Help patients stay the course when using OCs
Choosing the birth control pill for contraception may be easy, but maintaining its daily dosing regimen is not. Education is the key to staying on schedule with oral contraceptives (OCs), say Paula Hillard, MD, director of women’s health and professor in the OB-GYN and pediatrics department at the University of Cincinnati, and Linda Dominguez, OGNP, senior clinician with Planned Parenthood of New Mexico in Albuquerque.
Hillard uses this illustration: Think about how hard it is to complete a course of antibiotics to combat a painful sore throat. Contrast that with the long-term daily dosing regimen of OCs, in which a missed pill causes no symptoms or other immediate consequences. You now begin to understand why pills can remain in the pack.
Missing the daily dose
Forgetting to take the daily dose is the leading cause of missed OCs, say participants in the 1997 Contraceptive Technology Update Pill Survey. (See chart, below left.) More than half of respondents say they believe 20% or more of all unintended pregnancies in their pill-taking patients are the result of at least one missed OC in the cycle. Women need a clear understanding of the reproductive system and how the pill interacts with it, Dominguez says. If they can’t grasp the concept of how the pill functions within their bodies, patients may not fully realize the importance of daily pill dosing.
Try a team approach to education, with a counselor, clinic health specialist, or staff person leading off with discussion about birth control pills and how to take them. Allow patients to handle a pack of pills and see how they are set up for daily use. The clinician can follow up with detailed information on how the pill interacts with various parts of the reproductive system. Armed with this information, women can commit more easily to using the medication properly, says Dominguez.
No time for reticence
Recognize that patients come to the clinic with definite ideas and anxieties about contraception. Identify those concerns through a comprehensive sexual history form completed before the physical exam. Use evocative questions about sexual activities to help you cover the most ground possible.
"In my medical history form," Dominguez explains, "I have something that says, We recognize that some of these questions may be difficult to answer, but it will help us to tailor your care.’ So right up front, we acknowledge, This is tough, but if you can tell me this information, I can help you.’ And what I’m really saying is, I can help you faster.’ I know I’ve only got 15 to 30 minutes. But part of the pushing is from the patient. We have working women who have not got the time."
Get women to examine how the pill will fit into their normal routine, Dominguez says. "I think an important piece of anticipatory guidance is to help women to open up their day to you. Ask them, Tell me your day. Not only touch these pills, but touch your life in a story to me right now.’ It will hopefully merge those two pieces together, the technical piece of having to take the pill and the real piece, which is in the context of their lives."
Ask women about their weekend activities, since the "Sunday start" (beginning the pill the first Sunday after menstruation begins) is the preferred method of many pill users. Remind patients to have pills on hand so Sunday can be the beginning to a successful cycle of pill taking.
Before the visit ends, says Dominguez, be sure to ask, "What does your partner think or know about the birth control pill?" If the partner has had bad experiences (observing instances of premenstrual syndrome, weight gain, or decline in sex drive with previous partners on pills), he is less likely to support the patient’s contraceptive decision, she explains.
The period in which pills are missed plays a large role in the possibility of unintended pregnancy, Hillard says. (For more on the importance of missed pills, see CTU, June 1995, p. 69.) Many women may be lulled into a false sense of security after the first or second incidence of a missed pill with no pregnancy, so explain why it is important to begin and continue pills on schedule.
If your patient has no daily routine, pills may not be the best form of contraception, says Hillard. Admitting that fact is not a failure but a smart move in recognizing there may be a better birth control option available.
Some women may become overwhelmed by the thought of taking a pill every day throughout their reproductive lives, says Dominguez. Help them focus on the "here and now" and reassure them that other options are available if they need to switch methods.
Recommended reading
Potter L, Oakley D, de Leon-Wong E, et al. Measuring compliance among oral contraceptive users. Fam Plan Perspect 1996; 28:154-158.
Rosenberg M, Burnhill M, Waugh M, et al. Compliance and oral contraceptives: a review. Contraception 1995; 52:137-141.
Rosenberg M, Waugh M, Long S. Unintended pregnancies and use, misuse, and discontinuation of oral contraceptives. J Reprod Med 1995; 40:355-360.
Oakley D. Rethinking patient counseling techniques for changing contraceptive use behavior. Am J Obstet Gynecol 1994; 170:1,585-1,590.
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