Dr.naser Omar Mustafa Malas COC111

8/3/2019 Dr.naser Omar Mustafa Malas COC111

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What reasons make combined oral contraceptive pills (COC) users

to discontinue?Dr. Naser O Malas*, M D,Dr. Ehab Al-Rayyan*, M D. Dr.Wasef Al Dukum**, M D.

Objective:

The purpose of this study was to study the reasons for quitting the use of

combined oral contraceptive pills (COC) and their relation to the age of

users and duration of using the pills.

Setting:Princess Haya Military Hospital, Aqaba-Jordan.

Materials and methodsA retrospective study was conducted in which we reviewed the family

planning clinic files. 240 cases identified for women with previous use of

combined oral contraceptive pills from Jan.2006 till Dec.2007, we

analyzed them according to the reasons of discontinuation and there

relation to age of users at the time of quitting the use of the pills as well

as the duration of using the pills.

Results:

Only 25 % of cases discontinued the pills because of their desire to get

pregnant, while more than half of the users 52.5 % of cases stopped the

contraceptive pills due to side effects. Other causes as method related and

personal causes formed 13% and 9% respectively. The most common side

effect reported by the COC users was breast discomfort (60%).

Most of the patients who stopped using the pills due to side effects are of

young age group


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Combined oral contraception (COC), reasons and discontinuation.Department of obstetric and gynecology, Princess Haya Hospital* and King Hussein Medical Centre**.

Introduction:

Oral contraceptives are the most commonly used form of reversible

contraception in the United States (1).At least 10 million women in the

United States and 100 million women worldwide use COC pills (estrogen-

progestin) (2).While COC have several mechanisms of action, the most

important for providing contraception is estrogen-induced inhibition of the

mid cycle surge of gonadotropin secretion, so that ovulation does not occur

(3).When used properly, Oral contraceptives are highly effective in

preventing pregnancy; about 5 women per 100 typical users and fewer than

1 per 100 women with perfect use become pregnant per year (2).

An increased risk of unintended pregnancy has been documented among

women who have reported missing pillsbut this risk can be modified by twofactors: the timing of coitus and the use of backup contraception as the

increased risk was most likely during the first seven days and during the

third cycle of pill use (4,5).

Oral contraceptives provide high degree contraceptive efficacy and a range

of short- and long-term non-contraceptive health benefits. They include

protection from ovarian cancer (up to 80%), endometrial cancer (up to 40%-

50%), ectopic pregnancy, pelvic inflammatory disease, acne, menstrual

disorders, any many others (6-9).Although oral contraceptive pills are

highly reliable method, one third of the unintended pregnancies that occur

each year in the United States are because of pills misuse, failure, or

discontinuation (10). It should be useful to quantify and analyze the causes

of discontinuation COC methods, to prevent unplanned and unwanted

pregnancies. Some studies have documented that side effects were the most

common reasons given for discontinuing Oral contraception use. The most

common treatment-related adverse effects are breast discomfort, mood

changes weight gain headache, nausea and vomiting, dizziness, irregular

bleeding, and others (1, 11). This study identifies factors associated with

discontinuation of OCC use, where discontinuation refers to cessation of

COC use in the 6 months prior to our study.

Materials and methods:

A retrospective study was conducted after obtaining the ethical approval

from the ethical committee of the Jordanian Royal Medical Services. We

reviewed the files and records of the family planning clinic at Princess Haya


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Military Hospital at south of Jordan. This study was based on 240 married

women aged between 18-42 years who were previously used at least once a

combined oral contraceptive pills. The period of study was from January

2006 until December 2007. The information on womens past contraceptive

behavior was based on her self report of the reasons that lie behind quitting

the use of the pills. The clients were using 28-day pill pack with a 21 and 7

pills as combined oral contraceptive and iron pills respectively.

The data obtained from the files were analyzed according to the reasons for

discontinuation the use of COC pills and the relations between these variable

reasons to the age at the time of quitting this contraceptive method and the

duration of using the pills. The reasons studded for discontinuation the

method were the desire for getting pregnancy, side effects of the pills,

method related causes, and other unidentified personal causes. Types of side

effects experienced while using the pills and leading to discontinuation in

using this method were examined in the present study.

Results:

As shown In table one only 25% of cases (60/240) stopped using the method

due to desired pregnancy or no need for further contraception, while the

other 75% of the users stopped it due to side effects, method related (causes

as poor compliance to method or patients concerns regarding hormonalcontent), and other personal unspecified causes were as 52.5%(126/180

cases), 13.3% (32/180 cases), and 9.2%(22/180 cases) respectively. This

table shows that side effects of the pills was the most common cause of

quitting the use of this method, it forms more than half of the method users.

Table two showed the percentage of side effects as reported by our patients.

Most of the clients used to report one or more side effects and then we tabled

these side effects and their percentage against the total number of patients

who quitted the pills due to side effects (120 cases). Breast discomfort was

the most common side effect reported and it formed about 60.3% (76/126cases). Mood changes, weight gain, headache were reported as the following

percentages 56.3%, 53.2%, and 51.6% respectively. These were followed by

nausea and vomiting, dizziness, and irregular bleeding and formed 44.4%,

32.5%, and 30.2% respectively. However, only 10.3% (13/126) of cases

stopped the pills due to recommendation of clinician to stop using it.


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Table three showed that most of the patients who stopped using the pills due

to side effects are of young age group


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The actual incidence of discontinuation the use of COC varies between

different studies. A study done by Khan in total of 1600 COC users, current

or past, aged 15 to 49 years, 36% discontinued COC use because of different

reasons (11). This incidence was not included in our study.

Despite the occurrence of considerable COC discontinuation, few studies

have attempted to examine the factors that are associated with COC

discontinuation. The reasons reported for discontinuation the use of pills

were: wanting a child, husband's disapproval, the cost of COC, the desire for

a more effective contraceptive method, the unavailability and inconvenience

of taking the pill, and many others. Our study showed the occurrence of side

effects was most frequently cited as the reason for stopping COC use as it

formed about 52.5% , this finding is consistent with other studies (6,10,11).

In a recent study done in rural Bangladesh, 53% of the women who

discontinued oral contraceptives did so because of side effects, and 20% due

to desire for more children (7). Nevertheless, the rate was reported 46% byanother study (10).

The incidence and frequency of side effects reported varied between

different studies. In one study Khan reported dizziness to form the most

widely reported side effect, mentioned by 57% of the women, followed by

weakness or sickness by 29%, vomiting tendency by 23%, and burning

sensation in the body by 10%. (7). However, other study reported weight

gain as the most frequent side effect experienced by 60% of users, breast

discomfort by 55%, mode changes 54%, nausea 46%, spotting 44% (1).

However, our study showed breast discomfort was the most common side

effect reported and it formed about 60.3% of users. Mood changes, weight

gain, headache were reported as the following percentages 56.3%, 53.2%,

and 51.6% respectively. Other side effects cited in the studies were irregular

bleeding, nausea, headache, breast tenderness, irritability, Depression, and

vaginal dryness (17). These varieties may be related on the user's memory

for past events.

One study revealed that discontinuation of COC use was not significantly

associated with the number of side effects experienced during the first 3

months of COC use (7). However, a previous study in the United States

demonstrated that discontinuation more likely to occur if side effectshappened suddenly and specially if they were multiple because the

probability of its occurrence increase disproportionately with each additional

side effect experienced; a single side effect increasing the risk by 50%, two

by 220%, and three by 320% (10).

Its is well documented that most side-effects are expected during the first

few months of starting COC use and most of them disappear after a few


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cycles, this may be explained by woman's body adjusts to the hormones

present in COC. Good counseling, particularly that focused on low impact

adverse effects, is an important instrument to reduce dropout rate (18).

The findings of the present study also demonstrated that we have to

concentrate on patients


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children were using no method of contraception, thus leaving them with an

increase risk of unwanted pregnancies; he explained this finding due to

either the woman's inability to access a reliable method, or limited choices

of alternative contraceptive methods (11).It is imperative that parallel topromoting contraceptive use, the new effort should be paid in minimizing

the discontinuation of its use, especially among women who are reluctant to

use other contraceptive methods following COC discontinuation.

Conclusion:

The relatively high rate of the discontinuation COC with reasons for

stopping it, indicate the potential for improving management of COC use in

our institution. Firstly, counseling should include the consideration of

potential side effects of COC use, how long they last, how to manage them.Second, counseling should include what method should be used if COC did

not work out. Finally, we suggest that monthly follow up visits for the first 6

months of commencing COC should be scheduled.

Clinicians may need to encourage their patients to discuss their reasons for

wanting to discontinue the use of an effective contraceptive method and

assist them with their concerns or to switch to other effective methods to

protect themselves from unintended pregnancy.

References:

1- Rosenberg MJ, Waugh MS, Burnhill MS. Compliance, Counseling and Satisfaction

with Oral Contraceptives: A Prospective Evaluation. Family Planning Perspectives

1998;30(2).2- Petitti DB. Clinical practice. Combination estrogen-progestin oral contraceptives. N

Engl J Med 2003; 349(15):1443-50.

3- Webberley H, Mann Melanie. Oral contraception-Update. Current Obstetrics &Gynaecology 2006;16:21-29

4- Oakley D, Potter L, Leon-Wong E, Visness C. Oral Contraceptive use and protective

behavior after missed pills. Family Planning Perspectives 1997;29:277-79.

5- Mansour D, Fraser I. Missed contraceptive pills and the critical pill-free interval. TheLancet 2005;365:1670-1.

6- Rosenberg MJ, Waugh MS. Oral contraceptive discontinuation: A prospective

evaluation of frequency and reasons. Am J Obstet Gynecol 1998;179:577-82.7- Khan MA. Side effects and oral contraceptive discontinuation in rural Bangladesh.

Contraception 2001;64:16167.

8- Burkman R, Collins J, Shulman LP, et al. Current perspectives on oral contraceptiveuse. Am J Obstet Gynecol 2001;185:S4-12.


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9- D'Souza RE. Risks and benefits of oral contraception pills. Best Practice & Research

Clinical Obstet and Gynecol 2002;16(2):133-54.

10- Rosenberg MJ; Waugh MS; Meehan TE .Use and misuse of oral contraceptives: riskindicators for poor pill taking and discontinuation. Contraception 1995;51(5):283-8.

11- Khan MA. Factors associated with oral contraceptive discontinuation in rural

Bangladesh. Health Policy And Planning 2003;18(1):101-8.12- Middeldorp S. Oral contraceptives and the risk of venous thromboembolism. Gend

Med.2005;2;S3-S9.

13- Hannaford PC. Combined oral contraceptives: Do we know all of their effects?Contraception 1995;51:325-7.

14- Chen J, Smith KB, Morrow S, et al. The acceptability of combined oral hormonal

contraceptives in shanghai, people's republic of china. Contraception 2003;67:281-5.

15- Hannaford PC, Webb AM. Evidence-Guided prescribing of combined oralcontraceptives: Consensus statement. Contraception 1996;54:125-29.

16- Stewart FH; Harper CC; Ellertson CE; Grimes DA; Sawaya GF; Trussell J. Clinical

breast and pelvic examination requirements for hormonal contraception: Current practice vs

evidence. JAMA 2001;285(17):2232-9.17- Sabatini R, Cagiano R. Comparison profiles of cycle control, side effects and sexual

satisfaction of three hormonal contraceptives. Contraception accepted 20 March 2006.18- Colli E, Tong D, Penhallegon R, et.a. Reasons for contraceptive discontinuation in

women 20-39 years old in New Zealand. Contraception 1999; 59:227-31.

19- Trussell J, Vaughan B. Contraceptive failure, method-related discontinuation and

resumption of use: Results from the 1995 national survey of family growth. Family planningperspectives 1999;31(2):64-72.

20- Brunner Huber LR, Hogue C, Stein A, Drews C, Zieman M. Contraception use and

discontinuation: Findings from the contraceptive history, initiation, and choice study. AmJ Obstet Gynecol 2006;194:1290-5.


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Table (1) Reasons of discontinuation the use of COC

CAUSE 240 cases NO. %

DESIRED PREGANACY 60/240 25%

SIDE EFFECTS 126/240 52.5%

METHOD RELATED 32/240 13.3%

PERSONAL CAUSES (No cause) 22/240 9.2%

Table (2) % of Side effects among COC users

CAUSE (126 cases) NO. %

BREAST DISCOMFORT76/126 60.3%

MOOD CHANGES 71/126 56.3%

WEIGHT GAIN 67/126 53.2%

HEADACHE 65/126 51.6%

NAUSIA / VOMITTING 56/126 44.4%

DIZENESS 41/126 32.5%

IRREGULAR BLEEDING 38/126 30.2%

CLINICIANM RECOMENDATION 13/126 10.3%

OTHERS 11/126 8.7%

Table (3) Age at time of COC discontinuation.

Causes(240 cases) 36 Y

DESIRED PREGANACY (60) 19(32%) 21(35%) 20(33%)

SIDE EFFECTS (126) 77(61%) 45(35%) 4(3.1%)METHOD RELATED (32) 17(53%) 8(25%) 7(22%)

PERSONAL CAUSES (No cause)( 22) 6(27.2%) 8(36.4%) 8(36.4%)


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Table (4) The Duration of using COC in relation to the cause of

discontinuation.

Causes (240) 0-6 months 7-12 months

13-24 months >24 months

DESIRED PREGNANCY

(60)

0(0%) 2(3%) 7(12%) 51(85%)

SIDE EFFECTS

(126)

81(64%) 33(26%) 12(10%) 0(0%)

METHOD RELATED

(32)

12(37.5%) 11(34.4%) 6(18.8%) 3(9.3%)

PERSONAL CAUSES

(22)

4(18.2%) 6(27.3%) 5(22.7%) 7(31.8%)

25%

53%

13%9%

DESIRED PREGAN

SIDE EFFE CTS

METHOD RELATED

PERSONAL CAUSE

(No cause)


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Reasons of discontinuation the use of O

DESIRE

D

PREGANACY(60)

SIDEEFFE

CTS

(126)

METHOD

RELATED

(32)

PERSONAL

CAUSES

(22)


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DesiredPregnancy

(60)

Sideeffects(126)

Methodrelated(32)

Personalcauses(22)

0 - 6 months

13 - 24 months

51

03 7

7 126

52

33

11

60

81

12

40

10

20

30

40

50

60

70

80

90

0 - 6 months

7-12 months

13 - 24 months

>24 months

Duration of using OC in relation to the cause of

discontinuation.


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Dr.naser Omar Mustafa Malas COC111

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