EVIDENCE-BASED CONTRACEPTIVE GUIDANCE 

The rapidly growing body of evidence surrounding contraception is tremendously helpful to our patients. This chapter provides a brief update, with links to more in-depth resources. Keep in mind that many patients seeking abortion services will not desire contraceptive information or feel pressured to choose a method on the day of their abortion (Matulich 2015, Brandi 2018). The goal is not to have every patient leave with a contraceptive method; rather to remove barriers to access for those patients desiring contraception. 

Visual Aids for Counseling

It helps to use visual aids so patients can explore their options.It is important to acknowledge the priorities inherent in the chart being used, and focus on methods that match the patient’s priorities. Some examples of visual aids:

Simplified Screening (Class A Evidence; CDC SPR 2016)

Most methods can be safely initiated with few additional requirements, including:

  • Medical history for contraindications
  • Consult MEC; note MEC category 3: use shared-decision making to discuss risks
  • Required exam components for specific methods:
    • BP (self-report adequate): combined hormonal methods
    • Pelvic exam: IUD and some diaphragms
    • STI screening: IUD (same visit; only if risks & not yet screened; Sufrin 2015)
  • Not required to initiate contraception:
    • Heart, lung, breast or well-person exam, pap test, hemoglobin or “routine” labs

Quick Start – Initiation of Contraception (CDC QFP 2014)

Post Abortion Initiation of Contraception

  • Post aspiration, all methods can be started on day of procedure, if desired
  • Post medication abortion or miscarriage:
    • Implant and DMPA can be placed or given on day of mifepristone (Raymond 2016, Raymond 2016). Counsel same day DMPA associated with increased ongoing pregnancy rate (<5%), but patient satisfaction higher with same day administration. 
    • Pills, patch, and ring can be started after misoprostol administration
    • IUD at follow-up visit; offer bridging method if unable within 7 days (US SPR 2016)

Primer on IUDs and Implants

  • IUD and implant are safe, effective, & have high satisfaction and continuation rates
  • 3-year LARC continuation ~ 70% vs. among short-acting methods ~ 30% (Diedrich 2015), regardless of age (Rosenstock 2012)
  • Adopt same-visit protocols for improved access (ACOG 2015)
  • Over 20-fold more effective than short-acting methods, regardless of age (Winner 2012)
  • Assure removal upon request, for whatever reason, as part of informed consent process

Evidence-based IUD eligibility

  • No association of IUD with increased infertility risk (Hubacher 2001)
  • PID risk with IUD no greater than any other non-barrier contraceptive method
  • No restriction for multiple partners
  • Contraindications: Pregnancy, active cervicitis or PID, uterine cavity distortion
  • LNG-IUD 52 mg minimizes blood loss with menorrhagia, endometriosis, fibroids

IUD Selection for Individual Preferences

Cu-T IUD LNG 52 mcg IUD LNG 13.5 – 19.5 mcg IUD
Paragard ® Mirena ® / Liletta ® Skyla ®/ Kyleena®
Doesn’t want hormones Doesn’t mind hormones Doesn’t mind hormones; wants low dose
Wants regular menses Wants light menstrual flow
Amenorrhea 30%
Wants non-contraceptive benefits (for heavy menses or uterine protection)
Wants less menstrual flow
Amenorrhea 10%
Wants EC Wants EC (Use with LNG ECP)

LARC insertion and removal videos:

IUD insertion tips

Ensuring IUD / implant removal

  • Patients have a right to prompt LARC removal, without provider judgement or resistance
  • Clinicians often prefer to await symptom resolution (Amico 2018)
  • Resisting removal may jeopardize satisfaction & the clinical relationship (Raifman 2018)
  • Some patients more likely to consider IUD if aware of self-removal option (Foster 2014)
  • Self-removal is safe; among those who tried, one in five was successful (Foster 2014)

Progesterone only methods (Implant, LNG-IUDs, DMPA, POP):

  • Safe for patients with estrogen contraindications (e.g. migraines with aura)
  • Generally decrease bleeding & pain; possible amenorrhea (DMPA, LNG-IUD, Implant)
  • Decreased risk of endometrial and ovarian cancer (DMPA, 52mg LNG-IUD)
  • If LARC insertion delayed > 5 days after abortion, bridge or backup method for 7 days
  • For patients with metrorrhagia / menorrhagia, can add back estrogen for first few months

Combined hormonal contraceptives (COC, Patch, Ring):

  • Decreased dysmenorrhea, PMS & menstrual migraines, improved acne
  • Decreased gyn cancers, ovarian cysts, PID, benign breast tumors, osteoporosis 
  • Rare adverse health outcomes: VTE, heart attack, stroke, for some risk categories

Extended / continuous contraception to reduce/eliminate withdrawal bleeding

  • Safe, acceptable, and as efficacious as monthly cyclic regimens
  • Fewer scheduled bleeds; less estrogen-withdrawal symptoms (Edelman 2014)
  • Various monophasic OCP and vaginal ring can be used
  • Unscheduled bleeding decreases over time with these regimens

Contraceptive Care across the Gender Spectrum

  • Transgender and gender diverse (TGD) patients (those whose gender identity or expression is different from that assigned at birth) can be offered the full range of contraceptive options.
  • Testosterone therapy is not contraindication to estrogen or progesterone, though some may prefer to avoid exogenous estrogen (Krempasky 2020, Bonnington 2020).
  • TGD patients may want non-contraceptive benefits, like menstrual suppression (Boudreau 2019)
  • See Birth Control across the Gender Spectrum: www.reproductiveaccess.org/wp-content/uploads/2018/06/bc-across-gender-spectrum.pdf

Emergency contraception (EC):

  • EC will not disrupt an implanted pregnancy, thus will NOT cause an abortion.
  • After Ulipristal (UPA) EC pills, delay OCP, Implant, and DMPA for 5 days (ASEC 2016)
  • LNG EC pills (ECP) via US pharmacies / online without Rx for all ages / genders
  • EC effectiveness:
    • LNG ECP less effective with BMI > 25. UPA less effective with BMI > 30, However, UPA more effective than LNG ECP at any BMI.
    • CuT IUD ~ 100% effective at any BMI or repeat unprotected intercourse; provides ongoing contraception (Wu 2013, Cleland 2012)
    • Offer CuT if increased risk of ECP failure (Glasier 2011, Shen 2017)
    • LNG IUD + LNG ECP are as effective as copper IUD; preferred by many patients (Turok 2016). RCT pending of LNG IUD as EC (no LNG ECP).
Contraceptive Counselingimage
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EARLY ABORTION TRAINING CURRICULUM Copyright © 2020 by UCSF Bixby Center for Global Reproductive Health. All Rights Reserved.