Yasmin A Combined Oral Contraceptive Pill containing a new progestin called drospirenone

Deciding on the best pill oral contraceptive pill.

The objective is to choose an effective pill, with the lowest side effects and the lowest possible hormone content. A pill with 30 or 35mg ethinyl oestradiol is now the usual first choice. A 50mg pill may be recommended for women on some anti-epileptic drugs (20).

If a friend has recommended her brand of pill to you there is unlikely to be a reason why you should not try it. Similarly, if you are about to recommence oral contraception and have been happy with one preparation in the past, it would seem reasonable for you to try it again.

Whilst I am taking Yasmin, what monitoring should I receive?

Medical opinion varies as to how often patients on the combined oral contraceptive pill should be checked.

At your first visit the doctor will need to review your medical history and to undertake a general and pelvic examination.

A further review will be undertaken about three months later to ensure that the chosen pill is acceptable.

Many family planning clinics have specialist nurses to undertake some of these routine assessments.

The blood pressure is checked at each subsequent visit to the clinic, which will probably be at three to six monthly intervals. A persistent blood pressure of 160/100mm Hg or more would be an indication to stop the combined oral contraceptive pill and to consider medication to reduce your blood pressure.

Pelvic examination and cervical smears every three years are probably adequate unless you develop symptoms. More frequent monitoring may be indicated for those with risk factors.

Product information for oral contraceptives currently includes the recommendation that all women should have breast and pelvic examination before starting the combined oral contraceptive pill and at regular intervals whilst taking it.

The Committee on Safety of Medicines and the Faculty of Family Planning and Reproductive Health Care in the UK now believe that it is unnecessary for all women taking the combined oral contraceptive pill to have routine breast and pelvic examinations either before or whilst taking the combined oral contraceptive pill.

Blood pressure should always be measured but other physical examination should only be performed if considered appropriate by the clinician.

One of my family has had a blood clot (thromboembolism). Should I have any special tests?

Thromboembolism may occur during immobilisation particularly after a major operation. If your relative had a thromboembolism in such circumstances we would not anticipate that you are at increased risk.

Some families have disorders of the blood clotting mechanism, which predisposes them to thrombosis (thrombophilia). If several of your relatives have been affected, particularly when the blood clots have occurred spontaneously without an obvious cause, we would need to consider thrombophilia. There are blood tests that may detect these abnormalities but they are extremely expensive. In these circumstances, it may be appropriate to seek advice from a haematologist (blood disorder specialist).

Does an aeroplane journey increase the risks of taking Yasmin?

Modern commercial aeroplanes are pressurised. The increased risks of venous and arterial thrombosis associated with high altitude are therefore eliminated.

There have been reports of circulatory complications after a flight but this is equally true for those not taking the combined oral contraceptive pill. Underlying dehydration, following sunbathing, alcohol or a gastro-intestinal upset increases the risk.

Many airline stewardesses take the combined oral contraceptive pill. They know the importance of ensuring adequate fluid intake and they will take a little walk every hour or so to keep their circulation going.

It has been suggested that Aspirin 75mg daily should be considered before the flight and for a few days afterwards.

There is one concern about flights for women taking Yasmin particularly if they are travelling West as they may inadvertently take a pill late. It may be prudent to keep one watch set at the time of your home and use this to guide you on when you should be taking your pills.

Are there times when the combined oral contraceptive pill should be prescribed only with special caution?

Yes, there are times when a patient has medical problems such that the combined oral contraceptive pill can be prescribed but only with special caution. More careful monitoring is required. Examples are:

• moderately elevated blood pressure (hypertension) requiring medication (patients with a history of high blood pressure in pregnancy can be given the combined oral contraceptive pill but again the blood pressure should be checked more frequently).
• obesity (greater than 50% above ideal weight for height) is a reason for caution. Calorie control and exercise should be encouraged with a view to ensuring weight loss.
• hormones may, on occasion, aggravate depression.
• sickle cell disease (an inherited cause of anaemia found generally in people of Afro-Caribbean origin); this was regarded as a contraindication for the combined oral contraceptive pill as there is an increased risk of thrombosis; some authorities now suggest that the combined oral contraceptive pill can be given with caution. It may be prudent to discontinue the combined oral contraceptive pill during any episodes of immobilisation.

• some medical conditions when they are mild but not if they are severe. Examples are diabetes, systemic lupus (SLE), Crohn's disease and renal disease.

  Varicose vein problems are not a contraindication for Yasmin. Varicose veins are more frequently found in association with obesity and this would be a reason for caution. The pill should be stopped if you need injection treatment.

  When a woman has a medical problem that may be affected by Yasmin, the doctors involved in her care will usually liaise to ensure consistency of advice. Ultimately it is for the doctors caring for the woman to provide her with the information that she requires to make an informed choice.

  The more common contraindications to Yasmin include:-

  • pregnancy.
  • a history of arterial or venous thrombosis.
  • cardiomyopathy (an inflammatory condition of the heart).
  • ischaemic heart disease (heart attacks or angina).
  • familial conditions associated with thrombosis.
  • severe migraine.
  • strokes.
  • diabetes.
  • liver diseases.
  • gall stones (the combined oral contraceptive pill can be taken after surgical removal of the gall bladder).
  • porphyria (an inherited condition affecting the break down process of red blood cells)
  • very high blood pressure.
  • smoking at age 35 years or more.
  • severe systemic lupus (SLE) requiring steroid treatment.
  • cancer of the breast or uterus.

   As with any medication, your doctor will check to see if there is any specific medical reason contraindicating the combined oral contraceptive pill.

On which day of my menstrual cycle should I start my first course of Yasmin?

Nowadays, we recommend that it should be started on thefirst day of a period as this provides immediate contraceptive cover. The next period will occur after 23 days but subsequent periods will be at 28 day intervals.

Following childbirth, the combined pill can be taken if the baby is not being breast-fed; breast feeding combined with progestogen-only pills provides excellent contraception. During pregnancy and for the first two weeks after childbirth there is an increased risk of thromboembolism (blood clot problems - surgery risks) and this may be further increased by Yasmin (Q15.14).

• The pill should be commenced no earlier than 21 days after childbirth.
• If there has been a high blood pressure problem associated with pregnancy or there is a tendency to obesity, Yasmin should be further delayed.
• If Yasmin is commenced more than 21 days after childbirth, additional contraceptive precautions are required for the first seven days. The combined oral contraceptive pill can be commenced immediately after early miscarriage or pregnancy termination.

If periods are absent or infrequent, and this problem has been appropriately investigated (Q6.6), a course of progestogen tablets will usually provide a withdrawal bleed and Yasmin can be commenced on the first day of bleeding.

Can I start Yasmin whilst I am breast-feeding?

Yasmin is likely to reduce the quantity and quality of your milk which will contain a relatively large amount of hormones. If oral contraception is required the combination of a progestogen-only pill with breast-feeding will provide highly effective contraception for you.

Can I take Yasmin if I have had episodes when I did not see my periods (amenorrhoea)?

• The amenorrhoea should be investigated, before Yasmin is prescribed, and treated if a specific cause is found (Q6.21).
• If pregnancy has been excluded there is no reason why Yasmin cannot be prescribed.
• When Yasmin is subsequently discontinued the menstrual cycle will return to the pattern that would have occurred if Yasmin had not been taken.

This means that the amenorrhoea may recur and fertility medication may be required if a pregnancy is planned.

Can I start Yasmin if I am not currently seeing my periods?

Absence of periods (amenorrhoea) needs to be investigated (Q6.6). Provided that both pregnancy and a problem requiring treatment have been excluded, amenorrhoea is not a contraindication to Yasmin.

Does it matter if I do not see a period whilst taking Yasmin?

A withdrawal bleed ('period' whilst taking Yasmin) does not have to occur with every pill-free interval.

Provided you have taken Yasmin correctly, a pregnancy is very unlikely.

If you do not see a withdrawal bleed it usually means that the lining of your womb is not building up sufficiently to result in a bleed. This reflects the way that the womb is responding to the combined oral contraceptive pill and does not indicate what will happen when Yasmin is stopped if you wish to have a baby.

From the medical point of view there is no reason to change Yasmin if the problem continues and there is no need to run any tests.

If you are unhappy that you do not see a withdrawal bleed, a different pill may suit you better. One of the phasic pills could be tried if you are on a monophasic variety

A girl of 13 had extremely heavy and painful periods which were controlled for two years with a monophasic pill (Microgynon). At the age of sixteen she returned to my clinic as she kept missing withdrawal bleeds. She had not started sexual activity but was worried that she would lose her fertility. We reassured her that medically there was no anxiety. After discussion she was started on a phasic pill (Trinovum) and withdrawal bleeds occurred.

Some women find that when they stop the combined oral contraceptive pill they do not see their periods. Until twenty years ago this was called 'post-pill amenorrhoea'. Research then showed that, with few exceptions, patients with amenorrhoea after discontinuing the combined oral contraceptive pill had infrequent or absent periods before they commenced the combined oral contraceptive pill. The pill had simply masked an underlying problem and was not the cause.

What is the advice when my changing combined oral contraceptive pill preparation?

The simplest guide is that the current combined oral contraceptive pill should be taken until the course is completed and the new pill should commence on the first day of the withdrawal bleed; no additional contraception is required but the first cycle on the new pill will be just 23 days.

What should be done if breakthrough bleeding occurs whilst I am taking Yasmin?

The first course of action is to check that there is no cause for the bleeding other than Yasmin preparation. A missed pill, antibiotics or gastro-intestinal upset may have occurred. There may be a local cause such as vaginitis (inflammation of the vagina), a cervical polyp (cervical polyps) or other cervical disease. These can be assessed by medical examination. A bleed early in pregnancy can be mistaken for break-through bleeding.

Light breakthrough bleeding may be acceptable for perhaps three months and is likely to settle. Otherwise a change of pill preparation is appropriate. If the oestrogen content is very low increasing this may be the first line of approach. Increasing the progestogen content (Table 16.1) or changing from a monophasic to a bi-phasic or tri-phasic pill (Table 16. 2) are other possible remedies.

Can my combined oral contraceptive pill withdrawal bleed be planned to avoid weekends?

If a pill packet is commenced on a Sunday, the withdrawal bleed should occur on weekdays. When starting Yasmin for the first time, if you delay to the next Sunday rather than commence on the first day of the period, additional contraception is required for the first seven days. For those on monophasic pills (Table 16.1) who wish to convert to a Sunday start, it is probably best to take two packets back-to-back and then finish the second packet on the Saturday. The third packet is commenced on the following Sunday. The other option would be to continue taking Yasmin from a spare pack until the next Sunday. This spare packet can be kept in reserve for similar cycle adjustments when required. 

Can I take Yasmin without a seven-day pill-free gap?

From the medical point of view, there is no benefit in having the gap, and if you are taking a fixed, rather than a phasic pill, you can take Yasmin back-to-back without pill free days. This may avoid a bleed during a social event or a vacation.

The bleed that occurs during the gap we call a withdrawal bleed and not a period. The pharmaceutical companies produce the packaging with the combined oral contraceptive pill-free interval as women understandably feel that it is normal to have a monthly bleed. The only real advantage is that it provides an indication that there is no pregnancy. The phasic pills do not readily lend themselves to a pill-free interval although your doctor can usually provide appropriate advice (2)

If a pill is missed less than seven days before the combined oral contraceptive pill-free interval, Yasmin-free interval should be avoided (18).

The pill-free interval can be avoided for social convenience such as a vacation.

Some women have cyclical symptoms around the time of the combined oral contraceptive pill-free interval. If there are problems with headaches, heavy or painful periods the combined oral contraceptive pill can be taken back-to-back. We generally recommend three packets at a time leading to a withdrawal bleed every ten weeks. Yasmin is a treatment option for endometriosis and we may recommend avoiding the combined oral contraceptive pill-free interval for several months (21).

Related Medical Abstracts - Click on the paper title:-

• Effects of continuous versus cyclical oral contraception: a randomized controlled trial.(2008-01)

What should be done if a pill is missed?

If a pill is taken more than 12 hours late we regard it as missed. The missed pill can be taken and the course continued at the appropriate time. Additional precautions (usually condoms) should be used for the next seven days. If there are less than seven pills remaining in the course, the next packet should be commenced without a seven-day gap; if you are on an ED (every day) regimen, the seven inactive pills should be omitted. The risks of pregnancy are highest when the missed pill is at the beginning or end of a cycle.

Could I conceive whilst I am taking Yasmin?

There are few failures associated with the combined oral contraceptive pill provided that the combined oral contraceptive pill has been taken correctly.

Ideally, Yasmin should be taken at the same time each day.

There is a maximum safety limit of 12 hours.

If Yasmin is taken more than 12 hours late additional precautions are essential (18). The seven pill-free days allow the natural hormone cycle to begin.

If the gap is inadvertently increased, ovulation (egg release) can occur and pregnancy may ensue.

During a gastro-intestinal upset (vomiting or severe diarrhoea) Yasmin may not be absorbed and additional precautions are required. The additional precautions should be continued for at least seven days after the bowel has settled. Similarly, some antibiotics reduce the absorption of the combined oral contraceptive pill and the same precautions would apply.

Can combined oral contraceptive pills interact with other medication?

Some medications, such as those used in the treatment of epilepsy, increase the rate that the liver breaks down chemicals including the oestrogen and progestogen in Yasmin.

Rifampicin, used for a short course for those at risk of meningococcal meningitis, is so powerful at speeding up chemical breakdown pathways that although given for only 2 days, its effects may last for 4 weeks; additional contraceptive precautions are advisable to cover this. Rifampicin may also be prescribed for several months during treatment of tuberculosis. This may make the lower dose pills in particular less effective and breakthrough bleeding more likely. Higher dose pills (e.g. 50mg ethinyl oestradiol), in these circumstances, achieve similar hormone levels to lower dose pills taken by women not taking the anti-epileptic treatment.

Some broad-spectrum antibiotics (effective against a wide variety of bacteria) can reduce the absorption of oestrogen. Break-through bleeding may occur if the hormone levels fall below a threshold. For those on long-term broad spectrum antibiotics (e.g. for treatment of acne) the bacteria in the intestine become resistant to the antibiotic and after the first two weeks there is no need for additional contraception.

The combined oral contraceptive pills may interfere with treatment for diabetes, depression and high blood pressure; appropriate adjustments may be required.

Can Yasmin affect future fertility?

The short answer is no.

At one time it was thought that the combined oral contraceptive pill could cause 'post-pill amenorrhoea (absent periods after stopping the combined oral contraceptive pill - birth control pill) and this was associated with anovulatory (failure of egg release) infertility. Subsequent studies showed that those who developed post-pill amenorrhoea had similar cycle problems before commencing the combined oral contraceptive pill. The pill was not the cause but it had been masking the underlying problem.

It seems likely that, if anything, the combined oral contraceptive pill may conserve fertility by reducing the incidence of pelvic inflammatory disease (Q 20.2) and endometriosis (Q9.11). Pregnancy termination (abortion), which should be prevented by Yasmin, can have complications leading to infertility (Q19.14).

Modern contraceptive methods are extremely effective. There is a danger that one can assume that when Yasmin is discontinued a pregnancy will occur quickly. With increasing age, fertility decreases if you want a child, you should not leave it too long (Q9.6).

Related Medical Abstracts - Click on the paper title:-

• Post-"pill" amenorrhoea--cause or coincidence? (1977-01)

Taking breaks from Yasmin.

There is no medical advantage in taking a break from Yasmin. All too frequently, an unplanned pregnancy will occur. The concept that the combined oral contraceptive pill should only be taken for five or ten years at a time is based in mythology.

Surgery and Yasmin.

One of the potential complications following an operation is a blood clot in one of the veins in the legs or pelvis (surgery risks) and we surgeons try to reduce the risk as far as possible.

As the combined pill is also associated with a tiny risk of blood clot problems (Q15.14) we need to consider whether Yasmin should be stopped before we operate.

Ideally, Yasmin should be discontinued four weeks before major surgery or any operation on the legs.

 The pill can be recommenced on the first day of the next period provided that this occurs at least 14 days after the operation.

If there is need for a major operation when Yasmin has not been discontinued, your surgeon may recommend injections of heparin for a few days to thin the blood a little.

There is no reason to discontinue Yasmin for minor operations or intermediate operations such as laparoscopy.

There is no recommendation to stop progestogen-only pills or other progestogen contraception for surgery.

Until what age can I take Yasmin?

The official recommendation for women with no risk factors is that there is no upper age limit for taking the combined oral contraceptive pill.

Women who smoke should stop Yasmin by the age of 35 years as they are at increased risk of heart disease. The best medical advice is to stop smoking.

As we get older the risks of heart disease increase and fertility falls. If you are taking the combined pill and wish to continue with oral contraception, it is probably advisable to change to a progestogen-only pill at the age of 50.

Yasmin and the menopause.

The pill does not change the time of the menopause. Each egg appears to behave as if it has a timer which determines when it will go into an active phase (Q 2.3). If the hormone environment is not appropriate, the active phase is cut short and that egg fails to develop. One of the important ways that Yasmin works is that it creates a hormone environment that prevents further development of the eggs that are going into the active phase. The pill does not stop eggs from going into the early active phase (otherwise the menopause would be delayed in pill users).

I am taking Yasmin. How will I know if I have reached my menopause?

As you approach the age of 50 there is an increasing chance that you will be reaching your menopause but withdrawal bleeds will continue for however long the combined oral contraceptive pill is taken. There is no test that can absolutely define when the menopause has occurred even for a woman who is not taking the combined oral contraceptive pill and seems to have stopped her periods although a blood test for FSH and oestradiol levels (14) can be a useful guide. If you want to know if you are likely to have reached your menopause, the blood test should be scheduled for the last day of the combined oral contraceptive pill-free interval.

Related Medical Abstracts - Click on the paper title:-

• Laboratory criteria for menopause in women using oral contraceptives (1996).

In what circumstances should Yasmin be stopped immediately?

The pill should be discontinued and urgent medical advice sought if any of the following occur:-

• Severe headache accompanied by visual disturbance.
• Sudden visual disturbance or difficulty with speech.
• Weakness or numbness in one part of the body.
• Severe pain in a calf.
• Unexplained shortness of breath.
• Severe chest or abdominal pain.
• Jaundice.

What symptoms are commonly associated with taking the oral contraceptive pill?

Many women experience mild symptoms that are a nuisance or inconvenience although they are not damaging to their general health.

Many of these symptoms occur frequently amongst non-pill takers so the combined oral contraceptive pill may not be responsible. Anxiety that the combined oral contraceptive pill may be causing major problems frequently leads the patient back to her doctor.

The more common symptoms include

• breast discomfort,
• bloating,
• headaches,
• vaginal discharge,
• aches in the legs and
• weight change.

After checking that all is well, your doctor will probably only need to reassure you. frequent change of pill prescription is rarely indicated.

Should Yasmin be discontinued if I develop headaches?

Migraine involves a headache with visual disturbance. If severe migraine starts, Yasmin should be stopped immediately and not recommenced. The progestogen-only pill is not contraindicated. If mild migraine occurs, Yasmin should be stopped but it may be tried again later with careful monitoring and advice from your doctor.

Headaches by themselves are not a contraindication to Yasmin. If they occur around the time of the combined oral contraceptive pill-free interval, the combined oral contraceptive pill may be taken for nine weeks without a break before a pill-free interval reducing the symptom from 13 to 5 times each year.

Varicose veins and Yasmin.

Varicose veins are not a contraindication against taking Yasmin.

Vomiting and diarrhoea. How does this affect my oral contraceptive pill taking?

If you have taken a pill within two hours and you do not think that another will stay down, you should recommence Yasmin as soon as possible and use additional contraception until seven days after the vomiting has settled. The pill should be continued rather than omitted for the seven pill free days if they would occur during this time. Mild to moderate diarrhoea does not interfere with pill absorption.

Starting a pregnancy - When should I stop taking Yasmin?

There is no evidence of any increased risk of abnormality for the baby in women who conceive soon after stopping the combined oral contraceptive pill. The underlying risk of congenital abnormality (a structural defect of one or more parts of the body present at birth) is 2% of all babies. Even when pregnancy occurs accidentally in women taking the combined oral contraceptive pill, the risk of congenital abnormality is not increased above this 2% level.

At one time, one of the most common problems facing obstetricians was determination of the duration of pregnancy.

• Only if the menstrual cycle was normal and the mother was certain about the date of the first day of the last menstrual period (L. M. P.) could the obstetrician be reasonably confident about the expected time for delivery (expected date of delivery E.D.D).
• Knowing the dates is critical either when there is a possible need to induce labour, plan an elective Caesarean section or stop premature labour.
• Periods may be delayed or irregular for a few months after stopping Yasmin, reducing the accuracy of determining dates in a pregnancy.
• Ultrasound, which has been available for more than thirty years, can be reasonably accurate in the first half of pregnancy in determining dates usually overcoming this potential difficulty.

There is some evidence that folic acid supplementation reduces the risk of the spina bifida group of defects when taken before pregnancy and for a few weeks after conception. We now recommend folic acid supplements to all women contemplating pregnancy. 

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This is the personal website of David A Viniker MD FRCOG, Consultant Obstetrician and Gynaecologist - Specialist Interests - Reproductive Medicine including Infertility, PCOS, PMS, Menopause and HRT.

I do hope that you find the answers to your women's health questions in the patient information and medical advice provided.

This is the personal website of David A Viniker MD FRCOG, Consultant Obstetrician and Gynaecologist - Specialist Interests - Reproductive Medicine including Infertility, PCOS, PMS, Menopause and HRT.

I do hope that you find the answers to your women's health questions in the patient information and medical advice provided.

 

 

The aim of this web site is to provide a general guide and it is not intended as a substitute for a consultation with an appropriate specialist in respect of individual care and treatment.

David Viniker retired from active clinical practice in 2012.
In 1999, he setup this website - www.2womenshealth.com - to provide detailed
information many of his patients requested. The website attracts thousands of visitors every day from around the world.
Website design and search engine optimization became hobies that he plans to pursue in his retirement. If you would like advice on your website, please visit his website www.firstwebsitedesign.com or email him on david@firstwebsitedesign.com.