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Contraceptive counselling often features in OSCEs and it’s therefore important to be familiar with the various types of contraception available. This article focuses on counselling patients about the combined oral contraceptive pill (COCP), including the common questions patients ask, the answers you’ll be expected to articulate and how best to structure the consultation.
Opening the consultation
Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Confirm the patient’s name and date of birth.
Check the patient’s understanding of the types of contraception available.
Explore the reasons why the patient wants the COCP.
Ideas, concerns and expectations
It is important to explore the patient’s ideas, concerns and expectations early in the consultation, as you may need to correct any misconceptions about the COCP and address the patient’s concerns. When exploring concerns, it is important to do so in a sensitive and honest manner.
It’s also important to clarify the patient’s expectations of the COCP because if these are unrealistic, other forms of contraception may be better able to meet their needs.
Ideas
Explore what the patient currently understands about the COCP:
- “Have you heard of the combined oral contraceptive pill?”
- “What do you already know about the combined oral contraceptive pill?”
Concerns
Ask if the patient has any concerns about the COCP:
- “Is there anything that worries you about the combined oral contraceptive pill?”
Expectations
Explore the patient’s expectations of the COCP:
- “What are you hoping the combined oral contraceptive pill can do for you?”
- “Why do you think the combined oral contraceptive pill is the best choice for you?”
What is the combined contraceptive pill?
Using patient-friendly language, explain that the combined pill contains both oestrogen and progesterone. Explain that there are a number of different types of combined pills available.
“The combined contraceptive pill is what many people refer to as ‘the pill’. It is a pill that contains two hormones – progesterone and oestrogen. These hormones are similar to the natural hormones produced by your ovaries.”1
What are the different types of pill available?
Explain to the patient that there are three main types of combined pills:
- The monophasic 21-day pill is the most common type of combined pill. Each pill has the same amount of hormone in it and the monophasic pill is taken for 21 days followed by a 7-day break.1
- The phasic 21-day pill: each pill contains a different amount of hormone and therefore the pills must be taken in the correct order. The phasic pill is taken for 21 days followed by a 7-day break.1
- The everyday pill: there are 21 pills containing hormones and 7 placebo pills. Pills are taken for 28 days without a break in between packs.1
How does the combined pill work?
Explain to the patient that the pill prevents conception by inhibiting ovulation, thickening cervical mucus and thinning the endometrium to prevent implantation of the blastocyst.2
“The pill prevents you from getting pregnant by stopping your ovaries from producing an egg every month.”
“It also works by thickening the mucus around your cervix which stops sperm from entering your womb.”
“It can also make the lining of your womb thinner, which makes it less likely that a fertilised egg would be able to implant in the womb.”
How effective is the combined pill?
Patients understandably want to know how effective contraception is and this is often a major factor in their decision as to which type of contraception they want to use. As a result, it’s useful to know some basic statistics on efficacy. However, if you’re unsure, signpost the patient to a reliable source and don’t guess!
Explain to the patient that the effectiveness of the pill depends on compliance. However, if the pill is used correctly, it is 99% effective.1
“If you take the combined pill at the appropriate time each day and don’t miss pills, it is 99% effective at preventing pregnancy.”
Pros and cons of the combined pill
Always give patients as much information as possible so that they can make an informed decision. It is useful to do this by discussing the pros and cons of the combined pill.
“If it is okay with you, I’d like to tell you about the benefits and disadvantages of the pill, then hopefully you will then have enough information to make a decision.”
Advantages of the COCP
Non-invasive method
“Taking the pill does not require an invasive procedure like some other forms of contraception.”
Effective contraception
“The combined pill is 99% effective when taken correctly.”
Problems associated with periods improve
“Your periods may become more regular, lighter and less painful.”
Controls timing of periods
“You can run the pill packets back-to-back if you want to control the timing of your period for holidays or certain events.”
Improves acne
“In some people, the pill can improve acne.”
Reduces symptoms of premenstrual syndrome
“The pill may help reduce symptoms of premenstrual syndrome.”
Cancer risk
“The pill reduces the risk of ovarian, uterine and colon cancer.”
Disadvantages of the COCP
Side effects
“To start off with, you may experience some side effects such as a headache, nausea, mood changes or breast tenderness.” ¹
Breakthrough bleeding
“Especially in the first few months, you might experience bleeding on the days you are taking the pill. This is called breakthrough bleeding.”
Protection from STIs
“Unfortunately, the COCP does not protect you from sexually transmitted infections (STIs). Barrier contraception (e.g. condoms) is the only form of contraception to provide protection from STIs.”
User dependent
“This contraceptive method relies on you remembering to take it daily. Sometimes it is helpful to set a reminder on your phone or in your diary.”
Risks of the combined pill
It is important to explain the risks of taking the pill so that the patient is aware and can make an informed decision.
Venous thromboembolism
“There is a small increase in the risk of developing clots in your legs and lungs. There is also a small increase in the risk of having a heart attack or a stroke”
“If you have had any of these conditions in the past, then you should not use the pill.”
“The risk of developing these conditions is increased if you smoke regularly, have a high BMI or if you are immobile for a long period of time.”
Breast cancer
“Research has shown that there is a small increased risk of breast cancer compared to people who are taking non-hormonal contraception.”
“The risk reduces with time after stopping the pill.”
Cervical cancer
“Research has also shown that there is a small increased risk of developing cervical cancer with longer use of the combined oral contraceptive.”
Contraindications of the combined pill ²
A patient cannot take the pill if they:
- are pregnant
- are a smoker and over 35 years old
- are over 35 years old and stopped smoking less than one year ago
- have a BMI of greater than 35kg/m2
- suffer from migraine with aura
- are breastfeeding up to 6 weeks
- have cardiovascular and venous thromboembolism risk factors
Starting the pill and missed pills
This section of the consultation can be quite confusing for the patient. It is therefore important to explain this in a patient-friendly manner, check understanding at regular intervals and invite questions at the end.
Starting the pill
“You can start the pill at any time if you are sure you are not pregnant. You will need to use condoms for the first seven days of taking the pill.”1
Missed pills
One pill missed
If one pill is missed or a new pack is started one day late: “Take the missed pill straight away and continue taking the rest of the pack as normal. Emergency contraception is not required.”
Two or more pills missed
If two or more pills missed or a new pack is started two or more days late: “Take the most recent pill you missed straight away and leave any of the pills you missed before then. Use condoms or abstain from sex for the next 7 days. If you have had sex in the previous seven days you need to seek advice for emergency contraception.”
What to do with the rest of the pack after a missed pill
If seven or more pills left in the pack: “If there are seven or more pills left, then you should finish the pack and have the usual 7-day break.”
If there are less than seven pills left in the pack: “If there are less than seven pills left in the pack then the pack should be finished and a new pack should be started the next day. This means taking the pills back to back.”
Closing the consultation
Summarise the key points back to the patient.
Ask the patient if they have any further questions or concerns that haven’t been addressed.
Throughout the consultation you should check the patient’s understanding at regular intervals, using phrases such as “Can you just repeat back to me what we’ve just discussed regarding…”.
It may also be useful to direct the patient to any websites or leaflets with further information.
Offer the patient time to consider their decision.
Encourage the patient to use condoms if they are not currently using contraception.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Common patient questions
Below are some common questions that patients may have regarding the contraceptive pill. Sometimes, in an OSCE situation, they may ask you one or two questions at the end of your consultation. Having a good answer can be helpful in demonstrating to the examiner that you have a good understanding of the topic.
What happens if I’m sick or have diarrhoea?
If the patient is sick within two hours of taking the pill then they will need to take another one if they are feeling better.
If a patient has severe diarrhoea for more than 24 hours, they will need to take the pill as if they missed a pill and follow the instructions discussed above. This should continue until the diarrhoea is no longer severe.
Which common medicines affect the efficacy of the pill?
Explain to the patient that they should tell you what medicines they are currently taking.
“Some medicines such as some epilepsy medication, HIV medication and St John’s Wort can reduce the levels of contraceptive hormones and therefore reduce the effectiveness of the contraception. You should always check when you start taking a new medication if it will interact with your pill.”
Is it harmful to miss a withdrawal bleed?
It is not dangerous for a patient to miss their withdrawal bleed, also known as taking pills back to back. However, it is important to remind the patient that they may still get some bleeding or spotting.
What should the patient do if they want to try and become pregnant?
Patients are usually advised to stop taking the pill at the end of a pack and wait until after their first natural period before trying to become pregnant. Don’t forget to advise the patient on pre-pregnancy care such as folic acid and smoking cessation.
What should the patient do if they want to stop taking the pill?
Patients are usually advised to stop taking the pill at the end of a pack. However, if they cannot wait it is important to offer information about other contraception to prevent pregnancy.
Is it dangerous to take the pill for a long time?
Other than the risks mentioned above, it is not dangerous to take the pill for a long time.
This is because the hormones do not build up in the body. Furthermore, there is no evidence to show that taking the pill affects fertility.
References
- Fpa.org.uk. (2018). The Combined Pill- Your Guide. Available at: [LINK].
- Harding, M. (2014). Combined Oral Contraceptive Pill (First Prescription) COCP. Patient.info. Available at: [LINK].
