The women's health nurse practitioner is responsible for the assessment and management of women requesting oral contraception and for the prescription of oral contraceptives to eligible women, and for referral of ineligible women requesting oral contraceptives to the medical practitioner to ensure the need for contraception is addressed.
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Eligible women are non pregnant women whose risk factors do not exceed Category 2 and who request prescription of oral contraceptives, utilising the World Health Organisation (WHO) Medical Eligibility Criteria for Contraceptive Use.
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Combined oral contraceptives
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Eligible women are those who:
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- are not breastfeeding and less than six months post partum
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- are not less than 21 days post partum and not breastfeeding
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- are not 35 years or over and a smoker
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- do not have multiple risk factors for arterial cardiovascular disease, e.g. age over 35, smoking, diabetes and hypertension
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- have blood pressure less than 140/90
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- have no risk factors for Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE), including personal history of DVT/PE, major surgery with prolonged immobilisation
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- have no current nor history of heart disease including Ischaemic Heart Disease (IHD), cerebrovascular accident (CVA)
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- have no known hyperlipidaemias
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- have no migraine with neurological symptoms
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- have no liver disease nor previous cholestasis associated with use of oral contraceptive pill
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- have no diabetes with complications
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- have no malabsorption syndrome, with the exception of cystic fibrosis
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- have no family history of thrombus or embolus
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- are not taking drugs which affect liver enzymes such as rifampicin, griseofulvin, phenytoin, carbemazepine, barbituates, primidone
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In addition to the WHO criteria, eligible women are those who:
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- have no known or suspected carcinoma of the breast
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- have no abnormal vaginal bleeding
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- demonstrate the ability to understand and comply with recommendations pertaining to oral contraceptives
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Progesterone only oral contraceptives
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Eligible women are those who:
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- are more than six weeks postpartum and are breastfeeding
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- are postpartum and not breastfeeding
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- have no current and history of IHD, CVA
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- have no migraine with neurological symptoms
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- have no liver disease nor previous cholestasis associated with use of oral contraceptive pill
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- are not taking drugs which affect liver enzymes such as rifampicin, griseofulvin, phenytoin, carbemazepine, barbituates, primidone
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In addition to the WHO criteria, eligible women are those who:
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- have no abnormal breast symptoms nor known or suspected carcinoma of the breast
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- have no abnormal vaginal bleeding
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- demonstrate the ability to understand and comply with recommendations pertaining to oral contraceptives
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History
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The women's health nurse practitioner should document:
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- menstrual history - date of last normal menstrual period, cycle interval and volume, duration of bleeding, bleeding pattern and dysmenorrhoea
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- contraceptive history - previous and current methods, history of side effects, prior method failures, personal preferences
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- obstetric history - previous subfertility, exclude thrombosis and jaundice in pregnancy and hypertension in pregnancy
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- medical history - allergies, cardiovascular disease including clotting disorders and hypertension, epilepsy, intellectual disabilities, liver disorders, migraines, strokes, diabetes, current drugs and/or medications obtained over the counter, e.g. complementary/herbal such as St John's Wort
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- gynaecological history - cancers, lactation or pregnancy, risk assessment for sexually transmissible infections (STIs), dyspareunia
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- family history - deep vein thrombosis, pulmonary embolism, cerebrovascular accident, myocardial infarction
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- family history indicating risk of BRCA I and II mutations
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- social history - relevant lifestyle factors, smoking
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Examination
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- cervical screening if required
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- testing for STIs, blood borne viruses and genital tract infections as required
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- pregnancy testing as required
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For women over 40 years of age commencing combined oral contraception:
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- cholesterol and triglycerides
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- body mass index as required
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For women with a family history of venous thromboembolism, a thrombophilia screen should be performed prior to commencing combined oral contraception.
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Prescription
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Women's health nurse practitioners should check the client's medical history, medication history and history of allergies when prescribing medications. They should also ensure the patient understands the drug regimen and inform client of possible adverse reactions.
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Details of the prescription should be recorded in the client's file. All relevant fields on the medication order chart should be completed. This includes the name of the prescriber, the commencement date, the dose, the frequency, the date and time of prescribing, and the prescriber's name.
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Women's health nurse practitioners should utilise the current prescribing information regarding the following medication and ensure the patient is aware of appropriate storage required for the medication.
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Advice to women prescribed oral contraception
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Women should be provided with written information pertaining to oral contraception. They should also be given advice regarding emergency contraception and telephone advice lines such as Family Planning Victoria, women's hospitals.
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Common side effects
| Combined oral contraception
| - breakthrough bleeding
- breast tenderness
- nausea
- mood changes
- changes in libido
- fluid retention
- thrush
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|  | Progesterone only contraception
| - menstrual irregularity
- prolonged bleeding
- spotting
- amenorrhoea
- depression
- weight gain
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Women should be advised that their periods may be lighter and shorter and that blood loss may be darker in colour. The side effects usually settle within three months.
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Women should be advised to seek immediate medical advice if they experience: persistent headaches, nausea, oedema, visual disturbances, breathlessness with mild effort, or chest pain after commencement of oral contraception.
| Women should also be advised to seek medical advice should they experience abnormal vaginal bleeding beyond three months after commencement of the oral contraceptive pill.
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Women should be advised that hormonal contraceptives do not protect against sexually transmissible infections including human immunodeficiency virus. In addition to information on hormonal contraception, information on the correct use of condoms should be given to all women.
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Seven day rule
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The rule should be applied in situations where absorption of the pill may be compromised or if the pill has been omitted in certain circumstances. In the seven day rule, the pill should be taken as usual but extra precautions, e.g. condoms, abstinence, are advised until the woman has taken seven active pills. If the pill packet runs into the placebo section, these tablets should be omitted.
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The rule should be applied in the following situations:
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- where there is vomiting or diarrhoea within 3 hours of taking the pill
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| AND/OR
| - temporarily taking drugs that interfere with the pill's metabolism, e.g. antibiotics
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| Different rules may apply to women taking prolonged courses of antibiotics and medical advice should be sought.
| AND/OR
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A combined oral contraceptive missed pill is one that is more than 12 hours late. Progesterone only pills must be taken within three hours of the same daily time, or the missed pill rule will apply. The most hazardous times to miss pills are at the beginning or end of the active pill cycle.
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Emergency contraception
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Emergency contraception may be considered if two or more active pills are missed in the beginning or end of the cycle.
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Prescription of oral contraceptives
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Monophasic (9 entries)
| Ethinyloestradiol 30mcg; Levenogestrel 150mcg
| (eg Levlen ED™, Microgynon 30™ & ED, Nordette™, Monophene)
One tablet on the first day of bleeding from section marked with appropriate day and take one tablet daily, following arrows. Commence new pack immediately. May be taken with or without food, at the same time each day.
| OR
| Ethinyloestradiol 20mcg; Levonorgestrel 100mcg
| (eg Loette™, Microgynon 20™, Microleven™)
One tablet on the first day of bleeding from section marked with appropriate day and take one tablet daily, following arrows. Commence new pack immediately. May be taken with or without food, at the same time each day.
| OR
| Ethinyloestradiol 50mcg; Levonorgestrel 125mcg
| (eg Microgynon 50 ED™)
One tablet on the first day of bleeding from section marked with appropriate day and take one tablet daily, following arrows. Commence new pack immediately. May be taken with or without food, at the same time each day.
| OR
| Ethinyloestradiol 35mcg; Norethisterone 500mcg/1g
| (eg Brevinor 28 Day™ tablets OR Brevinor 1™, 28 day tablets OR Normin 28 Day™ tablets OR Normin 1™, 28 day tablets)
On first day of bleeding, take blue/white active tablet corresponding to that day of week from green section, then follow arrows, taking one tablet daily for 21 days, then take one orange inactive tablet daily for 7 days before starting new pack. May be taken with or without food, at the same time each day.
| OR
| Desogestrel 150mcg; Ethinyloestradiol 30mcg
| (eg Marvelon™)
1 tablet daily taken from first day of menstruation, starting with appropriate day's tablet from the green section, continue until all tablets are taken, start new pack next day. May be taken with or without food, at the same time each day.
| OR
| Gestodene 75mcg; Ethinyloestradiol 30mcg
| (eg Minulet 28™, Femoden ED™)
1 tablet daily the first day of menstruation until all tablets are taken, commence new pack next day. May be taken with or without food, at the same time each day.
| OR
| Drospirenone 3mg, Ethinyloestradiol 30mcg
| (eg Yasmin™)
On the first day of bleeding take active tablet corresponding to the day of the week then one tablet daily, following arrows until pack finished. Commence new pack the next day. May be taken with or without food at the same time each day.
| OR
| Mestranol 50mcg; Norethisterone 1000mcg
| (eg Norinyl-1™ 21 & 28)
On the first day of bleeding take active tablet corresponding to the day of the week then one tablet daily, following arrows until pack finished. Commence new pack the next day. May be taken with or without food at the same time each day.
Pack (21; 28) x4, 2 repeats. private prescription.
| OR
| Cyproterone acetate 2mg; Ethinyloestradiol 35mcg
| (eg Diane, Brenda Estelle)
On the first day of bleeding take active tablet corresponding to the day of the week then one tablet daily, following arrows until pack finished. Commence new pack the next day. May be taken with or without food at the same time each day.
Pack (21; 28) x4, 2 repeats. private prescription. |
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Triphasic
| Levonorgestrel 50mcg,75mcg,125mcg; Ethinyloestradiol 30mcg,40mcg,30mcg
| (eg Tripheme, Triphasil, Logynon ED, Triquilar ED)
On the first day of bleeding take active tablet corresponding to the day of the week then one tablet daily, following arrows until pack finished. Commence new pack the next day. May be taken with or without food at the same time each day.
| OR
| Norethisterone 500mcg, 1mg: Ethinyloestradiol 35mcg, 35mcg
| (eg SynphasicTM 28; ImprovilTM 28)
On the first day of bleeding take active tablet corresponding to the day of the week then one tablet daily, following arrows until pack finished. Commence new pack the next day. May be taken with or without food at the same time each day.
Pack (28) x4, 2 repeats. On PBS.
| Biphasic
| Levonorgestrel 50mcg, 125mcg; Ethinyloestradiol 50mcg (eg Sequilar™)
| On the first day of bleeding take active tablet corresponding to the day of the week then one tablet daily, following arrows until pack finished. Commence new pack the next day. May be taken with or without food at the same time each day.
Pack (28) x 4, 2 repeats. On PBS.
| Progesterone only
| Levonogestrel 30mcg (eg Microlut™ Microval™)
| 1 tablet daily beginning on the first day of menstruation taken at the same time each day with or without food. Begin new pack next day. OR Norethisterone 35 mcg (eg Micronor, Noriday) 1 tablet daily beginning on the first day of menstruation at the same time each day with or without food. Begin new pack next day.
| OR
| Norethisterone 35mcg (eg Miconor™, Noriday™, Locilan™)
| 1 tablet daily beginning on the first day of menstruation at the same time each day with or without food. Begin new pack next day.
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Links to consumer information
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Referral and follow up
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All women prescribed the oral contraception should be reviewed by the women's health nurse practitioner after four months. Following this visit, annual review is recommended unless a medical review is indicated.
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At the review visit, the following should be documented:
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- reported compliance and understanding of missed pill advice
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Referral to a medical practitioner and ceasing of the pill should be advised if the woman reports:
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- any warning signs, e.g. persistent headaches, visual disturbances, leg cramps, chest pain, breathlessness with mild effort, jaundice, oedema
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- or if blood pressure is above 130/85
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Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
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