Combined hormonal contraceptives

About combined hormonal contraceptives

Combined hormonal contraception is a very effective method of contraception if used correctly. The phrase 'combined hormonal contraception' means that this type of contraception contains two different types of female hormones: an oestrogen and a progestogen. The most common form of this type of contraception is the combined oral contraceptive pill, often just called 'the pill'. There are many different brands of the pill. There are also two other forms of this type of contraception - contraceptive skin patches and a vaginal ring formulation.

'Oestrogen' and 'progestogen' are terms which describe two types of female hormones. The strength and type of each can vary from brand to brand. Examples of oestrogens used in contraceptives are ethinylestradiol, mestranol and estradiol. Examples of progestogens used are norethisterone, gestodene, desogestrel, drospirenone, levonorgestrel, norgestimate, dienogest, norelgestromin, nomegestrol and etonogestrel. If you look at the listed ingredients on your contraceptive, you will find one ingredient from the list of oestrogens mentioned above, and one from the list of progestogens.

This type of contraceptive can also be classified according to its strength. Preparations are called 'low-strength' or 'standard-strength' depending on how much oestrogen they contain. Your doctor will have discussed this with you and will have chosen the product most suitable for you. In some packs of contraceptive pills there are two or even three different-strength tablets to take at different times during your monthly cycle. In these packs, each strength of tablet is a different colour.

Most preparations are taken or used for 21 days of a menstrual cycle, leaving a seven-day treatment-free interval during which time your period occurs. If you find it difficult to remember which weeks to take your tablets, there are some brands which contain 7 inactive tablets as well as the 21 active tablets. These types of pill are taken every day of the month. Brands containing both active and inactive tablets include Zoely® and products with the letters 'ED' for 'everyday' after the brand name.

Combined hormonal contraceptives prevent pregnancy in three ways:

• They change the body's hormone balance so that your ovaries do not produce an egg (ovulate).

• They cause the mucus made by the neck of the womb (cervix) to thicken. This makes it difficult for sperm to get through to the womb (uterus) to fertilise an egg.

• They make the lining of the womb thinner. This makes it less likely that a fertilised egg will be able to attach to the uterus.

Before taking combined hormonal contraceptives

Some medicines are not suitable for people with certain conditions, and sometimes a medicine may only be used if extra care is taken. For these reasons before you start taking a combined hormonal contraceptive, it is important that your doctor knows:

• If you are breastfeeding or think you may be pregnant.

• If you or a close family member have ever had a clot in a blood vessel, or any circulation problems.

• If you have ever had a problem with your veins (such as superficial thrombophlebitis).

• If you smoke.

• If you have high blood pressure.

• If you have a breast lump or have had breast cancer.

• If you have any problems with the way your liver works, or if you have gallstones.

• If you have heart problems, migraine, or diabetes.

• If you have any vaginal bleeding other than your normal monthly period.

• If you are not fully mobile for any reason.

• If you have ever had depression.

• If you have had a transient ischaemic attack (TIA), sometimes called a 'mini-stroke'.

• If you or a close relative have ever had high blood levels of fats (lipids).

• If during a pregnancy you have had problems such as severe itching and blistering of your skin, jaundice, or any involuntary jerky movements.

• If you have been told you have high levels of prolactin.

• If you have an inflammatory bowel condition.

• If you have systemic lupus erythematosus (often called SLE).

• If you have sickle cell disease or porphyria, or have had haemolytic uraemic syndrome (these are blood disorders).

• If you have ever had an allergic reaction to a medicine.

• If you are taking any other medicines. This includes any medicines you are taking which are available to buy without a prescription, as well as herbal and complementary medicines. This is important because some medicines may stop combined hormonal contraceptives from working properly.

How to take combined hormonal contraceptives

If you are taking 'the pill'

• Before you start taking the pill, read the manufacturer's printed information leaflet from inside your pack. It will give you more information about your specific brand of pill and will provide you with a full list of the side-effects which you may experience from taking it.

• Take one tablet each day. Most pills are taken for 21 days of each menstrual cycle, leaving a seven-day pill-free interval. If you find it difficult to remember which weeks to take your tablets, your doctor may have given you the type of pill which is taken every day of the month. If you are unsure how to take the tablets, ask your doctor or pharmacist for advice.

What to do if you forget to take a pill

• You should take your pill at the same time each day. If you forget to take it on time, take it as soon as you remember, and then the next dose at your usual time. Note: if you are taking Zoely® and you are more than 12 hours late taking a pill, your protection against pregnancy may be reduced and you may need to use additional precautions such as a condom. Follow the instructions on the 'missed pill chart' in the leaflet from your pack of pills, which tell you what you need to do, as the following points do not apply to you.

• If you miss one dose (this means you are 24-48 hours late taking a dose), take a pill as soon as you remember and then take the next dose at your usual time even if this means taking two pills together.

• If you miss two or more doses, the pill may not work and you may not be protected from becoming pregnant. As soon as you remember, take a pill and then continue taking the tablets as normal. In addition, for the following seven days you must either use another method of contraception such as a condom, or avoid sex. If these seven days run beyond the end of your packet of pills, start the next packet straightaway without any tablet-free days. This means you may not have a period until the end of the two packets. If you are using an everyday (ED) pill, miss out the seven inactive pills (the pills you take while you are having a period). If you are not sure which these are or if you are unsure about the advice, speak with your doctor or pharmacist.

• Important: if you miss two or more pills from the first seven tablets in the pack and you have had unprotected sex recently, ask your doctor or pharmacist for advice on what to do.

If you are using patches

• Before you start using the patches, read the manufacturer's printed information leaflet from inside the pack. It will give you more information about the patches and will provide you with a full list of the side-effects which you may experience from using them.

• Apply a patch on the first day of your period, and call this 'Day 1'. Change the patch for a fresh patch on the same day of the following week, and the week after that (that is, on 'Day 8' and 'Day 15' of your cycle). On 'Day 22' remove the patch and follow it with seven patch-free days before beginning a new cycle.
  

What to do if the patch comes loose or if you forget to change the patch

• If a patch becomes detached and you notice this within 24 hours, you can either reapply the same patch, or replace it with a fresh patch. Then continue as before, applying your next patch on your usual 'change day'.

• If a patch has been detached for more than 24 hours or if you do not know when it came off, start a new cycle by applying a new patch. You will also need to use another method of contraception such as a condom during the following seven days. This new patch is now your 'Day 1' patch and you must remember to change your patches on this same day of the week from now on.

• If you forget to apply a patch at the start of a new cycle, you will not be protected. If this happens, apply a 'Day 1' patch as soon as you remember and use another method of contraception, such as a condom, during the following seven days. If you have had sex during the time when you were not wearing a patch, speak with your doctor or pharmacist for advice.

• If you forget to change your patch on Day 8 or Day 15 but you remember when it is less than 48 hours overdue, change to a new patch straightaway and then remember to change it again on your usual change day.

• If you forget to change a patch on Day 8 or Day 15 and you only remember when it is more than 48 hours overdue, you may not be protected. Remove the old patch and apply a new patch straightaway. You will also need to use another method of contraception such as a condom during the following seven days. The new patch is now your 'Day 1' patch and you must remember to change your patches on this same day of the week from now on.

• If you forget to remove the patch at the end of a cycle (that is, on Day 22), remove it as soon as you remember and start your next cycle on your usual 'change day'.

If you are using the vaginal ring

• Before you insert the ring, read the manufacturer's printed information leaflet from inside the pack. It will give you more information about the vaginal ring and how to insert it correctly, and will also provide you with a full list of the side-effects which you may experience from using it.

• Insert one ring into your vagina on Day 1 of your cycle and then remove it on Day 22. After seven ring-free days, start another cycle. Remember to check the ring regularly to make sure it remains correctly in place.

What to do if your ring comes out

• If your vaginal ring comes out but it is for less than three hours, rinse it in cool water and re-insert it straightaway. You will not need to use any additional contraception.

• If your vaginal ring comes out for more than three hours (or if you do not know when it came out), you may not be protected from pregnancy. If this happens during week 1 or 2 of your cycle, rinse the ring with cool water and re-insert it. You will also need to use another method of contraception such as a condom during the following seven days. If this happens during week 3 of your cycle, you can either start a new cycle by inserting a new ring or (providing the ring has been used continuously for at least seven days before this happens) you can allow your period to occur and then insert a new ring within the next seven days.

• If your ring breaks, remove it and insert a new ring straightaway. Use another method of contraception such as a condom during the following seven days.

• If you forget to insert a new ring at the start of a new cycle, you will not be protected. If this happens, insert a new ring as soon as you remember and use another method of contraception such as a condom during the following seven days. If you have had sex during the time when you were not using a ring, speak with your doctor or pharmacist for advice.

• If you forget to remove the ring at the end of a cycle, remove it as soon as you remember and leave seven ring-free days. After the seven ring-free days start another cycle. If you are more than a week late in removing the ring, you may no longer be protected. If this happens, speak with your doctor or pharmacist for advice.

• The vaginal ring can occasionally be felt by sexual partners, although this is usually not a problem. If you choose to remove the ring before you have sex, make sure that you replace it again within three hours.

Getting the most from your treatment

• Try to keep your regular appointments with your doctor or clinic. This is so your doctor can check on your progress. You will need to have your blood pressure checked from time to time.

• If you suspect at any time that you may be pregnant, stop using the contraception and see your doctor or pharmacist for a pregnancy test straightaway.

• Important: if you have a bout of being sick (vomiting) or diarrhoea, it can reduce the effectiveness of the pill. If you are sick within two hours of taking a pill, take another pill as soon as possible. If the sickness continues, or if you have severe diarrhoea which lasts for more than 24 hours, you must also use another method of contraception. If this happens, use a condom if you have sex during the illness and for seven days after you recover. If the sickness and diarrhoea occur during the last week of your tablets, miss out the seven pill-free days and start a new pack of oral contraceptives straightaway. If you are taking an everyday (ED) brand of pill, miss out the seven inactive pills (the pills you take while you are having a period). If you are not sure which these are, or if you are unsure about the advice, speak with your doctor or pharmacist.

• Your doctor will discuss the risks of contraception with you, and will advise you on the most suitable preparation to use. There is a slight increased risk of a clot in a blood vessel (thromboembolism), although the risk of this is still less than during a pregnancy. Travelling that involves long periods of sitting still (for example, flying for more than three hours) can add to the risk of a blood clot. It's always a good idea to exercise your feet and ankles regularly while travelling, and you may wish to consider wearing flight socks during long flights.

• Before having any kind of surgery, you must tell your doctor or surgeon that you are using combined hormonal contraception. This is because your doctor may decide that you need to stop the contraception for a period of time to reduce your risk of unwanted blood clots.

• Combined hormonal contraceptives do not protect you from sexually transmitted infections or HIV infection. If you are concerned about either of these, ask your pharmacist or doctor for advice on safe sex.

• If you buy any medicines or herbal remedies, always check with a pharmacist that they are safe to take with your method of contraception. Some remedies which can be bought 'over the counter' can interact with a hormonal contraceptive, making it less effective and increasing the risk of unplanned pregnancy. An example of this is the herbal remedy called St John's wort.

• Taking combined hormonal contraception can increase the risk of some types of cancer, but it will also protect against other types. Research suggests a small increased risk of breast and cervical cancer, and protection against cancers of the ovary and endometrium. Your doctor will be able to discuss the risks of each of these with you.

Can combined hormonal contraceptives cause problems?

Along with their useful effects, most medicines can cause unwanted side-effects although not everyone experiences them. The table below contains some of the most common ones associated with combined hormonal contraception. You will find a full list in the manufacturer's information leaflet supplied with your medicine. The unwanted effects often improve as your body adjusts to the new medicine, but speak with your doctor or pharmacist if any of the following continue or become troublesome.

If you experience any other symptoms which you think may be due to the contraceptive, discuss them with your doctor or pharmacist.

How to store combined hormonal contraceptives

• Keep all medicines out of the reach and sight of children.

• Store in a cool, dry place, away from direct heat and light.

Important information about all medicines