SIDE EFFECT MANAGEMENT

SIDE EFFECT MANAGEMENT•Sideeffectsusuallydiminish within 3 monthswithcontinueduseofsamemethod17

• Reassure & educate patientstohelpestablishrealisticexpectations&decreasethechanceofunanticipatedsideeffects17

• Identify which componentislikelytobeatfault,butitcanbedifficulttoascertainwhichportion(eithertheoestrogen or progestogen or both)isresponsible

Oestrogen Related Side Effects

TheoestrogenusedinCOCs(usuallyethinylestradiol)islinkedtosomeminorsideeffects

Toresolve,lowertheoestrogendose

Changetoamoredominantprogestogen

Tryprogestogenonlyoptionsthatdonot contain oestrogen

Most common side effects:nausea,headache,thrush,excessbleeding,fluidretention,breasttenderness

Progestogen Related Side Effects

Degreeofandrogenicityislikelytocausenegativesideeffects

Ahigheramountofoestrogenhelpstoreduceandrogenrelatedsideeffects

Changetypeofprogestogentoonewithlowerandrogenicproperties

Increasetheoestrogenstrength

Most common side effects:acne,vaginaldryness,sustainedweightincrease&lowmood

Adverseevents&productcomplaintsshouldbereportedto theHealthProductsRegulatoryAuthority.Reportingforms&information

canbefoundatwww.hpra.ie.Reproduced with the kind permission of Dr. Deirdre Lundy

PRESCRIBING GUIDE 12 Oestrogen dosage

Generation 20mcg 30mcg 35mcg 1.5mg Phasic No oestrogen

Synthetic progestogen

1st Generation NORIDAY 350mcgNorethisterone

2nd Generation

OVREENA OVRANETTE 150mcgLevonorgestrel

VIOLITEMICROLITELEONORE

100mcgLevonorgestrel

LOGYNON 30/75/125mcg Levonorgestrel

3rd Generation

MINULET 75mcgGestodene

MERCILON MARVIOL 150mcgDesogestrel

AZALIACERAZETTE 75mcgDesogestrel

CILIQUE 250mcgNorgestimate

4th Generation

ZOELY 2.5mgNomegestrol

QLAIRA 2/3mcgDienogest

ELVINETTEYASMINELLE

YAZ

ELVINAYASMIN 3mgDrospirenone

ANDROGENICITY

HIGH

MEDIUM

LOW

ACNE

Reproduced with the kind permission of Dr. Deirdre Lundy

• Generallymediatedthroughprogestogen

• Morecommonsideeffectof2ndgenerationpills–switchtoa4thgenerationpill

• Ifpatientison4thgenerationpill&acneispersistent,increaseoestrogendose

ACNE

WHICH CONTRACEPTIVE?CAUSE ACTION

Too much progestagenic potency

Try less progestagenic 4th generation brands

Elvina • Elvinette • Qlaira Yasmin • Yasminelle • Yaz Zoely

Too much androgenic potency

Try less androgenic brands containing desogestrel Marviol • Mercilon

Too little oestrogen Increase oestrogen to a higher dose

Minulet • Ovreena • Ovranette • Logynon • Cilique

ANDROGENICITY

HIGH

MEDIUM

LOW

PRESCRIBING GUIDE 12 Oestrogen dosage

Generation 20mcg 30mcg 35mcg 1.5mg Phasic No oestrogen

Synthetic progestogen

1st Generation NORIDAY 350mcgNorethisterone

2nd Generation

OVREENA OVRANETTE 150mcgLevonorgestrel

VIOLITEMICROLITELEONORE

100mcgLevonorgestrel

LOGYNON 30/75/125mcg Levonorgestrel

3rd Generation

MINULET 75mcgGestodene

MERCILON MARVIOL 150mcgDesogestrel

AZALIACERAZETTE 75mcgDesogestrel

CILIQUE 250mcgNorgestimate

4th Generation

ZOELY 2.5mgNomegestrol

QLAIRA 2/3mcgDienogest

ELVINETTEYASMINELLE

YAZ

ELVINAYASMIN 3mgDrospirenone

Reproduced with the kind permission of Dr. Deirdre Lundy

Irregular pill taking Counsel patient on correct usage No change

Undiagnosed STI Sexual history STI screen No change

Too little oestrogen Increase oestrogen to a higher dose

Minulet • Ovreena • Ovranette • Logynon • Cilique

Too much progestagenic potency

Try less progestagenic 4th generation brands Elvina • Qlaira • Yasmin • Zoely

WHICH CONTRACEPTIVE?CAUSE ACTION

BREAK THROUGH BLEEDING

BREAK THROUGH BLEEDING

• Generallycausedbyirregularpilltakingandlackofpatientcompliance

• Canresultfromachangeinsexualpartner–thereforeitisimportanttoruleoutaSTI

• Mayimprovewithanincreaseinoestrogenorachangeinprogestogen

ANDROGENICITY

HIGH

MEDIUM

LOW

PRESCRIBING GUIDE 12 Oestrogen dosage

Generation 20mcg 30mcg 35mcg 1.5mg Phasic No oestrogen

Synthetic progestogen

1st Generation NORIDAY 350mcgNorethisterone

2nd Generation

OVREENA OVRANETTE 150mcgLevonorgestrel

VIOLITEMICROLITELEONORE

100mcgLevonorgestrel

LOGYNON 30/75/125mcg Levonorgestrel

3rd Generation

MINULET 75mcgGestodene

MERCILON MARVIOL 150mcgDesogestrel

AZALIACERAZETTE 75mcgDesogestrel

CILIQUE 250mcgNorgestimate

4th Generation

ZOELY 2.5mgNomegestrol

QLAIRA 2/3mcgDienogest

ELVINETTEYASMINELLE

YAZ

ELVINAYASMIN 3mgDrospirenone

Reproduced with the kind permission of Dr. Deirdre Lundy

Too much progestagenic potency

Try less progestagenic 4th generation brands

Elvina • Elvinette • Qlaira Yasmin • Yasminelle • Yaz • Zoely

Too much oestrogen

Reduce oestrogen to a lower dose

Elvinette • Leonore • Mercilon Microlite • Violite • Yasminelle • Yaz

Try non oestrogen medicines Azalia • Cerazette • Noriday

Consider non oral options Copper coil • Implanon Jaydess • Mirena • Nuvaring

WHICH CONTRACEPTIVE?CAUSE ACTION

BLOATING / BREAST TENDERNESS

• Bloatingisusuallyaprogestogensideeffect–changeprogestogenorincreaseoestrogendose• Breasttendernessisusuallyduetooestrogen–reduceoestrogendose• Considercoppercoilasit’shormonefree

BLOATING

BREAST TENDERNESS

BLOATING / BREAST

TENDERNESS

ANDROGENICITY

HIGH

MEDIUM

LOW

PRESCRIBING GUIDE 12 Oestrogen dosage

Generation 20mcg 30mcg 35mcg 1.5mg Phasic No oestrogen

Synthetic progestogen

1st Generation NORIDAY 350mcgNorethisterone

2nd Generation

OVREENA OVRANETTE 150mcgLevonorgestrel

VIOLITEMICROLITELEONORE

100mcgLevonorgestrel

LOGYNON 30/75/125mcg Levonorgestrel

3rd Generation

MINULET 75mcgGestodene

MERCILON MARVIOL 150mcgDesogestrel

AZALIACERAZETTE 75mcgDesogestrel

CILIQUE 250mcgNorgestimate

4th Generation

ZOELY 2.5mgNomegestrol

QLAIRA 2/3mcgDienogest

ELVINETTEYASMINELLE

YAZ

ELVINAYASMIN 3mgDrospirenone

HEADACHES

Reproduced with the kind permission of Dr. Deirdre Lundy

Too much of a hormone drop

Reduce oestrogen strength to a lower dose

Elvinette • Leonore • Mercilon Microlite • Violite • Yasminelle • Yaz

Shorten or omit pill free interval Logynon • Qlaira • Yaz • Zoely

Too much oestrogen

Reduce oestrogen to a lower dose

Elvinette • Leonore • Mercilon Microlite • Violite • Yasminelle • Yaz

Try non oestrogen brands Azalia • Cerazette • Noriday

Consider non oral options Copper coil • Implanon Jaydess • Mirena • Nuvaring

WHICH CONTRACEPTIVE?CAUSE ACTION

HEADACHES / HEADACHES DURING PILL FREE WEEK

• Ensureitisnotmigrainewithaura• Timingoftheheadacheisthemostimportantthingtoestablish• Ifheadachepersiststhroughoutthepillpack–likelycauseistoomuchoestrogen• Ifit’sduringpillfreeweek–loweroestrogendoseorreducepillfreeinterval

HEADACHES THROUGHOUT PILL PACK

HEADACHES DURING PILL FREE WEEK

ANDROGENICITY

HIGH

MEDIUM

LOW

PRESCRIBING GUIDE 12 Oestrogen dosage

Generation 20mcg 30mcg 35mcg 1.5mg Phasic No oestrogen

Synthetic progestogen

1st Generation NORIDAY 350mcgNorethisterone

2nd Generation

OVREENA OVRANETTE 150mcgLevonorgestrel

VIOLITEMICROLITELEONORE

100mcgLevonorgestrel

LOGYNON 30/75/125mcg Levonorgestrel

3rd Generation

MINULET 75mcgGestodene

MERCILON MARVIOL 150mcgDesogestrel

AZALIACERAZETTE 75mcgDesogestrel

CILIQUE 250mcgNorgestimate

4th Generation

ZOELY 2.5mgNomegestrol

QLAIRA 2/3mcgDienogest

ELVINETTEYASMINELLE

YAZ

ELVINAYASMIN 3mgDrospirenone

IRRITABILITY / DEPRESSION / LIBIDO LOSS

WHICH CONTRACEPTIVE?CAUSE ACTION

Reproduced with the kind permission of Dr. Deirdre Lundy

IRRITABILITY / DEPRESSION / LOSS OF LIBIDO

Too much progestagenic potency

Try less progestagenic 4th generation brands

Elvinette • Qlaira • Yasmin Yasminelle • Yaz • Zoely

Too little androgenic properties

Try levonorgestrel brands with androgenic properties

Leonore • Microlite • Violite Ovreena • Ovranette • Logynon

Too little oestrogen Increase oestrogen to a higher dose

Minulet • Ovreena • Ovranette Logynon • Cilique

• Progestogenisamoodsuppressant–changeprogestogen• Lossoflibido–linkedtoandrogenactivity.Ifdecreaseinlibido–trymoreandrogenicpill• Canhappenwithanycombinationofoestrogen/progestogen• Considercoppercoilasitishormonefree•Depressedmoodanddepressionarewellknownsideeffectsofhormonalcontraceptive care.Ifapatientdevelopsdepressionwhileonthepill,considerationshouldbegivento prescribinganon-hormonalalternative.

ANDROGENICITY

HIGH

MEDIUM

LOW

PRESCRIBING GUIDE 12 Oestrogen dosage

Generation 20mcg 30mcg 35mcg 1.5mg Phasic No oestrogen

Synthetic progestogen

1st Generation NORIDAY 350mcgNorethisterone

2nd Generation

OVREENA OVRANETTE 150mcgLevonorgestrel

VIOLITEMICROLITELEONORE

100mcgLevonorgestrel

LOGYNON 30/75/125mcg Levonorgestrel

3rd Generation

MINULET 75mcgGestodene

MERCILON MARVIOL 150mcgDesogestrel

AZALIACERAZETTE 75mcgDesogestrel

CILIQUE 250mcgNorgestimate

4th Generation

ZOELY 2.5mgNomegestrol

QLAIRA 2/3mcgDienogest

ELVINETTEYASMINELLE

YAZ

ELVINAYASMIN 3mgDrospirenone

NAUSEA

NAUSEA

Too much oestrogen

Reduce oestrogen to a lower dose

Elvinette • Leonore • Mercilon Microlite • Violite • Qlaira Yasminelle • Yaz • Zoely

Try non oestrogen brands Azalia • Cerazette • Noriday

Consider non oral optionsCopper coil • Implanon • Jaydess Mirena • Nuvaring

WHICH CONTRACEPTIVE?CAUSE ACTION

• Canbecausedbytoomuchoestrogen–reduceoestrogendose• Canalsobecausedbybothoestrogenandprogestogen• Advisepatienttotakepillintheeveningtimeafterfood

Reproduced with the kind permission of Dr. Deirdre Lundy

ANDROGENICITY

HIGH

MEDIUM

LOW

PRESCRIBING GUIDE 12 Oestrogen dosage

Generation 20mcg 30mcg 35mcg 1.5mg Phasic No oestrogen

Synthetic progestogen

1st Generation NORIDAY 350mcgNorethisterone

2nd Generation

OVREENA OVRANETTE 150mcgLevonorgestrel

VIOLITEMICROLITELEONORE

100mcgLevonorgestrel

LOGYNON 30/75/125mcg Levonorgestrel

3rd Generation

MINULET 75mcgGestodene

MERCILON MARVIOL 150mcgDesogestrel

AZALIACERAZETTE 75mcgDesogestrel

CILIQUE 250mcgNorgestimate

4th Generation

ZOELY 2.5mgNomegestrol

QLAIRA 2/3mcgDienogest

ELVINETTEYASMINELLE

YAZ

ELVINAYASMIN 3mgDrospirenone

THRUSH

Reproduced with the kind permission of Dr. Deirdre Lundy

THRUSH

Too much oestrogen

Reduce oestrogen to a lower dose

Elvinette • Leonore Mercilon • Microlite • Violite Yasminelle • Yaz

Try non oestrogen brands Azalia • Cerazette • Noriday

Consider non oral options Copper coil • Implanon Jaydess • Mirena

WHICH CONTRACEPTIVE?CAUSE ACTION

• Canbecausedbytoomuchoestrogen–reduceoestrogendose

• Considernonoraloptionssuchasthecopperintrauterinedevice

ANDROGENICITY

HIGH

MEDIUM

LOW

PRESCRIBING GUIDE 12 Oestrogen dosage

Generation 20mcg 30mcg 35mcg 1.5mg Phasic No oestrogen

Synthetic progestogen

1st Generation NORIDAY 350mcgNorethisterone

2nd Generation

OVREENA OVRANETTE 150mcgLevonorgestrel

VIOLITEMICROLITELEONORE

100mcgLevonorgestrel

LOGYNON 30/75/125mcg Levonorgestrel

3rd Generation

MINULET 75mcgGestodene

MERCILON MARVIOL 150mcgDesogestrel

AZALIACERAZETTE 75mcgDesogestrel

CILIQUE 250mcgNorgestimate

4th Generation

ZOELY 2.5mgNomegestrol

QLAIRA 2/3mcgDienogest

ELVINETTEYASMINELLE

YAZ

ELVINAYASMIN 3mgDrospirenone

WEIGHT GAIN

WEIGHT GAIN

Too much oestrogen

Reduce oestrogen to a lower dose

Elvinette • Leonore • Mercilon • Microlite • Violite Yasminelle • Yaz

Try non oestrogen brands Azalia • Cerazette • Noriday

WHICH CONTRACEPTIVE?CAUSE ACTION

• ThereisinsufficientevidencetosuggestCHCscanleadtoweightgain• PatientsstartingCHCsmayfindtheyhaveanincreasedappetitewhichcanleadtoweightgain

• Cyclicalweightgainmaybeoestrogenrelatedduetofluidretention–uselowdoseoestrogenpill

Reproduced with the kind permission of Dr. Deirdre Lundy

FLUID RETENTION