Readers share views on oral contraceptive use
When should patients begin their pill packs? When should new, non-breast-feeding mothers start combined oral contraceptives (OCs)? How about start times for nursing mothers when using progestin-only pills? Those are just some of the issues tackled by Contraceptive Technology Update readers in the 1998 pill survey. Following is an overview of how readers address the daily challenges of patient care.
CTU readers choose Sunday starts when it comes to initiating the first pack of pills. About 78% of those participating in the annual survey noted a preference for this practice. Sunday starts, which begin the pill pack on the first Sunday after the onset of menstrual bleeding, are easy to maintain since most pill packs are labeled this way, says Mary Anne Baker, CNM, a clinician at Health Quarters Reproductive Health Care Services in Beverly, MA. It also avoids withdrawal bleeding on the weekend, she notes.
Some practitioners would rather initiate pill use on the first day of the period, as does one Alaskan nurse practitioner, who preferred to remain anonymous. For patient populations including many teens and young women, that approach provides protection a little sooner and is easier to explain to some youth, she observes.
Pill choice for nausea
A patient comes into the exam room and seeks birth control. She reports bothersome nausea from a previous oral contraceptive, but she can't remember the name of the pill. What pill would you recommend? Survey respondents chose Ortho Tri-Cyclen (Ortho-McNeil, Raritan, NJ), Alesse (Wyeth-Ayerst, Philadelphia), and Loestrin (Parke-Davis, Morris Plains, NJ) as the top picks for the first-choice pill, with respective scores of 16.6%, 13.5%, and 11.7%. Pills listed as the second choice included Triphasil (Wyeth-Ayerst), Alesse, and Ortho-Cyclen (Ortho-McNeil.) (See charts, above right.)
Most of the time, nausea is an estrogen-type side effect, observes Charles Harper, MD, coordinator of ambulatory care/OB/GYN at Women's Hospital of Greensboro (NC). For patients who have nausea or headaches on the birth control pill, clinicians in his facility often try a different pill formulation by going to a lower-estrogen pill such as Loestrin 1/20 or Alesse. There may be a little more breakthrough bleeding with lower-dose pills, Harper observes, but if patients use it long enough, such bleeding may level off.
A total of 68% of survey participants provide written instructions that women who continue on oral contraceptives after developing nausea or diarrhea should use a backup method of birth control.
Check new, nursing moms
When it comes to starting new, non-breast-feeding mothers on combined oral contraceptives, CTU readers report several different initiation periods. Thirty-two percent would begin pills three to six weeks postpartum, while about 32% would initiate them between one and three weeks postpartum. About 16% would begin pills upon hospital discharge, while almost 10% would start them after first menses. (See above chart.)
"I prefer to start non-breast-feeding women on OCs at about two weeks postpartum," says Janet Realini, MD, MPH, medical director of the family planning program for the San Antonio Metropol itan Health District. "Since another pregnancy is theoretically possible as early as three to four weeks postpartum, I like to start the pill before the three-week mark."
For breast-feeding mothers who wish to use progestin-only pills, almost 35% of providers said they would start the pills between four and six weeks postpartum. Thirty percent said they initiate progestin-only pills between one and three weeks, while about 22% said they would start pills upon hospital discharge. (See above chart.)
In women who are exclusively breast-feeding their infants (offering no other form of supplemental feeding), Realini says contraception is not necessary until three months postpartum. However, since many women stop breast-feeding or begin to add bottles to the feeding regimen as time goes by, starting progestin-only pills at two weeks seems reasonable, she notes.
"I prefer to use progestin-only pills rather than combined OCs in women who are breast-feeding, although some doctors in our clinics are happy to prescribe combined OCs once the milk supply is established," Realini observes. "Sometimes, combined OCs have the advantage of providing regular 'periods'; sometimes they are preferable for a woman who occasionally misses a pill or two. However, I would not start combined oral contraceptives in a breast-feeding woman until a minimum of six weeks postpartum."
Women over 35 who smoke 10 cigarettes a day need to decide between their habit and their birth control pill, because the majority of CTU readers say they will not prescribe OCs for such patients. About 65% said they would not prescribe to women ages 35 to 39 who smoke that number of cigarettes, with the percentage increasing to about 87% for women age 40 and above who smoke that number of cigarettes. (See above chart.)
"My first line of argument for smokers over 35 is that they should quit smoking," says Steven Eisinger, MD, professor of family medicine and associate professor of obstetrics and gynecology at the University of Rochester (NY)/Jacob W. Holler Family Medicine Center. "This would give them the availability of taking oral contraceptives. If they will not or cannot, then depot medroxyprogesterone acetate [DMPA] or an IUD are suitable reversible methods, or sterilization is another option."
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