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Referral and warning signs
When to refer
Refer if: Contraindications identified. Development of warning signs (severe headache, chest pain, leg pain etc.). Persistent problematic side effects. Need for alternative method due to drug interactions.
Red flags
- Severe chest pain or shortness of breath
- Severe headache, visual changes, neurological symptoms
- Severe abdominal pain
- Severe leg pain or swelling
- Jaundice
- BP ≥160/100 mmHg
Signs and symptoms
- Common Side Effects (often improve after first few months): Nausea, vomiting, spotting/irregular bleeding, breast tenderness, headache, dizziness, weight gain (often minor), mood changes.
- Warning Signs (Complications - require immediate stop and medical attention): Severe headaches (migraine with aura, stroke sign), Blurred vision, Severe chest pain (PE, MI), Severe abdominal pain (gallbladder, liver tumour, clot), Severe leg pain/swelling (DVT), Depression.
Risk factors
- Contraindications (MEC Category 4 - Do Not Use): Current breast cancer, Severe liver disease (active hepatitis, cirrhosis, tumour), Migraine with aura, Age ≥35 AND Smoking ≥15 cigarettes/day, Multiple risk factors for cardiovascular disease (older age, smoking, diabetes, hypertension), Hypertension ≥160/100 mmHg, History of VTE (DVT/PE), Known thrombogenic mutations, Major surgery with prolonged immobilization, Ischaemic heart disease/Stroke history, Complicated valvular heart disease, <21 days postpartum.
- Relative Contraindications (MEC Category 3 - Risks outweigh benefits): Age ≥35 AND Smoking <15 cigarettes/day, Hypertension 140-159/90-99 mmHg, Past breast cancer >5yrs ago, Gallbladder disease, Malabsorptive bariatric surgery, Certain drug interactions (Rifampicin, some anticonvulsants).
Diagnosis
Clinical assessment
Eligibility assessment based on medical history, BP check, assessment of risk factors/contraindications using MEC guidelines.
Investigations
- Blood Pressure measurement (essential).
- Rule out pregnancy before starting.
- Assess for contraindications via history.
Diagnostic criteria
Client meets medical eligibility criteria for COC use.
Management
Non-pharmacological management
- Counseling: Explain mechanism, effectiveness, how to take daily, what to do if pills missed, side effects, warning signs, lack of STI protection.
- Supply 3 cycles initially.
Pharmacological treatment
- Standard regimen: Take one pill daily, preferably at same time. Typically 21 active pills followed by 7-day break (or placebo pills), or continuous regimens.
- Management of Missed Pills: Follow specific instructions based on number missed and week of cycle (refer to packet insert/guidelines - often requires backup contraception).
- Management of Side Effects:
- - Nausea: Take with food or at bedtime. Reassure often transient.
- - Breast Tenderness: Supportive bra, analgesia. Rule out pregnancy.
- - Mild Headache: Analgesia (Paracetamol, Ibuprofen). Rule out severe headache/migraine with aura.
- - Irregular Bleeding: Reassure often improves. Rule out other causes (pregnancy, infection). Consider short course NSAIDs. If persistent, may need method change.
- Drug Interactions: Reduced effectiveness with enzyme inducers (Rifampicin, some anticonvulsants - Phenytoin, Carbamazepine, Barbiturates, Topiramate; some ARVs - Efavirenz, Nevirapine). Requires backup method during and after use of interacting drug. Broad spectrum antibiotics generally do not significantly reduce efficacy, but backup advised if diarrhoea/vomiting occurs.
Monitoring
Follow-up visits for resupply, check BP, assess side effects/problems, reinforce correct use.
Complications
- Venous Thromboembolism (VTE - DVT/PE) - small increased risk.
- Arterial Thrombosis (MI, Stroke) - very small increased risk, mainly if other risk factors present.
- Hypertension (can worsen or develop).
- Gallbladder disease.
- Liver tumours (benign adenomas, rare malignant) - very rare.
- Cervical cancer (slight increased risk with long term use, likely related to HPV exposure).
Prevention
- Careful screening using MEC.
- Patient education on warning signs.
- Use lowest effective estrogen dose where possible.
Patient education
- Take one pill daily, same time.
- What to do if pills missed.
- Common side effects (often temporary).
- Serious warning signs (ACHES - Abdominal pain, Chest pain, Headaches, Eye problems, Severe leg pain) - seek help immediately.
- Does not protect against STIs/HIV - use condoms if needed.
- Drug interactions.
- Need for regular follow-up.
Uganda-specific notes
Commonly available method. Low-dose formulations preferred. Important to check BP. Counsel thoroughly about missed pills and interactions, especially with TB meds (Rifampicin) and some ARVs.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 15, Section 15.2.3
- MOH (2016) / WHO (2020) Medical Eligibility Criteria for Contraceptive Use
(Referenced for contraindications)