1.   Should a woman take a “rest” from COCs after taking them for a time?

No. There is no evidence that taking a “rest” is helpful. In fact, taking a “rest” from COCs can lead to unintended pregnancy. COCs can safely be used for many years without having to stop taking them periodically.

2.   If a woman has been taking COCs for a long time, will she still be protected from pregnancy after she stops taking COCs?

No. A woman is protected only as long as she takes her pills regularly.

3.   How long does it take to become pregnant after stopping COCs?

Women who stop using COCs can become pregnant as quickly as women who stop nonhormonal methods. COCs do not delay the return of a woman’s fertility after she stops taking them. The bleeding pattern a woman had before she used COCs generally returns after she stops taking them. Some women may have to wait a few months before their usual bleeding pattern returns.

4.   Do COCs cause abortion?

No. Research on COCs finds that they do not disrupt an existing pregnancy. They should not be used to try to cause an abortion. They will not do so.

5.   Do COCs cause birth defects? Will the fetus be harmed if a woman accidentally takes COCs while she is pregnant?

No. Good evidence shows that COCs will not cause birth defects and will not otherwise harm the fetus if a woman becomes pregnant while taking COCs or accidentally starts to take COCs when she is already pregnant.

6.   Do COCs cause women to gain or lose a lot of weight?

No. Most women do not gain or lose weight due to COCs. Weight changes naturally as life circumstances change and as people age. Because these changes in weight are so common, many women think that COCs cause these gains or losses in weight. Studies find, however, that, on average, COCs do not affect weight. A few women experience sudden changes in weight when using COCs. These changes reverse after they stop taking COCs. It is not known why these women respond to COCs in this way.

7.   Do COCs change women’s mood or sex drive?

Generally, no. Some women using COCs report these complaints. The great majority of COC users do not report any such changes, however, and some report that both mood and sex drive improve. It is difficult to tell whether such changes are due to the COCs or to other reasons. Providers can help a client with these problems (see Mood changes or changes in sex drive). There is no evidence that COCs affect women's sexual behavior.

8.   What can a provider say to a client asking about COCs and breast cancer?

The provider can point out that both COC users and women who
do not use COCs can have breast cancer. In scientific studies breast cancer was slightly more common among women using COCs and those who had used COCs in the past 10 years than among other women. Scientists do not know whether or not COCs actually caused the slight increase in breast cancers. It is possible that the cancers were already there before COC use but were found sooner in COC users (see Facts About Combined Oral Contraceptives and Cancer).

9.   Can COCs be used as a pregnancy test?

No. A woman may experience some vaginal bleeding (a “withdrawal bleed”) as a result of taking several COCs or one full cycle of COCs, but studies suggest that this practice does not accurately identify who is or is not pregnant. Thus, giving a woman COCs to see if she has bleeding later is not recommended as a way to tell if she is pregnant. COCs should not be given to women as a pregnancy test of sorts because they do not produce accurate results.

10.  Must a woman have a pelvic examination before she can start COCs or at follow-up visits?

No. A pelvic examination to check for pregnancy is not necessary. Instead, asking the right questions usually can help to make reasonably certain that a woman is not pregnant (see Pregnancy Checklist). No other condition that could be detected by a pelvic examination rules out COC use.

11.  Can women with varicose veins use COCs?

Yes. COCs are safe for women with varicose veins. Varicose veins are enlarged blood vessels close to the surface of the skin. They are not dangerous. They are not blood clots, nor are these veins the deep veins in the legs where a blood clot can be dangerous (deep vein thrombosis). A woman who has or has had deep vein thrombosis should not use COCs.

12.  Can a woman safely take COCs throughout her life?

Yes. There is no minimum or maximum age for COC use. COCs can be an appropriate method for most women from onset of monthly bleeding (menarche) to menopause (see Women Near Menopause in chapter 21).

COCs can be an appropriate method for adolescents. Adolescents may need extra support and encouragement to use COCs consistently and effectively.

13.  Can women who smoke use COCs safely?

Women younger than age 35 who smoke can use COCs. Women age 35 and older who smoke should choose a method without estrogen or, if they smoke fewer than 15 cigarettes a day, monthly injectables. Older women who smoke can take the progestin-only pill if they prefer pills. All women who smoke should be urged to stop smoking.

14.  What if a client wants to use COCs but it is not reasonably certain that she is not pregnant after using the pregnancy checklist?

A woman who answers "No" to all 6 questions on the Pregnancy Checklist can still start taking COCs. Ask her to come back for a pregnancy test if her next monthly bleeding is late. See Ruling Out Pregnancy.

15.  Can COCs be used as emergency contraceptive pills (ECPs) after unprotected sex?

Yes. As soon as possible, but no more than 5 days after unprotected sex, a woman can take COCs as ECPs (see Pill Formulations and Dosing for Emergency Contraception in Chapter 3 - Emergency Contraceptive Pills). Progestin-only pills, however, are more effective and cause fewer side effects such as nausea and stomach upset.

16.  What are the differences among monophasic, biphasic, and triphasic pills?

Monophasic pills provide the same amount of estrogen and progestin in every hormonal pill. Biphasic and triphasic pills change the amount of estrogen and progestin at different points of the pill-taking cycle. For biphasic pills, the first 10 pills have one dosage, and then the next 11 pills have another level of estrogen and progestin. For triphasic pills, the first 7 or so pills have one dosage, the next 7 pills have another dosage, and the last 7 hormonal pills have yet another dosage. All prevent pregnancy in the same way. Differences in side effects, effectiveness, and continuation appear to be slight.

17.  Is it important for a woman to take her COCs at the same time each day?

A woman can take her COCs at different times of day, and they will still be effective. However, taking them at the same time each day can be helpful for 2 reasons. Some side effects may be reduced by taking the pill at the same time each day. Also, taking a pill at the same time each day can help women remember to take their pills more consistently. Linking pill taking with a daily activity also helps women remember to take their pills.

18.  Should women who choose COCs and certain other hormonal contraceptives be routinely tested for high blood pressure?

It is desirable for all women to have blood pressure measurements taken routinely before starting a hormonal method of contraception. However, in some settings blood pressure measurements are unavailable. In many of these settings, pregnancy-related morbidity and mortality risks are high, and these methods are among the few methods that are widely available. In such settings women should not be denied use of these methods simply because their blood pressure cannot be measured.

Women with high blood pressure or very high blood pressure should not use combined hormonal methods—COCs, monthly injectables, patch, or combined ring. Where blood pressure cannot be measured, women with a history of high blood pressure should not use these methods. Women with very high blood pressure should not use progestin-only injectables. Women can use progestin-only pills (POPs), implants, and LNG-IUDs even if they have high or very high blood pressure readings or a history of high or very high blood pressure.

High blood pressure is defined as systolic pressure 140 mm Hg or higher or diastolic pressure 90 mm Hg or higher. Very high blood pressure is defined as systolic pressure 160 mm Hg or higher or diastolic pressure 100 mm Hg or higher.

For more guidance concerning blood pressure, see the Medical Eligibility Criteria checklists in Chapter 1 on COCs, Chapter 4 on progestin-only injectables, and Chapter 5 on monthly injectables.