Helping Continuing Users

Ask how the client is doing with the method and whether she is satisfied. Ask if she has any questions or anything to discuss.
Ask especially if she is concerned about bleeding changes. Give her any information or help that she needs (see Managing Any Problems).
Ask if she often has problems remembering to take a pill every day. If so, discuss ways to remember, making up missed pills, and ECPs, or choosing another method.
Give her more pill packs—a full year’s supply (13 packs), if possible. Plan her next resupply visit before she will need more pills.
Every year or so, check blood pressure if possible (see Medical Eligibility Criteria, Question 5).
Ask a long-term client if she has had any new health problems since her last visit. Address problems as appropriate. For new health problems that may require switching methods.
Ask a long-term client about major life changes that may affect her needs—particularly plans for having children and STI/HIV risk. Follow up as needed.

Managing Any Problems

May or may not be due to the method.

Problems with side effects affect women’s satisfaction and use of COCs. They deserve the provider’s attention. If the client reports side effects or problems, listen to her concerns, give her advice, and, if appropriate, treat.
Encourage her to keep taking a pill every day even if she has side effects. Missing pills can risk pregnancy and may make some side effects worse.
Many side effects will subside after a few months of use. For a woman whose side effects persist, give her a different COC formulation, if available, for at least 3 months.
Offer to help the client choose another method—now, if she wishes, or if problems cannot be overcome.

Reassure her that many women using COCs experience irregular bleeding. It is not harmful and usually becomes less or stops after the first few months of use.
Other possible causes of irregular bleeding include:
- Missed pills
- Taking pills at different times every day
- Vomiting or diarrhea
- Taking anticonvulsants or rifampicin (see Starting treatment with anticonvulsants or rifampicin)
To reduce irregular bleeding:
- Urge her to take a pill each day and at the same time each day.
- Teach her to make up for missed pills properly, including after vomiting or diarrhea (see Managing Missed Pills).
- For modest short-term relief, she can try 800 mg ibuprofen 3 times daily after meals for 5 days or other nonsteroidal anti-inflammatory drug (NSAID), beginning when irregular bleeding starts. NSAIDs provide some relief of irregular bleeding for implants, progestin-only injectables, and IUDs, and they may also help for COCs.
- If she has been taking the pills for more than a few months and NSAIDs do not help, give her a different COC formulation, if available. Ask her to try the new pills for at least 3 months.
If irregular bleeding continues or starts after several months of normal or no monthly bleeding, or you suspect that something may be wrong for other reasons, consider underlying conditions unrelated to method use (see Unexplained vaginal bleeding).

Ask if she is having any bleeding at all. (She may have just a small stain on her underclothing and not recognize it as monthly bleeding.) If she is, reassure her.
Reassure her that some women using COCs stop having monthly bleeding, and this is not harmful. There is no need to lose blood every month. It is similar to not having monthly bleeding during pregnancy. She is not infertile. Blood is not building up inside her. (Some women are happy to be free from monthly bleeding.)
Ask if she has been taking a pill every day. If so, reassure her that she is not likely to be pregnant. She can continue taking her COCs as before.
Did she skip the 7-day break between packs (21-day packs) or skip the 7 nonhormonal pills (28-day pack)? If so, reassure her that she is not pregnant. She can continue using COCs.
If she has missed hormonal pills or started a new pack late:
- She can continue using COCs.
- Tell a woman who has missed 3 or more pills or started a new pack 3 or more days late to return if she has signs and symptoms of early pregnancy (see common Signs and Symptoms of Pregnancy).
- See instructions on how to make up for missed pills.

Try the following (one at a time):
- Suggest aspirin (325–650 mg), ibuprofen (200–400 mg), paracetamol (325–1000 mg), or other pain reliever.
- Some women get headaches during the hormone-free week (the 7 days a woman does not take hormonal pills). Consider extended use (see Extended and Continuous Use of Combined Oral Contraceptives).
Any headaches that get worse or occur more often during COC use should be evaluated.

If symptoms continue:

Consider locally available remedies.
Consider extended use if her nausea comes after she starts a new pill pack (see Extended and Continuous Use of Combined Oral Contraceptives).

Recommend that she wear a supportive bra (including during strenuous activity and sleep).
Try hot or cold compresses.
Suggest aspirin (325–650 mg), ibuprofen (200–400 mg), paracetamol (325–1000 mg), or other pain reliever.
Consider locally available remedies.

Some women have changes in mood during the hormone-free week (the 7 days when a woman does not take hormonal pills). Consider extended use (see Extended and Continuous Use of Combined Oral Contraceptives).
Ask about changes in her life that could affect her mood or sex drive, including changes in her relationship with her partner. Give her support as appropriate.
Clients who have serious mood changes such as major depression should be referred for care.
Consider locally available remedies.

Acne usually improves with COC use. It may worsen for a few women.
If she has been taking pills for more than a few months and acne persists, give her a different COC formulation, if available. Ask her to try the new pills for at least 3 months.
Consider locally available remedies.