Providing pills: Readers speak out

When it comes to oral contraceptives (OCs), when should pills be prescribed, and when should they be withheld?

Respondents to the 2004 Contraceptive Technology Update Contraception Survey take a cautious approach when it comes to providing pills for older women who smoke. Almost three-quarters (72%) say they will not give pills to smokers ages 35-39, and 86% say they refuse pills to those age 40 and older.

While oral contraceptives represent a safe, effective choice of birth control for many women, smoking raises the risk of cardiovascular complications, particular among women age 35 and older. Results from a 2003 study, which compared women who used higher-dose OCs vs. those who relied on nonhormonal contraception, indicated a moderate increase in the risk of death from ischemic heart disease in smokers who used the Pill compared with nonsmoking pill users.1 In comparison with nonsmokers, researchers found an increase in death from all causes of about 25% for light smokers and more than a doubling of death risk from all causes for those who smoked more than 15 cigarettes a day.

When combined pills can be safely used, do you consider their noncontraceptive benefits? Use of combined OCs lead to reduced risk of ovarian cancer and endometrial cancer.2 About 34% of 2004 CTU survey respondents indicate they or clinicians in their facility have recommended pills to a woman specifically to decrease risk of cancer of the ovary.

When it comes to counseling on use of combined OCs for a new mother who chooses not to breast-feed, what is your approach? About 41% of 2004 CTU survey respondents say they prescribe OCs four to six weeks postpartum, a slight increase from 2003’s 39% level. About 30% say they initiate OCs one to three weeks postpartum, with about 12% providing pills upon hospital discharge. About 10% start pills at first menses, with about 3% using other approaches.

For new breast-feeding mothers, about 39% of survey respondents say they choose to initiate progestin-only pills four to six weeks postpartum, with 29% starting such pills at one to three weeks postpartum. Progestin-only pills represent a good option for breast-feeding women who prefer oral contraception, because the progestin does not reduce milk production.3

Which OC for nausea?

Which pill would you prescribe if a patient says she wants to use OCs, yet experienced nausea the last time she used the Pill? Respondents to the 2004 CTU Contraception Survey say they would prescribe Alesse, a monophasic 20-mcg pill from Wyeth-Ayerst Laboratories, Philadelphia.

"The lower estrogen seems to be better tolerated in teens and never pregnant women than previous pills," reports Carolyn Brown, RNP, nurse practitioner at Pinal County Health Department, a public health facility in Florence, AZ.

About 44% named the pill as their first choice in this category; 54% listed Alesse as the leading candidate in the 2003 survey. About 12% said they would use Ortho Tri-Cyclen Lo (Ortho-McNeil Pharmaceutical, Raritan, NJ), while 11.5% listed Mircette (Organon, West Orange, NJ).

If women have experienced nausea with pills, suggest they take their pills at their evening meal or at bedtime to allow them to sleep through high serum levels of hormones.2 Remind women to take pills consistently; missed pills can increase the incidence of nausea and vomiting.4

Pills over the counter?

Should oral contraceptives be made available over the counter (OTC)? Most CTU survey respondents continue to say "no" to OTC status for the Pill; About 63% say that pills should remain prescription-only, while 31% affirm support for the move. About 6% did not make a selection in the matter. The responses reflect a slight change from 2003’s figures, where about 69% said "no" to an OTC switch.

"Although I seem to be in the minority regarding OTC use of OC, my reasons are these: Unwanted pregnancies are our priority; the easiest access to these methods seems to be the most logical solution to this problem; anyone who can read can follow a manufacturer insert for use," says Judy Nicksich, women’s health care nurse practitioner at Western Wyoming Family Planning, a not-for-profit family planning agency in Rock Springs, WY.

"I agree that sexually transmitted diseases and pelvic exams are a must, but not at the expense of creating a pregnancy that is unwanted," she says.

References

1. Vessey M, Painter R, Yeates D. Mortality in relation to oral contraceptive use and cigarette smoking. Lancet 2003; 362:185-191.

2. Hatcher RA, Zieman M, Cwiak C, et al. A Pocket Guide to Managing Contraception. Tiger, GA: Bridging the Gap Foundation, 2004.

3. Blackburn RD, Cunkelman JA, Zlidar VM. Oral contraceptives — an update. Population Reports. Baltimore: Johns Hopkins University, School of Public Health, Population Information Program; 2000.

4. Zlidar VM. Helping women use the pill. Population Reports. Baltimore: Johns Hopkins University, School of Public Health, Population Information Program; 2000.