BNF for Children 2011-2012

BNFC 2011–2012 7.3.1 Combined hormonal contraceptives 399weakness, motor disturbances, very marked numbnesssuddenly affecting one side or one part of body;. hepatitis, jaundice, liver enlargement;. very high blood pressure;. prolonged immobility after surgery or leg injury;. detection of a risk factor which contra-indicates treatment(see Cautions and Contra-indications under CombinedHormonal Contraceptives below).COMBINED HORMONALCONTRACEPTIVESCautions see notes above; also risk factors for venousthromboembolism (see below and also notes above),arterial disease and migraine, see below; personal orfamily history of hypertriglyceridaemia (increased riskof pancreatitis); hyperprolactinaemia (seek specialistadvice); history of severe depression especially ifinduced by hormonal contraceptive; undiagnosedbreast mass; gene mutations associated with breastcancer (e.g. BRCA 1); sickle-cell disease; inflammatorybowel disease including Crohn’s disease;reduced efficacy of contraceptive patch in womenwith body-weight 90 kg; active trophoblastic disease(until return to normal of urine- and plasmagonadotrophinconcentration) —seek specialistadvice; interactions: see above and Appendix 1(oestrogens, progestogens)Risk factors for venous thromboembolism See also notesabove. Use with caution if any of following factors presentbut avoid if two or more factors present:. family history of venous thromboembolism in firstdegreerelative aged under 45 years (avoid contraceptivecontaining desogestrel or gestodene, or avoid ifknown prothrombotic coagulation abnormality e.g. factorV Leiden or antiphospholipid antibodies (includinglupus anticoagulant));. obesity—caution if obese according to BMI (adjusted forage and gender); in those who are markedly obese,avoid unless no suitable alternative;. long-term immobilisation e.g. in a wheelchair (avoid ifconfined to bed or leg in plaster cast);. history of superficial thrombophlebitis;. smoking.Risk factors for arterial disease Use with caution if anyone of following factors present but avoid if two or morefactors present:. family history of arterial disease in first degree relativeaged under 45 years (avoid if atherogenic lipid profile);. diabetes mellitus (avoid if diabetes complications present);. hypertension (avoid if blood pressure very high);. smoking (avoid if smoking 40 or more cigarettes daily);. obesity—caution if obese according to BMI (adjusted forage and gender); in those who are markedly obese,avoid unless no suitable alternative;. migraine without aura (avoid if migraine with aura(focal symptoms), or severe migraine frequently lastingover 72 hours despite treatment, or migraine treatedwith ergot derivatives).Migraine Women should report any increase in headachefrequency or onset of focal symptoms (discontinue immediatelyand refer urgently to neurology expert if focal neurologicalsymptoms not typical of aura persist for more than1 hour—see also Reason to stop immediately in notes above)Contra-indications see notes above; also personalhistory of venous or arterial thrombosis, severe ormultiple risk factors for arterial disease or for venousthromboembolism (see above), heart disease associatedwith pulmonary hypertension or risk of embolus;sclerosing treatment for varicose veins; migrainewith aura (see also above); transient cerebralischaemic attacks without headaches; systemic lupuserythematosus; acute porphyria (section 9.8.2); gallstones;history of haemolytic uraemic syndrome orhistory during pregnancy of pruritus, cholestaticjaundice, chorea, pemphigoid gestationis; history ofbreast cancer but can be used after 5 years if noevidence of disease and non-hormonal methodsunacceptable; undiagnosed vaginal bleedingHepatic impairment avoid in active liver diseaseincluding disorders of hepatic excretion (e.g. Dubin-Johnson or Rotor syndromes), infective hepatitis(until liver function returns to normal), and livertumoursPregnancy not known to be harmfulBreast-feeding avoid until weaning or for 6 monthsafter birth (adverse effects on lactation)Side-effects see notes above; also nausea, vomiting,abdominal cramps, changes in body-weight, liverimpairment, hepatic tumours; fluid retention,thrombosis (more common when factor V Leidenpresent or in blood groups A, B, and AB; see alsonotes above), hypertension, changes in lipid metabolism;headache, depression, chorea, nervousness,irritability; changes in libido, breast tenderness,enlargement, and secretion; reduced menstrual loss,‘spotting’ in early cycles, absence of withdrawalbleeding, amenorrhoea after discontinuation, changesin vaginal discharge, cervical erosion; contact lensesmay irritate, visual disturbances; leg cramps; skinreactions, chloasma, photosensitivity; rarely gallstonesand systemic lupus erythematosusBreast cancer There is a small increase in the risk of havingbreast cancer diagnosed in women taking the combined oralcontraceptive pill; this relative risk may be due to an earlierdiagnosis. In users of combined oral contraceptive pills thecancers are more likely to be localised to the breast. Themost important factor for diagnosing breast cancer appearsto be the age at which the contraceptive is stopped ratherthan the duration of use; any increase in the rate of diagnosisdiminishes gradually during the 10 years after stopping anddisappears by 10 yearsCervical cancer Use of combined oral contraceptives for 5years or longer is associated with a small increased risk ofcervical cancer; the risk diminishes after stopping and disappearsby about 10 years. The risk of cervical cancer withtransdermal patches and vaginal rings is not yet knownNote The possible small increase in the risk of breast cancerand cervical cancer should be weighed against the protectiveeffect against cancers of the ovary and endometriumLicensed use consult product literature for thelicensing status of individual preparationsIndication and doseContraception, menstrual symptoms (section6.4.1.2). By mouthEach tablet should be taken at approximately sametime each day; if delayed contraceptive protectionmay be lost (see Missed Pill, above)21-day combined (monophasic) preparations, 1tablet daily for 21 days; subsequent coursesrepeated after a 7-day interval (during whichwithdrawal bleeding occurs); first course usuallystarted on day 1 of cycle—if starting on day 4 ofcycle or later, additional precautions (barriermethods) necessary during first 7 daysEvery day (ED) combined (monophasic) preparations,1activetablet starting on day 1 of cycle(see also under preparations below)—if starting on7 Obstetrics, gynaecology, and urinary-tract disorders