Combined Oral Contraceptives (COC)

Combined Oral Contraceptives (COCs) contain 21 tablets of low doses of two hormones: a progestin and an oestrogen. The COC supplied by MoHP contains 30mcg (0.3 mg) ethinylestradiol, 150 mcg (0.15 mg) LNG and seven iron-containing tablets.
The COC is moderately effective. There is no delay in return of fertility once the pill is stopped.

How to use the COC?

Take the first tablet on the first day following menses, and then daily at the same time each day, for the first pack; repeat a new pack after the first pack is completed. Continue every day without any interruption as long as contraception is desired.

When to start COC?

Within first five days of menstruation
Any day of menstruation if it is reasonably certain the woman is not pregnant
Day one of MVA/spontaneous abortion
After delivery
(a) If lactating – start after six months
(b) If not lactating – start after six weeks.

What if a pill is missed?

If a woman misses one or more pills, she should take a missed hormonal pill as soon as possible and keep taking pills as usual, one each day. In addition:

If one or two pills are missed (or a new pill pack is started one or two days late): Take a hormonal pill as soon as possible.
If three or more pills are missed in the first and second rows/weeks (or a new pill pack is started three or more days late): Take a hormonal pill as soon as possible, use a back-up method for the next seven days (e.g. condom) and use an ECP if there has been unprotected sexual intercourse in the past five days.
If three or more pills are missed in the third row/week: Take a hormonal pill as soon as possible, finish all
remaining hormonal pills in the pack, throw away the seven non-hormonal pills, start a new pill pack the next day, use a back-up method (e.g. condom) for the next seven days, and use an ECP there has been unprotected sexual intercourse in the past five days.

Who should not use COC?

Precaution for the use of COC:
The Medical Eligibility Criteria (MEC) for contraceptive use provides guidance on whether women with certain medical conditions can safely and effectively use specific contraceptive methods.

Avoid use: use other methods if available (MEC – 3)

Smoker and >35 years of age, <15 cigarettes per day
<6 months post-delivery and breastfeeding
High BP: SBP 140–159mm Hg or DBP 90–99mm Hg
Past breast cancer
Current symptomatic gall bladder disease
Using antibiotics, rifampicin or rifabutin or anti-convulsant.

COC contraindicated (MEC – 4)

Smoker and >35 years of age, >15 cigarettes per day
Migraine headache with aura
Current breast cancer
Postpartum less than six weeks and breastfeeding
High BP: SBP >160mm Hg or DBP >100mm Hg
History of thromboembolism (DVT/PE), acute thromboembolism (DVT/PE)
Major surgery with prolonged immobilisation
Stroke, current and past history of ischaemic heart disease
SLE (Positive (or unknown) antiphospholipid antibodies
Liver tumours (hepatoma, adenoma)
Acute flare-up of hepatitis, severe cirrhosis.

Other Uses of COC

For Emergency Contraception (ECP)

Unscheduled (irregular or increased) bleeding following use of IUCD and other hormonal contraceptives
Abnormal uterine bleeding (see RH Protocol for ANMs/SN and RH Protocols for Paramedics)
Dysmenorrhea.

Non-contraceptive benefits