Maternity - Preconception, part 2: Hormonal Methods of Contraception
In this article, we'll cover these hormonal contraceptives: oral contraceptives, medroxyprogesterone (Depo-Provera), the transdermal patch, the vaginal ring, the subdermal implant, and IUDs.
This series follows along with our Maternity Nursing Flashcards which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.
When you see this Cool Chicken, that indicates one of Cathy's silly mnemonics to help you remember. The Cool Chicken hints in these articles are just a taste of what's available across our Level Up RN Flashcards for nursing students!
Hormonal contraceptives are called hormonal because they affect the amount of estrogen and/or progestin (which is the synthetic form of progesterone) in the body. If you need background on estrogen and progesterone, we give an overview on these hormones in our Medical-Surgical Nursing Flashcards!
Hormonal methods of contraception are only designed to prevent pregnancy and do not offer protection against sexually transmitted infections (STIs).
Oral contraceptives, which are colloquially referred to as "the pill" are hormone-based medications that suppress ovulation and prevent implantation of fertilized eggs. There are multiple types of oral contraceptives, most importantly combined oral contraceptives (estrogen and progestin) or progestin-only “mini-pills."
It's important to understand these different types of oral contraceptives—their presence or lack of estrogen is directly related to specific patient teaching that you'll need to know!
Neither combined oral contraceptives nor the mini-pill offers protection against STIs.
Side effects of hormonal oral contraceptives include breast tenderness, "breakthrough" vaginal bleeding (meaning not during the patient's normal period cycle), fluid retention, nausea, high blood pressure, and headache.
There are multiple contraindications for oral contraceptives that you should be aware of. The pill is contraindicated for smokers, because it increases the risk of blood clots.
It's contraindicated for pregnancy, which means it would not be prescribed if a patient was already pregnant! Patients taking oral contraceptives should discontinue use if they become pregnant.
Other contraindications of oral contraceptives include a history of blood clots, stroke, coronary artery disease, and uncontrolled hypertension.
Combined oral contraceptives are contraindicated for patients who are breastfeeding, because estrogen can be passed through breast milk.
It's important to educate patients taking the pill that they need to take it at the exact same time, every day, with the same amount of food in their stomach. It can change the absorption time of the medication if there is food in the stomach one day and not the next—and for a medication as time-sensitive as oral contraceptives, the absorption time can be the difference between effectiveness vs. non-effectiveness!
The mini pill is the only birth control pill that is safe for breastfeeding patients.
Combined oral contraceptives carry a risk for thromboembolic events like a deep vein thrombosis. Educate your patients to watch for pain in the leg, redness in the leg, chest pain, difficulty breathing—all symptoms of a deep vein thrombosis, which is very serious.
Oral Contraceptives Cause Clotting (CCC).
Medroxyprogesterone, which goes by the brand name Depo-Provera, is a progestin-only intramuscular or subcutaneous injection that suppresses ovulation, prevents implantation, and increases viscosity of cervical mucus (which decreases sperm's swimming ability).
Patients receive the Depo-Provera shot every 3 months. Depo-provera, like the other forms of hormonal birth control covered here, does not protect against STIs.
The key side effect to be aware of with Depo-Provera is that its long-term use can lead to bone demineralization.
Other side effects of Depo-Provera include menstrual irregularities (e.g., spotting), weight gain, decreased libido, headache, and nervousness.
One important patient teaching for the Depo-Provera shot is that when a patient is getting the shot, it's best practice to schedule the date for the next shot while they are still at the office or clinic. This helps prevent forgetting and human error.
The transdermal patch is a patch containing estrogen and progestin that is applied on the lower abdomen, buttocks, or upper body (excluding the breasts).
The transdermal patch is not applied to breasts because targeted estrogen may have harmful effects on the breast tissue.
The patient should rotate patch application sites each week for 3 weeks. Then, they won't wear a patch for 1 week to allow for menstruation (similar to the inactive pills week with oral contraceptives).
Like other hormonal birth control mentioned in this article, the transdermal patch does not offer STI protection.
The vaginal ring is a small, flexible ring, inserted in the vagina, that releases estrogen and progestin that act to suppress ovulation and prevent implantation by thickening the cervical mucus.
The vaginal ring is left in place for 3 weeks and is taken out for the 4th week to allow for menstruation. Side effects seen with the vaginal ring are similar to those seen with oral contraception:
Like other hormonal birth control methods covered on this page, the vaginal ring does not offer STI protection.
Side effects are similar to those with oral contraception: breast tenderness, "breakthrough" vaginal bleeding, fluid retention, nausea, high blood pressure, and headache.
The subdermal implant form of contraception is a progestin-only rod that is implanted under the skin in the upper arm, using local anesthetic. The subdermal implant provides 3 years of contraception.
The subdermal rod does not offer STI protection.
Side effects of the subdermal rod are similar to those seen with oral contraception (especially the mini-pill, since both are progestin-only).
Intrauterine Device (IUD)
An intrauterine device (IUD) is a T-shaped device inserted into the uterus that releases hormones or copper ions that harm sperm and prevent fertilization.
There are hormonal and non-hormonal IUDs. The copper IUD (Paragard) is a non-hormonal option for patients, but we cover it in this section because most IUDs are the hormonal kind.
Depending on which type of IUD a patient gets, it can be left in place and effectively prevent pregnancy for 3-12 years. It must be placed by a healthcare provider.
IUDs do not offer protection from STIs
Side effects seen with IUDs are an increased risk of ectopic pregnancy, Pelvic Inflammatory Disease (PID), and the possibility of uterine perforation if the IUD is placed improperly or shifts to the wrong location.
Other side effects seen with IUDs include irregular periods and cramping.
There are some important patient teaching points to know for patients who get an IUD. IUDs have strings that extend down to the cervix—these act as a handle for the provider to grasp the strings and remove it when needed. These strings are thin; similar to fishing line, and the longer they are left in the body, they will soften, curl up at the edges, and be non-obstructive and non-obtrusive.
Educate your patient to check the strings once a month. They need to make sure they can still feel the strings, that they haven't suddenly gotten much longer or much shorter or disappeared entirely. It is possible for an IUD to be expelled, meaning pushed out of the body. It is also possible for the IUD to become dislodged and either be too low in the cervix (not in the uterus), or perforate the uterus entirely and escape into the abdomen. This is why it's important for patients to check their IUD string length and if there's a change in their string length, to call their provider immediately.
Hi, I'm Meris, and in this video, I'm going to be talking to you about hormonal methods of contraception. I'm going to be following along using our maternity nursing flashcards. These are available on our website, leveluprn.com, and if you already have a set for yourself, I would absolutely invite you to follow along with me. All right. Let's get started.
Okay, so first up, we are talking about oral contraceptives, oral contraceptives, or the birth control pill, and these are going to be very popular. You will see many patients taking these. But there's some really important stuff to understand. First of all, there's something called the mini pill or a progestin-only pill, meaning that it only contains the synthetic form of progestin, it does not have any estrogen. Then we have combined oral contraceptives, and as their name may imply, that's going to be a contraceptive that is a combination of estrogen and progestin. Very important to understand because the teaching is different.
So with the mini pill, the progestin only-pill, there is no increased risk of clots, DVTs, anything like that. That risk comes from the estrogen. But what you do need to know is that this is the only birth control pill that is safe for breastfeeding patients. Because estrogen is passed through breast milk the only one that can be used when breastfeeding is the progestin-only mini pill. Very important to educate patients that they need to take it at the exact same time every day with the same amount of food in their stomachs because it can change the absorption time if there's food in the stomach one day and not the other, these are very time-sensitive.
Now, combined oral contraceptives, again, very important to take it every single day. But this one has some better coverage, it's more effective, but it carries the risk for thromboembolic events such as deep vein thrombosis. So educate your patients on what to look for there, pain in the leg, redness in the leg, chest pain, difficulty breathing, all of those would be a big deal. And if my patient were a smoker, if they had a personal or family history of blood clots or if they were over the age of 35 and a smoker, I would very much encourage them not to be taking a combined oral contraceptive. We do have a nice, cool chicken hint down here at the bottom. It says oral contraceptives cause clotting, but I would add another word in front of that and say combined oral contraceptives cause clotting. Very important to remember that. You'll see a lot of different side effects on here, too, that are worth reviewing, but not the huge red flags that the DVTs are.
All right. So let's move on to medroxyprogesterone. Medroxyprogesterone, the trade name is going to be Depo-Provera, so this is going to be an injection. This is actually an IM injection that a patient should receive. It's going to be about every three months and the patients will be receiving a card at each injection that tells them when their next one is due. And most of the time, it's a really good idea to go ahead and schedule that next injection as well. Lots of things that can go on with this one, but the biggest one that I want to call your attention to, and it is in big, bold red letters, is going to be that with long-term use of medroxyprogesterone, the patient can experience bone demineralization. So important patient teaching is going to be increase your intake of calcium and vitamin D along with weight-bearing exercise. Super duper important to know about that.
All right, moving on to a few more that you may have heard of. They're not quite as common, though, so we didn't go super in-depth. The transdermal patch, the vaginal ring, and the subdermal implant. And stay until the end of this video, because I'm going to tell you a true story about one of these. So the transdermal patch, this is a patch that is applied to the abdomen, the buttocks or the arm, do not apply it to the breast, though. This one is going to be a patch left in place for one week. It will be changed, so you'll wear it for a week, a new patch for a week, a third patch for a week, and then one week off. The vaginal ring is an actual ring, it's a small clear ring that is inserted vaginally and left in place for three weeks, removed for the fourth week, and that triggers a menstrual cycle. Okay, very important to know that. Subdermal implants, a subdermal implant is placed subcutaneously here in the arm and it can be left in place for three years. Really, really great option. It may cause menstrual irregularities, though. As with all hormonal methods of birth control, it is very important to educate your patients that these do not provide any protection against STIs, okay, only against pregnancy.
And lastly, we're going to talk about the intrauterine device. So this is commonly called an IUD, there are multiple different types. There are hormonal and non-hormonal types, such as the copper IUD, Paragard, is non-hormonal, but we kind of lump it in with hormonal because most of them are. So this one can be left in place for multiple years, depending on which type the patient receives. So anywhere from 3 to 12 years, it can be left in place, but it must be placed by a health care provider. Super duper important patient teaching. There are some strings that hang out of the cervix from the IUD, this allows the health care provider to grasp the strings and remove it when the patient would like to have it removed. These strings are kind of similar to fishing line, but the longer they are left in the body, they will soften and they will kind of curl up at the edges and they will be non-obstructive, non-obtrusive. You need to educate your patient, though, to check the strings once a month. The patient needs to make sure that they can still feel the strings, that they haven't suddenly gotten much longer or much shorter or disappeared entirely because it is possible for an IUD to be expelled, meaning pushed out of the body. It is also possible for the IUD to become dislodged and either be too low in the cervix, not the uterus, or perforate the uterus entirely and possibly escape into the abdomen. So this is why it's important for patients to check their string length and if there's a change in their string length, to call their provider immediately.
Okay, that is it for hormonal methods of contraception. Super duper important stuff, so be sure to brush up on it. I hope that review was helpful. If it was please like this video so that I know. If you have a great way to remember something or a great story you want to share, I definitely want to hear it, and I know everybody else does, too. So please comment below so that we can see it. And you definitely want to subscribe to the channel, you want to be the first to know when more videos come out. The next video in this series is going to be talking about permanent sterilization and also about infertility. All right, thanks so much and happy studying.
So when I was working outpatient OBGYN, one of my jobs was to be the phone triage person, so somebody would call the office and I would listen to their complaint or their question or whatever and either give them advice or move it on to the physician. And one time I got a call from a patient who said, "I was just in the other day, and I think I'm allergic to this NuvaRing," and I said, "Okay, tell me a little bit about what's going on." And she was like, "It's turned my fingers blue," and I thought, "What? The NuvaRing, the vaginal ring is turning your fingers blue? What?" And so I keep probing and asking her some more questions, and she says, "It's just so tight," and I had to say to her, "I'm so sorry. Where is the NuvaRing?" And she said, "It's around my wrist," she'd been wearing it like a bracelet, like a hair tie around her wrist, and it was cutting off the circulation to her fingers. If you've ever seen one or felt one, they are flexible, but they're not stretchy. So she had to fight it to get it over onto her wrist. And it was cutting off circulation to her fingers. Okay, it's a funny story. It's a true story. It really happened to me. But it also is just another example of why patient education is so important, why it is so important not to assume that your patients have the same level of health literacy as you do, because they definitely don't, and to take your time to go line-by-line and just really make sure that they understand what they're supposed to be doing with their medication or their lifestyle changes because otherwise, stuff like that can happen.
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