Issued: July 2013 Review date: July 2014
Medicine Standing Order Title Combined Oral Contraception
Rationale: In a rural GP clinic there are times when an authorised prescriber is not available and in order for patients to
access care a registered nurse using standing orders is the best option.
Organisation/clinic: Church Street Surgery Opotiki
Scope: To enable registered nurse working in the clinic to treat patients aged 12 and over who
are sexually active and at risk of unplanned pregnancy.
Medicine/s: Ethinyloestrodial combined with: Levonorgestrel, Norethisterone, Drospirenone
Cyproterone acetate, Gestodene or Desogestrel.
(Loette, Microgynon 20, M Loette, Microgynon 20, Monofeme 28, Microgynon 30, Levlen,
Norimin, Brevinor 28, Brevinor 1, Yasmin, Ginet, Mercilon, Marvelon, Femodene)
Dosage instructions for each medicine: At same time each day, (12 hr leeway)
20mcg Ethinyloestrodiol, 100mcg Levonorgestrel (Loette, Microgynon 20)
30mcg Ethinyloestrodiol, 150mcg Levonorgestrel (Monofeme 28, Microgynon 30, Levlen ED)
35mcg Ethinyloestrodiol, 0.5mg Norethisterone (Norimin or Brevinor 28)
35mg Ethinyloestrodiol, 1 mg Norethisterone (Brevinor 1)
30 mcg Ethinyloestrodiol, 3mg Drospirenone (Yasmin)
35 mcg Ethinyloestrodiol, 2mg Cyptroterone acetate (Ginet)
20mcg Ethinyloestrodiol, 150mcg Desogestrel (Mercilon)
30mcg Ethinyloestrodiol 150mcg Desogestrel (Marvelon)
30mcg Ethinyloestrodiol, 75mg Gestodene (Femodene)
Route of administration: Oral
Indication/circumstances for activating the standing order:
Female clients aged 12 yrs or older requiring Oral Contraception First visit / repeat visit Protocol
for Combined Oral Contraceptives has been followed (see attached.)
Precautions and exclusions that apply to this standing order:
Any client who has any two Category WHO 2 or one Category WHO 3 contra-indications (not
including those contra-indications authorised as exclusions by the issuer) is reviewed by the
issuer prior to commencement of the medication and the Standing Order is authorised, or the
client is offered an alternative method of contraception.
Contraindications : Category WHO 4 (Do not Use) Category WHO 3 (Caution / counselling)
Category WHO 2 (Broadly useable)
Persons authorised to administer the standing order:
Registered nurses
Competency/training requirements for the person(s) authorised to administer:
Prior to administering COC under this standing order the registered nurse is required to undergo the in-house training on the policy,
procedure and documentation requirements for this standing order. In addition the registered nurse may undertake Family Planning
and Sexual health training.A record of this training will be kept.
Countersigning and audit
Countersigning by the issuer is required within 7 days of use of this standing order
Definition of terms used in standing order:COC – combined Oral Contraception
Additional information: Follow attached protocol.
Signed by issuer:
Name:
Date:
Title: medical practitioner
Signed by management:
Name:
Date:
Title:
Signed by nurses working with Standing Order
Name/s :
Date:
This Medicine Standing Order is not valid after the review date.
Contra-indications
table
Cardiovascular
disease
WHO 2
VTE 1st degree relative 45+ years3
VTE in 2nd degree relative3
VTE 1st degree relative < 45 years +/precipitating factor (& client has normal
clotting factors)3
After major surgery without prolonged
immobilisation1,2
Ischaemic heart disease
Migraines
Migraine without aura < 35 yrs1 prior to
commencing COC.
WHO 3
WHO 4
1st degree <45 years + precipitating factor (&
thrombophilia screen not available)3
Long term partial immobilisation.
Wheelchair / debility3.
Client has previous / current VTE2
FH VTE/thrombophilia 1st degree <45 years &
client thrombophilia screen unavailable.
FH VTE 1st degree relative < 45 years & client
has abnormal thrombophilia screen.
Client has prothrombotic abnormalities of
coagulation / fibrinolysis
Multiple risk factors for cardiovascular
disease1,3
Severe or combined arterial and venous risks3
Major surgery (for 2 - 4weeks prior to 2 weeks
post) with prolonged immobilisation
Leg immobolisation3
High altitudes if other risk factor3
Amaurosis fugax (transient complete loss of
vision)3
Known hyperlipidaemia and responding to
treatment3
FH familial hyperlipidaemia or idiopathic event
in 1st degree <45yrs & clients lipids not
available 3
Personal past or present history of:
Ischaemic heart disease, MI, TIA, angina,
ATE disorder, CVA.
Familial hyperlipidaemia – persistant despite
treatment
Migraine without aura ≥ 35 yrs prior to
commencing COC.
Migraine without aura < 35 yrs since
commencing COC + one other arterial risk 3
Migraine with aura (any age) > 5 years ago2
Migraine with aura at any age.
Migrianes without aura ≥35yrs since
commencing COC .
Migraine without aura lasting > 72 hours2
Aura no headache2
All migraines and taking ergotamine2
Contra-indications
table
WHO 2
WHO 3
WHO 4
Age (uk)
< 35yrs and smoking any amount with no other
risk factor2
≥ 35 yrs and smoking < 15 a day2.
- ≥ 35 yrs and one other risk factor / smoke ≥
15 a day2
Weight
30 – 34 kg/m22
≥35 – 392
≥401
Smoking
< 35 yrs + no other risk factor.
< 35 yrs+ one other risk factor
≥ 35 yrs + smoking < 15 day.
≥ 35 yrs + smoking ≥ 15 day
Smoking ≥40 day3
Hypertension
Previous pregnancy related & now normal.
BP regularly upper limit normal1
Previous hypertension and BP unmeasured
(including pregnancy)
Controlled (on meds) & BP measured and
Normal
Systoloc: 140-1592,3
Diastolic: 90-993
Systolic ≥1601,2,3
Diastolic ≥1001,2,3
Vascular disease3
Diabetes
No vascular complications.
With nephropathy, retinopathy, neuropathy or
other vascular disease.
Diabetes > 20 years.
Structural Heart
Disease
Uncomplicated valvular heart disease
Varicose veins
History of superficial thrombophlebitis in lower
limbs & no DVT3
-
Current superficial thrombophlebitis in upper
thigh3
Following VV surgery until dressings removed3
Liver &
Gall Bladder Disease
Pregnancy related cholestasis.
Gallstones – asymptomatic or treated
Gilberts disease3
Glandular fever > 3months ago with no
complications
Previous COC related cholestasis
Mild cirrhosis.
Symptomatic gall stones / gall bladder
disease (current or medically treated).
Other porphyria3
Cholestatic jaundice (COC related).
Active liver disease(acute viral hepatitis, severe
cirrhosis).
Benign / malignant adenoma or hepatoma
Acute hepatic porphyria3.
During /after severe glandular fever or other
viral hepatitis until 3 months after LFT's
normal.
Complicated valvular heart disease (with
pulmonary hypertension,atrial fibrillation,
previous SBE).
Contra-indications
table
WHO 2
WHO 3
Serious condition
affected by sex
steroids/related to
previous COC use
WHO 4
Cholestatic jaundice, Chorea.
Pancreatitis due to hyper-trigylceridaemia
Pemphigoid (herpes) gestationis.
Stevens-Johnson syndrome or erythema
multiforme(if COC related).
Trophoblastic disease – until HCG not
detected3
Rheumatic Disease
SLE +/- Severe thrombocytopenia or
Immunosuppressive therapy1
Breast Disease
First degree relative < 40 years had
breast cancer.
Benign breast disease.
Undiagnosed breast lump occurring whilst on
COC2
History, remission more than 5 years.
Benign with epithelial atypia.
Undiagnosed breast lump occurring on
commencing COC2
Known carrier of BRCA1 mutation2
Current breast cancer or remission < 5 years.
Premalignant epithelial atypia3
Pregnancy / Post
Partum/
Breast feeding
> 6 months post partum and breast
feeding
6 wks to 6 months post partum & partial BF2
< 3 weeks post partum.
Known pregnancy.
6 wks to 6 months post partum & primarily BF
Breastfeeding < 6 weeks post partum
Vaginal Bleeding
Unexplained (pending evaluation).
Chronic Systemic
Diseases
All others not listed in category 3.
Sickle cell disease (trait WHO 1)
Inflammatory bowel disease1,2
Chronic renal disease.
Medications
NNRTI1,2
En zyme inducing medication
Ritonavir boosted protease inhibitor1,2
SLE + positive (or unknown) anti-phospholipid
antibodies1
Ovarian, Cervical,
Cancers.
Endometrial Diseases Benign ovarian tumour.
Abnormal smears during monitoring.
CIN during and after treatment
Miscellaneous
Very severe depression worsened by COC3
Secondary Raynauds disease without lupus
Hyperprolactinaemia3 GB only
Past benign intracranial hypertension3
Haemolytic urameic syndrome3
Contra-indications
table
WHO 2
anticoagulant 2
WHO 3
WHO 4
Thrombocytopenic purpura3
Allergy to constituents.
Secondary Raynauds disease with lupus
anticoagulant2
combined oral contraceptive policy
First Visit
1. Describe how COC works, failure rate, advantages/disadvantages.
2. Assess client suitability for COC and fully discuss risks and side effects.
3. - Check level of understanding, if in doubt do not issue medication, refer to doctor
4. Check History and exclude contraindications as per WHO tables above.
5. If there is a possible( relative) contraindication discuss on the day with doctor
prior to commencing on alternative eg. POP
6. Check BP, height and weight & start on 2nd generation subsidised COC (currently
either Levlen one tablet daily,or Norimin one tablet daily). Give script for 3 month
supply from stock if available, information sheet VTE risk sheet, and condoms.
Explain how to take pill and the 7day rule. Advise to continue with condom use in
addition to the COC where acceptable.
7. Countersigning is to be completed by issuer (To be set for the doctor on Medtech
task list)
Subsequent visits
1. Check compliance and suitability - May change to alternative 2nd generation or a 3rd
generation if having problems on initial pill choice and fully informed especially re
thromboembolic risks.
2. Check no new contraindications
3. BP check first two visits and then annually. Weight check if indicated by complaint of
weight gain or BMI is borderline ie. 28
4. Enquire if needs STI check and/or smear.
5. Check understanding of 7 day rule.
6. Give repeat script for 6 months.
7. Countersigning is to be completed by issuer (To be set for the doctor on Medtech task)
combined oral contraceptive (COC) protocol
Combined oral contraceptive checklist
for commencement or continued supply of COC pill
Describe how COC works
Advantages
-99% effective, convenient, regular
periods usually lighter, not permanent,
reduces risk or cancer of ovary and
endometrium by 50%, may improve
acne, PMT and iron deficiency anaemia
Serious side effects
Absolute contraindications
- oestrogen dependent neoplasms
- undiagnosed genital tract bleeding
- BMI > 39
-pregnancy
- Focal migraines ( with focal aura)
- Hypertension (BP > 160/95 on repeat
testing
- History of venous thromboembolism
(VTE)
- Liver disorder/disease
- Heart disease
- Medications, rifampicin, griseofluvin,
barbiturates, phenytoin,
carbamazepine, primidone,
topiramate, ritonavir
- Acute pophria
Check
- BP, Height, Weight and BMI
Pill start:
- day 1 –3 of cycle – safe straight away
- any other time – safe after 7 hormone
pills – use condoms
- Encourage client to discuss personal
health and contraception needs with
family/ caregiver/whānau esp. if under 16
yrs
- Check level of understanding, if in doubt
do not issue medication, refer to doctor.
Oestrogen and Progestogen in pill stops
ovaries from ripening
Disadvantages
-Remembering to take it, bleeding
between periods, breast tenderness,
nausea, headaches, sexual feelings, skin
changes
Chest pain(heart attack)
Cough up blood (blood clot in lung)
Breathless (blood clot in lung)
Pain in the lower leg (blood clot)
Severe headache (migraine, stroke)
Possible (relative) contraindications
Must see Medical Practitioner.
From family history:
- Heart disease – if primary relative <45
years (test fasting lipids)
- VTE – if primary relative < 45 years
- (test APC resistance, protein C,
Protein S, Factor 5 Leyden)
- Breast Cancer
Enzyme inducing drugs - management
by Medical Practitioner
Also:
- Cigarette smoking > 40/day
- Diabetes mellitus
- BMI 30 –39
- Prolonged immobilisation
- St Johns Wort
Start on 2nd Generation subsidised COC
- Levlen, or Norimin
7 day rule: - use condoms until 7
hormone pills are taken, if you: miss two
hormone pills, vomit within 3 hrs of taking
hormone pill, diarrhoea, taking other
medications eg. SJW
- Provide client with FP information re:
pill start if commencing on COC
-
Countersigning is to be completed by
issuer (To be set for the doctor on
Medtech)