Shared Decision Making (SDM) for Improved Contraceptive Counseling
Contraceptive services have gained national attention as part of the core of preventative services that should be available to all patients as part of health care reform. Most patients spend just a few years trying to get pregnant but over 20 years trying to prevent pregnancy. Patients at risk for pregnancy should be screened for their pregnancy intentions as a routine part of high-quality primary care, and offered contraceptive care or preconception counseling as needed (Bellanca 2013).
Contraceptive counseling has great potential as a strategy to empower patients who do not desire pregnancy to choose a method they can use correctly and consistently over time. The quality of interpersonal care, measured using both patient report and observation of provider behaviors, influences contraceptive use (Dehlendorf 2016). Patients who are more satisfied with their family planning experiences are more likely to use contraception. Given a history of reproductive coercion among marginalized populations and implicit biases toward long-acting methods among lower income patients, we encourage patient-centered decision-making that is focused on patient’s preferences (Dehlendorf 2016, 2014). Below is a simple approach to contraceptive counseling adapted from this model. * Starred items below are explicitly linked to improved contraceptive use, continuation, and adherence.
- Establish rapport, accessibility, and trust *
- Elicit and clarify a patient’s priorities, preferences, and personal situation *
- Provide evidence-based information including method safety, side effects, and bleeding changes for contraceptive methods that best align with patients’ preferences
- Encourage and enable the patient to ask questions
- Facilitate the selection of a contraceptive choice that reflects and satisfies patient preferences.
Additional Best Practices in Contraceptive Counseling
- Use active learning strategies (such as open-ended questions and teach backs)
- Simplify the choice process, using visual aids (see example below)
- If the patient has a strong interest in one method, ask permission to provide information on others
- Consider methods in order of patient priorities (e.g. effectiveness, bleeding changes, frequency, privacy, or modality of administration)
- Anticipate and address barriers to accurate and consistent use for their chosen method
- Address (mis)perceptions of low personal risk of pregnancy
- Address method switching and form a contingency plan in case of dissatisfaction
- Address quick start options where appropriate (see easy-to-follow Algorithm)
- Address dual use issues and negotiation of condom use to prevent STIs / HIV
- Ensure advance provision of emergency contraception if at risk for pregnancy
- Consider screening for reproductive coercion and offer harm reduction strategies
- Foster awareness of one’s own biases and work to consciously overcome them.
EVIDENCE-BASED CONTRACEPTIVE GUIDANCE
The rapidly growing body of evidence surrounding contraception is tremendously helpful to our patients. This overview is meant to provide brief updated information, links to more in depth resources and videos, and a jumping off point for further literature review.
Simplified Screening (Class A Evidence; CDC SPR 2013)
Most methods can be safely initiated with few additional requirements, including:
- Medical history for contraindications (CDC [MEC])
- Required exam components for specific methods:
- Blood pressure: combined hormonal methods
- Weight / BMI: levonorgestrel > ullipristal (UPA) emergency contraceptive pills
- Pelvic exam: IUD and cervical cap
- STI screening (on day of insertion): IUD (only if not already screened according to CDC Guidelines; Sufrin 2015)
- Not required:
- Heart, lung, breast or well-person exam
- Pap test, hemoglobin or “routine” lab tests
- Weight / BMI: DMPA, CHCs – may help monitor / counsel re: weight changes perceived to be associated with method over time)
Quick Start (CDC QFP 2014)
- Evidence supports method initiation on the day of the patient’s visit or if unable, providing a bridge method, to reduce the chance of an unintended pregnancy.
- Two visit protocols hinder patient’s ability to get a LARC (ACOG 2015)
- Quick Start Algorithm available and easy -to-follow
- Post uterine aspiration, all methods can be started on day of procedure
- Post medication abortion or miscarriage:
- Implant can be placed on day of mifepristone or follow-up (Park 2015)
- Pills, patch, and ring can be started after bleeding from misoprostol
- DMPA and IUD can be given at follow-up visit (preferably within 5 days)
- Dispensing 12 months of a method, such as contraceptive pills is safe, effective, and improves continuation (Foster, 2006). Rx: “method name x 365 days”, not 12 months.
Primer on long acting reversible contraceptives (LARCs)
- IUD and implant are safe, highly effective, and private, have high continuation rates, and are appropriate for most patients, including those contraindicated for estrogen.
- Over 20-fold more effective than short acting methods, regardless of age (Winner 2012)
- 3 year continuation ~ 70% among LARC users vs. ~ 30% among non-LARC users (Diedrich 2015), regardless of age (Rosenstock 2012)
- Population-level increased LARC use a reduced teen birth & abortion (Peipert 2012)
- Postpartum LARC linked to healthy birth spacing, 2 – 4 times other methods (Thiel 2013)
- Removal should be assured when a patient desires.
LARC types in the U.S. (click type for insertion video / information)
- Copper IUD: ParaGard (also most effective EC; non-hormonal)
- Progestin IUDs: Mirena, Liletta, Skyla (progestin-only)
- Implant: Nexplanon (progestin-only)
Evidence-based IUD eligibility (MEC)
- No restrictions for nulliparous or age < 25 years old (MEC 2)
- No association of IUD with increased risk of infertility (Hubacher 2001)
- No restriction for past history of PID, STI, ectopic pregnancy, non-monogamy
- No restriction for abnormal Pap, only cervical cancer
- No restriction for patients with HIV or AIDS (stable on ARVs)— (MEC 2)
- LNG-IUS can be used to treat menorrhagia and dysmenorrhea
- Contraindications: pregnancy, active cervicitis, active PID, uterine cavity distortion.
IUD Insertion Tips
- Insert at any time in cycle as long as reasonably sure the patient is not pregnant (U.S. SPR 2013)
- Routine antibiotic prophylaxis is not standard of care
- IUD insertion pain: lidocaine block helps; not routine miso (Pergialiotis 2014); ketorolac helps after insertion (Ngo 2012)
- After failed insertion, misoprostol improves subsequent insertion (Bahamondes 2015)
- Little evidence for routine IUD string checks: a barrier to many (Davies 2014)
Progesterone only methods (implant, LNG-IUDs, DMPA, POP and LNG EC):
- Safe for patients with contraindications to estrogen (e.g. migraines with aura)
- Generally decreased dysmenorrhea (particularly Mirena / Liletta)
- Decreased risk of endometrial and ovarian cancer
- Backup method 7 days if >5 days after cycle begins, aspiration, or delivery
- For patients with metrorrhagia / menorrhagia on method, can add back estrogen during first few months, as appropriate.
Contraceptives that contain estrogen (Ring, Patch, COC) (US MEC):
- Decreased dysmenorrhea, lessened PMS & menstrual migraines, improved acne
- Decreased risk of endometrial and ovarian cancer, ovarian cysts, PID, benign breast tumors, osteoporosis
- Rare adverse health outcomes, including venous thromboembolism, heart attack, stroke, for some risk categories (MEC).
Extended contraception to reduce / eliminate withdrawal bleeding
- Safe, acceptable, and as efficacious as monthly cyclic regimens (Nelson 2007, Edelman 2005). Fewer scheduled bleeds; less estrogen-withdrawal symptoms.
- Various monophasic OCP formulations or vaginal ring can be used (not patch).
- Unscheduled bleeding decreases over time with these regimens.
Emergency contraception (EC):
- Effectiveness of EC: Cu-T IUD > Ulipristal (UPA) EC > LNG EC (Turok 2014). CuT EC is nearly 100% effective, including with overweight and obese patients; provides ongoing contraception (Wu 2013, Cleland 2012).
- Patients offered CuT vs. LNG EC: pregnancy half as likely in 1 year (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)
- In primary care setting, routine counseling about CuT for EC seekers resulted in 11% same-day uptake; 80% still using CuT 12 months later (Schwarz 2014)
- EC will not disrupt an implanted pregnancy, thus is NOT an abortifacient
- LNG EC is available at pharmacies without a prescription for all ages