Contraceptive counseling often features in OSCEs, so it is important to be aware of the various forms of contraception available. This article will look at counseling patients about the combined oral contraceptive pill (COCP), including the common questions asked, expected answers, and best practices for structuring the consultation.
Begin by washing your hands and donning PPE, if appropriate. Introduce yourself to the patient, including your name and role. Verify the patient's name and date of birth. Check the patient's understanding of the different types of contraception. Explore the reasons why the patient wants the COCP.
It is important to explore the patient's ideas, concerns, and expectations early in the consultation. This will allow you to correct any misconceptions about the COCP and address the patient's concerns in a sensitive and honest way. Clarifying the patient's expectations of the COCP is essential, as other forms of contraception may meet their needs better if the expectations are unrealistic.
Explore what the patient understands about the COCP:
Ask if the patient has any concerns about the COCP:
Explore the patient's expectations of the COCP:
Explain to the patient, using patient-friendly language, that the combined pill contains both oestrogen and progesterone. Let the patient know 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
Explain to the patient that there are three main types of combined pills:
Explain to the patient that the pill works 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.”
Patients may want to know the effectiveness of contraception; statistics on efficacy can be useful. If unsure, signpost the patient to a reliable source.
Explain to the patient that the effectiveness depends on compliance but is 99% effective with proper use.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.”
Give patients as much information as possible to make an informed decision. Discuss 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.”
“Taking the pill does not require an invasive procedure like some other forms of contraception.”
“The combined pill is 99% effective when taken correctly.”
“Your periods may become more regular, lighter and less painful.”
“You can run the pill packets back-to-back if you want to control the timing of your period for holidays or certain events.”
“In some people, the pill can improve acne.”
“The pill may help reduce symptoms of premenstrual syndrome.”
“The pill reduces the risk of ovarian, uterine and colon cancer.”
“To start off with, you may experience some side effects such as a headache, nausea, mood changes or breast tenderness.” ¹
“Especially in the first few months, you might experience bleeding on the days you are taking the pill. This is called breakthrough bleeding.
The Combined Oral Contraceptive Pill (COCP) does not protect from sexually transmitted infections (STIs). The only form of contraception that provides protection from STIs is barrier contraception, such as condoms.
The COCP is dependent on the user remembering to take it daily. Setting reminders on phones or in diaries can be helpful.
It is important to explain the risks of taking the pill so that the patient is aware and can make an informed decision.
There is a small increase in the risk of developing clots in the legs and lungs, or having a heart attack or stroke. If the patient has had any of these conditions in the past, they should not take the pill. The risk is increased if the patient regularly smokes, has a high BMI, or is immobile for a long period of time.
Research has shown that there is a small increased risk of breast cancer compared to people using non-hormonal contraception. The risk reduces with time after stopping the pill.
Research has also indicated a small increased risk in developing cervical cancer with long-term use of the COCP.
A patient cannot take the pill if they:
Explaining this section to the patient in a patient-friendly manner, checking understanding and inviting questions at the end is important.
The pill can be started anytime if the patient is sure they are not pregnant. Condoms will need to be used for the first seven days of taking the pill.
If one pill is missed or a new pack is started one day late, the missed pill should be taken straight away and the rest of the pack taken as normal. Emergency contraception is not required.
If two or more pills are missed, or a new pack is started two or more days late, take the most recent pill missed immediately and leave any other pills missed before. Condoms or abstinence should be used for seven days. If sex has occurred in the past seven days, seek advice for emergency contraception.
If there are seven or more pills left in the pack, finish the pack and have the usual seven-day break. If there are less than seven pills left in the pack, finish the pack and start a new pack the next day, taking the pills back to back.
Summarize the key points back to the patient. Ask if they have any further questions or concerns that haven't been addressed. Throughout the consultation 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 can 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 aren't using contraception. Thank the patient for their time. Dispose of PPE appropriately and wash your hands.
Below are some common questions that patients may have regarding the contraceptive pill. Sometimes, in an OSCE situation, they may ask one or two questions at the end of the consultation. Having a good answer can be helpful in demonstrating a good understanding of the topic.
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 they have severe diarrhoea for more than 24 hours, they should take the pill as if they missed a pill and follow the instructions discussed previously. This should continue until the diarrhoea is no longer severe.
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."
It is not dangerous for a patient to miss their withdrawal bleed, also known as taking pills back to back. However, remind them that they may still get some bleeding or spotting.
Advise the patient 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 them on pre-pregnancy care, such as folic acid and smoking cessation.
Advise the patient to stop taking the pill at the end of a pack. If they cannot wait, inform them of other contraception to prevent pregnancy.
Other than the risks mentioned earlier, it is not dangerous to take the pill for a long time because the hormones do not build up in the body. Furthermore, there is no evidence to show that taking the pill affects fertility.
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