Systemic Hormonal Contraception Overview
Combined Oral Contraceptive Pills
Nuva Ring
Ortho Evra
Progesterone-Only Pills
With the development of new delivery systems for systemic hormonal contraceptives, specifically NuvaRing and Ortho Evra (the patch), the emphasis in this section shifts to the similarities, and not the differences, between methods. Much of the advice that applies to combined oral contraceptive pills (COCPs) can be applied to these methods as well. The similarities are presented first, and problems unique to each method are highlighted at the end of the chapter. Other methods that work systemically to prevent ovulation (such as Depo-Provera and Nexplanon) are discussed in separate sections. For the purposes of this book, we focus on OCPs, NuvaRing, and Ortho Evra.
Questions regarding the proper use of OCPs make up a large portion of telephone triage calls to obstetrics and gynecology (OB/GYN) offices and clinics. It is imperative that personnel in such triage roles are familiar with proper pill names and dosages. Many pills have similar names but come in varying dosages. Name confusion can lead to inappropriate prescribing and patient frustration. It should be a point of professional pride to know the names and available doses of the pills prescribed most often in your facility. Triage personnel should use every opportunity to reinforce the correct name when talking to patients because they often are confused about which pill they are taking.
All users of systemic hormonal contraceptives need to be aware of the potential warning signs of serious complications associated with their chosen method. Patients are initially instructed about what to look for but may forget over time. The acronym ACHES is used to remind patients (and providers) what warning signs need attention:
A—Abdominal pain (severe)
C—Chest pain (severe, cough, shortness of breath, or sharp pain on inspiration)
H—Headaches (severe, dizziness, weakness or numbness, especially if one sided)
E—Eye problems (vision loss or blurring)
S—Severe leg pain (calf or thigh)
The primary cause of most major systemic hormonal problems is the hormone component estrogen. Although some labeling information states otherwise, the conventional wisdom is that progesterone-only pills (POPs) do not carry the same risks.
Contraceptives in this category also provide many noncontraceptive benefits, including lighter and easier periods, less anemia, a beneficial effect on acne, less menstrual cramps, and, in some instances, alleviation of premenstrual dysphoric disorder, decreased risk for endometrial and ovarian carcinoma. This is one good reason why systemic hormonal contraceptives are the most popular group of options among contraceptive methods.
Additionally, there is an excellent website, GoodRx (https://www.goodrx.com), where patients are able to price shop to obtain the lowest price for their chose method of contraception. Coupons and significant discounts are available at GoodRx as well.
» BASIC TRIAGE ASSESSMENT FORM FOR SYSTEMIC HORMONAL CONTRACEPTIVES
When was your last menstrual period? ____________________ Was it normal? Yes No
Which method are you using? _________________________________________________________
What regimen (continuous or cyclic) are you using? __________________________________
If taking oral contraceptives, are you using a combined product or a progesterone-only product? _______________________________________ Generic? _____________________________________ Do you know the correct name? _________________________________________________________________ What time of day do you take your pill? ________________ Have you missed any? _________________
If using Ortho Evra, did you change your patch on the usual day? ____________________ Any trouble with adherence? ___________________________________________________________________
If using NuvaRing, is the ring properly in place? ___________________________________ How many days has it been in place? ___________________________________________________________
Are you taking any other medication(s)? Drug name ___________________________________ Dose ___________________________________ Duration of use ______________________________________
Are you taking any supplements? _____________________________________________________
Do you routinely use a backup method of contraception? Yes No
If yes, what method do you use? ____________________________________________________________
Abdominal Pain and Systemic Hormonal Contraceptives
» Key Questions
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» Actions
STEP A: Severe Pain
The patient may have an ectopic pregnancy, acute abdominal problem, or vascular condition; immediate referral to an emergency room (ER) or urgent care center is indicated. The patient or her agent should call 911. The patient should not drive herself.
STEP B: Prolonged Pain
The patient still may have an acute abdominal problem and needs evaluation, but the disease process may be milder. Refer the patient within 24 hours.
STEP C: Nausea, Vomiting, Diarrhea, or Fever
The patient may have gastroenteritis. If she has no other complications, her condition may be managed at home (see Patient Education).
Referral of the patient to a physician or ER is appropriate when evolving appendicitis is possible; instruct the patient to call back if she experiences:
increasing fever,
pain localized in the right lower quadrant, or
symptoms not improving during a period of 12 to 24 hours.
Other disease conditions are present (cardiovascular, pregnancy, diabetes, cancer, HIV).
Signs of significant dehydration are evident:
The patient is unable to keep down any fluids (not even sips of water).
The patient has not voided in the past 8 hours.
The patient reports dizziness.
» Patient Education
All patients need to be taught the serious warning signs associated with oral contraceptive use (see Systemic Hormonal Contraception Overview at the beginning of this chapter).
The patient with symptoms of gastroenteritis should be instructed to modify her diet for the next 24 to 48 hours.
Avoid milk and milk products.
Slowly rehydrate with sips of water (two sips of water every 5 to 10 minutes).
Begin the BRAT (bananas, rice, applesauce, toast) diet after tolerating clear liquids.
Remember that diarrhea may persist for several days after nausea and vomiting subside.
The patient should be instructed to call back if:
her symptoms do not begin to resolve within 1 to 2 days,
her symptoms increase in intensity (more vomiting/nausea), or
she begins to run a fever.
If you suspect the gastrointestinal (GI) complaints are only related to her contraception, refer to protocol on Gastrointestinal Complaints: Nausea/Vomiting and Systemic Hormonal Contraceptives, page 501.
Acne and Systemic Hormonal Contraceptives
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STEP A: Recent Skin Care Changes
This patient may have come into contact with an allergenic agent and could be experiencing dermatitis.
Instruct the patient to stop using the offending agent. If there is no improvement in 7 days, the patient should call back for an appointment.
For severe reaction, the patient should see her care provider within 24 to 48 hours.
STEP B: Change in Facial or Body Hair
This patient may be experiencing androgen excess, which may be caused by hormone use.
Have the patient discuss her symptoms with the prescribing provider.
STEP C: Skin Lesions
This lesion may indicate skin cancer or another skin problem. Refer the patient to her primary care provider or a dermatologist for an appointment within the next 7 days.
STEP D: Associated Symptoms
This may be rosacea, an acneform disorder in older adults characterized by vascular dilatation of the central face.
Rosacea is common in women older than 30 years.
Rosacea is more common in fair-complected women of Northern European descent.
Rosacea is associated with a “rosy cheek” appearance.
Rosacea commonly requires topical antibiotic treatment.
Refer the patient to a dermatologist or her primary care provider for an appointment within the next 2 to 4 weeks.
STEP E: Papules or Pustules (Pimples)
This could be acne, a common skin condition, which may improve or worsen with hormonal use.
Follow the treatment suggestions in Patient Education.
If the patient experiences no improvement after 4 to 6 weeks of therapy, she should see her primary care provider.
» Patient Education
Oral contraceptives may be prescribed to improve acne.
It may take several months to see a significant improvement.
Many oral contraceptives, not just those products with U.S. Food and Drug Administration (FDA) labeling that allows them to be marketed as such, are excellent for improving skin breakouts.
Patients should be instructed in proper skin care for mild-to-moderate acne.
Wash affected areas twice a day with a washcloth and noncreamy soap.
Consider using facial cleansers such as Cetaphil lotion or benzoyl peroxide wash 10%.
Avoid picking at lesions.
Avoid oil-based cosmetics/face creams.
Avoid moisturizers, such as Vaseline, or baby oil.
For dryness, Moisturel or Nutraderm may be helpful.
Amenorrhea and Systemic Hormonal Contraceptives
» Key Questions
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STEP A: Amenorrhea
Be sure to ask the patient if she is using her method continuously, as amenorrhea is the desired effect with continuous dosing. Amenorrhea may also occur in some women who use the method cyclically. Reassure the patient that the amenorrhea can be normal. (Continuous use of Ortho Evra is not recommended.)
If the patient has missed two cycles, have her perform a home pregnancy test. If the result is positive, instruct the patient to see an OB/GYN provider within the next 2 to 3 weeks. If the test result is negative, reassure the patient. If she is unsettled by this side effect, she may need to select an alternative form of contraception.
STEP B: Method Started Within the Past 3 Months
Determine whether the patient is using her method continuously and reassure her that amenorrhea is expected with that dosing schedule.
Menstrual patterns can be very erratic during the first 3 months of systemic hormonal contraceptive use. However, it is unusual for a woman to experience amenorrhea during this time with cyclic dosing. A major concern is pregnancy. If the result of a home pregnancy test is negative, review the information in Step A with the patient.
STEP C: Progesterone-Only Pills
POPs typically cause irregular spotting/bleeding. However, after several months of POP therapy, it is not uncommon for periods to stop completely. This is a desired effect for some women.
Have the patient take a home pregnancy test and follow the instructions in Step A.
STEP D: Missed Pills, Delayed Patch Change, or “Misplaced” or Delayed Ring
Patients who have made errors in using their method need to rule out the possibility of pregnancy. If a patient has made an error within the last 5 days, review the need for emergency contraception.
Have her do a sensitive home pregnancy test and follow the suggestions in Step A.
STEP E: New Medication
Have the patient do a home pregnancy test. If the results are positive, have the patient notify her OB/GYN provider because a medication change may be in order.
If the results are negative and the medication is for long-term use, encourage the patient to discuss possible interactions with her contraceptive method with her OB/GYN provider.
» Patient Education
All patients need to be educated about the expected side effects of their chosen method.
All patients need to know a backup method and use of emergency contraception in the event a method error occurs or other problems alter the efficacy of their method.
Breakthrough Bleeding/Spotting and Systemic Hormonal Contraceptives
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STEP A: Spotting While Taking Progesterone-Only Pills
Spotting is a completely normal side effect of taking POPs and may continue for many months or even years. If the patient finds this is undesirable, she should see her provider to discuss other contraceptive options. See Patient Education.
STEP B: Spotting or Breakthrough Bleeding in the First 3 Months of Systemic Hormonal Contraceptive Use
Spotting or breakthrough bleeding is common during the first few months of systemic hormonal contraceptive use regardless of the delivery system used. Reassure the patient that this is common and she is better off continuing with the method for at least 4 months before considering another method unless she is very bothered by the bleeding. Investigate other potential causes for spotting or breakthrough bleeding by continuing to Question 6.
STEP C: Missed Oral Contraceptive Pills, Patch Adherence Problems, or Delayed Patch or Ring Use
Basically, any action that disrupts the dose of systemic hormonal contraceptives can be a cause of spotting and breakthrough bleeding. Disruptions of deliverance of hormones will vary with the chosen method.
Missed oral contraceptives pills are a common cause of unexpected bleeding during their use. See Problems Unique to Combined Oral Contraceptive Pills and Problems Unique to Progesterone-Only Oral Contraceptive Pills (POPs) for management options.
Problems with patch adherence or a delay in changing patches can cause breakthrough bleeding with Ortho Evra use. See Problems Unique to Ortho Evra (the Patch) for detailed information.
Failing to insert the NuvaRing on time or leaving it out for more than 3 hours within an appropriate cycle can commonly cause spotting or breakthrough bleeding with this method. Refer to Problems Unique to NuvaRing for management options.
STEP D: Sexually Active and Not Using a Backup Contraceptive Method
A patient who is not using a backup method, such as a condom, may be at risk for sexually transmitted infections (STIs). The risk of STI exposure should be determined. Ideally, the patient should come in for evaluation within 3 to 5 days or sooner if other acute symptoms coexist. The patient should abstain from intercourse until evaluated and should be encouraged to use condoms in the future.
STEP E: Other Possible Causes of Spotting and Breakthrough Bleeding
Most women adjust to a chosen method of systemic hormonal contraceptives within a few months. If unexplained bleeding occurs after several months of use, and the cause is not found by answering the questions earlier, other possible causes should be explored. Question her as to other medication use that may interfere with systemic hormones. If she is taking COCPs, GI disruption may interfere.
A “one-time” episode of abnormal uterine bleeding may only warrant reassurance after investigation of the issues raised earlier. However, persistent problems require a physical evaluation within 1 to 2 weeks. The patient may be experiencing complications due to a cervical polyp or even an undiagnosed pregnancy.
Her complaints should not be dismissed.
» Patient Education
Patients using POPs need to know that bleeding and spotting are common. Some patients, despite perfect use, still experience this annoying side effect.
All patients, regardless of method, need to know how to use a backup method, such as condoms. Those at particular risk for STIs need to be especially careful.
All patients using systemic hormonal contraceptives need to know they can become pregnant, even with perfect use.
Breakthrough Bleeding/Spotting and Continuous Dosing With Systemic Hormonal Contraceptives
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STEP A: Bleeding Problems With Monophasic Oral Contraceptives Used Continuously
First, determine whether the patient is taking combined monophasic oral contraceptives or progesterone-only oral contraceptives. Progesterone-only oral contraceptives are designed to only be taken continuously and are “less forgiving” if pills are missed or skipped; for example, missing 3 hours with a POP may be similar to missing a day with a COCP. Counsel the patient on proper use and have her continue to take them continuously.
If the patient has been taking her monophasic COCPs correctly and has not skipped any pills, find out how long she has been taking them continuously. Sometimes, a bleeding pattern will develop over time that is unique to each woman; that is, some women may be able to take COCPs continuously for only 6 weeks before they have a tendency to bleed, and some may be able to take them for 12 weeks or longer without a tendency to bleed. Help her determine whether a pattern is developing that will guide her in the future.
If she has been spotting for 7 consecutive days or bleeding heavily for 3 days, have her stop and have a withdrawal bleed. She should restart her pills continuously in 3 to 4 days. Under no circumstances should she extend the pill-free interval longer than 7 days because this is likely to induce ovulation. Please refer to Patient Education.
STEP B: Bleeding Problems With Triphasic Oral Contraceptives Used Continuously
Triphasic oral contraceptives may be likely to cause spotting or breakthrough bleeding if taken continuously. The dosage varies as the color or shape of the active pills changes. The original intent of this dosing regimen was to “mimic a natural cycle” as hormone levels fluctuate in a “normal” cycle of ovulation and menstruation. If a patient is trying to take her triphasic pills continuously and experiences spotting for 7 consecutive days or heavy bleeding (one pad in 30 minutes or one tampon in 23 to 30 minutes) for 3 days, have her stop and have a withdrawal bleed. She should decide whether to continue using her triphasic preparation, in which case she may be better served by having a monthly cycle. Or, she may consider a monophasic pill, which she may be able to use more successfully. In any situation, she should restart a method within 3 to 4 days. Under no circumstance should she extend the pill-free interval longer than 7 days because this is likely to induce ovulation. Please refer to Patient Education.
STEP C: Bleeding Problems With NuvaRing Used Continuously
While each NuvaRing may be appropriate for 4 weeks of continuous use, some women may notice spotting as the end of that interval approaches. In such cases, the patient may be best advised to consistently plan on changing her ring before the end of the 4-week interval. If she experiences spotting for 7 consecutive days or heavy bleeding for 3 days, she should remove her ring and restart with a new ring in 3 to 4 days. Under no circumstances should she extend her ring-free interval longer than 7 days because this is likely to induce ovulation. Please refer to Patient Education.
STEP D: Bleeding Problems With Ortho Evra Used Continuously
It is not recommended that this method be used continuously. Please see the Continuous-Dose Systemic Hormonal Contraceptives protocol for the rationale.
» Patient Education
Breakthrough bleeding and spotting are common problems with continuous use of systemic hormonal contraceptives, regardless of the delivery system used. All women who choose this method should be counseled at the time of method selection as to how to deal with the problem.
Most women will develop a pattern to their bleeding that may guide them in choosing an appropriate time for a withdrawal bleed.
Many experts advise women to never extend the method-free interval even as long as 7 days, as is common in a 21/7 regimen. The thought is that the longer a method is used in a continuous fashion, the greater the tendency to ovulate spontaneously given the opportunity.
A 3- to 4-day method-free interval is usually enough to cause a significant withdrawal bleed and, as stated earlier, should never be extended beyond 7 days.
It can be helpful if patients retain any “day labeling” material provided with their method. This can be used to relabel packages when the method is restarted.
Breast Pain and Systemic Hormonal Contraceptives
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» Actions
STEP A: Bilateral Breast Pain
Both estrogen and progesterone have been implicated in breast pain associated with hormone use. This pain is usually bilateral.
Initiate Basic Triage Assessment Form for Breast Complaints found in Chapter 15.
Question the patient about her consumption of caffeine and foods that contain the amino acid tyrosine (bananas, nuts, red wine, and yellow cheese).
Ask the patient if she has experienced a change in bra size.
Go to Step C.
STEP B: Unilateral Breast Pain
Unilateral breast pain is rarely caused by hormone use. Other causes need to be investigated, such as breast cysts, fibroadenomas, costochondritis, breast cancer, and cardiac issues.
Ask the patient whether or not she has felt a lump.
Ask the patient where she is in her menstrual cycle.
If the patient is older than 35 years, have her come in within 24 to 48 hours for a physical evaluation. Prepare the patient that she may need a mammogram and/or ultrasound.
For younger patients, particularly those taking triphasic pills, the patient may wait for an examination until her hormone-free week. This should be the patient’s choice.
STEP C: Recent Pill Start
Reassure the patient that hormones can cause breast tenderness during the first few months of use.
Recommend a good supportive bra.
Recommend the patient avoid activities that cause aggravation of symptoms (e.g., the patient should walk rather than jog).
Recommend the patient initiate diet changes, such as decreased caffeine and tyrosine consumption.
If the symptoms are intolerable, refer the patient to a provider for other recommendations or a change in her method.
STEP D: Possible Pregnancy
All patients who are sexually active with male partners, even those who do not miss a pill, are at risk for pregnancy.
Ask the patient if she has missed any pills (see protocol Late or Missed Combined Oral Contraceptive Pills on page 513) or if she has been late changing her patch or inserting NuvaRing.
Question the patient as to the normalcy of last menstrual period or absence of withdrawal bleeding.
Encourage the patient to perform a urine pregnancy test or have the patient come in for a blood pregnancy test.
» Patient Education
One of the keys to successful use of systemic hormonal contraception is understanding the expected problems and usual course of action. Educating the patient regarding the possible nature of her pain, particularly in the case of recent method initiation with bilateral pain, may help the patient tolerate the symptoms until her body adjusts to the pill’s hormone dose.
Particular sensitivity is needed for patients with unilateral pain who may be at risk for breast problems of a more serious nature. Refer to the Chapter 15: Breast Complaints Overview for some approaches in dealing with women with additional concerns.
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