Combined hormonal contraceptives BNF 57

7.3.1 Combined hormonal contraceptives BNF 57

Obst

etrics,

gyn

aec

ology

, and

urinary-tract

disor

ders

BNF 57

7.3.1 Combined hormonal contraceptives 441

. smoking (avoid if smoking 40 or more cigarettes daily);

Dose

. age over 35 years (avoid if over 50 years); . By mouth , each tablet should be taken at approxi- .

obesity (avoid if body mass index above 39 kg/m ); mately same time each day; if delayed by longer .

migraine —see below. than 24 hours contraceptive protection may be lost Migraine Women should report any increase in headache

21-day combined (monophasic) preparations , 1 tablet frequency or onset of focal symptoms (discontinue imme-

daily for 21 days; subsequent courses repeated after a diately and refer urgently to neurology expert if focal neu- rological symptoms not typical of aura persist for more than

7-day interval (during which withdrawal bleeding 1 hour—see also Reason to stop immediately in notes

occurs); first course usually started on day 1 of above); contra-indicated in

cycle—if starting on day 4 of cycle or later additional .

migraine with typical focal aura, precautions (barrier methods) necessary during first 7 .

severe migraine regularly lasting over 72 hours despite

days

treatment, Every day (ED) combined (monophasic) preparations ,1 .

migraine treated with ergot derivatives; active tablet starting on day 1 of cycle (see also under use with caution in

preparations below)—if starting on day 4 of cycle or .

migraine without focal aura, later additional precautions (barrier methods) neces- .

migraine controlled with 5HT agonist (section 4.7.4.1). sary during first 7 days; withdrawal bleeding occurs Contra-indications

when inactive tablets being taken; subsequent courses see notes above; also pregnancy

repeated without interval (Appendix 4); personal history of venous or arterial

thrombosis, severe or multiple risk factors for arterial Biphasic and triphasic preparations , see under indivi- disease or for venous thromboembolism (see above),

dual preparations below heart disease associated with pulmonary hyper-

Changing to combined preparation containing differ- ent progestogen 21-day combined preparations: continue

tension or risk of embolus; sclerosing treatment for current pack until last tablet and start first tablet of new varicose veins; migraine (but see above); transient

brand the next day. If a 7-day break is taken before starting cerebral ischaemic attacks without headaches; liver

new brand, additional precautions (barrier methods) should disease including disorders of hepatic excretion (e.g.

be used during first 7 days of taking the new brand. Dubin-Johnson or Rotor syndromes), infective

Every Day (ED) combined preparations: start the new brand (first tablet of a 21-day preparation or the first active tablet of

hepatitis (until liver function returns to normal); sys- an ED preparation) the day after taking the last active tablet of temic lupus erythematosus; acute porphyria (section

previous brand (omitting the inactive tablets). 9.8.2); liver tumour; gallstones; active trophoblastic

Changing from progestogen-only tablet Start on day 1 of disease (until return to normal of urine and plasma

menstruation or any day if amenorrhoea present and gonadotrophin concentration); history of haemolytic

pregnancy has been excluded. Secondary amenorrhoea (exclude pregnancy)

uraemic syndrome or history during pregnancy of Start any day, additional precautions (barrier methods) necessary pruritus, cholestatic jaundice, chorea, pemphigoid

during first 7 days.

gestationis; history of breast cancer but can be used After childbirth (not breast-feeding) Start 3 weeks after after 5 years if no evidence of disease and non-

birth (increased risk of thrombosis if started earlier); later

hormonal methods unacceptable; undiagnosed vagi- than 3 weeks postpartum additional precautions (barrier nal bleeding; breast-feeding (until weaning or for 6

methods) necessary for first 7 days. Not recommended if woman breast-feeding—oral proges-

Obst

months after birth—Appendix 5) togen-only contraceptive preferred. Side-effects see notes above; also nausea, vomiting,

After abortion or miscarriage Start same day.

etrics,

abdominal cramps, changes in body-weight, liver . By transdermal application , apply first patch on day impairment, hepatic tumours; fluid retention,

1 of cycle, change patch on days 8 and 15; remove thrombosis (more common when factor V Leiden

third patch on day 22 and apply new patch after 7-

gynaec

present or in blood groups A, B, and AB; see also day patch-free interval to start subsequent contra- notes above), hypertension, changes in lipid metab-

ceptive cycle

olism; headache, depression, chorea, nervousness, Note If first patch applied later than day 1, additional

ology

irritability; changes in libido, breast tenderness, precaution (abstinence or barrier methods) should be used enlargement, and secretion; reduced menstrual loss,

for the next 7 days

‘spotting’ in early cycles, absence of withdrawal Changing from combined oral contraception Apply patch on the first day of withdrawal bleeding; if no with-

and

bleeding, amenorrhoea after discontinuation, changes drawal bleeding within 5 days of taking last active tablet, rule in vaginal discharge, cervical erosion; contact lenses

out pregnancy before applying first patch. Unless patch is

urinary-tract

may irritate, visual disturbances; leg cramps; skin applied on first day of withdrawal bleeding, additional pre- reactions, chloasma, photosensitivity; rarely gall-

cautions (barrier methods) should be used concurrently for first 7 days

stones and systemic lupus erythematosus Changing from progestogen-only method From an Breast cancer There is a small increase in the risk of having

implant, apply first patch on the day implant removed; breast cancer diagnosed in women taking the combined oral

from an injection, apply first patch when next injection due; contraceptive pill; this relative risk may be due to an earlier

from oral progestogen, first patch may be started on any day

disor

diagnosis. In users of combined oral contraceptive pills the after stopping pill. For all methods additional precautions cancers are more likely to be localised to the breast. The

(barrier methods) should be used concurrently for first 7 most important factor for diagnosing breast cancer appears

ders

days

to be the age at which the contraceptive is stopped rather After childbirth (not breast-feeding) Start 4 weeks after than the duration of use; any increase in the rate of diagnosis diminishes gradually during the 10 years after stopping and

birth; if started later than 4 weeks after birth additional precautions (barrier methods) should be used for first 7 days

disappears by 10 years. After abortion or miscarriage Cervical cancer Use of combined oral contraceptives for 5

Before 20 weeks’ gestation start immediately; no additional contraception required if years or longer is associated with a small increased risk of

started immediately. After 20 weeks’ gestation start on day cervical cancer; the risk diminishes after stopping and dis-

21 after abortion or on the first day of first spontaneous appears by about 10 years. The risk of cervical cancer with

menstruation; additional precautions (barrier methods) transdermal patches is not yet known.

should be used for first 7 days after applying the patch Note The possible small increase in the risk of breast cancer and cervical cancer should be weighed against the protective effect against cancers of the ovary and endometrium

7.3.1 Combined hormonal contraceptives BNF 57

Low strength (oral) Standard strength

Ethinylestradiol with Norethisterone c Ethinylestradiol with Levonorgestrel Loestrin 20 (Galen) A Logynon c (Schering Health) A Tablets , blue, norethisterone acetate 1 mg, ethinyles-

6 light brown tablets, ethinylestradiol 30 micr- ograms, levonorgestrel 50 micrograms; £2.70 Dose

5 white tablets, ethinylestradiol 40 micrograms, after 7-day tablet-free interval (during which withdrawal bleeding

levonorgestrel 75 micrograms; occurs); for starting routines see under Dose above

1 tablet daily for 21 days; subsequent courses repeated

10 ochre tablets, ethinylestradiol 30 micrograms, levonorgestrel 125 micrograms.

Ethinylestradiol with Desogestrel

ders

See Risk of Venous Thromboembolism in notes above

1 tablet daily for 21 days, starting with light brown tablet before prescribing

Dose

marked 1 on day 1 of cycle; repeat after 7-day tablet-free interval

disor

Mercilon c (Organon) A Logynon ED c (Schering Health) A Tablets , desogestrel 150 micrograms, ethinylestradiol

6 light brown tablets , ethinylestradiol 30 micr- ograms, levonorgestrel 50 micrograms;

Dose 1 tablet daily for 21 days; subsequent courses repeated , ethinylestradiol 40 micrograms, after 7-day tablet-free interval (during which withdrawal bleeding

5 white tablets

occurs); for starting routines see under Dose above levonorgestrel 75 micrograms;

urinary-tract

10 ochre tablets , ethinylestradiol 30 micrograms, levonorgestrel 125 micrograms;

, and

Ethinylestradiol with Drospirenone Yaz c (Bayer) A 7 white, inactive tablets. Tablets , f/c, pink, drospirenone 3 mg, ethinylestradiol

ology

1 tablet daily for 28 days, starting on day 1 of cycle with 28-tab (4 are inactive) pack = £19.80

Dose

aec active tablet (withdrawal bleeding occurs when inactive tablets

being taken); subsequent courses repeated without interval; for Cautions use with care if increased plasma-potassium concen-

gyn starting routines see under Dose above

tration might be hazardous; renal impairment (Appendix 3) Dose

1 tablet daily for 28 days starting on day 1 of cycle with Microgynon 30 active tablet (withdrawal bleeding begins when inactive tablets c (Schering Health) A Tablets , s/c, levonorgestrel 150 micrograms, ethiny-

etrics,

being taken); subsequent courses repeated without interval; for starting routines see also under Dose above

Obst

Ethinylestradiol with Gestodene 1 tablet daily for 21 days; subsequent courses repeated

Dose

7 after 7-day tablet-free interval (during which withdrawal bleeding

See Risk of Venous Thromboembolism in notes above occurs); for starting routines see under Dose above before prescribing

Microgynon 30 ED c (Schering Health) A Femodette c (Schering Health) A Tablets , beige, levonorgestrel 150 micrograms, ethi- Tablets , s/c, gestodene 75 micrograms, ethinylestra-

nylestradiol 30 micrograms, white inactive tablets. Net Dose

1 tablet daily for 28 days starting on day 1 of cycle with after 7-day tablet-free interval (during which withdrawal bleeding

1 tablet daily for 21 days; subsequent courses repeated

Dose

active tablet (withdrawal bleeding occurs when inactive tablets occurs); for starting routines see under Dose above

being taken); subsequent courses repeated without interval; for

c Sunya 20/75 starting routines see also under Dose above (Stragen) A Tablets , s/c, gestodene 75 micrograms, ethinylestra-

Ovranette c (Wyeth) A Tablets , levonorgestrel 150 micrograms, ethinylestra- Dose

1 tablet daily for 21 days; subsequent courses repeated after 7-day tablet-free interval (during which withdrawal bleeding occurs); for starting routines see under Dose above

Dose

1 tablet daily for 21 days; subsequent courses repeated after 7-day tablet-free interval (during which withdrawal bleeding occurs); for starting routines see under Dose above

Low strength (transdermal)

Ethinylestradiol with Norethisterone Ethinylestradiol with Norelgestromin

BiNovum c (Janssen-Cilag) A Evra c (Janssen-Cilag) A 7 white tablets, ethinylestradiol 35 micrograms, Patches , self-adhesive (releasing ethinylestradiol

norethisterone 500 micrograms; approx. 20 micrograms/24 hours and norelgestromin

14 peach tablets, ethinylestradiol 35 micrograms, approx. 150 micrograms/24 hours); net price 9-patch

norethisterone 1mg. pack = £16.26. Counselling, administration Dose

1 tablet daily for 21 days, starting with white tablet on day 1 lowed by a 7-day patch-free interval; subsequent courses repeated

1 patch to be applied once weekly for three weeks, fol-

Dose

of cycle; repeat after 7-day tablet-free interval after 7-day patch-free interval (during which withdrawal bleeding occurs); for starting routines see under Dose above

Brevinor Note c Adhesives or bandages should not be used to hold (Pharmacia) A patch in place. If patch no longer sticky do not reapply but

Tablets , blue, norethisterone 500 micrograms, ethi- use a new patch.

The Scottish Medicines Consortium has advised (September

2003) that Evra patches should be restricted for use in

1 tablet daily for 21 days; subsequent courses repeated women who are likely to comply poorly with combined oral

Dose

after 7-day tablet-free interval (during which withdrawal bleeding contraceptives

occurs); for starting routines see under Dose above

BNF 57

7.3.2 Progestogen-only contraceptives 443

Loestrin 30 c (Galen) A Cautions use with care if increased plasma-potassium concen- Tablets , pale green, norethisterone acetate 1.5 mg,

tration might be hazardous; renal impairment (Appendix 3) Dose

1 tablet daily for 21 days; subsequent courses repeated pack = £3.90

after 7-day tablet-free interval (during which withdrawal bleeding occurs); for starting routines see under Dose above

Dose 1 tablet daily for 21 days; subsequent courses repeated after 7-day tablet-free interval (during which withdrawal bleeding

Note The Scottish Medicines Consortium has advised (March occurs); for starting routines see under Dose above

2003) that Yasmin is not recommended

c Norimin Ethinylestradiol with Gestodene (Pharmacia) A See Risk of Venous Thromboembolism in notes above Tablets , norethisterone 1 mg, ethinylestradiol

before prescribing

Dose

1 tablet daily for 21 days; subsequent courses repeated c Femodene (Schering Health) A after 7-day tablet-free interval (during which withdrawal bleeding

Tablets , s/c, gestodene 75 micrograms, ethinylestra- occurs); for starting routines see under Dose above

1 tablet daily for 21 days; subsequent courses repeated Ovysmen (Janssen-Cilag) A after 7-day tablet-free interval (during which withdrawal bleeding Tablets , norethisterone 500 micrograms, ethinyles-

c Dose

occurs); for starting routines see under Dose above Femodene c ED (Schering Health) A

£1.58 Tablets , s/c, gestodene 75 micrograms, ethinylestra- Dose

1 tablet daily for 21 days; subsequent courses repeated after 7-day tablet-free interval (during which withdrawal bleeding occurs); for starting routines see under Dose above

inactive) pack = £7.18 Dose

1 tablet daily for 28 days, starting on day 1 of cycle with

c Synphase active tablet (withdrawal bleeding occurs when inactive tablets (Pharmacia) A being taken); subsequent courses repeated without interval; for

7 blue tablets, ethinylestradiol 35 micrograms, nor- starting routines see under Dose above ethisterone 500 micrograms;

Katya 30/75 c (Stragen) A

9 white tablets, ethinylestradiol 35 micrograms, Tablets , s/c, gestodene 75 micrograms, ethinylestra- norethisterone 1 mg;

1 tablet daily for 21 days; subsequent courses repeated ethisterone 500 micrograms.

5 blue tablets, ethinylestradiol 35 micrograms, nor-

Dose

after 7-day tablet-free interval (during which withdrawal bleeding Net price 21-tab pack = £1.20

occurs); for starting routines see under Dose above Dose

1 tablet daily for 21 days, starting with blue tablet marked 1 Triadene c (Schering Health) A on day 1 of cycle; repeat after 7-day tablet-free interval

6 beige tablets, ethinylestradiol 30 micrograms,

c TriNovum gestodene 50 micrograms; (Janssen-Cilag) A

5 dark brown tablets, ograms, gestodene 70 micrograms; norethisterone 500 micrograms;

7 white tablets, ethinylestradiol 40 micr-

ethinylestradiol 35 micrograms,

10 white tablets, ethinylestradiol 30 micrograms,

7 light peach tablets, gestodene 100 micrograms.

ethinylestradiol 35 micr-

ograms, norethisterone 750 micrograms;

Obst

1 tablet daily for 21 days, starting with beige tablet marked norethisterone 1 mg.

7 peach tablets, ethinylestradiol 35 micrograms,

Dose

‘start’ on day 1 of cycle; repeat after 7-day tablet-free interval

etrics,

Dose 1 tablet daily for 21 days, starting with white tablet on day 1 Mestranol with Norethisterone of cycle; repeat after 7-day tablet-free interval

Norinyl-1 c (Pharmacia) A Tablets , norethisterone 1 mg, mestranol 50 micr-

gynaec

Cilest 1 tablet daily for 21 days; subsequent courses repeated

Ethinylestradiol with Norgestimate c Dose

(Janssen-Cilag) A after 7-day tablet-free interval (during which withdrawal bleeding

ology

Tablets , blue, norgestimate 250 micrograms, ethiny- occurs); for starting routines see under Dose above Ethinylestradiol with cyproterone acetate

and ,

Dose 1 tablet daily for 21 days; subsequent courses repeated See Co-cyprindiol (section 13.6.2) after 7-day tablet-free interval (during which withdrawal bleeding

urinary-tract

occurs); for starting routines see under Dose above