Learning Objectives
By the end of this section, you will be able to:
- Compare and contrast the different types, benefits, side effects, and risks of combined oral hormonal methods of contraception
- Compare and contrast the different types, benefits, side effects, and risks of combined transdermal hormonal methods of contraception
- Compare and contrast the different types, benefits, side effects, and risks of combined vaginal hormonal methods of contraception
- Compare and contrast the different types, benefits, side effects, and risks of progestin-only hormonal methods of contraception
Hormonal contraceptives contain either estrogen and progesterone or progesterone only. They are highly effective and are available in many forms, such as pills, patches, vaginal rings, intramuscular injections, arm implants, and intrauterine device. Hormonal contraceptives are multifunctional, meaning they can be used as a contraceptive and may also be used to control other conditions such as dysfunctional uterine bleeding and dysmenorrhea. The nurse and health-care provider complete a thorough history and physical exam to identify any contraindications to hormonal contraception. Because this method is available in many forms, the nurse explores the person’s understanding of the method, reason for desiring for that particular method, and goals associated with the contraception to determine what method best meets their needs.
Combination Estrogen-Progestin Contraceptives
The estrogen-progesterone combination oral pill (combined oral contraceptive [COC]) is highly effective, with a perfect use effectiveness rate of 99.7percent and a typical effectiveness rate of 93 percent (Dickey & Seymour, 2021). The mechanism of action is inhibiting the release of the ovum, creating an atrophic endometrium, and maintaining thick cervical mucus that slows and prevents sperm transportation through the upper reproductive tract (Vallerand & Sanoski, 2022). Reversibility is quick by simply stopping the medication. Most pill packets available on the market contain approximately 3 weeks’ worth of “active” pills and 2 to 7 days of placebos, which can be a sugar tablet or more often an iron tablet (Figure 5.8). The placebo pills allow for a medically induced bleed, which can last anywhere from 3 to 7 days. Generally, this bleed is lighter and of shorter duration than menses without hormonal contraception. Persons with conditions improved by amenorrhea (e.g., iron deficiency anemia) can benefit from the lighter, shorter bleed that accompanies the continuous use of COCs.
After a thorough history and physical, assessment of the patient’s medications, and review of their last menstrual period and last sexual encounter, the nurse will perform a point-of-care pregnancy test to rule out pregnancy prior to starting the COCs (ACOG, 2022a). Additionally, the nurse will use the MEC Criteria (see 5.1 Contraception: The Nurse’s Role to ensure the person has no contraindications to combination hormonal birth control. The nurse will then educate the person on how and when to start COCs (Table 5.7). The nurse also educates the person on taking their pill at approximately the same time every day. The nurse can provide examples of ways to make reminders to take their pill. When COCs are not taken every day, there is a risk for irregular bleeding and a higher risk for pregnancy (Dickey & Seymour, 2021). The nurse will educate the person on what to do if they miss a pill. Table 5.8 provides instructions on missed COCs.
| Method | Description |
|---|---|
| Sunday start method | With the Sunday start method, the patient is educated to begin taking the COC pills on the Sunday that follows the first day of the next menstrual cycle. With this method, the patient will need to use a “backup method” (barrier method) for the first 7 days after starting the COC for additional protection against pregnancy. |
| Quick start method | In the quick start method, the patient can begin taking the COC pills on the day of the appointment because they have been deemed “reasonably certain” of not being pregnant due to history taking and point-of-care pregnancy test; with this method, a “backup method” (barrier method) is necessary for the next 7 days. Interestingly, research suggests that when this method is used, patients are more likely to be using the COC pills 3 months later when compared to those who used other startup methods (Zeiman et al., 2015). |
| Menstrual start method or day one start method | In the menstrual start method, the patient begins taking the COC pills on the first day of their next menstrual cycle. With this method, the COC pills will prevent ovulation from occurring, so no “backup method” is necessary. |
| Missed Pills | Time in Cycle | Instructions to Patients |
|---|---|---|
| 1 | Anytime | Take missed OC immediately and next OC at regular time. |
| 2 | First 2 weeks | Take two OCs daily for the next 2 consecutive days; then resume taking OCs on regular schedule. Use additional contraception for the remainder of the cycle. |
| 2 | 3rd week | Take two OCs daily until all active pills are taken. Restart OCs with one pill daily within 7 days. Use additional contraception until OCs are restarted and for the first 7 days of OC use. |
| 3 or more | Anytime | Stop OCs; restart OCs within 7 days with one pill daily. Use additional contraception through the first 7 days of the next pill cycle. |
Noncontraceptive Benefits of COCs
Combination oral contraceptives impact the hypothalamic-pituitary-ovarian (HPO) axis. Disruption of the HPO axis inhibits ovulation by interrupting the negative-positive feedback loop. causing a decrease in luteinizing hormone (LH) and follicle-stimulating hormone (FSH), thus preventing ovulation (Hatcher, 2018). Figure 5.9 demonstrates the process of the HPO axis.
Risks and Side Effects of COCs
Combination oral contraceptives have been thoroughly studied and widely used in the United States for many years. The risks involved with hormonal contraceptives are related to the use of ethinyl estradiol, a form of synthetic estrogen (Dickey & Seymour, 2021). In the past, the high dose of estrogen (150 mcg/dose) increased risk for myocardial infarction (MI); venous thromboembolism, or blood clots that form within veins; and strokes (Hatcher, 2018). Over the years, the estrogen dose has decreased to 10 to 35 mcg/dose, with COCs under 35 mcg/dose and 20 mcg being labeled as “low dose” (Hatcher, 2018; Allen, 2024).
The risk factors of COCs include venous thromboembolism (VTE), myocardial infarction, stroke, hypertension, gallbladder disease, cholestatic jaundice, hepatic neoplasms, and melasma (Hatcher, 2018). People who smoke or vape are at higher risk for VTE, especially those over the age of 35 years, and are not candidates for COCs. Other confounding conditions include obesity and genetic clotting disorders like factor V Leiden. The nurse educates the patient to call their health-care provider for signs of a possible VTE or other complication of COC use, including abdominal pain, chest pain, headaches, eye problems, and severe leg pain (ACHES; Hatcher, 2018). Table 5.9 provides further discussion of these symptoms. The side effects that a person may experience from use of a COC are listed in Table 5.10.
| Symptom | Diagnosis | Location | Further Symptoms |
|---|---|---|---|
| A: Abdominal pain | Mesenteric vein thrombosis, pelvic vein thrombosis | Intestines Pelvis |
Abdominal pain, vomiting, weakness |
| Hepatic neoplasms | Liver | Nausea, vomiting, weakness, jaundice | |
| C: Chest pain | Pulmonary embolism | Lungs | Cough, shortness of breath |
| Myocardial infarction | Heart | Crushing chest pain, left arm and shoulder pain, weakness | |
| Cholelithiasis | Gallbladder | Nausea, pain radiating to upper back (especially after meals) | |
| H: Headache | Stroke | Brain | Headache, weakness, numbness, visual problems, sudden intellectual impairment |
| Hypertension | Systemic | Headache, blurred vision | |
| E: Eye problems | Retinal vein thrombosis | Eye | Headache, complete or partial loss of vision |
| S: Severe leg pain | Thrombophlebitis | Leg | Swelling, heat, redness, tenderness in thigh or lower leg, calf pain |
| Symptom Due to Estrogen | Symptom Due to Progesterone |
|---|---|
| Increased cholesterol levels (HDL, LDL, total lipids, triglycerides) | Increased insulin or insulin resistance |
| Increased prothrombin time (PT), clotting factors, partial thromboplastin (PTT), fibrinogen | Flow length decrease (in progestin-only pills) |
| Cystic breast changes | Acne or oily skin |
| Dysmenorrhea | Depression |
| Increase in breast size | Fatigue |
| Uterine fibroid growth | Increased appetite; weight gain |
| Bloating | Pruritus |
| Weight gain (cyclic) | Decreased libido |
Positive Side Effects of COCs
Hormonal contraception can be used to treat certain conditions. Noncontraceptive positive side effects of COCs include treating dysfunctional uterine bleeding, dysmenorrhea, endometriosis/adenomyosis, menstrual migraines, and polycystic ovaries (Dickey & Seymour, 2021). Persons with premenstrual dysphoric disorder can prevent mood changes and depression by using COCs. The nurse can educate the patient on the protective properties associated with COCs, including decreasing the incidence of endometrial cancer, ovarian cancer, colorectal cancer, and iron deficiency anemia (Hatcher, 2018). Other benefits include treating acne and hirsutism (ACOG, 2023b). COCs can also be used for the perimenopausal age group who are experiencing vasomotor symptoms such as hot flushes but who are too young for menopausal hormonal replacement therapy (Dickey & Seymour, 2021).
Transdermal Hormonal Contraception
The combined hormonal contraceptive patch is a small, thin piece of plastic that releases approximately 150 mcg of progesterone and 20 mcg of estradiol daily (Figure 5.10). The nurse educates the person to place the patch on the skin of the lower abdomen, buttocks, upper outer arm, or trunk, but never the breasts, and to rotate placement with each replacement. The patch is changed weekly for 3 weeks. On the fourth week, the patch is left off to have a menstrual-type bleed. When the patch is removed, it should be disposed of in a place where pets and young children cannot reach it.
Risks and Side Effects of the Transdermal Patch
The contraceptive patch has the same mechanism of action, side effects, risk factors, and MEC criteria as all other combined hormonal contraception. The patch should not be used in persons weighing more than 198 pounds (90 kilograms) as it is not as effective (Birth control patch, 2023). The nurse provides education about ACHES and how to call the health-care provider if the patient experiences those side effects. The nurse should also explain that the patch can cause a rash or skin irritation and that the patient should call the office for these symptoms.
Patient Education
If the patch loosens or falls off before the week is completed, the nurse should advise the patient to replace it and use a backup method for pregnancy prevention for 7 days (Hatcher, 2018; Schuiling & Likis, 2016). The patch is as safe and effective as combination oral contraceptive pills and has a better rate of patient compliance (Jakimiuk et al, 2011).
Vaginal Contraceptive Ring
Another hormonal contraceptive option is the vaginal ring. The contraceptive ring has the same mechanism of action, side effects, risk factors, and MEC criteria as all other combined hormonal contraception, with the addition of vaginitis as a side effect. As of 2018, two vaginal contraceptive rings are available. NuvaRing is a flexible ring containing 2.7 mg of ethinyl estradiol and 11.7 mg of a progesterone and is 99 percent effective for perfect use and 97 percent effective for typical use (Dickey & Seymour, 2021) (Figure 5.11). This method is considered a safe, effective, low-dose form of contraception lasting for 3 weeks (21 days; Dickey & Seymour, 2021). The nurse instructs the person to place the ring far into the vagina and not to remove it for 3 weeks. On week four, the ring is removed, and a bleed will occur. Once removed, the ring should be disposed of safely.
The new vaginal contraceptive ring Annovera is slightly different from the NuvaRing, as it is larger in diameter, lasts for 1 year, can be washed when removed, and is nondisposable for 13 cycles (Dickey & Seymour, 2021). Annovera is a flexible silicone ring that emits 150 mcg of progesterone and 13 mcg of estradiol daily (Dickey & Seymour, 2021) (Figure 5.12). The ring emits this dose for 1 year and is 97.5 percent effective in perfect use (Virro, 2020). Due to the newness of this product, no statistics for typical use effectiveness are available. The nurse educates the person to insert the ring far into the vagina and leave it for 21 days. The ring is then removed for a week and washed with warm water and mild soap. The nurse explains that the person will have a bleed during that week and will then return the ring to the vagina for another 21 days. The contraceptive ring is disposed of safely after 13 cycles, and a new ring can be obtained from the health-care provider.
Progesterone-Only Contraception
Progesterone-only contraceptives do not contain estradiol. Instead, this form of contraception uses only progesterone, making it a safer option than estrogen-containing contraceptives. These methods of contraception are ideal for persons over the age of 35 who smoke, persons who are breast-feeding, and those at risk for cardiovascular disease (Hatcher, 2018). Progesterone-only contraception causes inhibition of ovulation, thickened cervical mucus that blocks sperm from penetrating the cervix, and altered endometrium that inhibits implantation (Hatcher, 2018). Progesterone also slows the activity of the cilia in the fallopian tubes, preventing sperm from reaching the egg (Hatcher, 2018). If a person does become pregnant, they have a slightly higher risk of ectopic pregnancy due to the slow movement of the cilia not pushing the fertilized ovum through the fallopian tube and into the uterus.
The reported side effects of progesterone-only methods include irregular bleeding, headache, nausea, breast tenderness, weight gain, and ovarian cysts (Dickey & Seymour, 2021). Adverse effects seen in progesterone-only contraceptives include the possibility of VTE, depression, and loss of bone density (injection only). The MEC criteria for progesterone-only methods include current breast cancer as the only absolute contraindication (Hatcher, 2018). The nurse can recommend a progesterone-only method to most persons considering hormonal contraception who need to avoid estrogen.
Progesterone Intramuscular Injection
Depo-Provera, or depot-medroxyprogesterone acetate (DMPA), is a long-acting, injectable, progestin-only contraceptive method containing 150 mg of DMPA for intramuscular administration every 12 weeks (Hatcher, 2018). DMPA has the same side effects, mechanism of action, and adverse effects as all progesterone methods, with the addition of decreased bone density and increased time to return to fertility. DMPA suppresses production of estradiol from the ovaries, and estradiol is a protector of bones by inhibiting bone resorption. Therefore, without the production of estradiol, the person’s bones are reabsorbed, causing decreased bone density (Hatcher, 2018). This decrease in bone density occurs rapidly during the first 2 years of use (Dickey & Seymour, 2021). After discontinuing DMPA, return to fertility can take 9 to 10 months, the longest of all contraceptive methods (Hatcher, 2018).
Patient Education
Patient education regarding DMPA should include the need to return to the clinic every 12 weeks for repeat injections to ensure effective contraception. The nurse explains the possibility of irregular bleeding and weight gain, encouraging the person to increase exercise and reduce calories if weight gain occurs. The nurse assesses the person’s desire for future pregnancies and explains the increased time needed to return to fertility (Hatcher, 2018). Warning signs are reviewed: repeated, very painful headaches; heavy bleeding; depression; severe lower abdominal pain (could be pregnant); and infection at the injection site (Hatcher, 2018). Education is also provided regarding decreased bone density in the first 2 years of use. The nurse encourages the person to supplement their diet with 1,200 mg of calcium and 5,000 IU of vitamin D daily. In 2004, the FDA issued a black box warning on DMPA because bone demineralization has been linked to the development of osteoporosis and recommended that persons discontinue DMPA after 2 years of use (Dickey & Seymour, 2021). Further information regarding the black box warning can be found on Pfizer’s website.
Clinical Safety and Procedures (QSEN)
Safety and DMPA Injection
Before administering DMPA, the nurse must confirm the patient is not pregnant. The following safety steps should be taken:
- Ask if the patient has been using any contraception. If not, a pregnancy test should be performed.
- Ask if the patient is switching from another contraceptive method. Assess if the patient has used the method perfectly (missing pills, broken condoms, use of spermicide, etc.). If not, a pregnancy test should be performed.
- Ask if the patient has missed their 12-week dose of DMPA. If so, a pregnancy test should be performed.
Overall, the goal of performing a pregnancy test before giving Depo-Provera is to confirm that the patient is not pregnant and to prevent inadvertent exposure to the medication during pregnancy. It is important to follow protocols and guidelines regarding pregnancy testing before administering Depo-Provera.
Progestin-Only Oral Pills
Progestin-only birth control pills (POPs) are also known as the “mini-pill.” POPs are found in medication packs containing 28 progestin active pills with no placebos (Figure 5.13). POPs are taken daily without an “off week.” POPs have the same side effects, mechanism of action, and adverse effects as all other progesterone-only methods. According to the MEC criteria, POPs are safe for those who cannot take estrogen and those who are breast-feeding (Hatcher, 2018). Like other hormonal contraceptives, POPs aid in decreasing symptoms of menstrual complications (dysmenorrhea, endometriosis pain, etc.). POPs are 99 percent in perfect use effectiveness and 91 percent in typical use effectiveness (Hatcher, 2018). Some POPs must be taken at the same time every day within 3 hours of the 24-hour time period. Newer-generation POPs are not as sensitive to time restraints, providing better efficacy. Nursing education includes explaining the side effect of irregular bleeding and stressing the importance of taking the pill at the same time daily. The nurse explains that return to fertility is immediate after discontinuation of the pill.
Table 5.11 compares and contrasts the various hormonal contraceptive options, and Table 5.12 summarizes additional information about each.
| Method | Pros | Cons | Perfect Use Efficacy (% successful pregnancy prevention) | Typical Use Efficacy (% successful pregnancy prevention) |
|---|---|---|---|---|
| COC | Very effective; resolves issues such as dysmenorrhea, menorrhagia, metrorrhagia, premenstrual dysphoric disorder (PMDD), etc.; quickly reversible; prevents acne | Health-care provider visit required; prescription required; can be costly; contraindications due to certain disorders; must be taken daily; no protection against STIs | 99.7 | 93 |
| Contraceptive patch | Only need to think about it weekly instead of daily; very effective; resolves issues such as dysmenorrhea, menorrhagia, metrorrhagia, PMDD, etc.; quickly reversible | Health-care provider visit required; prescription required; can be costly; contraindications due to certain disorders; no protection against STIs; can come off skin if not placed properly | 99.7 | 93 |
| Contraceptive vaginal ring | Very effective; resolves issues such as dysmenorrhea, menorrhagia, metrorrhagia, PMDD, etc.; quickly reversible; prevents acne; can be used for 1 month (NuvaRing) or 13 cycles (Annovera) | Health-care provider visit required; prescription required; can be costly; contraindications due to certain disorders; no protection against STIs; can cause vaginitis, vaginal discharge, or itching | NuvaRing: 99% Annovera: 97.5% |
NuvaRing: 97% Annovera: unknown |
| Progesterone-only injection (DMPA) | Longer-term option; can be used while breast-feeding; absence of menstrual bleeding; resolves issues such as dysmenorrhea, menorrhagia, metrorrhagia, PMDD, etc.; very effective | Health-care provider visit required initially and every 3 months; can be costly; decreases bone density; weight gain; longer time frame to return to fertility; irregular bleeding and no protection against STIs | 98.8 | 94 |
| Progesterone-only pill | Safe for those who cannot take estrogen; effective; resolves issues such as dysmenorrhea, menorrhagia, metrorrhagia, PMDD, etc.; quickly reversible; do not need to take a week-off pill for a bleed | Health-care provider visit required; can be costly; lower efficacy than with combined hormonal methods; less popular than COCs and can be difficult to access; increased risk of ectopic pregnancy, and no protection against STIs; important to take the pill around the same time of day for best effect | 99 | 91 |
| Method | Mechanism of Action | Side Effects | Adverse Effects | Ideal Candidate | Education |
|---|---|---|---|---|---|
| COC | Prevents ovulation by suppressing gonadotropin-releasing hormone (GnRH), LH surge, FSH; thickens cervical mucus; alters endometrial lining, preventing implantation | Breast tenderness, nausea and vomiting (N&V), weight gain, mood swings, headache | ACHES, VTE, stroke, MI, gallbladder disease, cholestatic jaundice, hepatic neoplasms, and melasma | Someone committed to taking a pill daily, can afford the method, and is healthy; persons with disorders/pain surrounding the menstrual cycle | If pill is missed, take the missed pill as soon as it is remembered or, if not remembered until the next day, take 2 pills at that time. |
| Contraceptive patch | Prevents ovulation by suppressing GnRH, LH surge, FSH; thickens cervical mucus; alters endometrial lining, preventing implantation | Breast tenderness, N&V, weight gain, mood swings, headache | ACHES, VTE, stroke, MI, gallbladder disease, cholestatic jaundice, hepatic neoplasms, and melasma | Teenager or person unable or unwilling to take something daily; can afford the method and is healthy; persons with disorders/pain surrounding the menstrual cycle | Place patch on clean, dry skin; can place on upper arm, buttocks, lower abdomen, or upper torso, avoiding breasts. Place one patch for 7 days, dispose of the patch, and replace with a new patch for a total of 3 weeks. Week 4, no patch is placed and a bleed will occur. |
| Contraceptive vaginal ring | Prevents ovulation by suppressing GnRH, LH surge, FSH; thickens cervical mucus; alters endometrial lining, preventing implantation | Breast tenderness, increased vaginal discharge | Vaginitis, vaginal discharge, pain, and itching; ACHES; VTE, stroke, MI; gallbladder disease, cholestatic jaundice, hepatic neoplasms, and melasma | Person looking for a longer-lasting contraception; person unable or unwilling to take something daily; can afford the method and is healthy; persons with disorders/pain surrounding the menstrual cycle | NuvaRing: Insert one ring vaginally for 21 days, then remove for 1 week; insert a new ring. Annovera: Insert one ring vaginally for 21 days, then remove for 1 week, wash with soap and water; reinsert. |
| DMPA | Inhibits ovulation, thickens cervical mucus, alters the endometrium | Weight gain, headache, irregular bleeding, decreased libido, breast tenderness | Bone demineralization; delay of return to fertility; warning signs of very painful headaches, heavy bleeding, depression, severe lower abdominal pain, and infection at the injection site | Breast-feeding person, in need of longer-term method, persons not able or willing to take a pill daily, persons with reliable transportation to receive injection every 12 weeks | Injections must be repeated every 12 weeks to ensure effective contraception; be aware of irregular bleeding; educate to increase exercise and reduce calories if experiencing weight gain; could take 10 months to return to fertility. |
| Progestin- only pill | Inhibits ovulation, thickens cervical mucus, alters the endometrium, slows cilia in fallopian tube | Irregular bleeding, headache, nausea, breast tenderness, weight gain, less forgiving regarding missing pills, ovarian cysts | Possible VTE, ACHES, increased risk of ectopic pregnancy | Breast-feeding person, smoker over age 35 years, responsible and can remember to take a pill at the same time every day | Warn for irregular bleeding; take pill at the same time every day (within 3 hours); if longer than 3 hours past 24-hour mark or missed a pill, use backup protection for 48 hours; do not stop the pill for a week for a bleed; fertility returns immediately after stopping pills |