Session II, Slide # 1

Combined OralContraceptive Pills

(COCs)Session II:

Who Can and Cannot Use COCs?

Session II, Slide # 2

COCs Are Safe for Nearly All Women

• Almost all women can use COCs safely, including women who:– Have or have not had children

– Are not married

– Are of any age

– Smoke (if under age 35)

– Have anemia now or had it in the past

– Have varicose veins

– Have an STI or HIV/AIDS

• Most health conditions do not affect safe and effective use of COCs

Session II, Slide 3

Who Can and Cannot Use COCs

Most women can safely use the pill.

But usually cannot use the pill if:

• High blood pressure

• Smoke cigarettes AND age 35 or older

• Breastfeeding

6 months or less

• May be pregnant

• Gave birth in the last 3 weeks

• Some other serious health conditions

Session II, Slide 4Source: WHO, 2010.

Breastfeeding a baby less than 6 months old

Had a heart attack or stroke

Had blood clots

in legs or lungs

Are pregnant

My period is late…

Think they may be pregnant

Who Should Not Use COCs (part 1)

Breastfeeding a baby less than 6 months old

Smoke and are age 35 or older

Have or had breast cancerHad a heart

attack or stroke

Had blood clots in legs or lungs

Are pregnant

Think they may be pregnant

Session II, Slide 5Source: WHO, 2010.

Breastfeeding a baby less than 6 months old

Had a heart attack or stroke

Had blood clots

in legs or lungs

Think they may be pregnant

Who Should Not Use COCs (part 2)

Have rheumatic disease, such as lupus

Take pills for TB, seizures (fits), or HIV

Have high blood pressure

I cannot eat

sweets.

Have diabetes (high sugar in blood)

Have seriousliver disease orgall bladder disease

Have bad headaches with nausea or vision problems

Gave birth in last 6 weeks

Source: WHO, 2010; Chu, 2005.

Session II, Slide # 6

Medical Eligibility Criteria

What are medical eligibility criteria?

Define the categories.

Review the job aid.

Session II, Slide # 7

WHO’s Medical Eligibility Criteria

Categories for IUDs, Hormonal and Barrier Methods

Source: WHO, 2010.

Category DescriptionWhen clinical judgment

is available

1 No restriction for use Use the method under any circumstances

2Benefits generally outweigh risks

Generally use the method

3Risks usually outweigh benefits

Use of method not usually recommended, unless other methods are not available/acceptable

4 Unacceptable health risk Method not to be used

Session II, Slide # 8

WHO’s Medical Eligibility Criteria

Categories for IUDs, Hormonal and Barrier Methods

Source: WHO, 2010.

WHO’s Medical Eligibility Criteria

Categories for IUDs, Hormonal and Barrier Methods

CategoryWhen clinical judgment

is available

1

Use the method

2

3

Do not use the method

4

Session II, Slide # 9

WHO Category Conditions (selected examples)

Category 1

menarche to 39 yrs; nulliparous; endometriosis; endometrial or ovarian cancer; uterine fibroids; family history of breast cancer; varicose veins; irregular, heavy, or prolonged bleeding; anemia; STI/PID; hepatitis (chronic/carrier)

Category 2

≥40 yrs; breastfeeding ≥6 months postpartum; superficial thrombophlebitis; uncomplicated diabetes; cervical cancer; unexplained vaginal bleeding; undiagnosed breast mass

Category 1 and 2 Examples (not inclusive):

Who Can Use COCs

Source: WHO, 2010.

Session II, Slide # 10

WHO Category Conditions (selected examples)

Category 3 Postpartum: •Breastfeeding between 6 weeks and 6 months •Non-breastfeeding <21 days (if no additional risk factors for blood clots)

Vascular conditions:•Hypertension (history of or BP 140-159/90–99)•Migraine without aura (older than 35 yrs)

Gastrointestinal conditions:•Symptomatic gall bladder disease (current and medically-treated)

Drug interactions:•Use of rifampicin, rifabutin, ritonavir

Category 3 Examples (not inclusive):

Who Should Generally Not Use COCs

Source: WHO, 2010.

Session II, Slide # 11

WHO Category Conditions (selected examples)

Category 4 Breastfeeding: <6 weeks postpartum

Smoking: ≥15 cigarettes/day and ≥ 35 yrs old

Vascular conditions:•Hypertension (≥160/≥100)•Migraines with aura•Ischemic heart disease or stroke•Diabetes with vascular complications•Deep venous thrombosis (history or acute)•Pulmonary embolism (history or acute)

Liver conditions:•Acute hepatitis •Severe liver disease and most liver tumors

Breast cancer: current or within 5 yrs

Category 3 Examples (not inclusive):

Who Should Generally Not Use COCs

Source: WHO, 2010; Sekar, 2008.

Session II, Slide # 12

COC Use by Women with HIV

• Women with HIV or AIDS can use without restrictions

• Women on ARVs other than ritonavir can use COCs safely

• Should not be used by women who take ritonavir (may reduce effectiveness of COCs).

• Using low-dose COCs is appropriate

• Condom use should be encouraged in addition to COCs

Source: WHO, 2010; Sekar, 2008.

WHO Eligibility Criteria

Condition Category

HIV-infected 1

AIDS 1ARV therapy(which does not contain ritonavir)

2

Ritonavir/ ritonavir-boosted PIs (as part of ARV regimen)

3

Session II, Slide # 13

COC Use by Postpartum Women

• Non-breastfeeding women should not initiate COCs before 3 weeks postpartum (6 weeks postpartum for multiple VTE risk factors)

• Breastfeeding women

– Should not use COCs before 6 weeks postpartum

– Should not use COCs from 6 weeks to 6 months postpartum unless no other method is available

– Can generally initiate COCs at 6 months postpartum

Source: WHO, 2010.

WHO Eligibility CriteriaWHO Eligibility CriteriaCondition Category

Non-breastfeeding <3 weeks

3

Breastfeeding <6 weeks 4

Breastfeeding >6 weeks and < 6 months

3

Breastfeeding ≥6 months 2

Session II, Slide # 14

Group Activity

Understanding the Checklist

Read questions 1–12 in the checklist.

How have you determined medical eligibility in the past?

The checklist also gives instructions

about initiating COCs.

This set of questions identifies women

who should not use COCs.

This set of questions identifies

women who are not

pregnant.