CHAPTER 7 TEACHING POINTS: CONTRACEPTION AND ABORTION AFTERCARE

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 patient concerns about contraception?
    • When talking about side effects or common patient concerns, try to empathize, reassure and normalize the patient’s feelings.  Saying things that would invalidate a person’s concerns is likely to make them feel unheard.
    • Avoid confrontational language. You are not trying to the change the patients mind, but instead, elicit the patient’s priorities, and understand their goals.
    • Uses phrases like:
      • “Tell me more about that.”
      • “I hear that concern from a lot of patients.”
      • “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?” If the patients give permission, then go on to share facts to help their understanding.
  1. I don’t like the idea of having something inside of my body.
    • It’s normal to be anxious about having something placed inside you; what concerns you most?
    • I know it can seem strange to have something inside you. Are you concerned that you will be able to feel it there? Or maybe that your partner(s) will feel it?
    • Many patients have shared that they don’t feel the method.
  2. I don’t want any hormones.
    • A lot of people feel that way. What is it about a hormonal method that concerns you?
    • Ok, there are definitely non-hormonal options we can discuss.  What is it about hormones that is concerning to you?
    • <If interested in a highly effective method> The copper IUD doesn’t have any hormones and works by having copper naturally repel sperm. It’s the most effective non-hormonal option.
  3. Won’t IUDs cause an abortion?
    • For an abortion to happen, someone has to first be pregnant, and these methods prevent pregnancy in the first place. IUDs work by preventing fertilization of an egg, either by blocking the sperm from reaching the egg or, in the case of Mirena/Skyla/Kyleena/Liletta, by sometimes also preventing the release of an egg.
  4. I want to have this (IUD / implant) removed (a few months after placement).
    • You can absolutely have your method removed today, and I’m happy to do that for you. I would also love to know more about what is making you want to have the method removed – there are often things we can do to help so that you could keep the method, if you like.

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  1. A 17-year-old G0 old patient comes to the clinic who is sexually active and currently using withdrawal and condoms.  Role play how you might initiate a conversation about their contraceptive priorities, and options based on a preference of privacy of contraceptive use (from parents) and avoiding STIs? 
    • Ask if satisfied with method or want to discuss others that address these preferences.
    • Discuss effectiveness of withdrawal, and times in cycle most important to use condoms.
    • Discuss how and where storage will work to keep condoms, patches, pills and / or rings.
    • Discuss common changes in menstruation with methods, which can be a signal of a change: DMPA, IUDs, & implants can change heaviness and frequency of periods.
    • Screen for safety at home and in intimate relationship(s) and discuss what they might do for contraceptive failures (i.e. emergency contraception, abortion access, etc.)
    • Make patient aware that insurance explanation of benefits (EOBs) can be sent to policy holder. [https://www.guttmacher.org/state-policy/explore/overview-minors-consent-law]
    • Know privacy laws in your state or country regarding reproductive health services, STI testing, and parental notification.

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  1. 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 being both the healthcare provider and patient whose priority is avoiding weight gain and other “hormonal side effects”.
    • Using the IQFP measure, what did you do as a provider to ensure the patient felt respected, listened to, had their preferences identified and received information?
    • 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 the patient’s needs and personalize discussions accordingly
    • If the patient has a strong interest in one method, ask permission before providing information on others
    • Consider methods that align with patient priorities (e.g. bleeding changes, frequency of use, privacy, effectiveness, or modality of administration)
  • Work with the patient interactively to establish a plan
    • Anticipate and address barriers to accurate and consistent use of chosen method
  • Provide information that can be understood and retained by the patient
    • Simplify the choice process using visual aids
  • 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 patient-centered 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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  1. What would you discuss with the following patients regarding their desire for contraception? (Consult MEC as a reference)

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.
  • It is important to review each of the MEC categories and explore the differences between MEC Categories 1 & 2 vs 3 & 4. 
  • MEC Category 1 and 2 are both considered safe and OK to proceed with use. 
  • MEC Category 3: Discuss risks and use shared decision-making with patient. Consult as needed. Document risk-benefit discussions.   
  • MEC Category 4 is considered an absolute contraindication with no acceptable use of the method with the specific health condition. 
  1. A 36-year-old smoker with moderate obesity who wants the patch.
    • There are two issues to consider:

      • Tobacco users who smoke >15 cigarettes/day and are >35 years old should not use estrogen-containing contraceptives due to increased stroke and M.I. risk (MEC 4).
      • Obesity is not considered a contraindication for any birth control (Lopez 2016).

      This patient could safely use any 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 a progestin-only or barrier method.  Additional MEC categories include:   

      • Migraine with aura or focal neurological symptoms any age (MEC 4).
      • 35 years old and migraine without aura (MEC 3).
      • <35 years old and migraine without aura (MEC 2).
      • Non-migraine headaches at any (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, 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 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 2). 
    • Prior concerns about infertility with IUD no longer pertain with modern IUD designs (using monofilament IUD strings).  Tubal infertility is linked to presence of Chlamydia antibodies, not to history of IUD use (Hubacher 2001). 
    • Return to baseline fertility is almost immediate upon 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 52mcg IUD compared with parous users (Birgisson 2015).
  4. A 28-year-old patient who has BMI > 30, has vaginitis, and wants emergency contraception as well as ongoing contraception. Pt had unprotected intercourse 3 and 5 days ago.
    • CuT IUD EC is nearly 100% effective, including with BMI > 30; provides ongoing contraception, if desired (Wu 2013, Cleland 2012).
    • Vaginitis (MEC 2), vs. purulent cervicitis or PID (both MEC 4).
    • Vaginitis should not preclude placement; simply initiate treatment today.
    • Patients receiving IUDs of EC were half as likely to become pregnant in the following year compared to oral EC (Turok 2014).
  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 history of a DVT is no longer considered a candidate for estrogen containing birth control, including the vaginal ring.  It is important to find out more about the patient’s disease.

      • A 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 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; use shared decision-making; 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 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
      • 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)
  7. 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 2014).
    • 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 2014).
    • Break through bleeding is common in the first six months of continual use; however this side effect usually resolves within 4-6 months.
    • Extended and continuous use formulations of mono-phasic COCs, and vaginal ring may be used.
    • Patch is not recommended due to concern over increased levels of estrogen.

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EXERCISE 7.2

Purpose: To review routine follow-up after uterine aspiration, 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, generally within 24 hours.  Nausea may be induced by CHC use.
    • 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. 

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  1. 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 100.4F / 38C ):
      • Raises concern about pelvic infection.

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  1. 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 

Many providers empirically discourage strenuous exercise and intercourse for 1-2 weeks after abortion, to prevent exacerbation of bleeding or cramping, or avoid infection, although there is no evidence that this makes any difference.

The patient may resume normal activity when they feel ready, this can be as soon as a few hours after their abortion, or more typically within 24 hours. 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

The patient may not feel like being intimate or having vaginal intercourse during this time. No data suggest increased infection with intercourse after an abortion, so advice may be liberalized. Encourage them to trust their body and resume intercourse when they feel ready. As ovulation can occur within 7-10 days, encourage the patient to initiate their chosen method of contraception promptly after abortion.

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