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• a former patient, a 37-year-old who wants contraceptives but is a heavy cigarette smoker;
• a new patient, a 28-year-old new mother;
• and a walk-in patient, a 23-year-old who has used pills in the past but had problems with nausea.
What approaches do you use? Respondents participating in the 1999 Contraceptive Technology Update Contraception Survey offer their insights into how providers may address these daily challenges of providing patient care in the family planning setting.
Providers who see women ages 35 and above agree: Oral contraceptives and smoking do not mix. Responses to the 1999 CTU survey fall in line with previous years’ findings, as 67% say they would not prescribe to women ages 35 to 39 who smoke 10 cigarettes a day; that percentage in 1998 was 65%. In the case of women ages 40 and above, the majority of providers again concur that OCs are contraindicated: 88% say they would not prescribe, compared with 1998’s 87% figure. (See chart at right.)
According to the Geneva, Switzerland-based World Health Organization’s (WHO) "Medical Eligibility Criteria for Starting Contraceptive Methods," OCs for female smokers ages 35 and above rank in the "WHO 3" category, which is described as follows: "Should not be used unless a doctor or nurse makes a clinical judgment that the client can safely use it. Theoretical or proven risks usually outweigh the advantages of the method. Method of last choice, for which regular monitoring may be needed."1
Providers at Shenandoah Valley Medical Center in Martinsburg, WV, follow the WHO guidelines, reports Marianne Fisher Vandiver, PA-C, certified physician’s assistant. "We try to stick as much as we can to those [guidelines], so some of those women are on progestin-only methods," she notes. "We generally also discuss surgical sterilization if they really don’t want to have kids, and we try to get them to stop smoking."
When you would begin combined OC use for new mothers who are not breast-feeding? About half (41%) of survey respondents say they would initiate use three to six weeks postpartum, up from 32% in 1998. For women who choose to breast-feed, 42% say they would begin progestin-only pills at four to six weeks postpartum. (See charts, below.)
Package labeling for combination OCs suggests not initiating OCs until one month or more postpartum, notes Andrew Kaunitz, MD, professor and assistant chair of the department of OB/GYN at the University of Florida Health Sciences Center in Jacksonville. According to Kaunitz, several issues determine when it is appropriate to start combination OCs in this setting:
• Combination OCs reduce the quantity of mother’s milk; thus, their use is not appropriate in the first month postpartum in nursing mothers.
• The puerperium is a time of hypercoagu lability. Starting combination OCs immediately postpartum could place new mothers at an unnecessary increased risk of thromboembolism.
• In non-nursing women, the earliest ovulation can occur is 27 days postpartum.
• Many couples resume sexual relations within two to three weeks postpartum.
Given each of these observations, an appropriate time to initiate combination OCs in non-nursing women is on the first Sunday after the infant is 2 weeks old, notes Kaunitz. This avoids starting the OCs immediately postpartum during the period of greatest puerperal hypercoagulability and ensures effective ovulation suppression before any possibility that ovulation has occurred.
At the University Medical Center in Jackson ville, FL, providers have moved routine postpartum visits, including cesarean and postpartum tubal sterilization wound checks, to three weeks postpartum rather than the traditional six-week visit, Kaunitz reports.
At three weeks postpartum, women can arrange to begin OCs, depot medroxyprogesterone acetate injections, Norplant implants, or intrauterine devices before there is any chance they may have conceived, he notes.
Which pill for nausea?
What is your next move when a patient says she has used pills in the past and can’t remember which brand but knows she had problems with nausea?
More than 40% of the CTU Contraception Survey respondents say they prescribe a 20 mcg pill for these patients. Providers pick Alesse, a 100 mcg levonorgestrel/20 mcg ethinyl estradiol OC manufactured by Wyeth-Ayerst Laboratories of Philadelphia, as their first- and second-choice pill in this category. (See charts, p. 104.)
Ortho Tri-Cyclen, a 35-mcg triphasic pill from Ortho-McNeil Pharmaceuticals of Raritan, NJ, fell from first to second place in the first-choice category, while Loestrin, a pill manufactured in both 20 and 30 mcg strengths from Parke-Davis of Morris Plains, NJ, rose to second place in the second-choice category.
"Nausea from OCs is usually related to estrogen dosage," notes Jonathan Weiner, MD, an OB/GYN in private practice in Fresno, CA, commenting on his choice of OC. "Alesse is a low-dose estrogen formulation."
1. Technical Guidance/Competence Working Group and World Health Organization/Family Planning and Population Unit. Family planning methods: New guidance. Population Reports. Series J, No. 44. Baltimore: Johns Hopkins School of Public Health, Population Information Program; October 1996.