BNF for Children 2011-2012

400 7.3.1 Combined hormonal contraceptives BNFC 2011–20127 Obstetrics, gynaecology, and urinary-tract disordersday 4 of cycle or later, additional precautions(barrier methods) necessary during first 7 days;withdrawal bleeding occurs when inactive tabletsbeing taken; subsequent courses repeated withoutintervalPhasic preparations, see under individual preparationsbelowChanging to combined preparation containing differentprogestogen 21-day combined preparations: continuecurrent pack until last tablet and start first tablet ofnew brand the next day. If a 7-day break is taken beforestarting new brand, additional precautions (barriermethods) should be used during first 7 days (9 days forQlaira c ) of taking the new brandEvery Day (ED) combined preparations: start the newbrand (first tablet of a 21-day preparation or the firstactive tablet of an ED preparation) the day after takingthe last active tablet of previous brand (omitting theinactive tablets)Changing from progestogen-only tablet Start on day 1of menstruation or any day if amenorrhoea present andpregnancy has been excludedSecondary amenorrhoea (exclude pregnancy) Startany day, additional precautions (barrier methods)necessary during first 7 days (9 days for Qlaira c )After childbirth (not breast-feeding) Start 3 weeks afterbirth (increased risk of thrombosis if started earlier); laterthan 3 weeks postpartum additional precautions (barriermethods) necessary for first 7 days (9 days for Qlaira c )After abortion or miscarriage Start same day. By transdermal applicationApply first patch on day 1 of cycle, change patchon days 8 and 15; remove third patch on day 22and apply new patch after 7-day patch-free intervalto start subsequent contraceptive cycleNote If first patch applied later than day 1, additionalprecautions (barrier methods) should be used for the next7 daysChanging from combined oral contraception Applypatch on the first day of withdrawal bleeding; if nowithdrawal bleeding within 5 days of taking last activetablet, rule out pregnancy before applying first patch.Unless patch is applied on first day of withdrawalbleeding, additional precautions (barrier methods)should be used concurrently for first 7 daysChanging from progestogen-only method From animplant, apply first patch on the day implant removed;from an injection, apply first patch when next injectiondue; from oral progestogen, first patch may be started onany day after stopping pill. For all methods additionalprecautions (barrier methods) should be used concurrentlyfor first 7 daysAfter childbirth (not breast-feeding) Start 4 weeks afterbirth; if started later than 4 weeks after birth additionalprecautions (barrier methods) should be used for first 7daysAfter abortion or miscarriage Before 20 weeks’ gestationstart immediately; no additional contraceptionrequired if started immediately. After 20 weeks’ gestationstart on day 21 after abortion or on the first day of firstspontaneous menstruation; additional precautions (barriermethods) should be used for first 7 days afterapplying the patch. By vaginaInsert ring into vagina on day 1 of cycle and leavein for 3 weeks; remove ring on day 22; subsequentcourses repeated after 7-day ring-free interval(during which withdrawal bleeding occurs)Note If first ring inserted later than day 1, additionalprecautions (barrier methods) should be used for the next7 daysChanging from combined hormonal contraceptionInsert ring at the latest on the day after the usual tabletfree,patch-free, or placebo-tablet interval. If previouscontraceptive used correctly and pregnancy unlikely, canswitch to ring on any day of cycleChanging from progestogen-only method From animplant or intra-uterine progestogen-only device, insertring on the day implant or intra-uterine progestogen-onlydevice removed; from an injection, insert ring wheninjection next due; from oral preparation, first ring maybe inserted on any day after stopping pill. For all methodsadditional precautions (barrier methods) should be usedconcurrently for first 7 daysAfter first trimester abortion Start immediatelyAfter childbirth (not breast-feeding) or second trimesterabortion Start 4 weeks after birth or abortion; ifstarted later than 4 weeks after birth or abortion additionalprecautions (barrier methods) should be used forfirst 7 daysOral (low and standard strength)For information on these preparations, see CombinedOral Contraceptives table, p. 401Transdermal (standard strength)Ethinylestradiol with NorelgestrominSee Risk of Venous Thromboembolism (in notesabove) before prescribingEvra c (Janssen) APatches, self-adhesive (releasing ethinylestradiolapprox. 33.9 micrograms/24 hours and norelgestrominapprox. 203 micrograms/24 hours); net price 9-patch pack = £16.70. Counselling, administrationDose1 patch to be applied once weekly for three weeks,followed by a 7-day patch-free interval; subsequentcourses repeated after 7-day patch-free interval (duringwhich withdrawal bleeding occurs); for starting routinessee under Dose aboveNote Adhesives or bandages should not be used to holdpatch in place. If patch no longer sticky do not reapply butuse a new patch.The Scottish Medicines Consortium has advised (September2003) that Evra c patches should be restricted for use inwomen who are likely to comply poorly with combined oralcontraceptivesVaginal (low strength)Ethinylestradiol with EtonogestrelSee Risk of Venous Thromboembolism (in notesabove) before prescribingNuvaRing c (Organon) TAVaginal ring, releasing ethinylestradiol approx.15 micrograms/24 hours and etonogestrel approx.120 micrograms/24 hours, net price 3-ring pack =£27.00. Counselling, administrationDose1 ring to be inserted into the vagina for 3 weeks, removedon day 22; subsequent courses repeated after 7-day ringfreeinterval (during which withdrawal bleeding occurs);for starting routines see under Dose aboveCounselling The presence of the ring should be checkedregularly. In case of expulsion see Expulsion, DelayedInsertion or Removal, or Broken Vaginal Ring, p. 397