Screening

COCP Script

Bolded items mean should not supply
More information available at https://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/New%20Zeland/02337-COC-checklist-2017_v5.pdf

Background details;

• Current COC:
• Compliance issues? (Consider pregnancy, LARCs): Yes No
• Any side effects/concerns? Yes No
• Use for contraception: Yes No
• New or worsening headaches/migraines with COC use? Yes No

Restarting oral contraceptive;

• Previous o/c:
• Date when last used:
• Unexplained vaginal bleeding? Yes No
• Possibly pregnant, lactating, <42 days post-partum, allergy to o/cs? Yes No

Cardiovascular and stroke risk;

• Any heart problems/stroke/diabetes? Yes No
• Blood pressure: [no supply if systolic =140 or diastolic =90, or on BP meds]
• BMI = 35: Yes No
• Migraine with aura? Yes No

If more than one of the below, no supply;

• Daily smoker current or in the last year? Yes No
• Migraines without aura? Yes No
• Known high cholesterol or other dyslipidaemia: Yes No
• BMI 30-34.9 Heart disease/stroke in father/brother <55 years or mother/sister <65 years? Yes No

VTE risk;

• Ever had thrombosis/blood clot in veins (DVT) or lungs? Yes No
• Mother/father/sister/brother had thrombosis/blood clot in veins or lungs? Yes No
• Immobile, planning major surgery? Yes No

Other health;

• History of breast cancer, liver or gall bladder disease, problems with blood circulation/clotting, organ transplant, lupus, severe Crohn’s disease, bariatric surgery? Yes No
  [No supply if currently on: BP meds, HIV meds, anti-epileptics, St John’s Wort, rifampicin, rifabutin, other CYP3A4 inducers]

If no contraindications

Full text of summary below can be found at https://medicinetoday.com.au/2015/september/feature-article/combined-ocps-how-choose-right-one

Counselling

• COCP
  • Combined Oestrogen and Progesterone
    • Progesterone is primary contraceptive effect, suppressing LH to prevent ovulation
    • Oestrogen enhances this effect by suppressing FSH, thus suppressing the maturation of ovarian follicles
  • Oestrogen
    • Provides the worst adverse effects such as VTE, adverse cardiovascular and cerebrovascular outcomes, breast tenderness, nausea and fluid retention
    • Provides some positive effects, such as stabilising endometrium (less irregular bleeding that POP) and can improve acne and hirsutism
    • Ethinyloestradiol (EE) has been most widely used and studied
    • Mestranol is still used in some older COCP’s, metabolised to EE to become active; 50mcg mestranol is equivalent to 30-35mcg EE
    • Oestradiol and oestradiol valerate more recently used (equivalent to ~20mcg EE, but a direct comparison is difficult), but are more similar to endogenous oestrogen giving it a weak effect which must be paired with a relatively strong progesterone dose/effect to suppress the endometrium and provide cycle control – but also provide less decrease in libido but provide less acne/hirsutism control
  • COCP’s are categorised by EE dosage
    • High dose is considered 50mcg or more
    • Low dose is considered 30-40mcg
    • Very low dose is considered 20mcg or less
    • The lower the dose, the lower the VTE risk particularly in the first few months
  • Progesterone
    • Affects glucose metabolism and insulin resistance
      • Levonorgestrel, desogestrel, gestodene and dienogest having greatest effect, cyproterone acetate and nomegestrol acetate the least – but are unlikely to be of clinical significance for most women
    • Some retain mildly androgenic qualities (which can promote acne and hirsutism) while others have been chemically modified to be antiandrogenic
    • Drospirenone is uique as derived from diuretic Spironolactone, retaining antiandrogenic and antimineralocorticoid qualities
    • All have anti-proliferative effect on endometrium
    • Older preparations such as levonorgestrel and norethisterone have more adverse effect on lipid profile (in particular LDL), less an issue with newer preparations
    • Norethisterone
      • Low potency progesterone, short half life so low efficacy if pills missed
      • Withdrawal bleeding is usually light to absent
      • Some women may find the lack of bleeding alarming, but can reassure is not abnormal and does not reflect any issues with future fertility
      • Good for those who wish to run multiple cycling of COCP to suppress bleeding for several months if on a COCP containing 1mg when taken continuously
      • Relatively non androgenic – most COCP’s are likely to result in overall improvement in skin problems and the dominance of preparations containing norethisterone may make them a useful first choice for those with acne!
    • Levonorgestrel
      • Relatively potent, requiring 1/10th the dose to suppress ovulation
      • When combined with 30mcg EE provides excellent cycle control and predictable withdrawal bleeds, but lower doses (20mcg EE/100mcg levonorgestrel) may get more irregular bleeding, particularly in the first month
      • Counteracts effect of oestrogen on sex homrone binding globulin, allowing higher circulating natural androgens and has less decreased libido than other preparations (but also increases risk of mood swings, weight gain and acne, particularly if paired with very low dose oestrogen)
    • 3rd Gen Progestogens
      • Include desogestrel, gestodene, dienogest, drospirenone, cyproterone acetate and nomegestrol acetate
      • May result in higher VTE risk
      • Less androgenic side effects compared to levonorgestrel and some may actually have antiandrogenic effects, enhancing positive effects of COCP’s on acne (evidence on superiority over other progestogens limited)
      • If moderate acne or hirsutism, or has failed o achieve sufficient improvement in symptoms on alternate COCP consider trial of one of these – particularly if fluid weight gain is an issue consider drospirenone with low dose oestrogen
      • Very light or transparent bleeding, good for extended cycling
      • Nomegestrol acetate has minimal effect on carbohydrate metabolism, so good for those with insulin resistance or diabetes
      • None of these are PBS listed (currently)

Next steps

• Check baseline weight and BP
• Remind COCP are a medication and should be divulged if asked for medical purposes
• Irregular bleeding, breast tenderness or mild cycle nausea common in first cycle, should persist unless severe
• Improvements in acne and hirsutism take several months to show
• Schedule follow up for 3-4 months to ensure chosen preparation suitable for Pt, rechecking weight and BP at that time