Prescribing Notes

Combined contraceptives

21-Day combined pills are taken for 21 days, followed by a 7-day tablet-free interval.

Phasic combined pills Phasic preparations attempt to reduce overall hormone intake while retaining efficacy by varying the hormone content throughout the cycle. Pills must be taken in the correct order.

Every Day (ED) combined pills contain seven placebo pills (two placebo pills for Qlaira and four placebo pills for Eloine and Zoely). The first pack is started on Day 1 of the period. Additional precautions are not required as packs start with an active pill.

All combined oral contraceptives other than Qlaira and Zoely can be started on Days 1—5 of the cycle (Qlaira and Zoely must be started on Day 1). Alternatively, if reasonably certain the woman is not pregnant, preparations other than Qlaira and Zoely can be started on any other day of the cycle using additional non-hormonal contraception for the first seven days.

Contraceptive patches and vaginal rings may help reduce user failure associated with combined oral contraceptives, ie pregnancy resulting from the user forgetting or failing to take the oral contraceptive correctly and consistently.
Contraceptive patches deliver consistent therapeutic levels of oestrogen and progestogen to the systemic circulation every day over a seven day period. One patch is applied weekly for three consecutive weeks, starting on the 1st day of menstruation, followed by one patch-free week. If the treatment cycle starts after the 1st day, additional non-hormonal contraception should be used for the first seven days.

Vaginal rings deliver consistent therapeutic levels of oestrogen and progestogen to the systemic circulation every day over a 21-day period. One ring should be inserted on the 1st day of menstruation and left in place for three weeks, followed by one ring-free week. If the treatment cycle starts after the 1st day, additional non-hormonal contraception should be used for the first seven days.

Missed pills, missed or detached patches, missed, expelled or broken vaginal rings
It is better if all oral contraceptives are taken at the same time each day, as they can fail if taken late or omitted. A combined pill is regarded as 'missed' if it is taken 24 or more hours late (12 or more hours late for Qlaira). If a single pill is missed, the missed pill should be taken immediately and normal pill taking resumed when the next dose is due with no requirement for additional contraception (see separate instructions for Eloine, Qlaira and Zoely below).

Emergency contraception is not usually required but may need to be considered if pills have been missed earlier in the packet or in the last week of the previous packet. If two or more pills are missed, the most recently missed pill should be taken immediately (earlier missed pills being omitted) and normal pill taking resumed when the next dose is due. Extra precautions must be taken for seven days, and if the seven days run beyond the end of the pack then a new pack should be started immediately and continued without a break. With ED pills, if the seven days run beyond the end of the last active tablet, the seven placebos should be missed and the next pack started immediately with an active tablet. If unprotected sex has occurred in the previous seven days and two or more pills are missed in the first week of a pack, emergency contraception may be required.

If Qlaira is missed in the first 17 days of the cycle, the missed pill should be taken immediately and pill taking then continued in the usual way. Extra precautions must be taken for nine days. If a pill is missed between days 18—24, the current packet should be discarded and a new packet started; extra precautions are needed for the next nine days. If a pill is missed between days 25—26, the missed pill should be taken immediately and pill taking continued in the normal way. Two pills may be taken on the same day if required. If a pill is missed between days 27—28, the missed pill should be discarded and pill taking continued in the usual way.

If Eloine is missed in the first 14 days of the cycle or Zoely is missed in the first 17 days of the cycle, the missed pill should be taken immediately and pill taking then continued in the usual way. If the pill was missed between days 1—7 or more than one pill was missed, extra precautions must be taken for seven days. If a pill is missed between days 15—24 for Eloine or 18—24 for Zoely, the missed pill should be taken immediately and pill taking continued until the active pills are used up; the placebo pills should then be discarded and a new packet started. Two pills may be taken on the same day if required. If a pill was also missed in the previous seven days, extra precautions must be taken for seven days. Alternatively, if no pill was missed during the previous seven days, active pill taking can be discontinued and placebo pills taken for up to four days (including the day the active pill was missed), then a new packet started. If a pill is missed between days 24—28, the missed pill should be discarded and pill taking continued in the usual way.

If a contraceptive patch becomes detached for less than 24 hours it should be reattached or replaced with a new patch immediately. No additional contraception is required. If the patch is detached for more than 24 hours, the user should stop the current treatment cycle and start a new treatment cycle immediately, ie a new Day 1. Extra precautions must be taken for seven days. If a patch is changed late at the start of a patch cycle, a new patch should be applied as soon as remembered, additional contraceptive cover will be required for seven days. During week 2 or 3, if a patch is changed late, but within 48 hours of the scheduled change time, a new patch should be applied and the next patch applied on the usual 'change day'; no extra precautions are necessary. If more than 48 hours have elapsed, the user should stop the current treatment cycle and start a new treatment cycle immediately. Additional non-hormonal contraception must be used for seven days.

If a vaginal ring is accidentally expelled from the vagina for less than three hours it may be reinserted with no loss of efficacy. If the ring has been out of the vagina for longer than three hours during the 1st or 2nd week of use it should be reinserted and additional precautions taken for seven days. If the ring has been out of the vagina for longer than three hours during the 3rd week of use the ring should be discarded then either: a new ring inserted immediately thereby starting a new three-week use period; or, assuming the ring was used continuously for the preceding seven days, a new ring inserted no later than seven days after the previous ring was removed or expelled. If a ring becomes broken during use it should be removed, a new ring inserted and additional precautions taken for seven days. If the ring-free interval exceeds seven days a new ring should be inserted and additional precautions used for seven days. If intercourse took place in the ring-free interval pregnancy should be considered. In case of lengthened ring use, adequate efficacy is maintained up to four weeks; if left in place for longer than four weeks pregnancy should be ruled out before inserting a new ring.

Starting contraception after pregnancy or termination
In non-lactating women, 21-day or 28-day brands may be started 21 days after vaginal delivery provided there are no additional risk factors for venous thromboembolism. Additional contraceptive measures are not required. After a first or second trimester termination, oral contraception may be started immediately. In such cases, additional contraceptive precautions are not required.

Relative risks of venous and/or arterial thrombosis
The incidence in women using combined contraceptives is low. It is higher than in women not using hormones, but still lower than that associated with pregnancy. The excess risk varies according to the progestogen (lowest with levonorgestrel, norethisterone and norgestimate), is highest in the first year a woman ever uses a combined contraceptive and increases with age, obesity, cigarette smoking, family history of thromboembolism, hyperlipoproteinaemia, hypertension, valvular heart disease, atrial fibrillation, major surgery or prolonged immobilisation.

SWITCHING CONTRACEPTION
Switching to combined oral contraception from other methods, whether hormonal or not, can be done at any time in the cycle. Additional contraceptive precautions are required for the first seven days if changing from a non-hormonal method outside the first five days of the cycle. Switching from a levonorgestrel- or norethisterone-only contraceptive to a combined contraceptive may be done on any day of the cycle but extra precautions must be taken for the first seven days (nine days for Qlaira).

Pills to patches If switching from a combined oral contraceptive to patches, extra precautions are not necessary provided a patch is applied on the 1st day of menstruation. If switching from a progestogen-only pill, additional contraception must be used for the first seven days.

Pills or patches to vaginal rings If switching from a combined hormonal contraceptive to a vaginal ring, extra precautions are not necessary provided a ring is inserted no later than the day following the usual tablet- or patch-free interval. If the woman has been using her previous method correctly and consistently and it is reasonably certain she is not pregnant she may also switch on any day of the cycle. If switching from a progestogen-only pill, the switch can happen on any day but additional contraception must be used for the first seven days.