Problems Reported as Side Effects or Problems With Use

May or may not be due to the method.

  • Problems with side effects affect women’s satisfaction and use of COCs. They deserve the provider’s attention. If the client reports side effects or problems, listen to her concerns, give her advice, and support, and, if appropriate, treat. Make sure she understands the advice and agrees.
  • Encourage her to keep taking a pill every day even if she has side effects. Missing pills can risk pregnancy and may make some side effects worse.
  • Many side effects will subside after a few months of use. For a woman whose side effects persist, give her a different COC formulation, if available, for at least 3 months.
  • Offer to help the client choose another method—now, if she wishes, or if problems cannot be overcome.

Missed pills

Irregular bleeding (bleeding at unexpected times that bothers the client)

  • Reassure her that many women using COCs experience irregular bleeding. It is not harmful and usually becomes less or stops after the first few months of use.
  • Other possible causes of irregular bleeding include:
  • To reduce irregular bleeding:
    • Urge her to take a pill each day and at the same time each day.
    • Teach her to make up for missed pills properly, including after vomiting or diarrhea (see Managing Missed Pills).
    • For modest short-term relief, she can try 800 mg ibuprofen 3 times daily after meals for 5 days or other nonsteroidal anti-inflammatory drug (NSAID), beginning when irregular bleeding starts. NSAIDs provide some relief of irregular bleeding for implants, progestin-only injectables, and IUDs, and they may also help for COCs.
    • If she has been taking the pills for more than a few months and NSAIDs do not help, give her a different COC formulation, if available. Ask her to try the new pills for at least 3 months.
  • If irregular bleeding continues or starts after several months of normal or no monthly bleeding, or you suspect that something may be wrong for other reasons, consider underlying conditions unrelated to method use (see Unexplained vaginal bleeding).

No monthly bleeding

  • Ask if she is having any bleeding at all. (She may have just a small stain on her underclothing and not recognize it as monthly bleeding.) If she is, reassure her.
  • Reassure her that some women using COCs stop having monthly bleeding, and this is not harmful.There is no need to lose blood every month. It is similar to not having monthly bleeding during pregnancy. She is not pregnant or infertile. Blood is not building up inside her. (Some women are happy to be free from monthly bleeding, and for some women this may help prevent anemia.)
  • Ask if she has been taking a pill every day. If so, reassure her that she is not likely to be pregnant. She can continue taking her COCs as before.
  • Did she skip the 7-day break between packs (21-day packs) or skip the 7 nonhormonal pills (28-day pack)? If so, reassure her that she is not pregnant. She can continue using COCs.
  • If she has missed hormonal pills or started a new pack late:
    • She can continue using COCs.
    • Tell a woman who has missed 3 or more pills or started a new pack 3 or more days late to return if she has signs and symptoms of early pregnancy.
    • See instructions on how to make up for missed pills.

Ordinary headaches (nonmigrainous)

  • Try the following (one at a time):
    • Suggest aspirin (325–650 mg), ibuprofen (200–400 mg), paracetamol (325–1000 mg), or other pain reliever.
    • Some women get headaches during the hormone-free week (the 7 days a woman does not take hormonal pills). Consider extended use (see Extended and Continuous Use of Combined Oral Contraceptives).
  • Any headaches that get worse or occur more often during COC use should be evaluated.

Nausea or dizziness

  • For nausea, suggest taking COCs at bedtime or with food.

If symptoms continue:

Breast tenderness

  • Recommend that she wear a supportive bra (including during strenuous activity and sleep).
  • Try hot or cold compresses.
  • Suggest aspirin (325–650 mg), ibuprofen (200–400 mg), paracetamol (325–1000 mg), or other pain reliever.

  • Consider locally available remedies.

Weight change

  • Review diet and counsel as needed.

Mood changes or changes in sex drive

  • Some women have changes in mood during the hormone-free week (the 7 days when a woman does not take hormonal pills). Consider extended use (see Extended and Continuous Use of Combined Oral Contraceptives).
  • Ask about changes in her life that could affect her mood or sex drive, including changes in her relationship with her partner. Give her support as appropriate.
  • Clients who have serious mood changes such as major depression should be referred for care.
  • Consider locally available remedies.

Acne

  • Acne usually improves with COC use. It may worsen for a few women.
  • If she has been taking pills for more than a few months and acne persists, give her a different COC formulation, if available. Ask her to try the new pills for at least 3 months.
  • Consider locally available remedies.

New Problems That May Require Switching Methods

May or may not be due to the method.

Unexplained vaginal bleeding (that suggests a medical condition not related to the method) or heavy or prolonged bleeding

  • Refer or evaluate by history and pelvic examination. Diagnose and treat as appropriate.
  • She can continue using COCs while her condition is being evaluated.
  • If bleeding is caused by sexually transmitted infection or pelvic inflammatory disease, she can continue using COCs during treatment.

Starting treatment with anticonvulsants, rifampicin, or rifabutin

  • Barbiturates, carbamazepine, oxcarbazepine, phenytoin, primidone, topiramate, rifampicin, and rifabutin may make COCs, patch, and combined vaginal ring less effective. Combined hormonal methods, including combined pills and monthly injectables, may make lamotrigine less effective. If using these medications long-term, she may want a different method, such as a progestin-only injectable, implant, a copper-bearing IUD, or an LNG-IUD.
  • If using these medications short-term, she can use a backup method along with COCs for greater protection from pregnancy.

Migraine headaches (see Identifying Migraine Headaches and Auras)

  • Regardless of her age, a woman who develops migraine headaches, with or without aura, or whose migraine headaches become worse while using COCs should stop using COCs.
  • Help her choose a method without estrogen.

Circumstances that will keep her from walking for one week or more

  • If she is having major surgery, or her leg is in a cast, or for other reasons she will be unable to move about for several weeks, she should:
    • Tell her doctors that she is using COCs.
    • Stop taking COCs and use a backup method during this period.
    • Restart COCs 2 weeks after she can move about again.

Certain serious health conditions (suspected heart or serious liver disease, high blood pressure, blood clots in deep veins of legs or lungs, stroke, breast cancer, damage to arteries, vision, kidneys, or nervous system caused by diabetes, or gallbladder disease). See Signs and Symptoms of Serious Health Conditions.

  • Tell her to stop taking COCs.
  • Give her a backup method to use until the condition is evaluated.
  • Refer for diagnosis and care if not already under care.

Suspected pregnancy

  • Assess for pregnancy.
  • Tell her to stop taking COCs if pregnancy is confirmed.
  • There are no known risks to a fetus conceived while a woman is taking COCs (see Question 5).