Combined Pill

Sexual & Reproductive Health

What is the Combined Pill?

The combined oral contraceptive pill contains two hormones – oestrogen and progestogen. It is one of the most widely used methods of contraception.

How effective is the pill?
With careful use the combined pill is 99% effective in preventing pregnancy, although with less careful use the efficacy may be as low as 92%.

The combined pill's effectiveness is reduced by:

  • Missed pills – if a person forgets to take her pill or is more than 12 hours late.
  • Vomiting – if a person vomits within 3 hours of taking the pill.
  • Severe diarrhoea.
  • Drugs which are either enzyme-inducers or affect the absorption in the bowel.
  • Taking antibiotics at the same time.

 


How does the pill work?
It prevents pregnancy by:

  • Inhibiting ovulation.
  • Making the endometrium unfavourable for implantation; thinner, so it is less likely to accept a fertilised egg.
  • Making the cervical mucus impenetrable to sperm.


What are the advantages of the pill?

  • Reliable and easily reversible.
  • Relief of excessive menstrual pain and heavy/prolonged menstrual periods.
  • Reduces risk of anaemia.
  • Reduces the risk of benign cysts in the breast and ovaries (ovarian cysts).
  • Relief of premenstrual symptoms.
  • Fewer ectopic pregnancies.
  • Less pelvic inflammatory disease.
  • Protects against endometrial and ovarian cancer.


What are the disadvantages of the pill?

  • Needs to be taken regularly, carefully, and consistently.
  • No protection against STIs and HIV.
  • Increased risk of circulatory disorders such as hypertension, arterial disease, and venous thromboembolism.
  • Increased risk of liver adenoma, cholestatic jaundice, gallstones.
  • Effect of COC on breast cancer.
  • Unsuitable for smokers over the age of 35.


When can I start the pill?
The combined 21-day pill should be commenced on the first day of the person's menstrual cycle, that is the first day of the person's period, when bleeding (menses) starts. When started on the first day of the period, no additional contraceptive measures need to be taken. This applies to all 21-day pills, whether they are monophasic, biphasic or triphasic. If the pill is commenced at any other time in the cycle, additional precautions (such as using a condom) are required for 7 days. The pill ought to be taken at the same time each day. Once 21 days of pills have been taken, a person should have a 7-day break where no pills are taken; this is known as the pill-free week, during which the person will experience bleeding (menses). This is known as a 'withdrawal bleed'. Following the 7-day break, the person should restart the pill on day 8. Each packet of pills will always be commenced on the same day of the week the first packet is commenced.

How do I take the pill?
There are four types of combined pills:

  • Monophasic pills.
  • Biphasic pills.
  • Triphasic pills.
  • Every day (ED) pills.

Monophasic pills are the most widely used combined pill. They contain the same amount of oestrogen and progestogen throughout the 21 days.

Biphasic pills are 21-day pills which contain the same amount of oestrogen throughout the packet but have pills with two different levels of progestogen in them. These are usually coded in different colours.

Triphasic pills are 21-day pills which contain varying amounts of oestrogen (usually two different levels) throughout the packet and have three different levels of progestogen in them. These pills are colour coded.

Every day (ED) pills are either monophasic or triphasic, but are 28-day pills. Twenty-one of these pills contain oestrogen and progestogen and seven of these pills are inactive pills containing no hormones. The aim of the ED pill is to improve compliance.

Am I protected from pregnancy during the pill-free break or placebo week?
Yes, you are protected if:

  • You took all the pills correctly.

and

  • You start the new pack on time.

and

  • Nothing else happened that might make the pill less effective.


What to do when a pill is missed, a person vomits, or has severe diarrhoea?
If a person forgets a pill, but it is within 12 hours from when she normally takes it, then she should take it immediately and no additional precautions are required.

If the pill is forgotten for more than 12 hours from when it is normally taken, then there are certain actions and precautions to be taken, depending on the type of pill taken (monophasic, biphasic, triphasic or ED pill) and the specific day on which the pill was missed. In such a situation, it is very important that a person seeks advice from her pharmacist, family doctor, or another designated healthcare professional such as a nurse or midwife, on what actions and extra precautions will be required to ensure that it would be safe to have intercourse without the risk of getting pregnant.

If a person vomits within 3 hours of taking the pill, or suffers from severe diarrhoea, then the pill will not be effective and additional actions and precautions will be required. These depend on how long a person suffers from bouts of vomiting or diarrhoea. In such circumstances, it is very important that a person seeks advice from her pharmacist, family doctor, or another designated healthcare professional, such as a nurse or midwife, on what actions and extra precautions will be required to ensure that it would be safe to have intercourse without the risk of getting pregnant.

Missed pill advice
Persons are safe to have sexual intercourse in the 7-day pill-free week, if they do not lengthen this gap. If a person lengthens this gap, then she is at risk of ovulating and pregnancy. If she forgets the last pill of her packet, she should count that as the first day of the pill-free week and only have a further 6 pill-free days.

If a person forgets to restart her next packet on time and has had an 8-day pill-free interval, then her pills will not be contraceptive effective until she has taken 7 days of pills; in the meantime she will need to use additional contraceptive precautions, such as using condoms.

If ever in doubt about what to do, a person should ALWAYS contact a family doctor, a pharmacist, or another designated healthcare professional, such as a nurse or midwife, for advice.

If I take other medicines will it affect my pill?

  • Antibiotics - The antibiotics rifampicin and rifabutin (medicines that treat tuberculosis and meningitis) can reduce the effectiveness of the combined pill. You may need to use additional contraception such as condoms while taking the antibiotic or sometime after. Other antibiotics should not have an effect.
  • Epilepsy and HIV medicine, and St John's wort treatment - These types of drugs are called enzyme-inducers (as they speed up the breakdown of hormones by your liver) and may make the pill less effective.

It is important to consult with your healthcare professional for guidance. You may be advised to use an alternative or additional form of contraception while taking any of the medicines mentioned above.

Can anyone use the pill?
The pill may not be right for you if you are:

  • Pregnant.
  • Breastfeeding a baby less than 6 weeks old.
  • Obese (body mass index (BMI) over 35kg/m2).
  • A smoker over the age of 35; or stopped less than a year ago.

The combined pill might not be suitable for you if you have or had in the past:

  • Undiagnosed vaginal or uterine bleeding.
  • Past or present venous thrombosis.
  • Past or present arterial thrombosis.
  • Cardiovascular and ischaemic heart disease.
  • Lipid disorders.
  • Focal and crescendo migraines.
  • Cerebral haemorrhage.
  • Transient ischaemic attacks.
  • Active disease of the liver.
  • Breast cancer.
  • Four weeks before major surgery or leg surgery.
  • Severe diabetes mellitus with complications.
  • Family history of arterial/venous disease in a first degree relative below the age of 45.
  • Acute episodes of Crohn's disease and ulcerative colitis.
  • Other medical conditions either related to previous use of the combined pill or affected sex steroids.
  • You are at high altitude (more than 4,500) for more than a week.


Are there any side-effects?
You may experience the following side-effects:

  • Nausea.
  • Breast tenderness and swelling.
  • Breakthrough bleeding.
  • Depression.
  • Changes in libido.
  • Contact lenses may become uncomfortable – this is usually associated with hard lenses and high dose pills.

When commencing oral contraception, the risks along with the benefits should be discussed fully with a medical doctor, so that one is able to fully understand and weigh up the risks and benefits of the contraceptive pill.

What are the risks?
A person experiencing any of the following problems while taking the contraceptive pill should seek medical attention immediately:

  • Pain and swelling in the calf of the leg.
  • Chest pain.
  • Shortness of breath.
  • Increasing headaches.
  • Headaches with speech or visual disturbances.
  • Pain, tingling or weakness in an arm or leg.
  • Sudden problems with speech or eyesight.
  • Jaundice.
  • Severe abdominal pain.
  • Bleeding after intercourse or any prolonged bleeding.


Do I gain weight if take the pill?
Research does not indicate that the pill causes weight gain. Persons tend to gain a little bit of weight due to fluid retention.

Where can you get the combined pill?

  • You can speak to your family doctor who will guide you accordingly.
  • Gynaecologist consultation or any other sexual health clinic that offers contraceptive advice.


Can I use the pill after a miscarriage?
You can start taking the combined pill up to 5 days after a miscarriage. If you start the pill more than 5 days after the miscarriage, you will need to use extra contraception until you have taken the pill for 7 days. It is important to consult with a medical doctor for advice and guidance.

I have just had a baby. Can I start using the pill?
If you have just had a baby and are not breastfeeding, it is recommendable that you wait until day 21 after birth. Always check with your medical doctor for guidance. If you start the pill later than 21 days, you will need additional contraception such as condoms for the next 7 days.

Can I change to a different pill?
Yes, you can change to a different pill, however, it is important to ask for advice from your healthcare professional for guidance on when to stop and start the new pill.

Can I bleed when I start the pill?
Bleeding is very common when you start taking the pill and usually continues until your body's reaction to it settles down. It is important to follow the instructions of the pill you are taking. If the bleeding does not stop after you have used the pill for some time, seek medical advice.

Can I get pregnant when I stop the pill?
When you stop taking the pill, fertility will return to what is normal for you. Your periods may not start immediately. Pregnancy can happen as soon as you stop taking the pill.

If you do not want to get pregnant and recently had sex, seek advice, as you are at risk of becoming pregnant.

How often should I go for a check-up?

  • You can start by taking the pill and following the instructions.
  • Your medical history, blood pressure and weight need to be checked at least once a year.
  • Ask for advice from your healthcare provider when are you due for a next appointment.
  • If you are experiencing any problems since you started having the pill, or have any concerns, speak to your healthcare professional.


If I am on the pill, am I protected from Sexually Transmitted Infections?
No, only male and female condoms (when used correctly and consistently) protect you from STIs.