Transcript: How to Choose Which Oral Contraceptive Pill for New Nurse Practitioners

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Liz Rohr:
Well, hey there, it's Liz Rohr from Real World NP, and you're watching NP Practice Made Simple, the weekly videos to help save you time, frustration, and help you learn faster so you can take the best care of your patients.

So today I'm going to be talking about combined oral contraceptives, birth control pills, and how to choose one, and the things you definitely don't want to forget about. So as a new nurse practitioner, I saw this in myself and I also see this in the mentees that I work with in my community. There's a really strong temptation when we leave school, or we're early on in practice, to jump right into the medications and the algorithms and kind of skip over some of the important stuff just because it's a lot, right?

And so the first thing I want you to think about, even though you know this, when you're in the middle of practice it can be easy to forget that there are some safety things that you want to think about first. And so is this even appropriate for your patient? So a lot of times patients will come in and they'll ask, "I just want to be on birth control." And it's very easy to say, "Oh sure, here you go." But that's our job, right? That's your new role. That's our role as providers to make that assessment and make those clinical judgments.


So the really excellent resource is the CDCs US Medical Eligibility Criteria, which I have linked down below this video. This is not a comprehensive list, that list is, but what I'm going to share with you are the most common ones. But for the full list, I definitely encourage you to check out that pdf. There're also a couple of different apps too, you can search for this. So basically you just want to assess what are the underlying conditions, what are the reasons they shouldn't have it or they couldn't have it because it would be unsafe?


So the first ones are smoking, high blood pressure, history of a DVT, a clotting disorder, cardiovascular disease, migraines with aura. Those are the most common ones that I see. And then some medications to keep in mind are phenytoin, phenobarbital, and refampin. Not very common medications, but those can definitely decrease the effectiveness.


One other really important one to think about is that most of the research has been done on patients who are under a BMI of 30. So patients who have BMIs of 30 and above may have a decrease effectiveness of the oral contraceptives. And so that's always a discussion that you want to have with your patient about the potential risk there for decreased effectiveness and considering the other options which might be safer for them. So again, that's not a comprehensive list, so definitely go check out that document down below this video.


The next thing to think about after safety or what are the reasons? So did somebody walk in and just say, "I want the pill," or are there certain things that they're struggling with? So do they have headaches that are hormonal? Do they have PMDD or severe PMS? Do they have dysmenorrhea? Things like that that may lead you to consider the longer kind of duration ones. They're all pills that are once a day, but those three month ones, the seasonal ones, instead of the monthly ones. So do they want a monthly mensies or do they want a less frequent one? So that's something to think about it depending on their underlying conditions.


And then that kind of brings me into the choices. So there's a lot of choices as you have probably seen. There're a couple of ways to go about it. So one just to point out is that there are multiphasic and then there are single phase. So one dose versus multiple doses. So for the whole month you have one dose of estrogen and progesterone, which are the two medications in there, versus one dose for one week, another dose for a second week, another dose for a third week. And then the fourth week is that placebo week.


For the most part, there isn't really necessarily a reason/difference to choose the multiphasic one compared to the single dose one. So typically speaking, most patients will be on the single phase one. The next thing to think about, because that's just more comfortable for patient ease, anecdotally, you might have some people feeling like the triphasic ones, the multiphasic ones, are more effective for certain reasons, but I think the evidence doesn't necessarily point to one more than the other.


And then the other two things to think about are the estrogen and the progesterone. So those are the two components. So estrogen is the estradiol, and that comes in multiple doses. The absolute lowest dose is 10 micrograms. For the most part you're going to find them in the 20 to 35 microgram range, and that's generally what's recommended. It's actually recommended to avoid anything above 35 micrograms for the purposes of daily contraception. And so most of the time the general rule of thumb that people use is that they will choose the lowest dose estrogen as possible to meet the needs of the patient.


The next part is the progesterone. And there are multiple types of progesterone. And I have to say that I am not an expert in all the different kinds. However, the main thing to think about is that some of them have more of an androgen effect than others. Meaning somebody with acne might want birth control pills, oral contraceptives, to be able to manage their acne better. There is some suggestion that the more androgenic ones can worsen acne, but there is also evidence that it isn't necessarily that meaningful and it's just the fact that they're on contraceptives that can help control the acne. 

So that's really up to your discretion. Which really brings me to my kind of wrap-up point is that this is really based on a number of things, but I think that a lot of the newer nurse practitioners that I work with, and myself included as I was making this transition, I felt like when I graduated from school there was one right answer. And sometimes there is, but sometimes there are multiple right ways to do things. And it really comes down to your philosophy of practice.

For me, I am very, very, very patient-centered because it's my personal philosophy of practice, but it's also is the most effective because it's patients lives and their bodies, which is another topic for another day. I have some strong feelings clearly, but I'm very patient-centered and I'm also evidence-based, but also very laid back because again, it's less exact. The practice of medicine is less exact than you kind of learn in school in a way because, so yeah, so basically what I do for patients is I have a low dose, lowest dose possible, start them on a medication and then reassess. And I always inform them of that is that some people will have some reactions, some people have do really well, some people need some titration. And then I just do a follow up based on how they're tolerating it. Do they have any side effects like big breakthrough bleeding, breast tenderness, things like that. And then we just kind of reassess and see. So that's really up to your personal practice.


So if you feel like you want to learn about each of the types of progesterone's and each of the little nuances of each of them, then absolutely go for that. I encourage you, and that sounds amazing. That is not my personal practice, but when it becomes necessary and depending on the side effects, I definitely go down those avenues.


But definitely check out the resources down below this video and let me know if you have any questions.

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Thank you so, so much for watching. Hang in there and I'll see you soon.