When it comes to oral contraceptives (OCs), what are the options when it comes to new mothers who are breast-feeding and older women smokers?
Think about your practice, and check your response against the views recorded in the results of the 2002 Contraceptive Technology Update 2002 Contraception Survey.
The majority of CTU 2002 survey respondents say they will not provide pill prescriptions for older women who smoke 10 cigarettes a day. For women ages 35-39, about 74% say they will not supply OCs, and for women ages 40 and older, the number climbs to 88.2%. These findings are in line with 2001 survey responses.
Helen Cook, ARNP, a nurse practitioner at Franklin County Health Department in Appala-chicola, FL, says her decision to deny OCs is based on state protocols for women who smoke ages 35 and older. As options, she discusses Depo-Provera injections, intrauterine contraception, barrier methods, and sterilization. For women who still desire to continue OCs following the counseling, Cook’s facility offers a smoking cessation program.
According to the Geneva-based World Health Organization (WHO), for women age 35 and older who smoke 20 or fewer cigarettes per day, use of OCs is not generally recommended unless other, more appropriate methods are not available or acceptable. For those in the same age bracket who smoke more than 20 cigarettes per day, OCs are not to be used.1
Nursing moms and pills?
When do you initiate combined pill use for a new mother who chooses not to breast-feed? About 46% of 2002 CTU survey respondents say they would prescribe OCs four to six weeks postpartum, an increase over 2001’s 40.2% level. About 28% say they would initiate OCs one to three weeks postpartum, with about 11% providing pills upon hospital discharge. About 8% would start pills at first menses, with about 6% using other approaches. These views are consistent with those reported in the 2001 survey.
For new mothers who wish to breast-feed, 44.4% of respondents say they would begin progestin-only pills (POPs) at four to six weeks postpartum, up from the 38% figure recorded in the 2001 survey. A total of 26% note they would initiate POPs at one to three weeks postpartum. About 21% would initiate POP use at hospital discharge, with fewer 1% starting mini-pills at first menses. About 8% say they would use other approaches.
According to the WHO guidelines, women who are not breast-feeding can begin combined OCs after the second to third postpartum week.1 If women choose to breast-feed and use progestin-only pills, the POPs may be started after six weeks postpartum, the WHO guidelines recommend.1
For women who have experienced bothersome nausea on previous OCs, but can’t remember the brand name of the pill used, almost half (49.7%) of the respondents to the 2002 CTU survey say they would prescribe Alesse, a monophasic 20-mcg pill from Wyeth-Ayerst Laboratories of Philadelphia.
Loestrin 1/20, a 20-mcg monophasic pill from Pfizer of New York City, increased its second place share in the 2002 survey, moving from 13.2% in 2001 to 20.2% in 2002. Mircette from Organon of West Orange, NJ, a pill with a unique dosing schedule (21 days of 150-mcg desogestrel/20-mcg ethinyl estradiol, two days of placebo pill, followed by five days of 10 mcg ethinyl estradiol) moved up to the third place, with 10.2% of responses. Less than 5% of respondents had named Mircette in the 2001 poll.
Cook offers the following approach if a patient says she experienced nausea with previous OCs:
- Take a detailed history about the nausea and when she experienced it.
- Educate the patient. Discuss the fact that nausea often decreases after the first couple cycles of OCs.
- Inform the patient that nausea is common when women double up on missed OCs, so it is important that pills are taken consistently.
Since most patients who take a 20-mcg OC have fewer problems with nausea, Cook says she starts her patients with her facility’s formulary drug, which is Alesse.
In your written patient instructions, do you recommend that women who continue pills after developing vomiting or diarrhea use a backup contraceptive until their next period? About 72% of 2002 survey respondents provide such information, a slight decrease from 2001’s 78.4% figure.
1. World Health Organization. Improving Access to Quality Care in Family Planning: Medical Eligibility Criteria for Contraceptive Use. Geneva: WHO, Family and Reproductive Health; 1996.