BNF for Children 2011-2012

BNFC 2011–2012 7.3.1 Combined hormonal contraceptives 397progestogens is very small and well below the riskassociated with pregnancy. The risk of venous thromboembolismin women using a combined oral contraceptivecontaining drospirenone may be between thatassociated with combined oral contraceptives containingsecond-generation progestogens and combined oralcontraceptives containing third-generation progestogens.The risk of venous thromboembolism associatedwith vaginal ring use compared to the risk with othercombined hormonal contraceptives is unknown.Provided that women are informed of the relative risksof venous thromboembolism and accept them, thechoice of oral contraceptive is for the woman togetherwith the prescriber jointly to make in light of herindividual medical history and any contra-indications.Travel Women taking oral contraceptives or using thepatch or vaginal ring are at an increased risk of deepveinthrombosis during travel involving long periods ofimmobility (over 5 hours). The risk may be reduced byappropriate exercise during the journey and possibly bywearing graduated compression hosiery.Missed pill The critical time for loss of contraceptiveprotection is when a pill is omitted at the beginning orend of a cycle (which lengthens the pill-free interval).If a woman forgets to take a pill, it should be taken assoon as she remembers, and the next one taken at thenormal time (even if this means taking 2 pills together).A missed pill is one that is 24 or more hours late; forwomen taking Qlaira c , see below. If a woman missesonly one pill, she should take an active pill as soon asshe remembers and then resume normal pill-taking. Noadditional precautions are necessary.If a woman misses 2 or more pills (especially from thefirst 7 in a packet), she may not be protected. She shouldtake an active pill as soon as she remembers and thenresume normal pill-taking. In addition, she must eitherabstain from sex or use an additional method of contraceptionsuch as a condom for the next 7 days. If these 7days run beyond the end of the packet, the next packetshould be started at once, omitting the pill-free interval(or, in the case of everyday (ED) pills, omitting the 7inactive tablets).A missed pill for a woman taking Qlaira c is one that is12 hours or more late; for information on how tomanage missed pills in women taking Qlaira c , refer toproduct literature.Emergency contraception (section 7.3.5) is recommendedif 2 or more combined oral contraceptivetablets are missed from the first 7 tablets in a packetand unprotected intercourse has occurred since finishingthe last packet.Delayed application or detached patch If a patchis partly detached for less than 24 hours, reapply to thesame site or replace with a new patch immediately; noadditional contraception is needed and the next patchshould be applied on the usual ‘change day’. If a patchremains detached for more than 24 hours or if the user isnot aware when the patch became detached, then stopthe current contraceptive cycle and start a new cycle byapplying a new patch, giving a new ‘Day 1’; an additionalnon-hormonal contraceptive must be used concurrentlyfor the first 7 days of the new cycle.If application of a new patch at the start of a new cycle isdelayed, contraceptive protection is lost. A new patchshould be applied as soon as remembered giving a new‘Day 1’; additional non-hormonal methods of contraceptionshould be used for the first 7 days of the newcycle. If intercourse has occurred during this extendedpatch-free interval, a possibility of fertilisation should beconsidered. If application of a patch in the middle of thecycle is delayed (i.e. the patch is not changed on day 8 orday 15):. for up to 48 hours, apply a new patch immediately;next patch ‘change day’ remains the same and noadditional contraception is required;. for more than 48 hours, contraceptive protectionmay have been lost. Stop the current cycle and starta new 4-week cycle immediately by applying a newpatch giving a new ‘Day 1’; additional non-hormonalcontraception should be used for the first 7 daysof the new cycle.If the patch is not removed at the end of the cycle (day22), remove it as soon as possible and start the nextcycle on the usual ‘change day’, the day after day 28; noadditional contraception is required.Expulsion, delayed insertion or removal, or brokenvaginal ring If the vaginal ring is expelled for lessthan 3 hours, rinse the ring with cool water and reinsertimmediately; no additional contraception is needed.If the ring remains outside the vagina for more than 3hours or if the user does not know when the ring wasexpelled, contraceptive protection may be reduced:. if ring expelled during week 1 or 2 of cycle, rinsering with cool water and reinsert; use additionalprecautions (barrier methods) for next 7 days;. if ring expelled during week 3 of cycle, either inserta new ring to start a new cycle or allow a withdrawalbleed and insert a new ring no later than 7 days afterring was expelled; latter option only available if ringwas used continuously for at least 7 days beforeexpulsion.If insertion of a new ring at the start of a new cycle isdelayed, contraceptive protection is lost. A new ringshould be inserted as soon as possible; additional precautions(barrier methods) should be used for the first 7days of the new cycle. If intercourse occurred during theextended ring-free interval, pregnancy should be considered.No additional contraception is required if the removal ofthe ring is delayed by up to 1 week (4 weeks of continuoususe). The 7-day ring-free interval should beobserved and subsequently a new ring should beinserted. Contraceptive protection may be reducedwith continuous use of the ring for more than 4weeks—pregnancy should be ruled out before insertinga new ring.If the ring breaks during use, remove it and insert a newring immediately; additional precautions (barrier methods)should be used for the first 7 days of the new cycle.Diarrhoea and vomiting Vomiting and persistent,severe diarrhoea can interfere with the absorption ofcombined oral contraceptives. If vomiting occurs within2 hours of taking a combined oral contraceptive anotherpill should be taken as soon as possible. In cases of7 Obstetrics, gynaecology, and urinary-tract disorders