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 Combined Oral Contraceptive 



The Introduction of birth control in 1960 revolutionized contraceptive practices around the world. Millions of women turned enthusiastically to this convenient and effective method of preventing pregnancy, but within a decade reports of  serious side effects of the pill began to appear and  the popularity of this  method declined substantially. Now After twenty-five  years of observation, what are the  facts about  the pill?

There are two types of oral contraceptives currently in  use a combination pill, which contains a synthetic estrogen and a progesterone -like synthetic substance called " progesterone," and a minipill with progesterone only in low dosage. This discussion will focus on combination pills ( unless otherwise specified ) because they are most commonly used. 

  • Women who use oral contraceptives swallow a pill each day to prevent pregnancy. Combined oral contraceptives contain two hormones  similar  to the natural hormones in a woman's body -- an estrogen and a protesting. Also called combined pills, COCs, OCs, the Pill, and birth control pills. 
  • Present combined oral contraceptives contain very low doses of hormones. They are often called low does combined oral contraceptives. 
  • There are two types of pill packets. Some packets have 28 pills. These contain 21 "active" pills, which contain hormones, followed by 7 " reminder "  pills of a different color that do not contain hormones. Other packets have only the 21 " active"  pills. 

Deciding About Combined Oral Contraceptives 

How Do they Work?

  • Stop ovulation (release of eggs from ovaries).
  • Also thicken cervical mucus, making it difficult for sperm to pass through 

 They do NOT work by disrupting existing pregnancy. 

How Effective ? 

Effective as commonly used : 6 to 8 pregnancies per 100 women in first year of use (1 in every 17 to 1 every 12).

Very effective when used correctly and consistently : 0.1 pregnancies per 100 women in first year of use ( 1 in very 1000 ). 

Important : Should be taken every day to be most effective. Many women may not take pills correctly and thus risk becoming  pregnant. The most common mistakes are starting new packets late and running out of pills.

Advantages and Disadvantages 


  • Very effective when used correctly. 
  • No need to do anything at tie of sexual intercourse. 
  • Increased sexual enjoyment because no need to worry about pregnancy.
  • Monthly periods are  regular: lighter monthly bleeding and fewer days of bleeding milder and  fewer menstrual cramps. 
  • Can be used at any age form adolescence to menopause. 
  • Can be used by women who have children and by women who do not.
  • User can stop taking pills at any time . 
  • Fertility returns soon after stopping. 
  • Can be used as an emergency contraceptive after unprotected sex.
  • Can prevent or decrease iron deficiency anemia. 
  • Help prevent : 

 - Ectopic pregnancies,                              - Ovarian cysts,

 - Endometrial cancer,                              - Pelvic inflammatory disease, 

 - Ovarian cancer,                                    - Benign breast disease. 

  •  Common side effects (not signs of sickness): 

-Nausea (most common in first 3 months) 

-Spotting or bleeding between menstrual periods, especially if  a woman forgets to take her pills or takes them late ( most common in first 3 months).

-Mild headaches,

-Breast tenderness,

-Slight weight gain ( some women see weight gain as an advantage).

-Amenorrhea (some women see amenorrhea as an advantage). 

  • Not highly effective unless taken every day. Difficult for some women to remember every day. 
  • New packet of pills must be at hand every 28 days.
  • Not recommended for breastfeeding women because they affect quality and quantity of milk. 
  • In a few women, may cause mood changes including depression, less interest in sex. 
  • Very rarely can cause stroke, blood clots in deep veins of the legs, or heart attack. Those at highest risk are women with high blood pressure and women who are age 35 or older and at the same time smoke more than 20 cigarettes per day. 
  • Do not protect against sexually transmitted diseases  (STDs) including AIDS. 

Important: Ask the client if she might have or get a sexually transmitted disease (STD), has more than one sex partner or could this happen in future. 

If she has or might get an STD , urge her to use condoms regularly. Give her condoms. She can still use combined oral contraceptives. 

Most Women Can Use Combined Oral Contraceptives 

In general, most women can use low dose combined oral contraceptives safely and effectively. Low dose combined oral contraceptives can be used in any circumstances by women who: 

  • Have no children,                                 
  • Are fat or thin,
  • Are any age, including adolescents and over 40 (except women who are age 35 or older and who smoke).
  • Smoke cigarettes but are under age 35, 
  • Have just had abortion or miscarriage. 

Also, women with these conditions can use low dose combined oral contraceptives in any circumstances: 

  • Heavy, painful menstrual periods or iron deficiency anemia (condition may improve). 
  • Irregular menstrual period, 
  • Benign breast disease, 
  • Diabetes without vascular, kidney , eye, or nerve disease, 
  • Mild headaches, 
  • Varicose veins,
  • Malaria, 
  • Schistosomiasis,
  • Thyroid disease, 
  • Pelvic inflammatory disease, 
  • Endometriosis, 
  • Benign ovarian tumors, 
  • Uterine fibroids,
  • Past entopic pregnancy, 
  • Tuberculosis 

IMPORTANT: Non-medical providers can safely offer low dose combined oral contraceptives. Non-medical providers include shopkeepers and community based distributors. These providers do not need to obtain medical consultation or approval to provide pills to a woman unless she has a condition  that  requires it.  

Starting Low-dose Combined Oral Contraceptives 

When To Start 

Important : A woman can be given combined oral contraceptives at any time and told when to start taking them . The following table show when to start. 


Woman's situation 

When to star

 Having menstrual cycles

  • The first day of menstrual bleeding is est.

  • Any of the first 7 days after her menstrual bleeding starts, if she is cycling normally. 

  • Any other time it is reasonably certain that she is not pageant. If more than  7 days since menstrual bleeding  started, she can begin combined oral contraceptives but should  avoid sex or also use condoms or spermicidal for the next 7 days. Her usual bleeding  pattern may change temporarily. 

After childbirth if breast feeding 

  • After she stops breastfeeding or 6 months after childbirth whichever comes first. 

Note : Can give her pills now. Make sure she knows when to start taking them

After childbirth if not breast feeding

  •  3 to 6 weeks  after childbirth. No need to wait for menstrual periods to return to be certain that she is not  pregnant. 

  • After 6 weeks, any time it is reasonably certain that she is not pregnant. 

Note : If not reasonably certain she should avoid sex or use condoms or spermicidal until her first period starts, and then begin combined oral  contraceptives. 

After miscarriage or abortion 

  •  In the first 7 days after or second trimester miscarriage or abortion. 

  •  Later, any time it is reasonably certain that she is not pregnant. 

When stopping another method 

  • Immediately. No need to wait for a first period after using injectables.


Providing Combined Oral Contraceptives 

Important : A woman who chooses low dose combined oral contraceptives benefits form good counseling. 

A friendly provider who  listens to a woman's  concerns, answers her question , and  gives clear, practical information about side  effects, especially nausea and vomiting and about proper use will help the woman use combined oral contraceptives with  success and satisfaction. 

You can follow these steps to provide combined oral contraceptives; 

  1. Give her plenty of pills a year's supply , if possible. Running our of pills is a major reason for unintended pregnancies.

  2. Explain how to use combined oral contraceptives .

  3. If possible, give her condoms or spermicidal to use; 

  • Until she can start taking her pills ( if needed)

  • If she starts a packet of pills late, if she forgets several pills in a row, or if she stop staking oral contraceptives for any reason; 

  • If she thinks she or her partner could get AIDS or any other STD. 

Show her how to use condoms or spermicidal. 

     4. Plan a return visit in time to give her more pills before her supply runs out. 

     5. Invite the client to come back any time she has questions, problems, or wants another method. 

For clients who use pill packets like the  one shown below this drawing can help explain what to do when they miss pills. Describe the pills by their colors. 

Missed pills ? Here's what to do 


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