1. Ask how the client is doing with the method and whether she is satisfied. Ask if she has any questions or anything to discuss.
2. Ask especially if she is concerned about bleeding changes. Give her any information or help that she needs (see Managing any problems, below).
3. Ask if she often has problems remembering to take a pill every day. If so, discuss ways to remember, making up missed pills, and ECPs, or choosing another method.
4. Give her more pill packs—a full year’s supply (13 packs), if possible. Plan her next resupply visit before she will need more pills.
5. Every year or so, check blood pressure if possible (see Medical Eligibility Criteria, Question 5).
6. Ask a long-term client if she has had any new health problems since her last visit. Address problems as appropriate. For new health problems that may require switching methods, see p. 19.
7. Ask a long-term client about major life changes that may affect her needs—particularly plans for having children and STI/HIV risk. Follow up as needed.
Managing any problems
Problems reported as side effects or problems with use
May or may not be due to the method.
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Problems with side effects affect women’s satisfaction and use of COCs. They deserve the provider’s attention. If the client reports side effects or problems, listen to her concerns, give her advice, and, if appropriate, treat.
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Encourage her to keep taking a pill every day even if she has side effects. Missing pills can risk pregnancy and may make some side effects worse.
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Many side effects will subside after a few months of use. For a woman whose side effects persist, give her a different
COC formulation, if available, for at least 3 months.
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Offer to help the client choose another method—now, if she wishes, or if problems cannot be overcome.
Missed pills
Irregular bleeding
(bleeding at unexpected times that bothers the client)
Reassure her that many women using COCs experience irregular bleeding. It is not harmful and usually becomes less or stops after the first few months of use.
Other possible causes of irregular bleeding include:
– Missed pills
– Taking pills at different times every day
– Vomiting or diarrhea
– Taking anticonvulsants or rifampicin (see Starting treatment with anticonvulsants or rifampicin)
To reduce irregular bleeding:
– Urge her to take a pill each day and at the same time each day.
– Teach her to make up for missed pills properly, including after vomiting or diarrhea (see Managing Missed Pills, p. 15).
– For modest short-term relief, she can try 800 mg ibuprofen 3 times daily after meals for 5 days or other nonsteroidal anti-inflammatory drug (NSAID), beginning when irregular bleeding starts. NSAIDs provide some relief of irregular bleeding for implants, progestin-only injectables, and IUDs, and they may also help for COCs.
– If she has been taking the pills for more than a few months and NSAIDs do not help, give her a different COC formulation, if available. Ask her to try the new pills for at least 3 months.
If irregular bleeding continues or starts after several months of normal or no monthly bleeding, or you suspect that something may be wrong for other reasons, consider underlying conditions unrelated to method use (see Unexplained vaginal bleeding, below).
No monthly bleeding
Ask if she is having any bleeding at all. (She may have just a small stain on her underclothing and not recognize it as monthly bleeding.) If she is, reassure her.
Reassure her that some women using COCs stop having monthly bleeding, and this is not harmful. There is no need to lose blood every month. It is similar to not having monthly bleeding during pregnancy. She is not infertile. Blood is not building up inside her. (Some women are happy to be free from monthly bleeding.)
Ask if she has been taking a pill every day. If so, reassure her that she is not likely to be pregnant. She can continue taking her COCs as before.
Did she skip the 7-day break between packs (21-day packs) or skip the 7 nonhormonal pills (28-day pack)? If so, reassure her that she is not pregnant. She can continue using COCs.
If she has missed hormonal pills or started a new pack late:
− She can continue using COCs.
− Tell a woman who has missed 3 or more pills or started a new pack 3 or more days late to return if she has signs and symptoms of early pregnancy (see p. 371 for common signs and symptoms of pregnancy).
Instructions on how to make up for missed pills.
Ordinary headaches
(nonmigrainous)
Try the following (one at a time):
– Suggest aspirin (325–650 mg), ibuprofen (200–400 mg), paracetamol (325–1000 mg), or other pain reliever.
– Some women get headaches during the hormone-free week (the 7 days a woman does not take hormonal pills). Consider extended use (see Extended and Continuous Use of Combined Oral Contraceptives, p. 21).
Any headaches that get worse or occur more often during COC use should be evaluated.
Nausea or dizziness
For nausea, suggest taking COCs at bedtime or with food.
If symptoms continue:
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Consider locally available remedies.
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Consider extended use if her nausea comes after she starts a new pill pack (see Extended and Continuous Use of Combined Oral Contraceptives, p. 21).
Breast tenderness
Recommend that she wear a supportive bra (including during strenuous activity and sleep).
Try hot or cold compresses.
Suggest aspirin (325–650 mg), ibuprofen (200–400 mg), paracetamol (325–1000 mg), or other pain reliever.
Consider locally available remedies.
Weight change
Review diet and counsell as needed.
Mood changes or changes in sex drive
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Some women have changes in mood during the hormone-free week (the 7 days when a woman does not take hormonal pills). Consider extended use (see Extended and Continuous Use of Combined Oral Contraceptives, p. 21).
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Ask about changes in her life that could affect her mood or sex drive, including changes in her relationship with her partner. Give her support as appropriate.
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Clients who have serious mood changes such as major depression should be referred for care.
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Consider locally available remedies.
Acne
New problems that may require switching methods
May or may not be due to the method.
Unexplained vaginal bleeding
(that suggests a medical condition not related to the method) or heavy or prolonged bleeding
Starting treatment with anticonvulsants or rifampicin
Migraine headaches
(see Identifying Migraine Headaches and Auras, p. 368)
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Regardless of her age, a woman who develops migraine headaches, with or without aura, or whose migraine headaches become worse while using COCs should stop using COCs.
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Help her choose a method without estrogen.
Circumstances that will keep her from walking for one week or more
If she is having major surgery, or her leg is in a cast, or for other reasons she will be unable to move about for several weeks, she should:
– Tell her doctors that she is using COCs.
– Stop taking COCs and use a backup method during this period.
– Restart COCs 2 weeks after she can move about again.
Certaom serious health conditions
(suspected heart or liver disease, high blood pressure, blood clots in deep veins of legs or lungs, stroke, breast cancer, damage to arteries, vision, kidneys, or nervous system caused by diabetes, or gall bladder disease). See Signs and Symptoms of Serious Health Conditions, p. 320.
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Tell her to stop taking COCs.
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Give her a backup method to use until the condition is evaluated.
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Refer for diagnosis and care if not already under care.
Suspected pregnancy
Extended and continuous use of combined oral contraceptives
Some COC users do not follow the usual cycle of 3 weeks taking hormonal pills followed by one week without hormones. Some women take hormonal pills for 12 weeks without a break, followed by one week of nonhormonal pills (or no pills). This is extended use. Other women take hormonal pills without any breaks at all. This is continuous use. Monophasic pills are recommended for such use (see Question 16, p. 24).
Women easily manage taking COCs in different ways when properly advised how to do so. Many women value controlling when they have monthly bleeding—if any—and tailoring pill use as they wish.
Benefits of Extended and Continuous Use
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Women have vaginal bleeding only 4 times a year or not at all.
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Reduces how often some women suffer headaches, premenstrual syndrome, mood changes, and heavy or painful bleeding during the week without hormonal pills.
Disadvantages of Extended and Continuous Use
Extended Use Instructions
- Skip the last week of pills (without hormones) in 3 packs in a row. (21-day users skip the 7-day waits between the first 3 packs.) No backup method is needed during this time.
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Take all 4 weeks of pills in the 4th pack. (21-day users take all 3 weeks of pills in the 4th pack.) Expect some bleeding during this 4th week.
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Start the next pack of pills the day after taking the last pill in the 4th pack. (21-day users wait 7 days before starting the next pack.)
Continuous Use Instructions
Take one hormonal pill every day for as long as she wishes to use COCs. If bothersome irregular bleeding occurs, a woman can stop taking pills for 3 or 4 days and then start taking hormonal pills continuously again.
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