.
o In iunprotected isex iwithin ilast i2 iweeks, istart ithe icontraceptive imethod
itodayiand iadvise ipatient ito ireturn ito ithe iclinic ifor ia ipregnancy itest iin i3
iweeks.
o Instruct iwomen iwho iare iusing ithe ipill, ipatch, iring, iinjection, ior iimplant ito
iuseibackup icontraception ifor ithe ifirst i7 idays.
o Research ishows ithat ithere iare ino isignificant idifferences iin ithe inumber
iofibleeding-spotting idays ior iany iother ibleeding iparameter ibetween ithe
iimmediate iand iconventional istarters.
• Mechanism iof iAction:
o The iprogestin iin iCOCS iis ithe imain iactor iin ipreventing ipregnancy. iIt
isuppressesithe isecretion iof igonadotropin i(mainly iluteinizing ihormone) iby ithe
ipituitary igland. iThe iestrogen iprimarily iinhibits ifollicle-stimulating ihormone
isecretion.
o The iestrogen ialso iworks isynergistically iwith ithe iprogestin ito iaffect ithe
iuterineilining iand icervical imucus iproduction.
• Candidates:
o Women iwith idysmenorrhea iand imenorrhagia
o Women iwho iwant ito iregulate imenses
o Women iwho iwill iuse ia idaily imethod iconsistently
• Advantages:
o Reduced imenstrual iflow iand idysmenorrhea ifor imost iusers
o Reduce ithe irisk iof iovarian icancer iby i40-80% iafter i~ ione iyear iof iuse
iandidecrease ithe irisk ifrom i10-12% iannually ithereafter
o Even iafter idiscontinuing iCOC iuse, iprotection icontinues ifor i15-20 iyears.
o COCs ialso ireduce ithe irisk iof iendometrial icancer iby i40-50%, iand ilike
iovarianicancer, iprotection iincreases iwith iduration iof iuse.
o 90 ipercent iprotection ifrom iectopic ipregnancy iwith icurrent iOC iuse.
o Reduced iincidence iof ibenign ibreast idisease
o Effective iin ireducing iacne.
o Possible iAdvantages: i1) iMay ipreserve ibone idensity, iand i2) iMay iprotect
iagainst iiron ideficiency ianemia, iovarian icysts iwith ihigher idoses, iand
ipelviciinflammatory idisease.
• Contraindications:
o Multiple irisk ifactors ifor iarterial icardiovascular idisease, isuch ias ismoking,
42
o Malignant iliver itumor
Combined iOral iContraceptives
• Combined ioral icontraceptives i(COCs) iare ia icombination iof iestrogen iand iprogestin.
• Most iCOC iformulations inow icontain ibetween i20 ito i35 imcg iof iethinyl iestradiol
iplusione iof i8 iavailable iprogestins.
• A ihigh inumber iof iunintended ipregnancies iare idue ito imisuse ior idiscontinuation
iofiOCs.
• Consider ithe i“quick istart” imethod iwhen iinitiating ioral icontraceptives.
o If ilast imenstrual iperiod i(LMP) iwas iwithin ithe ilast i5 idays, ithe imethod ican
ibeistarted iimmediately.
o In iunprotected isex iwithin ilast i2 iweeks, istart ithe icontraceptive imethod
itodayiand iadvise ipatient ito ireturn ito ithe iclinic ifor ia ipregnancy itest iin i3
iweeks.
o Instruct iwomen iwho iare iusing ithe ipill, ipatch, iring, iinjection, ior iimplant ito
iuseibackup icontraception ifor ithe ifirst i7 idays.
o Research ishows ithat ithere iare ino isignificant idifferences iin ithe inumber
iofibleeding-spotting idays ior iany iother ibleeding iparameter ibetween ithe
iimmediate iand iconventional istarters.
• Mechanism iof iAction:
o The iprogestin iin iCOCS iis ithe imain iactor iin ipreventing ipregnancy. iIt
isuppressesithe isecretion iof igonadotropin i(mainly iluteinizing ihormone) iby ithe
ipituitary igland. iThe iestrogen iprimarily iinhibits ifollicle-stimulating ihormone
isecretion.
o The iestrogen ialso iworks isynergistically iwith ithe iprogestin ito iaffect ithe
iuterineilining iand icervical imucus iproduction.
• Candidates:
o Women iwith idysmenorrhea iand imenorrhagia
o Women iwho iwant ito iregulate imenses
o Women iwho iwill iuse ia idaily imethod iconsistently
• Advantages:
o Reduced imenstrual iflow iand idysmenorrhea ifor imost iusers
o Reduce ithe irisk iof iovarian icancer iby i40-80% iafter i~ ione iyear iof iuse
iandidecrease ithe irisk ifrom i10-12% iannually ithereafter
o Even iafter idiscontinuing iCOC iuse, iprotection icontinues ifor i15-20 iyears.
o COCs ialso ireduce ithe irisk iof iendometrial icancer iby i40-50%, iand ilike
iovarianicancer, iprotection iincreases iwith iduration iof iuse.
o 90 ipercent iprotection ifrom iectopic ipregnancy iwith icurrent iOC iuse.
o Reduced iincidence iof ibenign ibreast idisease
o Effective iin ireducing iacne.
o Possible iAdvantages: i1) iMay ipreserve ibone idensity, iand i2) iMay iprotect
iagainst iiron ideficiency ianemia, iovarian icysts iwith ihigher idoses, iand
ipelviciinflammatory idisease.
• Contraindications:
o Multiple irisk ifactors ifor iarterial icardiovascular idisease, isuch ias ismoking,
42
