Combined Oral Contraceptive Pill (COCP) - User Instructions

What is the COCP?

How to Start

• Take one pill every day, at the same time each day, for 21 days.
• After the 21 active pills, take a 7-day break (or take the 7 inactive pills in a 28-day pack). A withdrawal bleed usually occurs during this time.
• Start the next pack after exactly 7 days, whether or not bleeding has stopped.

Missed Pill Rules (CDC / current guidance)

Missed 1 pill (pill is 24-48 hours late)

• Take the missed pill as soon as you remember (even if that means taking 2 pills in one day).
• Continue the rest of the pack at the usual time.
• No additional contraception needed.
• Emergency contraception is not usually needed but may be considered if pills were also missed earlier in the same cycle or in the last week of the previous cycle.

Missed 2 or more consecutive pills (>48 hours since last pill)

• Take the most recent missed pill as soon as possible (discard any other missed pills).
• Continue taking remaining pills at the usual time (even if it means taking 2 in one day).
• Use condoms or abstain from sex for the next 7 consecutive days.
• If pills were missed in the last week of the active pills (e.g., days 15-21 of a 28-day pack):
  • Skip the pill-free interval - finish the active pills and start a new pack the next day.
  • If no withdrawal bleed occurs, consider a pregnancy test.

Vomiting and Diarrhoea

• If you vomit within 2 hours of taking your pill, take another pill straight away.
• If vomiting or severe diarrhoea continues for more than 24 hours, treat it like a missed pill and use condoms during illness and for 2 days after recovery.

Drug Interactions

• Enzyme-inducing drugs: rifampicin, rifabutin, some anticonvulsants (carbamazepine, phenytoin, phenobarbital, topiramate), some antiretrovirals, St. John's Wort
• With these, additional contraception or a different method is usually recommended.
• Antibiotics (non-enzyme-inducing) do not reduce COCP effectiveness in current guidance.

When to Stop Immediately and Seek Medical Advice

• Sudden severe chest pain
• Sudden breathlessness
• Severe leg pain or swelling (possible DVT)
• Sudden severe headache unlike previous headaches, or new visual disturbance
• Severe abdominal pain
• Signs of a stroke (facial drooping, arm weakness, speech problems)

Contraindications (Do Not Use If...)

• History of venous thromboembolism (DVT or pulmonary embolism)
• Migraine with aura
• Uncontrolled hypertension or blood pressure >160/100 mmHg
• Current or past breast cancer
• Smoker aged 35 or over
• Active liver disease or liver tumours
• Pregnancy

Practical Tips

• Breast tenderness and nausea are common in the first 1-3 months and usually resolve - a 3-month trial is standard before changing formulation (Textbook of Family Medicine, 9e, p.633).
• Breakthrough bleeding in the first few cycles is normal and often settles. Persistent bleeding may indicate the pill dose needs adjusting.
• Taking the pill at the same time each day maximises efficacy.
• A physical examination including blood pressure check is recommended before starting.