By Emeritus Professor of Family Planning and Reproductive Health John Guillebaud
(Martin Dunitz) Margaret Pyke Centre, London, united kingdom. Pocket consultant for physicians protecting oral birth control, progestogen-only tablet, injectables, implants, intrauterine and postcoital birth control, and extra. colour illustrations. earlier version: c1998.
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Extra info for Contraception Today: A Pocketbook for General Practitioners
The lowest dose of contraceptive steroids that is just, but only just, above her bleeding threshold. If there is good cycle control, therefore, and a lower-dose brand in the same ‘ladder’ (Figure 4) is available, switching to it should be considered at the time of repeat prescription. 38 If BTB occurs and is unacceptable or persists beyond two cycles, a different or higher dose brand (Figure 4) should be tried, subject to the checks in the Box below. Phasic COCs are second-choice formulations in my own practice, but they are certainly worth trying for BTB and especially for absence of withdrawal bleeding.
These are in fact listed as the first six items in the Box on p. 47. 1. Migraine without focal aura, not in any of the categories opposite, under age 35. If these or other ‘ordinary’ headaches occur particularly in the pill-free interval, tricycling the COC may help (see p. 51) 2. Distant past history during adolescence of migraine with focal aura, before commencing the COC; the COC may be given a trial with the caveats above 3. Occurrence of a woman’s first-ever attack of migraine of any type while on the COC.
Even with triphasic pills, you should go straight to (the first phase of) the same brand. You may bleed a bit but you will still strengthen your contraception. This is quite different from postponing a ‘period’. See p. 51. 50 also be used to ‘strengthen’ contraceptively any 20 µg pill such as Loestrin 20). The gap may be shortened further in high-risk cases, such as during the use of enzyme inducers (see pp. 53–55). Once it has been appreciated that the ‘Achilles heel’ of the COC is the PFI, the COC can always be made ‘stronger’ as a contraceptive, by eliminating and/or shortening the PFI through variations on the tricycling theme depicted in Figure 11.