Combined Contraceptive Pill

The combined contraceptive pill is a very popular form of hassle-free contraception. It's only available to women on prescription after a consultation with their doctor so that suitability is established.

Other ways to get the pill include contraceptive clinics and some sexual health clinics. It's not possible to buy the pill over-the-counter, but you can purchase it online after you have first been prescribed it by your doctor.

To order the pill online you will need to complete an online consultation. Be sure to mention any new medication you are taking or any new health symptoms to ensure you remain fit and healthy on the combined pill.

Pregnancy occurs when an egg is fertilised by a sperm. The hormones in the combined pill mimic ones produced by the female body. These hormones act upon your reproductive system to prevent pregnancy in a number of ways.

• It stops ovulation; your ovaries will not release an egg each month.
• It thickens mucus; the entrance to your womb, the cervix, carries mucus that helps sperm enter. The pill thickens this mucus so that sperm cannot pass through.
• It alters the qualities of your womb lining (your period blood) thinning it so that if a fertilised egg should try to implant it would fail to grow.

Different brands of combined pill contain different strengths and differing hormones but all of them act in the same way to provide a very high level of pregnancy protection.

Your doctor is best placed to choose a pill for you, but if you find that it produces side effects or makes you feel unwell, then you can change to another type with a lower amount of hormone.

There are three types of combined contraceptive pill.

Monophasic pills: a 21-day pill is the most commonly prescribed type. You take one pill for 21 days and then have a seven-day break. During this break, you are likely to have a withdrawal bleed. Each pill contains the same amount of hormones.

Phasic pill: a 21-day pill with pills containing different amounts of hormone. These must be taken in the right order to be effective. Differing hormone amounts are marked with a colour coded strip.

Every day (ED) pills: a 28-day pill containing seven inactive pills. You must take these in the right order. You will have no pill-free days and should continue straight to the next packet as soon as you finish the 28 pills.

It's important to establish what kind of pill you are taking and to read the instruction leaflet thoroughly as they differ in missed pill procedures and side effects.

The combined pill provides one of the highest forms of contraception when it's taken properly. Many women choose to use the combined pill for this reason. To maintain the high levels of effectiveness you must follow the guidelines. This includes using extra barrier contraception when required, taking a pill every day and ensuring your break, where required, is not longer than seven days.

It is highly unlikely you will fall pregnant when you use the combined pill correctly, but there are some instances when its effectiveness is diminished. In these cases, you are required to take action.

Vomiting and diarrhoea

If you are sick within two to three hours of taking your pill then it won't have time to absorb and release its hormones. If you are no longer sick, take another pill. If you do not vomit again then you remain protected. If you have severe diarrhoea the same principle applies - take another pill and if you are no longer ill you are covered. If however, you continue to be ill and cannot take another pill you should follow this advice:

• Take your pills as usual as soon as you are able and use additional barrier contraception for seven days.
• If there are less than seven days left in the pack start another packet straight away without a seven-day break.

Other medications

The pill can be affected by other medications. If you are required to take any medicine in the short or long term, you should speak to your doctor about their effect on the combined pill.

Some medicines that interfere include antibiotics. It was previously thought that all antibiotics stopped the pill working correctly, but evidence shows that it is the antibiotic rifampicin and rifabutin that do so. However, you should always speak to your doctor about antibiotic interactions with the pill.

Other drugs that stop the pill working properly include:

• Some antifungals
• St John's Wort - an herbal remedy
• Some epilepsy medicines
• Some barbiturates
• Some anti-HIV drugs

This is because these medicines are enzyme inducers that speed up your liver's processes on the progesterone hormone, processing it before it has a chance to absorb properly.

If you buy medicine over-the-counter, tell your pharmacist that you're taking the combined pill and follow their advice.

As well as preventing pregnancy the combined contraceptive pill has many other benefits:

• The combined pill can manage periods. To skip a period you can take a pack of pills back-to-back without the seven-day break. This is helpful if you have an event or holiday planned.
• During your seven-day break you may experience a withdrawal bleed but this will be lighter, quicker and less painful than a regular period without hormonal contraception. Many women take the combined pill for this reason alone.
• Associated PMS will diminish as your body does not have to deal with a rush of period hormones each month. Your symptoms of back pain, mood swings, tearfulness, bloating and skin breakouts are likely to lessen.
• The combined pill does not interrupt sex. Barrier methods such as condoms require a break from sex to fit a device. Taking the pill means you don't have to stop sex.
• The effectiveness rate is higher than barrier methods. If you are used to using condoms then you may find you can relax and enjoy sex without the worry of breakage or pregnancy.
• The combined pill is sometimes taken to reduce acne on your doctor's recommendation. This is because it manages hormones and settles down your natural pattern.
• The pill can reduce the risk of ovarian, womb and colon cancer with long-term use, and it can reduce the risk of ovarian cysts, fibroids and benign breast disease.
• Thickening of the cervical mucus to prevent pregnancy can also protect against pelvic inflammatory disease. There is less chance of bacteria making its way into your womb if the mucus is thicker.
• The pill is completely reversible, meaning your fertility is restored when you stop taking it.
• It is a simple to swallow daily tablet. Other forms of contraception are invasive, for example, the IUD and IUS require a trained professional to fit a device into your womb, which can be painful. The implant needs to be fitted beneath your skin and the injection means a regular injection of hormones.

The combined pill should be swallowed once a day with or without water and food.

If you take the 21 day monophasic pill:

Follow the days of the week printed on your pill strip. When you reach the end of the pills you should have a seven-day break before beginning another strip. If you want to skip a period you can continue to the next strip immediately.

If you take the 21 day phasic pill:

Follow the pills in order of colour required. You should not change the order as this may mean you do not receive the correct amount of hormone. Take a seven-day break after you finish the packet or continue to the next packet if you want to skip your period. You should always start the next packet on day eight even if you are still bleeding.

If you take every day (ED) pills:

Take a pill labelled 'start' from your strip. Follow the order of pills, taking one each day. You do not take a break, but after 21 days you begin to take the dummy pills. During this time you may experience a period. Do not chew or crush your tablets or give them to anyone else.

It's not recommended that you take more than three packets of pills without a break. This is because you may experience breakthrough bleeding. Some women may experience bloating and backache too if they take more than three packets of pills without a break.

Starting The Combined Pill

It's easy to start the pill. Although you can begin at any time, it's recommended that you begin on the first day of your period. Doing this means you are protected against pregnancy immediately.

You can take it up to the fifth day of your period and be protected, but depends on the length of your menstrual cycle. If you bleed every 23 days or less, the pill may not have time to start working. You should use additional barrier contraception for seven days.

The seven-day rule of additional barrier contraception applies if you begin taking a combined pill at any other time during your cycle.

What To Do If You Miss A Combined Pill

Missing contraceptive pills can lead to pregnancy. You should always take your pill each day. If you are forgetful it may be wise to set up an alarm or choose a less regular form of contraception such as the patch or vaginal ring or implant.

Missed pills are common. Follow these instructions if you forget your pill.

• You have missed one pill - take the missed pill as soon as you remember. You are still covered against pregnancy.
• You have missed two or more pills, for example, you have started the next packet late - take the most recently forgotten pill and leave the others. Use additional barrier contraception for seven days until the pill has a chance to re-establish itself. Depending on your pill type you may need to continue straight to the next packet if you have less than seven pills left. Check your medical insert for more detail on your particular brand.
• If you are uncertain it's safest to use additional barrier contraception for seven days.

If you've had unprotected sex in the missed timeframe, you may fall pregnant. You should consider emergency contraception such as ellaOne. EllaOne can be taken up to five days after unprotected sex. It works by delaying ovulation. Take it as soon as you can to increase the odds. Be aware that ellaOne may adversely affect the contraceptive pill's effectiveness and you should use barrier contraception for nine days after.

The combined pill has an effectiveness rate equal to the mini pill and other contraceptives such as the IUD and IUS. However, unlike the mini pill, it contains oestrogen. Some women are sensitive to oestrogen and so the combined pill is unsuitable for them.

Other forms of contraception may prevent periods, but only the combined pill gives you total control over your bleeds. Taken long term, the combined pill reduces the severity of bleeding and associated PMS, but the major benefit is that you can skip periods by continuing straight to the next packet of pills without a break. Barrier contraceptives such as condoms, caps, sponges and diaphragms contain no hormones, but their effectiveness is lower than the over 99% rate offered by the combined pill.

The combined pill is easy to take. If you do not like hospitals or medical procedures the pill is a good option. You need only swallow a small tablet once a day. Contraceptives like the IUS/IUD or the contraceptive implant require medical procedures to insert devices into your body.

There are some side effects associated with the combined pill. These include:

• Breakthrough bleeding (spotting)
• Nausea
• Diarrhoea
• Rash
• Acne
• Breast tenderness
• Headaches
• Weight gain
• Missed periods
• Mood changes
• Changes in sex drive
• Visual problems with contact lenses
• High blood pressure

Minor side effects such as spotting, nausea and breast tenderness often pass after you have taken a few packets of the pill. This is because your body needs a chance to adjust to the new hormones. If you find the side effects unbearable or you experience breakthrough bleeding after a few months, speak to your doctor about changing your brand of pill.

Research has shown that on occasion the pill can cause serious side effects. These are very rare but can occur with regular use of the combined pill:

• Rarely oestrogen in the combined pill can cause blood to clot more easily. These clots can break free and travel through the circulatory system. The symptoms of a blood clot are cramping pains, warmth, or swelling in the leg. Breathlessness, wheezing, fainting and coughing blood are signs of a pulmonary embolism (blood clot in the lung).
• Depending on where a blood clot travels it may cause a heart attack, stroke or embolism. These can be fatal.
• The combined pill slightly raises the risk of breast cancer and cervical cancer although the rise in cervical cancer may be due to unprotected sex. The risk of breast cancer returns to normal ten years after you stop taking hormonal contraception.

Rarely women can experience an allergic reaction to the pill. If you feel wheezy, tight- chested, develop hives, or have swollen lips or throat you should seek immediate medical advice.

Many women choose to use the pill because of it numerous benefits not least its effectiveness rate against pregnancy and control over periods until menopause. However, there are some women who are not suitable. This is why the combined pill remains a prescription-only medicine.

If you do or have any of the following you should not take the combined contraceptive pill.

• If you are pregnant
• If you smoke and are over 35
• If you stopped smoking over a year ago and are over 35
• If you are overweight
• If your current medications cause a contraindication
• If you have or have had a blood clot
• If you have heart disease including high blood pressure
• If you experience migraines with visual disturbances
• If you've had breast cancer
• If you have gallbladder or liver disease
• If you have been diabetic for over 20 years or have diabetes with complications

You may be able to take the combined pill if you have one of the following. If you have two or more it is not suitable.

• You are over 35
• You smoke or have quit in the past year
• You are overweight
• You have migraines
• You have high blood pressure
• You've had a blood clot or stroke
• You have a close relative who experienced a blood clot under 45 years of age
• You've been immobile for a period of time

Speak to your doctor if you have one of the above risk factors. The benefits the pill offers may outweigh the risk. It depends on your personal circumstances.

After giving birth you can start the combined pill after day 21, but if you are breastfeeding you should wait until you have finished nursing your baby. The combined pill slows down milk production. If you start taking the pill after 21 days post birth you will need to use additional barrier contraception for seven days.

After a miscarriage or abortion it's possible to begin the combined pill after five days. If you start later than five days use extra barrier contraception for seven days.