6. TEACHING POINTS: CONTRACEPTION AND AFTERCARE

EXERCISE 6.1

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

  1. A 17-year-old G0P0 patient comes to the clinic that is sexually active and currently using withdrawal and condoms comes to your office.  Can you role play how you might initiate the conversation, learn about their priorities, and simplify the choice process for them?  Consider using either Your Birth Control Choices or How Well Does Birth Control Work chart as a visual aid.
  2. A 28-year-old G3P3 patient presents to the clinic seeking to switch to a new method of contraception. They are currently on DMPA, which has been causing 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 a healthcare encounter using a patient-centered model. (Adapted from Dehlendorf).
    • What did you like about it or find challenging?
    • How was it different or similar to other patient encounters you’ve had?

    For role-play 1: the patient’s priorities are privacy (from parents) and infection prevention.
    For role-play 2: the patient’s priorities are to avoid weight gain and other “hormonal side effects”.

    Teaching Points: Consider the following steps:

    1. Establishing rapport, accessibility, and trust is the most important first step, unless you already know the patient
    2. Acknowledge the patient’s priorities and preferences (such as effectiveness, side, effects, privacy, cost, etc.)
      • Can choice of withdrawal and condoms represent an informed choice?
      • Given a strong interest in one method, ask permission to discuss other methods that align with the patient’s priorities.
      • Provide education about relative effectiveness of methods as appropriate.
      • Promote continued use of condoms to prevent STI transmission
      • Address side effects for methods aligning with the patient’s preferences.
      • Recognize that patients may prefer to risk pregnancy rather than use a method that is not acceptable to them.
    3. Proactively provide evidence-based information including method safety, side effects, and bleeding changes for methods that align with patients’ preferences
    4. Encourage and enable the patient to ask questions
    5. Facilitate the selection of a contraceptive choice that reflects a patient’s preferences and satisfies them
      • When you finish each role-play, you might look over the Best Practice and consider other things that you might add. Return to Exercises
  3. What would you want to discuss with patients regarding to their desire for contraception?

    Classification of Categories for Medical Eligibility Criteria (MEC)

    1. A condition for which there is no restriction for the use of the contraceptive method.
    2. The advantages of using generally outweigh the theoretical or proven risks.
    3. The theoretical or proven risks outweigh the advantages of using the method.
    4. The condition represents an unacceptable health risk if the contraceptive is used.
    1. A 36-year-old smoker with moderate obesity who wants the patch.
      • There are 2 issues to consider:
      • Tobacco users who smoke more >15 cigarettes/day and are ³35 years old should not be prescribed estrogen-containing contraceptives due to increased risk of stroke and M.I. (MEC 3-4).
      • The patch is less effective in heavier patients (30% of failures in 3% of patients > 198+ lbs).
      • This patient could safely use an IUD, progestin-only, or barrier method.
    2. A 29-year-old with migraine headaches with aura who wants the pill.
      • Avoid estrogen-containing contraceptives in patients with migraines with aura because of an increased stroke risk. Use caution with patients with migraines without aura, and consider additional prothrombotic risks (e.g. smoking). These patients are best served with an IUD/IUS, progestin-only or barrier method:
        • Migraine with aura or focal neurological symptoms any age (MEC 4).
        • ³35 years old and migraine without aura (MEC 3).
        • <35 years old & migraine without aura (MEC 2).
      • Patients with non-migraine headaches at any age can use estrogen-containing contraceptives (MEC 1). 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.
        • Paresthesias (numbness and tingling).
        • Hemiparesis (weakness or partial paralysis in an extremity).
        • Dysphasia (slurred speech or inability to speak).
    3. A 20-year-old nulliparous patient with a history of Chlamydia at age 15 and who wants an IUD.
      • IUDs are safe and well accepted among nulliparous patients. MEC lists IUD category 2 for nulliparous patients; benefits outweigh risks.
      • Tubal infertility is linked to presence of antibodies to Chlamydia but not to history of IUD use (Hubacher 2001).
      • Return to baseline fertility is almost immediate upon 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 LNg52 IUD compared with parous users (Birgisson 2015).
    4. A 28-year-old patient, who is overweight, has vaginitis, and who wants emergency contraception (for unprotected intercourse 3 and 5 days ago), as well as ongoing contraception.
      • CuT is nearly 100% effective for EC and ongoing contraception, including for overweight and obese patients (Wu 2013, Cleland 2012).
      • Effectiveness of EC: Cu-T IUD > Ulipristal (UPA) EC > LNG  EC (Turok 2014).
      • Offer CuT or UPA EC to those at increased risk of EC pill failure: overweight, obese and patients with repeat episodes unprotected intercourse (Glasier 2011)
      • Vaginitis is a MEC 2 for IUD, so should not preclude placement today, although you should initiate treatment as indicated.
      • Patients receiving IUDs were half as likely to become pregnant in the following year compared to oral EC (Turok 2014).
      • Routine counseling patients seeking EC on CuT EC in a primary care setting resulted in 11% uptake and 80% 12 month continuation (Schwarz 2014).
      • Alternatively use Ullipristal with other method of ongoing contraception
      • After UPA: The patient needs to abstain from intercourse or use barrier contraception for 14 days or until their next menses, whichever comes first. (ASEC 2016).
      • LNG EC effectiveness drops to 65% after 3 days and is not recommended. 
    5. A 25-year-old with SLE who is interested in the ring.
      It is important to find out more about the patient’s disease. If the patient is:

      • Antiphospholipid antibody positive (MEC 4 for CHCs, 3 for most methods, 1 for Cu-T IUD).
      • Has associated thrombocytopenia (MEC 3 for DMPA and Cu-T IUD).
      • Is taking Immune modulators (MEC 2 for all methods). 
    6. A 31-year-old who takes anti-seizure medications and wants the pill.
      • Select anti-seizure medications, antibiotics, and anti-fungals activate the p450 enzyme system in the liver, resulting in faster metabolism of hormones, and decreased efficacy of combination and progestin-only pills and implants (all MEC category 3 while taking these select medications; see table below). Keep in mind that some of these medications may also be used to treat certain psychiatric illnesses, headaches, chronic pain and other conditions. Note that CHCs may reduce bioavailability of lamotrigine (Lamictal).
      • IUDs or DMPA are the best options (categories 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
  • St John’s Wort
  • 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)
  • Ketaconazole (anti-fungal)
  • Fluconazole (anti-fungal)
  1. A 27-year-old who wants a combined hormonal method but doesn’t want a monthly period.
    • Extended contraception is safe, acceptable, and as efficacious as monthly cyclic regimens (Edelman 2005, Nelson 2007).
    • Increased ovarian suppression is noted in regimens that shorten or eliminate the hormone free interval, with the potential for increased effectiveness (London 2016).
    • Regimens result in fewer scheduled bleeding episodes and fewer menstrual symptoms, particularly headache (Edelman 2005).
    • Break through bleeding is common in the first six months of continual use; however this side effect usually resolved within 4-6 months.
    • Seasonale, Seasonique, Mono-phasic COCs, and Nuvaring may be used.
    • Patch is not recommended due to concern over increased levels of estrogen. 

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EXERCISE 6.2

Purpose: To review routine aftercare, please answer the following questions.

  1. A patient has had nausea and vomiting throughout pregnancy. How long will it take for them to feel better after the abortion?
    • Nausea is one of the first pregnancy symptoms to subside after an abortion, usually within 24 hours.
    • If it persists beyond a week, rule out ongoing pregnancy or retained products.
    • Breast tenderness subsides in 1-2 weeks, but may be influenced by CHCs.
  2. Providers typically advise patients to call if they have certain “warning signs” following uterine aspiration. What “warning signs” would you include and why?
    • Persistent severe pain or cramping:
      • May indicate hematometra, infection, uterine trauma, or ectopic.
    • Pelvic / rectal pain with little or no bleeding:
      • Suggests hematometra.
    • Heavy bleeding (saturating >2 pads per hour for >2 hours) or orthostatic symptoms:
      • Suggests the need for intervention.
    • Peritoneal signs (pain with cough, palpation, or sudden movement):
      • May suggest perforation or infection and warrant reevaluation.
    • Sustained fever (greater than 100.4° F):
      • Raises concern about pelvic infection.
  3. After an aspiration, how long would you advise your patient to wait before resuming exercise, heavy lifting, and vaginal intercourse? What is the rationale for your recommendations?
    • Resuming exercise or heavy lifting
      The patient may resume normal activity when they feel ready, typically within 1-2 days. Providers empirically discourage strenuous exercise for 1-2 weeks, to prevent exacerbation of bleeding or cramping, although there is little evidence. Probably the best advice is to “listen to your body,” enjoy the activities that make them feel better, and avoid activities that make them worse.
    • Resuming vaginal intercourse
      No data suggest increased infection with intercourse after an abortion, so advice may be liberalized. As ovulation can occur within 8-10 days, encourage the patient to initiate their chosen method of contraception promptly after abortion.

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