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A new mother is breast-feeding. An older woman is a light smoker. What oral contraceptive (OC) options are available to them, if any?
Contraceptive Technology Update readers offered their viewpoints on these distinct patient populations, as well as other OC issues, in their responses to the 2001 Contraception Survey.
When it comes to older women who smoke, the majority of CTU survey respondents continue to hold the line against providing OC prescriptions. About 72% of those responding to the 2001 poll say they would not give pills to women ages 35-39 who smoke 10 cigarettes a day, a finding consistent with the 2000 survey results. And for women ages 40 or older, almost 90% say they would refuse OCs. (See chart on OC prescription practices for smokers, below.)
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
"I don’t feel comfortable with the increase in cardiovascular and cerebral vascular risks in smokers over age 35 on OCs," says Ruth Shaber, MD, women’s health leader at Kaiser Permanente Northern California in Oakland. "I encourage women who smoke more than five cigarettes per day to consider progestin-only contraceptives or an intrauterine device; however, I don’t see any contraindications for smokers over age 35 to use emergency contraception."
Jeffrey Maurus, MD, medical director of the Rock Island (IL) County Health Department says he very recently changed his opinion on the subject. For those women who smoke fewer than 15 cigarettes a day and have no other risk factors, he is willing to use combined OCs. He says he usually uses 20-mcg OCs in all women older than 34 years of age.
Research should be initiated on the use of low-dose OCs in women who smoke, says David Archer, MD, professor of obstetrics and gynecology and director of the Clinical Research Center at the Eastern Virginia Medical School in Norfolk.
"I believe that the risk-benefit ratio using pregnancy as a risk is in favor of the OCs in this group of women," observes Archer. "Pregnancy-related side effects are high in older women."
Moms need options
For new mothers who are not breast-feeding, about 40% of CTU survey respondents say they would prescribe OCs four to six weeks postpartum. About 30% say they would initiate OCs one to six weeks postpartum, with about 17% providing pills upon hospital discharge. About 8% would start pills at first menses, with about 5% using other approaches. These views are consistent with those reported in the 2000 survey. (See chart on pill practices for new mothers, below.)
For new mothers who choose to breast-feed, 38% say they would begin progestin-only pills (POPs) at four to six weeks postpartum, with about 33% beginning POPs at one to three weeks postpartum. About 23% would initiate POP use at hospital discharge, with 1.2% starting mini pills at first menses. About 5% said they would use other approaches. (See chart on pill practices for new mothers, p. 105.) The number of providers initiating POPs at four to six weeks postpartum dropped from the 2000 survey results, with a subsequent increase in those who would begin mini pills at one to three weeks postpartum.
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
Put it in writing
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? More than 75% (78.4%) of CTU survey respondents say they include such information, a significant rise from the 58.3% who indicated such practice in the 2000 poll.
The University of Texas Medical Branch’s New Caney Clinic uses such written instructions for its patients, says Ann Jacob, CNM, clinic director. Such information has proven helpful for patients, practitioners report. (See patient education handout on OCs enclosed in this issue.)
Patricia Carrick, FNP-C, a family nurse practitioner at Beaverhead Family Planning Clinic in Dillon, MT, says, "We try to offer information using a variety of approaches: written handouts, verbal counseling, initial video instruction. We encourage patients to share written materials with others if they can’t keep them at home [due to their living arrangement]."
1. World Health Organization. Improving access to quality care in family planning: Medical eligibility criteria for contraceptive use. Geneva: WHO; 1996.