Combined Oral Contraceptives

  • Birth Defects
  • Cancer
  • General Health Problems
  • How Often and When to Take the Pill
  • Infertility/Return to Fertility
  • Pill Absorption
  • Promiscuity
  • Sexual Desire and Sexual Pleasure
  • Weight Changes
Myth: Birth Defects
Some women who seek family planning incorrectly believe that using COCs will cause birth defects in their babies.
Good evidence shows that COCs will not cause birth defects and will not otherwise harm the fetusif a woman becomes pregnant while taking COCs or accidentally starts to take COCs when she already pregnant .
Counseling Messages:
You don’t need to worry that you will have a baby with a birth defect after you stop using COCs or even if you get pregnant while you are taking them. Research has found that COCs do not cause birth defects in babies. (Indonesia)
There is no scientific evidence to connect the pill with birth defects. The pill is active only while the woman is taking it. When she stops, its action stops. (Cyprus)
Women who don’t take any medication have about a 2% risk of having an abnormal baby. Studies show that this figure is no different even if a woman takes the pill while she is pregnant. (New Zealand)
A Critically Appraised Topics report on COCs and Down Syndrome shows evidence that COCs, even when taken accidentally while pregnant, do not increase the risk of having a baby with Down Syndrome. (Philippines)
Myth: Cancer
Some women who seek family planning believe that combined oral contraceptives (COCs) cause cancers such as breast cancer, uterine cancer, and ovarian cancer.
The use of combined oral contraceptives (COCs) is proven to decrease the risk of two gynecological cancers (ovarian and endometrial). It is difficult to know the effect of COC use on breast cancer and cervical cancer. The possibly increased risks that have been recorded in some studies are not large enough to outweigh benefits or to change current practice.
Ovarian and endometrial cancer
Use of COCs helps protect women from two kinds of cancers—cancer of the ovaries and cancer of the lining of the uterus (endometrial cancer). This protection continues for 15 or more years after stopping use.
Breast cancer
Research findings about COCs and breast cancer are difficult to interpret. In studies, breast cancer is slightly more common among women using COCs and those who have used COCs in the past 10 years than among other women. Scientists do not know whether or not COCs actually caused the slight increase in breast cancers. It is possible that the cancers were already there before COC use but were found sooner in COC users. Both COC users and women who do not use COCs can have breast cancer.
Cervical cancer
Cervical cancer is caused by certain types of human papillomavirus (HPV). HPV is a common STI that usually clears on its own without treatment, but sometimes persists. Use of COCs for five years of more appears to speed up the development of persistent HPV infection into cervical cancer. The number of cervical cancers associated with COC use is thought to be very small. If cervical screening is available, providers can advise COC users—and all other women—to be screened every three years (or as national guidelines recommend) to detect precancerous changes in the cervix, which can be removed.
Counseling Messages:
Studies show that uterine [endometrial] cancer and ovarian cancer are actually less likely among women who have used the pill. However, there is a very, very small increase in the risk of breast cancer among women with current or recent breast cancer who use the pill and a small increase in cervical cancer among certain women who have taken the pill for many years. Having regular Pap smears, as is recommended in this country, will help detect any changes in the cervix before they cause aproblem. (New Zealand)
There is a very small increase in the risk of breast cancer among women who currently have or recently have had breast cancer and who have taken the pill for more than five years. However, COC use largely reduces the risk of ovarian cancer and uterine [endometrial] cancer. (Australia)
You don’t have to worry that COCs will cause cancer such as uterine [endometrial] cancer or ovarian cancer. In fact, COC use can help to protect against these types of cancer. The World Health Organization has researched COC use and the risk of cancer for many years and has found that combined oral contraceptives do in fact reduce the risk of developing uterine and ovarian cancer. However, if you have had breast cancer in the past five years, we suggest that you choose another contraceptive method without hormones. (Indonesia)
Recent studies have found that the pill protects women from uterine [endometrial] and ovarian cancer specifically. Doctors would not give COC pills to women if they thought they would cause cancer. Doctors help to protect women’s health. (Cyprus)
There is evidence that shows that long-term COC use increases certain women’s risk of breast cancer or cervical cancer only very slightly. The Philippine Evidence-Based Reproductive Medicine Network is continuously working to produce Critically Appraised Topics reports on various contraceptive methods to help provide evidence-based information to health workers. This will enable health workers to correct any myths or misconceptions their clients may have. (Philippines)
Myth: General Health Problems
Some women believe that COCs cause hair loss (alopecia), asthma, and headaches.
A woman may experience short term side affects associated with use of combined oral contraceptive (COCs), including changes in bleeding patterns, headaches, and nausea. However such side effects are not a sign of illness, and usually stop within the first few months of using COCs. For a woman whose side effects persist, give her a different COC formulation. In women who are otherwise well, COC use may be continued for many years as there are no adverse effects related to long-term use.
In fact, there are also long-term non-contraceptive health benefits of using COCs as they:
  • Help protect against cancer of the lining of the uterus (endometrial cancer)
  • Help protect against cancer of the ovaries
  • Help protect against symptomatic pelvic inflammatory disease
  • May help protect against ovarian cysts
  • May help protect against iron-deficiency anemia
  • Reduce menstrual cramps
  • Reduce menstrual bleeding problems
  • Reduce ovulation pain
  • Reduce excess hair on face or body
  • Reduce symptoms of polycystic ovarian syndrome
  • Reduce symptoms of endometriosis
Counseling Messages:
These complaints are usually caused by some other medical problem and should be thoroughly checked before continuing with the pills. (Malaysia)
Myth: How Often and When to Take the Pill
Some women who seek family planning are misinformed about how often or when they should take the pill.
A woman can start using COCs any time she wants if she is reasonably certain that she is not pregnant. To be reasonably certain a client is not pregnant, providers can use the Pregnancy Checklist.
If a client is starting her pack of pills within five days after the start of her menstrual period, there is no need for a backup method as she is immediately protected from pregnancy. If she starts COCs more than five days after the start of her menstrual period, she can start them any time it is reasonably certain she is not pregnant. She will need to use a "back up" method of contraception, such as a male or female condom, for the first seven days of taking pills to ensure protection from pregnancy.
The effectiveness of oral contraception depends on a regular intake of the hormones contained in the pill. Therefore pills must be taken daily, until the pack is empty. Although the specific time of day does not matter, the pills should be taken at the same time every day to reduce side effects and to help women remember to take their pills more consistently. The client should be advised not to interrupt taking the pills before a pack is finished, even if she does not have sexual intercourse. If the pills are taken correctly, the client will always start a new pack on the same day of the week. If a client is taking pills from a 21-pill pack, she will wait seven days after taking the last pill in the pack before beginning a new pack. If a client is taking pills from a 28-pill pack, she will take the next pill from the next pack on the very next day.
Women do not need to take a “rest” from COCs after taking them for a time. There is no evidence that taking a “rest” is helpful. In fact, taking a”rest” from COCs can lead to unintended pregnancy. COCs can safely be used for many years without having to stop taking them periodically.
Counseling Messages:
If you have decided to use COCs, you have to follow the dosage requirements to have optimal effectiveness. One pill should be taken every day whether you have sexual activity or not. On the other hand, if you only take the pill at the time you have intercourse it will not protect you from pregnancy. (Indonesia)
The appropriate day to begin taking the pill is on the first day of your period. Choose a time of day to take the pill that will suit you. If in the morning, you will continue taking it in the morning, if in the evening, etc. You will continue to take the pill for 21 days. Then, you will stop taking the pill for seven days and on the eighth day you will start again, regardless of your period. During the break you are still safe. (Cyprus)
COCs should be taken once daily at approximately the same time each day. (Bahamas)
The pill should be taken in a regular fashion like with dinner at night, or when you brush your teeth or when you wash. (Bangladesh)
As you can see from this leaflet, it is important that you take the hormone pills every day. (New Zealand)
Myth: Infertility/Return to Fertility
Women who seek family planning may incorrectly believe that using COCs will cause a long delay in conceiving or prevent them from being able to have children in the future.
The combined oral contraceptive (COC) does not cause infertility. This is true regardless of how long a woman has taken the pill, the number of children the woman has had, or the age of the woman. In fact, some of the non-contraceptive benefits of the pill include preserving fertility by offering protection against pelvic inflammatory disease, endometriosis, and ectopicpregnancy.
There is no evidence that COCs delay a woman's return to fertility after she stops taking them. Women who stop using COCs can become pregnant as quickly as women who stop using nonhormonal methods.
Counseling Messages:
There is no scientific evidence to connect sub-fertility or infertility to the pill. However, we do know that a number of couples will face this problem whether a woman takes the pill or not. (Cyprus)
This is not true. There are many reasons for infertility. It is better to check other possible causes of infertility. (Bangladesh)
Yes, we have had clients who have waited for years to have another baby, but this is uncommon. There are many causes of infertility and these should be investigated. (Fiji)
With the low doses of hormones that we use these days, there doesn't seem to be any long-term effect on fertility. We find that a woman's usual fertility returns immediately after stopping the pill. (Australia)
The pill does not cause any permanent change. You should know that there is an interval of several months between deciding to have a child and actually getting pregnant. Doctors normally wait to begin investigating for fertility problems only after a year of trying to get pregnant. (Malaysia)
Using COCs will not make it difficult or impossible for you to have babies in the future because your fertility will return as soon as you stop taking them. Also, I will remind you that some women can get pregnant because they forget to take several of their pills. (Indonesia)
There is no delay in fertility once pill use is stopped. There is no evidence that taking the pill harms your chances of getting pregnant. In fact, if people miss the pill they can get pregnant while still on it. Some women may find that they don’t get pregnant after coming off the pill, but it seems that this has nothing to do with the pill. (New Zealand)
Once an individual decides to stop using COCs, she can get pregnant if no other contraceptive method is used. (Bahamas)
Myth: Pill Absorption
Many women who seek family planning incorrectly believe that COCs accumulate in the body and cause diseases and tumors, or get stored in the stomach, ovaries, or uterus and form stones.
After the pills are swallowed, they dissolve in the digestive system, and the hormones they contain are absorbed into the bloodstream. After they produce their contraceptive effect, the hormones are metabolised in the liver and gut and are then eliminated from the body. They do not accumulate in the body anywhere.
Counseling Messages:
Each pill lasts for only about 24 hours in your body and does not “get stuck” anywhere. In fact, if you do not take the pills regularly, there will not be a sufficient amount of medicine in your body and there is a chance you can get pregnant. (Malaysia)
The COCs will be absorbed through the digestive system and then will be metabolized through the liver system and excreted together with your feces. That is why you do not need to be worried that all of the pills you have taken will accumulate in your body. We won’t give women COCs if they have a serious problem with their liver, such as a painful or enlarged liver, active viral hepatitis, or liver cancer. (Indonesia)
The pill will dissolve in the body just like a paracetamol tablet dissolves in a baby.
(Show the patient how a tablet of paracetamol dissolves in a glass of water.) (Philippines)
Myth: Promiscuity
Some clients who seek family planning wrongly believe that the pill encourages infidelity, promiscuity, or prostitution in women.
There is no evidence that COCs affect women’s sexual behavior. The evidence on contraception in general shows that sexual behavioris unrelated to contraceptive use. In fact, using contraception shows responsible behavior in order to avoid unintended pregnancy and sexually transmitted infections.
Counseling Messages:
An increase in infidelity, promiscuity, or prostitution due to pill availability has not been found. (Cameroon)
The pill does not encourage infidelity. It is just for those women who want to prevent unwanted pregnancy. (Nigeria)
There are various reasons for that [promiscuity]. We need to check the research studies and then talk. Social issues affect people’s behavior including sexual choices and such matters. There is enough evidence from social and behavioral research to support this. (Bangladesh)
The majority of young people who come to get the pill are already having sexual intercourse, so we are just providing them with contraception to minimize the risks of these activities. (New Zealand)
Myth: Sexual Desire and Sexual Pleasure
Some clients who seek family planning may believe that COCs reduce sexual pleasure or interest in sex (loss of libido) or that they cause frigidity in women.
There is no evidence that COCs affect a woman's sex drive. Although some women using the pill have reported either an increase or decrease in sexual interest and performance, it is difficult to say whether such changes are a result of COCs or other life events.
Counseling Messages:
There are many reasons that this situation may arise. Excluding the other reasons, if COCs are causing the problem, you can change to another brand of pills and review your situation again. (Cyprus)
A women’s interest in sex is due to many factors, such as her well-being, her relationship with her husband, issues dealing with her children, and others. A woman may not have the same level of interest all the time, and it is usually not related to the pill. (Malaysia)
[In some women]COCs may cause mood changes, including depression, and some women will have less interest in sex. But, you may feel that taking COCs and protecting yourself from pregnancy is more pleasant then having sex with the fear of pregnancy. (Indonesia)
If [you experience changes in your level of interest in sex], consult a doctor, such as a general practitioner or a gynecologist. (Singapore)
Myth: Weight Changes
Some clients believe that COCs cause women to gain or lose weight.
Most women do not gain or lose weight as a result of COC use. A woman's weight may fluctuate naturally due to changes in age or life circumstance. Because changes in weight are common, many women attribute their natural weight gain or loss to the use of COCs. Although a very small number of COC users may report weight change following COC use, studies have found that, on average, COCs do not affect weight. A few women experience sudden changes in weight when using COCs. These changes reverse after they stop taking COCs. It is not known why these women respond to COCs this way.
Counseling Messages:
On average, there is no increase in weight while using the pill. This means that some women will gain a little bit of weight and others will lose a little bit of weight. Only a very small number of women will gain more than a few kilos. (Australia)
Weight gain or weight loss due to COC use depends on the make-up of the individual and is usually phasic. Diet and exercise can help. (South Africa)
An unequal balance between what is eaten and the energy expended causes weight gain in general. Everyone reacts differently to medications. (Barbados)
For some women, COCs can cause a slight weight gain. This will give an advantage to women who are too thin. However, you will become fat if you eat too much and you don’t have any exercise. You can keep your body slim while taking COCs if you reduce the amount of salt and sugar (calories) you eat. (Indonesia)
Weight gain may have occurred with older COC preparations, but the newer pills contain much lower doses of hormones so that you do not put on weight. You do need to watch your diet, though, and continue with regular exercise. (Malaysia)
The older brands may have caused women to gain a little bit of weight. The newer brands do not cause any weight gain. What causes weight gain is the food we eat. (Cyprus)
Studies show that the pill does not increase weight, but there are a few women who seem very sensitive to hormones who may notice that they gain weight. (New Zealand)
No scientific study has found that COC use causes women to gain or lose weight. (Cameroon)
The evidence shows that there is no association between taking COCs and weight gain. (Show client the Critically Appraised Topic report on COCs and weight gain) (Philippines) 

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