Prescribing the Pill for the first time

Tell Pill users about benefits and risks, says Dr Tillmann Jacobi.

Contraceptive Pill
Contraceptive Pill

The combined oral contraceptive Pill has been available for over 40 years, but it can be a complex medication to prescribe.

When a patient asks for her first combined oral contraception (COC) prescription it is important not to assume knowledge. She might feel uncomfortable, embarrassed or worried about confidentiality.

It is important to discuss all aspects of COC use.

Health benefits
In addition to being one of the most effective forms of contraception, the combined Pill can provide other health benefits.

It can alleviate symptoms of irregular, painful or heavy periods, premenstrual tension, endometriosis and symptomatic functional ovarian cysts. It can be taken to delay a period and can be used to treat hormonal skin problems.

The combined Pill also reduces the risk of ovarian and endometrial cancer. It might also reduce the risk of colorectal cancer

Health risks
There is a minimally increased incidence of breast tumours associated with COC, and the risk for cervical cancer is higher if there is a concurrent infection with HPV.

Liver disease is a contraindication to the Pill and it should be used with caution in patients with migraine or severe depression. Around 5 per cent of women develop hypertension within five years of starting the Pill.

DVT is rare after the first 12 months of COC use, but the risk increases after immobility and on long-haul flights.

However, the risk is still at least four times higher during pregnancy. There are very few contraindications for the typical young woman wanting to start on the Pill.

Focal migraines, diabetes with vascular disease or hormone-sensitive cancers are significant contraindications.

Smokers over the age of 35 and extremely obese women (BMI >39) should not take the combined Pill.

Although it is good practice to take a family history of cardiovascular problems and hyperlipidaemia, these are not good predictors of complications.

Checklist
A checklist can be useful to help give the first COC prescription (see box). It is a good idea to have a photocopy of the main information about COC that can be provided to patients.

The patient should be aware of all other contraceptive options in order to make an informed decision to start using COC.

It is important to ask about regularity of cycles and other menstrual problems. The risk of STIs should be discussed together with the benefit of using condoms in addition to COC.

The safest time to start the Pill is the first day of a period, but it can be started at other times as long as the patient understands the seven-day rule.

There is no good evidence to support the use of higher dosages in obese women.

The importance of taking the Pill regularly should be emphasised to the patient.

Concordance can be improved by prescribing a pack with dummy pills to take during the interval days.

Brief advice on what to do if a pill is forgotten should be given.

Drug interactions, and impairment of COC in cases of sickness or severe diarrhoea should be discussed.

Weight gain, the risk of irregular breakthrough bleeding and worsening skin problems during the first few months of use should also be mentioned.

Follow-up
The first follow-up should be after three months.

At this point, patient feedback should be evaluated before making a decision to issue a six or 12-month prescription for review after one year by either yourself or a practice nurse.

Smoking cessation should be advised again at this point.

The patient should be encouraged to read the product information once a year to refresh her memory and to learn the updated facts.

Dr Jacobi is a salaried GP in York

The FPA Contraceptive Awareness Week runs 11-18 February 2008. For more information see www.fpa.org.uk

Checklist for prescribing the pill
  • Indication: consider alternative forms of contraception and use of condoms in addition to COC.
  • Contraindications: family history, clots, migraine, liver or clotting problems, high BP, breast cancer, severe depression.
  • Cautions: smoking, severely overweight, over age 35.
  • Start time: first day of period, or following seven-day rule.
  • Careful: interaction with other medication including antibiotics, St John's Wort; sickness within two hours or severe diarrhoea.
  • Take it regularly: link with regular daily activities such as brushing teeth.
  • Missed pill: if a pill is missed take it as soon as you remember, but also read information or ask for advice if unsure. Take extra care if the pill was forgotten in the very beginning of a new pack or at the end of it.
  • Warning signs: bleeding, bruising, headaches or migraines or vision problems, chest pains, breathlessness, calf pain/swelling, jaundice or depression.
  • Follow-up: in young non-smokers review once or twice a year with a BP check.
  • Keep informed: read the product information and ask a pharmacist, practice nurse or GP if there are any questions.

References

  • Cosmi B, Legnani C, Bernardi F et al. Value of family history in identifying women at risk of venous thromboembolism during oral contraception; observational study. BMJ 2001; 322: 1,024-5.
  • Vessey M. Oral contraceptive failure and body weight: findings in a large cohort study. J Fam Plann Reprod Health Care 2001; 27: 90-1.

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