Combined Hormonal Contraception

Hormonal Contraceptives

The following are the standards for midwives to independently prescribe, order and administer hormonal contraceptives in the community, hospital or other sites of midwifery practice for clients in care, as designated under specialized practice certification. Midwives without Specialized Practice Certification in Hormonal Contraceptive Therapy are required to refer their clients to an appropriate health care practitioner for treatment. 

(Note: prescribing contraceptives requires certification in specialized practice)

The main mechanism of action of systemic combination contraceptives is to suppress gonadotropin secretion which inhibits ovulation. In addition, they 1) lead to endometrial atrophy making implantation less likely, 2) increase the viscosity of cervical mucus thus impeding sperm transport and 3) may impair secretion and peristalsis within the fallopian tube, interfering with ovum and sperm transport. They are available in monophasic, biphasic and triphasic combinations and include: 1) Desogestrel and Ethinyl Estradiol; 2) Ethynodiol Diacetate and Ethinyl Estradiol; 3) Levonorgestrel and Ethinyl Estradiol; 4) Norethindrone and Ethinyl Estradiol; 5) Norethindrone and Mestranol; 6) Norethindrone Acetate and Ethinyl Estradiol; 7) Norgestimate and Ethinyl Estradiol; and 8) Norgestrel and Ethinyl Estradiol. They are available in preparations that are delivered orally, by transdermal patch and intravaginal ring.

Prescribing:

Note: Prescribing contraceptives requires certification as a specialized practice. (See Framework for Certification in Prescribing Contraceptives).

The lowest dose preparation (35 mcg of ethinyl estradiol) that can achieve effective contraception, cycle control and minimal side effects should be prescribed. A variety of start dates for the combined OC can be considered: 1) Start during the first 5 days of the menstrual cycle or on the first Sunday after menses begin. No backup method of contraception is necessary to prevent pregnancy when all pills are taken; 2) Take first pill immediately upon ruling out pregnancy (regardless of timing in cycle). Back up contraception must be used for first 7 days.

Users of the 21-day regime should not exceed the 7 day pill-free interval between packs. The health-care provider should provide counselling about emergency contraception (EC) and provide a prescription for it. Dual protection with condoms is indicated if at risk of STIs and HIV transmission. Follow-up visit should be arranged to evaluate user experience and take blood pressure.

If prescriptive contraceptives are not affordable, there is the National Compassionate Oral Contraceptive Program SOGC at (800) 561-2416.

Instructions Regarding Missed Pills – from the SOGC:

  • If you miss 1 pill, take it as soon as you remember. This may mean taking 2 pills in 1 day.
  • If you miss 2 pills in a row during the first 2 weeks of the pack, take 2 pills on the day you remember and 2 on the following day. Use a backup method of contraception if you have sex in the 7 days after you miss the pills.
  • If you have had unprotected intercourse after missing a pill, use emergency contraception.
  • If you miss 2 pills in a row in the third week of the pack, throw out the remainder of the pack and start a new pack on the day you remember. You may not have a period this month. If you had unprotected intercourse after missing a pill, use emergency contraception.
  • If you miss 3 pills in a row, throw out the remainder of the pack and start a new pack on the day you remember.
  • If you had unprotected intercourse after missing a pill, use emergency contraception. Use a backup method of contraception if you have intercourse in the first 7 days of the new pack. You may not have a period this month.

Side Effects:

Include abnormal menstrual bleeding (breakthrough bleeding), nausea, weight gain, mood changes, breast tenderness, and headache.

Contraindications:

Absolute:

  • smoker over the age of 35 (≥15 cigarettes per day)
  • hypertension (systolic ≥160 mm Hg or diastolic ≥100 mm Hg)
  • current or past history of venous thromboembolism (VTE)
  • ischemic heart disease
  • history of cerebrovascular accident
  • complicated valvular heart disease (pulmonary hypertension, atrial fibrillation, history of subacute bacterial endocarditis)
  • migraine headache with focal neurological symptoms
  • breast cancer (current)
  • diabetes with retinopathy/nephropathy/neuropathy
  • severe cirrhosis
  • liver tumour (adenoma or hepatoma)

Contraindications:

Relative:

  • smoker >35 years old (
  • adequately controlled hypertension
  • hypertension (systolic 140-159 mm Hg, diastolic 90-99 mm Hg)
  • migraine headache over the age of 35
  • currently symptomatic gallbladder disease
  • mild cirrhosis
  • history of combined OC-related cholestasis
  • users of medications that may interfere with combined OC metabolism

Warnings and Precautions:

VTE; myocardial infarct; stroke; gall bladder disease; breast cancer and cervical cancer; estrogen component may reduce milk volume.

Adverse Reactions:

Include abnormal menstrual bleeding (breakthrough bleeding), nausea, weight gain, mood changes, breast tenderness, and headache.