Providing combined oral contraceptives

When to start

Important: a woman can start using COCs any time she wants if it is reasonably certain she is not pregnant. To be reasonably certain she is not pregnant, use the Pregnancy Checklist.

Also, a woman can be given COCs at any time and told when to start taking them.

Woman’s situation	When to start
Having menstrual cycles or switching from a nonhormonal method	Any time of the month If she is starting within 5 days after the start of her monthly bleeding, no need for a backup method. If it is more than 5 days after the start of her monthly bleeding, she can start COCs any time it is reasonably certain she is not pregnant. She will need a backup method for the first 7 days of taking pills. (If you cannot be reasonably certain, give her COCs now and tell her to start taking them during her next monthly bleeding.) Backup methods include abstinence, male and female condoms, spermicides, and withdrawal. Tell her that spermicides and withdrawal are the least effective contraceptive methods. If possible, give her condoms. If she is switching from an IUD, she can start COCs immediately (see Copper-Bearing IUD, Switching From an IUD to Another Method)
Switching from a hormonal method	Immediately, if she has been using the hormonal method consistently and correctly or if it is otherwise reasonably certain she is not pregnant. No need to wait for her next monthly bleeding. No need for a backup method. If she is switching from injectables, she can begin taking COCs when the repeat injection would have been given. No need for a backup method.
Fully or nearly fully breastfeeding Less than 6 months after giving birth	Give her COCs and tell her to start taking them 6 months after giving birth or when breast milk is no longer the baby’s main food— whichever comes first.
Woman’s situation	When to start
Fully or nearly fully breastfeeding (continued) More than 6 months after giving birth	If her monthly bleeding has not returned, she can start COCs any time it is reasonably certain she is not pregnant. She will need a backup method for the first 7 days of taking pills. (If you cannot be reasonably certain, give her COCs now and tell her to start taking them during her next monthly bleeding.) If her monthly bleeding has returned, she can start COCs as advised for women having menstrual cycles (see above).
Partially breastfeeding Less than 6 weeks after giving birth	Give her COCs and tell her to start taking them 6 weeks after giving birth. Also give her a backup method to use until 6 weeks since giving birth if her monthly bleeding returns before this time.
More than 6 weeks after giving birth	If her monthly bleeding has not returned, she can start COCs any time it is reasonably certain she is not pregnant. Where a visit 6 weeks after childbirth is routinely recommended and other opportunities to obtain contraception limited, some providers and programs may give COCs at the 6-week visit, without further evidence that the woman is not pregnant, if her monthly bleeding has not yet returned. She will need a backup method for the first 7 days of taking pills. (If you cannot be reasonably certain, give her COCs now and tell her to start taking them during her next monthly bleeding.) If her monthly bleeding has returned, she can start COCs as advised for women having menstrual cycles (see above).
Not breastfeeding Less than 4 weeks after giving birth	She can start COCs at any time on days 21–28 after giving birth. Give her pills any time to start during these 7 days. No need for a backup method.
Woman’s situation	When to start
Not breastfeeding (continued) More than 4 weeks after giving birth	If her monthly bleeding has not returned, she can start COCs any time it is reasonably certain she is not pregnant.Where a visit 6 weeks after childbirth is routinely recommended and other opportunities to obtain contraception limited, some providers and programs may give COCs at the 6-week visit, without further evidence that the woman is not pregnant, if her monthly bleeding has not yet returned. She will need a backup method for the first 7 days of taking pills. (If you cannot be reasonably certain, give her COCs now and tell her to start taking them during her next monthly bleeding.) If her monthly bleeding has returned, she can start COCs as advised for women having menstrual cycles.
No monthly bleeding (not related to childbirth or breastfeeding)	She can start COCs any time it is reasonably certain she is not pregnant. She will need a backup method for the first 7 days of taking pills.
After miscarriage or abortion	Immediately. If she is starting within 7 days after first- or second-trimester miscarriage or abortion, no need for a backup method. If it is more than 7 days after first- or secondtrimester miscarriage or abortion, she can start COCs any time it is reasonably certain she is not pregnant. She will need a backup method for the first 7 days of taking pills. (If you cannot be reasonably certain, give her COCs now and tell her to start taking them during her next monthly bleeding.)
After taking emergency contraceptive pills (ECPs)	She can start COCs the day after she finishes taking the ECPs. There is no need to wait for her next monthly bleeding to start her pills. –A new COC user should begin a new pill pack. –A continuing user who needed ECPs due to pill-taking errors can continue where she left off with her current pack. –All women will need to use a backup method for the first 7 days of taking pills.

Giving advice on side effects

Important: thorough counselling about bleeding changes and other side effects is an important part of providing the method. Counselling about bleeding changes may be the most important help a woman needs to keep using the method.

Describe the most common side effects

In the first few months, bleeding at unexpected times (irregular bleeding). Then lighter, shorter, and more regular monthly bleeding.
Headaches, breast tenderness, weight change, and possibly other side effects.

Explain about these side effects

Side effects are not signs of illness.
Most side effects usually become less or stop within the first few months of using COCs.
Common, but some women do not have them.

Explain what to do in case of side effects

Keep taking COCs. Skipping pills risks pregnancy and can make some side effects worse.
Take each pill at the same time every day to help reduce irregular bleeding and also help with remembering.
Take pills with food or at bedtime to help avoid nausea.
The client can come back for help if side effects bother her.

Explaining how to use

1. Give pills	Give as many packs as possible—even as much as a year’s supply (13 packs).
2. Explain pill pack	Show which kind of pack—21 pills or 28 pills. With 28-pill packs, point out that the last 7pills are a different color and do not contain hormones. Show how to take the first pill from the pack and then how to follow the directions or arrows on the pack to take the rest of the pills.
3. Give key instruction	Take one pill each day— until the pack is empty. Discuss cues for taking a pill every day. Linking pill-taking to a daily activity—such as cleaning her teeth—may help her remember. Taking pills at the same time each day helps to remember them. It also may help reduce some side effects.
4. Explain starting next pack	28-pill packs: When she finishes one pack, she should take the first pill from the next pack on the very next day. 21-pill packs: After she takes the last pill from one pack, she should wait 7 days—no more— and then take the first pill from the next pack. It is very important to start the next pack on time. Starting a pack late risks pregnancy.
5. Provide backup method and explain use	Sometimes she may need to use a backup method, such as when she misses pills. Backup methods include abstinence, male or female condoms, spermicides, and withdrawal. Tell her that spermicides and withdrawal are the least effective contraceptive methods. Give her condoms, if possible.

Supporting the user

Managing missed pills

It is easy to forget a pill or to be late in taking it. COC users should know what to do if they forget to take pills.

If a woman misses one or more pills, she should follow the instructions below.

Use the tool ( ) to help explain these instructions to the client.

Making Up Missed Pills With 30–35 μg Estrogen For pills with 20 μg of estrogen or less, women missing one pill should follow the same guidance as for missing one or two 30–35 μg pills. Women missing 2 or more pills should follow the same guidance as for missing 3 or more 30–35 μg pills.
Key message	Take a missed hormonal pill as soon as possible. Keep taking pills as usual, one each day. (She may take 2 pills at the same time or on the same day.)
Missed 1 or 2 pills? Started new pack 1 or 2 days late?	Take a hormonal pill as soon as possible. Little or no risk of pregnancy.
Missed 3 or more pills in the first or second week? Started new pack 3 or more days late?	Take a hormonal pill as soon as possible. Use a backup method for the next 7 days. Also, if she had sex in the past 5 days, can consider ECPs (see Emergency Contraceptive Pills).
Missed any nonhormonal pills? (last 7 pills in 28-pill pack)	Discard the missed nonhormonal pill(s). Keep taking COCs, one each day. Start the new pack as usual.
Severe vomiting or diarrhea	If she vomits within 2 hours after taking a pill, she should take another pill from her pack as soon as possible, then keep taking pills as usual. If she has vomiting or diarrhea for more than 2 days, follow instructions for 1 or 2 missed pills, above.

“Come back any time”: reasons to return

Assure every client that she is welcome to come back any time—for example, if she has problems, questions, or wants another method; she has any major change in health status; or she thinks she might be pregnant. Also if:

she lost her pills or started a new pack more than 3 days late and also had sex during this time. She may wish to consider ECPs (see Emergency Contraceptive Pills).
General health advice: anyone who suddenly feels that something is seriously wrong with her health should immediately seek medical care from a nurse or doctor. Her contraceptive method is most likely not the cause of the condition, but she should tell the nurse or doctor what method she is using.

Planning the next visit

1.Encourage her to come back for more pills before she uses up her supply of pills.

2. An annual visit is recommended.

3. Some women can benefit from contact after 3 months of COC use. This offers an opportunity to answer any questions, help with any problems, and check on correct use.

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