How to use OCs? Readers share pill strategies

As you check the chart of a new patient, you note that she has previously experienced nausea on birth control pills, but can’t remember the brand name of her prescribed oral contraceptive (OC). She would like to re-establish pill use. Which OC will you suggest?

Almost half (44%) of 2005 Contraceptive Technology Update Contraception Survey participants pick Alesse, a monophasic 20-mcg pill from Wyeth Pharmaceuticals, Collegeville, PA, as their top pill choice for women who have experienced nausea on previous OCs.

Alesse continues to lead all choices in this survey category; it has held the top spot since 1999. Other ranking selections in the 2005 survey include Ortho Tri-Cyclen Lo (13.61%, Ortho-McNeil Pharmaceutical, Raritan, NJ), Loestrin (9.95%, Organon, West Orange, NJ), and Yasmin (5.76%, Berlex Laboratories, Montville, NJ).

Why Alesse?

"I like the levonorgestrel pills in conjunction with 20 mcg of estrogen to minimize the estrogen effect related to nausea," says Martha Kleinerman, RNC, MS, health services director at the Planned Parenthood League of Massachusetts in Boston.

Take the time to discuss the hormonal components of different oral contraceptives, as women need a better understanding of what is inside their birth control pills, contraceptive experts say. According to a 2005 survey of 400 women who have used the Pill, 65% said they have switched two or more times between different types of birth control pills, with just more than one-third switching because of side effects.1

Which contraceptive pills come to mind when it comes to women older than age 40? Most (41%) participants in the 2005 survey look to Alesse; other top 2005 choices include Loestrin (11.52%), a monophasic 20 mcg pill from Pfizer of New York City, Ortho Tri-Cyclen Lo (10.99%), Mircette (7.85%), and Yasmin (6.81%).

Smoking can impact clinical decisions on whether older women can safely use combined oral contraceptives. Three-quarters of 2005 survey participants say they will not write prescriptions for women ages 35-39 who smoke 10 cigarettes a day, with numbers rising to almost 91% for women ages 40 and older who smoke.

Such thinking falls in line with the latest medical eligibility criteria from the Geneva-based World Health Organization (WHO). According to the WHO guidance, women aged 35 and older who smoke fewer than 15 cigarettes a day are ranked at 3, where "use of the method not usually recommended unless other, more appropriate methods are not available or acceptable," while women in the same age category who smoke 15 or more cigarettes a day are ranked at 4, where the "method [is] not to be used."2

What options do you discuss with these women?

"Due to risk of cardiovascular problems, smokers ages 35 and older are not prescribed combined oral contraceptives in our clinic," says Julia McAndrew, NP, a nurse practitioner at the Cattaraugus County Health Department Family Planning Clinic in Olean, NY. "We discuss progestin-only pills, Depo-Provera, intrauterine devices, diaphragms, condoms, and natural family planning as options."

What about new moms?

When it comes to initiating combined OC use in postpartum women who are not breast-feeding, about 40% of 2005 survey participants say they will begin pill use four to six weeks after delivery. About 28% say they start pills one to three weeks postpartum, while about 15% begin OC use upon hospital discharge.

For breast-feeding women who wish to use progestin-only pills, about 38% indicate they will initiate pill use four to six weeks postpartum, while about 27% say they begin pill use one to three weeks following delivery. About 21% state they start minipills upon hospital discharge.

While oral contraceptives provide reliable birth control, they also offer noncontraceptive benefits; use of combined OCs can lead to reduced risk of ovarian cancer and endometrial cancer.3

Josefina Tan-Domingo, MD, a physician at Lewis County General Hospital in Lowville, NY, estimates she has written 10 Pill prescriptions in the past year specifically to decrease the risk for ovarian cancer.

"Patients are accepting of this approach," says Tan-Domingo. "Many respond they have never heard of this use of OCs."

When it comes to increasing access to contraception, most 2005 CTU survey participants draw the line when it comes to moving oral contraceptives from their prescription-only status. About 72% say they are not in favor of such a move, up from 2004’s 63% level.

If OCs were moved to over-the-counter status, they might be taken by smokers older than age 35, or women with uncontrolled hypertension or previous clots, says Debbie Cline, RN, OGNP/FNP, a nurse practitioner at the Roanoke City (VA) Health Department.

"If OCs were over the counter, women would need to watch a visual and have a simple written how-to-do’ sheet," comments Lynn Fair, RNC, WHNP, a nurse practitioner at the Columbia/ Boone Health Department in Columbia, MO. "Could a pharmacy offer this? I think it is possible, but they would need how-to-do’ education."

References

  1. Berlex Laboratories. Knowing More about "What’s Inside" Birth Control Pills May Help Increase Compliance. Press release. June 1, 2005. Accessed at: www.berlex.com/html/press/articles/06012005.html.
  2. World Health Organization. Medical Eligibility Criteria for Contraceptive Use. 3rd edition. Geneva; 2004.
  3. Hatcher RA, Zieman M, Cwiak C, et al. A Pocket Guide to Managing Contraception. Tiger, GA: Bridging the Gap Foundation; 2004.