Providing combined OCs: Examine special issues
How to handle smokers, new moms
"I want to use the Pill," says your patient. But what do you recommend when that patient:
• is 35, healthy, yet smokes 10 cigarettes a day?
• has just had a baby?
• used to take oral contraceptives (OCs), but experienced nausea while on the Pill and can’t remember the brand name?
When it comes to smoking and women ages 35 and above, participants in Contraceptive Technology Update’s 2000 Contraception Survey are unwilling to prescribe combined OCs.
Nearly 72% say they would not offer pills to healthy women ages 35 to 39 who smoke 10 cigarettes a day, and 88.6% would refuse pills to smokers ages 40 and above. (See chart, at right.) Those figures reflect a slight increase from 1999, when about 67% indicated no pills in smokers in the 35 to 39 age category, and about 87% said no OCs to those ages 40 and above.
Those in favor of prescribing pills declined; 20% indicated they would give pills to smokers in their mid-30s, compared with 27.5% in 1999. More than 6% said they would prescribe OCs for smokers over 40.
Advise smokers to stop
Smoking increases the risk for developing cardiovascular disease. All smokers should be warned of that risk and encouraged and advised to stop smoking, write authors of Contraceptive Technology.1
"We do prescribe OCs [for those] over 35, but not for smokers," says Deborah Mathis, MSN, CRNP, women’s health coordinator at the University of Pennsylvania Student Health Service in Philadelphia. "The risk is too great, even for low-dose OCs."
Sharyn Ginsberg, RNP, CNM, a nurse practitioner at Kaiser Permanente Medical Group, Walnut Creek, CA, concurs, and says she believes the dangers of smoking add to the possible effects of estrogen in such women. She discusses the options of an intrauterine device, progestin-only methods such as the minipill, depot medroxyprogesterone acetate (Depo-Provera or DMPA), Norplant, and sterilization.
Diana Lithgow, RN, FNP, family nurse practitioner at Laguna Beach (CA) Community Clinic, also presents her patients with several choices. "We can give low-dose pills, but I work with the patient, and if they are lifelong smokers not willing to quit, we discuss Depo, Norplant, IUD, etc.," she says. "The patients are more than willing to use another method if they are made to understand that it is not in their best interest in the long run."
Lithgow says she has had no problems in working with smokers to find suitable contraception. "The patients see [the two of] us as a team, working to find the best contraception for them and their health," she notes. "It is never adversarial."
Nearly 40% of respondents to CTU’s 2000 Contraception Survey say they would start new nonbreast-feeding patients on combined OCs four to six weeks postpartum, slightly more than 1999’s 41.9% figure. Nearly 30% say they would initiate pill use one to three weeks postpartum, and 14.2% would start combined pills at hospital discharge, consistent with 1999 statistics. (See charts, above.)
Combined OCs generally should not be used by women who are breast-feeding because a reduction in milk supply is associated with the estrogen component in combined pills.1 About 45% of providers indicate they would initiate use of progestin-only pills for breast-feeding women at four to six weeks postpartum, slightly higher than 1999’s 41.9% figure.
Slightly more than 20% would start progestin-only pills at hospital discharge, with 26.4% at one to three weeks postpartum, similar to 1999 findings.
Which pill would you recommend for a woman who desires oral contraception but says she experienced nausea the last time she used it and can’t remember the brand name? About half of health care providers responding to the 2000 Contraception Survey say their first choice would be Alesse, a 20 mcg ethinyl estradiol/ 100 mg levonorgestrel pill from Wyeth-Ayerst Laboratories of Philadelphia. (See chart, above.) Alesse’s figures nearly doubled since 1999, when 27% of respondents indicated such a first-choice preference.
Other first-choice selections include Loestrin, an ethinyl estradiol/norethindrone acetate pill manufactured in both 20 and 30 mcg strengths from Parke-Davis of Morris Plains, NJ, and Estrostep, an ethinyl estradiol/norethindrone acetate phasic pill, also from Parke-Davis. A total of 14% said they would prescribe Loestrin, with about 8% naming Estrostep as their first choice.
In the second-choice category, Alesse was named by 24% of providers, with 20% selecting Loestrin; 12.8% naming Mircette, a 20-mcg pill with a shortened hormone-free interval from Organon of West Orange, NJ; and 11.6% indicating Estrostep. (See chart, above.) Alesse and Loestrin were top selections in 1999 and earned 15% and 14% respective figures.
Reference
1. Hatcher RA, Trussell J, Stewart F, et al. Contraceptive Technology. 17th ed. New York City: Ardent Media; 1998.
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