The Combined Pill (COC / CHC)
COC – The Pill – The Combined Oral Contraceptive – Birth Control Pills
This is an extract from
Sexplained Two – For Changing Times, by Helen J Knox ©
For more information on her books, please click to visit Knox Publishing
What is the COC Pill?
- It’s a drug combination of two of the female hormones you already make, oestrogen and progesterone, in the form of progestogen.
How does the COC Pill work?
- It’s an oral contraceptive pill, which fools a woman’s body into thinking that she’s already pregnant because pregnant women don’t ovulate or release more eggs until they’ve had the baby.
- It makes the mucus at the cervix thicker so sperm can’t get into the womb (uterus); it also changes the conditions in the lining of the womb (endometrium); and fallopian tubes.
- This ensures that a steady level of the hormones filter into the body, to keep the ovaries (where eggs are made) asleep – thereby ensuring that pregnancy cannot happen.
How do I take the combined oral contraceptive pill?
- Your active COC Pill should be taken at the same time every day for, usually 21 days, then you take a break for 7 days, starting your COC Pill again on the 8th day.
- (Note: Some brands have 22 or 24* active pills in a packet with different rules)
- Some COC Pill packets also contain 7 placebo (dummy or substitute) pills, which provide a useful reminder to help you take your pill on the days where you take a break between your active pills.
- They are known as ED (every day) combined oral contraceptive pills.
- ED COC Pills are taken EVERY day of the year. (They differ from the POP / mini-pill, which only contains one drug but is also taken every day).
- (* 24-day pills require only a 4-day break between packets).
What if I miss a COC Pill?
- Many people think that it takes several months to start releasing eggs again after coming off the COC Pill.
- This isn’t true. Ovulation occurs by Day 9.
- Manufacturer’s guidance and that of local organisations differ.
- This gives manufacturers’ licenced guidance, which is VERY safe, reliable and easy to remember.
- If you miss a COC Pill but take it within 12 hours from the time it should be taken, you will still be protected.
- If, however, it’s over 12 hours from the time you should have taken your COC Pill, you will no longer be protected.
- Don’t stop the pills.
- Continue to take your pills as usual, but use extra protection i.e., a condom, cap, diaphragm or not have sex (abstain) for the next 7 days.
- If those 7 days go into what would have been the 7-day break between packets – don’t take the break but start a new packet and take it to the end of the course (one day at a time).
- At the end of that packet, have the 7-day break as usual.
- This will not harm you.
- During the seven-day break, our ovaries start to wake up. If they’re not sent back to sleep in time then, there’s a risk of an egg being released.
- See the nearby charts for manufacturer’s guidance and that developed by the World Health
- Organisation, adapted by the UK Faculty of Sexual & Reproductive Health (FSRH).
- If you understand them both well, you can then decide which set of guidance you prefer to follow, carefully.
Do diarrhoea, vomiting or medication affect the COC Pill?
- If you have bad diarrhoea or vomiting, are taking some prescription medicines (particularly drugs used to treat TB, epilepsy and HIV) or the herbal antidepressant, St John’s Wort, you should assume that protection has been lost. (If you are on long term treatment, you may need to use an alternative method of contraception.)
- Extra protection (or no sex) is essential during any illness or when taking interacting medication or herbal remedies, and for 7 days afterwards.
- If any of that time goes into what would have been your 7-day break between pill packets, after completing the present one you should start taking the pills, in turn, from the next pill packet – and then have your usual break (as before).
- If you’re in any doubt as to which medicines cause problems, assume they will until you check with the person who prescribed them, ring any Contraception / Sexual Health Clinic; or ask a pharmacist.
- If you miss one COC Pill, continue as usual with the rest of your packet but if you have less than 7 days left in that packet, do NOT take the break but continue in to the next packet.
- Take all of those in turn, and then have your 7 day break, as usual.
- If you miss two or more pills, and have unprotected sex or an accident with a condom, seek immediate medical advice because you may require Emergency Contraception.
How reliable is The COC Pill?
- The COC Pill is extremely reliable if you remember to take it as directed – ie. it can be up to 99.8% effective when taken properly.
- In other words, only 2 women in 1,000 are unlucky enough to get pregnant each year, even if they take the COC Pill properly.
Do I have to be having sex to use the COC Pill?
- No, you don’t have to be having sex to use or continue using the COC Pill. Few people seem to realise that there are many benefits from taking the COC Pill apart from preventing pregnancy.
Who CAN take the COC Pill?
- Generally, the COC Pill is suitable for fit, healthy young women – particularly non-smokers (or those who only smoke a little) aren’t very overweight and don’t have any serious medical conditions.
- Its use also depends on the medical history of your close blood relatives (mother, father, brother(s) and sister(s)).
Why is the health of my parents and siblings important, when I want to use the COC Pill?
- The aim is to keep you healthy and safe, as well as protected against unplanned pregnancy when you use hormonal contraception.
- It is generally very safe but occasionally the risks of using a particular method are greater than the benefits of using it.
- Some medical conditions that close relatives have can suggest that you may be at increased risk of a particular condition, too.
- And for the sake of your health, it is extremely important that you are open about your family medical history when you are asked about it by healthcare practitioners.
- In these circumstances, a different method of contraception would be suggested.
- Your health is too important to hide information just because you think you want to use a particular method, for which you may not be suited.
Who can NOT use the COC Pill?
It’s not recommended for women who:
(a) are pregnant;
(b) have epilepsy – because of drug interactions that may alter the efficiency of the COC Pill. (But check with your prescriber as it may be OK.)
(c) have hypertension (high blood pressure);
(d) are already pregnant;
(e) get migraine, with aura;
(f) have or have had circulatory problems e.g. blood clots in your system (DVT / deep vein thrombosis, or PE / pulmonary embolism – clot in the lung);
(g) are breast feeding;
(h) smokers who:
1) are under 35 and smoke over 40 a day;
2) are over 35 years of age;
3) are over 35 and stopped smoking less than a year ago;
4) smoke shisha / hookah, regularly; (one hour is equal to smoking 200 cigarettes Ref: BBC.co.uk/WHO)
5) and people who chew tobacco;
(i) have active liver disease (hepatitis);
(j) have breast cancer;
(k) have diabetes – with complications;
(l) have unexplained vaginal bleeding;
(m) have sickle cell disease (a blood disorder), but not sickle cell trait;
(n) have tuberculosis (TB) – because of interacting drugs;
(o) have high cholesterol;
(p) have severe varicose veins;
(q) are bedridden (immobile) or use a wheelchair;
(r) have current gall bladder disease or some other rare medical conditions;
(s) are obese, with BMI more than 35 (ratio of height to weight calculation) or are a smoker with BMI over 30;
(t) are using St John’s Wort (herbal antidepressant); or are taking certain medication (enzyme inducers);
(u) women who do not want to use hormonal methods of contraception;
(v) and women with multiple risk factors.
What are the advantages of using it, apart from avoiding pregnanacy?
If you take it properly, some of the advantages may include:
(a) fewer acne-type spots (with some pills);
(b) less non-cancerous breast disease;
(c) regular withdrawal bleeds (periods);
(d) less painful periods;
(e) (generally) lighter periods;
(f) less anaemia;
(g) no ovulation pain;
(h) less unwanted hair growth;
(i) some protection against cancer of the ovaries and endometrium (lining of the womb), and also the bowel, which lasts long after the method is stopped;
(j) less endometriosis (a condition where tissue, similar to the lining of your womb, bleeds outside your womb into your pelvic cavity and causes pain);
(k) fewer ovarian cysts (small sacs of clear fluid on the ovary);
(l) less troublesome fibroids (non-cancerous/benign tumours or growths in your uterus);
(m) less rheumatoid arthritis;
(n) no anxiety over unwanted pregnancy; and
(o) it doesn’t interfere with sex.
What are the disadvantages of using the COC Pill?
Disadvantages may include:
(a) an initial and temporary sense of minor headache, nausea, mood swings and / or breast tenderness, which settles as the COC Pill’s hormones and your own balance;
(b) increased blood pressure;
(c) spotting and/or breakthrough bleeding i.e. bleeding on pill taking days whilst the COC Pill and your body settle together.
d) in some women, a very small increased risk of breast cancer, which reduces after stopping
Does the use of CHC increase the risk of cervical cancer?
- Yes, and no. Women who use methods of CHC (combined hormonal contraception) do not tend to use condoms regularly in stable relationships.
- Extended use of CHC may increase the risk of cervical cancer cells developing so regular cervical screening is advised to detect this promptly.
- However, this may be related to other factors, such as acquisition of HPV (human papilloma virus) and/or smoking.
Are there any risks associated with using the COC Pill?
- Most women are safe to use the COC Pill and don’t have any problems.
- The COC Pill is safe for women whose personal and family medical history give no cause for concern during careful assessment.
- However, women with some medical conditions (or whose family medical history suggests increased risk) may develop thrombosis (blood clots) and other medical problems if they use it.
When should I contact someone if I am worried about something new?
You should consult your healthcare professional if you experience any of the following for the first time: sudden, severe chest or abdominal pain; lower leg pain, particularly if you raise your toes towards your knee, if there is any redness or associated swelling;
- migraine ( a severe type of headache), especially ‘with aura’ (see information about migraine);
- breathlessness or coughing up blood;
- strong tingling, weakness or
- numbness in your arms or legs;
- fainiting; or, if you collapse.
These may not be associated with your COC Pill but it may not be safe for you to continue using it with such conditions.
For how many years can I take it?
- If you remain fit and well – and don’t smoke – you can use it until you’re 50, without a break.
- If you’re a smoker, you’ll be taken off it, automatically, by the time you’re 35.
Do I need to stop taking the COC Pill after a few months, to give my body a break?
- No. Your body gets a break from it every four weeks, anyway, and you are merely suppressing (resting) ovulation whilst you take it.
- By the end of the 7-day break between your packets, the drugs are virtually out of your system and you will be at risk of pregnancy if you don’t start your next COC Pill packet on time.
- That’s why you must use extra protection, or avoid having sex, if you start your next packet late.
Will the COC Pill control my periods?
- Yes, it will. Your bleeding will be regular and you may be able to predict them, right down to the hour they start.
Will it make my periods heavier or lighter?
- Generally, the COC Pill makes periods extremely regular, much lighter and less painful with fewer, if any, pre-menstrual symptoms.
What should I be aware of if my girlfriend’s using it?
- You have an interest and a responsibility to understand about the COC Pill and how it works to prevent your girlfriend becoming pregnant.
- Her outward appearance will not change, so you’ll have to trust her to take it properly because if your girlfriend were to become pregnant, with or without a termination you’d have to deal with some difficult emotions. Without a termination you’d be responsible for paying child maintenance for up to 25 years.
- When you understand it, you will realise that there will may be times when you will need to use condoms for protection against pregnancy, as well as for routine protection against infection.
- The only way to protect yourself in case she hasn’t taken it properly is to use a condom routinely for safer sex.
Do recreational drugs affect the COC Pill’s reliability?
- No. Not as far as is known.
- Drugs can, however, be bad for your long-term physical and mental health and can increase your risk of contracting sexually acquired infections.
- If you dehydrate you are more likely to develop thrombosis (blood clots).
Will the COC Pill make me put on weight?
- There is no evidence that it causes weight gain. Some women put on a little bit of weight (3-4 lbs / 1-2 kg) in the first couple of months due to water retention, but this wears off.
- A little extra weight is safer than pregnancy so, if you do put on weight, don’t stop taking your pills but watch what you eat and drink.
- Try to give it three months before deciding it doesn’t suit you. Although contraceptively protected when taken properly, it takes a little time for your body to fully adjust.
- Some women become aware of a slightly nauseous sensation in their throat – but this should wear off soon and you’re most unlikely to vomit.
- Don’t stop taking your pills. Try taking it at night instead, so you can sleep through or; take it after breakfast, which may be an easier time to remember to take them routinely.
- It’s often blamed for things it’s not guilty of!
When I take The Pill for the first time, how long does it take to start working?
- You’re contraceptively protected from the moment you take your 1st pill on the 1st day of your period.
- Manufacturers guide that if you start it later than day 2 of your period, you need to use extra protection or abstain (avoid sex) for 7 days.
- The same applies if you are re-starting to use the COC Pill after having stopped using it for some time.
- In both cases, you’re protected from pregnancy if you continue to take it properly, thereafter.
- Other guidance states that you are protected if you start it from the 1st to 5th day of the initial period, and that you are then protected if you carry on as prescribed.
- Be advised by your prescriber.
Why are smokers taken off the COC Pill but non-smokers are allowed to continue?
- Smokers are taken off the COC Pill to protect their health.
- Smoking makes blood more sticky and so can oestrogen in combined methods of contraception.
- With age, the risk of having a heart attack or stroke from a sticky blood clot (thromboembolism) lodging in heart muscle or the brain increases.
- If you stop smoking for at least a year before you are 35, you may be allowed to stay on it.
- This is why you will be advised to stop smoking, if you are using combined hormonal contraception.
- If you’re a non-smoker, and want to continue using it, you may be able to do so right up until your menopause (when periods stop, commonly between 48 and 52 years of age) and then, if you would like, transfer to HRT (hormone replacement therapy).
I was reading something about blood clots being serious if a woman is using hormonal contraception. I have blood clots during my period.
Is this dangerous?
- No. Although period blood clots, can appear to be quite large, this type of clot is not the same as thrombo-embolism.
- Clots from venous thromboembolism (VTE) travel around the body via the circulatory system.
- Period blood clots are leaving the body, not circulating inside it.
- It’s the internal type of blood clots that cause major risk to life and may kill.
What’s venous-thromboembolism (VTE) and why is it so serious?
- Thrombos means clot.
- The clot forms an obstruction, which is called an embolus.
- When an embolism (clot) gets stuck in a vein, it is called venous thromboembolism (VTE is also called venous thrombosis).
- VTE commonly develops as a deep vein thrombosis (DVT) or a clot in a vein, deep inside the body, rather than in a vein you can see near the surface of your skin.
- Sometimes, instead of the clot being formed from blood, it is formed from a fatty deposit or plaque that has stuck to the lining of an artery or vein and become dislodged in a similar way.
- This is called atherosclerosis and such plaque develops in medium or large arteries and may also be called ‘hardening of the arteries’.
- Unfortunately, across the general population, VTE is common and can be deadly.
What are the main risks for the development of VTE?
- Thromboembolism is a rare but serious complication, that can occur when using combined hormonal contraceptive methods.
- This is why each woman’s medical history is assessed carefully.
- Risks are higher during the first year of use or when re-starting combined hormonal contraception after a break of four or more weeks.
- Examples of conditions caused by thromboembolism are:
— D.V.T (deep vein thrombosis);
— M.I. (myocardial infarction or death of heart muscle / heart attack);
— C.V.A (cerebro-vascular accident / stroke);
— P.E (pulmonary embolism or clot in the lung(s)); and
— gastrointestinal embolism, which presents with severe abdominal pain, nausea, vomiting and shock.
Comparison DVT risk examples:
— general population 4 per 10,000
— women using combined methods of contraception – 6-10 per 10,000;
— pregnant women – 20 per 10,000.
And the chance of actually dying from a blood clot whilst using combined hormonal contraception is roughly one in a million. In other words, rare!
Is this why so many questions are asked about my health when I just want to use contraception?
- Yes. The questions are designed to protect your health.
- If you are worried about your risks, ask your doctor or nurse to guide you.
What might I notice if I develop VTE?
You may notice one or more of the following signs or symptoms, which may or may not be due to VTE, BUT if you are using combined hormonal contraception, you should not ignore:
- sudden, severe, shortness of breath unrelated to recent exercise;
- a persistent dry cough;
- chest pain;
- severe headache;
- pain in the lower leg, particularly if it is in one leg only, which increases when you raise your toes towards your knees, the area is red, swollen, warmer to touch than the other leg and/or tender;
- abnormal nerve sensations such as pins-and-needles, tingling, burning, prickling or similar feelings (known as parasthesia);
- weakness, particularly one sided;
- weak pulse;
- coughing up blood; and even perhapspersonality change.
- Indeed, anything worrying should be reported to an emergency service, so a correct assessment can be made and appropriate treatment organised.
Who is most at risk of developing VTE?
People at higher risk of developing VTE include, but are not limited to, those who:
- have already had a DVT;
- smoke, use shisha, snuff or chew tobacco;
- get migraine with aura;
- are obese (overweight);
- have high blood pressure;
- fly long distances without walking about or drinking much water during the flight;
- are pregnant;
- have major surgery, especially abdominal surgery;
- are on bed-rest, for extended periods of time (immobile);
- have had a stroke and are not able to keep mobile;
- taking some types of medication;
- have various medical conditions that affect their blood and/ or circulation;
- have some types of cancer;
- have had a heart attack;
- have a heart and lung condition called ‘congestive cardiac failure’;
- are increasing in age (esp. over 40);
- have high cholesterol;
- have a close family member who have had VTE; and also people who have had VTE are at higher risk of developing another.
This list is not exhaustive, and a combination of factors increase individual risk. But, this list shows how common VTE can be and why it is vital to ask relevant questions about someone’s medical history before a woman is given combined hormonal contraception; and why it is important to answer honestly.
What is the difference between a headache and a migraine. I thought they were the same thing?
No. They are not the same. There are different types of headache but they are usually limited in duration and severity. They are:
- common headache;
- tension headaches;
Migraines, however, tend to last longer than a simple headache and there are two types:
- simple or common migraine (without aura); and migraine with aura.
How can I tell if I get a common migraine or migraine with aura?
Adults who get migraine with aura tend to notice a recognisable set of symptoms during the hour before the headache starts (although it is possible to have the aura without an associated headache) e.g:
- an unpleasant smell;
- confused thoughts;
- zig-zag lines / blind spots on one side;
- the perception of a strange light / or a beam of light (as if looking at the
- light at the end of a dark tunnel).
This is commonly followed by a migraine of moderate severity, which
- occurs on one side of the head, is made worse during movement, and may have other symptoms, such as:
- sensitivity to noise / sound; ringing in the ears; nausea; and / or vomiting and / or spinning sensation (vertigo);
- noticing strange odours (smells) or tastes;
- sometimes muscle weakness,
- tingling, numbness, ‘pins and needles’;
- it may last from a few hours to a few days; and rarely, there is fainting and/or
- paralysis during the migraine.
Will the COC Pill protect me from pregnancy AND infection?
- No, it won’t. You will still need to use condoms for protection against sexually acquired infection.
- The barrier of mucus, which forms at your cervix, may slow down the progress of an infection into your womb and tubes, but it won’t prevent you from catching it.
Are the effects of the COC Pill reversible?
- Yes, they are. It’s virtually out of your system by the end of your 7-day break.
- But remember: you can get pregnant after that if you have unprotected sex. So use condoms from the day after your last pill, if you decide to stop using it, if you don’t want to get pregnant.
Is it safe to have sex during my 7-day break between packets?
- Yes it is. As long as you took your previous pack correctly, start your next packet of pills on time; you don’t have diarrhoea or vomiting; you aren’t taking medication which can interfere with the COC Pill; you’re contraceptively protected.
- If in doubt; ask your doctor, nurse, or pharmacist for advice.
If I’m going on holiday and don’t want to bleed while I’m away, is there anything I can do?
- Yes there is. To avoid your withdrawal bleed (period) – instead of taking your 7-day break between packets of pills/active pills, simply start your next packet of pills when you finish your present pack – take all of those in turn – and then take your usual break.
- It’s OK to do this occasionally, but not wise to do it every month without medical advice.
When should I call my doctor?
- Despite the many precautions used to ensure that only women who are medically fit to take it are given the COC Pill, sometimes complications do occur.
- If you notice sudden severe shortness of breath with chest pain, or a painful hot tender swelling in your calf (lower leg), contact your doctor immediately or Casualty Department (ER) in case a DVT has formed, for which you will need urgent medical treatment.
- Thrombosis is very rare in young, fit, healthy women but is an important reason why you should be open and honest with whoever asks you about your and your family’s medical history.
- When you visit to collect more pills, tell the doctor about any worries or concerns you may have however minor or silly you think they are. They may be very important.
How old do I have to be to start taking the COC Pill?
- You can start taking The COC Pill once you have regular, established periods. As already seen, it has many helpful, non-contraceptive uses than just protection against pregnancy.
Will they show me what to do if I go to a clinic, my doctor, practice nurse or pharmacist?
- Whoever prescribes you the COC Pill should teach you how to use it correctly before you leave them.
- They should also give you an instruction leaflet to keep as a reference – ie. in case you need to check what you were told at any time.
- If, for some reason you’re not shown how to take your Pill, ask them to make time to teach you before you leave, so you are sure of what to do.
- This is especially important for women who have dyslexia or are not able to read very well.
What should I do if I bleed on my COC Pill taking days?
- If you bleed on COC Pill-taking days, check that you are taking it at the same time each day.
- Continue taking your COC Pill and check with your healthcare provider.
- If you have not had a sexual health screen since changing sexual partner or in the last 12 months, it would be wise to do so incase the bleeding is caused by a sexual infection.
What should I do if I don’t bleed during my 7-day break?
- As long as you have taken all of your pills correctly, start your next packet of pills on time.
- However, if you’re worried or you think you made a mistake during the previous packet, check with your healthcare provider.
- They may suggest doing a pregnancy test, to make sure you are not pregnant, so don’t be too alarmed when they suggest this.
When should I stop using the COC Pill if I want to get pregnant?
- It used to be thought that it took some time for fertility to return after stopping the COC Pill, but it is now known that ovulation occurs by day 8 or 9 after the last COC Pill.
My boyfriend doesn’t like the idea of me taking hormones as our method of contraception.
- Your health is monitored closely and you are taking medication that is similar to what your body makes.
- Hormonal contraception is very safe and there are many non-contraceptive benefits.
- Pregnancy is not risk-free!
When can I use the COC Pill after I have a baby, have a miscarriage or an abortion?
After having your baby:
- If you ARE breastfeeding, you will probably be guided away from the COC Pill and other combined hormonal methods of contraception (The Patch and The Ring) until you stop, and guided towards another method, such as the progestogen-only pill (POP), implant, IUS (intrauterine system / Mirena®) methods or an IUD (copper coil).
- If you are NOT breastfeeding, the COC Pill (Patch or Ring) can be used after the baby is 21 days old. In some parts of the world, this guidance is changing, to ‘any time’, however. Check what your prescriber recommends locally.
After having a miscarriage or an abortion:
- The COC Pill can be used straight after an abortion or a miscarriage.
I’ve tried the COC Pill before and didn’t like it but I’m older now. If I try it again, will I get the same effects or will I feel better this time?
- It is impossible to predict how you will react to the COC Pill but if you’re still medically fit to take it, it would be sensible to try it again.
- You could either try the same one again or ask to try a different one.
- Remember, though, that you should allow three months for the COC Pill hormones to settle again, before saying you don’t like the new pill.
- Never take unnecessary risks.
- Check with your prescriber or your pharmacist if if you are in doubt about anything.
- Use extra protection unless you’re reliably informed that it’s not necessary.
- Take the pill you’ve forgotten, even if this means taking two pills on one day.
- There are many different types of pill, so if you think one doesn’t suit you, ask to try others until you find the one that is right for you.
- But remember to allow at least three months with a new hormonal method before deciding that it doesn’t suit you.
- Chewing tobacco is shredded like short cut grass, generally mildly acidic and intended to be chewed throughout the day as desired.
- Snuff is chopped into particles like large coffee grounds, moistened and used by holding between gum and cheek.
- Swedish snus (typically moist), is a variant on snuff but processed differently so that some must be kept refrigerated.
- Gutkha and other oral smokeless tobacco products are used in India and South-East Asia.
Ref: World Health Organisation
- Hookahs, Bhang, Narghiles, Shisha, Hubble-Bubble
- Smoking these for 1 hour is equivalent to smoking 200 cigarettes.
(ref BBC.co.uk quoting World Health Organisation)
Combined hormonal contraception may not be the first method of choice for women using these products regularly.
Healthcare professionals prescribing them should consider the use of these products when taking a woman’s medical history — and not just ask about their use of cigarettes!
COC – The Pill – The Combined Oral Contraceptive Pill
This is an extract from
Sexplained Two – For Changing Times, by Helen J Knox ©
For more information on her books, please click to visit Knox Publishing