Starting Oral Contraceptive

Most common s/e BTB

- Break through bleeding (BTB) most common reason women discontinuing OCs - Most common w/ low dose COCs and POPs - Bleeding < 10th pill = insufficient estrogen activity - Bleeding > 10th pill = insufficient progestin dose - More common in overweight women & smokers - More common in extended use cycles - Will occur if pt misses pills or does not take same time

Special Situations: Postpartum/ Not breastfeeding

- COCs can be started after 6th week pp - starting hormonal method before may increase chance of thromboembolism - pt cn use condoms and lubrication during first 3 wks pp or obstain - Mother should determine when resume sex NO ONE else

Special Situations - Acne

- COCs w/ low androgenic -to-progestin activity ratios & those w/ moderate-to-high estrogen contents will most likely help - still imp. to follow acne care directions - Pt on Accutane will have you sign a form indicating the usage of two forms of birth control - Good types to use: Yasmin, Cyclessa, Ortho Tri-Cyclen etc

Special Situations - Obesity

- Consultation w/ OB/GYN - Dep Provera inj can cause weight gain - Copper or Mirena IUD - May be a higher failure w/ some hormonal methods d/t absorption & dosing issues.

Basic Guidelines

- Don't use a med strength stronger than 1/35 (progestin/estrogen); 1/50 pills are reserved for ovarian suppression monitored by specialist - pt w/ family hx of clotting disorders get testing first (factor V Leiden) - Pt w/ fam hx of CVD < age 50 eval by specialist first - pt w/ heavy bleeding should get platelet fx test to r/o bleeding disorders before OCP start.

BTBs cont'd

- Eliminate possible prego (do UCG or serum HCG) - If bleeding starts after day 14: user higher progestational activity OC - If the pt is not a good historian as to when BTB occurs: higher androgenic activity can be used - If bleeding starts before day 14 or if menses continues into active pill cycle: switch to higher estrogen OC - The use of menstrual record cards (MRCs) can be very helpful to monitor BTB

First 3-6 mos

- Expect breakthrough bleeding - Adjustment to daily regimen: pills should be taken same time qd. Pt can set their phones to remind - Evening dosing can prevent some s/e from occurring during the day (nausea & fatigue)

Routine Assessment of Initial Pill Starts

- Have pt return in 3 mos for BP check & assess of SEs & ACHES. If ok, proceed another 6 mos Rx. Do not give more than 6 mos of OCPs, reassess. - Take time at annual exams to ask SEs & ACHES & explore new meds since last visit. Re-assess risk levels for OCs. - Encourage pill users to take multivit & cal daily b/c OCs decrease levels of B vit & minerals.

Special Situations - Pre-existing HTN

- If they have pre-existing HTN, even if it is controlled w/ meds, they are at risk. Let OB-GYN make call & then can follow plan after ok. - COCs increase angiotensin II and may cause fluid retention. Some pts may do fine on POPs, but let specialist make that call. - Consider other forms of non-hormonal birth control: Copper IUD (Paragard) or barrier method.

Special Situations - Smokers

- No COCs ages >35: POPs only or non-hormonal method such as copper IUD. If you are feeling unsure, get consult. - Under 35: Proceed w/ caution - use low dose pills or POPs. Consider all factors in pt's hx. - Remember teach - quit smoking at all times.

Types of pills

1. Combination Oral Contraceptives (COCs) 2. Progestin-only pills (POPs) 3. Tri-phasic pills are COCs have diff doses for each of 3 wks plus placebo wk. 4. Extended cycle pills are COCs that provide menses once q3-12mos. Seasonique or Seasonique Lo or you can use COCs (not tri-phasics) or POPs and drop placebo pills to mimic this regimen. Continuous cycling for a year: Lybrel

Special Situations - Migraines

- Previous hx of premenstrual migraines: consider continuous regimens - drop placebos & start new pack; usu drop in estrogen precipitates premenstrual migraines - Do not continue pills in pt w/ NEW ONSET or WORSENING h/a or migraines - Do not start OCPs in women w/ any type of migraine w/ aura

Special Situations: Depression

- Proceed w/ caution - Here are a few things to consider ~ continuous cycling (no placebo pills) may be helpful ~ Avoid Depo Prover injection - once its injected it can't be removed. Try POPs in oral form first to see how tolerated ~ Yaz is indicated for PMDD ~ Use low dose COCs & re-eval in 3 mos or sooner

How to start first pack of OCPs

- Sunday start: start pills on first Sunday after menses starts - Menses start: start pills first day of menses -Both methods common - quick start: start pills day of office visit regardless of point in cycle.

Special situations - Teens

- You need to know your pt - Teaching imp: same time qd, what to do if forget; common SE 1st 3 mos. Written reinforcement w/ pt. - Do parents know teen using contraception: If teen hiding pills likely to forget - suggest another method - Emphasize pills & condoms go together. Reinforce safe sex practices.

Special Situations - Breastfeeding

- use POPs not COCs (estrogen decreases milk supply) - Some practitioners institute POPs, Depo Prevera or IUD before 6 wks postpartum if pt high risk another prego. - Consider switching mothers to COCs once breastfeeding done, b/c decrease chance of failutre.

The First pill pack:

- use of a backup method of birth control (condoms) recommended first 7 days - expect breakthrough bleeding for 1st several cycles. -Most common s/e nausea & fatique

Menstrual Types

1. Light flow/mild cramps- OCP w/ low endometrial activity 2. Moderate flow/avg cramps- medium endometrial activity especially starting out 3. Heavy flow & sever cramps- high endometrial activity 4. Irregular menses + PCOS or insulin resistance- high progestin, low androgen 5. Irregular menses other than above - low estrogen/progestin

OCPs: Aches and Warning signs

A: Abdominal pain (thrombosis) C: Chest Pain (PE or MI) H: Headache (stroke) E: Eye problems (thrombosis) S: Severe leg pain (thrombosis)

Progesterone Deficient Women

Symptoms include: - Prolonged menses - Heavy menses - Severe cramping - Premenstrual breakthru bleeding or spotting - Premenstrual S/S Similar to women w/ anovulatory cycles, corpus luteum insufficiency, endometriosis and adenomyosis. Choose a COC w/ increased progestational and/or androgenic activities such as: Loestrin, Seasonal, Seasonique, LoOvral, Levlen, Necon 1/35.

Estrogen Sensitive Women

Symptoms: - Nausea or edema midcycle -Enlarged uterus -Uterine fibroids - Large or painful breasts - Fibrocystic breasts -Heavy menstruation - Severe cramps with menses Choose OC w/ low estrogen activity: progestin-only pills or those w/ 20 mcg ethinyl estradiol (EE)

Estrogen Deficient Women

Symptoms: - Scant menses - small uterus - small breasts - midcycle spotting Choose combo oral contraceptive (COC) w/ 20-25 mcg EE

Progesterone Sensitive Women

Symptoms: - premenstrual s/s: edema, abdominal bloating, headache, depression - or if they had these s/s during pregnancy: excessive appetite, weight gain or tiredness; htn; varicose veins Choose low progestational OCs or a tri-phasic pill: Progestin-only pills (POPs), Alesse, or Yasmin/Yaz