Contraceptive Care Across the Gender Spectrum

• Transgender & gender diverse (TGD) people should be offered the full range of contraceptive options as desired, and there is no restriction on the use of any method of contraception for TGD people with pregnancy potential (FSRH 2017).
• Testosterone does not serve as a contraceptive; its use is not a contraindication to hormonal contraception, though some people using testosterone prefer to avoid estrogens (ACOG 2021, Bonnington 2020, Krempasky 2020). TGD people may or may not want non-contraceptive menstrual suppression (Boudreau 2019).
• Include future fertility goals when discussing contraception with TGD people.
• See Birth Control across the Gender Spectrum (RHAP): https://bit.ly/3iczORk

Contraceptive Considerations for People with Disabilities

• For broader discussion of reproductive health access, accommodations, and patient-centered counseling for people with disabilities, see Ch. 2: Disability.
• Consider individual diagnoses, strengths, challenges, priorities, and needs.
• Some considerations for individual diagnoses are listed below (CDC MEC 2024), but counseling should be individualized based on personal risks and preferences.
• Manual dexterity considerations:
  • Some methods may be harder to use independently / privately (barrier methods, pill, patch, ring and IUD self-removal may be challenging).
• Immobility considerations (data from multiple sclerosis and major surgery)
  • Estrogens have a positive impact on bone mineral density (BMD), however, CHCs are MEC 3 with concern for VTE (specific data lacking).
  • While prolonged DMPA can lower BMD, osteoporosis and fragility fracture history are not contraindications to DMPA use per FDA label. Caution advised with prolonged immobility.
  • IUD placement: alternative exam positions, moderate sedation / anesthesia as needed
• Seizure Disorder
  • Seizure disorders occur at higher frequencies among people with disabilities and many people with seizure disorders report an unmet need for thorough counseling on their options (Kirkpatrick 2022).
  • Some anticonvulsants have teratogenic potential and can cause birth defects (Hutton 2017)
  • CHC and POPs can have drug-drug interactions with some anticonvulsants, resulting in faster metabolism of both medications (MEC Cat 3); while some interactions may result in lower contraceptive efficacy, others may result in lowered seizure threshold and specific medications should always be checked.
  • DMPA may reduce menstruation-related seizures (ACOG 2020).
• Autonomic dysreflexia (AD): occurs primarily in people with high spinal cord injuries
  • AD can cause sweating, uncontrolled HTN, arrhythmias, and seizures
  • May be triggered by pelvic discomfort (pelvic exams, IUD placement, painful menses)
  • Prevention: Minimize triggers (Wendel 2021)
  • Management: position patient upright, loosen tight clothing, eliminate precipitating stimulus, short acting antihypertensives for sustained hypertension.
  • IUD placement: alternative exam positions, moderate sedation / anesthesia as needed

APPENDIX A – PAIN MANAGEMENT FOR IUD PLACEMENT

• Pain and anxiety are common barriers to choosing or initiating IUDs, and have consistently been underestimated, or trivialized by clinicians (Akdemir 2019, CDC SPR 2024). Honesty and transparency about pain is also important for patient rapport. Discussing options and creating an individualized pain management plan is important to proactively address concerns and improve the person’s IUD placement experience (ACOG 2018, Akdemir 2019, Estevez 2024).
• Pain management measures are more effective if used proactively (i.e before pain occurs) (Hyland 2022).
• Evidence for pharmacologic and nonpharmacologic options show high acceptability (SPR 2024).
• The CDC (SPR 2024) urges providers to better address patient’s anxiety and pain.
• Multi-modal pain management approaches are recommended, and if someone is experiencing pain, stop and do something.

Trauma-Responsive Care

• Neutralize power imbalances, practice patient-centered care including shared decision making as applicable, and offer options and alternatives as they arise.
• Seek consent before and throughout the process, and peer support when feasible.
• Offer alternative exam positions; smallest appropriate speculum; self-insertion.
• Although data on non-pharmacologic means is limited for IUD placement, asking and offering may be patient-centered (see Ch 5: Trauma Informed Care).

Non-pharmacologic Strategies

Patients endorsed non-pharmacologic strategies as positive and helpful for similar procedures, even when they did not affect pain and anxiety scores (Tschann 2016). Although data are limited for IUD, offering these strategies is person-centered (CDC SPR 2024 Appendix, Estevez 2024). See Ch 5: Nonpharmacologic Strategies Summary.

• Support person, doula or bedside nursing support: minimal reduction in IUD pain (Harvey 2021); may increase patient satisfaction.
  • Doula Presence: UCSF LARC Doula Toolkit
• Music: no known IUD studies; mostly helpful for procedural abortion, especially calming and either in the room, or if headphones, keeping one ear available (Tschann 2016).
• Aromatherapy: inhaled lavender reduces anxiety with IUD placement (Shahnazi 2012).
• Verbal analgesia was not superior to tramadol for pain with IUD placement (Daykan 2021).
• Direct IUD placement (without sounding): less pain, but advanced skill needed to ensure appropriate placement and to avoid trauma (Bastin 2019).
• Acupuncture: bilateral LI4 acupuncture (1st web space) improves IUD pain (Erdoğan 2023).
• TENS unit non-inferior to IV sedation for gyn surgery, at lower abdomen & back (Piasecki 2023).

NSAIDs

• Naproxen and ketorolac improve IUD placement pain over placebo; post-procedure pain improved with several doses (Lopez 2015)
• Consider Naproxen 550 mg PO before placement and then q 6-8 hours after placement as needed.
• Ibuprofen primarily helps with post-procedure cramping (Ireland 2016).
• For CuT IUD users, prophylactic use in the first 3 cycles decreases cramping & intermenstrual bleeding (CDC SPR 2024); start 1-2 days before menses for anti-prostaglandin effect.

Benzodiazepines

• Data lacking for IUD. For abortion, benzodiazepines decrease anxiety and have amnestic effects (Bayer 2015), but without change in pain or satisfaction.
• If used, prescribe in advance for use during the procedure (will need a driver home).
• May give 30-60 min prior (Lorazepam 2 mg PO or Midazolam 10 mg PO).

Opioids

• Tramadol 50 mg PO pain scores and satisfaction improved over Naproxen or placebo for IUD placement (CDC SPR 2024, Karabayirli 2012).
• Verbal analgesia is as good as oral Tramadol (Daykan 2021).
• If used prior to the procedure will need a driver home.

Misoprostol 

• Routine misoprostol is not indicated for placements; routine misoprostol can worsen pain without improving satisfaction, placement success or ease (CDC SPR 2024, Dijkhuizen 2011, Ireland 2016, Pergialiotis 2014).
• After an unsuccessful placement attempt, misoprostol 400 mcg vaginally or buccally 2 hrs prior to the procedure may improve the success of placement (Bahamondes 2015).

Nitrous Oxide 

• Benefits during IUD placement in adolescents; IUD pain reduction at 70:30 ratio, but not 50:50 ratio (Fowler 2022). But “more satisfied with pain management” like in abortion & labor settings.
• Others showed no benefit with IUD placement (Singh 2015) or procedural abortion (Singh 2017).
• Typical regimen: N2O/O2 70/30 or 50/50 starting a few minutes prior to procedure.

Topical Anesthetics

• Improved pain with tenaculum placement (4 studies), IUD placement (8 studies), and post-insertion (2 studies) with topical lidocaine vs. placebo (SPR App 2024, Tavakolian 2015).
• Consider provider administration using a wait time of 1-7 min or self-administration with a wait time of 5-15 min.
• People are willing to self-administer; and wait if they think there will be pain reduction.
• Typical options: 2-4% lidocaine spray, 2% lidocaine jelly, lidocaine/prilocaine (EMLA) cream
• More potent options help, but 10% lidocaine is less available in the U.S..

Topical Estrogens 

• Patients with cervical atrophic changes (i.e. from prolonged testosterone use) may benefit from a short course (2-6 week) of estrogen prior to exam or IUD placement.
• Use shared decision making for placement today vs. following estrogen pre-treatment.
• Options include:
  • Topical: Conjugated equine estrogen cream 0.625 to 1.25 mg per day OR
  • Oral: Estradiol 1 mg to 2 mg daily for 2-6 weeks
  • If intact uterus, no progestin needed for topical or oral short course

Paracervical block

• Paracervical block (PCB) with lidocaine may reduce pain, with half of studies showing pain reductions at tenaculum placement, IUD placement, and post- placement (CDC SPR Appendix 2024).
• Both 10cc and 20cc of 1% lidocaine showed benefit for IUD placement (Akers 2017, Mody 2018), although 20-30 cc more effective for abortion (see Ch 5: PCB). Adding more local anesthesia in areas not reached initially if someone has pain with dilation can be useful.
• < 5% of U.S. providers routinely offer PCB (Reeves 2023).

Intracervical block 

• ~4 mL 2% lidocaine intracervical block decreases pain at tenaculum placement and IUD placement; may decrease vasovagal, improved overall procedure experience (De Nadai 2020).
• More effective than Naprosyn for IUD placement pain (de Oliveira 2021).
• No RCTs comparing PCB to intracervical block.

Intrauterine Instillation of Analgesic

• No benefit for pain, ease of placement, or patient satisfaction in 4 of 5 studies.
• Mepivacaine 2% improved placement pain in 1 study (SPR Appendix 2024).
• No pain improvement for procedural abortion with 1% intrauterine lidocaine infusion compared with PCB alone (Edelman 2004).

IV Sedation

IV sedation is available at many health centers/hospital-based settings, and may be especially beneficial for those with known predictors for pain, history of challenging procedures, or those with nervous system disabilities or contractures. See Ch 5 IV pain management options.

General Anesthesia

IV sedation is available primarily in hospital-based settings, and are occasionally needed for those with risk factors for challenging procedures, or with nervous system disabilities or contractures.