Clinicians reveal strategies on OC use
When it comes to providing oral contraceptives (OCs) to patients for the first time, 87% of respondents to the 2010 Contraceptive Technology Update Contraception Survey say they choose Quick Start, the immediate initiation of the hormonal method in the office. The figure is in line with 2009 statistics, which underlines clinicians' confidence in the practice.
Using Quick Start has improved the number of women initiating birth control on the first visit, says Sulola Adekoya, MD, lead physician at Richmond City Health District, Richmond, VA.
Quick Start eliminates the gap between decision and implementation, said Alison Edelman, MD, MPH, associate professor in the department of obstetrics and gynecology and assistant director of the Family Planning Fellowship at Oregon Health and Science University in Portland. Edelman presented on the topic at the 2010 Contraceptive Technology conference.1 The practice is endorsed by the World Health Association, Edelman noted. When used with the contraceptive pill, vaginal ring (NuvaRing, Merck & Co., Whitehouse Station, NJ) and the contraceptive injection depot medroxyprogesterone acetate (Depo-Provera, Pfizer, New York City; Medroxyprogesterone Acetate Injectable Suspension, USP, Teva Pharmaceuticals USA, North Wales, PA), research suggests the practice can lead to higher initiation rates, higher short-term continuation rates (in the pill only), and lower pregnancy rates.2 Using Quick Start is acceptable to women, Edelman stated.
If a clinician is reasonably certain that a woman is not pregnant, Quick Start of contraception can begin. Provide emergency contraception (EC) if indicated, and advise backup contraception for seven days.1
Yes to extended regimen
Kim Burtle, CMN, director of the Women's Health Care Clinic in Torrance, CA, says prescription of extended or continuous regimen oral contraceptives has increased in the last year. What has led to the increase? Patient requests, she reports. [Help patients understand menstrual suppression. Use the Association of Reproductive Health Professionals patient handout, "Understanding Menstrual Suppression.]
About 53% of 2010 Contraception Survey respondents say they increased use of such pill regimens in the last year, down slightly from 2009's 59% percentage.
Extended use of pills might mean one of four strategies, according to A Pocket Guide to Managing Contraception:
- manipulation of a cycle to delay one period for a trip, honeymoon, or a sporting event;
- use of active hormonal pills for more than 21 consecutive days followed by 2-7 days hormone-free days;
- continuous daily OCs for at least 21 pills, but after that, may break for two to seven days if spotting or breakthrough bleeding is bothersome; or
- use of a monophasic pill indefinitely.3
Pills in postpartum?
After what period of time postpartum do most clinicians recommend pill initiation? About 38% of 2009 survey respondents say they would start combined pills in new moms who are not breastfeeding from three weeks to three weeks and six days postpartum, with about 14% indicating initiation from one week to two weeks and six days postpartum, and 17% stating pill starts upon hospital discharge.
When it comes to use of progestin-only pills in breastfeeding women, 29% said they would issue the pills on hospital discharge. A total of 28% said they would start progestin-only pills from three weeks to three weeks and six days postpartum, and 14% indicated start dates from one week to two weeks and six days postpartum.
If a new mother is not breastfeeding, the U.S. Medical Eligibility Criteria for Contraceptive Use rates use of combined hormonal contraceptives in two time increments:
- less than 21 days postpartum: 3 (a condition for which the theoretical or proven risks usually outweigh the advantages of using the method);
- 21 or more days: 1 (a condition for which there is no restriction for the use of the contraceptive method).
In the case of progestin-only pills for breastfeeding mothers, the criteria offer three time segments:
- less than one month postpartum: 2 (a condition for which the advantages of using the method generally outweigh the theoretical or proven risks);
- one month to less than six months postpartum: 1;
- six months or more postpartum: 1.4
How to provide EC?
While emergency contraceptive pills (ECPs) can be provided from behind the counter for people ages 17 and older, many clinicians continue to provide ECPs in advance for their patients. More than two out of three (67%) say they offer advance EC provision.
Clinicians at Comprecare Clinic in San Jose, CA, continue to prescribe Plan B (Teva Pharmaceuticals USA) because patients can't afford it to purchase it over the counter (OTC), says Lisa Friedrichs-Sherard, OB-GYN NP, a nurse practitioner at the facility.
Nora Lewis, CNM, a certified nurse midwife with Santa Barbara County Public Health Department in Santa Maria, CA, reports a similar situation. Lewis says that clinicians provide advance prescriptions for EC or provide Next Choice (Watson Pharmaceuticals) in the clinic since the drug is covered by the state family planning program. The OTC version would be an out-of-pocket expense for the client, notes Lewis.
Tia Hansuld, FNP, a nurse practitioner at Casper-Natrona County Health Department in Casper, WY, says, "We don't often write advance prescriptions for ECP, but will provide a package of Plan B for them to keep at home if the need arises, especially if they do not want contraception other than condoms."
- Edelman A. Extended regimens and Quick Start: Why prescribe it? Presented at the 2010 Contraceptive Technology conference. San Francisco; March 2010.
- Lopez LM, Newmann SJ, Grimes DA, et al. Immediate start of hormonal contraceptives for contraception. Cochrane Database Syst Rev 2008;2: CD006260. Doi: 10.1002/14651858.CD006260.pub2.
- Zieman M, Hatcher RA, Cwiak C, et al. A Pocket Guide for Managing Contraception. Tiger, GA: Bridging the Gap Foundation. 2010.
- Centers for Disease Control and Prevention. U.S. Medical Eligibility Criteria for Contraceptive Use. MMWR 2010;59(RR04):1-6.