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How to use OCs? Check clinicians' strategies
The next woman in your exam room says she has had cramping, breast tenderness, and headaches during the pill-free placebo week of her oral contraceptive (OC). She is open to having less frequent withdrawal bleeding. What's your next move?
If you are considering extended cycle use of the Pill, you are not alone. About 59% of respondents to the 2009 Contraceptive Technology Update Contraception Survey say they increased use of extended or continuous pill regimens in the last year, down slightly from 2008's 62% percentage.
Women enjoy having fewer withdrawal bleeds each year and are beginning to understand that it is not biologically natural to have one every month, says Crystal Wilmhoff, CNP, a nurse practitioner at Planned Parenthood Southwest Ohio Region in Cincinnati.
Patients are becoming more knowledgeable about contraceptive options, says Rakiiba Jackson, CNM, a certified nurse midwife at the U.S. Virgin Islands Department of Health Family Planning Program in St. Thomas. "I see more interest in the extended regimens, especially as women understand that monthly menses is not necessary for the health of the uterus," says Jackson. "We use available monophasics when patients choose a continuous cycling option."
Extended regimens for OCs is proving popular among service women, reports Michele Rounds, CNM, a certified nurse midwife at Womack Army Medical Center at Fort Bragg, NC. "A lot has to do with marketing, but also, our population of active duty service women doesn't want to have periods when they are deployed," says Rounds.
The Quick Start method of pill initiation is now gaining hold in family planning clinics. About 87% of 2009 survey respondents say they are using the method for beginning pill users, a jump from 2008's 65% level.
Quick Start is defined as immediate initiation of oral contraceptives, the same day as the office visit. Pills may be provided if clinicians are reasonably certain the woman is not pregnant and not in need of emergency contraception. Backup contraception should be advised for seven days.1 Why prescribe in this manner? It eliminates the gap between decision and implementation, and it results in higher initiation rates, higher continuation rates (short-term), and lower pregnancy rates.1
Colleen Taylor, NP, a nurse practitioner at Kennebec Valley Community Action Program Family Planning in Waterville, ME, says, "We have been utilizing this for a long time with great success. We always try to start our clients on a method as soon as possible, when there is no contraindication. I believe this averts many unwanted/unintended pregnancies."
Quick Start isn't only for pills. It is being used with the contraceptive injection, depot medroxy-progesterone acetate (Depo-Provera, Pfizer, New York City; Medroxyprogesterone Acetate Injectable Suspension, USP, Teva Pharmaceuticals USA, North Wales, PA).
Depo Quick Start use results in fewer women lost to follow up, and it serves the patients' needs more readily, says Pat Jewell, CNM, a certified nurse midwife at Kalihi-Palama Health Center in Honolulu.
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 breast-feeding from three weeks to three weeks and six days postpartum. About 14% indicated initiation from one week to two weeks and six days postpartum, and 17% stated pill starts upon hospital discharge.
When it comes to use of progestin-only pills in breast-feeding 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 woman is breast-feeding, World Health Organization (WHO) criteria indicate that combined oral contraceptives should not be used during the first six to eight weeks postpartum (Category 4) and should be avoided from six weeks to six months postpartum unless other more appropriate methods are not available or acceptable (WHO Category 3).2 If a woman is not breast- feeding, WHO criteria rank use of combined pills as a Category 3 before 21 days postpartum, and a Category 1 (use method in any circumstances) 21 days and beyond.
In the case of progestin-only pills, before six weeks postpartum, breast-feeding women should avoid using such pills unless other more appropriate methods are not available or acceptable (WHO Category 3).2 From six weeks to less than six months postpartum in women who are primarily breast-feeding, progestin-only pills are rated as Category 1.2 If a woman is not breast-feeding, progestin-only pills can be started immediately.2
The Association of Reproductive Health Professionals (ARHP) offers several resources on menstrual suppression, including a free clinical fact sheet, "Menstrual Suppression," and a free patient handout in English and Spanish, "Understanding Menstrual Suppression." To access the publications, visit ARHP's web site, www.arhp.org. Click on "Publications & Resources." For the fact sheet, click on "Clinical Fact Sheets" on the left site of the page, and then the title. For the patient handout, click on "Patient Resources" and the title under "Fact Sheets."