Contraception: Counseling

Eve Espey MD, MPH

Basics
Description
Contraceptive counseling is paramount to help assist a woman in choosing a
method that fits her personal lifestyle and offers a/n:
o High degree of effectiveness
o ccepta!le side effect profile
Determination of a woman"s li#elihood of consistent and continuing use of a
given method will help avoid unintended pregnancy$
Contraceptive counseling includes counseling a!out emergency contraception,
a postcoital method$
ge%&elated 'actors
dolescents have the highest rates of unintended pregnancy of any age group$
dolescents have the highest rates of discontinuation of common
contraceptives li#e DMP and !irth control pills$
Married women are more li#ely to use contraceptives consistently and
correctly$
Epidemiology
()*+ of all pregnancies in the ,- are unintended$
()*+ of the unintended pregnancies in the ,- come from the .+ of women
who use no contraceptive method$
/he other half of unintended pregnancies in the ,- come from the 01+ of
women who use a method inconsistently, incorrectly, or use a method with a
high failure rate$
/he most common contraceptive methods used in the ,- are sterili2ation,
!irth control pills, and condoms:
o /he 3 top reversi!le methods 4!irth control pills and condoms5 are
highly user%dependent$
o /op%tier contraceptive methods do not re6uire continuing compliance
on the part of the woman:
7ntrauterine contraception
Hormonal implants
7mproved use of emergency contraception could reduce unintended pregnancy
!y 8/3$
3*+ of reproductive aged women were uninsured in 3**1$ /hey rely on a
num!er of underfunded family%planning programs for contraception$
39 states have mandated coverage of contraceptives for insurance plans that
offer prescription !enefits$ /hese laws have improved access to contraception$
&is# 'actors
ll se:ually active women of reproductive age are at ris# for unintended
pregnancy$
;oung, unmarried, poor women of color are at higher ris# for unintended
pregnancy$
dolescents are at higher ris# of contraceptive failure$
<enetics
=omen with unusual genetic and/or medical conditions such as hypercoagula!le
disorders, rheumatologic disease, or sei2ure disorders need more personali2ed
counseling a!out methods that are safe and effective$
Diagnosis
-igns and -ymptoms
History
/he ma>ority of serious adverse events that occur as a result of hormonal
contraceptives may !e determined !y ta#ing a detailed medical history$
Estrogen%containing contraceptives are contraindicated 4the ris#s outweigh the
!enefits5 for women with a history of:
o Migraines with aura
o History of throm!oem!olism 4D?/, PE5
o ,ncontrolled H/@
o -tro#e
o M7
o -mo#ing 4A8) cigarettes/d for women A1) years5
se:ual and contraceptive history are helpful in assisting a woman choose an
appropriate method:
o 8.%year%old <3P3 who has used pills as her only method of !irth
control in the past should consider another method$
o 1.%year%old <8P8 who has relied on condoms should not !e
discouraged from continuing to use them$
Physical E:am
pelvic e:am is rarely necessary to initiate contraceptives and may !e a
deterrent for certain populations, li#e adolescents$
7n the a!sence of medical contraindications, an e:am should not !e re6uired to
counsel a!out and initiate most contraceptives$
Blood pressure and weight should !e measured$
/ests
/esting to rule out pregnancy and -/7s is appropriate depending on the
patient"s age, history, and willingness$
,rine pregnancy testing
Cervical or urine gonorrhea and Chlamydia testing
Pap smear as indicated$ lthough cervical cytology testing is not mandatory
prior to initiating contraception, regular testing is indicated for preventive
health maintenance$ 7nitiation of contraception should not !e dependent on
Pap testing$
7maging
7maging is not re6uired for initiation of contraceptive methods$
/reatment
<eneral Measures
Counseling should stress:
o /horough review of all contraceptive options
o @on>udgmental !ut realistic e:pectations a!out difficulty of adhering
to a given method:
dolescents who must BhideC contraceptives may have more
difficulty adhering to a daily pill regimen$
,ninsured women may have difficulty continuing DMP
in>ections$
o @uisance side effects:
nticipatory guidance may improve a!ility to adhere$
o <uidance on missed pills, patch, shot, etc$
o /he method"s a!ility to protect against -/7s and the need for a dual
method 4i$e$, pills and condoms5 for women at ris# of unintended
pregnancy and -/7s
-tudies indicate that women have negative misperceptions a!out various
contraceptive methods:
o 7dentify specific negative perceptions
o &espectfully give accurate information
@oncontraceptive !enefits of certain hormonal contraceptives are generally
underappreciated:
o Cycle control
o &eduction in dysmenorrhea
o &eduction in acne
o &eduction in uterine and ovarian cancer
P$3D1
Postpartum women and women who have undergone termination of pregnancy
may !e particularly motivated to use contraceptives and should !e counseled
thoroughly a!out the variety of options$
Breast%feeding women may have concerns a!out the impact of hormonal
contraception on lactation and should !e counseled according to availa!le
evidence$
Contraceptive Choices
Most effective:
o -terili2ation
o 7ntrauterine contraception
o Hormonal implants
?ery effective:
o DMP
Effective:
o Birth control pills
o /he patch
o /he vaginal ring
Eess effective:
o Condoms
o Diaphragm
o -permicidal foams, films, >elly
-urgery
-terili2ation/Permanent contraception should !e offered as an option$ 7t may !e
performed !y:
Mini%laparotomy is most commonly performed for !ilateral tu!al ligation in
the immediate postpartum period$
Eaparoscopy is used for the ma>ority of interval procedures, most commonly
with inert metal clips or cautery$
HysteroscopyF the Essure sterili2ation system places coils hysteroscopically
into !oth tu!al ostia$
?asectomy, male sterili2ation, is accomplished !y interrupting the vas
deferens$
'ollowup
Disposition
7ssues for &eferral
=omen with complicated medical pro!lems may !e referred to family%planning
e:perts for specific advice regarding contraceptive choices$
Prognosis
Pediatric Considerations
-tates vary in their laws a!out parental notification or consent for
contraceptives$
7t is important to !e aware of relevant state laws regarding consent for
contraceptives$
Complications
/rue medical complications of hormonal contraceptives are rare in healthy
young women$
&is#s of mor!idity and mortality are typically greater with pregnancy than
with contraceptive methods$
Contraindications to estrogen%containing hormonal contraceptives include
migraine with auraF history of D?/, M7, or stro#eF H/@F and smo#ing A1)
years of age$
Bi!liography
Mosher =D, et al$ ,se of contraception and use of family planning services in the
,nited -tates, 80G3H3**3$ dv Data$ 3**DF1)*:8H1)$
-antelli I-, et al$ Contraceptive use and pregnancy ris# among ,$-$ high school
students 8008H3**1$ Perspect -e: &eprod Health$ 3**9F1G435:8*9H888$
-onfield , et al$ ,$-$ 7nsurance coverage of contraceptives and the impact of
contraceptive coverage mandates, 3**3$ Perspect -e: &eprod Health$ 3**DF19435:.3H
.0$
=HJ Department of &eproductive Health and &esearch$ -elected Practice
&ecommendations for Contraceptive ,se, 3nd ed$ <eneva: =orld Health
Jrgani2ationF 3**D$
Miscellaneous
-ynonym4s5
K Birth control
K Contraception
K 'amily planning
Clinical Pearls
K Many women re6uest !irth control pills !ecause that is the method they are familiar
with$
K Even if a woman re6uests a specific contraceptive method, review other options
with her to assure that she is aware of availa!le options$
K void scaring women a!out rare medical complications and instead focus on the
nuisance side effects that are more li#ely to lead to discontinuation$
K Consider discussing intrauterine contraception and implants with all women who
desire reversi!le contraception$ Even if they choose another method, you have given
them education a!out methods they may !e unfamiliar with and could use in the
future$
K &emem!er to discuss emergency contraception with all women, even if they have
decided on a method$
!!reviations
K DMPLDepot medro:yprogesterone acetate/Depo%Provera
K D?/LDeep vein throm!osis
K M7LMyocardial infarction
K PELPulmonary em!olism
K -/7L-e:ually transmitted infection
Codes
7CD0%CM
?3) Encounter for contraceptive management
Patient /eaching
K Discuss the full range of contraceptive options$
K Encourage long%term methods with the highest effectiveness$
K <ive anticipatory guidance a!out nuisance side effects$
K -pea# in lay language, e:plaining concepts in simple terms$
K <ive information without ma#ing >udgments$
K s# open%ended 6uestions:
H B=hat pro!lems do you anticipate in using this methodMC
H B=hat have you heard a!out this method, either positive or negativeMC
K ?alidate the woman"s feelings$
K Maintain confidentiality$
K Educate patients a!out the noncontraceptive !enefits of different contraceptive
methods$