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9/04
Dear Students,
One of the most difficult clinical problems for nurse practitioners and providers of contraception is what pill to put a patient on. I believe that a helpful and simple guide is the current edition of Hatcher et al's Contraceptive Technology.
Choosing a OCP or divide such as a patch, vaginal ring or monthly injection. Whenever there is a statement about using a contraceptive pill, remember there are additional methods of providing the hormones. Also remember that Seasonal is the three month continuous hormone. There are only 4 menstrual periods a year.
Use lowest dose possible. Never over 50ug!
Step 1 Is this woman a candidate for estrogen?
History should identify contraindications such as menstrual migraines, smoker 35 and older, current or history of circulatory diseases due to blood clots.
Step 2 Yes. Go to Step 3. If no, a progestin only method or a barrier method.
Step 3 Use lowest dose possible. Never over 50ug. Examples of 20ug pills: Loestrin 1/20; Alesse; Estrostep 21 (20/30/35 and fewer estrogen free days)
Step 4
A. Use 20 ug pills in women 40-50; diabetic, obese.
B. Suggested pills for estrogen side effects.
C. Suggested pills to minimize spotting.
D. Suggested pills to minimize androgen effects.
E. Suggested pills to produce the most favorable lipid profile.
F. Suggested pills for emergency contraception.
There are many great web pages about all aspects of contraception and types of contraceptives from the familiar to the less well known. Your text, Hatcher et al. (1998) has an extensive list of excellent websites, p271-275. Check some of them out. Here are a few very helpful websites.
www.columbia.edu/cu/healthwise/
CPT or V Codes for Contraception
V25.01 Oral Contraception
V25.02 Other contraceptive Measures
V25.09 Family Planning
V25.1 IUD
V25.2 Sterilization
Beneficial effects.
It is really important to emphasize the beneficial effects of OCP's. There is a really good handout that you may copy and use.
FDA approved for treatment of acne (Ortho tri cycline)
(Note that any birth control pill that is predominently estrogenic will
work. Progestin activity of the progesterone's in the OCP's.)
Decreased incidence of ovarian cysts
Decreased incidence of ectopic pregnancy
Decreased incidence of fibroadenomas of the breast or fibrocystic changes
Decreased anemia from blood loss
Increased cycle regularity
Decreased dysmenorrhea
Decreased incidence and severity of PID
Decreased risk of ovarian cancer
Decreased incidence of endometrial cancer
Decreased incidence of ectopic pregnancy.
Improvement of acne.
Physiology/Mechanism of Action
Estrogen effects:
Inhibits FSH and LH and inhibits ovulation.
Alters the endometrium
Luteolysis(corpus luteum degenerates)
Types of estrogens
Ethinyl estradiol - Derivative of estradiol is a potent estrogen that can be given orally and is metabolized in the liver.
Mestranol - Less potent that EE by about 1/3. Used in a few 50ug birth control pills.
What are two names of OCP's that contain mestranol?
Progestational effects:
Inhibits LH and thus ovulation
Thick cervical mucous inhibits sperm transport.
May inhibit sperm capacitation (ability to enter the egg)
Endometrium is altered (decidualized) 0.06 mg
Types of progestins
Note: progestins vary in their estrogen, androgen and progestin effects. However, all are
progestin's. Dickey (1998) extensively discusses the effect of the various progestins.
Combined estrogen/progestin
What is different about the new OCP Mircette from all the other OCP's?
Effectiveness
Hatcher, et al. (Current edition). Low dose hormonal contraceptives are about 95% effective. Higher dose pills were 99%.
Contraindications/Use with caution (FDA)
Thrombophlebitis or thromboembolic disorder or a history thereof
Cerebrovascular accident or a history thereof
Coronary artery or ischemic heart disease or history thereof
Known or strongly suspected breast cancer
Known or strongly suspected estrogen dependent neoplasia
Pregnancy
Liver tumor benign or cancer, hepatic disease
Undiagnosed genital bleeding
Past history of jaundice related to BCP's
Over 35 and smoker
Migrane headaches that begin with BCP’s with neruologic effects
Hypertension (160/100)
Diabetes Mellitus with complications
Elective surgery
other
Pill problems. See Hatcher, et al (current edition) and Dickey (current edition)
Spotting. Be patient. Don’t change for 3 cycles. Problems decrease with time.
Estrogen or Progestin excess or deficiency. Read about this area in Hatcher, et al. and Dickey (1998)
Poor candidates
History of poor compliance
Medications that decrease blood level of OCP’s
Long-term antibiotics (ampicillin & tetracycline)
Antiseizure medication (phenytoin)
Phenobarbitol & Tegretol (decreased contraceptive effect)
High dose Vitamin C (> 1 gm) increase estrogen availability
Acetaminophen (decreased pain relieving effect)
Antidepressants (possible increased effect of Elavil)
Beta blockers possible increased effect of beta blockers)
Smokers
Hormonal Contraceptives-Warning Acronyms
A Abdominal pain (severe)
C Chest pain (severe), cough, shortness of breath
H Headache (severe), dizziness, weakness, or numbness
E Eye problems (vision loss or blurring), speech problems
S Severe leg pain (calf or thigh)
Hormonal Interactions
Look up and be familiar with medications that induce or inhibit the Cyotcrome P450 system.
Hormonal Contraceptives, Progesterone Only:
Beneficial actions
Good for women who cannot take estrogen
Good for breastfeeding mothers
Disadvantages, General
No protection against STI's
Irregular bleeding
Weight gain 4-6 pounds /year; 15-16 pounds in 5 years
Breast tenderness
Depression
Types
Oral contraceptives
Norethendrone 0.35 mg (Nor Q D; Micronor)
Norgestrel 0.075 mg (Orvette)
Failure rate about 3%
Disadvantages of mini pills:
Variable efficacy
Depo-Provera:
Effectiveness: failure rate 0.3%/year
Positive effect on endometriosis
May decrease cycles
No know adverse effects when inadvertently used during pregnancy
Dose: 150 mg IM q 3 months. Do not message injection site.
Disadvantages of DPMA
No immediate discontinuation
Return q 12 weeks
Decreased HDL's
May be associated with decreased bone density
Headaches
Relative infertility
Decreased libido
Acne
Hair loss or growth
Management of irregular bleeding:
Several cycles of low-dose OCP's
Estrogens: estradiol (Estrace), Ethinyl estradiol (Estinyl), conjugated estrogens (Premarin)
Prostaglandins
Initial dose.
Give during menstrual period and q 12 weeks.
Immediately post partum
If might be pregnant, serum pregnancy test
Norplant
Although this is an effective contraceptive, it has fallen into disfavor. A shorter timed device is coming. Also, a degradable implant. Read about implantable contraceptives in Hatcher, et al. (1998).
Note: you can see these IUD's on www.plannedparenthood.org or www.opr.princeton.edu/ec/contrac
Mechanism of action
Prevents sperm from fertilizing the egg. "The copper IUD (Cu T 380A) causes an increase in uterine and tubal fluids containing copper ions, enzymes, prostaglandins, and white blood cells (macrophages) that alters tubal and uterine transport and effects the sperm and ovum so fertilization does not occur." Hatcher, et al. (1998), pp512. "Progestin IUDs (the Levonorgestrel 20 IUD and the Progestasert) have a primarily hormonal method of action: the cervical mucous is thickened, ovulatory patterns disrupted, endometrial lining altered, and uterine and tubal motility impaired." Hatcher, et al. (1998), pp512.
IUD's available
| IUD | Effectiveness | Pregnancy Rate |
|---|---|---|
| Copper IUD (Cu T 380A) | Effective for 10 years | First year pregnancy rate, 0.6% |
| Progesterone T (Progestasert) | Effective for 1 year | First year pregnancy rate, 1.5% |
| Levonogestrel IUD (LNg20)(not available yet in the US | Effective for 5 years | First year pregnancy rate, .1% |
Benefits
Excellent contraception for low risk women
Progestasert decreases bleeding. Consider for women with DUB.
Can be used for Emergency Contraception. www.princeton.edu/ec/contrac.html
Instructions for Users, Hatcher, et al. (current edition)
P Period late (pregnancy), abnormal spotting or bleeding
A Abdominal pain, pain with intercourse
I Infection exposure (any STD), abnormal discharge
N Not feeling well, fever, chills
S String missing, shorter or longer
Cautions
See Hatcher et all, (current edition)
Problems
Bleeding and Dysmenorrhea. Consider ibuprofin or other NSAID and iron supplementation
Complications of IUD’s
Increased incidence of pelvic inflammatory disease (PID)
Expulsion
Pregnancy complications if woman becomes pregnant.
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