The smart way to learn. The smart way to teach.

MRCOG PART 2 SBAs and EMQs

Course PAID
notes336
EMQ1502
SBA2115
Do you realy want to delete this discussion?
Forum >>

Essay 309 - COCP

Posted by Bindi J.
BJ:

A) Detailed history should be taken regarding parity,last menstrual period, bleeding pattern,dysmenorrhoea and gestational age of miscarriage. Current history of medical conditions of venous thromboembolism(VTE), migraine with/without aura,hypertension(consistently raised systolic blood pressure of >=140 or diastolic of>=90 mm of Hg), myocardial infarction and ischaemic stroke and cancer breast should be asked. History of enzyme inducing medications(Carbamazepine, Griseofulvin, Phenytoin) should be taken. Past history of use of combined oral contraception(COC) or other hormonal contraception and any complications with the use and VTE should be taken. Family history of VTE and cancer breast and cervix should be explored. Social history of smoking should be obtained and if she is a smoker to know how many cigarettes a day she smokes.
Examination includes blood pressure and BMI measurement. BMI>40, smoking>=15cigarettes a day, present or past history of VTE, migraine and hypertension contraindicate the use. The woman is advised to commence COC within seven days of evacuation if she fits into eligibility criteria. Histopathology results should be awaited in case of previous gestational trophoblastic neoplasia prior to commencing COC. Information leaflet should be provided to the woman.

B)
The woman is advised that the use of COC is safe in majority of cases, but can be associated with rare but serious harms. There is 15 fold increase in risk of VTE(with use of Norethisterone or Levonorgestrel containing COC) and 25 fold increase per 100000 women years(with Desogestrel, Norgestimate and Gestodene containing COC). There is a very small increased risk of myocardial infarction, ischaemic stroke and migraine though the absolute risk is low. There may be a small risk in increase of Breast carcinoma but the risk is reduced to no risk after 10 years of stopping COC. There may be a small risk of cervical cancer and this risk increases with increasing duration of use of COC. There is some evidence of hyperlipidemia and effect on carbohydrate metabolism with COC use.

C)
COC decrease dysmenorrhoea by decreasing menstrual prostaglandins, decrease in menstrual blood loss by 50% which helps in correction of iron deficiency anaemia. COC help in treatment of dysfunctional uterine bleeding like metropathia haemarrhagica. There is a decrease in incidence of acute pelvic inflammatory disease, ectopic pregnancy and acne vulgaris. COC decrease benign breast conditions and funtional ovarian cysts. There is a 50% decrease in endometrial and ovarian cancer and this protective effect continues for 15 years after discontinuation of pill. Also, there is decreas in colorectal carcinoma and Rheumatoid arthritis.
Posted by H H.
History taking will help to exclude contraindications to the pill , show suitability of patient to the pill and will give us idea if patient willing to take the pill accurately on regular daily basis.
I will ask her if she has any illness like migrain with focal aura
diabetes,hypertension,history of thrombophilia with venovenous or arterial thrombosis , systemic lupus erythmatosus or inflammatory bowel syndrome.Will ask of personal or family history of breast cancer . Family history of thrombophilia.
I will ask if she previously took the pill,what type, her acceptability and any side effects. Will ask if she is taking medications that might produce enzyme induction like phenytoin,or interfere with enter hepatic circulation of estrogen like antibiotics.
I will ask if she is a smoker and how many cigaretes per day. Will ask about her sexual history and risk of getting sexually transmited disease so as to advise regarding barrier contraception. Will ask regarding her pap smear history.
I will examine her for BMI, and measure BP. Patient just had an evacuation so was assessed vaginally and abdominally. Pills can be started soon after termination.



I will tell her that there is an increased risk of getting blood clots in the legs and that this can also go to the lung. The risk is increased in those pills containing the third generation progesterones,gestodene,norgistimate or desogestrel.
There is also increased risk of breast cancer and cervical cancer. The risk of breast cancer disappear with discontiuation of pill. There is the risk of getting pregnant if she does not use them as prescribed .
There is the risk of deterioration of the medical condition if used in patients with hypertension, diabetes or development of stroke if used in patient with migraine with focal aura.
There is no evidence to support that they increase weight gain .
I will give patient written information regarding about the pills and other contraceptives.




They reduce menstrual blood so that menstruation becomes lighter and less painfull, so will benfit patients having heavy painful periods. There is reduced risk of getting pelvic inflammatory disease , but will not reduce transmission of sexually transmitted dideases. There is a reduction of ectopic pregnancy rate when people on the pill are compared with those not taking them. There is a reduction of functional ovarian cysts. There is about 50% reduction in risk of development of ovarian and endometrial cancer.

Posted by Gowrishankar S.
a)A detailed history including medical conditions (past and present), drugs use(prescription, non-prescription and herbal remedies) and family history should be taken. Specific enquiries about migraine and cardiovascular risk factors (smoking,obesity, hypertension, thrombophilia, previousvenous thromboembolism and hyperlipidaemia) should be made as these could pose specific risks. BP and weight should be checked before prescribing combined oral contraceptive pill(COCP). There is no role for routine thrombophilia screen.

b) The risks associated with COCP are an increase the risk of VTE, MI and ischaemic stroke but the absolute risk is small. There is also an increased risk of breast cancer associated with COC use but the risk is small and is in addition to the background risk which is reduced to no increased risk 10 years after stopping. There may be a very small increase in the risk of cervical cancer with COC use, which increases with increasing duration of use. There may also be a small increase in of cholelithiasis, hepatocellular adenomas and hepatocellular carcinoma.
c) COCP reduces menstrual prostaglandin release thereby reducing uterine contractility and dysmenorrhoea. It is also useful in reduction of menstrual loss in menorrhagia and thereby helping to reduce the incidence of anemia. The incidence of functional ovarian cysts and benign ovarian tumours is reduced.The risk of ovarian and endometrial cancer is reduced by atleast 50% during use and for at least 15 years after stopping. The risk of colorectal cancer is reduced and the symptoms of acne vulgaris can improve. There is also a reduction in risk of ectopic pregnancy and rheumatoid arthritis.
Posted by SRABANI M.
SM
a. Before prescribing COC a clinical history including past and present medical conditions, drug use including prescription ( including liver enzyme inducing drug) , non prescription & herbal medicine ,Family history are very important.She should be asked about migraine ( with/without aura),cardiovascular risk factors including obesity, smoking, hypertension,thrombophilia, previous VTE, hyperlipidaemia .Her BMI should be checked as BMI >=40 is absolute contraindication for COC ( UKMEC 4).Her BP should be checked before prescription as COC is contraindicated if BP is >=160/95 & COC is generally not recommended if BP is consistently >140/90.Knowledge of previous contraception ,sexual and reproductive health including the recent miscarriage is also important. For this lady age is not a problem if there is no other risk factor present including smoking as COC can be continued till 50 yrs if no other risk factor is present. If there is personal history of VTE or known thrombogenic mutation,COC is not recommended .If there is H/O migraine with aura( UKMEC 4 ) and in this lady migraine without aura (as she is > 35), COC is not generally recommended (UKMEC 3 )
b. Risk of VTE is increased with COC & it depends on dose of oestrogen and also type of progesterone ( desogestrel/gestodene containing COC has got two fold increased risk of VTE than COC containg levonorgestrel/norethisterone).Although absolute risk of VTE with COC remains small , still women with F/H of VTE, severe varicose vein,obesity, immobility etc should not be recommended COC.Individuals with inherited thrombophilia has got increased risk of VTE but WHO does not recommend routine thrombophilia screening before starting COC.Very small increased risk of MI & ischaemic stroke with COC.risk of Breast Ca also small & no increased risk 10 yrs after stoppage of COC.Very small increased risk of cervical Ca & increase with duration of use. Risk of liver Ca increases but risk of ovarian , endometrial Ca & colorectal Ca decrease
c. Non contraceptive benefits are treatment for menorrhagia, dysmenorrhea,DUB and anaemia ( related to heavy vaginal bleeding ).It decreases risk of functional ovarian cyst and also benign ovarian tumours),It can be used for acne vulgaris. effect of COC on acute PID and on bone density are conflicting.It is sometimes helpful in PMS, endometriosis , menopausal symptoms but no RCT available.30% reduction of incidence of rheumatoid arthritis noted.No evidence of weight gain & decreased risk of benign breast disease but no data available.also decreased risk of ectopic pregnancy with use of COC

Posted by SRABANI M.
(I would like to add this to my previous answer )I would like to reassure her that COC is generally safe contraception if she does not have certain risk factors as we will discuss .I would also give her a leaflet of COC & advise her how to take the pills
Posted by F N.
37 year old woman is seen on the day surgery unit 3 hours after evacuation of retained products of conception for an incomplete miscarriage. She wishes to start taking the combined oral contraceptive pill. (a) Discuss your clinical assessment prior to prescribing the combined oral contraceptive pill [8 marks]. (b) What will you tell her about the risks associated with use of the combined oral contraceptive pill? [6 marks] (c) Discuss the non-contraceptive benefits of the combined oral contraceptive pill [6 marks]
Blood pressure and pulse should be recorded as to know her baseline BP and if her Bp is raised then other contraceptive options are considered.BMI should be recorded as raided BMI is one of the the contraindication for prescription of OCPs.History about medical disorders like inflammatory bowel disease,clotting disorders should be obtained as OCPs might not be a suitable option in such paients.History of medications like antiepiletic medication,antibiotics should be obtained as the effficacy of OCPs might be effected by it.History of smoking should be obtained as OCPs is not a suitable option if she is a heavy smoker and more than 35 years of age.It is important to assess that she is motivated to take daily tabelet,if she thinks she is not good at taking tabelts or forgets to take it,alternative option shoul be discussed.Details about mentural history should be obtained as it might help to choose the type and frequecy of pill in case of menstural irregularity.
Barrier methods should be emphasized to protect against STIs at the same time.information leaflets should be provided.
b:The risks associated with OCps are raised bilood pressure,weight gain,breahthrough vaginal bleeding,headache,deep vein thrombosis,pulmonary embolisim.These risks should be stratified to her according to the her risk factors.she should be made aware of the failure rate of OCPS in preventing pregnancy.
Ocps are an effective treatment for mennorrhagia,dysmenorhea,dysfuntional uterine bleeding.It can be given In polycystic ovarian syndrome.It can be prescribed to help with symptoms of premenstural syndrome.Certain OCPs are prescribed to help with increased facial hair associated with PCOS.OCps are protective against ovarian and endmetrail cancer.
Posted by Naheed M.
A.
The woman should be thoroughly assessed before prescribing combined oral contraceptive pill (COCP) as presence of some physical and medical conditions make use of COCP hazardous rather than beneficial.

She should be enquired about her general physical health and any history of medical condition such as: focal migraine, hypertension, venous thromboembolism
(VTE), any cardiac disease (uncorrected cardiac valvular disease or cardiomyoathy), systemic lupus erythematosus, acute porphyria, active liver disease
severe inflammatory bowel disease and breast cancer.
The drug history should be asked whether she uses any enzyme inducing drugs such as antiepileptic drugs.

The woman should be asked about the number and outcome of previous pregnancies; use, success/ failure or develoment of complications with any contraceptive method. History of any irregular or heavy menstruation and recent cervical smear report should be asked.

She should be assessed about her compliance, lifestyle and should be asked about smoking in detail.

General physical examination should be performed specially her BMI and blood pressure should be checked.

B.
She should be informed verbally and in written (leaflets)about the risks associated with COCP.
If she smokes (especially heavy smoking) she is at higher risk of myocardial infarction.
The risk of VTE is also higher and depends upon the dose of estrogen and type of progesterone used in COCP. Levonorgestrel and norethisterone increases risk of VTE 15/100,000 women. The third generation (desogestrel and gestodene) increases risk 25/100,000 woman.
There is also higher risk of hypertension, stroke, cholelithiasis, hepatic adenoma and hepatocellular carcinoma.
The risk of breast and cervical cancer is also increased and depends upon the duration of use. 10 years after stopping COCP the breast cancer risk equals to never users.

C.
The non-contraceptive benefits of COCP are: imrovement in the symptoms of certain gynaecological condition such as dysmenorrhea, premenstrual syndrome, chronic pelvic pain and endometriosis-associated pain.
COCP reduces the risk of ovarian, endometrial and colorectal carcinoma, ovarian functional cysts, ectopic pregnancy, development of fibroid, and benign breast disease.
It reduces menstrual blood loss and improves anemia.
The risk of acute pelvic disease is reduced and acne is improved.
Posted by Seham S.
SS

(a)detailed history about her menses,its duration, regularity and if accampanied with dysmenorrea or menorrhagia.Her previous deliveries,its outcome and complications occured.History of migrain,medical diseases as DM, hypertention,epilepsy or any other problems.Drugs still taking as enzyme inducer one which affect efficacy of cocp.Personal or family history of thrombo-embolic diseases(VTE).The result of her cervical smear and timing of last one done.History about her habits as alcohol intake and smoking and if she is smoker ,i will ask her how many ciggarrites per day to assess severity.Examination incude pulse, temperature,blood pressure and BMI should be done.

(b)COC is agood method of conraception regarding its efficacy however,it may have some risks which is not common but can occur in relation to other factors.The most serious one is VTE .Risk is 15/100 000 in second generation pills and 25/100 000 in new third generation pills ,this is applied to cocp contain gestodene and desogestrel but for noregestimate no evidece of increase risk.There is risk of myocardial infarction and stroke especialy if she is smoker, hypertensive and with increasing age.The incidence of hypertention and gall stone disease are increased.compared to non users the risk of cervical cancer is slightly increased especialy in HPV positve patients and is related to duration of use.Breast cancer is also slightly increased in coc users .This incidence is not related to duration of use or family history of breast cancer.Written information could be given.

(c)Beside its contraceptive effect ,coc has other benefits as it decrease the severity of dysmenorrhea,reduce menestrual blood loss so it can help in treating anaemia and affect quality of life.It improve cases with dysfunctional uterin bleeding.COC reduce incidence of functional ovarian cysts especialy in those contain > 50ug ethinyl estradiol . Also,it reduce incidence of ectopic pregnancy but its effect on PID is not clear and coflicting,but it may decrease its incidence through its progestronic effect on cervical mucous.Its use is associated with reduction of benign breast diseases.Low dose coc reduce total lesion and inflamatory lesions of acne.coc reduce incidence of colorectal cancer and reduce ovarian cancer if it is used for 4 and 8 years to 40% and 50% respectively.Also, decrease incidence of endometrial cancer to 50% and 60% if it is used for same duration.
Posted by SYAMALRANJAN S.
A 37 year old woman is seen on the day surgery unit 3 hours after evacuation of retained products of conception for an incomplete miscarriage. She wishes to start taking the combined oral contraceptive pill. (a) Discuss your clinical assessment prior to prescribing the combined oral contraceptive pill [8 marks]. (b) What will you tell her about the risks associated with use of the combined oral contraceptive pill? [6 marks] (c) Discuss the non-contraceptive benefits of the combined oral contraceptive pill [6 marks]


A.COCP can be started immediately after ERPC if there is no contraindication .
Through history about previous contraceptive measures and any problems, previous obstetrical history , medical history ( presence of diabetes, hypertension, hear disease, migranous headache,liver disorder), life-style history(compliance), previous history of blood clotting disorders or an suggestive family , any suggestive of malignancy in family or in her previous history must be enquired meticulously.

Clinical examination of BP, BMI, varicosity or other examinations ( if history suggested) like breast, heart, liver, any pelvic masses.

B..Mild increase in some risks which should be discussed according to WHOMEC (or UKMEC )criteria. Some risks related to increase in cardiovascular disorders, stroke, thrombosis, breast tumour, liver disorders. Progestogenic side effects like mastalgia , headache, nausea, vomiting, fluid retention may be increased.

C. Some benefits are there related to COCP use. Menstrual disorders like menorrhagia, dysmenorrhoea, intermenstrual bleeding, metrorrhagia might be improved. Decreased risk in benign breast diseases, ovarian cystic diseases, endometrial ca, ovarian ca, endometriosis, fibroid, premenstrual syndrome. Sometimes improvement may be found in CPP.
Posted by L S.
a) Detail history to exclude contraindications to combined oral contraception pill use (COCP), if she smokes cigarettes or had a previous history of thrombosis. Family history of venous thromboembolism (VTE), thrombophilia(Factor V Leiden, antithrombin III) or venous varicosity should be explored. Her medical history, if she has ischaemic heart disease, poorly controlled diabetes or has focal migraines enquired. Is she at risk of trophoblastic disease? Best to wait for HCG values prior to prescribing COCP. Her body mass index (BMI) should be determined as BMI of more than 39 are contraindicated for COCP use. Her blood pressure (BP) should be checked to confirm she is not hypertensive especially BP of more than 160/100mmHg are at risk. Her lifestyle history would determine which method of COCP to prescribe so that compliance can be ensured. Once all contraindications to COCP use have been excluded she should be advised on type and methods available. If she has any of above conditions for which the use of COCP is associated with unacceptable health risk, she should be counselled on alternatives to COCP.
b) Risk with COCP use is VTE which is associated with the dose of ethinyl estradiol and the type of progestogen. The higher the dose of estrogen the risk of VTE increases which is 10 folds for dose over 50mcg ethinyl estradiol, 7 fold increase for 50mcg and 4 fold increase with less than 50mcg. As for the type of progestogen, second generation is associated with 15/100000 risk of VTE and increases in third generation to 25/100000. The VTE risk in general population not taking COCP is 5/100000 and in pregnancy is 60/100000. VTE risk is increased further if there is concurrent risk of obesity, thrombophilia and other risk discussed above. Breast cancer has been associated with current users of COCP. However this risk is independent of duration of use and related to age of discontinuing COCP. Cervical cancer risk is found increased with increasing duration of COCP use. If she smokes, she will be at risk of myocardial infarction as she is at age more than 35. Myocardial infarction and stroke was found increased with COCP users who are hypertensive. Using COCP will also increase her risk of developing hypertension and liver disease like cholilithiasis, hepatocelular adenoma.

c) Non contraceptive benefits are low dose COCP reduces dysmenorrhoea by reducing prostaglandin release and contractility. Menorrhagia is improved by low dose COCP which reduces blood loss up to 43% in menstruating women leading to reduced incidence of iron deficiency anemia. There is reduction in risk of benign breast diseases like fibroadenomas in COCP users. Women with dysfunctional uterine bleed who take low dose COCP showed significant improvement of quality of life with regularity of their cycle. Low dose COCP is associated with total improvement of acne for women who suffers from this skin condition.
Posted by S S.
(a)The clinical assesment will be based on the UK Medical Eligibility Criteria for prescribing COCP. A history of medical problems inwhich COCPs are contraindicated should be taken like hypertension >/=160/95, heart disease, complicated diabetes, migraine, current or history of thromboembolism and thrombophilias. COCP avoided if she is a heavy smoker or her BMI>/=40 as there is increased risk of thrombosis. A drug history should also be taken as alternative methods are advised if she is on long term enzyme inducers.
(b)The risk of breast cancer is increased ( evidence conflicting). This risk disappears after 10 years of stopping COCP. There is a small increase in the risk of cervical cancer and hepatocellular carcinoma. The risk of thromboembolism is also increased to 15-25/100000 from a background of 5/100000.
(c)It is used in polycystic ovarian syndrome to induce withdrawl bleeds and hence decrease the risk of endometrial cancer. Dianette containing cyproterone acetate and Yasmin containing drosperinone with their anti androgenic effect are effective in hirsuitism and acne. COCPs are also effective in endometriosis related pain when used continuously. In premature ovarian failure, especially in young women they are used as hormone replacement therapy. They are also used in premenstrual syndrome, uterine fibroids and perimenopausal heavy and irregular bleeding after excluding endometrial pathology.
Posted by Shamita S.
(A) Assesment of the woman before starting her on COCPills should include a personal history of VTE or known thrombogenic mutations as the use of COCPills is associated with an increase in incidence of VTE ,a history of migraine with aura or without it should be taken as at this age migraine without aura is also contraindication for use of cocpills as there is a small increase in risk of ichemic stroke ,other medical problems like diabetes ,active liver disease severe inflamatory bowel disease or SLE should be loked for as they are contraindications for use.Personal history of smoking to be taken as smoking in women>35 yrs is associated with higher risk of stroke.Examination should include estimation of BMI ,as use of cocpills with BMI >35 is associated with increased risk of MI and VTE ,hence not recomended,The BP shoud be recorded as a bp which is persistently >140/90 is not recommended for use of ocpills.There are no inveswtigations to be done routinely before prescriptions ,but if there is a significant family history of thromboembolism ,trombophilia screening to be done before precription of cocps.
(B) The COCPills are safe and reliable method of contrception but is associated with an increased risk of in the development of venous thromboembolism from 5per 10,000 nonpill users to 15-30 per 10,000 pill users the risk reduces to non pill users within 3 months of stopping pills.
There is an association between pill users and myocardial infarction ,this is mainly related to smoking and and other riskn factors as high b.p, diabetes .For those who do not have these risk factors have little chances of MI.
It is associated with increased risk of ischaemic and and haemmorrhagic stroke ,higher in women who are hypertensive and smoke .there is an increase in risk of breast cancers in pill users,compared to never users there is an increase in cervical cancers with increasung duration of use.a small increase in hypertension witnh use of cocpillds is seen and also an increase in liver diseaes .
(C) Apart from being an effective contraceptive it has many benifits. The COCPills cause a reduction in menstraual cycle disorders such as mennorraghia and so a reduced incedence of iron deficiency anemia in users there is reduction in dysmenorhea both at entry and after 5 yrs use it is also associated vwith reduction in the size of fibroids ,with symptomatic releif of endometriosis ,.It offers protection from benign breast disease and benign ovarian cysts .it also protects against ectopic pregnancy as comparede to non users ,there is a reduction in acute pelvuc inflammatiry diseses .Pill users are assiociated with reduced risk of developing endometrial cancers and ovarian cancers .
Posted by Im F.
A
COCP is a reliable method of contraception with a efficacy of 99 %and safe in majority of users.Initial assessment will include history of menstrual cycle ,regularity ,duration bleeding whether heavy or not. The parity of the women and complications during prev pregnancy eg PE ,VTE,DM or history of molar.History of recurrent abortion suggestive of APS .Family history of breast cancer or cervical ca. History of medication enzyme inducers eg antiepileptics or antibiotics which reduce the efficacy of cocp .Social history including drug abuse or smoking ,alcohol abuse.Previous history of any major surgery such as cardiac surgery .Previous contraceptions and pap smears reports .history of migraine.

Examination blood pressure and BMI should be documented.,breast examination check for any varicose veins
rewiew histopathology report before starting COCP.

B
She needs to be compliant to medication or it might loose its efficacy and end up in pregnancy or bleeding..It is associated with stroke which is rare before the age of 45. ,increase risk of cerebrovascular accidents and VTE esp if thers a family history of thombophelia.or shes obese or suffers from varicose veins.Smoking and intravenous drug abuse will increase the risk of VTE. .theres a small increases in risk of breast ca cervical cancer which risk increases if theres afamily history. Theres increased risk of MI.

C
It will reduce the amount of bleeding which reduce the incidence of anemia.
Dysmenorrhea will be reduced.Protective against ovarian and endometrial (50% reduction )cancer. Skin condition acne hirsutism will imrove and reduction in lesions.
Incidence of ectopic pregnancy and pelvic inflammatory disease is reduced.

im
Posted by drvimaladkm@yah K.
Her previous menstrual cyclical details regarding regularity,amount & duration to be noted. Her parity and current status of lactation to be noted.Details of previous usage of any contraception & its side effects & her compliance to therapy to be marked.
Previous episodes of Deep venous thromboembolism,Migraine with aura, chronic liver disease ,uncorrected valvular diseases contraindicate use of oral contraceptive pills.Family history of inherited Thrombophilia especially FactorVLeiden increases (8 fold increases to33)the individual risk of thromboembolism much more.However routine thrombophilia screening is not recommended.Any history of prior treatment for breast malignancy also contraindicates use of oral pills. Her habits of smoking or alcoholism to be considered. Clinically her Body mass Index, blood pressure to be recorded as more than 160/100 mmof Hg blood pressure is contraindication for usage of oral pills.3rd generation of COCP should not be prescribed in presence of severe varicosities, morbid obesity(40Kg/mt2of BMI). Systemic disorders & sepsis to be excluded.Presence of Diabetes is not a contraindication for the use of lowdose oral contraceptive pills.
B. The oral pills are safe for the majority of women though rarely associated with serious harms. There is a small risk of blood clot formation in some women. There is also a very small increased risk of heart attack & stroke. Breast cancer risk is also increased to some extent but once pills are stopped,the risk returns to background risk.
Cervical cancer risk increases to a very small extent depending on the increasing duration of usage.
C.Non contraceptive benefits of oral pills are on the menstrual cycle. women with menorrrhagia get 43% reduction in menstrual blood loss along with relief of dysmenorrhoea in severity compared to nonusers.Low dose Oral pills reduces iron deficiency anemia in menstruating women. It reduces the incidence of ectopic pregnancy.The incidence of ovarian functional cysts are reduced with oral pills containing 50mcg doses of oestrogens.Benefit is not seen with low doses of estrogens.
Benign breast disease & acne is also decreased. There is a 30% reduction in the incidence of rheumatoid arthritis in pill users.

Posted by mno C.
A. I would ask either she is certain about her decision. She might not be able to make an appropriate choice following a miscarriage. Her previous history of contraception and their effectiveness need to be asked. Reason of any failure of contraception of choice need to be determined either due to poor compliance and method of usage that may be able to be reemphasised. I will ask her that she is aware of other method of contraception including its benefit and risks of each method. This is also includes the choice of male contraception. I will ask her parity and her intended family size. Her duration of contraception need to be determined whether she want it temporary, long term or permanent contraception. Her menstrual history should be asked whether has irregularities, dysmenorrhoea and menorrhagia that may alter her choice of contraception. Her past medical history like migraine, fulminant liver disease, inheritance thrombophilia need to be asked as these may contraindicate her choice. Medical history like taking liver enzyme inducer like antiepileptic drug need to be asked. Her social history of smoking need to be asked as this may contraindicate her choice. On physical examination, her BMI need to be calculated as she might be not suitable for COCP or a higher dose for effective contraception.

B. The risk of taking COCP should be informed including failure rate that may result unwanted pregnancy. The complication of individual component like progesterone my cause bloatedness, water retention, nausea, vomiting should be informed. Risk of oestrogen like headache, nausea vomiting should be warned. The risk of deep vein thrombosis if she undergoes major surgery, and she should be aware that she needs to stop about three months prior to the operation. Possible drug interaction should be informed.

C. Non contraceptive benefits include regulation of menstrual disturbance up to 45-50% of cases. It also reduces the amount of menstrual loss in menorrhagic patient and this may lead to correction of anaemia in patient who is anaemic secondary heavy menses. I t may then lead to improvement fecundity and fertility of patient. It also reduces pain in patient suffering dysmenorrhoea. It reduces incidence of benign breast disease, functional ovarian cyst and ovarian cancer. It reduces the risk of ectopic pregnancy in comparison to non user. It is also proven to reduce the risk of pelvic inflammatory disease.
Posted by Dr Dyslexia V.
X

a) Clinical assessment to include history of smoking, history of venous thromboembolism, hereditary thrombophilia such as factor V leiden, migraine and liver disease should be sort. Other history such as previous contraception usage and the failure of it as to address compliance of medication issue.

History of other drugs such as antiepileptic drugs or anti tuberculosis drugs such as rifampacin could interfere with the usage of COCP should also be gathered.

Her sexual history to ascertain if she has multiple sexual partners as an additional need will be required for STD protection.

Her menstrual history is also taken as the usage of COCP’s could address her menstrual irregularities if present.

Her examination should include her body mass index as obesity is a relative contraindication for COCP’s. Her blood pressure should be also taken as hypertension is also a relative contraindication for COCP’s. Presence of acne or hirsutism is also assessed as this are additional effects which could be addressed by COCP’s.

b) The risk include possibility of COCP failures as it has a pearl index of 0.1 with proper usage. There is also no benefit in the prevention of STD while using COCP.

There is also an increase in the incidence of venous thromboembolism during its usage. It is also associated in weight gain. There is a added risk of myocardial infarction, stroke, if patient has co-morbodities such as hypertension. The incidence of CA cervix is also increased with years of usage compared to background. There is a risk of increased breast cancer associated with the usage of COCP.

There is also increase risk of cholelithiasis and other liver disease associated with usage.

c) None contraceptive benefits include having better regulation of menstrual cycle, decreased incidents of dysfunctional uterine bleeding. It could also help in cases of patients with hirsutism and acne associated with PCOS. There is a relative protection against ovarian and endometrial cancer by about 50%. There is also a benefit against increase incidents of colorectal cancer.
Posted by shmaila S.
a)In order to advise on eligibility for combined oral contraceptive pills(COC),medical history of past and current illnesses should be taken.History of hypertension shoul be taken as COC is generaly not recommended when BP is consistently >140 systolic and >90 diastolic.Personal history of Venous thromboembolism or known thrombogenic mutation as COC is not recommended in the presence of such history.COC is contraindicated if there is current or history of Ischaemic heart disease.Migraine with or without aura,is a contraindication for COC use at this age.Current or past history of breast cancer or carrier of BRCA1 mutation should be enquired about,as COC cannot be prescribed for such woman.Enquiry should be made about smoking,as it is a risk factor for MI,VTE and stroke.Any history of liver enzyme inducing drugs (rifampicin,anticonvulsants) and non prescribed drugs (eg st johns wort) should be taken as the efficacy of COC is reduced with these drugs.COC is not recommended with a family history of VTE in first degree relative at less than 45 years, as it may indicate an increase likelihood of hereditary thrombophilia.History of previous contraceptive use menstrual history and sexual health history should also be taken.Before prescribing her BP should be checked.BMI should be documented as COC is not recommended with a BMI > 35years as it is associated with an increase risk of MI and VTE.A thrombophilia screening is not recommended routinely.
B) She should be informed that COC use is safe for majority but can be associated with rare but serious harms.There is a small increase in the risk of heart attack and two fold increase in the risk of stroke.COC is associated with upto five fold increase in relative risk of VTE, but in absolute terms the risk is still very low.There is small increase risk of breast cancer but returns to no increased risk ten years after stopping pills.There is small increase risk of cervical cancer which increase with increased duration of use (two fold inreased risk in 10 years).
C ) Dysmenorrhoe and menorrhagia improves with COC use.The incidence of benign ovarian tumours and functional ovarian cysts is reduced with COC use.There is atleast 50% redcution in risk of ovarian and endometrial cancer and the effect last for more than 15 years.Associated with a reduction in the risk of colorectal cancer.COC can improve acne vulgaris.Some studies have suggested that there is a reduction in benign breast disease and incidence of rheumatoid arthritis with COC use.
Posted by tahira jabeen J.
a)as this pt post evacuation should be dealt in sympathetic manner due to her preg loss.she wants cocp she will be assessed by taking detailed history including her parity,previous preg out comes,no of abortions as if she had recurrent abortions or she is known to have anti phospholipid syndrome risk outweighs the benefit .her menstural history if she has menorrhagia or dysmanorrhoea or irregular cycles as it will increase benefit of cocp.her social history if she smokes 15 cig /day &is 37 years she belongs to category 4 according to WHO eligibility criteria and its absolute contraindicated to give her cocp.her past medical history if she has HTN,diabetese,thrombophilias,migrain,IHD,stroke .her drug history if taking any drugs like antiepileptics,or pther drugs which will have intractions,.if she had cocp in past & any assosiated problems.h/o breast cancer as it is absolutly contraindicated.h/o pap smear & its result as cocp increases risk of cx cancer.
her BMI as >30 will be assosiated with risks.,past history of vte,family h/o vte or thrombophilias. b) risks assosiated with cocp will be mild side effects like nausea,breakthrough bleeding,chloasma,wt gain. more serious risks assosiated with cocp is increased risk of VTE which will be 3 folds icreased & more with third generation progestogens .risk will be as non users3/12 after stopping pills.risk is more in ist 4/12 after starting the pills.increase risk of cx ca about 2 folds.a small increase in risk of breast ca.if associated with somking there is increased risk of stroke &hyperlipidemia,IHD.l failure rate with perfect use is less than 1% but with typical use is about 5%. c) noncontraceptive advantages influence the acceptibility of cocp are decreases blood loss during mensturation so will help tp improve hb.decreases dysmanorrhea,PMS & regulates the cycle.some of cocp like ones containing ciproterone will improve acne or hirsuitism.decrease riskof ovarian &endometrial ca 50% after 5 years use.cocp helps in enomerium proliferationin ASHERMAN synd although estrogen alone is more effective.cocp can also help in improving symptoms of endometriosis if continously used for 3 months without break.
Posted by Mohammad A.
Patient should be evaluated clinically for her general condition, vital signs, pain and vaginal bleeding. She should be discussed about the procedure done for her, findings and waiting for histopathology of retained products of possible molar pregnancy, this may take couple of days. If so, she may need for further investigations and different follow up. She should be counseled for the most common symptoms and warned for possibility of pain, bleeding, fever and provided with specific medications. She should also, provided with patient’s information leaflet. She should be counseled regarding the different contraceptive options. Combined oral contraceptive pills (COCP) is not advisable with patients with high BMI (more than 30) as it may increase the incidence of deep venous thrombosis (DVT) also, its efficacy may be altered with increasing body weight. Her medical history should be reviewed and to be asked about personal history of DVT, hypertension, diabetes mellitus, migraine and liver disease. Her family history of DVT wit positive thrombophilia screen may be contraindicated for COCP. Also, the risk of breast cancer is higher of positive family history. She may start to use the COCP directly after procedure. She patient should be informed about the types of COC, first, second and third generation, biphasic and triphasic and local patches or vaginal ring and if she faced any problem with of them to prescribe the best option. She may be offered other options for contraception available with patients’ information leaflet.
The incidence of DVT increased significantly in cases of specific generation of progestogen (Desogestryl and Gestoden) to 15-30/ 100,000. Break through bleeding may be higher in COCP with low dose oestrogen component. Headache, gaining weight, breast tenderness and bloating are related to progestogen component in the pills. Persistent headache, migraine is an indication of COCP to be discontinued. The pearl index of COCP is about 1% and its effect may be altered in cases of gastroenteritis and antibiotics of enzyme inducing character.
There are several non contraceptive benefits of COCP, there is decrease incidence of simple ovarian cyst and endometriosis. It also reduce the fibroid size. It has great effect in cased of menorrhagia as, the blood loss was significantly reduced. It help to regulate the period in cases of oligomenorrhoea, polycystic ovarian syndrome. It reduce the incidence of benign breast lesions. Some forms of progestogens like doprinone, cyproterone acetate may help in case with hirsutism. On the other hand they may reduce the incidence of endometrial and ovarian cancer.
Posted by Mohammad A.
sorry for such fault,
(MA)
a) Patient should be evaluated clinically for her general condition, vital signs, pain and vaginal bleeding. She should be discussed about the procedure done for her, findings and waiting for histopathology of retained products of possible molar pregnancy, this may take couple of days. If so, she may need for further investigations and different follow up. She should be counseled for the most common symptoms and warned for possibility of pain, bleeding, fever and provided with specific medications. She should also, provided with patient’s information leaflet. She should be counseled regarding the different contraceptive options. Combined oral contraceptive pills (COCP) is not advisable with patients with high BMI (more than 30) as it may increase the incidence of deep venous thrombosis (DVT) also, its efficacy may be altered with increasing body weight. Her medical history should be reviewed and to be asked about personal history of DVT, hypertension, diabetes mellitus, migraine and liver disease. Her family history of DVT wit positive thrombophilia screen may be contraindicated for COCP. Also, the risk of breast cancer is higher of positive family history. She may start to use the COCP directly after procedure. She patient should be informed about the types of COC, first, secod and third generation , biphasic and triphasic and local patces or vaginal ring and if she faced any problem with of them to prescribe the best option. She may be offered other options for contraception available with patients’ information leaflet.

b) The incidence of DVT increased significantly in cases of specific generation of progestogen (Desogestryl and Gestoden) to 15-30/ 100,000. Break through bleeding may be higher in COCP with low dose oestrogen component. Headache, gaining weight, breast tenderness and bloating are related to progestogen component in the pills. Persistant headache, migraine is an indication of COCP to be discontinued. The pearl index of COCP is about 1% and its effect may be altered in cases of gastroetritis and antibiotics of enzyme inducing character.


c) There are several non contraceptive benefits of COCP, there is decrease incidence of simple ovarian cyst and endometriosis. It also reduce the fibroid size. It has great effect in cased of menorrhagia as, the blood loss was significantly reduced. It help to regulate the period in cases of oligomenorrhoea, polycystic ovarian syndrome. It reduce the incidence of benign breast leasions. Some forms of progestogens like doprinone, cyproterone acetate may help in case with hirutism. On the other hand they my reduce the incidence of endometrial and ovarian cancer.
Posted by Ulduz A.
a)
Women can start on COCP within 7 days of evacuation.But she needs to know that better to wait for histopathology of RPOCs to rule out molar pregnancy.
Clinical asssessment includes histoiry taking and examination.
History of migrane with aura,smoking,medical problems as HTN.DM,previous or current thromboembolism,brest cancer,liver disease,cardiovascular disease are contraindications for COCP use.
Examination includes BP measurement and BMI.Routine blood tests as thrombophilia screen, mammogram,Pap smear is not requested.
b)Clear information about risks and benefits of COCPs should be given to let the women to make an informed choice.It should be stated that that risk of VTE is increased with COCP use from 5/100 000 to 15/100 000 with second-generation pills.Risk of cardiovascular disease and stroke.Risk of breast cancer is inreased but returns to normal after 10 years after stopping COCPs.Risk of cervical cancer is increased but thought to be due to liberal sex practices(no barrier contraception,multiple partners).Written information and further appointment to disscuss patient concerns to be given.
c)Advantages including decrease in menstrual loss and pain,cycle control can be used to treat menstrual problems.COCPs are decresing incidence of ovarian cysts and ovarian cancer.The effect persists 10 years after stopping the pills.COCPs used in the symptom control of PMS and endometriosis.Incidence of PID is decreased due to cervical mucus thickening.COCPs are improving skin conditions as acne.Written information and further appointment provided.
Y from Saudi Arabia :)
Posted by AFSHEEN M.
A 37 year old woman is seen on the day surgery unit 3 hours after evacuation of retained products of conception for an incomplete miscarriage. She wishes to start taking the combined oral contraceptive pill. (a) Discuss your clinical assessment prior to prescribing the combined oral contraceptive pill [8 marks]. (b) What will you tell her about the risks associated with use of the combined oral contraceptive pill? [6 marks] (c) Discuss the non-contraceptive benefits of the combined oral contraceptive pill [6 marks]


A detailed history should be taken to exclude all the contraindications. COCP should not be prescribed to those who have a personal or family history of venous thromboembolim or personal history of thrombophilias.Obese women with BMI of 35 should avoid its use; in those with BMI 35-39, the risks outweigh benefits and in those with BMI >40, other alternatives should be prescribed.Also, should be avoided in smokers over 35 years of age;and those with persistent high BP of >140/90 mm Hg. It should also be avoided in women with history of focal migrane with aura,hisory of ischemic stroke or previous myocardial infarction.
Examination should include calculation of BMI and BP measurement. Also lower limbs should examined for severe varicose veins.
Other alternatives should be discussed and most suitable method according to woman life style prescribed.Pill teaching should be undertaken and advice on missed pills should be given.A follow up review appointment should be made.


b)I will inform her about increase in the risk of VTE,which is related to the dose of estrogen and type of progestogen.It is increased especially with the use of second and third progestogens and therefore, should be avoided in those who are obese or have personal or family history of VTE or history of thrombophilias.Universal screening prior to use is not recommended except in high risk.
Risk of breast cancer is increased; however returns to none after stopping pill for 10 years. Risk of cervical cancer is increased. Risk of myocardial infarction is increased in smokers over 35 years of age and those with hypertension.Risk of ischemic stroke is increased especially in those with history of focal migraines.Haemorrhagic stroke incidene is increased in those with history of hypertension.COCP is associated with small increased risk of high BP.Risk of liver disease and gallstones is increased.


c)Low dose COCP is associated with reduction in menstrual blood flow in menorrhagia and dysfunctional uterine bleeding and therefore decreases incidence of anemia in these patients. It also reduces prostaglandin release and can be used for treatment of dymenorrhea.High dose ethinylestradiol(50mg) COCP have been associated with reduced incidence of functional ovarian cysts, however not with low dose COCP.It also reduces incidence of ectopic pregnancy and possibly acute PID due to effect on cervical mucus. Low dose COCP is associated with reduction of acne.tHere is approxiamtelt 30% reduced incidence of rheumatoid arthritis in COCP use.
Posted by SUNDAY A.
Sunday’s answers
a) Clinical assessment prior to COCP is essential and should focus on exploring the suitability of the proposed treatment and avoidance if obvious contraindication is present. The patient must be made aware of the benefits and risk of the COCP and informed of alternative such as mini-pills, Hormonal injectables and implanon and intrauterine device, sterilisation. Past gynaecologic and obstetrics history with regard to previous and present sexual history and orientation, PID/ STI, previous pregnancy outcome and complication should be elicited. History of abnormal vaginal bleeding , previous use of COCP and any side effect should be asked as well as personal and family history of Breast cancer, deep vein thrombosis, varicose veins, pulmonary embolism, hypertension, Diabetes , thrombophilia . History of smoking, alcohol, drugs- use of hepatic inducing drugs which reduce the efficacy of COCP should be elicited. Then the Body mass index (BMI) should be calculated because the use of COCP is contraindicated if BMI >40 and Blood pressure should be checked as COCP is contraindicated if BP >160/90mmHg according to the FSRH guidelines. Once there is no absolute contraindication , then the patient should be informed to ideally wait for the result of the histology from tissue obtained from the evacuation of retained products to exclude trophoblastic disease prior to starting the COCP. Undertaking a thrombophilia screen is not indicated prior to prescribing COCP.
b) The greatest risk with COCP is the risk of venous thromboembolism which correlates with the dose of the oestrogen component and duration of use with the risk greatest at the 1st year of treatment and increased with age> 35years and the presence of other risk factor such as personal or family history of thrombophilia . The risk of breast cancer is highest at the commencement of use and rapidly reduces to the risk of non users 10 years after stopping COCP. The risk of cervical cancer should also be discussed and that of myocardial infarction particularly in this age group according to the WHI study which correlates with duration of use and dosage of the oestrogen component. There is also small risk of Hypertension while on COCP and risk of haemorrhagic stroke.
c) The non contraceptive benefits of COCP would include reduction of menorrhagia, dysmenorrhoea, dysfunctional menstrual bleeding with improvement in the quality of life of the user and objective reduction in anaemia. Menstrual cycles become regular, light with reduction in menstrual pain. There is also reduction in the risk of developing ovarian cyst, colorectal cancer, ovarian and endometrial cancers in COCP user with risk reduction between 45-60% after 4-6 years of use. Using COCP reduces the risk of ectopic pregnancy, PID compared to non contraceptive user as well as reduction of benign breast disease.
Posted by sutha  C.
SC
a) Clinical assessment of the patient would include a detail history of previous contraception she has used and if there were any problems with the medication. A menstural history is also important, looking into if she has complaints of menorrhagia, her cycle length and dysmenorrhoea. Medical history of myocardial infarct, Venous thromboembolism,migrane with or without aura, hypertension and liver disease is important as these are contraindication to the use of Combined oral contraception (COC).

Posted by sutha  C.
SC - Sorry my previous answer was incomplete.

a) Clinical assessment of the patient would include a detail history of previous contraception she has used and if there were any problems with the method . A menstural history is also important, looking into if she has complaints of menorrhagia, her cycle length and dysmenorrhoea. Medical history of myocardial infarct, Venous thromboembolism, migrane with or without aura, hypertension and liver disease is important as these are contraindication to the use of Combined oral contraception (COC). History of breast cancer and cervical cancer is also important.

History of smoking is asked into as it is a contraindication to the use of COC. Past history of breast and cervical cancer is also enquired into. Family history of VTE is enquired. She is also asked if she is on any long term medication that can alter the efficacy of COC like hepatic enzyme inducing drugs like carbamazepine, phenotoin and rifampacin.

Examination of the patient involves taking her blood pressure looking for evidence of hypertension. Her BMI is also important as COC are contraindicated in patients with BMI > 30. Examination for varicose veins is done as it is a contraindication for 3rd generation COC.

b) She should be reassured that COC is generally safe but there are a few rare complications. There is an increase in the incidence of Breast Cancer among patient who take COC, however the risk is reduced to that of non user 10 years after stopping the medication. The risk for cervical cancer is also increased. VTE risk is also increased with the use of COC though the risk is very small. There is an increase in incidence of myocardial infarct and stroke in patients whom are smokers and hypertensive when they are on COC. There is also risk of developing cholelithiasis and hepatocellular cancer in high risk patients with underlying liver problems.

c) With the use of COC, there is reduction of menstrual prostaglandin, thus reducing uterine contractability and dysmenorrhoea. There is also a 40% reduction in menstrual blood loss thus improving anaemia and iron stores in the body. Preparation containing 50umg or oestrogen preparation has been proven to reduce the incidence of functional ovarian cyst. Low dose COC can help improve acne and reduce the risk of benign breast disease.
Posted by Green K.
Green:

a) Patient\'s planned inter-pregnancy interval as this would influence the choices of appropriate contraception. Detailed previous menstrual history with regards to regularity, duration and amount of bleeding. Previous contraception(s), duration of use, acceptance and problems associated with them. History of smoking with as it is associated with increased risk of venous thromboembolism (VTE). Personal history of VTE or family history of VTE (age of onset <45 years) as it would be a contraindication for COCP. History of hypertension and hyperlipidemia would put her at increased cardiovascular risk. History of medical illness like migraine with or without aura as it can be made worse while on COCP. Drug history with regards to enzyme inducers and antibiotics intake as it influences the efficacy of COCP. Smear history and history of breast cancer would be enquired

Examination would involve assessment of blood pressure to exclude hypertension as it is a known cardiovascular risk factor and COCP not recommended if BP> 140/90mmHg. BMI calculated as obesity especially with BMI >35kg/m2 is associated with increased risk of myocardial infarction and venous thromboembolism.
Thrombophilia screening will not be done routinely but if done for having a family history of VTE, would need to be interpreted by a hematologist as it may not totally exclude thrombophilic mutations.

b) Increased risk of VTE depending on type of progestogen used (3 to 5 fold increased) but the absolute risk is small (15- 25 in 100,000 woman-years). Increased risk of stroke and myocardial infraction especially if obese and hypertensive but absolute risk is small. Small increased risk of breast cancer in addition to background risk but is reduced to no risk after 10 years of stopping. Increased risk of cervical cancer (invasive and insitu carcinomas) which increases with duration of use. 10% increase after 5 years of use and 20 % after 10 years.

c) COCP is associated with a reduction in risk of benign ovarian tumors and 50% reduction in risk of endometrial and ovarian carcinomas. Protective effect persist 15 years after stopping. Reduction in menstrual loss and dysmenorrhoea. May improve symptoms of acne vulgaris mainly COCP containing desogestrel and levonogestrel and cyproterone. Reduction in risk of colorectal carcinoma.
Posted by shmaila S.
respected DR PAUL,plz correct my answer also.i posted on 6jan.thanks
Posted by Lilantha W.
(a) Her benefits of using combined oral contraceptive pill (COCP) should outweigh the risks. I would explore them according to the UK medical eligibility criteria with a clinical history and physical examination. I would go through her case notes first, that objective assessment of her past medical and investigations history can be revealed.
Risks of developing venous thromboembolism (VTE) is very high if she is a thrombophilic e.g. Antithrombin III deficiency, Factor V Leiden homozygos, protein c deficiency, antiphospholipid syndrome; or personal history of oestogen related VTE or current smoking or in severe obesity or immobility which may be as a result of paraplegia. This risk is moderate if she has a family history of VTE, history of recurrent or mid-trimester miscarriages, stillbirth or BMI>30kg/m2, inflammatory bowel disease. The risk of VTE is higher with the third generation COCPs; hence, her choice will be discussed further. Risk of stroke and ischaemic heart disease become high if she has focal migraine, previous TIA or stroke, hypertension, severe heart disease if other cardiovascular risk factors such as diabetes, arteriopathy , hyperlipidaemia and smoking. Active liver disease or current breast cancer are absolute contraindications as COCP will worsen the prognosis. Strong family history of breast cancer is a relative contraindication. Active PID and undiagnosed uterine bleeding are contraindications for COCP. If we suspect molar pregnancy with current miscarriage, COCP should be withheld until proven otherwise or until BHCG becomes normal.
Contraceptive history would provide valuable information with regards to choosing the best contraceptive. Patient’s preference and tolerance with particular contraceptives should be explored and discussed. Drug side effects should be asked. Non-contraceptive benefits of COCP such as relief of secondary dysmenorrhoea, menorrhagia, DUB might be the reason why patient requesting COCP. Potential drug interactions should be addressed such as hepatic enzyme inducers e.g. phenytoin, carbimazole in epileptics and anti-TB medication like rifampicin, isoniazid. Patient’s lifestyle, sexual practices and previous contraceptive failures should be taken into account.
Examination includes measurements of height and weight (and calculation of BMI), blood pressure, auscultation of the heart, and detection of any apparent issues with mobility. Examination of the abdomen, neurological system and breasts may be carried out, if lesions are suspected.
(b) I will tell her that at the age of 37, the risk of VTE is the main concern, particularly if she has additional risk factors such as current smoking BMI>30kg/m2, previous VTE or if she is a thrombophilic. Some thrombophilias carry a very high risk of VTE e.g. Antithrombin III deficiency, carrier of factor V Leiden or prothrombin gene defect. Risk of stroke or heart attack is high if she has migraine with aura, previous TIA/stroke, strong family history of ischaemic heart disease.
COCP increases risks of developing liver disease and breast disease. Risk of developing breast cancer is high if she has a strong family history of breast cancer or if she is carrying BRCA 1 or BRCA 2 genes. COCP worsens the outcome of current liver disease, if used concurrently. COCP increases risk of hepatoma and hepatocellular cancer. Prevalence of gallstone disease is high amongst COCP uses.
There is always a risk of experiencing side effects of COCP such as bloatness, breast tenderness, mood swings, change in libido or breakthrough bleeds. Although the failure is unlikely with COCP, it can be higher with the typical use. Risk of heavy breakthrough is high with continuous use of COCP. If COCP started soon after a molar pregnancy, it may increase the risk of having chemotherapy for its treatment.
(c) COCP is the first line treatment for heavy menstrual bleeding (HMB), dysfunctional uterine bleeding (DUB), pre menstrual syndrome (PMS) and dysmenorrhoea secondary to endometriosis. Oestrogen component of the COCP maintains the endometrium, hence, regularises uterine bleeding and provides beneficial effects in DUB. It inhibits ovulation, hence relives symptoms related to ovulatory periods e.g. Yasmin in PMS although drospirenone also plays a part in this. Progestogen component of the COCP and inhibition of prostaglandin synthesis reduce the amount of bleeding in HMB and relieves symptoms endometriosis, particularly with continuous use. COCP results in thicker cervical mucous hence, reduce the incidence of pelvic inflammatory disease. Similarly, the COCP reduces incidence of chronic pelvic pain. COCP reduces the incidence of ectopic pregnancy by several ways. COCP reduces the risk of both ovarian and endometrial cancer, mainly as a consequence of ovulation inhibition in terms of ovarian cancer and by preventing endometrial hyperplasia in uterine cancer. Hence, it is used to prevent the risk of endometrial cancer in PCOS. COCP can be used for symptomatic relief of acne vulgaris. COCP reduces the risk of developing colorectal cancer.
Posted by Nadira N.
A I,ll take detail history of currant pregnancy and miscarriage .I,ll review the operation notes for procedure and her abdominal and pelvic assessment.I,ll take history of her previous pregnancies and their outcome.Her gynaecological history including menarche , LMP ,regularity of cycles and duration of period with amount of blood flow.Any history of dysmenorrhoea or dysparunea .History of contraception and compliance and rate of failure with previous methods.History of any sexually transmitted disease and risk of aquiring sexually transmitted disease .History of medical disorders,diabetes ,hypertension,migrain with or without aura ,cardiovasculer disease ,active liver disease ,inflammatory bowel disease .Her personal or family history of thrombosis or any diagnosed thrombophilia .Family or personal history of breast and ovarian or endometrial cancer.Result of her last PAP smear.History of smoking and number of cigarettas smoked per day.History of drugs such as liver enzyme inducers and antibiotics. I,ll examine her for her BMI and blood pressure ,I,ll perform breast examination .BMI more than 40 is absolute contraindication to cocp.BP more than 160/95 is also contraindication to the use of cocp.
B I,ll inform her that in the abscence of any contraindication to cocp ,it is generally a safe method of contraception and the benefit far out weigh the risk. A women more than 35 years who is a smoker has 3 fold increased risk of stroke and 30 fold increased risk of myocardial infarction. It is associated with increased risk of blood clot which is related to the dose of estrogen and type of progestogen.Background risk of thromboembolism is 5/100,000 which is increased to 15/100,000 with norethisterone and levonorgestral,and 25/100,000 with gestodine and desogestral, 60/100,000 with pregnancy which is far more than with cocp.There is 24% increased risk of breast cancer in currant user wich decline to non user over 10 yrs.There is increase in cevical cancer which increase over the duration of use.Small incease in hypertension and liver disease.
C The cocp use decrease dysmenorrhoea significantlly by decreasing menstrual prostaglandins and uterine contractality.Dicrease menstrual disturbances such as menorrhagia by reducing blood flow to 50%.Reduce metrorrhagia and polymenorrhagia by regulating the cycle. Reduce oligomenorrhoea and hirsutism in pcos by decreasing serum androgens and increasing SHBG.Reduce incidance of functional ovarian cyst.Reduce iron deficiacy aneamia by decreasing blood loss.significant reduced risk of ectopic pregnancy.Decreased risk of acute PID by thickening the cervical mucous from progestogens in cocp.decrease in benign breast disease.Reduce the incidence of colorectal cancer.50%to 60% decreased risk of endometrial cancer.40 %to 50% reduced risk of ovarian cancer.30% reduction in the incidance of rhumatoid arthritis.
Posted by Atashi S.
(a)Prior to prscribing it Iwill rewiew her reproductive history including her future intenton for fertility.Personal and family H/o HTN.DM,thrombophillia,DVT, migrane is to be asked. Smoking habit is to be asked.Cervical smear history is to be reviewed.Iwill check her Pulse and BP, BMI is to be assesed.Presence of any active liver or gallbladder disease need to be ruled out.
(B)She may experience of some sort of nausea and vomiting.Following its use there is risk of wt gain.Increase risk of DVT.Increase risk of cervical cancer.Reduce menstrual flow and pt may experince of break through bleeding inspite of taking pill regularly.BP may be raised and Bd sugar may be increased following its use.Inspite of use regularly there is a small risk of contraceptive failure.There is some delay in return of fertility following its discontunuation.Relative increase in risk of breast cancer.
(c )It relives dysmenorrhoea.It reduce menstrual blood loss, improve anemia which is benificial in pt with menorrhagia.Reduce incidence of fibrocystic disease of breast.Reduce incidence of ovarian cancer.Decrease incidence of acne , hirsutism.Correct menstrual abnormality in women with DUB.Reduce incidence of endometriosis and PID.
Posted by Nadira N.
Dear dr Paul, please check my anwser also ,
Posted by R S.
R S

a.Careful clinical history and examination is done including personal and family history of venous thromboembolism (VTE) and whether it was associated with hormonal intake or not. Also personal and family history of malignant breast disease as this will preclude the use of oral contraceptive pills (OCCP). If the woman is smoker, OCCP should not be use because of increased risk of VTE. We should also enquire about previous use of hormonal treatment and whether she experiences any complication from them. Medical history is also quoted like liver disease and coronary heart disease as they will also preclude OCCP use.
BMI is calculated, if it is 30 or more, there will be increased risk of developing complications and alternative safer contraceptive methods are advisable.
Vital signs are reported including blood pressure to rule out hypertension which increases risks in pill users. Breast examination is done after taking woman consent to rule out presence of mass or other suspicious features like podirounch skin or retracted nipple.

b.There is increased risk of developing VTE in current users (15-35 in 100 000 women) in comparison with (5 in 100 000 women) in non users, the risk is usually affected by woman age, weight, type of progesterone and positive personal and family history. The risk return to non user after stopping the pill. Incidence of breast cancer is also increased especially after 5 years from using OCCP. The risk will return to non users 10 years after stopping the pills.
There is also increased risk of stroke and coronary heart disease.

c.On the other hand, the OCCP has beneficial effects like cycle control, reducing premenstrual syndrome symptoms and reducing dysmenorrhoea. OCCP can have protective effect against pelvic inflammatory disease as they form cervical plague that prevent ascending infection, however, there are some evidence that they only mask endometritis. They do not protect against acquiring sexually transmitted disease. OCCP can ameliorate conditions like acne and hirsutism and they improve hair and skin.
In addition, they protect against benign breast disease, ovarian cysts and ovarian tumors.


Posted by AFSHEEN M.
Hi Dr.Paul,

Can you plesae check my answer ,as well? it was posted on jan 07.

Thanks.
Posted by AFSHEEN M.
Sorry, I guess, I missed it,

thanks.