Hormonal Methods of Birth Control (Nursing)

00:01 So we've talked about barrier methods and natural family planning, all the things that are non-hormonal. Now, let's talk about what kinds of medications we can use or devices with medications in order to stop conception. We'll talk about oral contraceptives or pills. We'll talk about injections, talk about the patch, the ring, certain IUDs, and I say certain because some IUDs actually don't contain hormones at all. We'll talk about that. And then finally, the implant or the Nexplanon. As we continue our discussion of hormonal methods, it's really important if we understand all the different sites that hormonal methods work on. So first, we have disruption of the HPO access and that primarily affects the ovary, so we halt ovulation. Some internal structures like the IUD that are placed actually inside the uterus can cause some local absorption of the hormones and can actually cause the uterine lining to become atrophic, so that means that it's very thin. Makes it hard for the egg to implant in the uterine wall, but what's really nice is that it also decreases the flow of blood. And then finally, for devices like the ring, we can actually have changes in cervical mucus. Now, that doesn't mean that the pills don't do this as well, but the ring is especially notorious for changing that cervical mucus and making it thick so that the sperm does not travel well in to the uterine cavity. Let's break down the pharmacologic action of progestins and estrogen. So you notice I said progestin and not progesterone? When we put in manmade progesterone into the body, it's actually called a progestin. So, progestin, progesterone.

01:45 Progestins actually cause an inhibition of the ovary and pituitary function. So that's how it stops ovulation. It also contributes to thickening the cervical mucus, making it hard for the sperm to travel through. And that atrophy of the uterine lining that makes it difficult for the egg to implant also happens as a result of progesterone or progestins. Now, progestins offer some cycle control. So that means if we want to control when we bleed and when we don't, the progestin helps to stabilize that. Estrogen, on the other hand, also inhibits ovarian and pituitary function. It causes thinning of cervical mucus, which again makes it hard for the sperm to get through. Endometrial proliferation is what estrogen does so it gives us something to shed at the end of the month and it also helps with cycle control. So look at those 2 and compare what the progestin does and what the estrogen does. Now let's look at birth control pills and how they work. So, estrogen and progesterone are components of what we call a combined oral contraceptive. So you remember what estrogen and progesterone does. So our progestin actually causes endometrial atrophy, thins the lining of the uterus, which is why for some clients after a few months of being on oral contraceptives their periods are much lighter, which is a nice thing. The estrogen causes thickening of the cervical mucus. Well, this may make it so thick that the sperm cannot get through. We also have our inhibition of our ovarian function, so it works on the pituitary gland and it suppresses LH and FSH. So that's going to stop someone from ovulating. So they all work together and that's why oral contraceptives are so effective. Now, there are some absolute contraindications for estrogen. Remember the pill has estrogen and progesterone, this is the combined pill. If during your history, you find that a client reports that they have a history of migraines with aura, then we do not want to give them a hormone that contains estrogen if they have uncontrolled hypertension. So just having high blood pressure is not a contraindication but if it's not in good control and it's consistently elevated, then we do not want to increase the chances that this client will have a stroke by giving them estrogen. If they have a history of deep vein thrombosis or pulmonary embolus, these are clots, we don't want to give someone estrogen because that actually can cause clots. So someone who's predisposed definitely doesn't want to use this method.

04:29 And finally, someone who is smoking who's over the age of 35. Because we know that tobacco use causes vasoconstriction and if the pills were to cause clots, then we have vasoconstriction and that increases the risk for having a stroke or a PE. So, these are going to be absolute contraindications. Now, notice I said combined oral contraceptives they are also what we call the minipill. Combined oral contraceptives contain estrogen and progestins. The minipill only has progestins. So that might be a method that works really well for someone who has a contraindication to estrogen. See how that works? The minipill is going to be prescribed by a provider the same way the OCPs would be and it has to be taken at the same time every day. So, combined oral contraceptives that have estrogen and progesterone provides a little bit of leeway. So you have about 24 hours and then maybe an hour or two on either side that actually would be okay. With the minipill, you really don't have that wiggle room. So if this is someone who cannot commit to taking the pill the same time everyday, the minipill would not be an option. So typical failure rate for the minipill is going to be around 7%. Now, I mentioned some non-contraceptive benefits that might be there for someone who is taking birth control. So let's look at what those are so we could describe that. Remember we're doing BRAIDED so we have to talk about the benefits and it's not just contraception. So clients who use oral contraceptives, so these are pills, they have less endometrial cancer, they have less benign breast disease, they have fewer endometrial fibroids, they have more regular bleeding which is what we want a predictable cycle. The amount of bleeding, however, that comes out is reduced. Remember that atrophy? They have less anemia because they bleed less. They have less salphyngitis so they have less cervical infection in through their tubes. And they have a 50% reduction, now this is debatable but it's there in the literature, a 50% reduction in pelvic inflammatory disease. So that's what PID is. And, as another benefit, patients who are on oral contraceptives tend to have less cyclic mood changes. So, PMS, premenstrual syndrome.

06:55 Thinking about other benefits. Less ovarian cancer. So, we don't have a disruption of the ovarian lining every month from ovulation so there's less chance of cancer. They have less ectopic pregnancies. Well, they have less chance of getting pregnant at all so that makes sense. They also have fewer functional ovarian cysts. So they get better suppression with higher doses of estrogen in the oral contraceptives but someone who has a lot of cysts this may help. They have less dysmenorrhea which means painful periods. So we may have painful periods because we have heavy cycles, we may have painful periods because we have lots of prostaglandins. All those things are there but it definitely can help with someone who is having those symptoms. There can also be less acne. Right? So, less acne and less hirsutism, which is hair in places on someone who is female that usually are associated with male, so having hair on the chin, chest hair, things like that. There are also some cases where we've noticed less activation of rheumatoid arthritis, so that maybe a benefit. And increase bone density. So that's a positive as well. Now, the patch is another hormonal method that contains estrogen. We want to think about where the patch is placed. So it can be placed on the upper body, the lower abdomen, or the buttocks. What we do not want to do is place it on the breasts. That is a no no no. So, almost anywhere else but specifically the arm, the lower abdomen, or the buttocks are going to be the most ideal places to place it. Now the patch releases progestin and estrogen directly into the bloodstream. So that is good. And so it's absorbed through the skin and as it moves through the skin it gets into the blood vessels. That's how it gets to where it's going. One patch is placed for an entire week, so 7 days and one patch is placed every week. So that's 3 patches in a pack and then the 4th week there's no patch so that there's no hormone and that's going to be the week when someone experiences their menstrual period. Typical failure rate is around 7%, so not too bad. The contraceptive ring, so this is placed inside the vagina, and this is going to release progestin and estrogen, so it has both hormones in it. It's going to be worn for 3 weeks, so that same ring, you don't replace it every week like you do with the patch, you wear the same ring for 3 weeks and then you take it out for a week.

09:24 So that reduction in hormone for that week, just like it did in the patch, will result in menstruation. Typical failure rate for the contraceptive ring is about 7%. What about those times when things don't go as planned or our contraception fails or unfortunately in an incident where someone's been assaulted, is there contraception available for those particular situations. And yes there is. There is something called emergency contraception which can be used within 72 hours of unprotected intercourse. Now you have a 72-hour window but the closer to the active intercourse that the medication is taken or the device is inserted, the more effective that it's going to be. So the risk of pregnancy is reduced by 80%, so that's absolutely worth a shot. So when we're talking to clients who are childbearing we want to make sure they're aware that contraception is available even in those cases when we forgot to do it in real time. So there are several types of emergency contraception. Plan B or using our pills that we may already have if the client is on a progestin-only pill or certain types of combined oral contraceptives if it's used within 3 days can also be used as an emergency contraceptive, now those are going to be available by prescription. Plan B, you can often get over-the-counter. And there are types of IUDs, the copper-released IUD if it's placed within 7 days can actually also be used as an emergency contraceptive option.