11/13/24, 8\:16 PM Guide | COCP counselling

COCP counselling

Table of contents

Introduction

Contraceptive counselling often features in OSCEs, and it’s important to be familiar with the various methods of
contraception available.
This article focuses on counselling patients about the combined oral contraceptive pill (COCP), including the common
questions patients ask, the information you'll be expected to give and how best to structure the consultation.

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Explain the reason for the consultation\:
c o r r e c t ?”
.
“ I u n d e r s t a n d y o u a r e i n t e r e s t e d i n u s i n g t h e c o m b i n e d o r a l c o n t r a c e p t i v e p i l l . I s t h a t
It is important to establish a good rapport and an open line of communication with the patient early in the consultation\:
h a v e a n y q u e s t i o n s a t a n y p o i n t , o r i f s o m e t h i n g i s n o t c l e a r , p l e a s e f e e l f r e e t o i n t e r r u p t a n d a s k m e .
”
“ I f y o u
Make sure to check the patient’s understanding at regular intervals throughout the consultation and provide opportunities to
ask questions (this is often referred to as ‘chunking and checking’).

Ideas, concerns and expectations

A key component of contraceptive counselling involves exploring a patient’s ideas, concerns and expectations (often referred
to as ICE).
In a contraceptive consultation, it is important to explore ICE, as many patients will have researched or have prior experience
with contraceptive methods. This will help you tailor the consultation and the advice you give regarding speci
important to identify any patient concerns and expectations early in the consultation, as this may a
method and subsequent contraceptive e
It can sometimes be challenging to use the ICE structure in a way that sounds natural in your contraceptive consultation, but
we have provided some examples for each of the three areas below.

Ideas

Explore what the patient currently understands about the COCP\:
“ H a v e y o u h e a r d o f t h e c o m b i n e d o r a l c o n t r a c e p t i v e p i l l ?”
“ W h a t d o y o u a l r e a d y k n o w a b o u t t h e c o m b i n e d o r a l c o n t r a c e p t i v e p i l l ?”

Concerns

Ask if the patient has any concerns about the COCP\:
“ I s t h e r e a n y t h i n g t h a t w o r r i e s y o u a b o u t t a k i n g t h e c o m b i n e d o r a l c o n t r a c e p t i v e p i l l ?”

Expectations

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Explore the patient’s expectations of the COCP\:
" W h a t f a c t o r s i n
" W h a t a r e y o u h o p i n g t h e c o m b i n e d o r a l c o n t r a c e p t i v e p i l l c a n d o f o r y o u ?"

Eligibility

Before starting any method of contraception, it is vital to check the patient's eligibility and for any contraindications.
The Faculty of Sexual and Reproductive Health (FSRH) produce the UK Medical Eligibility Criteria for Contraceptive Use
(UKMEC) which guides clinicians on the safety of di
characteristics and medical co-morbidities\:
UKMEC 1\: no restriction
UKMEC 2\: bene
UKMEC 3\: theoretical or proven risk generally outweighs the bene
UKMEC 4\: contra-indicated
The COCP has the strictest eligibility criteria of all the methods of contraception available. One of the main reasons for this is
that the COCP can increase the risk of venous and arterial thrombotic events. Therefore, many of the UKMEC 3 and 4 criteria
are related to other risk factors for venous or arterial thrombosis.

UKMEC 4 criteria

General
0 to \<6 weeks postpartum and breastfeeding
0 to \<3 weeks postpartum and not breastfeeding (with other risk factors for VTE)
Age >35 years and smoking 15 or more cigarettes a day
Cardiovascular
Systolic BP 160 mmHg or greater, diastolic BP 100 mmHg or greater
Vascular disease
Venous thromboembolism (current or history of)
Major surgery with prolonged immobilisation
Known thrombogenic mutations
Ischaemic heart disease or stroke/TIA (current or history of)
Complicated valvular and congenital heart disease
Atrial
Cardiomyopathy with impaired cardiac function
Neurological
Migraine with aura
Breast conditions
Breast cancer
Rheumatology
Positive antiphospholipid antibodies
Gastrointestinal
Severe decompensated cirrhosis
Malignant hepatoma
Benign hepatocellular adenoma

UKMEC 3 criteria

General
0 to \<3 weeks postpartum and not breastfeeding (without other risk factors for VTE)
3 to \<6 weeks postpartum and not breastfeeding (with other risk factors for VTE)
Age >35 years and smoking \<15 cigarettes a day
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Age >35 years and stopped smoking \<1 year ago
BMI greater or equal to 35 kg/m
2
Complicated organ transplant
Cardiovascular
Adequately controlled hypertension
Systolic BP 140 – 159 mmHg or diastolic BP 90 – 99 mmHg
Family history of VTE in a
Immobility
Multiple risk factors for cardiovascular disease (such as smoking, diabetes, hypertension or obesity)
Neurological
Migraine without aura during COCP use
History (greater than 5 years ago) of migraine with aura
Breast conditions
Undiagnosed breast symptoms on initiation
Carriers of known gene mutations associated with breast cancer (e.g. BRCA)
Past breast cancer
Endocrine
Diabetic nephropathy/retinopathy/neuropathy
Diabetes and vascular disease
Gastrointestinal
Symptomatic and medically treated gallbladder disease
Current symptomatic gallbladder disease
Past history of COCP-related cholestasis
Acute/
If a patient is pregnant this is also a contraindication to starting contraception, this means that you should be ‘reasonably
certain’ that individuals are not pregnant before starting any contraception.
Example
As there are many UKMEC 3 and 4 criteria for the combined contraceptive pill, it can be useful to group conditions
together\:
“ D o y o u h a v e a n y p e r s o n a l o r f a m i l y h i s t o r y o f b l o o d c l o t s , t h r o m b o p h i l i a ?
b r e a s t c a n c e r , h e a r t d i s e a s e , s t r o k e , v a s c u l a r d i s e a s e o r k n o w n
D o y o u h a v e a n y p e r s o n a l h i s t o r y o f d i a b e t e s , o r s m o k i n g ?
l i v e r d i s e a s e , g a l l b l a d d e r d i s e a s e , m i gr a i n e w i t h a u r a , h y p e r t e n s i o n , o b e s i t y ,
H a v e y o u r e c e n t l y g i v e n b i r t h o r a r e c u r r e n t l y b r e a s t f e e d i n g?”

What is the COCP?

Using patient-friendly language, explain that the COCP contains progestogen, a synthetic version of the hormone
progesterone, and oestrogen.
Example
“ T h e c o m b i n e d p i l l i s a t y p e o f c o n t r a c e p t i v e p i l l t h a t c o n t a i n s t w o h o r m o n e s . A h o r m o n e c a l l e d p r o ge s t o ge n , w h i c h i s
s i m i l a r t o y o u r b o d y' s n a t u r a l h o r m o n e p r o ge s t e r o n e , a n d a h o r m o n e c a l l e d o e s t r o ge n .
”
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How e

When counselling patients regarding contraception, it is very important to explain how e
any factors which may impact e
Explain to the patient that the e
With perfect use, the pill is around 99% e
Factors that reduce the e
Drug interactions (notably cytochrome P-450 inducers reduce COCP e
Missed/late pills
Vomiting and/or diarrhoea
Bariatric surgery\: there are theoretical concerns that both malabsorptive and restrictive bariatric procedures could decrease
the absorption of oral contraceptives
Other conditions causing malabsorption (e.g. small bowel resection)
With typical use, the combined pill is less e
contraceptive implant.
Example
“ W h i l s t t h e c o m b i n e d p i l l c a n b e v e r y e
i t b e c o m e p r e g n a n t w i t h i n t h e
b e c o m e p r e g n a n t a f t e r o n e y e a r .
”

What are the di

The combined pills vary depending on the amount of oestrogen and the type of oestrogen/progestogen.
The most common type of COCP is the monophasic pill. Each pill has the same amount of hormone in it.
Other types of COCP include\:
The phasic 21-day pill\: each pill contains a di
order.
The everyday pill\: there are 21 active pills (containing hormones) and 7 placebo pills. Pills are taken for 28 days without a
break in between packs. The placebo pills are equivalent to a 7 day hormone free interval.
In terms of oestrogen content, the μg or less of estrogen, with levonorgestrel
or norethisterone as the choice of progestogen. This is due to the reduced VTE risk.

Taking the monophasic COCP

Traditionally, the monophasic COCP was advised to be taken for 21 days followed by a 7 day break (a hormone free interval).
During the hormone free interval, patients would usually have a withdrawal bleed (mimicking a monthly period).
However, evidence suggests there is no health bene
womb does not build up because of the action of the COCP.
Therefore, patients have several options for taking the COCP\:
They can take the pill for 21 days followed by a 7-day break (described above)
They can have a shortened break of 4-6 days instead of 7 days
They can take the pill continuously without any breaks (however this can cause erratic breakthrough bleeding)
They can take the pill continuously until they experience breakthrough bleeding. When they experience bleeding, they can
stop taking the pill for up to 7 days.
They can ‘tricycle‘
, this involves taking three packets back to back and then having a break of up to 7 days to experience a
withdrawal bleed. This may reduce the risk of breakthrough bleeding.
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This can be tricky to explain to patients, and decisions on how to take the monophasic pill vary depending on patient
preferences and other intended bene

How does the COCP work?

The main mode of action of the COCP is to suppress ovulation. It also thickens cervical mucus and suppresses endometrial
growth.
Example
“ A s w e’ v e d i s c u s s e d , t h e C O C P i s a v e r y e
f r o m o v u l a t i n g a n d r e l e a s i n g a n e g g f r o m y o u r o v a r i e s . I t a l s o t h i c k e n s t h e m u c u s i n t h e n e c k o f y o u r w o m b ( c e r v i x ) t o
p r e v e n t s p e r m f r o m e n t e r i n g t h e w o m b a n d r e a c h i n g a n e g g. L a s t l y , i t t h i n s t h e l i n i n g o f y o u r w o m b t o p r e v e n t a f e r t i l i s e d
e g g f r o m i m p l a n t i n g .
”

Pros and cons of the COCP

When discussing contraceptive options, it is important to give the patient enough information to make an informed
decision and direct them to reputable sources of further information.
When explaining potential advantages and disadvantages, you should consider the patient’s ideas, concerns and
expectations (identi
Signposting is important to help you structure the consultation\:
h a v i n g t h e c o m b i n e d p i l l a n d s o m e o f t h e p o t e n t i a l d i s a d v a n t a ge s . “ N e x t , I’ d l i k e t o t a l k a b o u t s o m e o f t h e a d d i t i o n a l b e n e
I s t h a t o k ? .
”

Advantages of the COCP

Advantages of the COCP include\:
Non-invasive method
E
Reduce heavy menstrual bleeding, menstrual pain and improve acne
Regulate bleeding
Improvement in premenstrual symptoms
Reduces the risk of recurrence of endometriosis after surgical management
Used for management of acne, hirsutism and menstrual irregularities associated with polycystic ovary syndrome (PCOS)
Associated with a reduction in risk of ovarian and endometrial cancer
Associated with a reduced risk of colorectal cancer
Some patients may opt for the COCP due to its non-contraceptive bene
Example
“ T h e C O C P i s a n e
p e r i o d s b e c o m e m o r e r e g u l a r , l i g h t e r a n d l e s s p a i n f u l , a s w e l l a s i m p r o v i n g a c n e , a n d i m p r o v i n g p r e m e n s t r u a l s y m p t o m s .
T h e C O C P i s a l s o u s e d i n m a n a g e m e n t o f e n d o m e t r i o s i s a n d P C O S , i t h a s b e e n f o u n d t o r e d u c e t h e r i s k o f r e c u r r e n c e o f
e n d o m e t r i o s i s a f t e r h a v i n g s u r g e r y . A n d i s u s e d t o m a n a g e a c n e , e x c e s s i v e h a i r gr o w t h a n d i r r e gu l a r p e r i o d s f o r w o m e n
w i t h P C O S .
T h e C O C P h a s a l s o b e e n f o u n d t o r e d u c e t h e r i s k o f e n d o m e t r i a l a n d o v a r i a n c a n c e r a s w e l l a s r e d u c e t h e r i s k o f
c o l o r e c t a l c a n c e r .
”
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Disadvantages of the COCP

Potential disadvantages of the COCP include\:
User dependent\: e
Does not protect against sexually transmitted infections
Enzyme-inducing drugs can reduce e
Interacts with lamotrigine, potentially causing reduced seizure control or lamotrigine toxicity
Increased risk of cervical cancer and breast cancer
Side e
Example
“ A s w e’ v e d i s c u s s e d t h e C O C P c a n b e a v e r y e
y o u t a k e i t . T o b e 9 9 % e
”
“ O n l y c o n d o m s w i l l p r o t e c t a g a i n s t s e x u a l l y t r a n s m i t t e d i n f e c t i o n s . T h e r e f o r e , w e w o u l d a d v i s e u s i n g c o n d o m s a l o n gs i d e
t h e C O C P .
”
“ S o m e w o m e n m a y e x p e r i e n c e s i d e e
n a u s e a , d i z z i n e s s a n d b r e a s t t e n d e r n e s s w i t h t h e

Risks of the combined pill

It is important to explain the risks of taking the combined pill so that the patient is aware and can make an informed decision.
Venous thromboembolism (VTE)
The COCP is associated with a small increased risk of VTE. As mentioned previously, some formulations are associated with a
greater risk of VTE than others.
“ T h e r e i s a s m a l l i n c r e a s e i n t h e r i s k o f d e v e l o p i n g c l o t s i n y o u r l e gs a n d l u n gs”
“ I f y o u h a v e h a d a b l o o d c l o t i n t h e p a s t , t h e n y o u s h o u l d n o t u s e t h e p i l l .
”
“ T h e r i s k o f d e v e l o p i n g a b l o o d c l o t i s i n c r e a s e d i f y o u s m o k e r e g u l a r l y , o f t i m e .
”
h a v e a h i gh B M I o r i f y o u a r e i m m o b i l e f o r a l o n g p e r i o d
Myocardial infarction and ischaemic stroke
The COCP is associated with a small increased risk of myocardial infarction and ischaemic stroke. This risk appears to be
greater with formulations that have higher doses of oestrogen.
“ T h e r e i s a s m a l l i n c r e a s e d r i s k o f h e a r t a t t a c k a n d s t r o k e b u t t h e s e e v e n t s a r e s t i l l e x t r e m e l y u n c o m m o n i n p e o p l e w h o t a k e
t h e C O C P”
“ I f y o u h a v e m u l t i p l e o t h e r r i s k f a c t o r s f o r t h e s e c o n d i t i o n s t h e n u s e o f t h e C O C P s h o u l d n o r m a l l y b e a v o i d e d”
Breast cancer
The COCP is associated with a small increased risk of breast cancer. This risk reduces with time after stopping the COCP.
“ R e s e a r c h h a s s h o w n t h a t t h e r e i s a s m a l l i n c r e a s e d r i s k o f b r e a s t c a n c e r . T h i s r i s k r e d u c e s w i t h t i m e a f t e r s t o p p i n g t h e p i l l .
”
Cervical cancer
When the COCP is used for more than 5 years it is associated with a small increased risk of cervical cancer. This risk reduces
with time after stopping the COCP.
“ R e s e a r c h h a s a l s o s h o w n t h a t t h e r e i s a s m a l l i n c r e a s e d r i s k o f d e v e l o p i n g c e r v i c a l c a n c e r w i t h t h e u s e o f t h e C O C P f o r l o n ge r
t h a n 5 y e a r s . T h i s r i s k r e d u c e s w i t h t i m e a f t e r s t o p p i n g t h e p i l l .
”
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Starting the pill and missed pills

This section of the consultation can be confusing for the patient. It is important to explain this in a patient-friendly manner,
check understanding at regular intervals and invite questions at the end.

Starting the COCP

The COCP can be started without the need for additional precautions at any of the following times\:
Up to day 5 of a natural cycle
Up to 5 days after
Starting a COCP at any other time will require 7 days of extra contraceptive precautions.
Example
“ Y o u c a n s t a r t t h e c o m b i n e d c o n t r a c e p t i v e p i l l a t a n y t i m e i n y o u r m e n s t r u a l c y c l e i f y o u a r e s u r e y o u a r e n o t p r e gn a n t .
”
“ I f y o u s t a r t i t o n d a y 1 t o 5 o f y o u r m e n s t r u a l c y c l e ( t h e
”
i t’ l l w o r k s t r a i gh t a w a y a n d y o u’ l l b e
“ I f y o u s t a r t t h e c o m b i n e d c o n t r a c e p t i v e p i l l o n a n y o t h e r d a y o f y o u r c y c l e , y o u w i l l n o t b e p r o t e c t e d f r o m p r e g n a n c y
s t r a i g h t a w a y a n d w i l l n e e d a d d i t i o n a l c o n t r a c e p t i o n , s u c h a s c o n d o m s , u n t i l y o u’ v e t a k e n t h e p i l l f o r 7 d a y s .
”
"Quick starting" the COCP
In some cases, it may not be possible to completely rule out a very early pregnancy, but you may still consider initiating
contraception. It is important to remember that a pregnancy test will not be reliable until at least 21 days after the last episode
of unprotected sexual intercourse (UPSI).
If a pregnancy test is negative but there has been UPSI within the last 21 days, and there is an ongoing risk of pregnancy, you
can ‘quick start’ the COCP. However, the COCP will require 7 days to become e
pregnancy test 21 days after the COCP has become e
If the pregnancy test is positive, the patient must stop taking the COCP. Current evidence does not suggest that the COCP
poses any harm to a developing fetus, but obviously, it needs to be stopped!

Missed pills

The missed pill rules for the COCP are complex and vary depending on the type of pill. The FSRH publishes comprehensive
guidance on missed pill rules, and it is best practice to always refer to this and the manufacturer's guidance. It is vital patients
are given information on where to
A missed pill is de
If vomiting occurs up to 3 hours after taking the COCP or severe diarrhoea occurs for >24 hours individuals should follow the
missed pill instructions.
The advice below is for a monophasic pill that contains 21 active pills without placebo pills, with the patient taking the pill in
the traditional way (21 days of pills followed by a 7-day hormone-free interval)\:
Week 1\: COCP
Week 2\: COCP
Week 3\: COCP
Week 4\: No pills (hormone free interval)
Return to week 1 with a new packet
One pill missed
Take the missed pill ASAP
Continue taking the remaining pills as usual
No additional contraceptive measures required
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Example
“ W h e n y o u r e a l i s e y o u h a v e m i s s e d a p i l l , t i m e .
”
t a k e t h e m i s s e d p i l l s t r a i gh t a w a y . T h e n e x t p i l l s h o u l d b e t a k e n a t t h e u s u a l
2 - 7 pills missed in week 1
Consider emergency contraception if unprotected sexual intercourse has occurred during the hormone free interval or week
1
Take the most recent missed pill ASAP
Continue taking the remaining pills as usual
Use additional contraceptive measures (condoms) or abstain from sex until pills have been taken for 7 consecutive days
Consider a follow-up pregnancy test (at least 21 days after the episode of unprotected sex)
2 - 7 pills missed in week 2 or 3
Take the most recent missed pill ASAP
Continue taking the remaining pills as usual
If 2 or more pills are missed in the 7 days prior to a scheduled hormone free interval, the HFI should be missed (go straight to
a new packet)
Use additional contraceptive measures (condoms) or abstain from sex until pills have been taken for 7 consecutive days
More than 7 consecutive pills missed in any week
Consider emergency contraception and pregnancy test
Start a new COCP packet (or other e
Condoms should be used or sex avoided until pills have been taken for 7 consecutive days
Consider a follow-up pregnancy test (at least 21 days after the episode of unprotected sex)
Late restarting after hormone free interval
Patients may forget to start a new COCP packet after their hormone free interval.
If it has been 9 or more days since the last COCP was taken\:
Consider emergency contraception if unprotected sexual intercourse has occurred during or since the hormone free interval
Take the most recent missed pill ASAP
Continue taking the remaining pills as usual
Use additional contraceptive measures (condoms) or abstain from sex until pills have been taken for 7 consecutive days
Consider a follow-up pregnancy test (at least 21 days after the episode of unprotected sex)
Example
“ I t' s i m p o r t a n t t o k n o w w h a t t o d o i f y o u m i s s a p i l l . T h e r u l e s c a n s e e m c o m p l e x a n d c a n v a r y d e p e n d i n g o n w h a t s t a g e
y o u a r e i n y o u r p i l l -t a k i n g . F o l l o w i n g t h i s c o n s u l t a t i o n , I w i l l s e n d y o u a d v i c e o n w h a t t o d o i f y o u m i s s a p i l l . Y o u c a n r e f e r
t o t h i s i n f o r m a t i o n o r t h e m a n u f a c t u r e r' s gu i d a n c e w h i c h i s i n t h e p i l l p a c k e t”
“ I f y o u a r e u n s u r e w h a t t o d o , i t i s a l w a y s b e t t e r t o s e e k a d v i c e”

Follow up

Advise patients that a routine annual review of their contraception is recommended during COCP use.
At follow-up, medical eligibility (as per the UKMEC criteria), medication history, and compliance should be re-assessed. BMI
and blood pressure should also be reviewed.
The combined contraception pill can be continued by medically eligible women for contraception until age 50.
Advise patients to seek immediate medical review if they develop any of the following\:
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Leg pain, swelling or redness
Chest pain, breathlessness or coughing up blood
Acute neurological symptoms (e.g. loss of motor/sensory function)
Advise patients to seek advice as to whether the COCP is still safe and e
are started on new medications.
Advise patients to seek advice if they have upcoming surgery or a long-haul
Example
“ Y o u w i l l n e e d y e a r l y f o l l o w-u p w h i l s t t a k i n g t h e C O C P t o d i s c u s s a n y c h a n ge s i n y o u r m e d i c a l h i s t o r y , m i g h t b e h a v i n g , a n d t o d o c u m e n t y o u r b l o o d p r e s s u r e a n d B M I .
”
“ I f y o u r e m a i n e l i g i b l e t o t a k e t h e C O C P , y o u c a n c o n t i n u e u n t i l 5 0 y e a r s o l d .
”
“ M a k e s u r e y o u s e e k u r g e n t m e d i c a l a d v i c e i f y o u d e v e l o p a n y o f t h e f o l l o w i n g\: c a l f p a i n , s w e l l i n g o r r e d n e s s , b r e a t h l e s s n e s s o r c o u g h i n g u p b l o o d , w e a k n e s s o r l o s s o f s e n s a t i o n i n a n y o f y o u r l i m b s o r f a c e .
”
a n y p r o b l e m s y o u
c h e s t p a i n ,

Closing the consultation

Close the consultation by summarising what you have discussed. This allows you to emphasise the key points of the
consultation.
Ask the patient if they have any further questions or concerns that haven’t been addressed.
Finally, thank the patient for their time and o
contraceptive pill.
Dispose of PPE appropriately and wash your hands.

Reviewers

Dr Ashley Je
Community Sexual and Reproductive Health Registrar
Dr Rachel Ashton
General Practitioner

References

FSRH. Combined Hormonal Contraception. 2023. Available from\: [LINK]
FSRH. UKMEC April 2016 Summary Sheet. 2019. Available from\: [LINK]
FSRH. Recommended Actions after incorrect Use of Combined Hormonal Contraception. 2021. Available from\: [LINK]
Source\: geekymedics.com
https\://app.geekymedics.com/osce-guides/counselling/cocp-counselling/ 9/9