CHAPTER 7 TEACHING POINTS: CONTRACEPTION

EXERCISE 7.1

Purpose: To role-play different aspects of contraceptive counseling and to understand recent evidence-based contraceptive developments and medical criteria for use.

1. How would you respond to these common concerns about contraception?

• • When talking about side effects or common concerns, try to empathize, validate, reassure and normalize the patient’s feelings. Avoid saying things that might invalidate or trivialize a person’s concerns.
  • Avoid confrontational language. You are not trying to change the person’s mind, but instead, elicit the person’s preferences and priorities, and understand their goals.
  • Uses phrases like:
    • “Tell me more about that.”
    • “I hear that concern from a lot of people.”
    • “What worries you the most about that?”
  • Ask for permission to share information: For example, “Can I share some information with you about contraception and abortion?” or ask if they want to discuss it: “Would you like to discuss contraception (birth control options) or abortion?” If the person gives permission or agrees, then go on to share facts to help their understanding.

1. “I don’t like the idea of having something inside of my body.”
   • Thank you for sharing that with me. I have heard that concern from others. It’s normal to be anxious about having something placed in your arm/uterus;
   • There are methods that do not require anything to be placed inside of the body. Would you like to discuss those?
2. “I don’t want any hormones.”
   • I understand. A lot of people feel that way.
   • What is it about hormones that concerns you?
   • Ok, there are several non-hormonal options we can discuss.
3. “I want to have this (IUD / implant) removed (a few months after placement).”
   • You can absolutely have your method removed today. I am curious to know more about what is making you want to have the method removed – as there are often things we can do to help manage symptoms, if you like.
4. “I am concerned about pain with an IUD; can you explain pain management options?”
   • A lot of people are concerned about the discomfort with IUD placement. We can offer music/aromatherapy/guided meditation, topical options, medications to reduce pain/anxiety or numbing of the cervix with injections. Some health centers offer sedation during the placement.
   • Many people choose a combination of options and some do not want any of them.
   • Which of these methods would you be interested in learning more about?

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2. A 17-year-old old comes to the health center who is sexually active and currently using withdrawal. Role-play how you might initiate a conversation about their contraceptive priorities, and options based on a preference of privacy of contraceptive use (from family) and avoiding STIs?

• • Ask if they are satisfied with their method or want to discuss others.
  • Discuss effectiveness of withdrawal, and most important cycle times to use a backup method.
  • If they are interested in using a prescription/device for contraception:
    • Elicit their preferences and priorities first
    • Discuss pros/cons for the method(s) that align with their preferences.
    • Screen them for contraindications for their desired method.
    • Discuss common changes in menstruation with different methods.
    • Discuss how to stop/change a method.
    • Discuss how and where storage will work to keep condoms, patches, pills or rings.
  • Screen for safety at home and in intimate relationship(s) and discuss what they might do for contraceptive failures (i.e. EC, abortion access, etc.)
  • Tell them that an insurance explanation of benefits (EOBs) may be sent to home which would potentially alert their parent/guardian.
  • Know privacy laws in your state or country regarding reproductive health services, STI testing, and parental notification (Guttmacher 2022).

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3. A 28-year-old person presents to the health center seeking to switch to a new method of contraception. They are currently on DMPA, which has been causing 2-4 lb of weight gain, and want something non-hormonal. A friend mentioned having pain with an IUD, so your patient is hesitant to consider that option. Role-play being the healthcare provider and/or patient whose priority is avoiding potential weight gain and other hormonal side effects.
   1. Using the person-centered contraceptive counseling measure, what did you do as a provider to ensure the patient felt respected, listened to, had their preferences identified and received information?
   2. As the patient, is there more the provider could have done to establish rapport, identify priorities and share information?

Consider the following principles and steps:

• • Establish and maintain rapport with the patient
  • Assess their needs and personalize discussions accordingly
    • If the person has a strong interest in one method, ask permission before providing information on others
    • Focus on methods that align with their priorities (e.g. bleeding changes, frequency of use, privacy, effectiveness, or modality of administration)
  • Work interactively to establish a plan
    • Discuss potential barriers to accurate and consistent use of chosen method
  • Provide information that can be understood and retained by the user
    • Use visual aids as appropriate
  • Confirm understanding
    • Use active learning strategies such as teach back

There are many online tools, curriculum and videos to assist learners with contraceptive counseling. Bedsider has excellent videos discussing contraception from the patients’ perspective: https://www.bedsider.org/methods. Watching a few of the videos can help learners appreciate the impact of counseling on patients.

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5. What would you discuss with the following people regarding their desire for contraception? (Consult MEC as a reference)

1. 1. A 36-year-old patient who smokes tobacco and whose weight is > 198 lb / 90 kg (BMI > 30) wants the patch.
      • Recommendation: Tobacco users who smoke >15 cigarettes/day and are >35 should not use estrogen-containing methods due to increased stroke and M.I. risk (MEC 4).
      • Weight >198 lb / 90 kg (or BMI > 30) is an MEC Category 2 for combined hormonal birth control (Lopez 2016). Alone, this is not a contraindication.
      • This person could use any progestin-only, non-hormonal, or non-pharmacologic method.
      • If they insist on this method and you are not comfortable or willing to prescribe, discuss and document risks and recommendations. Consider referring for a “second opinion.”
   2. A 29-year-old with migraine headaches with aura who wants the pill.
      • Avoid estrogen-containing contraceptives in patients with migraines with aura due to increased stroke risk (MEC 4). Use caution with patients with migraines without aura (MEC 3) and consider additional prothrombotic risks (e.g. smoking). This patient may be offered progestin-only or non-pharmacologic methods.
      • Migraine with focal neurological symptoms is equivalent to migraine syndrome with aura (or classic migraine), and consists of one or more of the following that usually precedes and sometimes accompanies the headache:
        • Visual disturbances, scintillating scotoma, aura
        • Paresthesias (numbness and tingling)
        • Hemiparesis (weakness or partial paralysis in an extremity)
        • Dysphasia (slurred speech or inability to speak).
   3. A 20-year-old patient with a history of chlamydia at age 15 and who wants an IUD.
      • All types of IUDs are safe and well accepted among nulliparous patients (MEC 2).
      • Prior concerns about infertility with IUD no longer pertain with modern IUD designs (using monofilament IUD strings). Tubal infertility is linked to the presence of chlamydia antibodies, not to history of IUD use (Hubacher 2001).
      • Return to baseline fertility is usually immediate following IUD removal.
      • Although past studies suggested nulliparous patients have a slightly increased risk of IUD expulsion, a prospective study found no difference in rates of expulsions by parity among CuT users, and lower expulsion rates in nulliparous users of the LNG 52 mcg IUD compared with parous users (Birgisson 2015).
   4. A 35-year-old with chronic kidney disease (CKD; nephrotic syndrome; not on dialysis)
      • IUDs, nexplanon and most POPs are considered safe among patients with CKD (MEC 1-2). However, people with nephrotic syndrome and known hyperkalemia should not use drospirenone POPs (MEC 4) because of risk for worsening hyperkalemia.
      • Persons with nephrotic syndrome are at higher risk of thrombosis than the general population and use of DMPA (MEC3) and COCs (MEC 4) might further elevate risk for thrombosis.
   5. A 25-year-old with a history of deep vein thrombosis (DVT) 2 years ago, which occurred 6 weeks after a vaginal delivery. They are interested in the vaginal ring.

      • Any patient with a DVT history is no longer considered a candidate for estrogen containing contraception, including the vaginal ring. It is important to find out more about the person’s medical history.

      • postpartum DVT would be considered a pregnancy-associated DVT which is an absolute contraindication (MEC 4).
      • Family history (1st degree relative) is not a contraindication (MEC 2), but someone you should consider testing for thrombophilic conditions.
   6. A 25-year-old transgender man who became amenorrheic on testosterone, wants to prevent pregnancy with a partner that produces sperm.

      • If a person has a uterus and ovaries, they are capable of becoming pregnant, including transgender people who are taking testosterone and no longer having periods. People taking testosterone can use any method of contraception (Krempasky 2020). Testosterone does not reliably work as contraception, and does not interact with hormones in birth control, although some patients prefer to avoid exogenous estrogen. Some people choose a method to minimize or stop uterine bleeding. As with all people it is important to discuss the person’s preferences and assess whether there are any contraindications to specific methods.

      • See Birth Control across the Gender Spectrum: https://bit.ly/3iczORk
   7. A 31-year-old who takes anticonvulsant medications and wants the pill.
      • Certain anti-seizure medications, antibiotics, and antifungals activate the liver’s p450 enzyme system, resulting in faster metabolism of hormones, and decreased efficacy of combination and progestin-only pills and implants (all MEC category 3 while taking these medications; use shared decision-making; see table below).
      • CHCs may also reduce bioavailability of lamotrigine (Lamictal) (MEC3).
      • In standard doses, DMPAhas been shown to decrease seizure frequency (ACOG 2020).
      • IUDs or DMPA are the safest options (MEC 1 and 2 respectively).
        

        Drugs known to increase liver enzyme metabolism / reduce contraceptive effectiveness	Drugs with questionable effects	Drugs known not to effect liver enzyme metabolism or contraceptive effectiveness
        Carbamazepine (Tegretol, Equetro, Carbetrol)   Oxcarbazepine (Trileptal)   Phenobarbital   Phenytoin (Dilantin)   Primidone (Mysoline) Topiramate (Topamax) mild ↓   Rifampin   Rifampicin   Rifamate   Griseofulvin	Troglitazone (Rezulin) Felbamate (Felbatol)	Lamotrigine (Lamictal) Gabapentin (Neurontin) Tiagabine (Gabitril) Levetiracetam (Keppra) Valproic Acid (Depakote) Zonisamide (Zonegran) Vigabatrin (Sabril) Ethosuximide (Zarontin) Benzodiazepines INH (not in combination with Rifampin) Ketoconazole (anti-fungal) Fluconazole (anti-fungal)

   8. A 27-year-old who wants a combined hormonal method but does not want a monthly period.
      • Extended use of contraceptive pills (taking active hormones for a longer period than 21 days) and continuous use of contraceptive pills (no placebo pill interval) are safe, acceptable, and as efficacious as monthly cyclic regimens (Edelman 2014).
        • Extended and continuous use formulations of mono-phasic COCs and vaginal ring (Annovera or NuvaRing) may be used.
        • Continuous use of the patch is not recommended due to theoretical concern over increased levels of estrogen and VTE risk.
      • Extended use regimens result in fewer scheduled bleeding episodes and fewer menstrual symptoms, particularly headache (Edelman 2014).
      • Breakthrough bleeding is common in the first six months of continual use; however this side effect usually resolves within 4-6 months.