How to Choose Which Oral Contraceptive Pill for New Nurse Practitioners

Jul 13

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Show notes:

When it comes to choosing which oral contraceptive pill to prescribe, there are SO many options. How do you know which one is the right one? As a new nurse practitioner, you’ll usually get different recommendations from different providers.

Choosing a Contraceptive Pill

In this video I’ll be covering:

The first step to prescribing that’s easy to forget
What criteria to consider when choosing
The two main routes to follow (and how to know which one to go down)

Resources mentioned in this episode:

If you liked this post, also check out:

WEBVTT
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Hey there, welcome to the Real World NP podcast.
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I'm Liz Rohr, family nurse practitioner, educator, and founder of Real World NP, an educational
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company for nurse practitioners in primary care.
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I'm on a mission to equip and guide new nurse practitioners so that they can feel
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confident, capable, and take the best care of their patients.
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If you're looking for clinical pearls and practice tips without the fluff, you're in
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the right place.
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Make sure you subscribe and leave a review so you won't miss an episode.
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Plus, you'll find links to all the episodes with extra goodies over at realworldnp.com
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slash podcast.
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Well, hey there, it's Liz Rohr from Real World NP and you're watching NP practice
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videos to help save you time, frustration, and help you learn faster so you can take
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the best care of your patients.
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So today I'm going to be talking about combined oral contraceptives, birth control pills,
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and how to choose one and the things you definitely don't want to forget about.
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So as a new nurse practitioner, I saw this in myself and I also see this in the mentees
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that I work with in my community.
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There's a really strong temptation when we leave school or we're early on in practice
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to jump right into the medications and the algorithms and kind of skip over some of the
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important stuff just because it's a lot, right?
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And so the first thing I want you to think about, even though you know this, when you're
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in the middle of practice, it can be easy to forget that there are some safety things
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that you want to think about first.
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And so is this even appropriate for your patients?
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So a lot of times patients will come in and they'll ask, you know, I just want
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to be on birth control, right?
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And it's very easy to say, oh, sure, here you go, but that's like our job,
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right?
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That's like your new role.
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So that's our role as providers to make that assessment and make those clinical judgments.
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So the really excellent resource is the CDC's U.S. medical eligibility criteria,
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which I have linked down below this video.
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This is not a comprehensive list.
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That list is, but what I'm going to share with you are the most common ones.
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But for the full list, I definitely encourage you to check out that PDF.
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There's also a couple of different apps, too, that you can search for this.
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So basically, you just want to assess what are the underlying conditions?
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What are the reasons they shouldn't have it or they couldn't have it because it would be
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unsafe? So the first ones are smoking, high blood pressure, history of a DVT,
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a clotting disorder, cardiovascular disease, migraines with aura.
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Like those are the most common ones that I see.
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And then some medications to keep in mind are phenytoin, phenobarbital and
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rifampin. Not very common medications, but those can definitely decrease the
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effectiveness. One other really important one to think about is that most of the
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research has been done on patients who are under a BMI of 30.
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So patients who have BMI's of 30 and above may have a decreased effectiveness
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of the oral contraceptives. And so that's always a discussion that you want
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to have with your patient about the potential risk there for decreased
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effectiveness and considering the other options which might be safer for them.
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So again, that's not a comprehensive list.
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So definitely go check out that document down below this video.
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The next thing to think about after safety are what are the reasons?
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So did somebody walk in and just say, I want the pill or are there certain
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things that they're struggling with? So do they have headaches that are hormonal?
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Do they have PMDD or severe PMS? Do they have dysmenorrhea?
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Things like that. That may lead you to consider the longer kind
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of duration ones. They're all pills that are once a day,
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but those three month ones, the seasonal ones instead of the monthly ones.
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So do they want a monthly menses or do they want a less frequent one?
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So that's something to think about it, depending on their underlying
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conditions. And then that kind of brings me into the choices.
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So there's a lot of choices as you have probably seen.
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There's a couple of ways to go about it.
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So one, just to point out, is that there are multi-phasic and then
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there are single phase. So one dose versus multiple doses.
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So for the whole month, you have one dose of estrogen and progesterone,
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which are the two medications in there, versus one dose for one week,
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another dose for a second week, another dose for a third week,
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and then the fourth week is that placebo week.
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For the most part, there isn't really necessarily a reason slash difference
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to choose the multi-phasic one compared to the single dose one.
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So typically speaking, most patients will be on the single phase one.
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The next thing to think about, because that's just more comfortable
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for patient ease. Anecdotally, you might have some people feeling
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like the tri-phasic ones, the multi-phasic ones are more effective
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for certain reasons, but I think the evidence doesn't necessarily point
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to one more than the other. And then the other two things to think about
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are the estrogen and the progesterone. So those are the two components.
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So estrogen is the estradiol, and that comes in multiple doses.
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The absolute lowest dose is 10 micrograms. For the most part,
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you're going to find them in the 20 to 35 microgram range,
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and that's generally what's recommended. It's actually recommended to avoid
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anything above 35 micrograms for the purposes of daily contraception.
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And so most of the time, the general rule of thumb that people use
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is that they will choose a lowest dose estrogen as possible
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to meet the needs of the patient. The next part is the progesterone,
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and there are multiple types of progesterone. And I have to say
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that I am not an expert in all the different kinds. However,
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the main thing to think about is that some of them have more
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of an androgen effect than others, meaning somebody with acne
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might want birth control pills, oral contraceptives, to be able to manage
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their acne better. There is some suggestion that the more androgenic
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ones can worsen acne, but there is also evidence that it isn't
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necessarily that meaningful, and it's just the fact that they're
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on contraceptives that can help control the acne. So that's really
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up to your discretion, which really brings me to my kind of
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wrap-up point is that this is really based on a number of things.
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But I think that a lot of the newer nurse practitioners that I work
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with, and myself included as I was making this transition, I felt like
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when I graduated from school, there was one right answer. And sometimes
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there is, but sometimes there are multiple right ways to do things,
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and it really comes down to your philosophy of practice. For me,
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I am very, very, very patient-centered because it's my personal
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philosophy of practice, but it's also the most effective because
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it's patients' lives and their bodies, which is another topic for
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another day. I have some strong feelings, clearly, but I'm very
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patient-centered, and I'm also evidence-based, but also very laid back
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because, again, it's less exact. The practice of medicine is less
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exact than you kind of learn in school in a way. So basically,
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what I do for patients is I have a low dose, the lowest dose
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possible, start them on a medication, and then reassess. And I
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always inform them of that, is that some people will have some
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reactions, some people do really well, some people need some
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hydration, and then I just do a follow-up based on how they're
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tolerating it. Do they have any side effects, like breakthrough
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bleeding, breast tenderness, things like that? And then we
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just kind of reassess and see. So that's really up to your
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personal practice. So if you feel like you want to learn
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about each of the types of progesterones and each of the
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little kind of like nuances of each of them, then
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absolutely go for that. I encourage you, and that sounds
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amazing. That is not my personal practice, but when it
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becomes necessary and depending on the side effects, I
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definitely go down those avenues. But definitely check
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out the resources down below this video and let me know if
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you have any questions. Did you like this video? If so, hit
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like and subscribe and share with your NP friends so
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together we can reach as many new nurse practitioners as
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possible to help make their first years a little bit easier.
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And definitely head over to realworldnp.com slash guide
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if you haven't already. You can get the ultimate resource
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guide for the new NP. And you'll also get these videos
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sent straight to your inbox every week with notes from
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me, patient stories and exclusive content that I really
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just don't share anywhere else. Thank you so so much for
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watching. Hang in there and I'll see you soon.
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That's our episode for today. Thank you so much for
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listening. Make sure you subscribe, leave a review and
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tell all your NP friends so together we can help as many
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nurse practitioners as possible give the best care to their
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patients. If you haven't gotten your copy of the
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ultimate resource guide for the new NP, head over to
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realworldnp.com slash guide. You'll get these episodes
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sent straight to your inbox every week with notes from
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me, patient stories and extra bonuses I really just don't
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share anywhere else. Thank you so much again for
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listening. Take care and talk soon.

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Liz Rohr