Combined Pill

The combined pill is popularly known as “the pill”. As the name implies, it combines the artificial forms of the two major female reproductive hormones - estrogen and progesterone. The natural conditions of these hormones are produced by the ovaries and also partly by the adrenal gland.

Pregnancy occurs due to fertilization of the ova (human egg) by the sperm, but this can be prevented through contraception. Contraception stops this process by killing the sperm, keeping the sperm away from the ova, or avoiding the release of the ova from the ovaries during ovulation.

• The combined pill is about 99% effective if taken correctly. This implies that less than one woman in a hundred would get pregnant in a year if every one of them used the pill correctly. Although certain contraceptives are more effective than combined pills, some include implants, injections, IUDs, and more.
  
  
• The combined pill is usually taken for 21 days, with a daily dose of one pill, after which a short 7-day break is taken. Then, the pills are resumed afterwards for another 21 days. You may experience bleeding during the seven-day break (similar to your period), but this shouldn't bother you.
  
  
• These pills must be taken at a selected time of the day for the 21 days and should never be missed, as this could increase your chance of getting pregnant. If you also experience severe vomiting or diarrhoea during the 21 days, the drug's effectiveness may be affected.
  
  
• Certain drugs alter the effectiveness of the pill. Before taking drugs, ensure that you consult your doctor.
  
  
• The combined pill may reduce the pain in those who experience heavy and/or periods, premenstrual syndrome (PMS), or endometriosis.
  
  
• Some minor side effects of the combined pill include headaches, mood swings, breast tenderness and nausea.
  
  
• It does not cause weight gain.
  
  
• It rarely gives rise to serious side effects such as cervical cancer or blood clots.
  
  
• It only effectively prevents pregnancies and does not protect against STIs. To prevent infections, ensure you use a condom.

Every month, every woman’s (except those in the menopausal age and those who have not attained menarche) ovaries release an egg (ova) with hopes that it will be fertilized. The combined pill acts to prevent this release and also causes,

• Thickening and increased production of thick mucus within the cervix (the passage leading to your womb or uterus) make it difficult for the sperm to pass through or access the egg.
  
  
• The mucosal lining of your womb (uterus) becomes thin, preventing implantation of already fertilized eggs (pregnancy).

The combined pills are over 99% effective when used correctly but are less effective for most women because only a few use them correctly (most women cannot take the pills at a specific time daily). However, other contraceptive methods, such as IUS, implants and injections, and IUDs, have been more effective.

Like every other drug, the pills are produced by different brands but come in 3 major types.

This is the most frequently used type of combined pill. Each pack contains 21 pills, each containing an equal amount of hormone. A pill is taken daily for 21 days, after which a short 7-day break is taken. 

The pack of the phasic pills usually contains 2-3 sets of differently coloured pills. Each set, according to its colour, includes a different amount of hormone it. Just as the monophasic pills, these pills are also taken daily for 21 days and afterwards, a short 7-day break is taken. The phasic pills should be taken as instructed (according to sets) to achieve maximum effectiveness. A typical example is Logynon.

Unlike the monophasic and phasic pills, the ED pills contain about 28 pills, 21 active pills and seven inactive (dummy) pills. These two pills are usually coloured differently and can be easily identified. When taking the ED pills, a pill is taken daily for 28 days (with no 7-day break). Every day, pills should be taken in the correct order to ensure effectiveness. A typical example is Microgynon.

You must keep to the manufacturer’s instructions for your preferred pills. You can always consult your doctor, nurse, or pharmacist if you are confused or have questions.

To achieve maximum effectiveness, you need to follow the instructions correctly. Missing your pills, taking them at the wrong times or with certain medications can reduce the effectiveness.

• Each pack of pills usually comes with the days of the week marked above every pill. Identify the correct day of the week and take your medications. For the phasic pills, you are required to start with the first pill of the first colour.
  
  
• Select a specific time and take your pills daily at the selected time until the pack is exhausted.
  
  
• After you have completed the pills for 21 days, take a 7-day break immediately (you may get a bleed during this period).
  
  
• On the eighth day, start a new pack (it doesn’t matter if you are still bleeding). The eighth day usually falls on the same day of the week as when you started your first pill on the previous pack.

• Begin with the first pill labelled “start” on the first set of pills. This set usually contains active pills.
  
  
• Take one pill daily in the right order, as directed, and at a specific time each day until the pack is exhausted (after 28 days).
  
  
• Whilst taking the inactive pills, you may get a bleed (similar to your period).
  
  
• After completing the pack, begin another -It doesn’t matter if you are still bleeding.

Most women can still start their pills even while experiencing their menstrual cycle or period. You must seek a medical professional's advice if you have just delivered, had an abortion or had a miscarriage.

Sometimes, you may be required to use an extra contraceptive method when taking your first pill- this would depend on how far or early you are into your menstrual cycle.

Starting the combined pill on the first day of your menstruation cycle offers complete protection against pregnancy. In this case, there would be no need for extra contraception.

If you start on the fifth day, the pills will not offer absolute protection until 7 days after starting. Therefore, you would have to make use of extra contraceptive methods.

When starting this pill, you must avoid getting pregnant and ensure that you haven’t put yourself at risk already since your previous period. Carry out a pregnancy test at least 3 weeks after your last unprotected sex if you suspect you are pregnant.

Missing a pill or pills, starting a pack late or taking the pills alongside certain medications can alter its effectiveness. The risk of getting pregnant after you have missed a pill or pills would depend on

• The time at which the pills are missed
• The number of times you miss the pills.

There are specific steps to take if you miss a combined pill. To find out about these steps, check here.

Vomiting within 2-3 hours after taking your pills can affect its effectiveness. This is because the process of drug absorption may still be ongoing. If this happens, take another pill immediately and then take your next one at the selected time.

If your illness persists, you must use extra contraception until you have recovered (and stopped vomiting).
Severe diarrhoea (with a frequency of about 6- 8 watery stools a day) can also impair the pills' absorption, altering its effectiveness. If you experience this, ensure that you use extra contraceptive devices like condoms until at least 2 days after you have recovered.

If you don’t smoke or have medical reasons or conditions preventing you from taking the pills, you can take them, even until menopause. Nevertheless, these pills are still not recommended for every woman. If you want to know whether you are accessible to the pills, see your doctor, nurse or pharmacist.

These pills are not recommended for or should not be taken by women who

• Are presently pregnant.
  
  
• Are smokers 35 years or older
  
  
• They are either overweight or obese.
  
  
• Just quit smoking less than one year ago and are 35 years or older
  
  
• Are on certain medications (for proper information and understanding, speak to your GP or a health professional in any contraception clinic).

These pills are also not recommended for you if you have or have had

• A stroke or other conditions that cause the arteries to narrow.
  
  
• A close family member under 45 years who has or has had thrombosis,
  
  
• Blood clot (thrombosis) in any vein at all, for example, in your lungs or legs
  
  
• A heart condition, including hypertension (high blood pressure).
  
  
• Cancer of the breast
  
  
• Liver or gallbladder diseases
  
  
• Extremely severe migraines (especially those with warning symptoms like auras).
  
  
• Complications of diabetes or diabetes for 20 years or more.

Women who have just had a baby can begin taking pills at least 21 days after delivery if they aren’t breastfeeding but need to consult their doctor for guidance. If you do this, the pills will offer you complete and immediate protection against pregnancy.

If the combined pill is started anytime later than 21 days, it becomes less effective and would require extra contraception, like condoms, for at least 7 days.

• Taking the combined pills while breastfeeding is not advised, but pills can be taken at least 6 weeks after delivery.

You can begin the pills at least 5 days after you have had an abortion or a miscarriage. Doing this, offers maximum and immediate effectiveness of the pills. However, taking pills 6 or more days after the abortion or miscarriage would require you to use extra contraceptive methods for at least 7 days.

• Smooth flow of sex- no interruptions
  
  
• It regularizes your period, reduces the pain and makes it lighter.
  
  
• Decreases the risk of developing ovarian, colon and uterine cancer.
  
  
• It can help to reduce PMS (premenstrual syndrome) symptoms
  
  
• Sometimes, it helps to clear and reduce acne.
  
  
• It may offer protection against pelvic inflammatory diseases (PID)
  
  
• It may decrease the risk of developing ovarian cysts, fibroids and certain breast diseases (that are not cancerous).

• During your first time of use, you may experience certain side effects temporarily, and some include
  headaches, sudden mood swings, nausea and breast tenderness-if these symptoms persist, you may need to consult your doctor for a change of pills
  
  
• It can cause your blood pressure to rise over time
  
  
• It offers no protection against STIs
  
  
• You may experience spotting or breakthrough bleeding during the first few months of use.
  
  
• These pills have been connected to an increased risk of developing serious health conditions such as breast cancer and thrombosis (blood clots in the vessels).

Certain medicines, when administered with the pills, alter their effectiveness. A few of these drugs have been listed below. To confirm if your medications are compatible with the combined pills, you can:

• Talk to a doctor, nurse or pharmacist.
  
  
• Read the information leaflet that you find in the packet of your medication.

Certain antibiotics such as rifampicin and rifabutin (used in the treatment of conditions such as tuberculosis and meningitis) can alter the effectiveness of the pills. However, other antibiotics do not alter its effectiveness.

If you are taking rifampicin or rifabutin, you may need to add an extra contraceptive like condoms, while on this medication. You can also consult your doctor or nurse for medical advice.

Certain enzyme inducers interact with combined pills and affect their effectiveness. These medicines make the breakdown of these drugs by your liver faster, thereby giving the drugs little time to act. This, in turn, reduces its effectiveness.

Some enzyme inducers include;

• Drugs used in the treatment of epilepsy such as Carbamazepine, primidone, phenytoin, oxcarbazepine, phenobarbital and topiramate.
  
  
• St John’s wort (a local herbal remedy)
  
  
• Drugs used in treating HIV (antiretroviral medicines)–studies reveal that the interaction between these medications and the progestin-only pills can make both drugs unsafe and ineffective.

Your doctor may advise you to use another contraceptive instead or an extra contraceptive while taking either drug.

Specific health risks may be associated with the use of combined pills. However, the associated risks are small and can be outweighed by the benefits.

Blood clots

The hormone estrogen in the pill is capable of causing your blood to clot easily within your blood vessels. If this occurs, it could cause

• Deep vein thrombosis (formation of a blood clot in your leg)
  
  
• Pulmonary embolus (formation of a mobile blood clot in your lungs)
  
  
• Stroke
  
  
• A heart attack

Although the risk of developing a blood clot is low, you would need to be examined and assessed by your doctor for specific risk factors before the combined pill can be prescribed.

Sometimes, you may be advised to take the combined pills cautiously if you have any of the following risk factors. Although, if you possess two or more risk factors, you may be advised against taking the combined pills.

You will be advised against it if you

• Are 35 years old or older
  
  
• Is a smoker and has just quit smoking less than a year before attempted use.
  
  
• Are significantly overweight (the risk is in women with a BMI of 35 or more, greatly outweighs the benefits).
  
  
• Have been diagnosed with hypertension
  
  
• Have severe migraines (do not take combined pills if you experience regular and severe migraine attacks with warning symptoms such as auras).
  
  
• Have previously had a stroke or thrombosis.
  
  
• Have or had a close relative who is younger than 45 and has or has had a blood clot.
  
  
• Prolonged immobility- if you have been in a wheelchair or have had a leg plaster on for a while.

Cancer

Research is ongoing to determine the link or connection between the combined pill and breast cancer. Some studies reveal that women who use contraception are slightly at a higher risk of developing breast cancer than those who don’t. However, women who stop using contraceptive pills for at least 10 years have just the same level of risk as women who have never used contraceptives.

Certain researchers have revealed that there may be a link between the intake of combined pills and the chances of developing cervical cancer and a rare type of liver cancer. However, these pills may reduce your risk of developing ovarian, endometrial and colon cancer.

The advice you are given and also the decisions you make.

This is because doctors and nurses work under stringent guidelines when handling, treating, advising or attending to people under 16. The most they can do is try to encourage or convince you to tell your parents or caregivers, but you would not be forced to tell.

• There are a few cases where a medical professional might disclose that information to someone else. In these kinds of issues, the professional has to be sure that you may be at risk of harm (either by someone or yourself), for example, abuse. For this to happen, the risk has to be significant. Usually, your doctor or nurse would discuss the risks and their intended actions with you before acting.