The author has been asked to advise Sara, aged 33, in response to her wish to begin the Combined Oral Contraceptive Pill (COC).Accordingly, the author has been made aware of and has accordingly taken into account the following facts about the patient:
- That she is using the COC for the first time
- No other method of hormonal contraception has been used by her before
- She is an occasional/social smoker
- It is known that she suffers from headaches but the frequency of the same has not been mentioned. Also it is unknown whether these headaches arise as a consequence of the condition of migraine and if so what type of a migraine it is
- It is also not known whether she may be currently pregnant
- Her medical history has not been provided in the brief or case study.
Pertaining to the author’s role as an extended nurse responsible for the care and management of Sara, it has to be remembered that Sara is a first-time COC pill user. Consequently, it becomes imperative within the author’s role as a nurse clinician at a nurse led contraception clinic to keep in mind the PGD objectives of patient group directions which are to:
- Provide a high quality, efficient and acceptable service to patients such as Sara
- Ensure the safety of such services in terms of the environment it is delivered in
- To improve patient care
- To maintain and enhance the authors own professional practice through subscription to ethical conduct and the common regulatory goals (Department of Health, 1998)
The contraceptive nurse as public health practitioner
In the light of the above the author’s role will be to assess and take down a good personal and medical history from her before ensuring that Sara has a good understanding of the health benefits and health risks associated with taking combined oral contraception (FFPRHC, 2006). Another factor to consider in the advisory and management process is her age, her occasional smoking tendency and a complaint of occasional headaches as well as addressing a number of information gaps in the facts provided in the case study (O’Sullivan et al, 2005). Furthermore, it has to be remembered that the author here is delivering these services in line with his/her obligations as a public health practitioner where as her duty to promote the patients health is the top priority (WHO, 2003 and 2004).
One of the most significant functions of the contraception nurse in her role as a public health practitioner is to prevent the spread of sexual disease and unwanted pregnancies in line with the patient’s health and to generally promote healthy practices with in the community (Costello and Haggard, 2003:20-25). Thus the care and management of women by the contraceptive nurse inevitably bring forth issues of empowerment and Scriven and Orme, (2001: 9) have identified two types of interrelated forms empowerment: individual empowerment and community empowerment. Community empowerment is most readily characterized by the terminology of the Ottawa Charter as an active participating community whereas individual empowerment is associated with certain beneficial psychological characteristics of which the most significant are beliefs about personal control including realistic causal attribution together with a relatively high level of self esteem (Tones, 1994:169 cited in Scriven and Orme 2001: 9) (See also Naidoo and Wills, 2005)
Another role of a contraceptive nurse is to be a facilitator (Orme et al, 2005:67). This involves establishing therapeutic rapport using counselling kills, active listening, taking account of non-verbal messages, checking understanding, motivating and educating both female individuals, as well as the community, about opportunities to acquire supportive knowledge as well as giving them essential information about contraception (Scriven and Orme, 2001:16). It would be important to mention that this role is supported by the current government initiative, (White paper: Choosing Health; Making healthier Choices Easier (DoH, 2004)), which endorses the idea that individuals need more information and support to help them make healthier choices and sought to encourage healthier lives. (DoH, 1998)
Last but not least is the need for contraceptive nurses in their role as public health promoters to observe and promote ethics. (FFPRHC, 2006) According to Earle et al (2007:24) an awareness of ethical issues is fundamental to an understanding of public health promotion for female contraception since ethical dilemmas arise almost at every turn in the practice of promoting health (NMC, 2008).
Based on the above, care has been taken to follow and subscribe to the guidelines provided in WHO literature as well as local Department of Health Guidance. Accordingly, the author has been careful also to observe and act upon the interaction between public heath environmental factors (WHO (2003). In the WHO (2003) there is also a clear emphasis upon the organization’s obligation to ensure the assessment of the patients’ individual needs in terms of health promotion and any necessary rehabilitation requirements (WHO (2003).
The style of patient management adopted by the author
It has to be remembered in terms of professional conduct and the code of ethics that the role of the contraceptive nurse is to elicit a true state of affairs especially from a patient like Sara who is a first time COC user (Donaldson, 2004). We are told that she attends clinic but not whether her entire medical history is on record. Thus the advice given proceeds on the assumption that no medical history other than the one stated has been provided. The aim then is to base an unbiased opinion for Sara on her responses to carefully asked open questions which allow her to deal with and expose her fears for her sexual health and contraception methods in greater detail (FFPRHC Clinical Effectiveness Unit, 2005). Much of Sara’s care and management in addition to medical advice also consists of dealing with and assessing her needs, beliefs, desires and opinions as well as any other options she might have than the COC.
In addition to counselling the advice will be structured around the following issues, which will be addressed throughout this advice.
- When can Sara start the COC?
- How the COC is to be taken or administered and when the tablets have to be stopped or restarted
- At what times Sara may be vulnerable to pregnancy during the intake of COC
- At what times does she have a stronger chance of avoiding pregnancy during the intake of the COC?
- What she can do if she misses her COC tablets or does not take them in time
- How to deal with concurrent medication being taken in addition to the COC
- The side effects she may or may not suffer based on her current or unknown circumstances. (Faculty of Family Planning, 2002)
Hormonal Contraceptives and Combined Oral Contraceptives.
It is a accepted fact among the medical academia that hormonal contraceptives are one of the most effective reversible methods for avoiding pregnancy and have the advantage of being reversible (Sherif, 1999). Currently, there are many types of hormonal contraceptives available consisting of the well known Combined Oral Contraceptive Pill (which is a combination of synthetic oestrogen and progestin), the Mini Pill (the progestin only pill (Vizthum,2005). Other methods that do not require the contraceptive to be taken in internally include injections, implants, and patches (Mishell, 1999).The COC is a good option for Sara in many ways. Firstly, because medical evidence in its totality suggests that the current formulations of the COC do not carry substantial health risks (Ernst et.al 2002) and this occurrence is even more reduced in the use of progestin-only contraceptives. In terms of its formulation the COC has come a long way. Its early formulations included combinations of mestranol, progestin in high proportions (Vizthum,2005).This was discontinued due to negative steroid effects and the new generation of COC’s included the use of ethinyl estradiol,norethynodrel, norethisterone, norethindrone, ethynidiol diacetate,levonorgestrel, norgestrel, norgestimate and desogestrel, gestodene in their formulation(Vizthum,2005). In medical terms the COC acts by preventing conception through manipulating the ordinary processes which act by “the hypothalamic-pituitary-ovarian axis (suppressing) synthesis and secretion of follicle-stimulating hormone and the mid-cycle surge of luteinising hormone, thus inhibiting the development of ovarian follicles and ovulation” (Willacy 2009:1) and thereby effecting the “cervical mucus to prevent penetration of sperm and the endometrium to inhibit blastocyst implantation” (Willacy,2009:1).
The Combined Oral Contraceptive has been reported to confer several positive and negative side effects which pertain to reductions in physical or psychological discomfort in menstrual cycles (Vizthum, 2005). The method is 99% accurate and is coitus independent (Vizthum,2005). It has also been medically reported that the COC’s reduce the occurrence of acne and lipid levels and protect against osteoporosis, endometriosis, pelvic inflammatory disease, ovarian/endometrial cancers and rheumatoid arthritis. Thus Sara has to be made aware of these positive side effects and the negative side effects, which generally include a decrease in sexual libido (Vizthum,2005). This is a view (Graham et al, 1995) which has been disputed in recent studies (Ernst et. al, 2002) with the contention that the psychological comfort associated with the reduced fear of pregnancy can actually enhance the sexual experience.
Medical History of Sara generally
It is essential to understand properly the medical history of Sara to assess how this will affect the care and management strategy for her. One of the most significant issues with first time COC drug users remain the often severe side associated with hormonal contraceptives which arise mainly from varied biological variations amongst female patients depending on their social circumstances, age and medical history. The COC intake entails consumption of exogenous hormones and these varied outcomes depend upon the biological etiology of the side effects of the same (Vizthum ,2005).
Since this is the first time Sara will be using COC’s and she is nearing thirty-five now there is a chance that the high levels of oestrogen in the COC’s might cause her temporary nausea and vomiting, headaches, breast tenderness, and late-cycle breakthrough bleeding (The Contraception Report 1997,1999,2004). In such circumstances it becomes imperative then, during her care and management, to encourage her not to discontinue the pill as these are hormonal adjustments of her body which are often known to cause irregular menstrual flow with the bleeding returning to normal patterns over time. If these issues persist too far with Sara and it is felt that her condition does not improve within two menstrual cycles it may be better to prescribe to her the Progestin-only contraceptives which are available much more widely in terms of delivery as pills, injections and implants(Vizthum,2005). Furthermore, Sara’s social smoking and tendency of headaches will also have an effect on the care and management strategy. This will include taking a detailed history of her drinking and smoking frequencies as well as her current weight and eating habits.
The most significant risk being faced by Sara right now is the likelihood of developing venous thromboembolism and in her care and management it becomes my duty to assess her individual risk of developing the same when prescribing her any brand of combined oral contraceptives (Vizthum, 2005). It is well known that the presence of combined oral contraceptives containing desogestrel or gestodene are associated with a relative risk of venous thromboembolism is greater than that found for levonorgestrel-containing contraceptives. In terms of her medical history then other factors will become more prominent like her tendency of irregular menstrual bleeding and her overall regularity in her menstrual cycle (Vizthum, 2005). This would entail taking a comprehensive personal and family history from Sara in terms of contraceptive use by any maternal ancestor and any possible allergies for to exclude any future risks to her health in the use of combined oral contraceptives (Vizthum, 2005). During her management if she reveals it that she has a family history of thromboembolism, the author would strongly advise her to be screened for thrombophilia with further advice from her haematologist.
Advice for Sara based on the history provided
After the review of Sara’s personal and family history (in order to better identify contraindications for the future use of any type of combined oral contraceptives and any chances of risks of venous thromboembolism) the next step will be to counsel her about the risks and benefits associated with the future use of the COCs. As a first time user Sara has to be warned that the efficacy of the COC is highly dependent on its consistent, correct and punctual use. Also the efficacy of the COC can at times be decreased by severe vomiting or diarrhoea as well as the concurrent use of certain medications (Willacy, 2009). Furthermore, Sara has told us that she suffers from headaches; it will therefore be necessary to ask her about any previous history of cardiovascular and migraine related conditions (Willacy, 2009).
In addition to this she has to be asked about her smoking, hypertension and tendency for obesity. Some studies have shown that most women wrongly believe that COC’s cause unnecessary obesity problems (Willacy,2009:1). This has to be clarified to her and she will be advised to reduce or stop smoking as well. In her care and management a note should be taken of her blood pressure levels (which should not exceed 140 mm HG systolic) and current Body Mass Index (Gallo et al, 2008).
The ethical concern here would be to bring to her attention the associated risks of breast and cervical cancer with longer use of such COCs. In addition, professional conduct entails that although she has not reached the age of 35 yet, she is already 33, and there is a chance of Myocardial Infarction if she uses COCs for too long. I would advise her to look for alternative means of contraception after a few years. This is also true if her Body Mass Index exceeds 35 and to avoid unnecessary risk of cancer (WHO, 1995).
It is unknown at this stage whether these headaches for Sara are due to a persistent migraine condition or other causes. It is also unknown whether if this is a migraine condition, it is a simple migraine or a migraine with aura. In this connection it is of particular concern that her she is nearing 35 and if this condition is found with her it would be unethical to prescribe her COCs.
We have been told that she has recently changed her partner. The use of female condoms is always much more preferable until it is ensured that the new sex partner is free from any VD (venereal disease) or sexually transmitted infections (STIs). Until she is sure of her partner’s health I will also advise her not to discontinue the use of male or female barrier methods i.e. condoms.
If Sara is using a liver-enzyme inducing drugs she has to be warned that concurrent use of COC’s in such situations can not only reduce the efficacy of COCs but also induce toxicity (Spitzer et al, 1996). The same is the case of the concurrent use of broad-spectrum antibiotics, which reduce the efficacy of COC’s and in the duration of their use Sara might have to resort to other exogenous means of protection (DoH, 1998.1999,2002).
Guidance on administration of the COC for Sara
The care and management for Sara will also involve counselling her on the correct use of the COC. It will be emphasized that the COC first time users have to use the tablet for 21 days regularly preferably each taken at the same time. After this period there has to be a 7-day break to allow for bleeding to take place and pave the way for endometrial shedding (FFPRHC, 2006). Although it is not necessary to begin the COC during her period, it is good practice nevertheless. After a confirmation via a pregnancy test that she is not pregnant, I will advise to Sara to start the tablet as soon as she wishes, especially if she has an active sexual life currently. Moreover, she would be advised to utilize either male or female condoms during the first ten days of the use of the COC (FFPRHC, 2006).
In the event of missing a COC she will be advised to subscribe to the written recommendations in the COC package and not to be disheartened by missing one or two pills, as this does not compromise her overall contraception regime. Furthermore, if she has nausea and vomits within two to three hours of COC intake she should take another tablet to ensure COC absorption in her blood. Also, regular use of the COC could mean she may, at times, miss her periods or experience lighter menstruation. It is not known at this point whether she has a condition of ovarian cysts or an endometrial condition.
Follow-up advice for Sara
Sara will be advised to revisit the clinic after a period of three to four months unless she experiences volatile symptoms indicative of an allergy or even an increase in headaches. Unless her body shows violent reactions, Sara will be encourage to try the COC for two to three months, and if even then her body does not accept the COC, there will be a consideration of a progestin-only alternative. Sara’s blood pressure will need to be monitored every few months as well and her concerns will have to be documented.
At this point Sara will be asked, through open-ended questions, about her ease or difficulty in using the COC and whether she has experienced any side effects such as headaches, or irregular bleeding or pain. She will be asked about the timing and regularity with which she has used the COC and whether she has used the correct procedure. Finally, there will be questions about her management of missed or delayed tablets and the occurrence of any break through bleeding (Missed Pills, 2005). She will also be asked about her smoking and drinking patterns in this period followed by giving her an opportunity to voice her concerns. It will be checked whether a cervical examination or a breast exam is due for Sara
Conclusions and observations
In terms of conclusions, the author has made every effort to recognize and interpret the various needs and symptoms of the patient, Sara, who would like to opt for COC. An evaluation of the medical history of the patient from a nursing perspective has been attempted and the gaps in the information provided have accordingly been revealed. In line with the requirements of the Department of Health the author deemed it his/her duty to achieve an overall satisfaction with the quality of the interactions with the contraceptive nursing staff. The role of a contraceptive nurse in such a situation is to launch successful psychological preparation for the side effects of COC in the coming months which comprise good staff–patient contact and adequate information, and is likely to alleviate the absorption process for the COC: this can become one of the strongest predictors of good patient treatment. Care was taken for the need to provide adequate information to Sara by nursing staff and to give patients realistic expectations of the COC treatment and outcome. Care was taken as much as possible to avoid a case of toxicity and questions were asked in accordance with the duties under the Medicine Act 1960 to avoid medication errors. The situations in which the COC should be avoided have been discussed above. The integrity of the medical practitioners remains controversial to the public, especially the individual affected by medical errors. This may affect the whole organization of the medical field compromising the trust of the public towards their operations. Such thorough clinical management is necessary as contraceptive nurses, as other nurses, involved in administering and prescribing drugs sometimes may be negatively viewed by society considering the rise of nursing errors in medicine mismanagement. Among strategies for reducing these errors is to ensure that the contraceptive nurse asks adequate questions and applies appropriate knowledge, and the required experience, in dealing with the COC advisory and prescription process.
Finally, another issue that has become prominent above in line with the need to ensure Sara’s health is the risk toxicity due to the lack of proper dosage. Certain patients cannot afford to take high potency COC pills in the early months and it is at these times that keen observation and investigation on the side effects of the drugs to the contraceptive patient is essential. Correct documentation is also important to trace Sara’s medical history and to avoid any errors in the future to the detriment of Sara due to missed history details. Thus, the analysis of this case study has demonstrated an overall need to improve nurse–patient contact at nurse-led contraception clinics, the quality of care given, and this may increase contraceptive nurses’ caring competence.
- (FFPRHC) Faculty of Family Planning and Reproductive Health Care (2006) First prescription of combined oral contraception,
- O’Sullivan et al (2005) Contraception and Sexual Health, 2004/05. Office for National Statistics, London, UK: Her Majesty’s Stationery Office (HMSO), 2005.
- WHO (2004) World Health Organization, 2004. Selected practice recommendations for contraceptive use.
- Gallo et al (2008). Combination contraceptives: effects on weight. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD003987. DOI: 10.1002/14651858.CD003987.pub3.
- Missed Pills (2005) Faculty of Family Planning and Reproductive Health Care RCOG (2005)
- WHO (1995) Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception. Venous thromboembolism and combined oral contraceptives: results of international multicentre case-control study. Lancet 1995;346:1575-82.
- Spitzer WO, Lewis MA, et al. Third generation oral contraceptives and risk of venous thromboembolic disorders: an international case-control study. Brit Med J 1.996;312:83-8.
- The Contraception Report. 1997. “Trends in oral contraceptive development and utilization.” The Contraception Report 7(5): 4–14.
- The Contraception Report (1999). “Understanding oral contraceptive progestins: Classification of estranes and gonanes.” The Contraception Report 9(6): 9–10.
- The Contraception Report (2004)10 (2): 12–14.2004. “Approach to oral contraceptive nuisance side effects.” The Contraception Report 14 (4): 13–15.
- Ernst, U., L. Baumgartner, U. Bauer, and G. Janssen. 2002. “Improvement of quality of life in women using a low-dose desogestrel containing contraceptive: Results of an observational clinical evaluation.” European Journal of Contraception and Reproductive Health Care 7(4): 238–243.
- ESHRE Capri Workshop Group. 2000. “Continuation rates for oral contraceptives and hormone replacement therapy.” Human Reproduction 15(8): 1,865–1,871.
- Michel, D.R. 1993. “No contraceptive benefits of oral contraceptives.” Journal of Reproductive Medicine 38 (12, Supplement): 1,021–1,029.
- O’Brien, B. and S. Nabbed. 1992. “Nausea and vomiting during pregnancy: Effects on the quality of women’s lives.” Birth 19(3): 138– 143.
- Sheriff, Katherine. 1999. “Benefits and risks of oral contraceptives.” American Journal of Obstetrics and Gynecology 180(6, part 2): S323–S328.
- Isthmus (2005) Hormonal Contraception and Physiology: A Research-based Theory of Discontinuation Due to Side Effects Studies in Family Planning Volume 36 Number 1 March 2005 13
- Doha (1998) Review of Prescribing and Administration of medicines-Report on the supply and administration of Medicines under group protocols.
- DoH (1999) Review of Prescribing and Administration of Medicines.
- DoH (2002) Items prescribeable by nurses under the extended scheme London Department of health.
- Faculty of Family Planning (2002) UK selected Practice recommendations for contraceptive use (2002) London FPRHC
- FFPRHC Clinical Effectiveness Unit (2005) FFRHC Guidance (July 2005) The Use of Contraception Outside the Times of the Product Licence London FFPRHC
- FFPRHC (2006) Service Standards for Sexual Health Services January 2006 London FFPRHC
- NMC (2008) The Code The NMC code of Professional conduct: Standards for conduct, performance and ethics, London NMC
- Willacy (2009) Combined Oral Contraceptive (First Prescription) EMIS available at http://www.patient.co.uk/showdoc/40001580/
- Donaldson LJ (2004). Clinical Governance: a quality concept. In: Clinical Governance in Primary Care. 2nd edition. Zwanenberg T and Harrison J (Eds). Oxford: Radcliffe Medical Press, 2004.
- Naidoo, J and Wills, J (2005) Public health and health promotion: developing practice London: Bailliere Tindall
- Costello, J., Haggart, M., (2003) Public health and Society Palgrave Macmillan
- Orme, J., Powell, J., Taylor, P., Grey, M. eds (2007) Public Health for the 21st century 2nd ed. Open University Press
- Baggott,R. (2000) Public Health: Policy and Politics Palgrave
- Earle, S., Lloyd, C., Sidell, M., Spurr, S. (eds.) (2007)Theory and research in promoting public health Sage / Open University
- Orme, J., Powell, J., Taylor, P., Grey, M. (eds) (2007) Public Health for the 21st Century 2nd ed. Maidenhead: Open University/McGraw
- Scriven, A, Garman, S. (eds) (2007) Public health; social context and action Maidenhead: McGraw-Hill/Open University
- Scriven, A (ed.) (2005) Health Promoting Practice: the contribution of nurses and allied professionals Palgrave